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Susan Blumenthal, M.D.

Susan Blumenthal, M.D.

Posted: November 29, 2010 08:04 AM

Science matters. By generating new knowledge and fueling innovation, science provides solutions to national and global health challenges. And that is why I am delighted to be included in this year's Rock Stars of Science educational campaign -- released today -- supported by GQ magazine and the Geoffrey Beene Foundation. The initiative shines a spotlight on science and scientists, underscoring the urgent need for increased investments in research to find cures for the diseases that devastate people's lives, strategies to promote better health, as well as to attract young people to careers in medical and public health research and practice. The campaign does this by pairing doctors with rock stars, highlighting the synergies of both professions, in the December, 2010 issue of GQ magazine and online. You see, rock stars and scientists share passion, creativity and the thrill of discovery. Where musicians use their minds, instruments and voices to create new rhythms, researchers use science and technology to make the music of medicine: new discoveries that improve health and eradicate disease.

The campaign draws attention to the fact that in order for the United States to continue making significant improvements in the quality of our lives and in longevity as well as to remain competitive in an increasingly technology-driven global economy, our country must strengthen its investments in science and support a new generation of researchers. [1]

The challenges and opportunities for our nation's research enterprise highlighted by the Rock Stars of Science Campaign were the subject of a recent report, "A 21st Century Roadmap for Advancing America's Health: The Path from Peril to Progress," developed by a Commission that I co-chair of national health care experts convened by the Center for the Study of the Presidency and Congress (CSPC). The Commission on U.S. Federal Leadership in Health and Medicine has proposed six key actions, described below (excerpted from the report), to ensure that the support of research, science education, and the career development of the next generation of scientists is at the forefront of our nation's public policy agenda:

1. Create a National Strategy for Sustaining Investment in Research
An essential ingredient for securing America's future in the 21st century is investing in scientific research. However, U.S. funding for biomedical and public health research has been erratic in recent years -- resulting in a real decline in the amount of funding that is available to support medical breakthroughs and a new generation of scientists. Investing in research (including basic, behavioral, social science, health care delivery, comparative effectiveness, public health and translational research) is the foundation for all health and medical interventions, serves as a cornerstone of health care reform efforts, and is an engine of economic and societal progress. Scientific discoveries are often the result of years of work and thus require dedicated, ongoing funding. President Obama's plan to invest more than 3 percent of the GDP in science is commendable, [2] but must be linked to an implementation strategy that will sustain funding for research in the years ahead. The race to find better treatments, cures and prevention strategies for cancer, heart disease, AIDS, Alzheimer's and other illnesses -- and to address global epidemics such as AIDS, tuberculosis and malaria -- depends on robust long-term investment in health research. [3] This investment also has an impact beyond the scientific sector. If funding for NIH were to be increased by 6.6 percent, the economic benefit to our country could result in an estimated $3.1 billion worth of new business activity, 9,185 additional jobs and $1.1 billion in new wages. [4]

Additionally, the intellectual advances created by publicly funded research will continue to lead to the creation of new companies in biotechnology and other scientific and engineering fields that can then export their products to the rest of the world.

To realize these benefits, there is an urgent need to reverse the recent declines in public and private support for health and medical research in the United States. [5] Over the last several years, erratic funding for biomedical research has severely crippled the field with below-inflation funding at the NIH and other science agencies.

Fortunately, the American Recovery and Reinvestment Act (ARRA) of 2009 significantly increased funding for research in Fiscal Years 2009 and 2010, providing $10.4 billion of supplementary funding at the NIH [6,7] and more than $12 billion for other agencies including the National Science Foundation (NSF). [8] The Administration's most recent NIH budget request increases the agency's FY 2010 $31 billion budget [9] to $32 billion for FY 2011. [10] These boosts in financial support provided by the Recovery Act should be the catalyst for innovative research for years to come, if it marks the beginning of sustained increases in research funding. A short-term spike in support without continued increases in post-stimulus funding will have a far less significant impact on the sciences. In the past, stricter pay lines for grants have resulted in a decrease in the numbers of young investigators being supported, prevented new innovative research from being funded and resulted in the termination of many creative projects that were underway. Other consequences include scientists becoming more conservative in their research projects and young investigators becoming discouraged from pursuing research careers, which may significantly impede the nation's scientific competitiveness and progress. Increased funding to train scientists must be coupled with enhanced research funding in order to fully realize success from our investments in both.

