FROM THE EOITOR
Limited
Research Funds and Cardiac Without Cardiac Surgery
B
ad times have befallen the National Institutes of Health (NIH). Although NIH’s total budget rose steadily during the 1980s (in constant dollars it increased by 50% between 198 1 and 1990), the number of new and renewable grants funded dropped sharply in 1989 and will plunge again in 1990 (Figure 1). Although some of the new monies have been allocated to national priorities such as AIDS ($300 million in 1990) and the human genome project ($59 million in 1990) the major explanations for the drop in funding of new and renewable grants are the increased number of grants awarded in previous recent years, the increase in average cost of each grant, and the increase in average length of each research project. The number of new and renewable grants that received funding went from 5,493 to 6,477 from 1984 to 1987 and the average length of each project went from 3.3 to 4.1 years from 1983 to 1988. Thus, research projects approved in previous years are soaking up most of the available grant money, and little is left to launch new ones. Federal medical research monies are not being allocated in proportion to the magnitude of the problems. According to the National Center for Health Statistics, in the USA in 1989 AIDS will cause about 34,400 deaths, cancer about 494,400, and heart disease 777,630 deaths. In contrast to these death totals, federal spending in fiscal 1989 for research and education in AIDS will amount to $1.3 billion, for cancer $1.4 billion, and heart disease, $1 .O billion.
MORE MONEY;
The National Heart, Lung, and Blood Institute (NHLBI) has been hard hit. Only 13% of its approved grants will be funded this year and of those funded, the numbers of dollars allocated will be 13% less than the amount ap proved. The intramural program (the on-campus research program) of the NHLBI also is being hard hit. A big item in the intramural budget is that spent for patient care, and nearly 60% of the $17 million so spent is for cardiac surgery. Thus, the elimination of cardiac surgery would free up a sizable amount of money for research in other NHLBI laboratories. And that’s what was done. The Surgery Branch will discontinue clinical activities in June 1990 and research activities in June 1991. But can a broad clinical research program in heart disease exist without cardiac surgery? Can cardiology be strong in the absence of cardiac surgery? I think not. Unfortunately, with certain notable exceptions like systemic hypertension, most symptomatic heart diseases are best treated by surgery because most heart diseases produce mechanical blood flow problems. Congenital heart disease (with its defects in cardiac septa or abnormal communications or connections between vessels or cardiac chambers or obstruction at, below or above cardiac
FEWER GRANTS
THE ROOT OF THE PROBLEM NUMBER
NUMBER 7000
Medicine
OF GRANTS
OF GRANTS
$0 8 7
6000 6 5
5000
4 4000 80
81
82
83
84
85
86
87
88
89
90:
YEAR
83
84
* Estimate
FtGURE l.NIN’stotalbudgetromsteadtyduingthe 1SSOs,butthemmberotnewandumpedng 1989MdRwn~~in1990.Thcknlga~arein~ddhrr.Incon~~,NIH’s~~incrcll~by 50% between 1981 md 1990. Asthemmnbefotnewgrantsinueased inthemid-19803NIHtodconaoom~thaRcould~keap.UnW19gs,(he commitmantindex,~tedbymultCplyingthcnumbarotncwgr~by~ravcrage~,~muchfrukr~nthetotal numberofgmntsNIHcodd~.Repmrhmd with permidm frem P&e J, Schce
536
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
65
85
86 YEAR
87
88
grantsdroppsdshauplyin
1989(November
24);246:988.
