A Word from the President

Prospects Dim for a Soft Landing

Remember Apollo 13? After those incredible booster rockets finished the job of liftoff, and while the astronauts were still far short of reaching their destination, we heard those awful words: “Houston, we’ve got a problem!”

In an eerie way, that’s not unlike where we are today with the NIH. After the incredible boost the research community got from the doubling of the NIH budget, and while we’re still far short of realizing the full potential of that “liftoff,” we’ve got a problem! Namely, a serious federal budget crunch that is threatening to preclude the post-doubling, “soft landing” we all had hoped would occur.

Here are the facts. In fiscal year 2004, the year after the doubling was completed, Congress increased the agency’s appropriation by only 3.5%. That funding increment was far below the 7%-8% needed both to honor the commitments made during the doubling phase and to avoid dissipating the momentum created by the ramp up in the first place. Worse than that, the 2004 appropriation wasn’t even adequate to match the 3.8% rate of inflation in biomedical research costs. Congressional action earlier this year portends a similarly small increase for 2005 and predictions for the forthcoming years are just as bleak. We definitely have a problem.

The first order of business is to redouble our advocacy efforts to ensure that Congress understands what’s at stake and appreciates the phenomenal payoff that is certain to flow from steady investments in medical research. In addition to the uncommonly intense fiscal constraints that are perm- eating the halls of Congress, many legislators harbor the notion that the NIH was “taken care of” by the recent doubling, and that it’s now time to turn to other federal priorities, including the non-biomedical science agencies.

In this atmosphere, advocacy that focuses narrowly on one disease, or one NIH institute or on one scientific issue will doubtless appear self-serving and can only work to undermine the integrity of the merit allocation system that has served science and the nation so well. We must continue to acknowledge the critical dependency we have on related, non-biomedical sciences, without which our efforts would stall. Most important, our advocacy efforts must focus on the enterprise as a whole, on the aggregate impact of medical research on the public’s health and on the importance of maintaining America’s pre- eminence in science.

No matter how successful we are in helping to secure more reasonable appropriations for the NIH, the scientific opportunities on the horizon are certain to outstrip whatever resources will be available to pursue them. As a result, for the foreseeable future, we’re going to be confronted with many uncomfortable tradeoffs. Indeed, that process has already begun. One example involves the Kirschstein-NRSA Training and Fellowships Awards. During the doubling period, the NIH began at long last to increase the stipends on these critical awards and promised to continue doing so until levels were reached that were commensurate with the need to recruit and support the best and brightest graduate students and post docs. NIH’s ability to meet this commitment is now in jeopardy. The options are to forgo the promised increases or to forgo a certain number of training slots in return for more competitive stipends for those remaining.

Yet another example of a tradeoff involves the NIH Roadmap. This visionary plan conceived by NIH Director Elias Zerhouni calls for several forward-looking initiatives designed to seize major scientific opportunities that no single NIH institute could tackle alone. To succeed, the Roadmap initiatives must be funded either through “new” money or through reallocation of money in the budgets of individual NIH centers and institutes. Given the dearth of new money (if any!), the options are to forgo the Roadmap’s promised advances or forgo some support for more narrowly targeted areas, albeit ones with an already vested constituency.

In addressing these and the dozens of similarly difficult tradeoffs that tight budgets engender, our central challenge will be to protect the integrity of the system from overweening self-interest. Two core principles seem especially at risk of being compromised under these circumstances.

The first is reliance on competitive merit review by peers as the means for determining the allocation of limited funds. As the gap between worthy projects and available funds widens, the temptation to seek earmarked funds for parochial interests is bound to intensify. Resisting that temptation is the only way to ensure that the very best science is funded and that the public receives the maximum benefit from whatever investments it makes.

The second core principle is the fair reimbursement of institutional sponsors for the real costs of conducting NIH supported research. As competition for the available pool of grant funds increases, past experience suggests that the NIH – sometimes at the urging of well-meaning but short-sighted faculty – will be tempted to enlarge the pool by shifting a larger percentage of the total costs of funded research projects onto the recipient institutions. Given the already fragile financial state of many academic medical centers, such arbitrary cost shifting would be intolerable and could cause serious, long-term damage to the public/private partnership that has characterized America’s successful research enterprise.

Like the crew of Apollo 13, if we keep our heads about us and remain focused on the integrity of our enterprise, we’ll weather this problem and be ready for the next liftoff.

Jordan J. Cohen, M.D.
AAMC President

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