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Hematology-oncology physician Adeel Khan discusses his article, “Universities must tap endowments to sustain biomedical research.” He explains how declining federal support for the National Institutes of Health threatens America’s position as a global leader in medical science and why universities must use a fraction of their massive endowments to sustain research innovation. Adeel highlights the moral and economic case for investing in science, the urgency of supporting early-career investigators, and the need for academic institutions to bridge funding gaps left by federal cuts. Viewers will learn why this call to action matters for medicine, patients, and the future of health advancement.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Adeel Khan. He’s a hematology oncology physician. Today’s KevinMD article is “Universities must tap endowments to sustain biomedical research.” Adeel, welcome to the show.

Adeel Khan: Thank you so much for having me. Pleasure to be here, Kevin.

Kevin Pho: All right, let’s start by sharing your story and then we’ll jump right into your KevinMD article.

Adeel Khan: I like to think of myself as dual trained between medicine and public health. I’ve really loved the overlap between the two. I attended medical school at the University of Michigan and did my internal medicine residency at the Cleveland Clinic. I did my hematology oncology fellowship at Beth Israel Deaconess in the Harvard system.

Along the way, I did a master in public health at Harvard and another master’s in epidemiology at Columbia. I’ve really liked the intersection between the two where, as medicine allows one to look at the patient at the individual level, public health really lets you talk about things at the population level and trends. That’s been my focus here.

Kevin Pho: All right, so you wrote more about the funding regarding biomedical research. Tell us what led you to write this article.

Adeel Khan: I’m still an early career physician. I’m at UT Southwestern now as an assistant professor, and as I’ve been trying to get my legs on the ground, one of the things that we all do is apply for grants. I certainly have done my share and updated the NIH bio sketch in the same way that everyone does.

As things became clear where the election was turning and certain themes within the sociopolitical environment, it was clear that funding, which had always been stagnant over the past few years (a few being about a decade and a half), was becoming increasingly tight. This meant that opportunities for doing the kind of work that I wanted to do became all the more limited. With what I do, which is more epidemiologic, I need less funding than those people who are doing bench work, who need a lot more funding. Then with clinical trials, that’s yet another level.

All of this relies pretty heavily in one way or another on the NIH. As that has continued to dry up, as it’s continued to be slashed and threatened, that leaves fewer and fewer opportunities for many of us. That ultimately causes the entire field to suffer. It causes all the progress that we as a country and as an academic force have been able to push forward to lose momentum, which I think is already happening.

Kevin Pho: For those who aren’t keeping up with the budget cuts and funding cuts at the NIH, give us a primer in terms of what areas are being targeted.

Adeel Khan: Looking at the consumer price index changes with the NIH in general, there was a great amount of funding in the early 2000s. There’s what’s called the doubling period that was around the late 1990s to around 2003, 2004, or 2005. The CPI-adjusted NIH funding was at its peak in 2003. Since that time, there have technically been nominal increases in the NIH budget growth overall, although there have been cuts in certain sectors. Overall, it has been increasing technically but has not kept up with inflation.

As it becomes increasingly threatened, it becomes all the more of a problem. Now, in terms of real dollars and CPI-adjusted value, there is less money now than in 2003, and this being 2025, it should be far greater. The budget stands around 50 billion (48 to 51 is what I typically see quoted), and it depends on what gets included, which is a large pool of money.

But even that does not underscore the fact that science is very expensive. Aside from the work itself, administrative costs are very high, and that is one thing that the current administration has threatened, saying that we need to have much less overhead.

To some degree, I don’t disagree with the fact that we should be more efficient, but a lot of what is done in science has a bureaucracy behind it. There’s a lot of support needed, not just for paying for reagents or supplies, but also for the fact that you need people who manage data, people who manage the administrative tasks that come with all of this to do it properly and ethically.

Those are the ones that are threatened, which, as soon as those go to the wayside, the broader issues start to become all the more emergent. Fundamentally, if you don’t have the administrative backing to do the work that you want to do, you’re not going to get to do it. A lot of the administrative-heavy work, and particularly for those who are proposing new projects in early career who have less establishment and less likelihood to get this funding, those are the ones that are the most threatened.

Kevin Pho: What happens when funding is cut midstream? I sometimes see mainstream media headlines that experiments need to be thrown out midstream. Obviously there are going to be layoffs. From a boots-on-the-ground perspective, what happens when funding gets cut off because of a change in the political agenda, for instance?

