Should the National Institutes of
Health (NIH) allocate more research dollars for
cardiovascular diseases (CVD)? According to a recent
Institute of Medicine (IOM) study entitled "Scientific Opportunities
and Public Needs: Improving Priority Setting and Public Input at
NIH," many other diseases that claim fewer lives are funded at much
higher levels by the NIH.
The study was mandated by the US Congress, who do not regard themselves
as equipped to set the research-funding priorities of NIH, an agency
headed by a Nobel laureate in medicine, staffed by scientists, and
ideally advised by formal and informal groups of many of the nation's
leading researchers. However, for several reasons outlined in the
report (the increasing centralization of decision making in the NIH
director's office, for example), national nonprofit groups that
represent specific diseases have been turning more and more to
members of Congress, bombarding them with heartfelt and typically
legitimate arguments for more NIH research funding for specific
diseases.
And the result, according to the IOM report, is that some members of
the US Congress have questioned the NIH decision-making process. They
"point to widely different amounts of research funding per afflicted
person from one disease to another. ... They also note that the
largest amounts of NIH funding do not always go toward research on
diseases that cost the federal government the most through the Medicare
program," says the report.
The number of people afflicted by a disease is only one of several
factors that influence the decisions of the NIH about levels of
research funding. Because the number of people with the disease is an
important factor, the IOM panel recommends that the NIH strengthen
"its analysis and use of health data, such as burdens and
costs of diseases, and of data on the impact of research on the health
of the public." And, according to the panel report, the NIH should
improve its communications to the public about these data and include
more representatives of the public on its
decision-making bodies, so that the public's voices, as well as the
opinions of the scientific community, can be heard and considered. In
his presentation to the IOM panel conducting the study, AHA
national science volunteer Dr Michael Rosen of Columbia University's
College of Physicians and Surgeons called for "new mechanisms to
enhance public input. ... The AHA believes that there is little
opportunity for public input into the NIH priority setting
process."
AHA leaders have been very concerned about the relatively low level of
NIH funding for CVD research. But our goal is to work with the NIH, not
against it. It is essential that we work together to correct this
funding dilemma. Many lines of communication are now open. Along
with several AHA science volunteers, I'm in constant contact with
Claude Lenfant, MD, Director of NHLBI. We are trying to synergize
AHA's and NHLBI's efforts to better serve our common goal of fighting
cardiovascular disease. AHA science volunteers and I have also talked
with Harold Varmus, MD, the director of the NIH. We have their
attention, their interest, and their concern.
Although the AHA argues that more NIH dollars should be invested in CVD
research, the AHA is opposed to reductions in the NIH research budgets
for other diseases to increase funding for heart disease and stroke
research. The entire budget of the NIH should be increased
significantly. Indeed, Research!America, a coalition of health advocacy
groups that the AHA joined under the 1997–1998 AHA presidency of
Martha Hill, RN, PhD, of Johns Hopkins University, has called for
doubling of the NIH budget in 5 years. In its advocacy efforts for more
NIH funding, the AHA calls for a 15% increase in the NIH budget each
year until the doubling of the budget is achieved.
For many of us who are committed to the AHA's mission of reducing
death and disability from CVD, the amount of NIH funding for heart
disease and stroke research has been somewhat puzzling. Jan L. Breslow,
MD, of Rockefeller University, had the vision during his AHA presidency
(1996–1997) to create a slide program entitled "Myths about Heart
Disease and Stroke" for AHA volunteers to use in
presentations to awaken the public's interest, concern,
and indeed justifiable fear of CVD. The myths highlighted were that
"heart disease is going away," "living with heart disease is not
so bad," "heart disease is a good way to die," "only older
people have strokes," "women don't get heart disease," and "no
more research is needed."
The first myth—"heart disease is going away"—is the one
that perhaps has had the greatest impact on NIH funding decisions. In
countering this myth, Dr Breslow pointed out that although the
age-adjusted death rate for coronary heart disease (CHD), the
most common form of cardiovascular disease, has been
declining, "the age adjusted death rate tells only part of the
story." When the NIH updates the age-adjusted death rate, which is
now based on the 1940 population, to the year 2000, the currently cited
death rate for CHD will almost double because of the "aging"
of the population. In the early part of the 21st century, CHD will jump
from fifth to first place in the World Health Organization's list of
causes of death and disability worldwide. Clearly, CHD is not going
away.
Neither is stroke, another form of CVD of great concern to the AHA.
After declining for many years, stroke deaths are rising. As
presented at the AHA's 23rd International Joint Conference on
Stroke and Cerebral Circulation in February 1998, recent studies
indicate that the incidence of stroke in this country is 40% higher
than "official" estimates. The aging of the population also will
result in more than double the number of stroke victims per year by
2050.
By supporting initiatives to double the NIH budget and working
with leaders of the NIH in our efforts to bring the scientific
opportunities in CVD, we will reach our goal of more research dollars
for CHD and stroke and more effective approaches to reducing death and
disability from these diseases.
Footnotes
Dr Fuster is director of the Cardiovascular Institute of Mount Sinai Medical Center in New York, NY.
© 1998 American Heart Association, Inc.
Cardiovascular News
Dilemmas of NIH Funding for Cardiovascular Research
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