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NIH Fails to Institute Health

Keywords

war-on-disease, 1-percent-treaty, medical-research, public-health, peace-dividend, decentralized-trials, dfda, dih, victory-bonds, health-economics, cost-benefit-analysis, clinical-trials, drug-development, regulatory-reform, military-spending, peace-economics, decentralized-governance, wishocracy, blockchain-governance, impact-investing

The Allocation Scandal

55.0 million people die annually132. The National Institutes of Health has an annual budget of approximately $47B. You would think those two facts would be related. They are not.

Of $247 billion the NIH spent over a decade, exactly 3.3% went to testing whether treatments actually work in humans133. The other 96.7% went to everything else.

That might be defensible if we’d already tested all the known safe compounds that are piled up waiting for human testing. We haven’t. There are roughly 9.50 thousand compounds with established safety profiles, and 99.7% of their possible disease applications have never been tested. The pipeline is overflowing with candidates. The bottleneck is trials.

It’s like spending 96.7% of your grocery budget on cookbooks and 3.3% on food, then wondering why you’re starving.

This isn’t just inefficiency. It’s a body count.

The NIH spends 85 percent on research and 3 percent on humans. Apparently mice are more important.

The NIH spends 85 percent on research and 3 percent on humans. Apparently mice are more important.

A JAMA study133 broke down $247.3 billion in NIH spending (2010-2019). Each of these categories funds valuable work. The question is whether the ratio makes sense when thousands of safe compounds sit untested. - 84.9% - Basic research ($209.9B): Understanding disease mechanisms, molecular biology, genomics. Essential for identifying new targets, but 85 cents of every dollar is a lot of understanding and not much testing. - 11.8% - Applied research (non-trial) ($29.3B): Translating discoveries toward practical use, but without the final step of testing them in patients. - CTSA infrastructure program: ~$1B/year in trial infrastructure, coordination, and training134 - Observational studies: Population health data collection (All of Us135: $2.16B). Valuable for identifying patterns, but observation without intervention doesn’t cure anyone. - Other applied research: Drug characterization, health services research, epidemiology - 3.3% - Phased clinical trials ($8.1B): The only category that directly tests whether treatments work in humans (Phases 1-3) - Phase 1: $1.5B (18.5% of clinical trial budget) - Phase 2: $3.5B (43.2%) - Phase 3: $2.6B (32.1%). NIH covers only 3.7-4.3% of Phase 3 costs, leaving completion to industry, which only funds trials with patent-protected profit potential. - Other/unclassified: $0.5B (6.2%) for cross-phase overhead, pilot studies, and trials not classified to a single phase - Pragmatic trials1 (30x cheaper): Severely underfunded despite proven efficiency

Why This Allocation Exists

This isn’t bureaucratic accident. It’s lobbied outcome.

The revolving door between pharma, government, and academia spins so elegantly. It’s performance art, if the art was killing people slowly.

The revolving door between pharma, government, and academia spins so elegantly. It’s performance art, if the art was killing people slowly.

Drug companies love the NIH. Taxpayers absorb the risk of basic research; industry patents whatever works. It’s like if your neighbor paid for your kitchen renovation, and then you charged them rent to eat there.

But independent trials comparing drugs head-to-head? Those are terrifying. They might reveal that the $80,000 drug works about as well as the $4 generic. PhRMA, the pharmaceutical lobby, has consistently opposed comparative effectiveness research. When Congress created PCORI in 2010, industry successfully lobbied to prohibit it from making coverage recommendations based on cost-effectiveness136. Congress literally passed a law saying “don’t fund research that might lower drug prices.” They wrote it down. In legislation. On purpose.

The revolving door helps. NIH advisory committees include industry representatives. Former NIH officials join pharmaceutical boards. Academic researchers depend on industry grants. Everyone’s incentives align against cheap, fast trials testing whether expensive drugs outperform generics. It’s not a conspiracy. It’s just that everyone involved happens to benefit from the same terrible outcome, purely by coincidence, repeatedly, for decades.

Basic research produces publications. Publications produce tenure. Tenure produces more grants. Nobody in this cycle needs anyone to get better. They need papers.

The 3.3% allocation isn’t a mystery. It’s a business model.

