[Transforming medicine through discovery. Major trends in biomedical research]

The NIH, which originated from the Marine Hospital Laboratory of Hygiene (1887), was established as the national agency for medical research by President F. D. Roosevelt in 1944. The NIH rests on its independent, world-class peer review process and its distinctive scientific and public advisory structure. The two-fold mission of NIH is to define research priorities based on public health needs and to allocate funding. Eighty-four percent of the budget supports 300,000 extramural scientists and research workers at more than 3,000 universities. Only 16% of the budget is spent within the NIH itself (on administration and the 27 institutes and centers, including some 10,000 intramural scientists, that make up NIH today). The ecosystem of science and biotechnology connects NIH, the public, Congress, universities, the FDA, industry, and investors. The budget, which in 2007 was $29 billion, is submitted to Congress by the Director. The impact of biomedical research over the last 30 years is demonstrated by an increase in life expectancy anda decrease in death and disability from many diseases. Five evolving challenges in public health include acute conditions becoming chronic, the aging of the population, health disparities, emerging or re-emerging infectious diseases, and emerging non-communicable diseases (obesity, mental illness). Medical strategies must clearly be transformed for the 21st century. Molecular diagnosis of preclinical disease is the paradigm of the future: intervening before symptoms appear because the preclinical molecular events are known and because we have the ability to detect at-risk patients constitutes the "future paradigm of the 4 P's." Currently, the fundamental scientific barrier is our limited understanding of the complexity of biologic networks. New theoretical concepts are needed in this "hardware-to-software phase." Any roadmap for the acceleration of medical discovery will have to integrate new pathways, future research teams, and the restructuring of clinical research.