The Bias In Medical Research: Africa Carries A Huge Disease Burden But Is Missing From Clinical Trials

Researchers at the Institute of Medical Research and Medicinal Plant Studies in Yaounde, Cameroon. Daniel Beloumou Olomo / AFP via Getty Images

BY BAMBA GAYE

ADJUNCT PROFESSOR, UNIVERSITE

CHEIKH ANTA DIOP DE DAKAR

Modern medicine prides itself on being a universal science, built on evidence from clinical trials.

But there’s a bias in medical research. While Africa accounts for roughly 25% of the global disease burden and 19% of the global population, the continent’s people are largely invisible in some clinical trials.

The scale of the erasure is revealed in a landmark study of 2,472 randomised controlled trials globally published between 2019 and 2024.

I led this team of researchers, who scrutinised the world’s most influential medical publications to quantify African representation. They included the New England Journal of Medicine, The Lancet, the Journal of the American Medical Association, Nature Medicine, and the British Medical Journal. There were also three leading cardiovascular journals in the study: Circulation, the European Heart Journal and the Journal of the American College of Cardiology.

I am a physician-scientist working at the intersection of cardiometabolic epidemiology and biomedical data science. I also focus on large-scale population studies in Africa and data-driven cardiovascular prevention.

Randomised controlled trials are a cornerstone of evidence-based medicine. Introduced in the mid-20th century, they rigorously evaluate the safety and effectiveness of treatments by randomly assigning participants to different groups. This is done to minimise bias. Trials like these have been central to major medical breakthroughs, from cardiovascular therapies to vaccines. They continue to guide clinical decisions and the development of new treatments worldwide.

What we discovered

Our findings show a profound imbalance in the global clinical research landscape. Across the five most prestigious general medical journals, only 3.9% of trials were conducted exclusively in Africa. In cardiovascular health, the numbers drop to a statistical whisper. Of the major trials published in leading cardiology journals, just two studies (0.6%) were conducted solely on African soil.

This is a crisis of scientific accuracy. When clinical trials exclude African populations, they produce evidence that lacks “external validity”. This refers to how well the results of a study can be generalised beyond the participants. It asks whether findings from a clinical trial will still hold true when applied to different populations, settings, or real-world conditions.

Without that validity, doctors are essentially conducting unmonitored experiments on millions of patients every day.

Modern medicine cannot claim to be universal if entire populations remain invisible in the evidence base. Biology, health systems and disease patterns are not identical across the world.

The gap and why it matters

Many treatments used across the continent are based on evidence generated in non-African populations, raising concerns about their applicability.

Moreover, most Africa-based trials still focus on infectious diseases, despite the rising burden of non-communicable diseases such as cardiovascular disease.

Emerging evidence shows that genetics, environment and diet can radically alter how a body responds to a drug. It therefore makes no medical sense that an entire continent is left out of the trial net.

There’s also evidence showing that certain treatments have different safety profiles in Black patients. Diabetes and gout are just two examples. So are certain common blood pressure medications, such as angiotensin-converting enzyme (ACE) inhibitors. Research shows that they carry a three- to four-fold higher risk of severe, life-threatening side effects in people of African descent compared to other populations.

When clinical trials exclude populations, doctors are forced to extrapolate findings from one population and apply them to another.

The study also highlights a dangerous lag between global research funding and the evolving reality of African health. The new data show that nearly 76% of trials conducted exclusively in Africa focused on infectious diseases. But the continent is undergoing a massive epidemiological shift. Non-communicable diseases – heart disease, stroke, and diabetes – now account for about 38% of all deaths in many African nations.

The middle class in Africa has tripled to 300 million people from roughly 100 million people in the early 2000s. More people are now living long enough with lifestyles that increase the risk of chronic conditions such as heart disease, diabetes, and hypertension. Consequently, there is a growing need and market for long-term treatments that manage these diseases, rather than short-term therapies for infections. Yet cardiovascular trials continue to be discouraged.

Even within the continent, the data show deep “black holes” of information. South Africa accounted for over 62% of all trials conducted on the continent. Central Africa, a region that’s home to more than 180 million people, was virtually non-existent in the global research record. It contributed less than 3% of the continent’s limited trial output. Possible reasons include South Africa’s decades of cumulative investment, seen in stronger academic hubs, research governance, experienced trial units, and more established sponsor relationships. Other regions face barriers like fewer resourced research institutions, less access to trial platforms, and sometimes language and publication issues that can reduce visibility in top-tier journals.

The inequity extends into the hierarchy of science itself. Even when African sites are included in large, multicontinental trials, they are often relegated to the role of “recruitment hubs” rather than scientific partners. Our study found that African scientists led only 3.6% of multicontinental trials that included an African site.

Towards a new era of African science

Africa should not simply be a location where studies are conducted.

It must be a place where research is conceived, led and interpreted. The current model creates a cycle of external dependence where international institutions manage the funding and the data. This leaves local research systems fragile and unable to translate evidence into national policy.

There is need for “ring-fenced” funding for African-led research, the development of regional trial networks, and a mandate for medical journals to report on the diversity of trial populations.

There are signs of a rising momentum. Organisations like Alliance for Medical Research in Africa are working to equip a new generation of African investigators. Africa must create a research ecosystem that is too important for the global community to ignore.

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What Causes Depression? What We Know, Don’t Know And Suspect

BY CAROLINE GURVICH, DEVELINE MU AND JAYASHRI KULKARNI

Depression is a complex and deeply personal experience. While almost everyone has periods of sadness, low mood or grief, depression is different. Major depressive disorder is persistent, interferes with day-to-day activities, and can affect work, life and relationships.

One in five people will experience depression in their lifetime. Women are nearly twice as likely as men to develop it – a disparity that emerges around puberty and persists into adulthood.

But what causes it? The short answer is: many different things.

While there are various theories, we know brain chemistry, genes, hormones, stress, lifestyle and personality can all play a role. How these interact can vary greatly from one person to another.

An imbalance of brain chemicals?

The traditional “monoamine hypothesis” of depression was proposed more than half a century ago, in the 1950s. This theory suggests the root cause of depression is a deficiency in certain brain chemicals (or neurotransmitters) called monoamines – serotonin, dopamine and norepinephrine.

Several antidepressants have been developed based on this. They primarily work by increasing levels of monoamines such as serotonin.

However, it has become clear that the “chemical imbalance” explanation is an oversimplification.