However, as a result of the recent 2010 congressional elections, there are now proposals circulating to cut the budgets of federal agencies to 2008 levels. If this were to be enacted for FY 2011, it has been estimated that research agencies including NIH, NSF and the National Oceanic and Atmospheric Administration (NOAA) would experience decreases in their budgets ranging from 9 to 34 percent. [11]

2. Invest in Human Capital and Academic Education Reform to Drive High-Impact, Innovative Research and Fund the Next Generation of Scientists.
America has witnessed a slow, steady erosion in its homegrown scientific talent base. As of 2003, only 12 percent of all college graduates held jobs in the fields of science and engineering. [12] For medicine and public health, training of new professionals must begin at the earliest stage of primary education, and continue through adult life. In the big picture of global competition and societal needs, it is critical for the United States to produce more scientists and engineers in order to sustain its leadership in research. Primary and secondary education systems are currently suffering from a wide variety of challenges: a morass of educational standards; high student-to-teacher ratios; "burnout" of quality teachers; and teacher preparation and compensation disparities. [13] Beyond the secondary level, inadequate preparation in mathematics and science prevents many students from achieving their potential, as do increased costs of science-intensive college and postgraduate education. The nation's research universities are also undergoing financial stress because of recent federal research funding cuts, which typically provide 65 percent of these institutions' total biomedical research funding. [14] None of these problems are easy to solve, yet all will need to be addressed if the United States is to maintain its scientific and medical leadership.

Studies and subsequent action are required to address the questions of how youth, at different age levels, learn about science, how to interest them in preparing for a science and information based economy, and how to facilitate the science education of students from diverse communities. This is of particular urgency, given the likelihood of a decline in the number and quality of scientists as the Baby Boomer generation reaches retirement age in the next decade. Because of this trend, along with deficiencies in science, technology, engineering and mathematics (STEM) education in the United States, the long and inflexible career tracks in science, and the unpredictability of funding for long periods of training (20+ years), it is clear that innovative budget, training, and education mechanisms are needed if America is to recruit and retain a new generation of creative scientists.

The federal government and private foundations should encourage scientific investigation as a central educational goal starting in elementary and secondary schools. This must involve supporting teaching programs that infuse scientific and engineering creativity and innovation into the elementary, middle and high school curricula as well as college, graduate and postdoctoral education. The current K-12 education system in the United States does not adequately equip a sufficient number of students with the skills needed to pursue graduate scientific training and research careers. The president's "Educate to Innovate" extracurricular enrichment campaign to increase middle and high school students' interest in science, math and technology is an important step towards this goal, although it does not directly provide funds for school measures such as improving the quality of teachers. [15,16] An investment is needed in America's children, providing every child with scientific education opportunities and teaching them the responsibilities of a technological society. Scientists, educators and the community should willingly play a major part in this; they must be engaged in the teaching process at all levels, including elementary and secondary school education. The Gates Foundation has embarked on a series of science and technology educational efforts across the country that can serve as potential models for some communities.

The college education of scientists and engineers in the United States has been strong. We need to maintain this strength through recruitment of the best young students, providing support for institutions that stress creative and rigorous technical training and scientific learning, and through mechanisms that connect college graduates with opportunities for exciting employment and further training.