The Efficiency Gap: A Tale of Two Trials

The difference between efficient and inefficient trial design isn’t theoretical. Humanity accidentally ran a controlled experiment on itself during COVID. Two countries. Same disease. One spent like it was trying to cure death. The other actually did.

RECOVER Initiative (NIH Approach)

RECOVER spent 1.6 billion over four years, enrolled 30,000 patients, and completed zero trials. That’s like paying for a wedding and forgetting to get married.

RECOVER spent 1.6 billion over four years, enrolled 30,000 patients, and completed zero trials. That’s like paying for a wedding and forgetting to get married.

Budget: $1.665 billion ($1.15B + $515M in 2024) (source137) Timeline: 4 years and counting138 Patients enrolled: ~30,000139 Trials completed: Zero138 Cost per patient: $55,500

RECOVERY Trial (UK Approach)

Budget: $20M Timeline: 6 months140 Patients enrolled: 48,00066 Treatments found: Multiple, including dexamethasone141 (saved over 1.00 million lives) Cost per patient: $500

The NIH spent 111x more per patient and achieved infinitely less (dividing by zero trials completed produces infinity, which is fitting because that’s how long patients waited). This efficiency gap is not unique to RECOVERY. A systematic review of 64 pragmatic trials found a median cost of $97/patient74.

The UK trial cost 111 times less per patient and actually finished. America: where we do everything bigger, including waste.

The UK trial cost 111 times less per patient and actually finished. America: where we do everything bigger, including waste.

The British cured disease for the price of a nice dinner per patient. America spent the price of a luxury SUV per patient and cured nothing. The problem isn’t that curing disease is hard. The NIH doesn’t have a capability problem. It has a shopping addiction.

The Death Toll: Opportunity Cost of Misallocation

When you misallocate the vast majority of a $47B annual budget into low-efficiency research instead of high-efficiency clinical trials, you aren’t just wasting money. You are composting people.

Cost Per QALY (Quality-Adjusted Life Year)

  • Standard NIH Portfolio: $50K per QALY65 (and that’s being generous)
  • Pragmatic Platform Trials: $4.00 per QALY

Every $1 spent on efficient pragmatic trials buys 12.5kx more health than a dollar spent on the current NIH portfolio. The ADAPTABLE trial proved pragmatic trials cost 30x less than traditional RCTs1 ($14M vs $420M). Same science. Fewer catered meetings.

One method saves lives efficiently. The other publishes papers expensively. You’re currently funding the papers.

One method saves lives efficiently. The other publishes papers expensively. You’re currently funding the papers.

The “Death Equivalent” of Budget Misallocation

Annual Opportunity Cost: ~100 million QALYs and ~7 million death-equivalents per year. Even the most conservative estimate: ~10 million QALYs and ~700,000 preventable deaths annually.

For every dollar spent on pragmatic trials producing QALYs, the NIH spends $12,500 to achieve the same result. You are operating at 0.008% of your potential capacity to save lives. If your car ran at 0.008% efficiency, it would move one inch per gallon. If your heart pumped at 0.008% efficiency, you’d be dead before finishing this sentence. Your medical research system runs at 0.008% efficiency, and you gave it a raise.

The Translation Crisis: All Theory, No Medicine

The problem is not a shortage of ideas. It is a shortage of anyone bothering to test them.

  • FDA-approved drugs: >20.0 thousand known safe in humans
  • Repurposable compounds: ~4,700-6,800 clinically-tested candidates142 (including 3,422 marketed drugs) gathering dust
  • Plausible dementia interventions: Hundreds
  • Clinical trials available for your grandma in St. Louis: Zero

You have a warehouse of safe molecules that have never been systematically tested for new uses. The warehouse is full. The testing facility is closed for a team-building retreat.

Imagine a massive lake of possible cures connected to the ocean by a drinking straw. You built the straw that way on purpose.

Imagine a massive lake of possible cures connected to the ocean by a drinking straw. You built the straw that way on purpose.

The NIH is, by its own metrics, a publishing house that occasionally dabbles in medicine:

  • Papers published: 2.5 million NIH-funded annually143
  • New treatments approved: ~50 annually13
  • Conversion rate from paper to patient: 0.002%

For every 50,000 papers, one drug reaches a human. The rest become citations in other papers, which become citations in other papers, in an infinite loop of academics reading each other’s homework.

