Common readers know that I’m a longtime critic of Robert F. Kennedy Jr., specifically his promotion of antivaccine propaganda that contributed to actual deaths in a poor nation, his promotion of weird conspiracy theories about vaccines and COVID-19, his HIV/AIDS denialism, and, properly, nearly every part about this overprivileged addled idiot. That’s, after all, why earlier than the election I characterised RFK Jr. as an “extinction-level menace to federal public well being applications and science-based well being coverage.” Nothing has modified my opinion of him for the reason that election. Certainly, I described Kennedy’s nomination for Secretary of Well being and Human Companies not lengthy after Donald Trump received the 2024 Presidential election as a “disaster for public well being and medical analysis.” And so it has been up to now, with President-Elect Donald Trump’s picks for high-ranking federal well being positions underneath his steerage having been a assortment of antivaxxers, grifters, and quacks. I imply, significantly: Dave Weldon for CDC Director? He was a hardcore antivaxxer—one of many two or three go-to antivaxxers in Congress for the antivaccine motion—again within the days even earlier than RFK Jr. first inflicted the Simpsonwood conspiracy principle on us. And don’t even get me began on Dr. Mehmet Oz for CMS Administrator, a task during which he would oversee the large Medicare and Medicaid applications, in addition to all applications underneath the Inexpensive Care Act. (Come to think about it, perhaps “antivaxxers, grifters, and quacks” is just too well mannered a characterization of Trump’s picks to date.)
Then there’s Dr. Jay Bhattacharya, who was just lately nominated for NIH Director. In comparison with previous administrators nominated by Presidents of each events, Bhattacharya is inarguably grossly underqualified, a well being economist who, not like previous NIH Administrators—significantly, evaluate him even to the present NIH Director Dr. Monica Bertagnolli—has no document of ever performed something resembling innovative biomedical analysis or run a company anyplace close to as giant because the NIH. His sole declare to fame for the reason that pandemic is COVID-19 contrarianism and his assaults on public well being as one of many signatories of the Nice Barrington Declaration. As you may recall, the GBD was an October 2020 proposal to let the virus rip by way of the “low threat” youthful inhabitants, with the futile aim of reaching “pure herd immunity,” with a poorly outlined technique of “targeted safety” that may have supposedly stored these most weak to extreme illness and demise from COVID-19 secure, permitting the presumably younger and wholesome to die at a a lot decrease price than the aged and in poor health because the virus rampaged by way of the inhabitants. It was a tendentiously libertarian and profoundly social Darwinist method to “open up the economic system” on the expense of illness and demise that by no means would have labored and in the end did trigger huge harm to public well being.
Dr. Jonathan Howard has been doing a bang-up job of calling out sure COVID-19 contrarian physicians who’ve been of late praising RFK Jr. on their monetized Substacks, to nice acclaim from antivaxxers within the feedback., all whereas claiming to be pro-vaccine and blaming provaccine docs for his ascendency whereas, risibly, claiming that “sabotaging RFK Jr.’s affirmation will improve vaccine hesitancy.” (Trace: They aren’t, a minimum of not anymore.) Chief amongst these is, after all, Dr. Vinay Prasad, the UCSF medical oncologist who has made a reputation for himself by downplaying COVID-19 severity, worry mongering about public well being interventions starting from masking to vaccines (even parroting the antivax message of “don’t comply”), and usually weaponizing evidence-based drugs (EBM) in opposition to public well being science within the identify of ideology, even going up to now to name for Anthony Fauci and different scientists to be tried and imprisoned (one other frequent antivax chorus). I had considered piling on a bit extra, and this submit is (form of) that, however as I used to be occupied with what to put in writing right this moment I assumed I ought to zero in on one thing that Dr. Prasad retains throwing on the market that no different SBM contributor has the expertise or background to deconstruct. It’s a small a part of the general promotion of RFK Jr. and his picks from “medical conservatives” like Dr,. Prasad, however it bothers me and, if applied, would change NIH funding selections eternally—and really probably not in a great way.
Research sections are a waste of time?
I’ve briefly alluded to Dr. Prasad’s concept earlier than, however given Dr. Prasad’s repetition of the thought, an increasing number of I assumed I simply needed to write about it as the problem is, as traditional, far more advanced than Dr. Prasad portrays it. Is the query of how the NIH doles out analysis funding to scientists primarily based on their grant purposes sort of “area of interest”? Maybe, however it’s critically necessary in a approach that even most physicians don’t notice. Prasad started selling his concept for “reform” of the NIH system for figuring out who will get analysis grants on the day after the election, when, amongst different good issues that he thought he noticed coming from Trump’s victory, Dr. Prasad wrote on his private monetized Substack:
The NIH is a failure. It has by no means examined give grant cash. We don’t know if the present system is healthier than modified lottery or different proposal. It has no real interest in information transparency, publishing in well timed vogue, and reproducibility. The company additionally wants a hair reduce, and a frontrunner who understands these considerations.