Adeel Khan: There are some people who have definitely gotten “stop work now” orders, and that is really unfortunate because that means you have no further funding. Whatever you have in progress, essentially, is gone. Unless you can wrap that up right there, you are cooked, and there’s nothing further you can do and no further support. The appeals process for it is extremely limited.

Universities to some degree have tried to patch some of that, but there’s only so much that can be done because they themselves rely on federal funding. They rely on that as their backbone. Whatever goes to a given PI’s salary, the research assistants, or reagents, the university itself is also relying on that funding for the support for all of that. When something is immediately cut, that is just the worst situation that can happen.

We are seeing some of that. That has definitely happened, and some of those have made headlines. Fortunately, I know of some cases happening in my own university where that’s happened, and it’s really been mentally and emotionally devastating to the people affected.

The downstream effect of all these cuts is, as new projects continue to not be funded, the overall system starts to slowly crumble. It starts to diminish. Few people go into it, and the robustness of the entire field, in which we rely on a network (this collaboration that happens across universities) and the opportunity to explore all of that, starts to whittle away bit by bit.

The effects that we’ll see are not necessarily now, not necessarily the stuff that’s getting cut now, but five or ten years down the line. Absolutely. Everything takes years to progress. Any squeezing of the bottleneck now means that there’s less to be done later.

One thing that people always talk about is the doubling rate of publications on PubMed, for instance. There was fantastic growth through the nineties and early 2000s. While there are still publications coming out, and the rate continues to fortunately rise, the rate of growth itself has started to slow. Part of this is the COVID-19 era, but all of this meshes together. There are already some of these effects being seen.

Kevin Pho: Who makes the determination of what gets cut? Are these funding cuts across the board? Is there an overseer that determines which products or which areas specifically get cut? Give us some insight in terms of who makes that decision and what criteria go into that decision.

Adeel Khan: Unfortunately, at the highest level, it really is very political. It’s set by HHS. Classically, the NIH director and the NCI directors have had a lot of control, but that has been threatened by even higher-ups, all the way up to the administration itself.

At the level of where a grant is submitted, though, that still is very much done by reviewers or people in the field. Whether or not they share the concerns with their immediate higher-ups is not technically relevant because if there’s less of a pool of money for them to distribute, there’s simply less for them to do with it.

They automatically become that much more selective, so they will preferentially go to more experienced investigators, those with a track record. These are the people who are already benefiting from the halo effect. Those who are early career or who have a more exploratory project, which sometimes leads to fantastic things, will not get funded.

It’s very much a hierarchy. Anything at the top that starts to have changes ripples down rapidly. Then on the ground, it’s very much seen when you don’t get the money that you were otherwise expecting.

Kevin Pho: With universities and academic medical centers being so reliant on government funding, you propose tapping into endowments. Talk more about your article on that proposal.

Adeel Khan: As this has been coming up (and this is not a new idea; it has been proposed before), the purpose of endowments for universities is really to make sure that you have a pool of money. It stabilizes the university as a whole. Because of the way that it’s invested, and it’s often invested with private individuals who manage this money, it has grown very rapidly over the decades.

If you take, for instance, Harvard’s endowment, as of last week, it’s roughly 51 billion. That’s roughly the NIH budget itself. By no means would I expect that to ever be fully spent, but to chip into it is very reasonable. Even Yale’s endowment is roughly 45 billion at this time.

There is certainly a disparity in that these elite universities have far more funding than those that are not within that same tier. But there is money there, and that is not used day-to-day. The operating budget that universities use versus what is their endowment is considered completely separate. Their operating budget is something that they tightly bracket. That’s where tuition costs get changed, where on-the-ground decisions are altered, everything from salaries to what resources they offer.

That does not even touch the endowment pool, which is very much just invested and left there. It’s literally a gold vault in a sense.

I understand and respect the hesitancy to spend endowments because wasteful spending would be detrimental in all kinds of ways. But I think the scenario now that we’re seeing is if the momentum of the scientific progress that had been achieved over decades is starting to be lost, and particularly in the biomedical sciences where a lot of money is needed and there’s so much fantastic work already being done, to just maintain that, it is extremely reasonable to start to use endowment money.

It’s very reasonable to be a bridge until circumstances in the federal government change at some point later. I fully recognize that Columbia has had quite a bit of its funding threatened federally, Penn has had some similar issues, and Harvard has been undergoing this large lawsuit, which I’m sure will pan out over years with the current administration.

But again, that money is there and it is available, and it is up to their boards to use as they deem fit. If there’s a change in mindset that would allow young investigators and the current projects being done to at least continue, I don’t think it would be a meaningful hit to the endowment overall. This is where I argue that it just has to happen. Otherwise the progress that has been made would be lost, and it’s very hard to regain that momentum. How do you revamp the system when so many people have either fled science or there’s just not the enthusiasm for it that there once was?

