How Trump's NIH pick could upend the agency

• There's generally less risk-taking today that pushes science in new directions, in part because of economic incentives and the higher likelihood that research confirming earlier work will pay off.
• "Getting science right is arguably the single-most important thing we can do in society," says Caleb Watney, co-founder and co-CEO of the Institute for Progress.

Catch up quick: Trump last month nominated Bhattacharya, a Stanford University health economist, to run the NIH and its nearly 19,000 employees across 27 institutes and centers.

• Bhattacharya was a polarizing figure during the pandemic, criticizing COVID-19 lockdowns and vaccine mandates, and pushing the idea of protecting vulnerable populations like the elderly while letting others resume their lives.
• Ex-NIH director Francis Collins dismissed it as fringe thinking and a diversion from mainstream science. He and others said it was dangerous.
• Collins, who retired at the end of 2021, has more recently expressed some remorse for not considering the full effects of the government's pandemic policies.

What's received less attention is Bhattacharya's work analyzing aspects of NIH funding and calls for revamping the agency.

• He's floated the idea of setting term limits for NIH officials, reevaluating the agency's process for reviewing grant proposals, rethinking how the NIH measures novelty and success so it can take on more risk, and developing other ways to spur and support novel ideas, or what's known as "edge science."
• Bhattacharya "will be a critical asset to bring in needed outside perspectives to re-evaluate the NIH's operations and processes to restore the organization's former gold standard of medical research and better address America's health challenges," Kush Desai, spokesperson for the Trump-Vance transition team, told Axios in an email.

The big picture: Bhattacharya is far from the first to identify how the NIH and other agencies struggle to support risk-taking. (The agency has set up "high-risk, high-reward" programs to support innovative science.)

• And beyond biomedical science, there's an ongoing debate about why the rate of scientific progress appears to be slowing down despite an increase in the number of scientists, amount of funding for their work, and the quantity of papers they publish.
• Some researchers believe the low-hanging fruits of discovery have simply already been plucked, meaning scientists have to work harder and more money needs to be invested to get what remains.
• Others, including Bhattacharya, argue something has gone institutionally wrong with how science is funded — including with taxpayer dollars — and evaluated and are looking for ways to correct the course.

Along with economist Mikko Packalen, his former student who is now an economist at the University of Waterloo in Ontario, Bhattacharya has found NIH is overall supportive of novel scientific ideas.

• But their analysis showed the funding of innovative ideas at the agency skews toward basic science rather than clinical research. They argue the NIH should double down on novel and incremental research in basic science that the private sector doesn't have an incentive to fund.
• They acknowledge, though, that the agency, as a taxpayer-supported institution, is under pressure to deliver results.
• Other researchers have put forth a range of ideas for spurring innovative science, including adopting a model of funding people not projects — an approach taken by the Howard Hughes Medical Institute — or offering prizes as incentives.

Zoom in: Bhattacharya and many others have homed in on the grant review process as an arena for reform.

• Bhattacharya has called for more younger scientists — who have been found to be more innovative than their older counterparts — to be involved in the process.

• Other researchers have suggested changing how grant proposals are scored or using a modified lottery to select grants after those that clearly aren't viable are removed from the pool.
• "Everyone complains about peer review," one former senior NIH official said. But "picking the winners isn't that easy in science."

And any changes could be slow in coming since the NIH director doesn't have the undisputed final word.

• Committees at the NIH and across agencies are bound by the Federal Advisory Committee Act, or FACA, of 1972.
• Changes instituted under former President George W. Bush's NIH director Elias Zerhouni in 2006 took an act of Congress.

Others argue the root of the risk-taking problem runs far deeper and beyond the bounds of the NIH.

• Harold Varmus, who led the NIH under former President Clinton, says the real problem is hypercompetition. "Too many good people are looking for support and the result of high-level competition is a tendency to look for the most secure ideas to pursue."
• "When the success rate of a grant being funded is 10% or 20%, scientists look for a safe route."

Between the lines: Another big question is how much high-risk science the NIH — or any agency's — portfolio should have, and what level of risk is acceptable for public funding.

What to watch: Bhattacharya's supporters — and those who expressed cautious optimism about his nomination — say he could run some experiments to test these ideas in the high-risk, high-reward programs where the director does have more direct discretion.

• "There is so much to do. None of this glamorous," says Pierre Azoulay, an economist at MIT who was a co-investigator on a grant with Bhattacharya before the pandemic.
• He says its also important not to lose sight of the fact that the NIH "still funds a lot of great research" and "you can imagine some reforms doing more harm than good."
• But he says, "it leaves me hopeful that there is a nominee ... who has thought about the scientific enterprise using the scientific method — that is a complete first."

Editor's note: The story has been updated to include Collins' more recent reflections on the COVID pandemic response.