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To reform NIH, maybe you should first understand it?

You don’t have to convince me that NIH grant funding needs to be reformed, but all this article in The Atlantic did was show that even people who get their funding from NIH (i.e. the two authors) have no clue about how NIH operates or what its mission is.

For instance, this assertion:

“… the NIH, the largest public funder of clinical trials in the United States, should also have been well positioned to create treatment guidance for doctors caring for patients hospitalized with a brand-new disease.”

is followed shortly by:

“Moreover, the NIH has mostly retreated from clinical research. By some estimates, the pharmaceutical and medical-device industries now sponsor about six times as many clinical trials as the NIH. In practice, this dynamic narrows the type of clinical-research questions being investigated; only new drugs and other products that can sell on the market receive rigorous scientific scrutiny.”

There is a hint there that Drs. Cary Gross and Ezekiel Emmanuel don’t differentiate between the NIH’s extramural activities, i.e. awarding grants to entities which are not NIH, its Intramural Research Program which conducts its own — usually high-risk high-reward and sometimes clinical — research, the individual institutes and investigators at the NIH who may contribute to creation of disease guidelines (its work on GVHD assessment is a good example), and the investigators at other institutions who and which may receive NIH funding who also contribute to those guidelines, maybe even as part of an NIH-funded grant.

The rest of the article is as jumbled. It highlights Drs. Kizzmekia Corbett and Barney Graham, correctly naming them “NIH scientists” (they were part of the Intramural Research Program when they worked on what was to become the Moderna vaccine), but as a counterpoint bring up a failing of the extramural program to fund Dr. Katalin Karikó’s mRNA research back in the 1990s. It talks about “NIH-sponsored clinical trials” without qualifying what that means (Which NIH? Financial or IND sponsorship?). It brings up the RECOVERY trial (full disclosure: I am a big fan of the trial) and faults the NIH for… not pushing for a single-payer system and unified electronic medical records that the UK has and which enabled RECOVERY, I guess?

It is clear that NIH needs to rethink its extramural funding mechanisms. Maybe make them more like the intramural program? Make some of them into a lottery (good opportunity for a randomized controlled trial there!)? Fund people not projects, as Gross and Emmanuel (and others long before them) propose?

But several attempts at reform have failed, often because of pushback by incumbent senior scientists who said that whoever proposed the change did not fully grasp what they were dealing with. And you know what: they were right. Do not attempt to reform something which you do not understand. As the first step in understanding, Matt Faherty’s 30+ thousand word report on the NIH is a good start. Mood affiliation pieces like the one in The Atlantic, not so much.