Initially, by any non-ideological measure, the NIH is not a failure. We will argue about whether or not it’s doing its meant job as properly or effectively because it might, however it’s not a failure. As I put it once I first realized that Dr. Bhattacharya was Trump’s choose for NIH Director, the NIH is the largest public funder of biomedical analysis on this planet and arguably the biggest engine of biomedical analysis ever created. No matter its flaws—and, as a human-created authorities establishment, it has many—the NIH is about as near a scientific meritocracy as one can think about in authorities (apart, after all, from facilities that have been created by political meddling, such because the Nationwide Heart for Complementary and Integrative Well being (NCCIH), which research the kinds of quackery that RFK Jr. likes). No, that’s not to say that the NIH can’t be improved, maybe improved quite a bit, however NIH-funded analysis has, straight or not directly, contributed to innumerable advances in drugs and fundamental medical science, together with the Human Genome Venture, gene modifying, advances within the understanding and therapy of most cancers, HIV/AIDS, and way more. Certainly, the NIH is the envy of most rich industrialized nations.
What makes the NIH a “failure,” then? Dr. Prasad doesn’t say aside from that in his opinion the NIH has supposedly “by no means examined give grant cash.” If you need a greater distillation of what I prefer to name “EBM fundamentalism,” the assumption that randomized managed trials are the one strategy to check a speculation and anything is ineffective, I’ve a tough time pondering of 1. It’s the identical perception that COVID-19 contrarians have weaponized in opposition to public well being on the whole, and vaccines as properly, for the reason that pandemic. Certainly, Dr. Prasad himself invoked “RCTs über alles” when he fell for RFK Jr.’s and Aaron Siri’s extremely deceptive longtime antivax trope about vaccines within the CDC schedule not having been all examined in opposition to “saline placebo.” What, although, does Dr. Prasad really imply by a “modified lottery”? I’ve been making an attempt to determine it out; so I did some searches of each his Substack and the group Substack Smart Drugs for which he’s one of many most important bloggers. Unsurprisingly, when Trump introduced his nomination for NIH Director, Dr. Prasad thought that Dr. Jay Bhattacharya was a “excellent choose” to run the NIH and introduced up this chestnut once more:
Jay will run randomized trials to determine which strategy to give grants is perfect. One examine might be the present system vs. a modified lottery, the place anybody who passes a fundamental check of completeness is entered right into a lottery. If 5 years later, there isn’t a distinction in publications, citations, h indices or some other metric, then it’s secure to say examine sections are a waste of time.
This has a bit extra “meat” to the proposal, however solely a bit. All that Dr. Prasad has has added are three issues:
- Grant purposes passing a “check of completeness,” no matter this implies.
- Including metrics to look at to find out if there’s any distinction between the 2 teams (publications, h-indices, or “some other metric).
- Including a timeframe.
Readers on the market who’ve had NIH grants or who’ve ever evaluated NIH grants on a examine part will instantly acknowledge some critical issues right here, the primary of which is the timeframe. 5 years is just too transient. It’s usually solely within the final couple of years of a 5 yr NIH grant—typically simply the final yr!—that the publications begin flowing, primarily as a result of the primary three or 4 years are spend doing the background work that results in the publications. Second, the selection of metrics is fairly odd. H-indices have a whole lot of issues and might be gamed. Lastly, simply what the heck is a “check of completeness”? The satan, after all, can be within the particulars. Does “completeness” simply imply that the grant utility has all of the element elements in it? Would there be any standards, as an illustration, about what the background, analysis plan, and different sections of the grant require? What concerning the traditional necessities by the NIH that the grant applicant show that the analysis crew assembled (co-investigators, consultants, and so on.) can really do the work proposed and that the establishments included within the grant have the precise services and experience to do what’s proposed? How would one assess that. It appears to me that one would want one thing very similar to a examine part.
Additionally unnoticed of this dialogue is the plethora of grant funding mechanisms that the NIH already has. Studying between the traces, what I feel that Dr. Prasad appears to be most involved with is the “gold normal” flagship NIH grant mechanism, the R01. the grant that each one biomedical researchers search. These grants are awarded for 5 years for as a lot as tons of of 1000’s of {dollars} a yr for an outlined analysis venture and are renewable after every cycle, primarily based on progress reviews and a brand new grant utility proposing what the PI will do within the subsequent 5 yr cycle. Nevertheless, the NIH has a variety of different grant mechanisms, together with the R21 (for early stage analysis and pilot tasks), trainee grants, and small enterprise grants to encourage the interpretation of discovery into marketable merchandise.
