- BIOETHICS FORUM ESSAY
The Missing Piece: The Need for NIH Reform Is Pressing, but Ignored
Two recent bits of news, each barely noticed in the avalanche of economics and electioneering of the past few weeks, combine to raise troubling questions about the future of America’s biomedical research enterprise.
In late September, Elias Zerhouni, the director of the National Institutes of Health, announced his forthcoming departure from the agency after six years at its head. Zerhouni has been an adept and able manager of the massive biomedical research funding entity, seeing it through the completion of the doubling of its budget and the leaner days that followed, navigating complex conflict of interest concerns at the increasingly complex juncture of private and public research, and walking a line (if not always successfully) between his support for embryo-destructive research and his duty to a president who disagreed.
But Zerhouni has also been a staunch and very effective opponent of fundamental structural reform at NIH. Again and again, the Office of Management and Budget proposed streamlining the agency’s bulky and wasteful institutional design, and again and again Zerhouni would masterfully outmaneuver them in internal administration discussions – offering modest changes (like the establishment of a common fund) in place of large reforms. I was witness to several of these iterations as a White House staffer, and was always left impressed with Zerhouni’s finesse, but also worried that needed reforms were not carried out. Zerhouni defended his agency’s prerogatives and practices, and one could hardly blame him, but in the process the cause of American medical research likely was set back.
One striking feature of these internal negotiations was the degree of reticence among senior research scientists and administrators to support reform. In private, one would hear complaints about NIH inefficiencies, but in public there were few serious calls for change.
This is where the second bit of recent news comes in. Last month, ScienceDebate2008, a coalition of research advocates that had earlier pressed for formal public debates about science policy, released the results of a questionnaire they had submitted to the two Presidential campaigns. The document addressed fourteen questions to McCain and Obama and offered their answers side by side.
The questions and answers mostly confirmed the sense – which both campaigns at least implicitly shared – that a public debate on science would not have been a good use of the candidates’ time. The questions were general, the answers were predictable, and there was very little disagreement or controversy. Even on the hot button issues of science policy – like stem cell research and global warming – these two candidates actually agree.
Perhaps the most notable element of the exchange, though, was the absence of any discussion of institutional reform of America’s science funding bureaucracy. The candidates were asked for their general approach to encouraging American innovation in science and technology, and for their general attitude regarding research funding, but they were not asked to remark on the efficiency or effectiveness of America’s research funding enterprise. Neither the scientific community nor these policy makers showed much interest in institutional reform.
Such reform is badly needed, especially at the NIH. The agency has been through a complicated decade, seeing its budget double between 1998 and 2003 – an effort spanning four Congresses and two presidents – but then inevitably entered a period of far slower growth. The doubling, which was a politically appealing gimmick, was very poorly thought out as a matter of fiscal and institutional planning, and in retrospect looks clearly to have been far too rapid, and inadequately tied to structural reforms that might enable NIH to best make use of its resources.
The steep growth in spending, roughly 15 percent per year for five years, built expectations and momentum that set the agency up for disappointment when the doubling was done. Research institutions used the added funds to initiate new projects, support many more graduate students, and establish more programs and labs. But these all require continuing support beyond the five-year doubling period, which meant that once the steep increases were done and the NIH budget returned to normal growth rates of about 3 percent per year (rates many other agencies would jump at), an enormous portion of the budget went towards continuing support for projects established in the fat years, and not enough was left to fund new ventures.
The glut of graduate students enticed by growing support a few years ago has found it difficult to get their own work funded once they finished their training, and the sudden deceleration in funding has left many researchers feeling slighted even though their funding has grown by leaps and bounds. Slower growth over a longer period would have offered a far more stable and sustainable means of expanding the American biomedical research enterprise.