Graduate-level and post-graduate-level science education needs modernization, to match a very different professional environment than existed 20-30 years ago. These will, in many cases, need to be re-conceptualized to prepare students for a much wider variety of science-critical careers. Science programs that have been focused very narrowly on training of a small cadre of academic researchers (professors) should be broadened to prepare individuals to enter a broad spectrum of valuable science-related positions, including serving as science teachers, science journalists, government staff, in private industry and as active members of their communities. A multidisciplinary conceptual training model for post-graduate science education can also help drive innovative interventions. This multifaceted education system would foster collaborations between medical, engineering and business schools, involving students in the entire spectrum of activities involved in the innovation process from design to delivery to implementation. In the future, science education and training programs should be evaluated on the full impact that their graduates have on a broad spectrum of activities in society, not just on the number that enter tenure track academic positions. At the same time, grant mechanisms and career pathways should be made more flexible in terms of requirements and time to independence in order to adapt to the potential and talents of each individual scientist, rather than the "one size fits all" approach of today.

Federal agencies should target their scientific budgets and programs toward promoting innovation and substantial advances at all levels, in particular by supporting early-career independent scientists. The independence of young investigators needs to be emphasized. In 1981, that average age of scientists receiving their first NIH grant was 36; today, the average age is 42. [17] As the age at which individuals get their first grant has increased, an age distribution and demographic shift in funding has occurred that may favor more established scientists. This phenomenon may discourage young investigators from entering the field as well as impede their career development. At a professional level, a talent pool with flexibility is also required, one that is able to adapt quickly to unexpected needs and novel opportunities. An effective scientific and technical corps in the United States is required so that this country can rapidly address existing and emerging medical and public health issues. The establishment of the U.S. Public Health Sciences Track in the Patient Protection and Affordable Care Act, which will award advanced degrees in public health, epidemiology, and emergency preparedness and response, is an important step forward in developing a multidisciplinary workforce. [18] Additionally, efforts are needed to attract more women and underrepresented U.S. racial and ethnic minorities to research careers.

Mechanisms are needed to allow productive and creative investigators of all experience levels to pursue what they consider to be the most promising approaches towards understanding and treating disease. Providing incentives for innovative work needs to begin at the earliest possible stages, with substantial resource allocations for programs that allow the best postdoctoral and graduate investigators to directly pursue their own innovative research projects. Programs such as the "Pathway to Independence Awards" of the NIH, which fund about 170 post-doctorates a year for independent research, should be expanded and generalized to other agencies. Furthermore, much of the problem in fostering the career development of new investigators resides with institutional policies, not just federal funding issues. Independent research is impeded when general university operating and construction budgets are leveraged with research grant funds. Federal support for research should be designed for synergy or neutrality with respect to institutional contributions, with the goal being to de-leverage the research enterprise from other institutional needs, allowing creativity and innovation of scientists to be the major driving force shaping the research enterprise. Post-doctoral fellows should be permitted to apply for independent research grants. Additionally, medical and other professional school training must become more flexible in time and content to maximize the potential of promising young scientists to be productive and creative. Rigid professional certification processes should be adjusted, and modified peer review systems that measure early-career investigators against each other, rather than in the context of a wider experience pool, should be established.

Innovative budget, training, and education mechanisms are needed if America is to recruit and retain a new generation of creative scientists. These mechanisms must overcome the challenges of federal spending cuts to research universities, deficiencies in science, technology, engineering, and mathematics (STEM) education at the primary level, the long and inflexible career tracks in science, and the unpredictability of funding for long periods (20+ years) of scientific training. Support for employment and further training for college graduates with scientific backgrounds should be increased, and graduate-level science education must prepare students for a much wider variety of science-related careers, including teaching, journalism, and work in government and private industry as well as academia. Collaborations between medical, engineering and business schools will be invaluable for providing students with the interdisciplinary training necessary to succeed in today's world. Finally, additional flexibility and recognition should be given to early-career researchers so that they have greater opportunities to establish themselves as independent scientists.