In equity, although, simply because Dr. Prasad has by no means really fleshed out this proposal in any critical approach (past throwing it on the market in listicles in two Substack posts) and has by no means, to my information, really written an in depth submit concerning the execs an cons of the present examine part system for shelling out grant funding versus different programs, “modified lottery” or among the different mechanisms proposed (e.g., the Howard Hughes Institute methodology of funding researchers, not tasks, and giving them freedom to do no matter they need with the funding they obtain), doesn’t imply that there isn’t a benefit to the thought. Nonetheless, if even Dr. Prasad can’t appear to marshal proof and arguments for this concept, you may perceive why I appear to view it with all of the seriousness of his proposal to check the childhood vaccine schedule with “randomized cluster trials,” one other proposal that he by no means fleshed out, regardless of challenges to take action. So that you see why I believe that the “modified lottery” proposal for NIH funding is as a lot shitposting one thing that sounds good to these with out class experience however is in the end meaningless.
Nonetheless, opposite to the whines of somebody like Dr. Adam Cifu, we right here at SBM don’t simply “assault.” We analyze and criticize. It seems that there exist literature and a debate about this concept. Let’s have a look. One factor I instantly seen, although, is that nearly nobody is proposing changing the present system with a “modified lottery,” simply experimenting with one. I did discover one article proposing changing the present system not simply with a “modified lottery” during which purposes are screed for sure standards however a “pure lottery,” however I doubt that even Dr. Prasad needs to go that far into fantasyland.
Research part vs. modified lottery
Let’s evaluate the present methodology of funding grants with the thought of a “modified lottery.” I’ve mentioned in excessive element the present methodology earlier than, which includes a number of layers of overview and analysis of the grants by committees referred to as examine sections, which collect collectively scientists, physicians, statisticians, and different related consultants to judge grant purposes after which give you a precedence rating that’s the main metric used to find out which grants obtain funding. (As a matter of disclosure, I’ve served as an advert hoc member on quite a few NIH examine sections, most just lately this September, in addition to on the examine sections for personal foundations.) Typically, with uncommon exceptions, the NIH funds as many grants as it could actually utilizing its budgeted funds, beginning with purposes that garner the bottom precedence rating—sure, decrease is healthier in NIH scoring!—and dealing its approach up the checklist of grant purposes by precedence rating till all its funds budgeted for analysis grants are allotted. It’s a fancy system, with a number of layers to display and consider the grant purposes submitted, after which to manage the funding and oversee progress reviews and purposes for renewal (for grant funding mechanisms that permit renewals). It’s additionally pretty costly. The FY 2024 funds for the NIH Heart for Scientific Evaluate (CSR), which manages all examine sections and grant peer overview, was $130 million, though this can be a fairly small share of the general NIH funds of $47 billion.
I additionally observe that CSR has lengthy been making adjustments to how the NIH opinions grants, most notably when Dr. Antonio Scarpa (who was the chairman of the Division of Physiology and Biophysics at Case Western Reserve College once I was there learning for my PhD) ran CSR. Beneath his management, quite a few adjustments have been made to the peer overview system, some good, some not-so-good, all of which past the scope of this submit to debate. My level is that the NIH has been tweaking and making an attempt to enhance its peer overview system so long as it has had a peer overview system. Simply because it hasn’t “examined” a system that Dr. Prasad likes doesn’t imply that it’s a “failure.”
