Distinguishing real from invented problems with the NIH

The incoming administration has pledged, for a second time, to take a sledgehammer to the institutions of the federal government and beyond. This includes the National Institutes of Health, an agency that has funded some of the most important clinical research and technology development of the past century. I personally think the most likely outcome of the next four years is a tax cut for wealthy elites like myself, a carve-out for our Teslas, and some directionless chaos. But there is a chance the chaos will end up directed at the institution I see as one of America’s crown jewels, so it is important to be clear-eyed about what the NIH actually does and where there are genuine opportunities for reform.

In a nutshell, the NIH funds research on health and disease. In 2019, 60% of the NIH budget went to research project grants (abbreviated, somewhat aggressively, as “RPGs” in the figure below) and another 35% went to research that was either happening at the NIH itself (“intramural”), through R&D contracts, in specialized research centers, or as training. What’s left? 6% for management, support, and other expenses. Research is far and away the largest component.

To understand how this money gets distributed, let’s focus on the RPGs which form the single biggest chunk of research funding. The NIH review process itself is interesting and mostly unknown to the public. Each year, the NIH issues multiple calls or requests for RPGs with essentially no prerequisite other than “ fall[ing] within the mission of the participating institutes” and coming from an eligible investigator and institution. Investigators submit their proposals, which are then directed to a “study section”, a topic-specific group consisting of other researchers, which meet several times a year to review and score the submitted proposals. In general, study section members themselves previously received a grant through the corresponding study section, and volunteer either for a fixed term or on an ad hoc basis (serving on a study section is seen as prestigious and comes with some small administrative perks, but is otherwise not mandatory or compensated). Each study section consists of several dozen members and the roster is made publicly available, making the review process quasi-anonymous: investigators are aware of who was in the discussion but not which specific members reviewed their proposal.

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