Breakthroughs Blog: Congress

Last Friday, President Donald Trump signed into law a US$1.3 trillion spending bill to fund the US government through the rest of fiscal year (FY) 2018. Reluctantly signed by the President among a flurry of “will he, won’t he” tweets, the legislation represents a forceful rebuke by Congress of the Administration’s proposal to drastically slash funding for global health and medical research programs. Key US agencies and programs that advance global health research and development (R&D) not only saw their funding protected in the spending bill, but many also saw increases. This outcome demonstrates that our community’s appeals and messages have not fallen on deaf ears and that Congressional policymakers on both sides of the aisle want to see the United States continue its leadership in advancing innovation to improve the health of those in need around the world. Here are some of the key takeaways from the 2,000+-page bill: US Agency for International Development & State Department While the Trump Administration proposed slashing funding for global health programs at the US Agency for International Development (USAID) and the State Department by 25 percent, Congress stood firm in protecting these programs. The bill ultimately sustained overall funding for these programs at FY17 enacted levels. A few programs received increases including a boost of $15 million for GAVI, the Vaccine Alliance; $20 million for tuberculosis (TB); and $15 million for maternal and child health. Funding for USAID HIV and AIDS programming and family planning at State and USAID, which the President proposed eliminating fully, was protected at FY17 levels. Congress also directed $135 million from repurposed Ebola emergency supplemental funding to support USAID’s global health security programs.   USAID plays a leading role in developing health technologies for low-resource settings through its various global health programs, so it is critical that these programs receive adequate funding, so they can continue to prioritize R&D among their other activities. In light of the President’s proposal for deep cuts to these programs, a combination of level funding for some programs and increases for others is a positive sign in the midst of a challenging budget environment. National Institutes of Health   Strong bipartisan support for the National Institutes of Health (NIH) continued for FY18. While the President proposed a 21 percent cut to NIH funding, the final spending bill instead provided the agency with an increase of $3 billion—8.8 percent—over FY17 levels. This represents a historic funding high for NIH in actual dollars with increases spread across various NIH institutes and programs. Notably, the National Institute of Allergy and Infectious Diseases received a 7.2 percent increase—39 percent above the President’s FY17 request—while the Fogarty International Center, which was targeted by the Administration for elimination, received a boost of 5.2 percent compared to FY17.   NIH is the world’s leading funder of R&D for neglected diseases, providing approximately 40 percent of total global funding, so any changes to its funding produce a ripple effect felt by global health research institutes and people around the world. It is encouraging to see Congress continue its record of bipartisan support for NIH and take action to strengthen our nation’s leadership in medical research. Centers for Disease Control and Prevention   The US Centers for Disease Control and Prevention (CDC) also received a plus up in the FY18 omnibus. The agency saw its funding increased by $1.1 billion—nearly 15 percent—over FY17 levels. This was in sharp contrast to the 16 percent cuts proposed by the Administration. The CDC Center for Global Health (CGH) received a 12 percent increase, compared to a 21 percent proposed cut. This included a $1.5 million boost for parasitic disease and malaria and a substantial increase of $50 million for global health security programming, which supports implementation of the Global Health Security Agenda (GHSA). Funding for global immunization and AIDS programming within CGH remained level. The National Center for Emerging and Zoonotic Infectious Diseases also received a more modest 5 percent increase over FY17 funding.   CDC plays a critical role in advancing technologies and improving health systems to better detect, prevent, and respond to infectious disease threats worldwide. There was much concern surrounding the FY18 budget for CDC as the agency is facing a funding cliff. CDC and USAID received $1 billion from the Ebola emergency supplement to fund GHSA, but this money is set to run out in 2019. As a result, the agency has already announced plans to scale back its GHSA work in 39 of 49 countries. While more funding is still needed to sustain these programs, and the agency has yet to clarify how it will adjust programming in light of its FY18 appropriations; it is promising to see Congressional appropriators recognize the value of CDC’s engagement in improving global health security. Biomedical Advanced Research and Development Authority   The Biomedical Advanced Research and Development Authority (BARDA), which develops medical countermeasures against health threats including emerging infectious diseases and antimicrobial resistance (AMR), also received a boost in the FY18 spending bill. The agency saw its funding increased by $25 million—about 5 percent—over FY17 levels.   BARDA has played an increasing role in R&D for naturally occurring threats and emerging infectious diseases in response to the Ebola and Zika epidemics. With its focus on bridging the “valley of death” in product development and its ability to use unique contracting mechanisms to forge innovative and long-term private-sector partnerships, BARDA is well positioned to make an impact in this space. However, the agency has been constrained by a lack of dedicated funding for its emerging infectious disease portfolio. While it is promising to see appropriators increase the agency’s overall funding for FY18, GHTC will be pushing for more dedicated funding for emerging infectious diseases in FY19. Department of Defense   The Department of Defense’s (DoD) activities in infectious disease research also saw increases in the omnibus. DoD’s Peer Reviewed Medical Research Program—a program that conducts research on AMR, diarrheal diseases, emerging infectious diseases, malaria, TB, and vaccine development for infectious diseases—received $330 million in funding, which is an increase of $30 million over FY17 levels.   The FY18 spending bill is a big win for global health R&D stakeholders and advocates, but this victory may only be temporary. The legislation funds the government through the end of September, and the Trump Administration has once against proposed drastic cuts to global health and medical-research programs for FY19. So while the ink dries on this year’s spending bill and we take a moment to celebrate, GHTC is already gearing up for another difficult battle ahead on next year’s budget.