As compared, a “modified lottery” would introduce some randomness into the method by establishing a system that screens grant purposes to choose those that meet sure predetermined standards after which randomly selecting from amongst these purposes the grant purposes that may obtain NIH funding. For instance, in a 2016 editorial advocating a modified lottery, Feric Fang and Arturo Casadevall mapped out such a system thusly:
The concept is that “meritorious” equals something that achieves a sure precedence rating, say in one of the best 20% of scores (or, in NIH lingo, decrease than the twentieth percentile). I’ll let the authors elaborate:
Given overwhelming proof that the present technique of grant choice is neither honest nor environment friendly, we as a substitute counsel a two-stage system during which (i) meritorious purposes are recognized by peer overview and (ii) funding selections are made on the idea of a computer-generated lottery (Fig. 1). The scale of the meritorious pool might be adjusted in accordance with the payline. For instance, if the payline is 10%, then the scale of the meritorious pool is perhaps anticipated to incorporate the highest 20 to 30% of purposes recognized by peer overview. This is able to remove or a minimum of alleviate sure damaging points of the present system, specifically, bias. Critiques can be issued just for grants which might be thought of nonmeritorious, eliminating the necessity for face-to-face examine part conferences to argue over rankings, which might result in rapid price financial savings. Distant overview would permit extra reviewers with related experience to take part within the course of, and higher numbers of reviewers would enhance precision. Funding can be awarded to as many computer-selected meritorious purposes because the analysis funds permits. Functions that aren’t chosen would grow to be eligible for the subsequent drawing in 4 months, however particular person researchers can be permitted to enter just one utility per drawing, which would scale back the necessity to revise at the moment meritorious purposes that aren’t funded and free scientists to do extra analysis as a substitute of rewriting grant purposes. New investigators might compete in a separate lottery with the next payline to make sure that a particular portion of funding is devoted to this group or might be given elevated illustration within the common lottery to enhance their probabilities of funding. Though the proposed system might convey some price financial savings, we emphasize that the first benefit of a modified lottery can be to make the system fairer by eliminating sources of bias. The proposed system ought to enhance analysis workforce range, as any feminine or underrepresented minority applicant who submits a meritorious utility may have an equal probability of being awarded funding. There would even be advantages for analysis establishments. A modified lottery would permit analysis establishments to make extra dependable monetary forecasts, for the reason that chance of future funding might be estimated from the share of their investigators whose purposes qualify for the lottery. Within the present system, directors should take care of higher uncertainty, as funding selections might be extremely unpredictable. Moreover, we observe that program officers might nonetheless use selective pay mechanisms to fund people who persistently make the lottery however fail to obtain funding or within the unlikely occasion that necessary fields grow to be underfunded because of the vagaries of luck.
To be sincere, perhaps it’s only a failure in imaginative and prescient, or perhaps I’m simply not as good as Dr. Prasad (one thing that Dr. Prasad, given his large ego, will surely agree with), however I fail to notice how this method, which appears to be one thing like what Dr. Prasad proposes, improves on the present system, on condition that figuring out which grants are “meritorious” underneath this method would seem to take practically nearly as a lot effort and assets as the present examine part system. In truth, it might fairly conceivably require extra work. Why? First, as is famous above, they system might included or require extra reviewers, who must be paid for his or her time. Nevertheless, even leaving that apart, underneath the present system, throughout examine part it’s the grants given the upper precedence scores by the three or 4 assigned main reviewers that aren’t mentioned as a result of they don’t have any probability of being funded. (That is generally known as an utility being “triaged.”) The candidates whose grants are triaged obtain the written evaluations of the first reviewers, however, not like grants thought of to be probably within the fundable vary, there isn’t a dialogue or debate. Within the circumstances of better-scoring grants which might be mentioned, the Scientific Evaluate Officer who organizes and runs the examine part assembly will write up an in depth abstract of the dialogue and add it to the opinions by the examine part members assigned main overview.
After all, I’m not even positive that that is the form of concept that Dr. Prasad means, as a result of he hasn’t bothered to elucidate what he means past buzzwords, aside from referring to a “modified lottery.” Prasad’s concept fairly jogs my memory of the Nice Barrington Declaration, during which the proposal is so imprecise that it’s inconceivable to know what he means in apply, though in equity even the Nice Barrington Declaration, as imprecise and poorly argued because it was, included extra element in its “pure herd immunity technique with “targeted safety” than Dr. Prasad has about his “modified lottery” concept. One can think about all types of variants of the “modified lottery” system that might be proposed, however one factor is for positive. All of them would nonetheless require a peer overview system resembling the present examine part; that’s, except one goes for a “pure lottery,” which not even Dr. Prasad appears to be proposing.
Additionally, opposite to Dr. Prasad’s have been quite a few research inspecting whether or not precedence scores for grant purposes are predictive of productiveness of the PI doing analysis utilizing the grant funds. Certainly, Feliciani et al just lately printed a taxonomy of funding mechanisms that contain a lottery, all or partially. Right here’s a chart from the overview article:
Concerning no matter it’s that Dr. Prasad means, I’m fairly positive that he doesn’t imply Sort 0 or 1 and pretty positive that he doesn’t imply Sort 4. What he in all probability means is Sort 2 or 3. Sort 3 is a system just like the one described within the first article I cited, during which peer overview determines which proposals are “meritorious” within the conventional method, assigning scores to all purposes after which selecting a share of the best-scored purposes primarily based on the anticipated funding line, after which these proposals are funded by lottery. A Sort 2 system is a hybrid system during which it’s mandated that the funding of proportion of “meritorious” grant purposes is set by peer overview, and the remainder are positioned right into a lottery pool. The concept right here is to ensure that exceedingly meritorious purposes don’t fail to obtain funding due to the “dangerous luck” of a lottery:
Sort 2 choice procedures are a distinct taste of partial lotteries with focal randomization. Whereas in Sort 1 the overview panel should give you a bypass set and could create a lottery pool to resolve ties, in Sort 2 the panel should arrange a lottery pool.7 The lottery pool usually consists of all eligible proposals deemed to be funding-worthy. Partial lotteries with bypass (Sort 2) intention to make sure that glorious proposals will not be being missed to dangerous luck (due to the bypass), and in addition promote an opportunity for these transformative, progressive or riskier analysis tasks that could be disliked by some reviewers (due to the lottery).