Research over the past few decades has not found consistent evidence that individuals with depression always have lower levels of serotonin, or any single neurotransmitter.

And while antidepressants can increase serotonin levels within hours, improvements in mood typically take days or weeks to emerge. This delay suggests depression cannot be explained by neurotransmitter levels alone.

Current understanding recognises depression as a complex condition influenced by multiple interacting factors, including genetics, trauma, medications, diet, sleep patterns and social interactions.

Genetic factors can increase your risk

According to one 2021 review, around 30 to 50% of the risk someone will develop depression may be inherited.

No single “depression gene” has been found. But large studies have identified over 100 genetic risk markers on chromosomes.

The genetic risk of depression is also thought to be “polygenic”. This means multiple genetic variants (each carrying a small effect) interact and collectively contribute to someone’s genetic risk.

One important and longstanding research question has been whether there is a genetic reason women are more likely than men to develop depression.

In 2025, a large study revealed substantial overlap between men and women’s genetic risk. However, on average, women with depression tend to carry more of the genetic variants linked to depression.

This suggests that there may be a greater genetic risk for depression in women and perhaps a stronger environmental influence on depression risk in men.

Still, carrying a genetic risk does not mean someone will necessarily develop depression. The interplay between genetic and non-genetic factors is complex.

Hormones and biological sex

Hormones – the body’s chemical messengers – also play an important role in mood and wellbeing.

In women, estrogen and progesterone levels naturally fluctuate across different life stages, including the menstrual cycle, pregnancy, the period after childbirth and menopause.

Our 2025 review found some women are more sensitive to these normal hormonal shifts, and more vulnerable to mood disturbances.

For instance, in the premenstrual phase of their cycle, around 8% of women experience a severe depression, with intense mood swings and irritability, called premenstrual dysphoric disorder.

Similarly, the dramatic hormonal changes during pregnancy and after childbirth (combined with sleep loss and stress) can contribute to postnatal depression.

Later in life, fluctuating and falling estrogen levels during the menopause transition years may also increase the risk of developing depressive symptoms or intensify existing ones.

Hormonal contraceptives – which contain synthetic forms of estrogen and progesterone – have also been linked to mood changes and depression symptoms. In fact, these are some of the most common reasons women stop taking them.

These effects appear to depend on the specific type and amount of progesterone used in the formulation.

These findings show how hormones can act as biological triggers, and help explain why women are statistically more likely to experience depression at certain stages of life.

The effect of hormones on depression in men has predominantly focused on the protective role of testosterone, but findings remain inconclusive.

Stress is another important factor

Chronic or repeated stress can have lasting effects on both the brain and body.

When we experience stress, our bodies activate the hypothalamic–pituitary–adrenal (HPA) axis, also known as the “stress-response system”. This helps us cope by maintaining balance in our body – what scientists call physiological homeostasis.

But when stress is constant or overwhelming, this system can become dysregulated. Stressful or traumatic experiences in childhood – such as neglect, abuse or severe adversity – can also disrupt the stress-response system.

As a result, we overproduce the stress hormone cortisol. High or persistent cortisol levels can alter the structure and functioning of key brain areas (the hippocampus and pre-frontal cortex) which are important for regulating mood and memory.

Cortisol can also trigger the release of inflammatory chemicals, which then cross into the brain or influence neural signals, leading to mood changes and depressive symptoms.

Importantly though, not everyone who experiences stressful life events becomes depressed.

Some people may be more vulnerable due to genetic factors, early life adversity or differences in brain chemistry. Others might cope with the same stress without developing depression or other conditions.

Does personality play a role?

Personality traits also influence how people respond to stress and may affect their risk of developing depression.

People who tend to experience anxiety, sadness and self-doubt are more likely to develop depressive symptoms, especially after stressful events. In contrast, traits such as resilience, optimism, and emotional stability seem to protect against depression.

This suggests that personality plays an important role in shaping both vulnerability and resilience to depression.

Lifestyle choices can help lower your risk

These include not smoking, limiting alcohol use, eating a balanced diet, staying physically active, getting enough sleep, maintaining a healthy body weight and having social supports.

Research shows these healthy habits and lifestyle factors can have a protective effect on mental health. They may even reduce the impact of genetic risk factors for depression.

There’s no single cause – and no universal treatment

Depression arises from a mix of factors – biological (genes and hormones), psychological (personality and thoughts) and social (stress and life events).

Treatment options are based on all of these factors, as well as considering how severe the depression is and whether a person has responded to previous treatments.

While science has made some progress in understanding depression, what underpins each person’s experience is unique.

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New Federal Loan Limits Will Worsen America’s Nursing Shortage And Leave Patients Waiting Longer For Care

Nursing students work in a simulation lab at the Florida A&M University Campus School of Nursing in Tallahassee in April 2023. Glenn Beil/Florida A&M University via Getty Images

BY KYBERLEE MONTGOMERY AND MARY ELLEN SMITH GLASGOW

There is growing need for nurses in the United States – but not enough nurses currently working, or students training to become nurses, to promptly see all of the patients who need medical care.

Tens of thousands of nurses have left practice since the pandemic, and many more plan to leave within a few years, according to the 2024 National Nursing Workforce Survey, which reviews the number of registered nurses working in the U.S.

Meanwhile, the U.S. Bureau of Labor Statistics projects that there will be an average of 189,100 openings for registered nurses each year through 2032. In addition, there will be a need for approximately 128,400 new nurse practitioners by 2034 – making it the fastest-growing occupation in the country.

The tax and spending package signed into law in July 2025 will take effect on July 1, 2026. Among other things, it will likely make it even harder for people to take out loans and help pay for a graduate nursing degree.

We are nurses and professors who oversee large nursing programs at universities. We believe that new restrictions on how nursing students can take out federal loans to pay for their education are likely to prevent people from pursuing advanced nursing roles.

These new regulations will cause the shortage of practicing nurses to intensify – in turn, worsening the quality of care patients receive.

Clinics may offer fewer appointments, hospitals may be forced to reduce services, and nursing programs may have to accept fewer students. As a result, some patients will wait longer, travel farther, or not see nurses altogether.

Paying for nursing education

Someone can become a registered nurse with an associate or bachelor’s degree. But a graduate-level degree is needed for other nursing roles – including nurse practitioners, nurse anesthetists and nurse midwives.

Nursing school costs vary greatly, depending on which degree students are seeking and whether they attend a public or private school. Roughly three-quarters of graduate nursing students rely on student loans and graduate with debt to pay for programs that can range from US$30,000 to $120,000 or more.

