Summer 1995 Volume 4, Number 3

In any business setting, a financial analysis of "return on investment" would take it as axiomatic that the current total funding level is far too small. The current biomedical research spending of the National Institutes of Health (NIH) is only one percent of the nation's annual health care cost, or approximately two months' inflation in that cost. If other federal biomedical research spending and private spending (industrial and philanthropic) is added to the analysis, the ratio is about three percent. Faced by an expense as huge as that of health care, and one which is growing as fast, no financial analyst would pause for a moment before committing more resources to understanding the fundamental issues and reducing that cost with new ideas.

We all know that the cost of health care touches every aspect of our economy. For example, in the automobile industry in the United States, the cost of health care (in the form of employee benefits) typically exceeds the cost of steel for each car coming off the line! Enormous efforts have been expended by manufacturers in understanding and reducing their cost of steel (creating alliances with producers, redesigning the product, raising efficiencies, etc.). Yet reductions in the health care expense have been sought primarily by challenging price, with relatively little attention to the underlying causes of that expense or the potential of long-term prevention or correction. Beating down the price is a short term strategy only. An increased investment in long-term change is essential.

We should have a mammoth debate about the level of investment in research into the causes, diagnoses, treatment, and prevention of disease. The question should be how dramatic an increase we can wisely invest and where. The basic issue is getting lost in the frenzy of the federal budget debate. This is perhaps understandable, but how can we turn attention back to the basic issue?

The nonprofit science advocacy organization, Research! America, has conducted Harris polls demonstrating that 73 percent of the public supports increased biomedical research funding, even if that requires increased taxes. Undoubtedly, Americans take that view intuitively, even with little knowledge of the details. On them, the fundamental issue is not lost, despite their corresponding concern about total federal spending. They live with the consequences of the under-investment in prevention, improved treatment, more efficient diagnoses, and fundamental cures.

We, collectively, in the academic establishment have to share part of the responsibility for this paradox between action and belief. We have not been articulate in expressing the realistic hopes and costs of biomedical research. In addition, a small number of our institutions have inadvertently damaged our collective credibility through haphazard administration of funds.

As a discipline, science has occasionally been arrogant, has even developed a certain sense of entitlement by decades of easy federal support, and perhaps has even been too casual in its custody of the public trust. Certainly, in the last few years, with lessons learned from difficult experiences, and with the fear of direct funding cuts, the leadership in our field has been sensitized to the need for exacting stewardship of that trust and for the eradication of entitlement.

The shift of membership in Congress has created the challenge of leadership transition in this very sensitive area of national science policy. Key members of the Republican party certainly understand and believe in the value of investment in basic research, perhaps more than ever, and they believe in its appropriateness as a serious component of a slimmeddown federal agenda. However, it is possible that their memory of episodes of arrogance by some institutions may lead to cynicism about the efficiency of expenditures. There is always somehow a fundamental belief that there is no budget that is free of fat --no budget that can't be cut.

In that mood, with that history, and with the seriousness of the federal deficit, the large issues and opportunities of biomedical research can easily get lost. We need to avoid that. Instead of arguing over the details of the last few percent of the NIH budget (the trees), we have to work to get the forest back in focus.

The costs of disease to employers from loss of productivity, to individuals and families with reduced quality of life, and to patients in out-of-pocket expenses add up to an unofficial additional health care bill of huge, unappreciated proportions. Those costs are particularly staggering for the consequences of brain injury and disease, which are often chronic and lifelong. This hidden tax is, of course, not counted in the federal budget.

It is time for us to express, in thousands of ways, large and small, to the Congress and to the public, the potential leverage of our small ongoing federal NIH research investment, and its ultimate payoff in future progress. If the funds have not always been spent with perfect efficiency, we can improve. But that is not the fundamental issue. The efficiency has been high enough; the returns will come. More investment will provide a greater return, given the most rudimentary analysis and the most conservative assumptions.

With Dr. Jonas Salk's recent death, everyone has been stimulated to remember the fear of devastation of polio epidemics before the vaccine. More than 20,000 cases in a typical summer, with the deaths of children and young adults, the costs of the halfway technology of iron lungs, the fear, and the crippling are all within memory. Forty summers have gone by since the introduction of the vaccine, and that terrible cost is now eradicated, along with the enormous fear that parents and children once carried.

Every science has its seasons. This is the high summer season for biomedical science, full of opportunities which should not be missed. Scientists, physicians, and their patients have to participate in arguing the point, not out of entitlement, but out of logic. Supporting basic research has always been a core function of government, and few regret the fruits of past expenditures. Now, here, in this biomedical field, we have the best opportunity in memory for a dramatic return on a larger investment.

Dr. Newbower is Senior Vice President for Research and Technology at Massachusetts General Hospital.