The Asco Post

The Future of Biomedical Research
A Conversation With Francis S. Collins, MD, PhD

By Jo Cavallo
March 1, 2014, Volume 5, Issue 4

Figures:

“After 3 years of congressional gridlock in terms of support for scientific research, we have seen the first evidence that the parties can get together and formulate a plan. It’s not a perfect plan, but it certainly portends some chance of moving forward to do something better.”
—Francis S. Collins, MD, PhD

In January, Congress approved a $1 trillion appropriations bill for the rest of fiscal year 2014. While the new bill includes $29.9 billion for the National Institutes of Health (NIH)—$1 billion above FY2013 levels after sequestration—including $4.9 billion for the National Cancer Institute (NCI), it does not restore NIH funding to presequestration spending levels. In addition, the budget leaves the NIH with about 10% less purchasing power in current dollars compared to FY2007.

In a wide-ranging interview with The ASCO Post, Francis S. Collins, MD, PhD, Director of the National Institutes of Health, addressed the impact that budget stagnation is having on biomedical research and on the careers of young investigators, his optimism for the future, and the outlook for improvements in global health care.

Impact of Sequestration

Please talk about the short-term impact sequestration has had on biomedical research.

The impact in fiscal year 2013 was extremely damaging. ASCO conducted a survey1—as did others, including the American Society for Biochemistry and Molecular Biology (ASBMB)2—showing that scientists trying to do research found this to be an extremely difficult period. Some had to cut back on projects, some had to let people go, and some found that even though their research was very exciting, it was unfundable. Last year has been the worst year on record, I think, in terms of the ability of scientists to get their work supported through NIH, with the success rate of grant applications plummeting down to about 16%.

Turning a Corner

What steps are being taken to adapt to the budget limitations in biomedical research?

First, let me say that while I would love to have seen an even better uptick in support in FY2014 compared to FY2013, it is a relief to see that after many years of a downward spiral in real support for NIH, we seem to have finally turned a corner. All those watching this situation should be grateful to House Appropriations Chair Congressman Hal Rogers (R-KY) and Senate Appropriations Chair Senator Barbara Mikulski (D-MD) for working out a genuine appropriations process, as opposed to the gridlock that has led us successively downward in terms of financial support.

One hopes that this turning of the corner will portend an upward trajectory going forward in FY2015 and beyond. The latest action only recovered slightly more than half of what NIH had lost in the sequester, so we are still going to have fewer resources in FY2014 than we did in FY2012. That will stress the system in very serious ways as we try to prioritize and support the very best science.

Clearly, success rates for grant applicants will get a little better than they were in FY2013 but not dramatically so. We at NIH are doing everything we can with these resource constraints to try to keep this amazing engine of discovery moving forward. We are particularly concerned that early-stage investigators may not be in a situation to get their research programs going. To address this, we will continue the process of having first-time investigators compete against each other in peer review instead of going up against the entire pool of research applicants. This seems like a fairer way to give them a chance to get started.

We are also looking at the current organizational structure of our peer-review system to see if there are ways to assess how well it meshes with today’s areas of greatest scientific opportunity, or whether we need to do some rethinking about how peer-review study sections are organized. But that’s a complicated question.

In circumstances where we really want to encourage people to be innovative and take risks, we are looking at whether we should consider investing a somewhat larger proportion of our research dollars into programs like the NIH Director’s Pioneer Award Program, which we have now been funding for about 10 years. Those awards allow individuals who have a groundbreaking idea, but haven’t yet developed a whole raft of preliminary data, to come forward and seek support to pursue the idea.

Those awards, which are for up to a half-a-million dollars per year for 5 years, have produced pretty impressive results. Perhaps we ought to think about expanding that model beyond a rather small program in the NIH Common Fund, which is coordinated by my office, to some of the other NIH institutes.

Making the Most of Funding

Is the NIH experiencing a loss in younger researchers, especially cancer researchers?

Yes, and it is true across the board. The way in which the sequester was applied provided no flexibility to move money around within the NIH. We had to apply the same 5% cut to all of the institutes, including the National Cancer Institute. There was no chance to prioritize anything at that point.

Cancer research right now is at an incredibly important juncture. It’s exciting to see the revelations coming forward in basic, translational, and clinical cancer research. I would love to see this effort move forward at the pace that it could with better funding, instead of being hobbled by the current resource constraints.