89
valves) is definitively treated only by surgery. Valvular heart disease (with its obstructions and leaks) is deftitively treated only by surgery. Coronary artery disease today is more definitively treated by surgery than by other means. Pericardial disorders often require surgery. The cardiac catheterization laboratory is purely a diagnostic one-not a therapeutic one-without cardiac surgery readily available. Treatment of heart dii today requires both cardiology and surgery and centers without both will, in my view, not be major centers for long. The intermingling of specialists in cardiac medicine and in cardiac surgery under the same roof is essential for the proper development of each. So Surgery at the National Heart, Lung, and Blood Institute is going because the money is needed elsewhere for more “high-risk research.” (Other reasons given for its demise also include the “changing nature of the cardiology research programs,” the “inability to recruit and maintain a permanent cadre of qualified surgeons,” and “program priorities.“) The entire NIH budget in 1990 is about $7.5 biion. In contrast, the Defense Department’s budget currently is $302 billion-nearly 30?&of the entire federal budget. By contrast, $249 billion is spend on Social Security, $18 1 billion on interest payments, and $99 billion on Medicare. Of the $302 biion defense budget, $86 billion is spent for operations and maintenance-the cost of keeping troops in the field and maintaining weap ens; $85 billion for procurement-the cost of weapons and other supplies; $79 billion for payroll and retirement benefits, and $38 billion (5 times the NIH budget) for research and development on new weapons systems. The cost of the M-l battle tanks ($1.9 billion) is nearly twice that of the entire NHLBI budget. The cost of the F/A- 18
A Hornet jet fighter planes ($2.2 biion) is over twice the NHLBI budget. The cost of the F-16 Falcon jet lighter planes ($3.3 billion) is over 3 times the NHLBI annual budget. The United States share of NATO costs is now $130 billion, over a third of the entire Defense Department budget, and some estimate that 604 of every dollar in our $302 billion defense budget is devoted to the de fense of Europe. Over 50 years after the end of World War II the USA still has 305,000 troops in Europe. And now after the crumbling of the Berlin Wall and of the Communist regimes in Eastern Europe, the cold war is over. Troops must come home. Resources must be reallocated. To discontinue cardiac surgery and its potential research arm in the largest cardiac research center in the world because 11 million dollars could better be used elsewhere is a statement to cardiac surgeons the world over that surgeons are no longer players in the cardiac investigative world. In actuality, there is no better re search laboratory for human beings than the operating room. When cardiac surgery goes, cardiac medicine will soon follow for obstructed coronary arteries or cardiac valves or intracardiac defects or maldirected blood flow usually require operative therapy. Mr. President, a few less M-l battle tanks every year and a major cardiac research center will prosper, not fade away.
THE AMERICAN
William
Clifford
Robeds,
MD
Editorinchled
JOURNAL
OF CARDIOLOGY
FEBRUARY
15, 1990
537
Limited
Research Funds and Cardiac Without Cardiac Surgery
B
ad times have befallen the National Institutes of Health (NIH). Although NIH’s total budget rose steadily during the 1980s (in constant dollars it increased by 50% between 198 1 and 1990), the number of new and renewable grants funded dropped sharply in 1989 and will plunge again in 1990 (Figure 1). Although some of the new monies have been allocated to national priorities such as AIDS ($300 million in 1990) and the human genome project ($59 million in 1990) the major explanations for the drop in funding of new and renewable grants are the increased number of grants awarded in previous recent years, the increase in average cost of each grant, and the increase in average length of each research project. The number of new and renewable grants that received funding went from 5,493 to 6,477 from 1984 to 1987 and the average length of each project went from 3.3 to 4.1 years from 1983 to 1988. Thus, research projects approved in previous years are soaking up most of the available grant money, and little is left to launch new ones. Federal medical research monies are not being allocated in proportion to the magnitude of the problems. According to the National Center for Health Statistics, in the USA in 1989 AIDS will cause about 34,400 deaths, cancer about 494,400, and heart disease 777,630 deaths. In contrast to these death totals, federal spending in fiscal 1989 for research and education in AIDS will amount to $1.3 billion, for cancer $1.4 billion, and heart disease, $1 .O billion.