We have found that nursing students, unlike medical students, often work while enrolled in their programs, stretching their education over longer periods and accumulating additional costs.

The tax and spending law eliminates several federal grants and loan repayment programs for nurses and aspiring nurse educators – faculty members who teach nursing students in colleges and universities.

The law also sharply restricts how much money graduate nursing students can borrow through federal student loans.

Approximately 59% of 1,550 nurses surveyed in December 2025 said that they are now less likely to pursue a graduate degree with the new borrowing limit changes.

A fractured system

Nurse practitioners provide the majority of primary care in the U.S. – particularly in rural areas and communities with few physicians.

In addition, certified registered nurse anesthetists administer anesthesia for surgeries and procedures in many areas. Meanwhile, certified nurse-midwives deliver babies and provide prenatal and postpartum care, especially in areas where there are few obstetricians.

Long waits for new patient appointments are now common across the country, with national surveys showing that patients often wait weeks to months before they receive medical care.

About a decade ago, new patients could often book appointments within days to a few weeks; but today, there are fewer available medical appointments and medical professionals to treat them. This is particularly true for many medical practices serving women, older adults and rural communities.

One of us – Dr. Montgomery – is a women’s health nurse practitioner who routinely sees patients wait months for new appointments in the mid-Atlantic. These delays translate into postponed cancer screenings, delayed medication management and untreated chronic conditions.

Research consistently shows that nursing shortages are associated with worse patient outcomes, including higher mortality and delayed treatment.

Nursing left off the professional degree list

Under the new law, the Department of Education created a classification system that distinguishes professional from nonprofessional graduate degrees. Nursing is now considered a nonprofessional degree.

As a result, graduate nursing students will soon face lower borrowing limits than they currently do.

Previously, there was no need to label nursing as professional or not, because federal student loan borrowing was not capped in a way that required this distinction.

Now, students in professional graduate programs, such as medicine and law, may borrow up to $50,000 per year in federal loans and $200,000 in total.

Graduate nursing students, by contrast, will soon face a federal student loan cap of $20,500 per year and $100,000 total over the course of their education – a significant reduction from prior borrowing options.

The new law also eliminates the Direct PLUS Loan program. This separate, federal student loan program allows students to borrow up to the full cost of attendance of graduate nursing school after they reached annual loan limits on traditional federal loans.

More than 140 members of Congress from both political parties urged the Department of Education in December 2025 to reverse course and classify nursing as a professional degree.

The faculty bottleneck

Graduate loan limits will worsen another critical problem – the shortage of nursing faculty.

There are currently 1,693 full-time vacancies for nursing faculty positions, according to a survey in 2024 by the American Association of Colleges of Nursing. Of those open positions, 84% require or prefer a doctoral degree.

Universities cannot admit nursing students if there are not enough faculty to teach them.

Nursing programs in the U.S. turned away more than 80,000 qualified applicants to baccalaureate and graduate nursing programs in 2023, in part because they did not have enough faculty.

Better solutions exist

There are policy changes that could prevent this domino effect.

Policymakers could classify nursing as a professional degree for loan purposes, aligning borrowing limits with the documented costs of accredited programs.

Congress and individual states could expand scholarships and loan-repayment programs for nurses who teach or serve in rural and underserved communities.

Universities and governments could work together to share nurse training costs.

Graduate nursing education is not a luxury. It is a cornerstone of the country’s health care system.

Helping nurses afford an education is not just about nurses – it is about patients, communities and the future of medical care in the U.S.

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How Does Your Immune System Stay Balanced? A Nobel Prize-Winning Answer

Regulatory T cells (red) interact with other immune cells (blue) and modulate immune responses. National Institute of Allergy and Infectious Diseases/NIH via Flickr

BY AIMEE PUGH BERNARD

ASSOCIATE PROFESSOR OF IMMUNILOGY

AND MICROBIOLOGY, UNIVERSITY OF

COLORADO ANSCHULZ MEDICAL CAMPUS

Every day, your immune system performs a delicate balancing act, defending you from thousands of pathogens that cause disease while sparing your body’s own healthy cells. This careful equilibrium is so seamless that most people don’t think about it until something goes wrong.

Autoimmune diseases such as Type 1 diabetes, lupus and rheumatoid arthritis are stark reminders of what happens when the immune system mistakes your own cells as threats it needs to attack. But how does your immune system distinguish between “self” and “nonself”?

The 2025 Nobel Prize in physiology or medicine honors three scientists – Shimon Sakaguchi, Mary Brunkow and Fred Ramsdell – whose groundbreaking discoveries revealed how your immune system maintains this delicate balance. Their work on two key components of immune tolerance – regulatory T cells and the FOXP3 gene – transformed how researchers like me understand the immune system, opening new doors for treating autoimmune diseases and cancer.

How immune tolerance works

While the immune system is designed to recognize and eliminate foreign invaders such as viruses and bacteria, it must also avoid attacking the body’s own tissues. This concept is called self-tolerance.

For decades, scientists thought self-tolerance was primarily established in the parts of the body that make immune cells, such as the thymus for T cells and the bone marrow for B cells. There, newly created immune cells that attack “self” are eliminated during development through a process called central tolerance.

However, some of these self-reactive immune cells escape this process of elimination and are released into the rest of the body. Sakaguchi’s 1995 discovery of a new class of immune cells, called regulatory T cells, or Tregs, revealed another layer of protection: peripheral tolerance. These cells act as security guards of the immune system, patrolling the body and suppressing rogue immune responses that could lead to autoimmunity.

While Sakaguchi identified the cells, Brunkow and Ramsdell in 2001 uncovered the molecular key that controls them. They found that mutations in a gene called FOXP3 caused a fatal autoimmune disorder in mice. They later showed that similar mutations in humans lead to immune dysregulation and a rare and severe autoimmune disease called IPEX syndrome, short for immunodysregulation polyendocrinopathy enteropathy X-linked syndrome. This disease results from missing or malfunctioning regulatory T cells.

In 2003, Sakaguchi confirmed that FOXP3 is essential for the development of regulatory T cells. FOXP3 codes for a type of protein called a transcription factor, meaning it helps turn on the genes necessary for regulatory T cells to develop and function. Without this protein, these cells either don’t form or fail to suppress harmful immune responses.