We are going to be forced to be very creative in trying to make the most of the dollars that are available because—at least for this year and next year—it’s unlikely that we are going to see significant relief from the stress on the system that has been increasing over the past 10 years.

Greatest Concerns

What worries you most about the effect the reduced budget will have on advances in biomedical medicine?

I worry the most about our most critical resource, which are the people. I worry that the scientists who have great ideas—who are energized and inspired about coming up with answers to how life works and how disease occurs—will increasingly be discouraged and demoralized. I worry that these scientists will become reluctant to take risks in their research because of concerns that their efforts won’t be supported.

I worry that these scientists will begin to seriously consider doing something other than research as their primary career choice. The ASBMB report documented that about 18% of the people surveyed were seriously considering going to another country to do their research. And it might be better for them.

At the moment, the United States is unique in the way medical research has been suffering cutbacks. The rest of the world looks at the United States as a role model and is trying to replicate our success, but we seem to have forgotten that success and what it took to achieve it.

Looking Ahead

Are you optimistic about the future of biomedical research in the United States?

I think that there is room for guarded optimism. After essentially 3 years of complete congressional gridlock in terms of support for scientific research in the United States, we have now seen the first evidence that it is possible for the parties to get together and formulate a plan. It’s not a perfect plan, but it certainly portends some chance of moving forward to do something better.

I’m convinced that our case, which is a strong one, will be listened to, and the value of biomedical research, including cancer research, will be seen for what it is: an incredibly important means to learn new ways to prevent and treat disease, which will reduce our health-care costs and offers a great way of stimulating the economy.

I think that message is increasingly being heard in important places like the U.S. Congress. I am hopeful—although I must admit to being a diehard optimist—that this will result in getting NIH back on a stable funding trajectory in the next couple of years, a trajectory by which researchers will have some sense of what they can count on for support, instead of the crazy roller-coaster budget ride that we’ve been on.

Progress in Global Health

You attended the World Economic Forum in Davos, Switzerland, where the focus was on global health. What was the consensus on the state of global health?

I’ve been going to the World Economic Forum almost every year for the past 18 years. It was interesting this year because the mood was more optimistic than it’s been in the previous 3 or 4 years, since the beginning of the world economic downturn.

This time, it seemed as if the participants were generally supportive of the idea that an economic corner had been turned. So, we could talk more optimistically about proactive things the world could do to make people, particularly those from countries with limited resources, have a better chance at a full and happy life.

There was a lot of conversation about global health advances and what could be done to further accelerate progress. It’s gratifying to see that progress. I think that not everybody is aware of what’s happened over the course of the past decade or more in terms of improvements in longevity around the world.

I think also that many people don’t know that a major factor contributing to these improvements is the improved control of communicable diseases, such as HIV/AIDS, malaria, and tuberculosis. Although we still have a long way to go with these diseases, we are making progress.

Now, it’s the noncommunicable diseases including cancer that are emerging as the fastest growing causes of mortality and morbidity around the world. So in Davos, there were a lot of conversations about whether we have a plan in place to address these health problems. One suggestion put forward by some of us was to build upon the health delivery systems that were established to deliver antiretroviral therapy. Perhaps we can turn those systems into more comprehensive health-care delivery options to provide good preventive care and treatment for diseases like hypertension, diabetes, and cancer.

There was also a sense in Davos that we should stop thinking so much about health as a cost. We should think about health as an investment. Even in low-income countries, there is very strong evidence that if you invest in improving the health of the population, the economy will respond positively because you will have more of your citizens who are physically able to work.

Furthermore, if you reduce childhood mortality, experience shows that almost inevitably there is a drop in the fertility rate, because couples decide that they don’t need to keep having more children in order for some of them to make it to adulthood. That translates into what’s called the “demographic dividend,” where a higher proportion of a nation’s population is working instead of being dependent (as young children would be).

All of those points on health, which I don’t think had been emphasized as much in previous meetings, were front and center at this year’s World Economic Forum.

Dr. Francis S. Collins is Director of the National ­Institutes of Health.

Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO.

References

1. American Society of Clinical Oncology: Impact survey: Federal funding cuts to cancer research. September 2013. Available at:
www.asco.org/sites/www.asco.org/file/results_of_asco_federal_research_funding_survey.pdf.

2. American Society for Biochemistry and Molecular Biology: Nondefense discretionary science, 2013 survey: Unlimited potential, vanishing opportunity. Available at www.asbmb.org/uploadedFiles/Advocacy/Events/UPVO%20Report%20V2.pdf.

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