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The National Institutes of Health (NIH) grant-making process is slow, even during a pandemic

StatNews reports that the NIH is “a slow-moving glacier” and that the agency’s “sluggish and often opaque efforts to study long Covid draw patient, expert ire.” The news get worse: Congress allocated $1.2 billion to study long COVID, but “so far the NIH has brought in just 3% of the patients it plans to recruit.” The major defense of one NIH employee? The $1.2 billion effort is moving “much faster than we’ve done anything else before” and the NIH’s “usual pace can be even slower.” How reassuring. Unfortunately, the NIH’s Covid-19 response is typical; as we wrote in August 2021, the federal grant-making apparatus is so slow that the private “Fast Grants” initiative attempted to do just what its name implies: make grants fast. And it did: within days at first, and then within two weeks. By contrast, the NIH has never learned how to go fast, and, as far as we can tell, neither have other federal agencies (although HRSA did eventually kick out some telemedicine money faster than we’d have imagined).

Why haven’t federal agencies learned to go fast? I think part of the answer is poor feedback mechanisms. No federal agency goes out of business from moving slowly—no one loses a job, money, or anything else. If even a pandemic can’t shake NIH out of their torpor, what will? A war? Maybe. We couldn’t even bother to make substantial modifications to the absurd clinical trials process during the COVID-19 pandemic, and instead relied primarily on throwing more money at the problem, while NIH continued to crawl at a snail’s pace.

America does the same thing with infrastructure construction: instead of reforming and eliminating bureaucratic rules to reduce the cost of building new infrastructure, we attempt to throw money at the problem until we manage to (partially) bulldozer our way through it. The problems being that the “throw money at it” solution takes way too long, costs too much, and leaves us with too little infrastructure at the end. But there is no single Directly Responsible Individual (DRI) for bureaucratic rules, so nothing changes—much like the stalled COVID study. The StatNews article notes that “A group of two dozen COVID-19 experts recently released a report that excoriated the NIH’s progress as well, noting that recruiting for the study has been painfully slow” and that “The experts argued the Biden administration should create a long COVID task force to hold agencies accountable for progress.” Unless the task force has the power to fire, demote, and restructure, it’s unlikely to achieve much.

Speed is important for many reasons, one being that the faster you can do something, the more you can do of the thing, and the sooner you can get feedback. One sees this feedback process—sometimes called the “Observe, Orient, Decide, and Act” (OODA) loop—in all sorts of endeavors: as the loops tightens, more of the thing gets done, or learned. In computer programming, for example, compiling or deployment that used to take hours or days now happens instantly, allowing for fast feedback to programmers, and letting the programmers get better, fast. Something similar is true in writing: the faster a person writes and gets useful critical feedback, the quicker the revision process becomes (assuming the editor is good and the writer in an improvement mindset).

The opposite is also true: as noted above, our bloated infrastructure rules from laws like the National Environmental Policy Act (NEPA) and California Environmental Quality Act (CEQA) mean that building things like subway or light rail line extension takes a decade and costs billions of dollars. So we build that infrastructure with such agonizing slowness that we never get network effects going, and most people talk of “toy trains” that “go to nowhere,” and, unfortunately, they have a point: if it takes 10 or more years to build a few miles of rail, most people are going to scoff at that rail. The road to improving the U.S.’s transit emissions starts with reforming NEPA. The law is supposedly designed to improve the environment, but instead it locks in the current system, which is not very climate friendly—the law is having the exact opposite of its intended effect.

By the time the NIH completes its studies, the studies might not matter any more. It’s like a person taking five years to decide to ask someone to get married: by the time person 1 asks, person 2 may already be married and have kids. If you wait sufficiently long, opportunities disappear.

Failure to study COVID with sufficient speed will leave people suffering, and possibly dead. That is bad. Despite it being bad, no one seems able or willing to attempt to overcome the problem.

If you don’t think speed and attention matter, try writing anything substantive with interruptions every few minutes: you’ll never get anywhere, and the end result will be unpalatable.

I wish I had a solution to these problems, but I don’t. The normal grant-making process works on a “good enough” basis, and it is typically more about redistributing money to favored communities and populations of focus than truly achieving the nominal goal of whatever the grant-funded program happens to be. Once you realize that, the rest of the system’s apparent peculiarities fall into place. Unless and until Congress wants to make substantial changes to how the federal government works, I think we’re likely to see business-as-usual continue. By far, the most successful part of the federal response to COVID was Operation Warp Speed, which rapidly kicked money to the usual suspects, in the form of pharma companies, and made pre-committments to buy large numbers of vaccine doses even if the clinical trials didn’t work out, such that trials could be conducted quickly and, if the money is “wasted” on ones that don’t work out, that “waste” is trivial relative to the amount of benefit from even a single successful trial.

Warp Speed operated at warp speed, while the NIH is still ambling along in a buggy. That’s been our experience with federal grant-making agencies: they stroll along, and nothing can or will hasten them. That’s a shame, because the country and world face real problems. As with NEPA and CEQA, however, many problems are mandated by legislators, or increased by the rule-making machinery, and no one with sufficient clout seems interested in solving them. These problems also don’t map neatly to right or left ideological talking points. The answer to whether we need “more” or “less” government, for example, is that we need more efficient and effective government, which is neither “more” or “less:” it’s orthogonal to that question, and the solutions aren’t amenable to sound bites.

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