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In evaluating the G20 Bali Leaders’ Declaration, Global Health Technologies Coalition (GHTC) recognizes and applauds several encouraging commitments but urges leaders to walk the walk when it comes to making greater investments in research and development (R&D) and addressing emerging and persistent health threats with greater urgency. Promising support for The Pandemic Fund, ACT-A, and enhancing local capacity GHTC was pleased to see G20 leaders launch The Pandemic Fund in concert with this week’s summit in Bali. We believe this fund will be a critical mechanism for new R&D capacity-building investments and will help facilitate a coordinated and consistent approach to pandemic preparedness and response strengthening. We also echo the declaration’s focus on equity and inclusive membership in The Pandemic Fund’s governance structures, though we remain concerned that concrete targets and accountability provisions should have been included to establish a deeper commitment to diverse representation.  Additionally, GHTC welcomes G20 leaders’ expressed support for the Access to COVID-19 Tools Accelerator (ACT-A), highlighting the continued importance of this cooperative framework to accelerate the development, manufacturing, distribution of, and equitable access to new health technologies in the fight against COVID-19. As the initiative enters a new phase, R&D must continue to be a central pillar to ensure that vaccines, therapeutics, and diagnostics keep up with new variants. While we commend G20 leaders for highlighting the need to draw lessons from ACT-A external evaluations, they did not specify recommendations from those reports that they look to act upon. Several evaluations noted the need for greater integration of lower- and middle-income countries and partners in ACT-A’s model and that a joint platform should be established to coordinate work across product areas. We urge leaders to take tangible steps in advancing these recommendations in the coming months. GHTC was also encouraged to see the G20 articulate the need for strengthening local and regional health product manufacturing capacities and cooperation, as well as sustainable global and regional R&D networks, to facilitate better access to health technologies in lower- and middle-income countries. Insufficient urgency to mobilize against AMR and “the big three” While it was noteworthy to have global health R&D reflected throughout the final communique from G20 leaders, unfortunately the declaration also fell short in several areas. For instance, while GHTC was pleased to see that antimicrobial resistance (AMR) was elevated as part of pandemic preparedness, it was disappointing that countries failed to specify commitments and plans for addressing AMR, including planned investments to strengthen the pipeline of new tools to combat this growing health threat.  Similarly, enduring health challenges such as tuberculosis, malaria, HIV, and neglected tropical diseases did not receive a single mention, reinforcing the perception that they have fallen further off global leaders’ radars, even as new data confirms that the COVID-19 pandemic has eroded hard-won progress in these areas. Continued neglect of these pandemics is a recipe for increased backsliding and puts the goal of universal health coverage at risk. Investment in developing new tools to combat these long-standing threats is key to achieving broad health goals endorsed by the G20 in recent years.  A promising vision must be backed by greater commitment and accountability It was refreshing that this year’s declaration highlighted the importance of global health R&D in several areas, especially in relation to pandemic preparedness, and underscored that R&D investments and prioritization must continue to be a focus of national, regional, and global bodies to combat emerging and ongoing health threats. However, the declaration was light on tangible commitments and failed to address some of the world’s leading and most persistent health threats. To realize the vision of this declaration and the G20’s health goals more broadly, we call on leaders to make specific pledges and be more accountable to the principles outlined in the communique.  

The 2022 midterm elections on November 8 were expected to deliver a decisive power flip from Democrats to Republicans. However, as the new landscape comes into focus, it appears that Democrats will hold the Senate, and Republicans are likely to win the House of Representatives by a handful of seats. These margins and the composition of new committees will determine the trajectory of global health research and development policy over the next two years.Both chambers on a knife edge splitRepublicans underperformed most analysts’ projections in both chambers. In the House, they are expected to eke into power by only a handful of seats. In the Senate—where several Republican candidates failed to overtake their competitors in close races—Democrats have retained control and may even net gain one seat, depending on the outcome of a special runoff election in Georgia on Tuesday, December 6, between incumbent Senator Raphael Warnock (D) and Herschel Walker (R).Implications on makeup of key committeesNext steps for both parties include electing new party leaders, which is expected to happen later this year. Following that, early next year, the parties will designate committee assignments, which will impact oversight and policymaking for the next two years of global health research. In the House, committee majorities will be determined by who holds the majority in the full House. In the Senate, if the final split is 50-50, then committees will also be evenly split. But if Senator Raphael Warnock wins his reelection in Georgia, then the Senate will be 51-49, and Democrats will take the majority on each committee with one extra seat.Though we do not yet know exactly how the committees will look next year, we do know which members from the 117th Congress will return to the 118th and which current members will be stepping down.Leadership of most committees relevant to global health research and development (R&D) are expected to remain relatively stable with top Democrats and Republicans trading positions as chairs and ranking members. Some exceptions include Representative Karen Bass, chairwoman of the Subcommittee on Africa, Global Health, Global Human Rights and International Organizations, who is stepping down in pursuit of becoming the next mayor of Los Angeles and Rep. Hal Rogers (R-KY), ranking member of the House Appropriations State, Foreign Operations, and Related Agencies Subcommittee, who may become chair of the subcommittee or may be