  2018 is shaping up to be another important year for US policy related to global health and medical research. As Congress returns for a busy work session and the White House continues to roll out policy reforms, here are the top five issues GHTC will be following in 2018: 1. US funding for global health R&D President Trump’s fiscal year 2018 (FY18) budget proposal called for dramatic cuts to global health, medical research, and public health accounts across the National Institutes of Health, US Centers for Disease Control and Prevention, US Agency for International Development (USAID), and the Department of State. While legislators pushed back sharply on these proposed cuts, Congress has not yet passed final FY18 spending bills. This means that we still do not have a final picture of what US government funding for global health and medical research will look like for this year. As Congress tries to navigate budget caps and other pressures that may constrain overall government spending, GHTC will continue to advocate for strong, stable public funding for critical global health and medical research programs. We’re also looking ahead to the fiscal year 2019 (FY19) budget and appropriations process, and bracing for a proposal from President Trump that may include even more significant spending cuts than those proposed in FY18. Despite verbal acknowledgement from the Trump Administration that US global health and medical research programs remain critically important, as the Administration continues plans to streamline government activities and reign-in spending, we do not expect to see prioritization of these issues reflected in Administration-driven spending proposals. GHTC will closely monitor FY19 proposals in the coming months and continue to engage with Congress, who ultimately sets government spending levels. 2. USAID and State Department reorganization As part of the Trump Administration’s plans to streamline and reshape the federal government, it has announced plans to reorganize the State Department and USAID. USAID plays an important role in global health research and development (R&D), supporting late-stage clinical research and implementation research as well as operating Grand Challenges to identify and advance promising health innovations from around the world. USAID and the State Department submitted reorganization plans to the White House Office of Management and Budget on September 15, 2017, but details of those plans have not yet been made public and further information remains scarce. GHTC will continue to monitor evolving plans and policy and strongly advocate for continued leadership of USAID in global health innovation. 3. BARDA reauthorization The Pandemic and All-Hazards Preparedness Act (PAHPA), which authorizes the Biomedical Advanced Research and Development Authority (BARDA), is due for reauthorization this year by Congress. In recent years, BARDA has played an increasingly important role in the advanced development of medical countermeasures for emerging infectious diseases, like Ebola and Zika, and antimicrobial resistance. Reauthorization presents a potential opportunity to bolster BARDA’s role in the global health R&D space. GHTC will monitor the PAHPA reauthorization process and work with Congress to support a strengthened role for BARDA in the emerging infectious disease space. 4. Global health security GHTC is also watching US efforts to promote global health security, including continued support for the Global Health Security Agenda (GHSA)—an international partnership launched in 2014 to help countries strengthen their ability to respond to health threats. The United States is now funding GHSA through the one-time emergency Ebola supplemental funding, which expires in FY19, so future financing for the program remains uncertain. Without renewed commitment and financial support for global health security activities, the United States will have to pull back critical disease detection, prevention, and response operations around the world. GHTC will also work to include R&D in global health security policy decision-making. During the two most recent global disease epidemics, Ebola and Zika, a lack of proactive, sustainable funding for R&D meant that United States and the world did not have the drugs, diagnostics, and other tools needed to contain these diseases. Despite this, GHSA in its current form lacks any prioritization or commitment to R&D to detect, prevent, and respond to global epidemics. As domestic and global discussions on global health security continue, GHTC will advocate for R&D as a critical component of epidemic preparedness and response. 5. US engagement with key multilateral bodies Multilateral organizations and partnerships are vital mechanisms to help advance a healthier and more secure world. In our modern and increasingly globalized world, new, emerging, or long-standing health challenges, which do not respect borders, cannot be tackled by individual countries alone. Strong US leadership and funding for organizations like the United Nations (UN), the World Health Organization, and the Global Fund to Fight AIDS, Tuberculosis and Malaria are key to advancing global health and ensuring that these organizations function effectively in support of US priorities. Despite several senior Trump Administration officials expressing support for strong multilateral engagement, the United States’ role in pushing for a recent $285 million cut to the UN’s overall budget appears more indicative of how the United States can be expected to engage in the near future. While it is currently unclear exactly how these cuts will be implemented across the various UN health-related programs, GHTC anticipates significant impact on the various UN technical agencies’ ability to support global health, including R&D. GHTC is committed to leading strong, coordinated action to advance US leadership in global health R&D in 2018 and beyond. The United States has long been a leader in global health, development, and medical research, and we look forward to sustaining and bolstering this legacy in the years ahead.  