Although training American scientists is critical to our research infrastructure, the United States has never produced all of its own researchers. Scientific enterprise and the economy in the United States have flourished over time by accepting the best and the brightest from all communities and countries. At present, over 25 percent of all college educated scientists and engineers and 40 percent of doctorate holders in science and engineering occupations in the United States are foreign born. [19] From 1995-2005, nearly 25 percent of science and technology start-up companies America had at least one senior executive who was foreign-born. [20]

However, with more jobs and emerging research efforts overseas, America can no longer count on a net inflow of highly trained and educated scientific and technical professionals. Although the internationalization of science has many benefits, there will always be issues and challenges here in the United States that will need to be dealt with by our scientific infrastructure. Just as America will lose some of the scientists who have trained in our universities, there is a significant need to keep an open door policy for highly-trained individuals who are not U.S. citizens, but have the potential to contribute to America's research enterprise in critical ways. Innovative approaches are needed to maintain a productive scientific workforce, in an ever-changing national and global environment.

3. Support Comparative Effectiveness Research to Guide Public Policy and Disseminate Findings to Practitioners, Policymakers and Consumers.
Comparative effectiveness research is a critical component of determining the most cost-effective medical and public health interventions, serving as an important ingredient for helping to guide practice standards, accelerating innovative health systems redesign and encouraging innovation in health delivery. Research is needed on which diagnostic, treatment and preventive interventions are most effective. An independent CER entity (the nonprofit Patient-Centered Outcomes Research Institute) will be established as specified in the recent health reform legislation, the Patient Protection and Affordable Care Act of 2010. This Institute could gather the results of studies conducted by federal agencies and private sector research entities involved in the field. A centralized, accessible clearinghouse of findings should be established online to help guide clinical practice and speed the delivery of research outcomes to health care providers, policymakers and the public. There is currently an estimated 15 year science to service gap between the time of a new discovery in the laboratory and its wide dissemination in community practice. In the Information Age, why shouldn't this be a nanosecond? Such strategies are critical to ensuring that this and other types of research have a significant health improvement and cost-saving impact in our lifetimes.

4. Foster the Development of Health Care Delivery Systems Research.
While 4.5 percent of U.S. health care spending is devoted to biomedical research, a proportion higher than any other nation, health services research represents only 0.1 percent of this amount, a proportion significantly lower than that seen in other industrialized countries. [21] Health care delivery systems research has a direct impact on patient treatment and care. Research on the design and outcomes of population and community-based interventions as well as on systems evaluation must be supported. Additionally, a process that engages with the FDA needs to be developed to accelerate the transfer of research findings to impact in clinical, public health and community settings, reducing that 15-year science to service gap that currently exists between the time of a new research discovery and its wide application to improve the care of patients. [22]

5. Increase Funding for Behavioral and Prevention Research.
As much as 50 percent of the causes of the 10 leading killers of Americans are attributable to lifestyle and environmental factors. 38 percent of all deaths in the United States are linked to four health behaviors including tobacco use, physical inactivity, diet and alcohol consumption. [23] The U.S. spends $2.6 trillion on health care -- 18 percent of GDP -- and 75 percent of these costs are linked to behavioral and lifestyle factors. More research is needed on these issues. A strong body of public health and prevention research supports adopting a "health in all policies" approach that mobilizes all government agencies working with private sector organizations to improve health and decrease the costs of illness.

6. Enhance Investments in Global Health Research and Training.

In an interconnected world, health concerns -- such as chronic illnesses and infectious diseases including pandemic flu and HIV/AIDS -- know no borders. They affect both industrialized and developing nations. Sustained increases in both government and private sector funding are needed to synergize efforts in global health research, education, training, and service delivery, as well as to fuel partnerships between research institutions in the United States and in the developing world to respond effectively to international health issues. [24]

Summary
Our country has a unique opportunity to move the U.S. health system on a path from peril to
progress. Despite the potential challenges ahead, we cannot waver from this path, nor can we fail to act. From cutting-edge medical research to the triumph of public health interventions; from engaged communities to bold government action; from access to quality health care for all Americans to a strategy for advancing global health, all of the instruments in our national toolbox must be effectively and innovatively utilized to build a healthy America in a healthy world. [25] Only by working together across the government and private sectors and by significantly investing in research can we be successful in moving towards a healthier future for all in the 21st century.

