Time for a Hard Look at the NIH


November 24, 1992|By DANIEL S. GREENBERG

WASHINGTON. — Washington -- While Bill Clinton and his incoming crew are at it, they ought to take a close look at one of the least-scrutinized, taken-on-faith institutions on the federal landscape, the National Institutes of Health, manager and financier of the world's greatest health-research enterprise.

With a budget of $10.3 billion this year, the NIH is far bigger than similar agencies in all other countries put together. Revered by Congress, which piles on money while rarely asking questions about results and priorities, the agency nearly tripled its budget during the otherwise lean years of the Reagan era. Under its hard-driving and ambitious director, Bernadine Healy, even greater expansion is planned.

Historically, the power lines in health research have run directly from Capitol Hill to the NIH campus in Bethesda, with the White House virtually excluded from decision making. The close and effective partnership is enshrined in NIH buildings named after departed legislators who have delivered the budgets, John Fogarty, Lister Hill, Warren Magnuson, Claude Pepper.

Congress often badgers and prods the NIH management -- but only in the direction of expanding its programs. Otherwise, the agency is accorded self-governance in running its own laboratories and in paying for research and training in universities, hospitals and research institutes throughout the country. Does it carry out its responsibilities wisely?

That's difficult to know. The National Institutes of Health works with the untested faith that sooner or later most health research pays off in useful knowledge. Congress never asks for a detailed accounting of what came out of the many billions appropriated years ago. The NIH touts the 20-year-old war on cancer as a great success, but many highly respected bio-statisticians have concluded that it has had little The National Institutes of Health works with the untested faith that sooner or later most health research pays off in useful knowledge.

impact on the number of cases or the death rate.

Director Healy, in office 18 months, depicts the NIH's new emphasis on women's health research as evidence of good policy making. And so it is. But when left to its own choices, the NIH system -- which draws advice from thousands of scientists -- failed America's women. Testing of drugs for heart disease and other ailments was often confined to men, and the results were more or less reconfigured as best as could be done to determine the effects on women.

The agency was initially awakened to its failings in this area by several warning blasts from the Congressional Caucus for Women's Issues. Remedies were promised, but the NIH bureaucracy tends to move slowly.

In 1991, four years after the women in Congress expressed their outrage, the General Accounting Office reported that the agency had ''made little progress in implementing its policy to encourage the inclusion of women in research study populations.'' Now, with a congressionally mandated program for women's health research, real changes seem to be occurring.

But sluggishness exists in other areas. In 1983, after several important studies concluded that personal behavior -- such as smoking, food preferences and sex habits -- are important factors in health, the Senate asked the NIH to increase spending on behavioral research. Five years later, an internal NIH study found spending in that area unchanged, at a minuscule 3 percent of the research budget. It remains low.

In its internal operations, the agency is a cumbersome enterprise that has difficulty doing anything quickly. A scientist seeking money for research can rarely get a yes or no decision in less than nine months. If the answer is yes, several more months may elapse before a check arrives.

The pace of operations has not changed in 10 years, and in the computer age, it still relies on paper -- mammoth quantities of paper. Last year, the NIH received 25,330 applications for research grants. These can be weighty documents, running over 100 pages each.

Scores of copies of each application are made for distribution to reviewers. And scores of copies of their responses are made for further distribution. When it's all added up, NIH officials say, the review system handles about 3 billion pieces of paper a year.

The NIH has evolved as a sacred institution, exempt from the harsh but beneficial scrutiny that other parts of government customarily receive. There's no reason to expect that the Clinton White House can take part in health politics any more than its predecessors have managed. But it's worth a try. The best start would be in the transition period, when the new chieftains of health policy are being recruited.

Daniel S. Greenberg is a syndicated columnist specializing in the politics of science and health.

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