Richard A. Rettig, Reorganizing The National Institutes Of Health, Health Affairs 23(1):357-262, January/February, 2004.

Special Report

Reorganizing The National Institutes Of Health

A review of an important National Research Council–Institute of
Medicine report to revitalize the NIH.

by Richard A. Rettig

ABSTRACT: A committee of the National Research Council and the Institute of 
Medicine recently released a report on reorganizing the National Institutes 
of Health (NIH). This report responds to a request by Congress in connection 
with the fiscal year 2001 budget for the NIH. The report contains some 
pragmatic proposals, avoids postulating an ideal NIH but does propose a 
radical new “special programs office” that would function as does the 
Defense Advanced Research Projects Agency, and advocates that clinical 
research be strengthened.

...

Conservatism And Boldness Underlying the committee’s concern is the inherent 
conservatism that is embedded in the existing NIH structure. The report 
calls for boldness in several ways. Congress is asked to charge the director 
“to lead a trans-NIH planning process to identify major crosscutting issues 
and their associated research and training opportunities” (no. 4). The 
report also recommends that the intramural research program take risks and 
be innovative” (no. 8). 

Perhaps the most breathtaking recommendation to this reviewer is that a 
director’s special projects program be created, fashioned after the Defense 
Advanced Research Projects Agency (DARPA) (no. 7). (The report was publicly 
released July 29, just as DARPA’s terrorism futures market was being 
eliminated in response to scathing political criticism.)18 In the 
committee’s view, Congress should fund this program initially at $100 
million, be prepared to have that amount grow to $1 billion annually, and 
commit to supporting it for eight to ten years “so that a sufficient number 
of projects can reach fruition and a full assessment of program efforts can 
be made.”19 

The high-risk, high-reward DARPA approach is weakly supported by examples of 
DARPA-like opportunities that confront the NIH. The argument that a special 
initiatives program would work, or work well enough to sustain scientific 
and political support, is highly speculative and rests on a corporate model 
that might be inappropriate. The DARPA strategy involves both supporting 
leading-edge research and carrying that through to application in a 
“research, development, test, and evaluation” process wholly owned by the 
Department of Defense (DOD). It is based on the “common defense” clause of 
the Constitution, which grants the DOD a virtual monopoly in national 
security matters. The NIH, which flies under the public health and general 
welfare clauses of the Constitution, does not own the entire process from 
bio-medical research to application in clinical practice. The issue, 
therefore, of who defines defense needs for DARPA raises the question of who 
might define health research needs for the NIH. (Back to mission we go.) 
Moreover, DARPA is largely sheltered from public view, whereas any special 
programs office in the NIH will exist in a domestic fishbowl and be 
scrutinized by the scientific community, clinical medicine, and 
disease-oriented advocates, to say nothing of the working press.

...