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COMMENTENVIRONMENT Integratedresearch programme neededfor contaminants p.577

MUSEUMS A call to unifyGermanys universitycollections p.576

COOKING Nathan Myhrvold onmolecular gastronomyand Microsoft p.575

GEOSCIENCE The meteorite,from Roman reverance todinosaur doomsday p.573

Time to rethink the NIHA radical restructure is the only way to solve the systemic problems of the worldsbiggest funder of biomedical research, argues Michael M. Crow.Bethesda, Maryland, recently determinedthat a new centre will help the agencysnumerous other institutes and centres betterconvert blue-sky research into treatmentsand diagnostics1.

A firestorm of discussion has eruptedsince Collins announced his plans for theNational Center for Advancing Transla-

tional Sciences (NCATS) in December2,3.

The United States bets aroundUS$30 billion a year that advancesin basic research will yield improve-

ments in national health care. Yet the nationsglobal leadership in biomedical sciencespending has not translated into leadershipin health.

Francis Collins, the director of the US

National Institutes of Health (NIH) in

Much of the debate reflects concernsabout what the move will mean for exist-ing programmes and budgets. In myview, Collinss NCATS plan perpetuatesthe same outmoded beliefs that have ledto the current disconnect between thelaboratory and the clinic,and sidestepsan opportunity to address the fundamen-

tal limitations of the NIH. Therefore IILLUSTRATIONS

BYDAVID

PARKINS

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shall not weigh in on the debate aboutNCATS.

Instead, I propose a thought experiment.If the United States were to start fromscratch, what institutional arrangementwould do a better job of improving thehealth and well-being of its citizens for$30 billion of annual expenditure? I basethis experiment on three decades of expe-rience designing large-scale knowledgeenterprises such as the Earth Instituteat Columbia University in New York Cityand the recently reorganized Arizona StateUniversity.

Researchers, policy-makers and thegovernment have failed to recognize thatprogress in health care results from a com-plex integration of scientific advances withtechnological, behavioural, social and cul-tural shifts. To improve clinical outcomes,the NIH needs to be reconfigured aroundthe many determinants of health withfundamental research as an importantcomponent, but integrated and co-equalwith others.

THE ROAD TO HEREIn 1945, Vannevar Bush, the director of the

Office of Scientific Research and Devel-opment under US presidents FranklinRoosevelt and Harry Truman, issued hisscience policy manifesto Science: The End-less Frontier, which set the stage for US gov-ernment support of science in exchange forscientists securing national defence, eco-nomic prosperity and a healthy life for theAmerican people. Influenced by this, andespecially by the success of the scientificcontribution to victory in the Second WorldWar, the government expanded its invest-ment in all forms of science but mainly indefence and health.

NIH funding in 1939 totalled less than

$500,000 a year, a sum that supported justone institute.Adjusting for inflation, thebudget has since increased nearly 4,000-fold and now funds a Byzantine arrayof 27 institutes and centres, most of whichfocus on a particular group of diseases. Thatthe NIH budget has grown at such a ratereflects the strong belief ofpolitical sup-porters, including scientists, activist groupsand other constituencies, that more scienceinevitably leads to more social good.

This model for discovery and applicationin health care is failing to deliver. A 2009report4 found that the United States rankedhighest in health spending among the30 countries that made up the Organisationfor Economic Co-operation and Develop-ment (OECD) in 2007, both as a share ofgross domestic product and per capita. Infact, the country spent 2.5 times the OECDaverage (see Big spender). Yet life expec-tancy in the United States ranked 24th of

the 30 countries4 (see Poor returns). Andon numerous other measures includinginfant mortality, obesity, cancer survivalrates, length of patient stays in hospital andthe discrepancy between the care of high-versus low-income groups the countryfares middling to poor.

What is missing is not translationalresearch, but stronger links between alltypes of knowledge-generating activitiesrelated to health, and a focus on outcomesbeyond science.

