Can Faith Guide Public Health? NIH Director Answers | Dr. Jay Bhattacharya

I can see why, because I think you probably shouldn't have both these hats on for very long.

Oh my goodness. Okay, well, I'll try to live up to this.

Well, I mean, I think the — I'm a Christian. I accepted Christ when I was 18. That changes you, right? It changes the nature of my — what my purpose in life is, is to serve others. It's the basis of that commitment that comes from faith, from my commitment to Christ, is that I'm not living for myself. I'm living for the betterment of other people, especially vulnerable people. And that informs everything I think about. If — I resisted — you're talking about how I have the two hats and no one else has had, because it doesn't matter, right? If I don't do the job in a way that improves the health and well-being of everybody. If I don't make — these are hard decisions, these are hard jobs — but if I don't make those decisions in a way that are consistent with the calling that I have, that I believe comes really from my commitment to Christ, to do things for the betterment of others rather than for myself, then I'll have failed.

Sure. So the human fetal tissue wasn't actually all that hard a choice, in part because there's two sets of arguments that I think were very persuasive to me. First, a scientific argument. We were tracking at the NIH the use of fetal tissue in research over time. And what we've seen is a pretty sharp collapse in our support for fetal tissue because scientists weren't asking to use it anymore, or at the same levels that they were 10, 15, 20 years ago. And the reason is that there are better alternatives available. Induced pluripotent stem cells, a whole host of organoid technologies and so on. And so in that sense, the scientific importance of them, to the extent they ever were scientifically important, has been supplanted by new technologies. So that's one argument. The second argument that's persuasive to me is a public health argument. I'll just use an example from the pandemic. There were COVID vaccines that were produced using embryonic stem cells. The Johnson & Johnson vaccine, as a production matter, used them. I had the privilege of being on a bunch of Catholic radio shows during the pandemic. And routinely when I was on those shows, I would get questions about: is the J&J vaccine produced using embryonic stem cells or human fetal tissue? And then for the mRNA vaccines, were human fetal tissue involved at all in the research? And the answer is yes. For many people — not everybody, and certainly not every Christian, because every Christian, I think this is a matter of discernment and something where Christians can legitimately disagree — but for many Christians, they felt it was unethical to use these products. If you have a public health intervention where you're expecting basically almost everybody to want to use it or to have to take advantage of it, you want products that are as ethically unconflicted as possible. So a broad range of people can use it. And so, I think from a public health point of view, it really is a good idea for research to use as ethically unconflicted [materials] as possible. That's not always possible. There may be situations where some people disagree about the ethics of certain things. That's just the nature of our society. But we should seek in research to make investments in research streams that are ethically unconflicted for as broad a range of society as possible.

Let me start with the second one. I can't wait until the president nominates a permanent director and the Senate confirms. That's how long it'll last — however long that takes. I have to say though, it's been an amazing time the last three weeks. I spent a lot of time down here in Atlanta meeting with the folks in the CDC. They're two different organizations, two very distinct missions. The NIH has primarily a research mission. The research is aimed at improving the health and longevity of the American people and the world — biomedical research. Whereas the CDC has a public health mission. Both communication and on-the-ground activities, a whole host of policies and guidance to people for how to live better, healthier lives. Two distinct missions. Now, the CDC's mission has to be grounded in science for it to be really tenable. And that's where I think I've been trying to use the time at the CDC, because of the unique relationship I have with the NIH, to better integrate the CDC and NIH activities together than they might otherwise be when two busy people are trying to lead two big organizations. We've made a little bit of progress. One of the things I'm super excited about — I don't know if you remember back in 2019, the president issued a challenge to the country to end the HIV pandemic by 2030. And I remember sitting at Stanford then thinking to myself, there's no way. We don't have the technology. There's no way to do this. It's impossible. Aspirational goal, great, but how do we do this? In 2024, there was a big advance, in part based on NIH-funded research, on a drug that if you get an injection for up to a year — I think six months to a year — you're not going to get HIV even if you're exposed. You can be needle-stuck or whatever and you're not going to get HIV. It's called lenacapavir. There's other products that are coming out that provide similar protection to people who don't have HIV for an extended period of time. It's not a vaccine. It's a different kind of product that provides really broad protection against HIV for people who are uninfected. And of course, there's all these products that are already in use by people with HIV who, if you take them, first you're going to live a long life — you're not going to die from AIDS like people did in the '80s and '90s before these products were available. And also, your viral load becomes so low as to be undetectable. So, even if you have HIV, you won't necessarily spread it if you're on these drugs. You take those two things together — a way to stop HIV from spreading from people who already have HIV, and a way to prevent you from getting HIV if you don't have HIV — and if you deploy those two things in the right way, you can actually achieve the president's objective. Now, what I've done at the NIH is I've directed research to devise strategies of outreach to communities to figure out which communities are most at risk, and so on. A research mission. The CDC's public health mission can help accomplish the actual on-the-ground interventions we need to do this. We can reduce the HIV pandemic to nothing by 2030 with these two technologies. We don't need to wait for a new vaccine. I've waited 40 years for a vaccine that's never come. It's just a huge, huge opportunity, and it's being able to wear both hats — I can see how both organizations, I can motivate both organizations to take this on as a challenge. Something like JFK telling us we're going to the moon by the end of the century.