Rear Admiral Susan Blumenthal, M.D., M.P.A. (ret.) is Director of the Health and Medicine Program at the Center for the Study of the Presidency and Congress in Washington, D.C., a Clinical Professor at Georgetown and Tufts University Schools of Medicine, Chair of the Global Health Program at the Meridian International Center, and Senior Policy and Medical Advisor at amfAR, The Foundation for AIDS Research. She is also the Public Health Editor of the Huffington Post. Dr. Blumenthal served for more than 20 years in senior health leadership positions in the Federal government in the Administrations of four U.S. Presidents, including as Assistant Surgeon General of the United States, the first Deputy Assistant Secretary of Women's Health, as a White House Advisor on Health, and as Chief of the Behavioral Medicine and Basic Prevention Research Branch at the National Institutes of Health. Admiral Blumenthal has received numerous awards including honorary doctorates and has been decorated with the highest medals of the US Public Health Service for her pioneering leadership and significant contributions to advancing health in the United States and worldwide. She is the recipient of the 2009 Health Leader of the Year Award from the Commissioned Officers Association. Admiral Blumenthal was recently named a 2010 Rock Star of Science.

This article presents recommendations from the report, "A 21st Century Roadmap for Advancing America's Health: The Path from Peril to Progress," developed by The Commission on U.S. Federal Leadership in Health and Medicine that I co-chair with Denis Cortese, M.D., Emeritus President and CEO of the Mayo Clinic. The Commission is comprised of national research and health care experts convened by the Center for the Study of the Presidency and Congress (CSPC). The report was published in May, 2010.

Sources:
[1] American Physical Society, "Recent Activity, FY 2008 Budget Progress," (accessed February 16, 2010).

[2] Office of the White House Press Secretary, "Remarks by the President at the National Academy of Sciences Meeting," Statements and Releases, 27 April 2009. Available at: http://www.whitehouse.gov/the_press_office/Remarks-by-the-President-at-the-National-Academy-of-Sciences-Annual-Meeting/ (accessed January 12, 2010).

[3] amfAR, The Foundation for AIDS Research and Treatment Action Group, "Issue Brief - A Sound Investment: The Multiplier Effect of AIDS Research," March 2010.

[4] Families USA, "In Your Own Backyard: How NIH Funding Helps Your State's Economy," Global Health Initiative Report, June 2008. http://www.familiesusa.org/issues/global-health/publications/backyard-key-findings.html (accessed February 16, 2010).

[5] E. Ray Dorsey et al., "Funding of US Biomedical Research, 2003-2008," JAMA, 2010; 303(2):137-143. Available at: http://jama.ama-assn.org/cgi/reprint/303/2/137.

[6] National Institutes of Health, Statement from the Director, "NIH's Role in the American Recovery and Reinvestment Act (ARRA)," http://www.nih.gov/about/director/02252009statement_arra.htm (accessed February 16, 2010).

[7] National Institutes of Health, "Recovery Act Grant Information: Supported by the American Recovery & Reinvestment Act of 2009 (ARRA)," National Institutes of Health Website, (Bethesda, MD: Department of Health and Human Services). http://grants.nih.gov/recovery (assessed January 6, 2010).

[8] American Recovery and Reinvestment Act of 2009, H.R. 1.111th Congress, 1st Session. (2009). See also American Association for the Advancement of Science, "Final Stimulus Bill Provides $21.5 Billion for Federal R&D," AAAS R&D Funding Update on the 2009 Stimulus Appropriations Bill, 12 Feb 2009. http://www.aaas.org/spp/rd/stim09c.htm (accessed January 13, 2010).

