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    Francis Collins, MD, PhD, reflects on his tenure — and his legacy

    After serving 12 years and three presidents as director of the National Institutes of Health, the physician-scientist shares his thoughts on the pandemic, this country's deep divisions, and the future of biomedical research.

    Francis Collins, MD, PhD
    Francis Collins, MD, PhD
    Courtesy: The National Institutes of Health

    Francis Collins, MD, PhD, could be forgiven if he weren’t able to single out just a few of the most memorable accomplishments from his 12-year tenure as director of the National Institutes of Health (NIH). The 71-year-old physician-geneticist has launched at least a half-dozen major efforts, including the BRAIN Initiative, an ambitious campaign to plumb the origins of such neurological conditions as Alzheimer’s disease, and the All of Us Research Program, a massive attempt to study health factors in 1 million diverse Americans.

    Then there’s his work to end structural racism in the scientific community, his unwavering campaign to increase federal support for biomedical research, and his calm leadership during the worst public health crisis in more than a century — not to mention his own research, which has resulted in such breakthroughs as the collaborative discovery of the genes that cause cystic fibrosis and the rapid-aging disease progeria.

    During his last week at the helm of the NIH, AAMCNews sat down with Collins to discuss his achievements, his plans for the future, and his hopes for the nation.

    This interview has been edited for brevity and clarity.

    You are stepping down after leading the NIH for 12 years. Why now?

    Twelve years is a long time — longer than any previous presidentially appointed NIH director has served. All previous directors served just one president. I'm now on my third president, which has been a great privilege. But institutions that lead scientific research need turnover from time to time and the opportunity for a new vision. Twelve years seems like it's already stretching that a bit.

    If I wasn’t going to stay through this entire presidential term, it would not be good to leave late in that term, because then the president might not have much of a chance to nominate and get a replacement confirmed.

    People ask, ‘Well, what about COVID? We're not over that yet, and you've been in the middle of it.’ The NIH’s contributions to COVID’s challenge have been remarkably strong and effective, and we're in a very good place to continue making those contributions.

    Looking back over the past 12 years, what do you consider your greatest achievements?

    [There is] the BRAIN project to figure out how circuits in the brain do what they do. That’s terribly complicated and bold, but it's time to do that.

    The All of Us longitudinal cohort study — taking precision medicine to a new level of specificity — is going to have profound consequences for our understanding of both health maintenance and disease management.

    The Accelerating Medicines Partnership has advanced understanding of [conditions such as] Alzheimer’s disease, diabetes, Parkinson's disease, and schizophrenia. It has brought together the best and brightest from the public and private sectors to figure out what we could do together that neither could do very well separately.

    The HEAL Initiative has focused on the opioid crisis and devising better means of preventing and treating drug addiction — and also on developing medicines for people with chronic pain that will not carry the risks of opioids.

    Those are a few. I could go on and on — and if you're not careful, I just might.

    You have been involved in the development of COVID-19 vaccines. What’s your sense of how they will fare in the face of the omicron variant?

    I have been obsessed about omicron since it emerged, tracking all the laboratory and real-world data to assess how serious this highly mutated variant might be.

    There's bad news in that it appears to be highly contagious. The somewhat better news is that it appears to be less severe, although it's early to be sure of that.

    The also somewhat encouraging news — although not as good as I might have hoped — is that it looks as if vaccines do provide protection against omicron, albeit at a reduced level.

    And boosters do seem to give really nice [support] for the immune system to be ready for omicron. So, if we were arguing previously that everybody who's eligible should take advantage of boosters, now we are really confident in that.

    Some say the United States has failed to distribute vaccines equitably across the world and that this inequity has led to the appearance of new variants. What are your thoughts?

    The U.S. has led the world in making vaccines available to low- and middle-income countries. We have made commitments for more than a billion doses and have already sent out almost 300 million, which is more than all other countries combined.

    But this is a complicated issue. It’s not just about supply, it’s also about distribution. Vaccines have to actually go into people's arms, which is a big challenge in some countries.

    South Africa, where omicron emerged, is not limited by vaccine supply. It’s limited by distribution issues — and by vaccine hesitancy that has been exported by the United States to the rest of the world, which is truly heartbreaking.

    You have called it “bizarre” that politics influences precautions like mask-wearing. Can you talk more about divisiveness and disinformation around science?

    We have two epidemics. One is caused by the virus that causes COVID-19. The other is an epidemic of misinformation and distrust about science.

    People’s conclusions about almost everything seem to be driven by what their 'tribe' says is right. Objective facts often get overruled by the latest political statement or the conspiracy that just popped up on Facebook.

    Estimates are that more than 100,000 Americans have died in 2021 unnecessarily because of misinformation campaigns that discouraged people from taking advantage of lifesaving vaccines.

