National Institutes of Health feels budget squeeze

At the National Institutes of Health, the days of living large seem to be over. Since fiscal 2003, when Congress finished its five-year effort to double the NIH budget, the medical research agency has been struggling to keep up with inflation and redirect its spending.

Now, facing a third year of losing ground to inflation, the biomedical researchers who depend on government funds are complaining that there isn't enough money to go around. Conflicts are brewing that could pit new priorities such as finding vaccines to stop bird flu against long-standing efforts such as developing drugs to combat Alzheimer's.

Much of NIH's $28.6 billion budget flows to university researchers through the agency's 26 centers and institutes devoted to different specialties. According to the American Association for the Advancement of Science, the NIH request would fund $27.8 billion in research and development.

Traditionally, the research community's varied disease groups, such as the American Cancer Society and the American Heart Association, have presented a unified front in pressing for research dollars. That comity may erode as competition increases for slices of a budget pie that has stopped growing.

The signs of tension are sometimes subtle. The American Cancer Society raised eyebrows when it won an earmark in the Senate's budget resolution. At an April 6 hearing before the House Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies, members supported greater overall spending on biomedical research. They then urged NIH Director Elias Zerhouni to focus more on specific problems, such as mental health, or on particular groups, such as women and racial minorities.

"If the knives are going to come out, now is when it will happen," said Samuel Gandy, who chairs the scientific advisory panel of the Alzheimer's Association. His group depends on the roughly $650 million spent annually by NIH on Alzheimer's research. That amount, though, makes its cause an also-ran compared with the $4.8 billion devoted to cancer. But Gandy's association says it won't try to snag other groups' funding, because "we may need [support from] the dentists and cancer guys tomorrow."

The disease groups won a round on March 16, when the Senate voted to add $7 billion to the budget for health, education, and labor programs, with several senators citing the need to help NIH. In the House, the budget was pulled from the floor partly because a group of moderate Republicans led by Rep. Mike Castle, R-Del., was pushing for a similar increase, while conservatives stood firm.

In the end, "the highest likelihood is that [NIH's budget] will be flat in real dollars," said Rep. Dave Weldon, R-Fla., who sits on the Appropriations subcommittee. Other lawmakers said that Congress may find enough money to keep up with inflation, but not more. That's still enough of a squeeze to send researchers tussling for dollars.

The Bush administration requested $28.6 billion for NIH, the same funding it received in fiscal 2006. That level would result in $1 billion of lost purchasing power when adjusted for inflation, according to Rep. David Obey, D-Wis., who is the ranking member on the Appropriations Committee. (Inflation in the medical field ran about 4.1 percent last year, compared with a 3.4 percent rise in consumer prices.) Advocates say that NIH's purchasing power has fallen by roughly 10 percent since 2003.

Obey argued that President Bush's tax cuts for the wealthy should be traded for more NIH money. Obey estimates that the proposed budget would translate into 656 fewer research grants than in fiscal 2006, and 1,570 fewer than in 2004. It would cut funding for clinical trials by 8 percent over 2005 levels, he said, and for research on critical diseases such as diabetes, stroke, Parkinson's, arthritis, and Alzheimer's.

Other biomedical programs would fare no better. The $8.2 billion proposed for the Atlanta-based Centers for Disease Control and Prevention represents a cut of $179 million from the current year.

The biomedical research budget has grown much faster than other important areas, such as the funding for physical science and NASA, said Weldon, who has a large NASA facility in his district. Still, members of Congress are loath to directly reject the advocates' calls for greater funding. "I'll try for more than a flat budget," Rep. Ralph Regula, R-Ohio, chairman of the Appropriations subcommittee told National Journal, while also cautioning that money is tight.

Internal budget changes within NIH are reducing the pot of money earmarked for specific diseases. The White House is backing Zerhouni's effort to promote collaborative research by taking roughly $332 million from the semi-independent NIH research centers and placing the money in the director's "Roadmap for Biomedical Research."

Because of worries about natural and man-made plagues, the White House has been directing more funds to the National Institute of Allergy and Infectious Diseases. This year, it is seeking a 6.2 percent increase for the NIH's "biodefense research" program to bring its budget up to $1.9 billion.

