Wednesday, April 13, 2011

A healthy change for health research....or just day dreaming?

The problem, and a suggested solution
A commentary in the March 31 issue of the journal Nature has taken on the challenge of what to do about the NIH, the research behemoth that couldn't--couldn't deliver on its promise, despite decades of public largesse.  (And no, we're not criticizing Nature this time!)  The commentary is by the President of Arizona State University, Michael Crow, and suggests ways to take a huge operation that isn't doing its job in proportion to its funding, and reform it so it might.  Crow has done some other program turnarounds, including a serious reorganization at ASU, which gives him credibility in writing such a commentary.

From Crow, Time to rethink the NIH, Nature 471:569
NIH spends way more than anybody else on health research (on this planet, at least), but Americans have worse health and longevity, consistently and by many different measures, than many other countries.
This model for discovery and application in health care is failing to deliver. A 2009 report4 found that the United States ranked highest in health spending among the 30 countries that made up the Organisation for Economic Co-operation and Development (OECD) in 2007, both as a share of gross domestic product and per capita. In fact, the country spent 2.5 times the OECD average (see 'Big spender'). Yet life expectancy in the United States ranked 24th of the 30 countries... And on numerous other measures — including infant mortality, obesity, cancer survival rates, length of patient stays in hospital and the discrepancy between the care of high- versus low-income groups — the country fares middling to poor.
And it's not that these other countries exploit our research results better than we do ourselves.  To a great extent it's because our research isn't bureaucratically designed to improve health but to foster the interests of peer-reviewed research.  Crow suggests reorganizing and simplifying to have as much research attention paid to actual improvements to health as to basic science.  With accountability built in to the system, which is not the case now.  He'd like to see a new NIH restructured around just three institutes, a fundamental biomedical systems research institute, a second institute focused on research on health outcomes, "measurable improvements in people's health" (fancy that!), and a third "health transformation" institute, whose funding would be contingent on success. 

Of course, as we note regularly here on MT, the system is a System, interlaced with stubborn vested interests, from NIH's bureaucracy of portfolio-protecting officials and institutes, to investigators dependent on NIH grants regardless of whether anybody's health is improved or not, to universities (dare we say Dr Crow's included?) that hunger for the grants and the overhead which gives their administrators sustenance, to journals and news media who need 24/7 stories to sell, to the biotech industry that feeds on technology-glamorized research, to doctors who like or feel empowered by hi-tech tools and tests (some of which actually work, of course!), to social scientists and epidemiologists who do endless studies to evaluate and re-evaluate the health care system, to politicians who can preen themselves by playing the fear card ("I support research to help your health, so vote for me!").

A more radical solution
How to dislodge such a system and get back to science that works towards basic understanding of the world in a less self-interested way, and make health research about health, is not an easy question. Crow suggests that his ideas are radical, but one doubts that they are nearly radical enough, because truly radical change would have to undercut the bloat in self-proclaimed 'research university' 'research' activities.

Moving agencies like the Genome Institute to NSF would perhaps help.  NSF budgets are typically lower, and their grants pay less or no faculty salary, so tech-hungry investigators and overhead-hungry universities would object.   Many investigators at the NIH trough are paid on grants, not by their universities, a corrupt system that should never have been allowed to begin 30 or 40 years ago, so that it became vital to so many of us today.  But that salary dependency leads to wasteful, often dissembling research, in part because of  the very understandable need always to have external funding--can't blame investigators for wanting to be paid!

Moving genetics research to NSF would force it to focus on real scientific problems, not ones based on exaggerated or even disingenuous promises of health miracles.  It would force NIH to do research on things that mattered to health (shocking idea!).  Some of that would certainly involve genes, for traits that really are 'genetic', but most would involve less glamorous, non-tech, boring things like nutrition and lifestyle changes (not research about such changes, as we already largely know what would deliver the most health for the buck, and that research, soft to begin with, leads to nothing but the claimed need for more follow-up studies).  NIH budgets for research could be greatly pared down with no loss.

If lifestyle changes were made, then diseases that are seriously genetic would be clearer, and they would be the legitimate targets of properly focused genetic research.  Meanwhile, researchers with reasonable ideas could do basic research funded by NSF---but, with less money available, they (we) would have to think more carefully, and not assume we'll always have a huge stream of funding, or that just more tech or more data meant better science.

Universities would have to  phase in a strange policy of actually paying their faculty, would have to provide at least modest lab-continuity support to allow investigators to think before they wrote grant applications, and universities would have to scale-down, gradually having fewer faculty, more stress on actual teaching (another shocking idea!), less dependency on grant overhead, and less emphasis on 'research' (much of which demonstrably goes nowhere).

This could be good for everybody.   Science would be less frenetically and wastefully competitive.  The competition could be more about ideas, less about money and publication-counts.  Such changes could, in principle, put science back toward a path more closely connected to understanding nature, than to feeding Nature.  And the journals, including Science and Nature, could phase out the gossip columns (which, in the current careerist system, we naturally read hungrily--they are probably read far more than the science articles themselves) and get back to reporting rather than touting science in a way more closely connected to their articles' actual import.

Of course, the current system feeds many, and that is probably what it is really about.  So dream-world reforms are unlikely to happen, unless simply forced not by thoughtfulness but by a plain lack of funds.

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