A cluster of studies from public-healthand research-and-development economistsindicates that progress in treating diseasesresults from complex feedbacks betweena range of academic disciplines, techno-logical innovation and clinical practice5.Take, for example, the advances in treat-ing and preventing cardiovascular disease,which account for most of the gains in lifeexpectancy in the United States during thepast half-century. About one-third of thereduction in mortality has been tracedto high-tech invasive treatments, suchas coronary bypass surgery; one-thirdhas been linked to medications that treatconditions such as hypertension; and

one-third to behavioural changes shiftsin smoking habits, diet and exercise achieved through education and clinicaltrials revealing the risks of, say, a high-fat,high-salt diet6.

Another example illustrates the cost ofletting scientific momentum alone driveresearch strategies. According to the NIHsNational Cancer Institute, more than220,000 people in the United States werediagnosed with cancer of the lung andbronchus last year. Between 80% and 90%of lung cancers have been linked to smokingtobacco. Yet of the $2.45 billion that the NIH

has spent on trying to find a cure during the

In 2007, US life expectancy was ranked 24th ofthe 30 member countries of the OECD.

POOR RETURNS

720 2 4

Health spending per capita (US$ thousands)

6

USA

HUN

SVK

POL

CZE

JPNCHE

NOR

DNK

KOR

PRT

NZL

LUX

AUSITAESP CAN

FRA

ISL

FIN

GBR

GRCIRL

BEL

AUT

NLDDEU

SWE

MEX

TUR

8

74

76

78

80

82

Lifeexpectancy(years)

84

BIG SPENDERThe US health spend is almost 2.5 times the average for Organisation for Economic Co-operation and Development (OECD) countries, but the countryscores middling to poor on a range of health measures including infant mortality and cancer survival rates (data from 2007 unless otherwise stated).

Percapitaspending(US$

thousands)

7

Public expenditure on health

Private expenditure on health6

5

4

3

2

1

0

Unite

dStates

Norw

ay

Switz

erlan

d

Luxembo

urg

Cana

da

Netherlan

ds

Austr

ia

Fran

ce

Belgium

Germ

any

Denm

ark

Irelan

d

Swed

en

Icelan

d

Austr

alia

Unite

dKing

dom

OECD

Finlan

d

Gree

ceIta

lySp

ain

Japa

n

NewZe

aland

Portu

gal

SouthKo

rea

CzechRe

publi

c

Slovak

Rep

ublic

Hung

ary

Polan

d

Mexico

Turkey*

*2005 2006 2006/7 2009

OECD average$2,984

United States$7,290

SOURCE:REF.4

SOURCE:REF.4

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past decade, most has been directed towardsthe discovery of molecular and geneticcauses and treatments rather than on estab-lishing how to modify peoples behaviour.Thirty-two years of data7 show that lung-cancer death rates overall are worse thanthey were in the early years of the war oncancer, initiated by US president Richard

Nixon in the early 1970s.

THE ROAD AHEAD

What if the NIH were reconfigured to reflectwhat we know about the drivers of innova-tion and progress in health care?

This new NIH should be structuredaround three institutes. A fundamentalbiomedical systems research institute couldfocus on the core questions deemed mostcrucial to understanding human health inall its complexity from behavioural, bio-logical, physical, environmental and socio-logical perspectives.

Take, for instance, the obesity pandemic.In the United States, medical costs relatedto obesity (currently around $160 billion ayear) are projected to double within the dec-ade. And by some estimates, indirect spend-ing associated with obesity by individuals,employers and insurance payers forexample on absenteeism, decreased pro-ductivity or short-term disability, exceedsdirect medical costs by nearly threefold8.The NIH conducts and supports leadingresearch on numerous factors relevant toobesity, but efforts are fragmented: 27 NIHcomponents are associated with the NIHObesity Research Task Force, a programmeestablished to speed up progress in obesityresearch.

Within a systems research institute,scientists could better integrate investi-gations of drivers as diverse as genetics,psychological forces, sedentary lifestylesand the lack of availability of fresh fruitand vegetables in socioeconomicallydisadvantaged neighbourhoods.