Harnessing the immune system for medicine

Regulatory T cells can be heroes or villains, depending on the context. When regulatory T cells don’t work, it can lead to disease. A breakdown in immune tolerance can result in autoimmune diseases, where the immune system attacks healthy tissues. Conversely, in cancer, regulatory T cells can be too effective in suppressing immune responses that might otherwise destroy tumors.

Understanding how FOXP3 and regulatory T cells work launched a new era in immunotherapies that harness the immune system to treat autoimmune diseases and cancer. For autoimmune diseases such as rheumatoid arthritis and Type 1 diabetes, researchers are exploring ways to boost the function of Tregs. For cancer, the goal is to inhibit Tregs, allowing the immune system to target tumors more aggressively.

Beyond disease treatment, this research may also improve organ transplantation, where immune tolerance is crucial to prevent rejection. Scientists are exploring how to engineer or expand Tregs to help the body accept transplanted tissues over the long term.

Continuing to unlock the secrets of immune regulation can help lead to a future where the immune system can be precisely tuned like a thermostat – whether to turn it down in autoimmunity or rev it up against cancer.

The 2025 Nobel Prize reminds us that science, at its best, doesn’t just explain the world – it changes lives.

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A New Treatment For Huntington’s Disease Is Genuinely Promising – But Here’s Why We Still Need Caution

While rare, Huntington’s disease is inherited and fatal. Izuchukwu Onyeka/Getty

BY BRYCE VISSEL

COJOINT PROFESSOR,

SCHOOL OF CLINICAL 

MEDICINE, UNSW SYDNEY

Imagine knowing in your 20s or 30s that you carry a gene which will cause your mind and body to slowly unravel. Huntington’s disease is inherited, relentless and fatal, and there is no cure. Families live with the certainty of decline stretching across generations.

Now, a new treatment is being widely reported as a breakthrough.

Last week, gene therapy company uniQure announced that a one-time brain infusion appeared to slow the disease in a small clinical study.

If confirmed, this would not only be a landmark for Huntington’s disease but potentially the first time a gene therapy has shown promise in any adult-onset neurodegenerative disorder.

But the results, which were announced in a press release, are early, unreviewed and based on external comparisons. So, while these findings offer families hope after decades of failure, we need to remain cautious.

What is Huntington’s disease?

Huntington’s is a rare but devastating disease, affecting around five to ten people in 100,000 in Western countries. That means thousands in Australia and hundreds of thousands worldwide.

Symptoms usually start in mid-life. They include involuntary movements, depression, irritability and progressive decline in thinking and memory. People lose the ability to work, manage money, live independently and eventually care for themselves. Most die ten to 20 years after onset.

The disease is caused by an expanded stretch of certain DNA repeats (CAG) in the huntingtin gene. The number of repeats strongly influences when symptoms begin, with longer expansions usually linked to earlier onset.

Looking for a treatment

The gene that causes Huntington’s disease was identified in 1993, 32 years ago. Soon afterwards, mouse studies showed that switching off the mutant huntingtin protein even after symptoms had begun could reverse signs and improve behaviour.

This suggested lowering the toxic protein might slow or even partly reverse the disease. Yet for three decades, every attempt to develop a therapy for people has failed to show convincing clinical benefit. Trials of huntingtin-lowering drugs and other approaches did not slow progression.

What is the new treatment?

The one-time gene therapy, called AMT-130, involves brain surgery guided by MRI. Surgeons infuse an engineered virus directly into the caudate and putamen brain regions, which are heavily affected in Huntington’s.

The virus carries a short genetic “microRNA” designed to reduce production of the affected huntingtin protein.

By delivering it straight into the brain, the treatment bypasses the blood–brain barrier. This natural wall usually prevents medicines from entering the central nervous system. That barrier helps explain why so many brain-targeted drugs have failed.

What did they find?

Some 29 patients received treatment, with 12 in each group (one low-dose, and one high-dose) followed for three years. According to uniQure, those given the higher dose declined much slower than expected.

The study compared how much participants’ movement, thinking and daily function declined, compared to a matched external group from a global Huntington’s registry (meaning they weren’t part of the study). The company claimed those given the higher dose had a 75% slowing in their decline.

On a functional scale focused on independence, the company reported a 60% slowing in decline for the higher dose group.

Other tests of movement and thinking also favoured treatment. Nerve-cell damage in spinal fluid was lower for study participants than would be expected for untreated patients.

Why should we be cautious?

These findings are an early snapshot of results reported by the company, not yet peer-reviewed. The study compared treated patients to an external matched control group, not people randomised to placebo at the same time. This design can introduce bias. The numbers are also small – only 12 patients at the three-year mark – so we can’t draw solid conclusions.

The company reports the therapy was generally well tolerated, with no new serious adverse events related to the drug since late 2022. Most problems were related to the neurosurgical infusion itself, and resolved. But in a disease that already causes such severe symptoms, it is often hard to know what counts as a side effect.

The company uniQure has said it plans to seek regulatory approval in 2026 on the basis of this dataset.

Regulators will face difficult decisions: whether to allow access sooner before all the questions and uncertainties are addressed – based on the needs of a community with no effective options – and wait for further data while people are being treated, or to insist on larger trials that confirm results before approval.

What does it mean?

If upheld, these results represent the first convincing signs that a gene-targeted therapy can slow Huntington’s disease. They may also be the first evidence of benefit from a gene therapy in any adult-onset neurodegenerative disorder. That would be a milestone after decades of failure.

But these results do not prove success. Only larger, longer and fully peer-reviewed studies will show whether this treatment truly changes lives. Even if approved, a complex neurosurgical gene therapy may not be easily accessible to all patients.

The company has said the drug’s price would be similar to other gene therapies – which can cost over A$3 million per patient – and will have the added cost of brain surgery.

The takeaway

For families who carry this gene, the hope is profound. But caution is just as important.

We may be witnessing the first credible step toward slowing an inherited adult-onset neurodegenerative disease, or just an early signal that may not hold up.

Ultimately, only time and rigorous science will show whether this treatment delivers the benefits so urgently needed.

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Being Alone Has Its Benefits − A Psychologist Fips The Script On The ‘Loneliness Epidemic’

BY VIRGINIA THOMAS

ASSISTANT PROFESSOR OF

PSYCHOLOGY, MIDDLEBURY

Over the past few years, experts have been sounding the alarm over how much time Americans spend alone.