Be aware that Sort 2 might be additional distinguished by the scale of the lottery pool. For instance, a funder utilizing a Sort 2 process could mandate that quite a few funding selections (e.g. 10% of them) is to be decided by lottery (and 90% chosen straight by way of the bypass): on this case, we will say that the Sort 2 lottery is operating with a ten% lottery selection price. A distinct funder could mandate a 90% lottery selection price, that means that 90% of funding awards are chosen from the lottery pool, and solely 10% by way of the bypass. Such lottery selection charges will grow to be necessary in our simulation experiment and proposals for funders.
Come to think about it, I don’t assume that Dr. Prasad means a Sort 2 system. In any case, solely a fraction (which might vary from a small to a big fraction) of “meritorious grants” can be distributed as decided by a lottery.
In any occasion, the authors really ran simulations of the varied strategies. You may learn the paper in depth if you’d like, however, to summarize, there was growing distributive (“funding ought to be distributed evenly.”) and unbiased equity (“funding ought to be distributed with out gender, racial, geographic, or different biases.”) because the investigators modeled strategies from Sort 0 to kind 4 that was related to reducing epistemological correctness (“funding ought to go to the ‘finest’ proposals”), the impact being much less pronounced when it comes to epistemological correctness within the excessive competitors situation (low paylines), which, reality be instructed, has ben the state of affairs with NIH funding since I’ve been college. You may get an concept of what I imply from this determine:
Because the authors themselves observe, this was a modeling examine meant for use to information analysis on these methodologies if they’re adopted and thus can present information. Furthermore, balancing equity versus correctness is a coverage determination, not strictly a scientific determination. I can even observe that underneath this mannequin a “pure” lottery would produce the worst epistemological correctness with essentially the most equity, however is that actually what we would like in an NIH funding mechanism? If the parameters of this mannequin resemble actuality, it’s inconceivable to provide a system that’s completely honest and completely capable of choose the “finest” grant purposes, one thing that anybody who takes a while to consider the problem (not like Dr. Prasad) is probably going to determine intuitively.
Certainly, one paper steadily cited to argue that the present NIH system poorly predicts which grants would be the most scientifically productive really fairly makes some extent that the NIH is definitely fairly good at doing simply that, simply not at differentiating grants that obtain one of the best precedence scores. I’ll cite the passage that exhibits what I imply:
In distinction, a current evaluation of over 130,000 grant purposes funded by the NIH between 1980 and 2008 concluded that higher percentile scores persistently correlate with higher productiveness (Li and Agha, 2015). Though the constraints of utilizing retrospective publication/quotation productiveness to validate peer overview are acknowledged (Lindner et al., 2015; Lauer and Nakamura, 2015), this massive examine has been interpreted as vindicating grant peer overview (Mervis, 2015; Williams, 2015). Nevertheless, the relevance of these findings for the present state of affairs is questionable for the reason that evaluation included many funded grants with poor percentile scores (>fortieth percentile) that may not be thought of aggressive right this moment. Furthermore, this examine didn’t look at the necessary query of whether or not percentile scores can precisely stratify meritorious purposes to determine these more than likely to be productive.
We subsequently carried out a re-analysis of the identical dataset to particularly deal with this query. Our evaluation targeted on subset of grants within the earlier examine (Li and Agha, 2015) that have been awarded a percentile rating of 20 or higher: this subset contained 102,740 grants. This percentile vary is most related as a result of NIH paylines (that’s, the bottom percentile rating that’s funded) seldom exceed the twentieth percentile and have hovered across the tenth percentile for some institutes lately.
