So there’s talk that Robert F. Kennedy Jr will defund the NIH. Or something like that. In full disclosure, I am not a fan of the man. But, I also view the hysteria of academics and institutionalists about his nomination to head HHS with a somewhat jaundiced eye.
The National Institutes of Health is the nation’s – and world’s – premier health and disease research institute. The NIH has been around in some form since 1887 and is the branch of the federal government responsible for biomedical research. It has an annual budget of $47 billion dollars, of which about $30 billion is spent on grants to researchers at colleges and universities across the nation and the world. (For context, the US as a nation spends less than $165 Billion a year on primary care. $47 billion would fund primary care for 94 million people. There are 27 million Americans without health insurance in the US in 2024, so the NIH budget could pay for providing primary care to those who lack access to it three times over.)
The NIH has 27 institutes and centers of excellence. Huge discoveries have come out of the NIH – vaccines against hepatitis B, haemophilus influenza, human papilloma virus (which is actually a vaccine that prevents cancer) and Covid 19. Hundreds of Nobel prizes. The NIH discovered how fluoride prevents tooth decay, how lithium can be used to control bipolar disorder, and developed the MRI, among a zillion other more wonky discoveries that have contributed to our ability to reduce death and disability from cancer, heart disease and diabetes.
So what’s the problem Bobbie? And Don?
RFK Junior has been quoted as saying that he’ll lay off 600 people at NIH on his first day in office, that he’ll stop research on infectious disease and lean into research on chronic disease. Isn’t that crazy?
Well, yes. And no.
The yes first. It’s crazy to stop research on infectious disease. Viruses and bacteria are always mutating, always changing and always finding a new way to infect us and spread themselves. Human beings have become incredibly numerous and we travel all the time, spreading viruses and bacteria and giving those viruses and bacteria a perfect laboratory in which to develop a true killer bug, which will emerge, I promise you, and make Covid 19 look like a Saturday morning kiddy show. It is critical we work and work hard to stay ahead of what’s coming, and to develop tools, treatments and vaccines to blunt the impact of the killer bug, when it emerges.
But no, everything Bobby Jr says isn’t crazy, not passing judgement on the man himself.
Chronic diseases are a huge public health problem. And we as a nation are terrible at controlling them. Just twenty percent of people with high blood pressure have it diagnosed and treated appropriately.[i] Many of us think a similar number of people with diabetes haven’t been diagnosed and treated appropriately, though I don’t have access to a precise count. These are diseases and conditions that cause most heart disease and stroke, diseases and conditions that we know how to diagnose and treat today, with today’s science, no further research necessary. That’s also true of colon cancer, HIV and Hepatitis C, all diseases that we know how to prevent or treat with today’s science, only we don’t use the science we have, much of which was developed at NIH, to help care for the population of the US.
Turning the focus of HHS, CDC, HRSA, Medicare and Medicaid to chronic disease makes huge sense. And will save millions of lives.
There’s one other problem with the health care world and NIH, which RFK Jr hinted at in his public statements. The culture of medicine today, which is too much wrapped around products and profits and too little focused on the needs of people, families and communities, is a culture that rewards research and teaching, not clinical practice. The high-status guys, the folks who get to be deans and chairs of medical school departments, build their reputations on their ability to get NIH grants, not on their ability to take care of people, families and communities. There’s a whole mentorship process out there that actually starts in medical school and even before, selecting for the people who like research and can build a career getting NIH grants. And a medical industrial complex, in which the same people rotate in and out of the NIH, university research and academic jobs, and the biotech industry, a medical industrial complex focused on profit, not better public health outcomes.
There’s even something of a code of silence around all this. I suspect a number of dear friends will stop talking to me after I publish this because they have built careers around this process, and anything that threatens the NIH threatens them, their careers, and their incomes, their prestige and even their sense of self-worth.
But that’s the cart pulling the horse, the tail wagging the dog. We need a world in which patient care and the public health of communities come first, where researchers exist to help the incredibly important people who work with patients and in communities be more effective at their work.
Will taking apart the NIH create such a world? Not on its own. But a thoughtful and honest critique about what NIH does and how it functions, combined with a deep national commitment to training a zillion more primary care clinicians and making sure all Americans have a robust primary care relationship, probably will.
So is RFK Jr crazy to be critical of the NIH, and want to change it if confirmed? I can’t speak to the man or the worm that may or not be in his brain. But he, and we, wouldn’t be at all crazy if we looked hard at the NIH, and rethought it, and at the way the health care bureaucracy and medical industrial complex serves, or fails to serve, all Americans.
[i] Hypertension prevalence, awareness, treatment, and control among adults age 18 and older: United States, August 2021–August 2023. NCHS Data Brief, no 511. Hyattsville, MD: National Center for Health Statistics. 2024. DOI:
https://dx.doi.org/10.15620/cdc/164016