Over the past seven decades, the US Centers for Disease Control and Prevention (CDC) has played a vital role in global health, responding to the world’s most deadly disease outbreaks and advancing critical research that promotes health and security of communities around the world while protecting the lives of Americans.This makes it all the more distressing to see the US Administration and Congress call for significant cuts to CDC in Fiscal Year 2018 (FY18).The President’s FY18 budget proposal called for US$1.2 billion in reductions for CDC, including over a $100 million cut to CDC’s global health work. While the House of Representatives did not propose the same cuts—and largely supported CDC’s global health activities—the House is still considering a $200 million cut to CDC’s topline funding, straining key operations that protect Americans from deadly threats.Here’s why CDC’s operations are vital, and why cuts would severely curtail critical activities that protect everyone, including Americans:1. CDC is the world’s leading disease surveillance program. CDC responders, including former director Dr. Tom Frieden, exit an Ebola treatment unit in Monrovia, Liberia, during the 2014 West African Ebola outbreak. Photo: Sally Ezra/CDCCDC’s Emergency Operations Center (EOC) in Atlanta is at the forefront of tracking disease outbreaks and public health events both within the United States and abroad. Since its inception in September 2001, the EOC has responded to more than 60 public health threats around the world including Ebola, Zika, and anthrax. The surveillance and tracking data generated inform states, other countries, and international bodies like the World Health Organization as they make critical decisions on response and intervention. 2. CDC trains and deploys “disease detectives” to stop outbreaks faster. CDC plays an unparalleled role in training and deploying epidemiologists and other “disease detectives”—US citizens and those in partner countries—to monitor and respond to infectious disease threats. CDC’s Global Rapid Response Team of 350 US public health experts is ready to deploy anywhere in the world on short notice. Their Field Epidemiology Training Program has trained more than 3,100 people in over 72 countries, ensuring that experts are present and prepared to keep deadly outbreaks from turning into pandemics on US shores.3. Scientists at the CDC lead long-term research in deadly and unexplained diseases to ensure we understand long-term effects and develop the best treatment methods. A CDC researcher works with an HIV sample to extract DNA. Photos: CDC/James Gathany.Though the Ebola outbreak in West Africa has subsided, scientists from CDC’s National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) continue to conduct follow-up studies with survivors to learn what long-term symptoms they face, how long the virus can persist, and how some people are better able to survive Ebola. This work is important so that we are better prepared when and if there is another Ebola outbreak. 4. Their overseas labs lead the world in disease discovery and learning. Since 2005, CDC’s 10 Global Disease Detection Centers have discovered 12 pathogens and organisms. These discoveries help us understand new diseases and disease mutations, and protect all of us from emerging diseases. 5. CDC pioneers cutting-edge research and development of innovative diagnostics for infectious diseases. For instance, CDC HIV and AIDS labs created a novel diagnostic that can identify if a person is HIV positive and, for the first time, if the infection is recent or longstanding. This innovation promises to be a game changer in efforts to end the AIDS epidemic through better, more rapid contract tracing to contain the virus’s spread. NCEZID also developed the Triloplex test early in the Zika outbreak that detects and differentiates between three similar mosquito-borne viruses: Zika, dengue, and chikungunya.6. They’re a critical partner in flagship US global health programs. In June, a group of global health advocates led by the Global Health Council, Global Health Technologies Coalition, and PATH visited the CDC headquarters in Atlanta, Georgia, to learn more about the agency’s work in global health. Photo: PATH.CDC’s contributions to the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2015 provided antiretroviral treatment for 5.8 million people, prevented mother-to-child transmission of HIV in over 420,000 women, and supported voluntary male circumcision to prevent the spread of the virus in more than 1.3 million men. CDC’s PEPFAR work has also supported lab quality improvements in more than 1,000 labs worldwide, expanded access to HIV screening, and helped countries build better HIV surveillance systems. 7. CDC’s global work has health and economic benefits to Americans at home. CDC’s global health security work helps 49 countries detect, prevent, and respond to emerging outbreaks of diseases—which not only protects citizens of these countries but also prevents diseases from entering the US. This important work also helps strengthen economies overseas and develop trading partners for the US. According to 2015 US Department of Commerce data, all 49 global health security partner countries spent over $308.5 billion annually on American exports, supporting 1.6 million American jobs.As the US Senate considers FY18 funding for CDC, we hope they will recognize that CDC’s work to protect global and American health is unique, matters, and warrants robust funding. Ongoing investment is critical to maintain CDC infrastructure at home and overseas, which gives us the capacity we need to respond to diseases we know—and those we haven’t heard of yet. Without appropriate funding, we risk losing ground in our global fight against infectious diseases—and we risk lives.