It’s true that the examine discovered that there was little or no distinction between grant purposes within the best-scored 20% of all purposes when it comes to the chosen end result metrics of publications (e.g., publications). In different phrases, it discovered that, opposite to what’s implied by Dr. Prasad that the NIH examine part system is a “failure,” really examine sections are fairly efficient in figuring out essentially the most scientifically meritorious purposes out of the entire pool of purposes. They simply can’t stratify the actually good purposes that garner one of the best scores finely sufficient to foretell which ones shall be most efficient; in different phrases, they’re a (considerably) blunt instrument. Certainly, scientists (together with myself) have been saying this form of factor earlier than, primarily that when paylines are solely across the tenth percentile (or, as they’ve been steadily over the past 20 years, even decrease), it turns into a crapshoot—a lottery, if you’ll—which actually glorious grant purposes shall be funded, and sure actually nice grant purposes will fail to be funded—and never as a result of they aren’t nice grant purposes that should be funded. In any case, what goal standards are there to differentiate between a grant with a precedence rating on the seventh percentile versus one on the eighth percentile. But, funding selections have to be made as a result of there’s solely a finite pool of cash, and subsequently a cutoff must be determined. Certainly, I’ve steadily mentioned that the answer to this drawback, which contributes to NIH examine sections being conservative and tending to fund “safer science” is to offer extra funding, in order that the paylines rise, not essentially to radically alter the examine part system.
Nonetheless, though it’s Dr. Prasad making the proposal, a modified lottery will not be essentially inherently a foul concept, on condition that it’s much more probably that the Trump administration will reduce, fairly than improve, the NIH funds, one of the best case state of affairs probably being that the NIH sees no vital improve in funding adjusted for inflation through the subsequent 4 years. The issue, after all, is that it’s onerous to determine simply what the heck Dr. Prasad is definitely proposing. So far as I can inform primarily based on his advocating that the grants to be distributed by lottery, he appears to be proposing a system extra just like the Sort 4 system within the taxonomy above than a Sort 3 system. Bear in mind, the Sort 3 system includes the grant pool being winnowed right down to the small share of grants deemed “meritorious,” maybe two to a few occasions the variety of grants as might be funded, after which that pool getting used to choose the winners randomly by lottery. It will contain a lot greater than only a “fundamental check for completeness” to perform that.
Then there’s the problem of how one may do a “randomized trial” of the present system versus the system that Dr. Prasad proposes that features a modified lottery? Does he even have any concept of how troublesome such a trial can be to design and perform? Simply give it some thought a minute. You’d should arrange one other parallel system for evaluating grants, after which discover a strategy to randomly assign new grant purposes to 1 or the opposite. You may guess that a whole lot of the extra outstanding and longer-funded NIH grant recipients would do their damnedest to sport the system to get their grants assigned to the previous system, and you may as well guess that those who’re assigned the brand new system and fail to win funding will use each final step of the NIH attraction course of that the can give you, not unconvincingly arguing that they have been unfairly handled as a result of they weren’t handled like everybody else. Once more, identical to his risibly dangerous proposal for a “cluster RCT” of childhood vaccination schedules primarily based on states or counties, Dr. Prasad’s proposal for a randomized trial of the previous examine part system together with his concept (if he can flesh it out) of a “modified lottery reveals simply out out of contact with actuality he’s grow to be in his ivory tower at UCSF, protected against any trace of vital pondering from the viewers that has captured him.
I’ll conclude this part by reiterating that together with some form of modified lottery within the grant approval course of will not be a wholly loopy concept. Researchers (myself included) have lengthy complained that, when you get a precedence rating that’s within the tenth percentile or under, it’s inconceivable reliably differentiate between them when it comes to which purposes are extra scientifically meritorious. It’s not totally unreasonable to attain the grants, choose one of the best 20-30% for a lottery, after which determine which of them obtain funding primarily based on a lottery or a mix involving selecting “one of the best of one of the best” within the pool after which utilizing a lottery to decide on among the many “remainder of one of the best.” Once more, although, that doesn’t look like what Dr. Prasad is proposing. Reality be instructed, I don’t assume that even Dr. Prasad is aware of what he’s proposing. He simply is aware of that he actually detested the NIH management through the pandemic, notably Anthony Fauci and Frances Collins, and, simply because he doesn’t like how the NIH carried out through the pandemic (though the NIH was not liable for public well being interventions or approving vaccines) and thinks that the NIH “has failed” in every part else that it does, notably peer overview of grant purposes by its examine sections. Furthermore, he has allowed his EBM fundamentalism coupled together with his love of shitposting to steer him to make a profoundly unserious proposal.
Similar because it ever was. However why?
An axe to grind?
One wonders why Dr. Prasad would maintain repeating this proposal, though he positive seems unable to say precisely what he means by it. I have to confess that I’ve an concept. To me, it positively appears that Dr. Prasad has an axe to grind concerning the NIH primarily based on his having educated there, having performed his hematology/oncology fellowship on the Nationwide Most cancers Institute. Two years in the past, when Dr. Prasad was promoted to full professor, he wrote:
Professors ought to have time to assume, however this has been devalued. In a delicate cash world, I usually really feel like a Mary Kay salesperson—holding a job with no assured earnings—the place you might be perennially trying to find open shifts or grants or educating slots to fund your self. I’ve been deeply lucky to be grant-funded by an extremely bold and visionary philanthropic group: Arnold Ventures. On the similar time, I’ve repeatedly seen the constraints of the NIH. That’s the reason I agree with Adam Cifu that with every 5 years after being an affiliate professor, 10% of your time ought to be purchased out by the college.