replaced by Rep. Mario Diaz-Balart (R-FL).Among the members currently serving on the House Foreign Affairs Committee who have retained their Congressional seats are Reps. Susan Wild (D-PA), Maria Elvira Salazar (R-FL), Young Kim (R-CA), and Abigail Spanberger (D-VA). Members who were defeated include Reps. Tom Malinowski (D-NJ) and Steve Chabot (R-OH). Some other members of Congress on relevant appropriating and authorizing committees to global health research who are retiring or lost their primaries earlier this year include Reps. Albio Sires (D-NJ), David Price (D-NC), Lucille Roybal-Allard (D-CA), Cheri Bustos (D-IL), Jaime Herrera-Beutler (R-WA) and Fred Upton (R-MI). In the Senate:There were no major losses among incumbents on the Foreign Relations Committee; Health, Education, Labor, and Pensions (HELP) Committee; or the Appropriations Labor, Health, nor on the Human Services, Education, and Related Programs (LHHS) and State and Foreign Operations subcommittees. Some big names will be retiring, including Sens. Richard Shelby (R-AL), ranking member on the Appropriations Committee; Roy Blunt (R-MO), ranking member on the LHHS Subcommittee; Richard Burr (R-NC), ranking member on the HELP Committee; and Rob Portman (R-OH).Some leadership changes are expected. Sen. Patty Murray, previous chair of the Senate HELP Committee, is expected to become the head of the Senate Appropriations Committee. The Senate HELP Committee will likely be led by Sen. Bernie Sanders (I-VT) and Sen. Rand Paul (R-KY) or Sen. Bill Cassidy (R-LA). The Senate LHHS subcommittee may be led by Sen. Joe Manchin (D-WV) and Sen. Marco Rubio (R-FL). Both 2022 GHTC Innovating for Impact award winners, Sen. Sherrod Brown (D-OH) and Sen. Todd Young (R-IN) retained their seats.  A potentially challenging landscapeWith Democrats elected to retain control of the Senate in the 118th Congress, leadership in both parties of the current Congress may be more interested in passing an end-of-year funding package so that the 118th Congress can begin with a clean slate. The same may not be true next year, though. If Republicans have a slim majority in the House as projected, it could empower more conservative members to dangle threats to regular governance, such as annual passage of an appropriations package, as bargaining chips—a threat some members have already referenced. Such a dynamic may also lead to hardball negotiations over raising the debt ceiling, a final agreement on which is due in July of next year. Ultimately, these dynamics could limit the potential for global health R&D funding growth in the next two years, despite the need for greater resources. Beyond the funding picture, if Republicans win control the House, they plan to increase oversight over many US government agencies, including several public health and research agencies such as the National Institutes of Health and the Centers for Disease Control and Prevention. Oversight over the executive branch is a critical function of Congress, but aggressive oversight can also threaten the basic functioning of these agencies as staff efforts are redirected. This could ultimately impact the pace of progress for global health research and science in general.Looking aheadGlobal health R&D has historically received bipartisan support, yet this will be the first Congress to be seated after the COVID-19 pandemic, a global health catastrophe that has provoked some policymakers to question the value of certain types of research and the global health status quo. The results of this election are still being finalized, but regardless of who is in charge, there will remain opportunities for crafting and passing good policy. Whether progress happens and at what pace will largely depend on the ability of advocates to make the bipartisan case for why global health R&D is a force multiplier for creating a healthier and safer future for Americans and all global citizens.  

Interested in more global health innovation news? Every week GHTC scours media reports worldwide to deliver essential global health R&D news and content to your inbox. Sign up now to receive our weekly R&D News Roundup email.Last week, the Coalition for Epidemic Preparedness Innovations (CEPI) announced plans for a US$1.76 million investment to advance and expand the scope and technology of the Spillover app, a platform created at the University of California, Davis that could be key to identifying and preparing for “Disease X,” a virus with pandemic potential that has yet to be identified. The platform includes a database with more than 500,000 samples from an estimated 74,000 animals in 28 different countries around the world, and CEPI’s investments will further its capabilities to identify viruses that are most likely to spill over to humans. The platform is hoping to use that data to prioritize and streamline investments in a library of vaccines, aimed at protecting against the viral families that pose the greatest threats, that are ready to be adapted against “Disease X” within 100 days of its identification.South Africa will begin piloting a new every-other-month HIV prevention shot as new modelling released last week showed that the shot could prevent as many as 52,000 new infections over the next 20 years if rolled out nationally. The pilot will begin after approval from the South African Health Products Regulatory Authority, which is expected early next year. Two large clinical trials found that the shot was more effective than the oral HIV prevention pill, Truvada, in part because it is taken much less frequently than the daily pill. However, the shot will only be available, at least in the short-term, in small pilot projects, and the high price is still a major barrier to the product being cost-effective in South Africa.Results from the STREAM clinical trial, shared last week at the Union World Conference at Lung Health showed that two shorter treatment regimens for multi-drug resistant tuberculosis (MDR-TB) including a fully oral nine-month bedaquiline-based regimen and a six-month injection-containing regimen have been shown to be safer and more effective that the nine-month regimen, which combines pills and injections, that is still in wide use. The STREAM trial was the largest-ever MDR-TB trial ever conducted with more than 1,000 participants across eight countries. The findings from the trial strengthen the evidence for bedaquiline as a component of improved drug-resistant therapies (bedaquiline is also a component of the six-month BPaL and BPaLM regimens, which were endorsed for use against most forms of drug-resistant tuberculosis in the World Health Organization's rapid communication on tuberculosis treatment guidelines released earlier this year).