Plenty of Knowledge. No Translation.

  • Patients who’ve participated in trials: ~5%11
  • Patients willing to participate if invited: ~50%67
  • Patients actually invited: ~9-11%67

Half of all patients would join a clinical trial if asked. Almost nobody asks. It’s like having a room full of volunteers and a clipboard, and choosing to study the clipboard.

Understanding disease and curing disease are completely different activities. One requires microscopes. The other requires giving people medicine and seeing if they stop dying. The NIH chose microscopes.

The Public Goods vs. Club Goods Scam

The NIH claims to produce “public goods” like open science and training. What it actually produces is a free R&D department for pharmaceutical companies, funded by the same people who then pay full price for the drugs.

You pay for the research. They take the profits. It’s socialism for corporations, capitalism for you. You invented that.

You pay for the research. They take the profits. It’s socialism for corporations, capitalism for you. You invented that.

Taxpayers funded research behind 99% of new drugs144 (356 drugs, 2010-2019). Industry patents the winners. The public pays again through high drug prices. When research leads to a dead end, the public eats the loss. You pay for the lottery ticket. They cash the winnings.

The only things the NIH should fund are things private companies cannot profitably fund:

  • Open pragmatic trial platforms: 30x cheaper than traditional trials1, yet receive minimal NIH funding
  • Re-purposing generic drugs: 4,700+ clinically-tested compounds142 where no patent = no profit = no interest
  • Comparative effectiveness data: Head-to-head trials revealing which drugs actually work best (pharma’s nightmare)

These are the only things the NIH should be funding. Instead, the NIH explicitly avoids them to “not crowd out industry.” Translation: “We won’t run the trials that would lower drug prices, because the people who set drug prices asked us nicely.”

The Patient Disconnect: Zero Correlation with Health Outcomes

Correlation between NIH funding priorities and actual disease burden: 0.07145

That is not a typo. On a scale of 0 (random) to 1 (perfect), the NIH scores “basically a coin flip.” A dartboard would allocate research funding more rationally.

NIH funding has a 0.07 correlation with disease burden. That’s worse than random. A dart-throwing monkey would do better.

NIH funding has a 0.07 correlation with disease burden. That’s worse than random. A dart-throwing monkey would do better.

What patients want

  • Medicine that works
  • Access to experimental therapies
  • Trials they can join
  • A cure before they die

What NIH funds

  • Molecular mechanisms
  • Papers in prestigious journals
  • Research empires
  • Institutional overhead

Patients don’t control the money. Committees do. And committees optimize for the continued existence of committees. This is true of all committees, everywhere, since the invention of committees. Nobody has ever convened a committee that recommended fewer committees.

Money goes in. Papers come out. Patients die in the middle. The loop is working perfectly, depending on your definition of working.

Money goes in. Papers come out. Patients die in the middle. The loop is working perfectly, depending on your definition of working.

The Track Record

Since 1970, the NIH has spent over $1.1 trillion (inflation-adjusted). Diseases eradicated: Zero146.

WHO spent 300 million and eradicated smallpox. NIH spent 1.1 trillion and eradicated zero diseases. At least they published many papers.

WHO spent 300 million and eradicated smallpox. NIH spent 1.1 trillion and eradicated zero diseases. At least they published many papers.

This isn’t because eradicating disease is impossible:

  • The WHO eradicated smallpox for $300 million89
  • Jonas Salk developed the polio vaccine in a university lab and gave it away for free (which is why nobody at the NIH talks about him at parties)
  • Veterinarians have eradicated multiple animal diseases147 while the NIH was forming subcommittees about forming subcommittees

Cows have better healthcare outcomes than you do.

What Would Actually Work

The UK RECOVERY trial already proved it. $500 per patient instead of $41K. First life-saving result in under 100 days148. Over 1.00 million lives saved. The blueprint exists. It is not theoretical. It happened. In England. During a pandemic. While Americans were arguing about horse dewormer.

The recipe:

  1. Pay for results: Treatment = payment. No treatment = no payment. Radical, I know.
  2. Publish everything: Including failures (especially failures)
  3. Eliminate gatekeepers: Let patients vote with participation
  4. Automate administration: Smart contracts instead of committees (committees cannot be trusted; see above)