[9] Office of the Budget, National Institutes of Health, "Enacted Appropriations for FY2008-FY2010." Available at: http://officeofbudget.od.nih.gov/pdfs/FY11/FY%202010%20Enacted%20Appropriations.pdf .

[10] Office of Management and Budget, Budget of the United States Government, Fiscal Year 2011, Department of Health and Human Services. Available at http://www.whitehouse.gov/omb/budget/fy2011/assets/health.pdf.

[11] American Association for the Advancement of Science. "AAAS Report XXXV: Research and Development FY 2011." May 2010. Available at http://www.aaas.org/spp/rd/fy2011/.

[12] Nirmala Kannankutty, "2003 College Graduates in the U.S. Workforce: A Profile," National Science Foundation, Division of Science Resources Statistics, (Arlington, VA: NSF 06-304, December 2005). Available at: http://www.nsf.gov/statistics/infbrief/nsf06304.

[13] Roosevelt Y. Johnson, Daryl E. Chubin, and Shirley M. Malcom, "Education and Human Resources in the FY 2010 Budget: Investing in the Future of STEM Education." Research and Development FY 2010, AAAS Report XXXIV: Chapter 4, Intersociety Working Group, American Association for the Advancement of Science (2009). Available at: .

[14] Thomas F. Boat, "Insights From Trends in Biomedical Research Funding," JAMA. 2010;303(2):170-171. Available at: .; See also E. Ray Dorsey et. al., "Funding of US Biomedical Research, 2003-2008," JAMA, 2010; 303(2):137-143. Available at: .

[15] Office of the White House Press Secretary, "President Obama Launches 'Educate to Innovate' Campaign for Excellence in Science, Technology, Engineering & Math (STEM) Education," 23 November 2009. Available at: .

[16] Kenneth Chang, "White House Pushes Math and Science Education," The New York Times, November 22, 2009. Available at: (accessed February 16, 2010).

[17] Collins, Francis. Scientists Need a Shorter Path to Research Freedom. Published online 6 October 2010 | Nature 467, 635 (2010). < http://www.nature.com/news/2010/101006/full/467635a.html> accessed Nov. 9, 2010.

[18] Patient Protection and Affordable Care Act, H.R. 3590, 111th Congress, 2nd Session (2010).

[19] National Science Board, "Science and Engineering Labor Force", Science and Engineering Indicators 2008: NSB 08-01, NSB 08-01A, Chapter 3 (Arlington, VA: National Science Foundation, Division of Science Resources Statistics, January 2008). Available at: .

[20] Associated Press, "Immigrants Behind 25% of Start-Ups," USA Today, January 3 2007, (accessed Feb. 16 2010).

[21] E. Ray Dorsey et al., "Funding of US Biomedical Research, 2003-2008," JAMA, 2010; 303(2):137-143. Available at: ; See also Thomas F. Boat, "Insights From Trends in Biomedical Research Funding," JAMA. 2010;303(2):170-171, available at: < http://jama.ama-assn.org/cgi/reprint/303/2/170>.

[22] E. A. Balas and S. A. Boren, "Managing clinical knowledge for health care improvement," Yearbook of Medical Informatics (2000): 65-70. Available at: .

[23] Ali H. Mokdad et al., "Actual Causes of Death in the US, 2000," JAMA 2004; 291(10); 1238-1245.

[24] Michael H. Merson and Kimberly Chapman Page, "The Dramatic Expansion of University Engagement in Global Health Implications for U.S. Policy," Center for Strategic and International Studies, Global Health Policy Center, April 2009. Available at: .

[25] Blumenthal, SJ and Cortese, D (eds.), "A 21st Century Roadmap for Advancing America's Health: The Path from Peril to Progress," Center for the Study of the Presidency and Congress, May 2010