The Free Press
Dr. Jay Bhattacharya is an outstanding choice to be the next director of the National Institutes of Health for the incoming Trump administration. He has a rare opportunity to reform and revitalize a crucial institution that has become sclerotic.
I am a cardiologist at Johns Hopkins Medicine who has a longtime interest in health policy. During Covid, I watched in alarm as Dr. Bhattacharya was maligned and sidelined for raising necessary and thoughtful objections to draconian Covid policies, such as lockdowns and school closings. Both these policies and the attacks on Dr. Bhattacharya were promoted by top NIH officials. So it is indeed “poetic justice” that he is now going to be in charge. Dr. Bhattacharya has said his mandate is to bring change to the NIH. Here are my ten suggestions for where he should start.
1. Term limits of 5–10 years for all institute directors.
Dr. Anthony Fauci led the National Institute of Allergy and Infectious Diseases (NIAID) for 38 years. The NIH can’t afford to have any more such leaders exercising control of entire fields for decades. Over those decades, Dr. Fauci accumulated political clout that he exerted to increase funding for infectious disease research. But ultimately, this led to the distortion of funding priorities (see #9). Such power may result in tunnel vision rather than a director adapting to the needs of the public. Regular turnover of leadership brings fresh ideas and a healthy reassessment of priorities.
2. Direct more funding to research in primary and early stage chronic disease prevention.
A foundational principle of the Make America Healthy Again (MAHA) agenda is that the U.S. spends too much on “sick care” relative to prevention of illness. That is, we focus on the treatment of people with full-blown chronic disease. This treatment often results in patients being on multiple medications for years—which benefits pharmaceutical companies. We spend too little on understanding and preventing chronic disease. This issue was an important, and unexpected, one in the presidential election. The public voted for preventing illness, and the NIH should listen. Keeping people healthy longer is a good use of public money.
3. Reduce financial conflicts of interest and provide greater transparency on them.
During Covid, the NIH, research universities, and individual scientists received millions in royalty payments from a vaccine manufacturer using the new mRNA technology. I am not against institutions and individuals profiting from their scientific discoveries. But in this case, NIH leaders wielded their enormous influence to insist that these vaccines were essential to ending the pandemic. When legitimate questions were raised about the efficacy and safety of Covid vaccines, along with objections to vaccine mandates, this conflict of interest undermined public confidence in both the vaccines and the NIH. The NIH should require that all industry payments to individual scientists and to the various institutes be made available to the public in an easily searchable database.
4. Consolidate the number of institutes and streamline the bureaucracy.
The NIH began in 1887 as a one-room laboratory. It is now 27 separate institutes, each in its own bureaucratic silo. In academic medicine today, divisions and departments are being reshaped to consolidate research based on a more modern understanding of the interactions of disease processes. A similar reorganization of the NIH’s structure is overdue. Early on, the new director should also authorize a review of where there are departmental redundancies and outdated rules.
5. Make it easier to dismiss employees for incompetence and malfeasance.
The difficulty of dismissing poorly performing federal employees is a general problem that plagues all of government. As far as anyone can tell, no one has been fired from the CDC for their production of a flawed test in February 2020 for the virus that causes Covid. This was a failure that delayed testing implementation, and set back the U.S. Covid response during those crucial first weeks.
Then in May of 2024, the shocking Congressional testimony of NIAID scientist David Morens, a top adviser to Dr. Fauci, revealed how Morens used his personal email to evade government accountability. Morens, who was placed on paid administrative leave earlier this year and is still listed as a “senior scientific adviser” to the new head of NIAID, may have sought this subterfuge to conceal the NIH-funded research at the Wuhan Lab, which is now suspected to have been the source of the pandemic. The new NIH director needs to make employees accountable for their poor decisions.
6. Establish greater oversight and restriction on the use of mammals for research, particularly dogs, cats, and primates.
The public has developed a greater sensitivity to this issue over the years, and while I think there’s a place for the limited, humane use of animals in scientific research, the standards of care must be high and well enforced. This issue was recently brought home to the public by the escape last month of 43 rhesus macaque monkeys from a lab in South Carolina where there had been prior escapes and citations for violation of animal welfare protocols. The FDA also took a step in this direction with the FDA Modernization Act 2.0, passed by Congress in December 2022, which reduces mandated use of animal testing in drug research.
7. Require each institute director and every grant recipient to write and post an annual letter of appreciation.
This letter should be addressed to the American public, thanking them for funding their work and briefly describing how their research benefits the public’s health. This policy would have the salutary effect of reminding NIH-sponsored researchers where their support comes from, and would also help educate the public on the important work that the NIH does on their behalf. Researchers supported by private philanthropists and foundations regularly provide this kind of feedback to their donors. The public deserves the same courtesy.
8. Bar all institute directors from participation in public health policy creation or advocacy.
An NIH institute director sets the research agenda for that institute, establishes policies for awarding grants, and makes recommendations for other important appointments. So when a director publicly supports a particular health policy—as happened during Covid—scientists who depend on the director for funding and other support are unlikely to speak up in opposition to the position, no matter their qualms. This dual role by institute directors inhibits open scientific debate, promotes groupthink, and creates an illusion of consensus. Policymakers seeking guidance should get it from biomedical experts who do not wield the kind of power that NIH directors have.
9. Decentralize and depoliticize research funding priorities.
The National Institute of Allergy and Infectious Diseases (Dr. Fauci’s former home) receives about $6.5 billion in annual funding. The National Heart, Lung, and Blood Institute (NHLBI) gets about $4 billion. But heart disease alone kills far more people in the U.S. than infectious diseases. Even at the height of the pandemic in 2020–21, heart disease killed nearly twice as many Americans as Covid. The year before the pandemic, heart disease killed more than 10 times as many Americans as influenza, pneumonia, and other infectious diseases. But the NIH funding disparities likely reflect political and personal influences rather than a rational measure of public need. Investigators from the many medical fields represented at the NIH, along with members of the public, need to have more of a say in establishing research priorities—priorities that should be based on need.
10. Hold the NIH accountable for results.
The U.S. spends $4.5 trillion on healthcare and about $100 billion on publicly funded biomedical research. Yet we do relatively poorly on many measures of health and some are actually getting worse, including rising rates of obesity, diabetes mellitus, and stagnating life expectancy relative to other countries. The NIH itself, and the recipients of its $33 billion in grants, should measure success not by how much money is spent but by how much biomedical knowledge, health, and public benefit are generated. Establishing these metrics of success will be challenging, and the new director should engage with a wide range of public voices to establish them.
The common theme in all of these proposed reforms is that the NIH, which was established as a public health agency, should be more responsive to the American people. During the pandemic, their leadership exhibited a sense of entitlement, grandiosity, and self-importance that is unhealthy for the NIH and anathema to good medicine and science. The NIH is an important institution that has supported critical research which has advanced human health. A fresh perspective is sorely needed to address the roots of the U.S. chronic disease epidemic and restore public trust in our federal health agencies.
Joseph Marine, MD is a cardiologist and a professor of medicine at the Johns Hopkins University School of Medicine.
A version of this piece appeared in the Sensible Medicine Substack.
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