Opinion | Advice for the next NIH director: Drive with both feet

That happened today, after a 16-month wait, with the news that the White House has nominated Monica M. Bertagnolli. If confirmed, the cancer specialist will become just the second woman to be named permanent director.

As NIH director during the pandemic, Francis S. Collins was able to keep a lower public profile than one of its institute directors, Anthony S. Fauci. But with biomedical research, from reproductive health to the study of viruses, now caught up in America’s culture wars, Collins’s successor might be in for a rougher ride.

Before quitting the Beltway for California and the private sector, I spent three decades at NIH. Having lived in both the public and private worlds of research and health, I hereby offer Bertagnolli congratulations — and some unsolicited advice.

The director represents NIH as a collective while managing a federation of 27 institutes and centers, each with its own Fauci. A previous incumbent once described it as playing the piano with 27 fingers. The director has a smaller budget and leaner staff relative to many of its institutes, yet all the responsibility for making the music that Congress and the White House expect.

Out of the nearly 20,000 employees at NIH, the director is one of two political appointees (the other is the director of the National Cancer Institute, which is Bertagnolli’s current job), and the only one with 535 bosses.

What I learned from your recent gifted predecessors, Elias Zerhouni and Collins, was that the job of NIH director required a brilliant brain, a stiff spine, a strong stomach and a big heart. Wise advice for any leadership position. I would add that the director of NIH must also have an extraordinary sense of balance.

Driving with both feet might not be safe on the Beltway, but it is the only way to lead — with the right foot accelerating toward scientific discovery and the left putting a brake on the politics.

The concept of a federal agency for scientific discovery might seem like an oxymoron. Federal agencies are rule-bound, risk-averse and responsive to political and taxpayer demands. Discovery requires innovation, risk-taking and, at its best, a willingness to upset common wisdom. It is rarely rapid or linear.

The person running NIH must reconcile the political reality of Washington, where legions make their living finding scandal or creating havoc, and the world of science, where failure is inevitable and ubiquitous. The next gene-editing or vaccine technology might emerge only after a decade of grinding, incremental experimental work, with plenty of wrong turns.

How to find the right balance? Longevity in the job depends on the left foot. As with any federal agency, personal relationships with appropriators, channels to journalists and collaboration with other agency heads are critical for leading effectively. Legacy depends on the right foot: nurturing the most innovative ideas and impactful projects to leverage breakthroughs in information science, behavioral science and biophysics.

The public needs both stability and creativity. And, of course, the public need might emerge in places and forms that none of us can predict.

Witness the pandemic and the painful difference between developing safe and effective vaccines and delivering enough vaccinations to safeguard the population. The plague of misinformation, the lack of trust in science, and the nation’s dysfunctional public health and health-care infrastructure stymied what should have been a proud moment for bridging science and service.

There are two lessons to take from this. First, NIH cannot succeed in a vacuum. Our nation’s biomedical research agency needs to address the social determinants of our nation’s health, which takes in more than health care and health science. Second, the pandemic revealed the power of public-private partnerships to unlock rapid progress. Could the Operation Warp Speed approach taken for vaccine development be applied to, say, 10 other urgent public health issues from microbial resistance to youth suicide?

In the 1940s, NIH became an umbrella agency for scientific discovery. It evolved to become an engine for improving public health in the nation and beyond. The job of NIH director is overwhelming, inspiring, surprising and sometimes infuriating. It is also the chance of a lifetime to make a difference for millions of people.

When in doubt, use the right foot.