Kevin Pho: My understanding of endowments is that it is not just sitting in a bank, and there are a lot of these donations. They have a lot of conditions attached to them. They can only be used for a specific purpose, and it isn’t just like withdrawing 50 billion from a bank. I think that it’s a little bit more nuanced than that. What’s your understanding with that?

Adeel Khan: Yes, and there are things like legacy donations. Absolutely. The way that grants are often given, particularly these gift grants, they’re very conditional. I fully acknowledge that.

Especially with different universities, their rules of how they’re used and for what purposes certainly have regulation. But there is some degree of it that is discretionary and ultimately, it can be adjusted.

In the current scenario, that’s where I think it needs to be done. I recall a few years ago during COVID-19, when it was 2020, when Harvard had largely shut down. This was the spring of 2020. They were releasing essential workers. The argument was made there that, for such a wealthy university, it seems like a shame to not support these people who are vital to the function of the university, and it would be a very small chip into the available pool of money (endowment related) to just support them.

This was made in an article at the Harvard Crimson. Ultimately, arrangements were made, but only after controversy was raised. My point in the article (and again, I’m not the first to say it) is really, I think we need a little bit of a push to use that funding appropriately.

Kevin Pho: Tell us about some of the obstacles that you face or others have faced when this request or this push has been made.

Adeel Khan: In general, there’s not really a good mechanism for it. When a young investigator is looking for a grant, we are looking at large societies. We’re looking at the NIH, or we’re looking at private entities. In Texas, there’s something for cancer called CPRIT. I’m looking at that.

The way to petition your actual university or academic center for its money usually comes from your boss as part of the startup package. Beyond that, there really is not a great mechanism for it, which is interesting.

I’m sure at some level, unbeknownst to me, there are more details to how that can be done. But because there’s not an established path, it simply is not an option. What is in the operating budget versus what is in the pool that might be otherwise available at the board level? There’s a huge chasm between that. Without a reliable way to even request in an alternate way, like, “Hey, can I get some alternative dollars for this?” it simply doesn’t happen.

Kevin Pho: Who would make that decision to tap into the endowment for research? Is it the board, the university president, who actually makes that final call?

Adeel Khan: The board, by and large. Some of these universities have a corporate entity attached to it, and they’re the ones who are ultimately in control of the money. They often allow investment groups to invest the dollars that they have to grow them.

That’s where there’s been fantastic growth because some of these groups do extremely well with what they are able to put into the market. They very actively manage it. It’s not just sitting there. It’s very actively bought, traded, etc.

That’s what has really led to a lot of rise in what they have. That being set aside, what they actually then make available out of that, again, does not have an established mechanism, but it would be the board of each university that can set it.

Kevin Pho: To your knowledge, has there been any comment from university leadership or a board in terms of considering using part of that endowment for research purposes, anywhere in the country?

Adeel Khan: Interestingly, at my own institution, for some of the work that was done for some of these smaller projects, requests were made to higher-ups for the available pools that they have in their dean’s pool, etc., to fund some of these, to bridge some of these issues that were initially brought on.

But that can dry up very quickly. That’s really discretionary funding. Most investigators have some. As part of the startup package, there’s usually a pool that’s given, and that’s what’s then maintained.

As you get higher up, the discretionary funds for the offices also expand. There have certainly been requests made, myself included. I don’t know how well those are tracked, so I would be curious to see what the actual data looks like on how many people are requesting how much in a given circumstance.

If you look at, for instance, NIH funding, that is very well tracked. You can see the number of projects and how that’s evolved over 20 years, where the funding goes, and who does what with it. But some of these more private considerations or inter-institutional considerations are not well tracked. It’s hard to know exactly what that is looking like on the ground.

Kevin Pho: We’re talking to Adeel Khan. He’s a hematology oncology physician. Today’s KevinMD article is “Universities must tap endowments to sustain biomedical research.” Adeel, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Adeel Khan: I think for one, the NIH funding situation that we are seeing is likely not going to improve anytime soon. Even if funding does start to become more available, the stipulations that are attached to it might even become stricter. Overall, the funding has not kept up with the consumer price index, with inflation and other metrics. In this scenario, it is time for universities to dip into their endowments to bridge people to continue to do the great work that they’re doing so that the momentum of the scientific progress that has been made over the decades is not lost.

Kevin Pho: Adeel, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Adeel Khan: Thank you for having me. Pleasure being here.