Moreover, even during those five years of rapid growth, the NIH did not use its expanding resources to broaden the field of funded institutions and programs. While the size of the average NIH grant grew significantly during that period (the average size of an individual investigator grant grew by nearly 25 percent), the pool of institutions receiving funding hardly changed at all. As the Chronicle of Higher Education found in reviewing lists of NIH grantees in the wake of the doubled budget, of the 515 institutions receiving direct grants to investigators in 2003, only five had not been receiving such grants prior to 1998. Moreover, the portion of grants going to the top 100 research institutions in 2003 was 92 percent, exactly the same as it was in 1998. In other words, more NIH funding meant more money for the same relatively small cadre of elite institutions, and even there it contributed to a surplus of new projects and researchers that quickly became burdensome once the growth spurt ended.
The blame for expanding the NIH budget too quickly rests largely with Congress, and especially Senators Specter and Harkin, who preferred the symbolic “doubling in five years” to a more sensible course of slow and steady sustainable growth. But the failure to adequately spread the wealth falls also at the feet of the NIH itself. It is particularly the fault of the agency’s exceedingly inefficient and bulky institutional structure, which wastes resources on needless duplication of administrative overhead and is so specialized that it creates overly rigid and nearly permanent channels of funding.
NIH consists of 27 different institutes, each with its own administrative staff, overhead costs, and management structure. There is one institute for the study of alcohol abuse, and another for the study of drug abuse. There is an institute for neurological disorders, and a separate institute for deafness. There are specialized institutes whose interests intersect, like the National Cancer Institute and the National Heart, Lung, and Blood Institute; or the National Institute of Arthritis, Musculoskeletal, and Skin Diseases and the National Institute on Aging. And there are institutes with generic support purposes – the National Library of Medicine, the National Center for Research Resources, the Center for Scientific Review, the Center for Information Technology, and others – that are not collected under a single administrative umbrella.
This proliferation of institutions not only duplicates administrative costs, it also creates excessively specialized avenues of funding, and with them relationships between the NIH institutes and their supported research labs that inherently constrain the scope of potential NIH grantees.
These structural problems have a lot to do with the politics of medical research funding. Powerful patient groups, or those with the backing of a particularly influential member of Congress, can exercise great sway over the workings of NIH through legislation, even creating a special institute to focus on their particular concerns. Any proposal to consolidate, moreover, is inevitably described as a cut in funding for research on the relevant ailment or condition, and so is simply a non-starter.
A reasonable consolidation would serve the interests of medical research by freeing up more dollars to support actual work in the labs, and would make the agency easier to manage and direct. Consolidation could take a variety of forms. A modest effort might combine several particularly duplicative institutes – the ones for alcohol abuse, drug abuse, and mental health, for instance – and eliminate those institutes devoted to support and administration, moving their functions into the director’s office. A more ambitious effort would seek to organize the work of NIH along just a few broad categories of research, like brain science (or neurology), internal medicine, and public health. Some duplication would persist in any scheme, of course, but a few institutes with broad mandates, rather than numerous overspecialized bodies, would encourage interdisciplinary work and permit new categories of research to emerge. Such reforms could make for both greater efficiency and less rigid channels of funding to the same seasoned investigators.
Intelligent reform of the agency would do far more for American biomedical research than a crude injection of funding, of the sort both presidential candidates have promised. But the impetus for such reform must come from the scientific community; it will not come from policy-makers too fearful of finding themselves besieged by patient groups.
The National Academies would be an ideal source for a thoughtful, detailed, and pragmatic institutional reform proposal. This would require some of those who benefit from the current inefficiency of the NIH to put the larger cause of medical research above their own budgets. Such selflessness is rare and difficult, but it is crucial now, and the beginning of a new administration – regardless – of who wins the November election – is the ideal time for a reform proposal.
Yuval Levin is a fellow at the Ethics and Public Policy Center and senior editor of The New Atlantis. His new book Imagining the Future: Science and American Democracy will be published later this month.
Published on: October 3, 2008
Published in: Health Care Reform & Policy