The Trump Administration, Congress, and the Future of Global Health Funding
The recent budget proposals from the Trump administration have generated real concern for the future of global health funding, and for one the key engines of innovation in global health, the biomedical research enterprise. There is no question that biomedical advances are at the heart of our remarkable advances in global health. Child survival gains are dependent on immunization programs, and they in turn, on vaccine research and development, which in turn depends on basic research in immunology and virology. The U.S. PEPFAR program has been so successful because antiviral therapy is so effective--as both treatment and prevention for HIV infection--and the development of that effective therapy required both a great deal of basic research on the HIV virus, and some 800 clinical trials, largely funded by the U.S. National Institutes of Health, to achieve.
The U.S. NIH is the largest, and by far the most essential supporter of biomedical research worldwide. Continued investment in the NIH is vital to furthering health gains and to sustaining the next generation of researchers. But how to we speak that truth to the key decision makers in this new political reality? The Administration’s proposals to cut federal funding for the NIH by some 18 percent for next year (the “Skinny Budget,”) and by 1.2 billion $USD in this year’s allocation, largely by reducing research grants, are only the start of engagements with the Congress and with the American people.(1) But as policy position statements, these proposals are radical, unprecedented, and markedly inconsistent with the public and with the Congress. The previous Congress, among the most divided in recently American history, nevertheless passed the 21 Century Cures Act in late 2016 with broad bipartisan support. And a republican majority House and Senate were willing to send this legislation to President Obama for signature in the final weeks of his presidency.
In communicating to the new Congress, the Administration, and to the American people, it is vital to highlight some of the key arguments in favor of sustained and expanded support for the NIH and for the US biomedical research and training enterprise more broadly. But it is also vital to underscore that this is not simply a debate about spending levels, and not just about money. The strength of the U.S. biomedical enterprise is also about the qualities of our system.
I’ve spent my career at Johns Hopkins, one of this countries’ great research universities We are a research university, and a teaching hospital. Our hospitals and clinics, our Medical School, School of Public Health, and School of Nursing are all consistently ranked among the very best of American institutions. And we are one the largest recipients of NIH research funding in health. That is not a coincidence. The reason we provide such outstanding care, and train such remarkable providers and researchers is inseparable from the NIH research enterprise. That is how our system of research support and medical advances works. NIH funds the highest priority health research through an extremely competitive peer review system, and those funds support the research that leads to improved treatments across the disease spectrum, and ultimately to better outcomes for patients and their families. Those NIH dollars also help support the training enterprise, the essential infrastructure in research ethics, data safety and storage, maintenance of labs, and all the other elements that it takes to uphold the highest levels of safety, quality, and integrity of the biomedical research enterprise.
That excellence, that greatness, is why our research universities are the envy of the world, why they continue to be enormous draws for talent, and why the health sciences remain one of the areas where the US continues to lead globally.
And, while some would argue that the enterprise has grown to large, in fact, times have been very tough. We’ve lived with flat funding across virtually the entire Obama Administration, with consequent real declines in NIH purchasing power when cost of living is factored into spending. The last real increases in NIH funding were the historic doubling of the NIH between 1998-2003. The years of flat funding have had significant impact on younger colleagues willingness to make a career in research. Cuts at the level the Administration has proposed would likely cost us the next generation of investigators.
So, what are the compelling arguments for maintaining and expanding U.S. leadership in biomedical research? And here let me acknowledge the Katz and Wright NEJM perspective out last week.(2)
There are two broad areas I’d highlight.
Return on Investment on Government supported research.
Improved health. NIH funded research has led to major reductions in deaths from heart disease, stroke, cancer, and HIV/AIDS, to name a new. Rates from all diseases dropped 43% between 1969-2013.(2)
Increased safety and value. Agency for Healthcare Research and Quality (AHRQ) has contributed to lowering hospital acquired conditions by 21% since 2010, 3 million fewer adverse events, 125,000 lives saved, estimated to save 28 billion USD.(2)
Research and Drug Development. NIH does much of the “upstream” research in R and D. more than 150 new drugs and vaccines in past 40 years, including preventive vaccines for hepatitis B, cervical cancer, and Ebola.
Biosecurity. Emerging infectious diseases know no borders, as we know. It is vital to our biosecurity to have surveillance capability where infections emerge. And that’s why an institution like the Fogarty International Center at the NIH is such a wise investment.(3)
Our System is Better
But it’s not just the resources, or the NIH support. Our competitive advantage is also because our system of peer review, of transparency and fairness, our meritocracy, is so much better for science than those of our competitors. Some consider the FDA too slow and to bureaucratic. That charge was made when intense pressure was put on the FDA to approve Thalidomide for treatment of morning sickness, which was already in wide use in Europe. When we think about dismantling the administrative state, these are the kinds of protections at stake.
I’ve done health research in China, Russia, and India to name a few competitors. In 25 years of being an NIH funded investigator, no NIH official has ever even hinted at corruption of the peer review process, or that a kickback might garner a more favorable score. Yet China has had trouble making safe infant formula, even safe pet food, because her regulatory processes are so vulnerable to manipulation, to graft, and to the influences of the powerful and politically connected.
Russia is totally out of the modern medical/public health engagement since it's system is so corrupt and politically influenced. Russian life expectancy continues to fall, and she has one of the most rapidly expanding HIV epidemics in the world—and a system which actually outright rejects evidence based medicine. That is not strength, it is profound weakness.
As some seek to reduce public sector engagement and look to private sector solutions I think it's also vital to be clear this is not and should not be an either/or. NIH has hugely supported the private sector, and universities like Hopkins and our many peers have trained their talent pool. Indeed, that’s where much of the University IDC goes—and again, there's a reason we're called a teaching hospital. And why you, and so many members of Congress, want to be at our great institutions if you or a loved one are seriously ill.
Our biomedical research institutions, and the public system that supports and sustains them, are an American treasure. The American people want advances in cancer, in Alzheimer’s, in diabetes. We want a cure for HIV and for breast cancer and for a host of other causes of suffering. And only continued investment in biomedical research can get us there.
[ For the full recording of the public roundtable event, hosted by CSIS in Washington DC on Thursday, April 6th 2017, please click here. ]
REFERENCES
1. Pear, R. Bipartisan Concern Over Trumps Plan to Cut Funding for Biomedical Research. New York Times, April 4th, 2017.
2. Katz IT, Wright AA. Scientific Drought, Golden Eggs, and Global Leadership—Why Trump’s NIH Funding Cuts Would be a Disaster. NEJM, March 29th, 2017. D01: 10:1056/NEJMp703734.
3. McNeil, DG. Muffling an Early-Warning System. New York Times, March 21, 2017.