MORE MONEY;
The National Heart, Lung, and Blood Institute (NHLBI) has been hard hit. Only 13% of its approved grants will be funded this year and of those funded, the numbers of dollars allocated will be 13% less than the amount ap proved. The intramural program (the on-campus research program) of the NHLBI also is being hard hit. A big item in the intramural budget is that spent for patient care, and nearly 60% of the $17 million so spent is for cardiac surgery. Thus, the elimination of cardiac surgery would free up a sizable amount of money for research in other NHLBI laboratories. And that’s what was done. The Surgery Branch will discontinue clinical activities in June 1990 and research activities in June 1991. But can a broad clinical research program in heart disease exist without cardiac surgery? Can cardiology be strong in the absence of cardiac surgery? I think not. Unfortunately, with certain notable exceptions like systemic hypertension, most symptomatic heart diseases are best treated by surgery because most heart diseases produce mechanical blood flow problems. Congenital heart disease (with its defects in cardiac septa or abnormal communications or connections between vessels or cardiac chambers or obstruction at, below or above cardiac
FEWER GRANTS
THE ROOT OF THE PROBLEM NUMBER
NUMBER 7000
Medicine
OF GRANTS
OF GRANTS
$0 8 7
6000 6 5
5000
4 4000 80
81
82
83
84
85
86
87
88
89
90:
YEAR
83
84
* Estimate
FtGURE l.NIN’stotalbudgetromsteadtyduingthe 1SSOs,butthemmberotnewandumpedng 1989MdRwn~~in1990.Thcknlga~arein~ddhrr.Incon~~,NIH’s~~incrcll~by 50% between 1981 md 1990. Asthemmnbefotnewgrantsinueased inthemid-19803NIHtodconaoom~thaRcould~keap.UnW19gs,(he commitmantindex,~tedbymultCplyingthcnumbarotncwgr~by~ravcrage~,~muchfrukr~nthetotal numberofgmntsNIHcodd~.Repmrhmd with permidm frem P&e J, Schce
536
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
65
85
86 YEAR
87
88
grantsdroppsdshauplyin
1989(November
24);246:988.
89
valves) is definitively treated only by surgery. Valvular heart disease (with its obstructions and leaks) is deftitively treated only by surgery. Coronary artery disease today is more definitively treated by surgery than by other means. Pericardial disorders often require surgery. The cardiac catheterization laboratory is purely a diagnostic one-not a therapeutic one-without cardiac surgery readily available. Treatment of heart dii today requires both cardiology and surgery and centers without both will, in my view, not be major centers for long. The intermingling of specialists in cardiac medicine and in cardiac surgery under the same roof is essential for the proper development of each. So Surgery at the National Heart, Lung, and Blood Institute is going because the money is needed elsewhere for more “high-risk research.” (Other reasons given for its demise also include the “changing nature of the cardiology research programs,” the “inability to recruit and maintain a permanent cadre of qualified surgeons,” and “program priorities.“) The entire NIH budget in 1990 is about $7.5 biion. In contrast, the Defense Department’s budget currently is $302 billion-nearly 30?&of the entire federal budget. By contrast, $249 billion is spend on Social Security, $18 1 billion on interest payments, and $99 billion on Medicare. Of the $302 biion defense budget, $86 billion is spent for operations and maintenance-the cost of keeping troops in the field and maintaining weap ens; $85 billion for procurement-the cost of weapons and other supplies; $79 billion for payroll and retirement benefits, and $38 billion (5 times the NIH budget) for research and development on new weapons systems. The cost of the M-l battle tanks ($1.9 billion) is nearly twice that of the entire NHLBI budget. The cost of the F/A- 18
A Hornet jet fighter planes ($2.2 biion) is over twice the NHLBI budget. The cost of the F-16 Falcon jet lighter planes ($3.3 billion) is over 3 times the NHLBI annual budget. The United States share of NATO costs is now $130 billion, over a third of the entire Defense Department budget, and some estimate that 604 of every dollar in our $302 billion defense budget is devoted to the de fense of Europe. Over 50 years after the end of World War II the USA still has 305,000 troops in Europe. And now after the crumbling of the Berlin Wall and of the Communist regimes in Eastern Europe, the cold war is over. Troops must come home. Resources must be reallocated. To discontinue cardiac surgery and its potential research arm in the largest cardiac research center in the world because 11 million dollars could better be used elsewhere is a statement to cardiac surgeons the world over that surgeons are no longer players in the cardiac investigative world. In actuality, there is no better re search laboratory for human beings than the operating room. When cardiac surgery goes, cardiac medicine will soon follow for obstructed coronary arteries or cardiac valves or intracardiac defects or maldirected blood flow usually require operative therapy. Mr. President, a few less M-l battle tanks every year and a major cardiac research center will prosper, not fade away.
THE AMERICAN
William
Clifford
Robeds,
MD
Editorinchled
JOURNAL
OF CARDIOLOGY
FEBRUARY
15, 1990
537
