Research is a powerful tool to improve health. Our national investments in biomedical research are producing astonishing advances in technology to diagnose and treat human illnesses. Yet, without matching national investments to strengthen complementary forms of health research, opportunities are limited for research to inform how to prevent clinical encounters in the first place or how to ensure that clinical care equitably makes us healthier when care is needed.
For example, greater insight into the origin of disease has yielded molecular signatures to guide disease treatments, gene editing for sickle cell disease, and immune system engineering and manipulation for once incurable forms of cancer. Yet, preventable death and disability continue to occur because pathways to support and apply complementary forms of research are not as well developed as the paths from discovery to drug development. Less funding is available to incentivize understanding how to effectively intervene on modifiable disease risk factors and to deliver unbiased, safe, and the most current primary and specialized care to all patients.
Funding Is Just the Beginning of the Story
At the Doris Duke Foundation, we have seen the impact that funding has on careers. Our goal to seed innovative thinking for a more creative, equitable, and sustainable future yielded insights into the molecular basis of disease, field leaders, and advances in health about which we are proud. Yet, we remained aware and concerned for the clinical research and careers in which we did not invest as much.
Paraphrasing a recent article we wrote for Issues in Science and Technology (“Medicine Means More Than Molecules,” Vol. XL, No. 4, Summer 2024), we have become concerned that our support is reinforcing an existing system of recognition and prestige tied to traditional paths of scientific inquiry that, in effect, exclude some research that may have incredible potential to improve human health.
What’s Been Overlooked
Prioritizing applicants and projects deemed most likely to draw future NIH funding, as is needed to pave a path for a sustainable career, also resulted in favoring a narrow set of people and project characteristics defining success. In our most recent competition data analyses, we also learned that too often, we overlooked research on practices that could make health care visits more effective, ways to treat disease that would result in more equitable outcomes, or interventions that might prevent clinical encounters in the first place.
Through analyses of our career development award funding for the last decade (2013–2023), we found that 40% of applicants proposed research to improve care, reduce disease, or boost the impact of proven interventions, but this group received fewer than 30% of our grants. Proposals in categories such as outcomes research, treatment, and prevention had success rates of 7%, while those focused on basic discovery or mechanisms of disease had a success rate of 11%—more than a third higher.
There is no doubt that proposed projects offered worthwhile investigations. However, time is a precious commodity and in many cases concentration on molecular-level research can impede or preclude the exploration of questions that could yield actionable solutions much more quickly than the extended process required for drug development and approval.
Questions like “What genes do cancer cells need to survive?” fit the current mold and might, eventually, lead to effective new drugs and diagnostic tests. But other important questions such as “How can we improve perinatal health outcomes for incarcerated women?” or “Can telehealth help to more effectively manage kidney disease?” tend to receive less enthusiasm within the medical research community, even though their answers could readily improve health outcomes.
Disrupting Patterns of Preference
This pattern of preference for molecular research extends beyond the Doris Duke Foundation. We are part of a subgroup of 33 nonprofit health research funders in the Health Research Alliance that have shared their 2012–2022 grant data to enable aggregate analyses. Overall, support for research on population and health services within this subgroup amounted to only 8% of the total over the 10-year span—compared to 77% for biomedical research and 15% for clinical research.
Unquestionably, many distinguished scientists are working to advance implementation, care, and prevention, and our goal is to do more to heighten the recognition of that work. That is why we have launched The Collective to Strengthen Pathways for Health Research – a joint effort of Doris Duke Foundation, the American Cancer Society, American Heart Association, Burroughs Wellcome Fund, Dana Foundation, The Donaghue Foundation, the Robertson Foundation, and Susan G. Komen – that seeks to further innovation in prevention and care. We are beginning our work in the most critical way – by listening. Through the sponsorship of a series of symposia all over the country, we hope to learn about opportunities and challenges, elevate fresh thinking, and invite the research community to help develop a roadmap to greater success. Technological innovation in molecular science has yielded huge benefits for society. But as we concluded in our IST essay, “it is also time to extend our belief in the power of science a little further—to the researchers who prioritize how to deliver care and improve health.”