So, Brett, can I just clarify? When you say private versus public, do you mean private funders or public funders? What — or private or public —

Yeah, there certainly is a bias toward academic centers right now. So, broadly, why should the NIH exist? The argument really is that there are research streams that no private entity would ever have any interest in funding, but that are publicly beneficial. A lot of basic science work that can't be patented, for instance — the discovery of the double helix, for instance, you couldn't have patented that discovery. And yet it's fundamental to so much of biology. Fundamental biology is research that publicly — if you just relied on private funding, you would have less of it than is the right amount. And so, the NIH exists partly to fill that hole. But the NIH also exists to bring those discoveries to help usher them to the bedside. There's the so-called valley of death, where you have a great idea, a biological idea, you have maybe a product you want to try out, but it's very hard to get people excited about it in the private sector until you have some evidence that it's going to work. And so, yeah, I think the NIH also has a role in that. So, all the way across the research continuum, from basic science to trying new ideas out in human populations early stage, up to almost everything including potentially phase three studies for drugs, the NIH has some role. Now, the private sector has a tremendous role also to play. Most of the funding for testing drugs at scale happens by private sector investments. But they rely on NIH-funded innovations in order to get to that stage. Let me get back to your other point about which kind of institutions should be funded. Here, I think we actually have a problem. The NIH traditionally funds academic institutions. I think about a third of our portfolio goes to about 20 institutions in this country, all the big-name universities including Stanford. We also fund, through small business grants, some private companies and some independent labs. But primarily, the big bulk of our extramural portfolio goes to a few top universities. I think that's a problem. And the reason why I think it's a problem is not that I think those top universities shouldn't be supported, because I fundamentally do — obviously, I worked at one of them for a long time. It's that I think if you go across the country and you talk to people — I've been now to University of Alabama, University of Oklahoma, University of Iowa, Arizona State, Medical College of Wisconsin — I've been around the country. And what I've seen is that there's tremendous scientific talent with people with amazing biological ideas that have the capacity and potential to really transform how we treat a whole host of diseases, and they just have a lot of trouble getting NIH funding. And it's because of the way that we direct funding — facility support. Because the NIH doesn't just fund projects, it also funds the facilities themselves. Almost 8 to 10 billion dollars of funding goes for facility support. And so, the way we fund the facility support is: you have to have great scientists at your institution that can win the awards, and then piggybacked on top of that you get facility support. But you can see the problem, because how do you get great scientists at your institution unless you have great facilities? It's a catch-22 that guarantees that our funding is going to be concentrated. You get scientific groupthink. You get great ideas that don't have a chance because of this. I'm thinking of ways to really open that up so the funding can go to places that it doesn't traditionally go, where all the great ideas are. Fund the great ideas rather than just the facilities and the institutions themselves.

Yeah, so we have 27 different institutes and they're all focused on particular disease areas or particular biological areas. For instance, we have a National Institute of Child Health and Development, focused on research on helping kids. There's a National Institute of Aging. There's a National Institute of Heart, Lung, and Blood. There's a Dental Institute, for instance. So 27 different institutes. Each institute has its own strategic priorities for the area. For instance, one of the priorities for the National Institute of Allergy and Infectious Disease is solving the HIV crisis. That's a major focus. Each institute is led by scientists who look through this whole opportunity space and say, 'Well, here are great ideas, great places for scientists to come.' Then what we do is we put out requests for proposals from scientists across the country. Every year, last year I think we received 100,000 proposals. We can't fund maybe 8,000 to 10,000. So only a small fraction of that. So how do you choose the 8 to 10,000? Science first. Each proposal, each of the 100,000 proposals goes to a scientific review committee. It's read by three scientists, three different scientists drawn from across the country, not NIH employees. They give a score for the proposals based on three criteria. One is: how important and innovative is the proposed work? Two: are the methods somewhat reasonable? Do they have a chance of succeeding for the aims of the proposal? And then three: how good is the scientist and the institution? A lot of that third thing — when I came to the NIH, it was graded on a one to nine scale, all this detailed information. Ultimately, it doesn't really matter if the institution is fantastic or the investigator is fantastic. What matters is: does the institution and the investigator have the capacity to do the work? So, we turned it from a one-to-nine thing to a binary — zero or one. So, if you're sitting at an institution outside the top 20 and you have a great idea, you have a pretty good background, and you are capable of doing the work you're proposing, you should be able to get funding. You'll get a one on that. For the other two scores, the innovation — we have now made the institutes able to fund really highly innovative ideas. Because often you have a highly innovative idea — sounds like you had one — and then that means the methods are going to be uncertain. You don't know if it's going to work. Too often in the past, the NIH has been too conservative in not funding ideas that might not work, but if they did work, oh my gosh, you could cure type two diabetes or something. And so I've turned the culture of the institution toward being willing to take those kinds of intellectual risks even on projects. So now you may see portfolios of projects where a lot of them don't work, but the ones that do transform science or transform medicine or cure disease. In fact, I don't care if you have a portfolio of 50 projects and all they do is produce papers that sit on a shelf. What have you done? It doesn't help anybody. That's actually evidence of a failed portfolio. Instead, we're going to find a portfolio of projects — some of them will fail, it's fine. We don't know in advance. If they're constructive failures, that's actually a good thing for science. And then some of them will succeed spectacularly because they're taking big intellectual risks.

