COVID, racism, China: three tests for the next NIH leader

Francis Collins will leave big shoes to fill when he steps down later this year, after 12 years as director of the world’s biggest public funder of biomedical research. By then, he is expected to have obtained bipartisan support for a funding increase that would bring the US National Institutes of Health (NIH) budget to US$43 billion for the fiscal year 2021; when he took on the job, in 2009, it was $30 billion. His scientific credentials as a physician and geneticist — which include heading up the public effort to sequence the human genome in the 1990s and early 2000s — positioned him to establish a number of big-biology initiatives at the agency. These have allowed the NIH to maintain its position as a global research powerhouse.

The challenge now comes in replacing him — a process that involves nomination by the president, followed by hearings and a vote in the Senate. Whoever takes on the role will need to be able to work with presidents and members of Congress, and to have the requisite scientific and administrative skills. The job also has a big diplomatic component, involving liaison with heads of international governments, as well as business leaders and those running philanthropic foundations, who are an increasing force across many research fields.

The agency’s new leader will face myriad challenges, among them guiding biomedical research during and after the COVID-19 pandemic; dealing with systemic racism and inequity in science; and navigating scientific cooperation with China. That is in addition to the core role: securing the agency’s budget, and being ever-more creative in making the case for supporting basic research. The choice of director must reflect an increasingly diverse nation. For all but 2 years of its 134-year history, the NIH has been led by a man; cardiologist Bernadine Healy, who ran the NIH from 1991 to 1993, is the only woman to have led the agency. It’s time for change.

COVID response

The NIH director oversees the agency’s 27 institutes and centres, which together employ more than 20,000 people, including 1,200 principal investigators and over 4,000 postdocs. But the agency’s reach extends well beyond its headquarters in Bethesda, Maryland. More than 80% of the NIH’s funding supports hundreds of thousands of researchers in labs across the United States and around the world.

The pandemic is an immediate priority. COVID-19 prompted the NIH, under Collins, to speed up some of its grant-distribution systems and to initiate rapid-response research into SARS-CoV-2 testing, vaccines and therapeutics. The success of mRNA vaccines against the virus stemmed, in part, from groundwork laid before the pandemic by NIH-funded research. The agency has also launched a $1.15-billion research investigation over four years — one of the world’s most ambitious so far — into long COVID.

The next director must build on these initiatives and find the best way for the NIH to support basic research on efforts to bring the current pandemic to an end — and to prepare for the next one. One of the biggest challenges will be to balance this need with the other priorities and disease burdens that NIH is set up to address.

Racism and equity

As one of many organizations confronting discrimination, the NIH has had mixed results on its efforts to boost diversity, equity and inclusion in bioscience and its workforce. Under Collins, the agency announced that it will end its over-reliance on male animals and cells, and take sex into account in the design of biomedical studies. But the NIH was slower than some other US federal agencies to adopt strict reporting guidelines when grant recipients are found to have violated an institution’s sexual-harassment policies.

Anti-racism work needs to be a priority for Collins’s successor. Black applicants received only 1.8% of NIH grant awards in 2020, a number that has barely budged since 2013 — and their success rate is lower than that for applicants from white, Hispanic and Asian communities. Earlier this year, the NIH embarked on an initiative called UNITE, intended to end structural racism in biomedical science. The agency plans to spend $90 million on projects to reduce health disparities, and on studying how structural racism affects the health of minority communities. This work must also draw on the latest social science.

These are welcome moves, but much more funding and commitment are needed to tackle the persistent under-representation of Black researchers among the agency’s grant recipients. It is imperative that the next director addresses real systemic barriers.

Diplomacy

The ability to work effectively with elected representatives is a crucial aspect of the NIH director’s role — it involves responding to known and predictable diplomatic and political challenges, as well as reacting swiftly to new situations as they arise.

One such situation is US concerns that China’s government might be using research collaborations as a means of spying on US research institutions. The NIH is among a number of science agencies caught up in allegations relating to these concerns, and some NIH-funded scientists with links to China have lost their jobs. Civil-rights groups say that many were targeted unfairly, partly as a result of relations between the United States and China taking a downward turn. The next NIH leader should advocate for clearer rules that enable US and Chinese researchers to be supported by each other’s funding agencies — as universities are calling for.

The president calls

The size and scale of the NIH, and its importance to US science, means that the NIH director works closely with the office of the president. President Joe Biden has a deep personal interest in biomedical research, having worked extensively with research advocates, particularly in cancer, when he served in the Senate and as vice-president under former president Barack Obama.

The NIH will be expected to advance other priorities Biden has flagged, including an ambitious vision for redrawing the nation’s science and technology enterprise, and the creation of an advanced research projects agency, or ARPA, focused on health (ARPA-H). This would follow the widely touted model of the defence ARPA, DARPA, in funding high-risk, innovative research projects.

Biden has proposed allocating $6.5 billion to set up ARPA-H, although it’s not yet clear to what extent Congress will go along with this request. Questions facing the new NIH director will include whether ARPA-H should reside within the NIH — as Collins has advocated — or whether it should sit elsewhere within the US government. Wherever it finds a home, ARPA-H must be given enough authority and independence to avoid becoming bogged down by the slow gears typical of NIH operations.

Collins also served during the four years of the administration of Donald Trump, who reappointed him to the post. It’s a reminder that the NIH chief must have a constructive working relationship with whichever party is in office. That relationship is often tested — especially when it comes to research priorities. Collins has backed the need for research involving fetal tissue, which comes from elective abortions. But this was not enough to stop the Trump administration drastically restricting research with fetal tissue. Although the Biden administration has reversed that decision, the next NIH director must prepare the case and build coalitions against future restrictions in this area.

The next NIH director will not be working alone — they will be able to draw on the expertise and wisdom of staff throughout the agency, as well as in the national and international research community. They must create opportunities and space to listen to diverse voices and perspectives. The pandemic has demonstrated the crucial importance of fundamental biomedical research in solving global problems and enhancing health. Now the world’s leading biomedical research body must position itself to tackle many other problems — chronic disease, health inequality and the health dimensions of climate change — for which solutions have so far remained stubbornly out of reach.