Statistics show that we’re choosing to be solitary for more of our waking hours than ever before, tucked away at home rather than mingling in public. Increasing numbers of us are dining alone and traveling solo, and rates of living alone have nearly doubled in the past 50 years.

These trends coincided with the surgeon general’s 2023 declaration of a loneliness epidemic, leading to recent claims that the U.S. is living in an “anti-social century.”

Loneliness and isolation are indeed social problems that warrant serious attention, especially since chronic states of loneliness are linked with poor outcomes such as depression and a shortened lifespan.

But there is another side to this story, one that deserves a closer look. For some people, the shift toward aloneness represents a desire for what researchers call “positive solitude,” a state that is associated with well-being, not loneliness.

As a psychologist, I’ve spent the past decade researching why people like to be alone – and spending a fair amount of time there myself – so I’m deeply familiar with the joys of solitude. My findings join a host of others that have documented a long list of benefits gained when we choose to spend time by ourselves, ranging from opportunities to recharge our batteries and experience personal growth to making time to connect with our emotions and our creativity.

So it makes sense to me why people live alone as soon as their financial circumstances allow, and when asked why they prefer to dine solo, people say simply, “I want more me time.”

It’s also why I’m not surprised that a 2024 national survey found that 56% of Americans considered alone time essential for their mental health. Or that Costco is now selling “solitude sheds” where for around US$2,000 you can buy yourself some peace and quiet.

It’s clear there is a desire, and a market, for solitude right now in American culture. But why does this side of the story often get lost amid the warnings about social isolation?

I suspect it has to do with a collective anxiety about being alone.

The stigma of solitude

This anxiety stems in large part from our culture’s deficit view of solitude. In this type of thinking, the desire to be alone is seen as unnatural and unhealthy, something to be pitied or feared rather than valued or encouraged.

This isn’t just my own observation. A study published in February 2025 found that U.S. news headlines are 10 times more likely to frame being alone negatively than positively. This type of bias shapes people’s beliefs, with studies showing that adults and children alike have clear judgments about when it is – and importantly when it is not – acceptable for their peers to be alone.

This makes sense given that American culture holds up extraversion as the ideal – indeed as the basis for what’s normal. The hallmarks of extraversion include being sociable and assertive, as well as expressing more positive emotions and seeking more stimulation than the opposite personality – the more reserved and risk-averse introverts. Even though not all Americans are extraverts, most of us have been conditioned to cultivate that trait, and those who do reap social and professional rewards. In this cultural milieu, preferring to be alone carries stigma.

But the desire for solitude is not pathological, and it’s not just for introverts. Nor does it automatically spell social isolation and a lonely life. In fact, the data doesn’t fully support current fears of a loneliness epidemic, something scholars and journalists have recently acknowledged.

In other words, although Americans are indeed spending more time alone than previous generations did, it’s not clear that we are actually getting lonelier. And despite our fears for the eldest members of our society, research shows that older adults are happier in solitude than the loneliness narrative would lead us to believe.

Social media disrupts our solitude

However, solitude’s benefits don’t automatically appear whenever we take a break from the social world. They arrive when we are truly alone – when we intentionally carve out the time and space to connect with ourselves – not when we are alone on our devices.

My research has found that solitude’s positive effects on well-being are far less likely to materialize if the majority of our alone time is spent staring at our screens, especially when we’re passively scrolling social media.

This is where I believe the collective anxiety is well placed, especially the focus on young adults who are increasingly forgoing face-to-face social interaction in favor of a virtual life – and who may face significant distress as a result.

Social media is by definition social. It’s in the name. We cannot be truly alone when we’re on it. What’s more, it’s not the type of nourishing “me time” I suspect many people are longing for.

True solitude turns attention inward. It’s a time to slow down and reflect. A time to do as we please, not to please anyone else. A time to be emotionally available to ourselves, rather than to others. When we spend our solitude in these ways, the benefits accrue: We feel rested and rejuvenated, we gain clarity and emotional balance, we feel freer and more connected to ourselves.

But if we’re addicted to being busy, it can be hard to slow down. If we’re used to looking at a screen, it can be scary to look inside. And if we don’t have the skills to validate being alone as a normal and healthy human need, then we waste our alone time feeling guilty, weird or selfish.

The importance of reframing solitude

Americans choosing to spend more time alone is indeed a challenge to the cultural script, and the stigmatization of solitude can be difficult to change. Nevertheless, a small but growing body of research indicates that it is possible, and effective, to reframe the way we think about solitude.

For example, viewing solitude as a beneficial experience rather than a lonely one has been shown to help alleviate negative feelings about being alone, even for the participants who were severely lonely. People who perceive their time alone as “full” rather than “empty” are more likely to experience their alone time as meaningful, using it for growth-oriented purposes such as self-reflection or spiritual connection.

Even something as simple as a linguistic shift – replacing “isolation” with “me time” – causes people to view their alone time more positively and likely affects how their friends and family view it as well.

It is true that if we don’t have a community of close relationships to return to after being alone, solitude can lead to social isolation. But it’s also true that too much social interaction is taxing, and such overload negatively affects the quality of our relationships. The country’s recent gravitational pull toward more alone time may partially reflect a desire for more balance in a life that is too busy, too scheduled and, yes, too social.

Just as connection with others is essential for our well-being, so is connection with ourselves.

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Doctor Shortages Have Hobbled Health Care For Decades − And The Trend Could Be Worsening

BY ROCHELLE WALENSKY AND NICOLE MCCANN

Americans are increasingly waiting weeks or even months to get an appointment to see a health care specialist.

This delay comes at a time when the population of aging adults is rising dramatically. By 2050, the number of adults over 85 is expected to triple, which will intensify the strain on an already stretched health care system. We wrote about this worsening challenge and its implications for the health care workforce in a January 2025 report in the New England Journal of Medicine.

We are health care scholars who are acutely aware of the severe shortfall of specialists in America’s health care system. One of us, Rochelle Walensky, witnessed the consequences of this shortage firsthand as the director of the Centers for Disease Control and Prevention from January 2020 to June 2023, during the critical early years of the pandemic.

The COVID-19 pandemic brought the physician and overall health care workforce shortage to the forefront. Amid the excess daily deaths in the U.S. from COVID-19, many people died of potentially preventable deaths due to delayed care for heart attacks, deferred cancer screenings and overwhelmed emergency departments and intensive care units.