    We need all those who have the ability to sift through evidence to work tirelessly to get accurate information out to the public. It can't just be coming from the government or scientists, because sadly we're now considered a little bit suspect. It also needs to come from community leaders.

    And politicians who have been some of the worst offenders in spreading misinformation need to recognize that history is going to judge them harshly.

    You apologized to biomedical researchers who have suffered from structural racism. What are your thoughts on diversifying the research workforce?

    2020 will be recalled as not just the year that COVID-19 decimated the world but also the year of a realization in the United States of how structural racism is built into pretty much all of our institutions.

    It has been clear for some time that NIH does not have the workforce diversity that we should, and we are determined to change that. Since the summer of 2020, we’ve had a remarkable group of visionaries, in an empowered group called UNITE, to make recommendations about what more we can do.

    The FIRST program is one example. It encourages academic institutions to recruit underrepresented individuals to tenure-track opportunities — not one at a time, but as a cohort, so there can be a sense of support among the recruits, as well as focused mentoring.

    Much of NIH research funding goes to academic medical centers. Are there ways that academic medicine and the NIH can collaborate more effectively?

    The success of NIH over these many decades has largely been dependent upon the fantastic research going on in the academic institutions who are our grantees. And we want that to flourish in every possible way.

    But we need to focus particularly on the next generation of independent scientists, the early-stage investigators.

    In 2014, only 600 early-stage investigators got their first NIH grant. My colleagues and I concluded this was insufficient. So, we started pushing hard to make those researchers getting started in their careers a high priority. I’m happy to say that in the most recent year, we funded about 1,400 early-stage investigators.

    A major part of our success with this has been that, for the last six years, Congress has been willing to see an investment in NIH as really important. Our budget now is 40% higher than it was in 2015. I can't say enough about the leaders in both parties who decided to make that a priority.

    Also, the AAMC has been a wonderful partner, working alongside us with training, with research, with trying to make the whole ecosystem as productive as it can be. And with David Skorton [MD] leading the AAMC — somebody who has been a friend of mine for many years — I think we have an amazing future.

    You have worked 100-hour weeks during the pandemic. How have you managed to avoid burning out?

    Over these past two years, I have tried to juggle all of the aspects of NIH investments in [COVID-19] vaccines, in therapeutics, in diagnostics — as well as all the rest of the NIH portfolio that couldn't go on hold just because we had a pandemic.

    It has been exhausting, and I have at times felt on the edge of burnout. But I have various ways I have dealt with that.

    I'm a person of faith. I try to start every day getting myself square from a spiritual perspective, so I spend a little time in prayer and reflection.

    I also find music a great source of stress relief. When the pressure seems to be ganging up on me, I will get up from my desk and play the piano for 10 minutes to get a different part of my brain to kick in.

    Most importantly, my wife, Diane Baker, has been a complete partner with me. She’s a genetic counselor, but she’s thrown herself heart and soul into supporting NIH and to helping me convey that this is not just a bureaucracy. This is an institution that cares about people.

    You’re not retiring but returning to the lab. What are you looking forward to?

    I've been running a research lab at NIH since 1993. It’s been a wonderful way for me to stay anchored in the reality of what science can really accomplish.

    My lab is working on two major projects. One is the epigenomics of Type 2 diabetes, gaining significant insights into how hereditary risk factors play out and how this might lead to new therapies.

    The other project is on a very rare disease called progeria, which is a dramatic form of premature aging that affects children who, without treatment, die by age 12 or 13 of heart attacks or strokes. We’re on the path toward a clinical trial that will use in vivo gene editing to fix a single misspelled nucleotide. This has worked spectacularly in a mouse model. Now we want to see if it actually works in humans.

    Are there any particular moments that you will miss once you are no longer NIH director?

    I will miss those moments where I can convene people from different disciplines around a project idea and see the sparks start to fly when they recognize that something really innovative could happen.

    I’ll miss those moments when there's been a phenomenal scientific advance that NIH had something to do with, like the first patients with sickle cell disease who were cured with gene therapy — that’s an advance that I didn't expect to see in my lifetime.

    I will miss all those meetings I had with members of Congress — probably 1,000 or more. I remember fondly the chance in those meetings to tell the story of what NIH does and to see their interests get piqued by the potential that’s offered for themselves, their families, and their constituents.

    But an important part of my feeling good about stepping away is the leadership that I am leaving in place.

    Larry Tabak [DDS, PhD], who's been my principal deputy, will be acting director and will do a superb job until the president identifies a permanent director. And the NIH has 27 institutes and centers, and they each have a director who is a really capable, well-respected, knowledgeable, visionary scientist. I recruited most of them. They are spectacular leaders.