So last year Congress funded and the president signed a budget for the NIH for 48 billion dollars and we spent all that money on science. This year again Congress funded and the president signed a budget to give us a little bit over 48 billion dollars. And we're going to spend all that money on excellent science. I don't know what to tell you. I don't understand why — it's almost like people want the NIH to fail from a political point of view. They just want people to think that the NIH is failing. The numbers just don't support it. We fund right now 55,000 projects, again 8 to 10,000 new ones every year, many of them multi-year projects. I just don't know what they're looking at. There were disruptions at the beginning of last year — when a new administration comes in, there's often disruptions. But we got back on track and we put out the 55,000 projects of funding. I just don't understand. Part of it maybe is that we've changed our funding decision-making so that it favors newer investigators, favors new intellectually risky ideas. And so that means people who are used to getting funding on ideas that are just marginal or incremental, they're not getting funding and they're complaining. Of course.

Well, I think — I mean, you know, it's funny because when you talk about vaccines as a group, of course, generally many vaccines have been tremendously useful and successful in prevention. Smallpox is eradicated in part because we had a great vaccine for it. But you shouldn't be talking about vaccines as a group. You should be talking vaccine by vaccine by vaccine. You should apply good science to the story of each vaccine. Some vaccines work very, very well to prevent disease, like the measles vaccine. If you get the MMR shot, you're not going to get measles most likely. A very, very small fraction of people do, and that provides lifetime protection from measles. The COVID shots didn't provide protection against getting COVID, very famously. So they're both called vaccines, but they have very different properties regarding the disease they're supposed to prevent. They have different side effect profiles. The old chickenpox vaccine, Zostavax — I remember getting the Zostavax vaccine and I didn't even feel it. It was like nothing. The new one, Shingrix — but that Zostavax vaccine didn't do well against actually protecting you from zoster. You could still get zoster with it. The new one, Shingrix, seems to do much better at protecting against zoster, but you're going to get a sore arm for several days. You might even get a fever. All that'll happen to you. Each vaccine has its own story. And at the NIH, we are investigating that story in scientific ways. It shouldn't be a religion. It should be a matter of science for deciding what properties each vaccine has, and you direct money to places where you have diseases that are really harming people. And if you can develop a vaccine for those diseases, then that'll be — I mean, this is why the NIH has spent 40 years trying to develop an HIV vaccine. It's harmed so many people for so many years. It's a very difficult virus to develop a vaccine for. Haven't been successful at it. It's a scientifically challenging question. There have been many candidates that have failed. Failing means it doesn't actually protect you from getting HIV. I just want to take it out of this realm of almost quasi-religious awe that public health people and doctors sometimes give to it, and just make it in the space of scientific discovery and scientific questioning.

Well, I signed off on the revised schedule — signed as recommended to the former acting CDC director — and it's different than the American schedule. It's much closer in spirit to the Scandinavian schedule. I do — I think — the reason I signed off on it is not for any specific vaccine. I think that when I look at what happens in Scandinavia or the UK or a bunch of other European countries, they don't

Very few of those countries actually have vaccine mandates, and yet they have very high rates of uptake of some of the most essential vaccines like the MMR vaccine. And the reason they have that is because the public health officials trust the public to make the right decision and they give them good information to try to make those decisions, and as a consequence reciprocally the public trusts public health. That reciprocal trust is the basis for their success in vaccinations for the most essential vaccines. In the United States, we've taken a different approach. You could see this during the COVID pandemic. Public health too often took the approach of demonizing people who chose differently than what the public health recommendations said. There were polls that absolutely shocked me during the pandemic where large groups of people, often politically divided, would say if you don't vaccinate your children for COVID, then your children should be taken away from you. Essentially this idea that there's a clean and unclean class, and the unclean class chooses not to get vaccinated and the clean class does. That is the death of public trust and it guarantees that you're never going to get the high levels of vaccine uptake for the most essential vaccines that you need. I would love to restore a situation where people trust public health and public health trusts people. And that's the philosophy I've taken toward my public health engagement throughout my career.