Even before the pandemic, 80% of U.S. counties lacked a single infectious disease physician. Before going to the CDC, I – Dr. Walensky – was chief of the Division of Infectious Diseases at Massachusetts General Hospital. When COVID-19 hit our hospitals, we were in desperate need of more infectious disease expertise. I was just one of them.

At the local level, these infectious disease-trained subspecialists provide essential services when it comes to preventing and controlling transmissible outbreaks, carrying out diagnostic testing, developing treatment guidelines, informing hospital capacity planning and offering resources for community outreach. Each of these experts plays a vital role at the bedside and in systems management toward effective clinical, hospital and community responses to infectious disease outbreaks.

Uneven health care outcomes and access

For decades, experts have warned of an impending decline in the physician workforce.

Now, Americans across all regions, specialties and socioeconomic backgrounds are experiencing that decline firsthand or personally.

The National Center for Health Workforce Analysis projects a national shortage of 140,000 physicians by 2036, with that shortfall spanning multiple specialties, including primary care, obstetrics, cardiology and geriatrics.

However, some geographic areas in the country – especially some of those with the poorest health – are disproportionately affected. The brunt of the effect will be felt in rural areas: An estimated 56% shortage is predicted in nonmetro areas, versus only 6% in metro areas.

States such as Massachusetts, New York and Maryland boast the highest density of physicians per 100,000 people, while states such as Idaho, Mississippi and Oklahoma rank among those with the lowest. And even in states with the highest physician density, demand may still overwhelm access.

Although doctor shortages do not necessarily cause poor health outcomes, regions with fewer physicians tend to have lower life expectancy. The mean life expectancy in Mississippi is six years lower than that of Hawaii and more than four years below the national average. This underscores the substantial differences in health outcomes depending on where you live in the U.S.

Notably, areas with fewer doctors also see higher rates of chronic conditions such as chronic pulmonary disease, diabetes and poor mental health. This crisis is further exacerbated by the aging baby boomer population, which places increasing demand on an already strained health care system due to rising rates – especially among those over 85 – of multiple chronic diseases, complex health care needs and the concurrent use of multiple medications.

How the US reached this point

Some of these workforce challenges stem from the unintended consequences of policy changes that were originally aimed at improving the rigor of medical education or curtailing a once-anticipated physician glut.

For example, the 1910 Flexner Report was commissioned to restructure American medical education with the goals of standardizing curricula and improving quality. While the report succeeded at those goals, it was shortsighted in important ways. For instance, it recommended closing rather than strengthening 89 of the 155 existing medical schools at the time. This created medical school deserts that persist in some U.S. regions to this day.

Additionally, the report further divided the study of medicine, focused on disease, from the study of public health, which is focused on health care systems, populations and society. This separation has led to siloed communication and data systems that continue to hinder coordinated responses to public health crises.

Decades after the Flexner Report, in 1980, policymakers anticipated a physician oversupply based on medical school enrollment projections and government investments in the medical workforce. In response, funding constraints were introduced by Congress to limit residency and fellowship training slots available after medical school.

But by the early 2000s, discussions shifted to concerns about physician shortages. Despite the calls for reforms to address the issues more than a decade ago, the funding and training constraints have remained largely unchanged. These have created a persistent bottleneck in postgraduate medical training that requires acts of Congress to reverse.

Forces shaping the physician bottleneck

In the wake of the Dobbs vs. Jackson Women’s Health Organization decision, states with restrictive abortion policies are now facing an emerging and troubling workforce challenge: It may get more difficult to recruit and retain tomorrow’s medical school grads.

Research surveys suggest that 82% of future physicians, not just obstetricians, prefer to train and work in states that uphold abortion access. While it may seem obvious that obstetricians would want to avoid the increasing liabilities associated with the Dobbs decision, another point is less obvious: Most medical trainees are between the ages of 25 and 35, prime childbearing years, and may themselves want access to a full range of obstetric care.

And given that 20% of physicians are married to other physicians and an additional 25% to other health professionals, marriage within the health care workforce may also play a substantial role. A physician choosing not to practice in one of the 14 states with limited abortion access, many of which already rank among the poorest in health outcomes and lowest in physician densities, may not only take their expertise but also their partner’s elsewhere.

Shifting the trajectory

The doctor shortage requires a combination of solutions, starting with addressing the high cost of medical education and training. Medical school enrollment has increased by only 10% over the past decade, far insufficient to address both the shortage today and the projected growth of the aging population needing care.

In addition, many students carry large amounts of debt, which frequently limits who can pursue the profession. And existing scholarship and compensation programs have been only modestly effective in incentivizing providers to work in high-need areas.

In our New England Journal of Medicine report, we laid out several specific strategies that could help address the shortages and the potential workforce crisis. For instance:

Rather than the traditional medical education model – four years of broad medical training followed by three to seven years of residency – medical schools could offer more specialized training pathways. These streamlined programs would focus on the skills needed for specific medical specialties, potentially reducing training duration and costs.

Reforming physician compensation could also help address imbalances in the health care system. Specialists and subspecialists typically earn substantially more than primary care doctors, despite the high demand for primary care. Raising primary care salaries and offering incentives, such as student loan forgiveness for physicians in high-need areas, could encourage more doctors to practice where they are needed most.

Additionally, addressing physician burnout is crucial, particularly in primary care, where administrative burdens such as billing and charting contribute to stress and attrition. Reducing these burdens, potentially through novel AI-driven solutions, could allow doctors to focus more on patient care and less on paperwork.

These are just an assortment of strategies we propose, and time is of the essence. One thing is certain: The U.S. urgently needs more doctors, and everyone’s health depends on it.

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A Brief History Of Medicaid And America’s Long Struggle To Establish A Health Care Safety Net

President Lyndon B. Johnson, left, next to former President Harry S. Truman, signs into law the measure creating Medicare and Medicaid in 1965. AP Photo

BY BEN ZDENCANOVIC

POST DOCTORAL ASSOCIATE 

IN HISTORY AND POLYCY

UCLA

The Medicaid system has emerged as an early target of the Trump administration’s campaign to slash federal spending. A joint federal and state program, Medicaid provides health insurance coverage for more than 72 million people, including low-income Americans and their children and people with disabilities. It also helps foot the bill for long-term care for older people.

In late February 2025, House Republicans advanced a budget proposal that would potentially cut US$880 billion from Medicaid over 10 years. President Donald Trump has backed that House budget despite repeatedly vowing on the campaign trail and during his team’s transition that Medicaid cuts were off the table.