To offset the squeeze this year, NIH headquarters directed its various centers to slice 2.35 percent from the funding allocated for a variety of multiyear grants. Some centers choose to impose deeper cuts in particular projects.

For example, Gandy, the director of the Farber Institute for Neurosciences at Thomas Jefferson University in Philadelphia, said that his multiyear grant to develop an anti-Alzheimer's drug was sliced by almost 20 percent.

The biomedical sector has turned to several coalition groups, such as Research!America, and professional groups, including the Association of American Universities and the Federation of American Societies for Experimental Biology, to seek budget increases. The coalitions include universities, disease groups, and industry executives. The sector's lobbyists were able to more than double the research budget from $12 billion in 1996 to $28 billion in 2004.

But away from the cameras, the disease groups also compete against each other. They race to out-organize each other, to raise more money, and to attract more volunteers and revenue from pharmaceutical companies. They competitively lobby legislators, advertise, pitch their message to the media, and recruit the most-prestigious champions from Hollywood they can find.

The American Heart Association is one of the leaders in this race; it argues that heart disease causes 40 percent of American deaths, but heart research gets only 7 percent of NIH's budget. A flat budget in fiscal 2007, said Robert Eckel, president of the AHA, would mean that funding for cardiovascular research, when adjusted for inflation, would be 15 percent less than that spent from 2003 to 2007.

The bigger groups, such as the American Cancer Society, are powerful enough to push the limits of collegiality. In the Senate budget debate, for example, the society helped win unanimous support for an amendment introduced by three senators that reserved an extra $390 million for cancer research.

That boost is "a fair, rational, do-no-harm kind of growth," said Wendy Selig, the society's vice president for legislative affairs. "There is a very, very good story to tell in cancer, and I'm not saying there are not good stories elsewhere ... [yet] the promise for the cure of cancer is enormous," she said.

These groups, both large and small, worry that the draft NIH reforms being pushed by Zerhouni will drain more money from their priorities. In particular, the cancer society fears a proposal to reduce the autonomy of the National Cancer Institute.

The institute's unique status allows its director to submit his own budget request, in consultation with cancer-related disease groups, to the Office of Management and Budget without going through the NIH director or the Health and Human Services secretary. Although the larger disease groups worry that a reform will cause some of their money to be shifted to small groups, the smaller groups fear they may lose their shirt in post-reform lobbying blitzes.

"None of the stakeholders want to change, although they agree they need to," said House Energy and Commerce Chairman Joe Barton, R-Texas, who is writing an NIH reform bill that would give the director clout to force more collaboration among the semi-independent research centers. "I'd love to give them a 10 percent increase, but there's no money, so we have to use existing funds better," he said.

No government agency welcomes a flat budget, even when it is set at almost $30 billion. But because of the peculiar economics of the research sector, a flat budget at NIH causes intense pain to many researchers on several fronts:

• Grants are worth prestige -- and more. Universities want grants, in part, to boost their status vis-a -vis their university rivals. The grants also allow researchers and universities to discover drug-related ideas that can be patented and then sold to biotech or pharmaceutical companies. In 2004, NIH distributed $14.7 billion to outside researchers, most of which was spent on drug development in universities. Surgery-related work at medical schools, which has less profit potential, got only $322 million.
• Researchers' careers are at stake. If university researchers can't get grants, they find it difficult to publish scientific papers or to win patents. In turn, they lose laboratory space to campus rivals. The "kiss of death," said Gandy, comes when a university prods a researcher to do more teaching, thus reducing his or her ability to pursue grants and research. Many university researchers lack tenure, and serve as franchisees of their universities' brand -- Harvard or Columbia, for example -- and they keep those franchises only if they win grants.
• It's hard for scientists to switch specialties. If scientists change specialties to follow funding shifts, they may lose time getting up to speed, and they would start low on the totem pole because they're competing against established scientists.

"Depending on where we're going in the future, there's going to be an undoubling" of NIH's funding, said Sue Nelson, vice president of federal advocacy at the American Heart Association and a former Democratic aide to the Senate Budget Committee. "It's like we made all this progress only to watch it erode before our eyes. This is not the time to be doing this, when we're facing the retirement of the Baby Boom Generation."