Tocsins are ringing over the Trump administration’s initial attempts to rein in the National Institutes of Health (NIH) $47 billion annual budget. Health and Human Services Secretary Robert F. Kennedy Jr. announced a 25 percent reduction in staff, amounting to 20,000 job cuts across the NIH, the Food and Drug Administration (FDA), and the Centers for Disease Control (CDC). Some 28 divisions will be consolidated into 15 to centralize functions related to addiction, mental health, and safety. Predicted annual savings are $1.8 billion. The administration has directed the NIH to terminate hundreds of research awards (out of some 50,000 a year), including over 100 ongoing clinical trials. Cuts have led to the suspension of programs like the NIH postbaccalaureate program.
A March 17 New Yorker piece, “Health Hazard,” assailed potential reductions as an attack on science itself leading to the deaths of children. The protests to all appearances are universal; not one article to the contrary. We have lost the ability even to imagine an alternative. “Creative destruction,” however it might apply here, is literally inconceivable. We cry out with one voice “to arms, to arms, we are attacked”!
The response, here, is the same as to the Administration’s broader assault on “big government”: the NIH system has become an automatic funding machine that directs tens of billions of taxpayer dollars each year to mostly the same major institutions, leading laboratories, and, in many cases, the same scientists. One happy family.
Is this the only way innovation blossoms? Did the great biomedical pioneers of history — Louis Pasteur, Robert Koch, or Alexander Fleming — advance science by reinforcing establishment ideas? They challenged conventional wisdom, broke new ground; they were not guided by government priorities. But NIH has settled into a predictable pattern: funding the most prestigious research centers year after year.
Has good work been done? Of course. But has the $47 billion a year taken from taxpayers been invested optimally?
There Was a “Before”
Before government took over biomedical research, history’s great medical advances came from independent minds. The Scientific Revolution and the Enlightenment brought forth a surge of medical discoveries, driven not by government grants but by individual curiosity, private patronage, and competitive innovation. Edward Jenner developed the first smallpox vaccine without state funding. Louis Pasteur revolutionized microbiology while working with private industry and university support. Joseph Lister pioneered antiseptic surgery through independent research.
Throughout the nineteenth and early twentieth centuries, major biomedical breakthroughs came from privately funded research, university-affiliated scientists, and industrial laboratories — not centralized state direction. The great discoveries of bacteriology, anesthesia, germ theory, and X-rays all occurred without bureaucratic funding mechanisms or grant committees deciding what lines of research were acceptable.
In the aftermath of World War II, America underwent a fundamental shift. The war had demonstrated the strategic power of science — radar, the atomic bomb, and advances in antibiotics and vaccines. Seeing this success, a few policymakers worried that a voluntary system would be too confusing and inefficient. They argued that leaving science in private hands could lead to uncertain funding and research gaps, putting national security and public health at risk.
Heading this transformation was former MIT President Vannevar Bush, the scientific advisor to President Franklin D. Roosevelt and the architect of modern US government-funded science. His 1945 report, Science: The Endless Frontier, argued that government should lead in funding research, particularly in medicine, to sustain America’s postwar leadership. (Reliably, the recent New Yorker article advanced the same argument: China could seize leadership in biomedical research.)
Cold War fears of Soviet gains in science and technology — fears ignited by the launch of Sputnik in 1957 — led to massive federal investment in research, with the NIH a pillar of the edifice. By the 1960s, the NIH had ballooned into the dominant force in American biomedical science; its budget has only grown since. What was justified as a wartime necessity and Cold War security guarantee became (as such ‘temporary’ government programs always do) a self-perpetuating funding behemoth.
And so, we mostly forget that private money once led in biomedical research. The Rockefeller Foundation achieved early breakthroughs in public health, including work on yellow fever and meningitis. The Commonwealth Fund, one of the leading biomedical research supporters in the early twentieth century, financed pioneering studies in medicine and health policy. I was a program officer at the Fund in the early 1970s, when all that remained of the biomedical research program were grants-in-aid for writing books on biomedicine then published by the Harvard University Press.