Medicaid covers one-fifth of all Americans at an annual cost that coincidentally also totals about $880 billion, $600 billion of which is funded by the federal government. Economists and public health experts have argued that big Medicaid cuts would lead to fewer Americans getting the health care they need and further strain the low-income families’ finances.

As a historian of social policy, I recently led a team that produced the first comprehensive historical overview of Medi-Cal, California’s statewide Medicaid system. Like the broader Medicaid program, Medi-Cal emerged as a compromise after Democrats failed to achieve their goal of establishing universal health care in the 1930s and 1940s.

Instead, the United States developed its current fragmented health care system, with employer-provided health insurance covering most working-age adults, Medicare covering older Americans, and Medicaid as a safety net for at least some of those left out.

Health care reformers vs. the AMA

Medicaid’s history officially began in 1965, when President Lyndon B. Johnson signed the system into law, along with Medicare. But the seeds for this program were planted in the 1930s and 1940s. When President Franklin D. Roosevelt’s administration was implementing its New Deal agenda in the 1930s, many of his advisers hoped to include a national health insurance system as part of the planned Social Security program.

Those efforts failed after a heated debate. The 1935 Social Security Act created the old-age and unemployment insurance systems we have today, with no provisions for health care coverage.

Nevertheless, during and after World War II, liberals and labor unions backed a bill that would have added a health insurance program into Social Security.

Harry Truman assumed the presidency after Roosevelt’s death in 1945. He enthusiastically embraced that legislation, which evolved into the “Truman Plan.” The American Medical Association, a trade group representing most of the nation’s doctors, feared heightened regulation and government control over the medical profession. It lobbied against any form of public health insurance.

During the late 1940s, the AMA poured millions of dollars into a political advertising campaign to defeat Truman’s plan. Instead of mandatory government health insurance, the AMA supported voluntary, private health insurance plans. Private plans such as those offered by Kaiser Permanente had become increasingly popular in the 1940s in the absence of a universal system. Labor unions began to demand them in collective bargaining agreements.

The AMA insisted that these private, employer-provided plans were the “American way,” as opposed to the “compulsion” of a health insurance system operated by the federal government. They referred to universal health care as “socialized medicine” in widely distributed radio commercials and print ads.

In the anticommunist climate of the late 1940s, these tactics proved highly successful at eroding public support for government-provided health care. Efforts to create a system that would have provided everyone with health insurance were soundly defeated by 1950.

JFK and LBJ

Private health insurance plans grew more common throughout the 1950s.

Federal tax incentives, as well as a desire to maintain the loyalty of their professional and blue-collar workers alike, spurred companies and other employers to offer private health insurance as a standard benefit. Healthy, working-age, employed adults – most of whom were white men – increasingly gained private coverage. So did their families, in many cases.

Everyone else – people with low incomes, those who weren’t working and people over 65 – had few options for health care coverage. Then, as now, Americans without private health insurance tended to have more health problems than those who had it, meaning that they also needed more of the health care they struggled to afford.

But this also made them risky and unprofitable for private insurance companies, which typically charged them high premiums or more often declined to cover them at all.

Health care activists saw an opportunity. Veteran health care reformers such as Wilbur Cohen of the Social Security Administration, having lost the battle for universal coverage, envisioned a narrower program of government-funded health care for people over 65 and those with low incomes. Cohen and other reformers reasoned that if these populations could get coverage in a government-provided health insurance program, it might serve as a step toward an eventual universal health care system.

While President John F. Kennedy endorsed these plans, they would not be enacted until Johnson was sworn in following JFK’s assassination. In 1965, Johnson signed a landmark health care bill into law under the umbrella of his “Great Society” agenda, which also included antipoverty programs and civil rights legislation.

That law created Medicare and Medicaid.

From Reagan to Trump

As Medicaid enrollment grew throughout the 1970s and 1980s, conservatives increasingly conflated the program with the stigma of what they dismissed as unearned “welfare.” In the 1970s, California Gov. Ronald Reagan developed his national reputation as a leading figure in the conservative movement in part through his high-profile attempts to cut and privatize Medicaid services in his state.

Upon assuming the presidency in the early 1980s, Reagan slashed federal funding for Medicaid by 18%. The cuts resulted in some 600,000 people who depended on Medicaid suddenly losing their coverage, often with dire consequences.

Medicaid spending has since grown, but the program has been a source of partisan debate ever since.

In the 1990s and 2000s, Republicans attempted to change how Medicaid was funded. Instead of having the federal government match what states were spending at different levels that were based on what the states needed, they proposed a block grant system. That is, the federal government would have contributed a fixed amount to a state’s Medicaid budget, making it easier to constrain the program’s costs and potentially limiting how much health care it could fund.

These efforts failed, but Trump reintroduced that idea during his first term. And block grants are among the ideas House Republicans have floated since Trump’s second term began to achieve the spending cuts they seek.

The ACA’s expansion

The 2010 Affordable Care Act greatly expanded the Medicaid program by extending its coverage to adults with incomes at or below 138% of the federal poverty line. All but 10 states have joined the Medicaid expansion, which a U.S. Supreme Court ruling made optional.

As of 2023, Medicaid was the country’s largest source of public health insurance, making up 18% of health care expenditures and over half of all spending on long-term care. Medicaid covers nearly 4 in 10 children and 80% of children who live in poverty. Medicaid is a particularly crucial source of coverage for people of color and pregnant women. It also helps pay for low-income people who need skilled nursing and round-the-clock care to live in nursing homes.

In the absence of a universal health care system, Medicaid fills many of the gaps left by private insurance policies for millions of Americans. From Medi-Cal in California to Husky Health in Connecticut, Medicaid is a crucial pillar of the health care system. This makes the proposed House cuts easier said than done.

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NIH Funding Cuts Will Hit Red States, Rural Areas And Underserved Communities The Hardest

Inside an NIH lab in Bethesda, Md., where researchers work on treatments and cures for disease, including cancer. Saul Loeb/AFP via Getty Images

BY PRAKASH NAGARKATTI AND MITZI NAGARKATTI

The National Institutes of Health is the largest federal funder of medical research in the U.S. NIH funds drive research and innovation, leading to better understanding and treatment of diseases and improved health outcomes.

The NIH provided more than US$35 billion in grants to over 2,500 universities and other institutions in 2023 to support biomedical research. Thus, it came as a shock to these institutions when the NIH, based on a new Trump administration policy, announced on Feb. 7, 2025, that it intends to cut the funding used to support the grantee institutions by $5.5 billion annually.