That is, after all, a not-uncommon grievance concerning the present mannequin for biomedical analysis in academia, though the issue of 1’s complete wage solely being partially funded by one’s college, with the researcher anticipated to fund the remainder by way of grants, is primarily a difficulty for analysis college. The salaries of medical college are normally funded by way of a mix of college funding plus reimbursements for medical companies rendered to sufferers, both by way of a person “you eat what you kill” mannequin or by way of a extra “socialist” mannequin during which medical college are paid salaries from the pooled medical earnings of their departments, with some clinicians who usher in much more income than their bills subsidizing the salaries of others—normally these doing a big quantity of analysis or who’re in low-reimbursement specialties (like breast surgical procedure)—who don’t handle to cowl their bills with medical earnings.
Many are the MD medical researchers who in the end discover themselves shifting their actions to an increasing number of medical work as a result of it’s grow to be an increasing number of troublesome to acquire grant funding to cowl the tutorial/analysis a part of their salaries. One additionally notes that, by no means having obtained NIH funding (extra on this under), Dr. Prasad appears to have discovered as an alternative choice to the NIH an ideologically aligned sugardaddy in Arnold Ventures, a non-public funding fund created by ex-Enron hedge fund billionaire John Arnold, for tasks that assist hospitals scale back prices, normally by slicing “pointless” or “low-value” care, which aligns fairly properly with Dr. Prasad’s opposition to public well being interventions. To be honest, although I have to level out that, alternatively, Arnold Ventures has supported Ben Goldacre and that “Second Modification” activists actually hate Arnold Ventures as a result of it additionally funds analysis into causes of and options to the issue of gun violence; so perhaps it’s not all dangerous. It isn’t the NIH, nevertheless, and Arnold Ventures has additionally supported meals crank Gary Taubes, who claims that saturated fats doesn’t contribute to weight problems. Again within the day, we wrote quite a few articles about Taubes’ claims about sugar and his declare that it isn’t “energy in/energy out” that determines weight problems however what you eat, no matter energy.
In any occasion, Dr. Prasad continued:
Throughout residency I anticipated to like cardiology, however it by no means clicked. As a substitute, H.G. Munshi, Shuo Ma, and others confirmed me how fascinating hematology and oncology might be. I went to the NIH with the imprecise concept that one might mix curiosity in oncology, EBM and regulatory science, and briefly contemplated working at FDA. However I shortly realized our present Oncology FDA was much less dedicated to EBM than it was to serving to for-profit corporations convey merchandise to market. Tito Fojo, Susan Bates, Barry Kramer, Sanjeev Bala, Sham Mailankody and plenty of others at NIH influenced my pondering. My digital mentors grew to the tons of, as I poured by way of previous problems with JCO, NEJM, JAMA and plenty of others. They included Korn, Freidlin, Tannock, Sargent, Moertel, and numerous others. I liked my time at NIH and was very productive there; Cifu and I completed our Reversal e book in my ultimate yr.
To be brutally sincere, I’ve lengthy suspected that one motive why Dr. Prasad is so hostile to the present system of figuring out which grant purposes obtain NIH funding comes from his failure ever to compete efficiently for NIH funding. I went to NIH RePorter, the NIH’s searchable database for all of its funding, the place you may lookup any grant funded since 1985. A seek for “Vinay Prasad” underneath principal investigator pulled up 4 lively grants, three to Dr. Vinayaka Prasad, a professor within the Division of Microbiology and Immunology on the Albert Einstein Faculty of Drugs, for HIV/AIDS analysis, the opposite to the World Well being Group for tobacco regulation analysis. Increasing the search to all fiscal years within the database introduced up a number of grants by Dr. Vinayaka Prasad for HIV/AIDS analysis at Albert Einstein going again to 1991. Backside line: It appears to be like as if, not like myself, Dr. Prasad has by no means been the PI on an NIH grant. Granted, I haven’t been PI on an NIH grant since 2011; so I perceive the frustration.