Pharmaceutical companies such as Eli Lilly, Merck, and Bayer grew by developing new drugs and treatments through their own research investments. Industrial laboratories funded by these firms led to the creation of insulin, antibiotics, and vaccines — long before NIH funding became dominant. Now, CEOs of these companies tend to warn that they could do little without basic research by government investigators.
Admittedly, even the Administration’s gingerly slices at the NIH budget leave companies caught between regulatory mandates: Verve Therapeutics, developing genetic medicines for cardiovascular disease, complains that the Trump executive action withholding support to private companies with DEI policies is a U-turn away from the 2022 mandate requiring them to enroll “more diverse patient populations” in clinical trials.
The Behemoth on “Automatic”
NIH funding is routinely allocated across 10 core research areas, which receive automatic funding increases year after year:
1. Cancer Research
2. Cardiovascular Research
3. Neuroscience (including Alzheimer’s research)
4. Infectious Diseases (e.g., HIV/AIDS, influenza)
5. Genetics and Genomics
6. Stem Cell Research
7. Rare Diseases
8. Environmental and Occupational Health
9. Behavioral and Social Sciences Research
10. Public Health and Health Disparities
Government agencies do not underspend their budgets. They spend all allocated funds to justify future increases. There is ceaseless lobbying by special interest groups for every disease and disorder — and by the 40,000 or so annual grantees (“investigators”). Also, as of last year, NIH had 20,000 staff at the campuses in the Bethesda/Rockville (MD) area, the Research Triangle (NC), and elsewhere. There are 27 separate centers and institutes. And every one is a champion of more money sooner.
NIH’s claim to legitimacy rests upon the peer review system. Decisions on grant applications are made by scientists in the grant-seeker’s field. But all government decisions supposedly are made by people knowledgeable in the field. To be a bureaucrat is not to be ignorant; it is to work in a legally rule-bound system…and to judge potential research competitors whose proposals may disagree with your research and its premises. Fields of science are hugely invested in concepts like “mainstream science,” “state-of-the-art-methods,” “leading researcher,” “leading hypothesis,” and “the cutting edge.”
Obviously, critics of NIH among scientists are rare, but Dr. Vinay Prasad, a hematologist-oncologist, professor in the Department of Epidemiology and Biostatistics at the University of California, San Francisco, and head of the VKPrasad lab there, said: “The current NIH funding mechanism discourages innovative research and perpetuates a cycle where only established investigators receive grants.”
NIH amply dramatizes how common such criticism has become, whether or not made publicly, by developing small programs of “High Risk High Reward Research”: the “Pioneer Award,” the “New Innovator Award,” the “Transformative Research Reward,” the “Early Independence Award.” Annual funding of the HRHR program appears to be about $60 million, about 13 ten-thousandths (0.0013 percent) of the NIH budget but an excellent investment in answering Congressmen who carp about the inherent contradiction in ‘bureaucratic science.’ Make no mistake: NIH can point to many benchmarks of success: Nobelists, output of research papers, vaccines, other medical advances, the Human Genome project, myriad databases, investigators trained, facilities built… But then, wouldn’t you expect to see something for tens of billions of dollars a year over decades? Left in the hands of those who earned it, the money would have bought something else.
The only real argument for massive government funding of biomedical research is that private investment would not reach the same scale. Only the federal government has the power to tax the public to amass $47 billion annually. But do we forget that what government taxes for biomedical research otherwise would be left in the economy, still available for voluntary investment, including in biomedical research?
(The National Science Foundation, established in 1950, has an annual budget of approximately $9.5 billion and funds research across multiple disciplines, including biology, engineering, and computer science. Meanwhile, NASA — best known for space exploration — allocates over $25 billion annually, supporting astrophysics, planetary science, and aeronautics.)