On March 5, a U.S. district judge in Boston issued a nationwide injunction blocking the administration from implementing the proposed cuts to NIH funding, arguing that the planned cuts were unlawful.

However, the White House will almost certainly appeal.

We are a husband-and-wife team of immunologists who have been funded by the NIH for several decades. We believe our research has led to a better understanding of inflammatory and autoimmune diseases. In addition, one of us (Prakash Nagarkatti) served as vice president for research at the University of South Carolina for over a decade, managing all NIH grants awarded to the university.

While we believe such cuts will be detrimental to the entire country, they will disproportionately hurt states that traditionally have received very low levels of NIH funding, the majority of which are red states that supported Trump’s election to a second term. This is because such states lack resources to develop advanced research infrastructure necessary to compete nationally for NIH funding.

Several Republican senators have vocally opposed the funding cuts, including Susan Collins of Maine, who said they “would be devastating, stopping vital biomedical research and leading to the loss of jobs.”

Support for cancer, Alzheimer’s research

NIH funding is crucial for advancing biomedical research, improving public health and fostering innovation. It has a broad impact on different facets of society.

The agency funds biomedical research leading to the development of vaccines or new drugs to prevent and treat infectious diseases and clinical disorders. The NIH played a crucial role in funding research on pandemics and global health crises caused by HIV/AIDS and COVID-19.

In addition, the NIH supports advanced research in focused areas such as cancer, through the establishment of designated centers that offer cancer prevention, diagnosis, clinical trials and advanced treatment. Each year, approximately 400,000 patients receive cancer diagnoses and treatment at such centers.

Similarly, the NIH supports research in other focused areas, such as Alzheimer’s disease, through the establishment of specialized research centers.

The NIH also supports Small Business Innovation Research and Small Business Technology Transfer opportunities. These programs stimulate technological innovation by funding small businesses to commercialize new research ideas.

Moreover, the agency provides funding to train the next generation of biomedical scientists, clinicians and public health professionals. Thus, the NIH awards create jobs at universities, biotechnology companies and related industries. Together, such NIH programs promote local and national economies.

In 2024, NIH funding generated an estimated US$92 billion in economic activity. Every $100 million in NIH funding generates 76 patents, which creates $598 million in further research and development, as reported by NIH.

Therefore, any cuts to the agency’s budget will have far-reaching and significant consequences on health outcomes and the economy.

Caps on indirect costs

When the NIH awards grants, it is divided into two separate categories: the direct costs, which include expenses that are necessary to pursue the proposed work and that are provided to the scientists, and the indirect costs. These cover expenses such as maintenance of lab space, utilities, grant management, federal regulatory compliance, security and other miscellaneous needs. These funds are provided directly to the institution.

Indirect costs are negotiated between the institution and the federal agency and expressed as a percentage of the direct costs. Because each institution has unique operational expenses, the indirect cost rates vary from 30% to 70%.

The new policy rolled out by the NIH capped the indirect costs for all institutions at a fixed rate of 15%. In 2023, NIH spent $35 billion to support research at various institutions, of which $9 billion was used to cover indirect costs. Thus, NIH estimates it could save $4 billion by capping indirect costs at 15%.

How red states get hurt the most

There is a significant geographic disparity in NIH funding that most people are unaware of. There are 27 states in the U.S. that receive 94% of NIH funding, while the other 23 states receive only 6%. Moreover, the NIH funding received by the 23 states has remained relatively unchanged for the past 20  years.

There are many reasons why the latter states are less competitive. These include: lack of large medical centers, hospitals and research-intensive universities; thin and more rural populations; less robust economies; and lack of cutting-edge research infrastructure driven by less investment by the states in research and development.

It is for these reasons that Congress in 1993 authorized the NIH to start a new program called the Institutional Development Award, or IDeA, to support the 23 states plus Puerto Rico that have traditionally received low levels of NIH funding. Such states are commonly called IDeA states and contain predominantly rural and medically underserved communities.

These awards, which constitute less than 1% of the total NIH budget, are expected to help these states grow their research infrastructure and make them more competitive nationally.

The IDeA states are: Alaska, Arkansas, Delaware, Hawaii, Idaho, Kansas, Kentucky, Louisiana, Maine, Mississippi, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Oklahoma, Rhode Island, South Carolina, South Dakota, Vermont, West Virginia, and Wyoming, plus Puerto Rico. All the states but Delaware, Hawaii, Maine, New Hampshire, New Mexico, Rhode Island and Vermont voted for Trump in the 2024 election.

Indirect costs pay for cutting-edge technologies

Indirect costs, in addition to supporting the management of specific grants, are also helpful in promoting the institutions’ research infrastructure.

The indirect costs help purchase and upgrade state-of-the-art research equipment and technologies. They help institutions develop high-performance computing facilities that are critical for research missions and provide access to journals and books through the library facilities. These costs also renovate old labs and help create new cutting-edge facilities such as germ-free facilities for microbiome research.

Thus, the indirect costs are critical for IDeA states that have limited resources such as state support for pursuing research.

According to the Higher Education Research and Development Survey, in 2023, non-IDeA states like California invested $548 million and New York over $303 million in R&D. In contrast, IDeA states Kentucky and West Virginia invested $49 million and $15 million, respectively, in R&D.

Such data clearly demonstrates how challenging it would be for IDeA states to face cuts in NIH funding and advance research infrastructure.

In our view, it is critical that all states have access to NIH research funding to enable the states to solve the unique challenges they face, such as environmental issues and population health disparities.

For example, biomedical scientists and clinicians trained by NIH grants are addressing locally relevant issues such as coal workers’ pneumoconiosis, commonly known as black lung disease, which occurs when coal dust is inhaled. This is an occupational hazard linked to the coal industry in West Virginia and Kentucky.

Similarly, Hawaii, with its tropical climate, has mosquitoes that can carry dengue virus, so dengue infection can pose a unique health and economic problem for this state when compared with the others in the U.S.

Training the biomedical workforce and physicians in IDeA states also helps with retaining health providers in the state to further address these local challenges and prevents brain-drain to other non-IDeA states.

IDeA states heavily rely on NIH funds to pursue and advance their research capabilities and address local and general health challenges. For such states, already struggling to receive NIH funding, reducing indirect costs would further exacerbate their disadvantages, increasing the risk of falling behind in medical research, patient care and regional economic growth.

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