On Tuesday, the Trump Administration released its full fiscal year 2018 (FY18) budget proposal, “A New Foundation for American Greatness.” As foretold by the “skinny budget” proposal released in March, this budget proposes dramatic increases in defense spending and border security, offset by cuts to discretionary spending—including significant cuts to programs that support global health and medical research at the National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), and the US Agency for International Development (USAID). Dramatic cuts to global health programs at the State Department & USAID At a high-level, President Trump proposed roughly a 25 percent cut to global health programs at the State Department and USAID, when compared to final fiscal year 2017 (FY17) funding levels. Looking just at USAID global health programs, funding levels were reduced over 50 percent from FY17 levels, from US$3.05 billion to $1.5 billion. The Administration also used the budget proposal to advance goals of streamlining USAID and State Department operations to find cost savings and efficiencies. Despite strong bipartisan support for the United States’ flagship global HIV and AIDS program, the President’s Emergency Plan for AIDS Relief (PEPFAR), HIV and AIDS programs across State and USAID were targeted for cuts and consolidation. Direct funding for PEPFAR through the State Department received a $477 million cut, dropping to $3.85 billion from $4.32 billion, and USAID funding for complementary HIV and AIDS programs was zeroed—reflecting a funding cut of $330 million. The zeroing of HIV and AIDS programs at USAID also means associated research and development (R&D) funding for HIV vaccines and microbicides was eliminated. Man and woman standing in front of a sign that reads "USAID." (PATH/Felix Masi)Other funding cuts include a $62 million cut to global tuberculosis (TB) programs—including cuts to the TB drug facility and multidrug-resistant TB financing—a $65 million cut to maternal and child health programs, a $47 million cut to nutrition programs, and a $25 million cut to programs for neglected tropical diseases. USAID malaria programs (the President’s Malaria Initiative) received an $81 million cut, after factoring in a proposed $250 million transfer of remaining Ebola funds. USAID family planning programs were eliminated.Slashed funding for medical research at NIH and public health protection at CDC Biomedical research also saw significant cuts, with a proposed $7 billion or 21 percent cut to NIH. Of particular importance to global health R&D, the Administration proposed a $1.1 billion cut to the National Institute for Allergy and Infectious Diseases—which leads research in infectious diseases like HIV and AIDS, Ebola, and Zika—and elimination of the $70 million Fogarty International Center, which builds partnerships and trains researchers around the world. Instead, the Administration allocated $25 million to the Office of the NIH Director to coordinate global health research. At the CDC—our lead agency for preventing, detecting, and responding to public health threats at home and abroad—overall budgets were cut by $1.3 billion, over 15 percent. This included a $70 million cut to CDC’s National Center for Emerging and Zoonotic Infectious Diseases and an $85 million cut to the Center for Global Health.What happens next for global health R&D?These broad and wide-ranging cuts proposed for global health and medical research programs are deeply concerning, and threaten to reverse gains achieved through our landmark global health programs, stall progress in promising research, and ultimately jeopardize lives at home and abroad. They also are in stark contrast to stated goals of the Trump Administration to honor our commitments to global health, bolster global health security, and support high-priority biomedical science.Fortunately, Congress has ultimate control over government spending, and leadership on both sides of the aisle has asserted that dramatic cuts to foreign aid, global health, and medical research will not pass muster. As FY18 negotiations continue in Congress, GHTC will continue to stress the importance of global health R&D programs across the US government and highlight the critical role US-supported research plays in saving lives at home and around the world.