As the next Trump administration overhauls the federal government, the National Institutes of Health could be among the top targets for restructuring.
"I do think you probably will see changes in NIH, as well as other public health agencies like CDC and maybe even FDA," says Dr. Joel Zinberg, a senior fellow at the Competitive Enterprise Institute and director of the Public Health and American Wellbeing Initiative at the Paragon Health Institute, both conservative think tanks. "And that's primarily I think because there was a real erosion in trust in those agencies during the pandemic," he says.
While the NIH — which gets $48 billion annually for biomedical research — has historically enjoyed bipartisan support, Trump proposed cutting its budget during his first term. And the pandemic didn't leave positive feelings towards the agency in some quarters.
"I think changes are warranted. It's important to restore trust in public health agencies, of which NIH is one," Zinberg says.
Some major changes at the NIH would require congressional approval. Trump has the authority to pick the NIH director right away, though the new director would have to be confirmed by the Senate. The current director, Monica M. Bertagnolli, was appointed by President Biden in November.
And shaking up the NIH has fans. Robert F. Kennedy Jr., a vocal critic of mainstream medicine, has President-elect Donald Trump's ear. Over the weekend, Kennedy said he'd like to immediately replace 600 NIH employees.
"We need to act fast, and we want to have those people in place on Jan. 20 so that on Jan. 21, 600 people are going to walk into offices at NIH, and 600 people are going to leave," Kennedy said while speaking at the Genius Network Annual Event in Scottsdale, Ariz.
And Republican members of Congress as well as conservative think tanks like the Heritage Foundation have been floating long to-do lists for changing the NIH.
One proposal would winnow the NIH from 27 separate institutes and centers to 15.
"The agency now works in discreet silos that are largely organized on the basis of either diseases or organs rather than taking a more holistic approach to disease," Zinberg says. "So I think there's an appetite to break down those silos, to streamline the agency [and] make the various institutes more cross-cutting."
Dr. Brett Giroir, who held several health positions and played a significant role in the COVID response during Trump's first term, agrees.
"I do think a potential reorganization could be important. The institutes have become very stove-piped," he says.
"Cross-institutional kinds of scientific needs were not very well addressed. And I wound up introducing people at the NIH who had never met each other before or had never worked seriously with each other before."
Another proposal would impose term limits on NIH leaders to prevent the establishment of future figures like Dr. Anthony Fauci, the long-time head of the National Institutes of Allergy and Infectious Diseases. Fauci became a lightning rod for Republican criticism because of his changing advice about masks during the pandemic, his advocacy for the vaccines and his criticizing the use of ineffective treatments, as well as the debate about the origins of the SARS-CoV2 virus, which caused the pandemic.
"No one could think after that these agencies were competent or capable of providing good information," Zinberg says.
There's a lot of talk about revamping how the agency spends its budget.
"There's a lot of concern that the grant-making process at NIH is inefficient, burdensome — it requires a awful lot of paperwork and preliminary data," Zinberg says. "And that it's kind of inbred and ossified in the sense that most of the grants go to people who've had previous grants. Most of the grants go to a small group of universities — most of the grants go to older researchers."
One proposal causing special concern among some NIH supporters is to give at least some of the NIH budget directly to states through block grants, bypassing the agency's intensive peer-review system. States would then dispense the money.
Many proponents of biomedical research agree that some changes may be warranted and helpful.
But some fear they could result in big budget cuts to the NIH, which could undermine the scientific and economic benefits from the biomedical research generated by the agency.
"Why would you want to dismantle an institute that is the leading research institute in the world?" says Ellie Dehoney, a senior vice president at Research!America, a nonprofit group that advocates for scientific research. It would be like saying, 'Let's undo our national defense and block grant it.' There's no reason to take a successful institution and dismantle it."
Many in the medical community are "deeply, deeply concerned," says Dr. George Daley, dean of the Harvard Medical School. "Any restructuring that would lead to an overall decrease in the support for medical research could really have a devastating effect."
The states don't have the expertise to pick the best scientific projects through block grants, according to Dr. Elias Zerhouni, who ran the NIH from 2002 to 2008 under President George W. Bush.
"I don't think it will work because it wouldn't really guarantee what I think is the crown-jewel process that we have and that is independent peer review," Zerhouni says. "It's going to be more political than it needs to be and that it should be. You want it to be above politics. It's one of those things that we need to protect from political influence."
The next Trump administration may also crack down funding certain kinds of biomedical research, such as "gain-of-function" research that studies how pathogens become dangerous, as well as human embryonic stem cell research, which raises ethical issues for some.
Restricting certain types of research has some supporters.
"There are potential positives that a Trump administration might bring to NIH and its agenda," says Daniel Correa, chief executive officer at the Federation of American Scientists. "Tightening lab security and revisiting and strengthening oversight over risky research, like gain-of-function research, may be central to the next NIH agenda. And I think that would be welcome."
But Correa and others say that the new administration also appears likely to impose restrictions on other types of medical research as well. For example, the Trump administration is likely to restore restrictions on using tissue from aborted fetuses for biomedical research, which were lifted by Biden.
"It would be a mistake to restore a ban on fetal tissue research since it was based on false and misleading claims of a lack of important progress and use of fetal tissue," says Dr. Lawrence Goldstein, who studies fetal tissue at the University of California, San Diego. "If Americans want to see rapid research on repairing organ damage and brain damage and all the other diseases we're trying to fight, fetal tissue is a really important part of that tool box."
Goldstein is far from alone in his opinion.
"The impact of fetal tissue research and embryonic stem cell research is undisputed and has led to some extraordinary advances in treating disease," agrees Heather Pierce, senior director for science policy and regulatory counsel for the Association of American Medical Colleges.
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