Forcing Americans to “Do the Right Thing”
If biomedical research is the urgent priority claimed by NIH proponents, why assume Americans would not willingly support it? Individuals, businesses, philanthropies, and medical foundations have demonstrated their willingness to fund major research efforts when they see the value. The premise of government funding, however, is that left to make their own judgments, Americans would not allocate “enough” to biomedical research. Individuals left to live by their own value systems would not sacrifice enough in the future of science beyond their lifetimes. The money must be taken from them. That is the premise of collectivism that justifies the endless growth of government beyond the role specified by America’s founders (protection of individual rights: freedom of judgment, freedom of action, and freedom to use and dispose of property). But to repeat: the premise of insufficient investment in the future is belied by private support especially for the biomedical sciences. And that support is given year after year, even with the knowledge that our taxes pay for the world’s largest biomedical research establishment.
Is it the role of government to override the values and choices of individuals in their “true” interests, for their own good? Let us suppose that taxpayers at first might choose to invest less in biomedical research. Is the virtue of their government that it forces them to do so? Does government rest on the premise that citizens are incapable of making rational decisions about their own future?
A fundamental premise is operating here, everywhere, but rarely articulated. It is that medical research is an absolute good, good without limit or context. An “intrinsic good” without reference to the only possible beneficiary: individuals in the context of their lives and values. The notion of “good” without reference to any actual person is the justification underlying all regimes coercing citizens for some “greater good.”
At best, this practice results in sacrificing the good of some to the good of others. At worst, it means massive sacrifice of lives in the present for some overriding future ideal. The American credo of individualism leaves each of us free to act on our judgment or conscience, for our own values, our own vision of our future, to take responsibility for the consequences–and to respect the right of all other individuals to do the same. Such a system makes possible an infinity of voluntary collaborations.
I trust no one will point out that biomedical research today is infinitely more complex, instrument-dependent, and team-based than when William Harvey (1578-1657), an English physician educated at the University of Padua, explained blood circulation. That is true, but has nothing to do with government funding. Yes, academic medical centers (220 today), pharmaceutical companies, and other research enterprises now are funded by NIH — because NIH takes $47 billion a year from the US economy that otherwise might be available. Those research enterprises grew not with NIH, but with the American economy. It is interesting that in Harvey’s time universities and later “academies” also were the nodes of research sophisticated in medicine.
Too Big to Think About…
The NIH — like other behemoths fattened with tax support — by its sheer size defies the notion of dissolution. My God, how would we begin…!? If 20 years were required, 20 years of declining federal budgets (and lower taxes), who could but cheer? The secret is to recruit men of the caliber of Vannevar Bush but inspired by the vision of the federal government not as seen by FDR and LBJ but Jefferson, Madison, Adams, Washington… That, after all, propelled the seeming miracle we call the United States of America. They were men of the Age of Reason. And to reason we must now appeal against a deeply entrenched collectivist and statist model of a supposedly capitalist nation’s science enterprise.
We are not debating the proposition that biomedical research is vital to human progress. Indeed, that had been demonstrated to the undeniable benefit of mankind before it was concluded that it was so important that government must take it over. So powerful was the demonstration that it put the government’s eventual $47 billion annual investment beyond scrutiny. The NIH funding model prioritizes institutional stability over disruptive innovation. The New Yorker is panicked: “…people who were getting lifesaving treatments will no longer be able to — they will start to populate not invisible graveyards in the future but visible graveyards today.”
Is this a reasonable objection to the first restraining hand in decades on the NIH sacred mission — for example, no longer honoring negotiated rates for indirect costs under grants?
The New Yorker asks the wrong question. It is not if biomedical research should be funded. It is who should decide how much of your money and mine, when, should go for biomedical research — and what research? If we still want our funds invested through an enshrined bureaucratic system, believe me, any great American academic medical center will do. But a serious passion for “breakthroughs” in research implies that we are willing to challenge the status quo.