A second institute should be devotedto research on health outcomes, that is,on measurable improvements to peopleshealth. This should draw on behaviouralsciences, economics, technology, commu-

nications and education as well as on fun-damental biomedical research. ExistingNIH research in areas associated with out-comes could serve as the basis for expandedprogrammes that operate within a purpose-built organization. If the aim is to reducenational obesity levels currently around30% of the US population is obese toless than 10% or 15% of the population,for example, project leaders would meas-ure progress against that goal rather thanaccording to some scientific milestone suchas the discovery of a genetic or microbialdriver of obesity.

T h e th ir d inst i tute , a h e a l th

transformation institute, should developmore sustainable cost models by integrat-ing science, technology, clinical practice,economics and demographics. This is whatcorporations have to do to be successful ina competitive high-tech world. Rather thanbe rewarded for maximizing knowledge pro-duction, this institute would receive funding

based on its success at producing cost-effec-tive public-health improvements.This kind of tripartite reorganization

would limit the inevitable Balkanizationthat has come from having separate NIHunits dedicated to particular diseases.

Indeed, such a change would reflect todaysscientific culture, which is moving towardsconvergence especially in the life sciences,where collaboration across disciplines isbecoming the norm, advances in one fieldinfluence research in others, and emergingtechnologies are frequently relevant acrossdifferent fields.

What remains unclear is how to bringabout the change in mindset that is neededto focus scientific research and techno-logical innovation on outcomes that bene-fit society. A committee of the National

Research Council considered the question

of whether to rethink the organization of theNIH in 2003. This committee concluded9that despite its theoretical attractiveness,restructuring would be difficult because thestructure of the NIH is the result of a set ofcomplex evolving social and political nego-tiations among a variety of constituenciesincluding the Congress, the administration,

the scientific community, the health advo-cacy community and others interested inresearch, research training and public policyrelated to health.

Shifting the mindset of scientists andpolicy-makers alike must begin with trans-

disciplinary under-graduate and graduatecurricula that stress theimportance of societaloutcomes. The USMayo Clinic and Ari-zona State University,for instance, are jointly

developing a masters degree in the scienceof health-care delivery a concept initi-ated by the Mayo Clinic, whose Center forthe Science of Health Care Delivery designsand evaluates best practice in areas such ashealth maintenance.

As Harold Varmus, former director ofthe NIH, put it in 2001, the perception thatthe NIH represents the jewel in the crownof the federal government has led to newfacets being added without much thought tooverall design10. Especially in these reces-sionary times, spending $30 billion effec-tively requires that the accretions of the pastbe replaced with a framework that betteraddresses the health-care priorities of thetwenty-first century.

Michael M. Crowis president of ArizonaState University, Tempe, Arizona 85287-7705, USA. He previously served asexecutive vice-provost and professor ofscience policy at Columbia University.e-mail: michael.crow@asu.edu

1. NIH Scientific Management Review BoardReport on Translational Medicine and Therapeutics(2010); available at http://go.nature.com/fxygkj

2. http://go.nature.com/wsqt923. Kaiser, J. Fourteen More Senators Question NIH

Reorganization. Science Insider(17 February2011); available at http://go.nature.com/zuprcf4. Health at a Glance OECD Indicators (OECD,

2009); available at http://go.nature.com/rcbqtf5. Sampat, B. N. in The New Economics of

Technology Policy(ed. Foray, D.) 148162(Edward Elgar, 2009).

6. Cutler, D. M. & Kadiyala, S. in Measuring the Gainsfrom Medical Research: An Economic Approach(eds Murphy, K. M. & Topel, R. H.) 110162 (Univ.Chicago Press, 2003).

7. http://go.nature.com/vbzvan8. Algazy, J., Gipstein, S., Riahi, F. & Tryon, K. J.

Health International 10, 88101 (2010).9. Committee on the Organizational Structure

of the National Institutes of Health. Enhancingthe Vitality of the National Institutes of Health:Organizational Change to Meet New Challenges(National Research Council, 2003).

10. Varmus, H. Science291, 19031905 (2001).

A new NIH

should be

structured

around three

institutes.

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