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In the US, federal funds for scientific research are tight—a situation that is unlikely to be reversed in the near future. But how different biomedical fields will fare under conditions of restricted funding and whether existing disparities will be exacerbated are issues that have yet to be resolved. Is a reassessment of funding priorities overdue?

Consider the example of diabetes. In the US, diabetes is estimated to afflict 20.8 million individuals, of whom 14.6 million have been diagnosed. Approximately 5–10% of cases are type 1, and type 2 diabetes accounts for the remainder. According to 2002 data from the American Diabetes Association, the economic costs of diabetes in the US, including medical care and lost productivity, amount to $132 billion annually. And yet, in 2005, the National Institutes of Health (NIH) devoted only $1.055 billion to diabetes research, a figure expected to drop further by 1% in 2007.

In contrast, in 2003, about a million individuals were estimated to be infected with HIV in the US, and NIH funding for research on HIV/AIDS in 2005 totaled $2.921 billion, nearly 48 times the per-case support for diabetes. West Nile virus provides an even more extreme example of NIH funding discrepancies: in 2005, $43 million were spent on research and 3,000 infections were reported—amounting to an approximate funding level of $14,333 per infection compared with $72 per diagnosed case of diabetes. Is something wrong with this picture?

The Type 1 Diabetes Special Statutory Funding Program does provide a supplement to NIH funds for diabetes research. Established by the Department of Health and Human Services, the program has allocated $1.14 billion over ten years for research on the prevention and cure of type 1 diabetes, amounting to an extra $150 million per year since 2004. But the program ends in 2008, and a new fund does not exist to take its place.

Granted, diabetes is not an infectious disease and its cure may not have the urgency associated with efforts to prevent the worldwide spread of infection, as with HIV. And in the case of type 2 diabetes, the disease is usually associated with diet and behavior, and is consequently assumed to be preventable, eliciting little sympathy. But unlike HIV and West Nile virus infections in the US, the incidence of diabetes and associated death rates—primarily attributed to type 2 diabetes—are rising dramatically. According to the US Centers for Disease Control and Prevention, new diagnoses of diabetes increased by 54% between 1997 and 2004, and diabetes was the sixth leading cause of death in 2002. In contrast, infectious diseases did not count among the top five primary causes of death.

Diabetes is by no means unique as a disease that incurs significant societal cost and yet is arguably under-funded. So how are funding decisions made, and who determines the relative importance of a given disease?

Patient advocacy groups have an important role in influencing certain funding decisions. In California, Proposition 71's commitment of $3 billion of taxpayer money to stem cell research will be monitored by a 29-member Independent Citizens Oversight Committee, of whom 10 members are patient advocates. Private foundations, whether established by patient advocacy groups or not, also provide an important source of grants earmarked for specific biomedical research: the National Multiple Sclerosis Society devotes $40 million each year to its research programs, the Juvenile Diabetes Research Foundation in 2006 committed $100 million toward a cure for type 1 diabetes, and the Bill & Melinda Gates Foundation donated $287 million for HIV vaccine research.

Do such efforts also influence how NIH money is spent? What are the most objective means of allocating public funds for disease research? If there were a formula for translating disease burden to a dollar figure, what would be the most equitable distribution of research monies?

In the case of diabetes, type 1 accounts for 5–10% of total incidence yet garners 30% of federal funding for diabetes, according to The New York Times (May 16, 2006). However, individuals with type 1 diabetes are considered at greater daily risk of morbidity and mortality due to their disease than those with type 2 diabetes. Do such distinctions in disease impact and outlook generally account for differences in the distribution of research funds?

We can't overlook the fact that insight into one type of diabetes can contribute substantially to understanding the other. The same is true of biomedical research in general and basic science in particular—advances inform more than just the disease under study. Thus, with a decreasing NIH budget and new grants for individual investigators at record lows, the rationale for funding priorities merits closer attention—not to divert funds away from particular areas, but to highlight the need for greater support of others. At current funding levels, research simply won't offset the costs of disease.