The distinction between Dr. Prasad and me is that I view my incapability to be funded by the NIH besides as co-investigator on different tasks extra as my failure, not a manifestation of the NIH being “damaged.” Mainly, I used to be “ok” scientifically when NIH paylines have been a bit extra beneficiant (as they have been in 2005), however now not ok after they fell to their present low ranges. Don’t get me fallacious. I’ve mentioned issues with NIH funding mechanisms earlier than, primarily its conservatism when it comes to funding “safer” science, however that conservatism tends to be a product of low funding. When you may solely fund, say, 8% of grant purposes that come by way of, taking a threat turns into harder, as I mentioned above and right here. That I used to be a casualty of that decrease funding is painful, however I nonetheless take the extra lifelike view that what was as soon as “ok” now not is after which attempt to transfer on. In distinction, Dr. Prasad blames the system 100% and doesn’t even settle for that a minimum of a part of the explanation why he hasn’t been funded by the NIH is himself.
As I alluded to earlier on this submit, when in the midst of discussing and deconstructing and refuting a proposal being promoted by an influencer like Dr. Prasad higher than the influencer himself can defend (and even describe it), that’s usually a sign that the influencer making the proposal is profoundly unserious about it. I consider that’s the case right here with Dr. Prasad, simply because it was when he mentioned that he thought that RFK Jr. had some good concepts, particularly his opposition to the start dose of the hepatitis B vaccine and his agreeing with RFK Jr.’s extremely misleading declare and longtime antivax trope implying that the childhood vaccine schedule will not be secure as a result of it hasn’t been “adequately examined” in opposition to saline placebo, full with repeated requires an unethical, impractical, and unfeasible “cluster RCT” of childhood vaccine schedules. Each are claims that betray a lack of awareness and—dare I say?—seriousness about scientific and coverage points concerned.
If that isn’t sufficient, then contemplate this. Dr. Prasad and his fellow RFK Jr. sycophants, toadies, and lackeys complain that there’s bias in NIH funding. For instance, Dr. Prasad decries what he perceives to be the “wokeness” of the NIH within the type of funded research methods to offer entry to most cancers screening checks to homeless individuals. All that goes alongside together with his rants about “woke” agendas in medical colleges. No marvel Dr. Prasad appears completely unconcerned about proposals being brazenly proposed by Dr. Bhattacharya that may withhold analysis grants from colleges that Donald Trump and his allies contemplate too “woke”:
Trump’s nominee to move the Nationwide Institutes of Well being, Dr. Jay Bhattacharya, a doctor and economist at Stanford, reportedly needs to focus on so referred to as “cancel tradition” at quite a few prime progressive universities, in accordance with The Wall Avenue Journal.
These with information of Bhattacharya’s pondering instructed the newspaper that he’s contemplating linking the doling out of billions in federal analysis grants to a measure of “educational freedom” on campuses and punishing people who apparently don’t adequately embrace views championed by conservatives.
Bhattacharya needs to tackle what he views as educational conformity in science, which pushed him apart over his criticism of the response to the COVID-19 pandemic, together with his opposition to high school closures and masks mandates to cease the unfold of the virus. He steered in a Wall Avenue Journal op ed in 2020 that solely as much as 40,000 Individuals can be killed by the pandemic. Greater than 1.2 million individuals died.
Significantly, it’s Lysenko yet again, and these types of proposals are a dagger aimed on the coronary heart of biomedical analysis, during which solely colleges deemed politically appropriate by the present administration can compete efficiently for analysis funding, the standard of the science behind their grant proposals however. In the long run, NIH examine sections are removed from a waste of time. They do distinguish scientifically meritorious proposals from these which might be missing; they only aren’t a fantastic sufficient measure to reliably distinguish between glorious proposals. That’s why we must always proceed to review methods to enhance how examine sections function, to be able to improve their scientific rigor and reduce any bias, and I’m not in opposition to including the aspect of a lottery to picking amongst proposals which might be extremely meritorious whose success and output the present system doesn’t predict precisely. Nevertheless, if among the anti-“cancel tradition” proposals of Dr. Bhattacharya are applied, such {that a} colleges’ politics matter as a lot or greater than the standard of its analysis proposals, any enhancements or “reforms” made to the NIH peer overview system would find yourself being akin to rearranging the deck chairs on the Titanic after it hits the iceberg of Trumpian political correctness as interpreted by RFK Jr. and Dr. Bhattacharya. Dr. Prasad is unconcerned about that as a result of it’s a type of political correctness that he likes, viewing it as simply revenge in opposition to his harshest critics.
“Profoundly unserious” doesn’t even start to explain that, nor does it describe Dr. Prasad’s lack of description of simply how one would do a “randomized trial” of the 2 analysis programs. Significantly, does Dr. Prasad even assume about what he’s proposing? It positive doesn’t look as if he does, however, then, thought is pointless, a minimum of scientifically-based thought. He’s not making these proposals for an viewers of scientists. He’s making them for an viewers of ideologues who don’t understand how vaccine schedules are constructed or how the NIH work.