An “alternative history” has revealed the potential impacts a smaller National Institutes of Health (NIH) would have had on past drug development—and the results paint a troubling picture. If the NIH budget had been 40% smaller from 1980 to 2007—the level of cuts that President Donald Trump has proposed for the agency—the science underlying numerous drugs approved in the 21st century would not have been funded, according to an analysis.
The study, led by economist Pierre Azoulay, Ph.D., of the MIT Sloan School of Management and the National Bureau of Economic Research, was published in Science on Sept. 25.
Drugs affected in this data-driven thought experiment include Sanofi’s Cerdelga, a daily pill for Gaucher disease type 1; Gilead Sciences' HIV meds Emtriva and Truvada; and Novartis’ breakthrough cancer treatment Gleevec.
All in all, in a shrunken NIH, 14 approved drugs would have had research directly supporting their patents defunded, while 59.4% of the 557 drugs in the sample would have lost citations in their patents. Cerdelga is one drug with a patent that would have been directly impacted, while Emtriva, Truvada and Gleevec would have lost cited research.
The results suggest that “massive cuts of the kind that are being contemplated right now could endanger the intellectual foundations of the drugs of tomorrow,” Azoulay told Fierce Biotech in an interview.
While the what-if analysis is imperfect, “there are lots of reasons to think that what we provide here is an underestimate,” Azoulay said. For one thing, the analysis focused solely on small molecule drugs, and only direct citations were examined; following citation trails further would have likely revealed even more NIH-funded work underpinning drugs.
“It often takes decades and significant investment and expertise to make therapies available to patients for serious diseases as well as important preventative medicines,” Gilead told Fierce in response to a request for comment on the new study. “U.S.-led medical innovation has helped millions of Americans live longer, healthier lives—we owe these improvements to an ecosystem that fosters innovation and includes basic academic research.”
The Biotechnology Innovation Organization, a trade group representing the biotech industry, declined to comment for this story, saying it is still reviewing the new study.
A spokesperson for the Pharmaceutical Research and Manufacturers of America (PhRMA) said the trade organization is “continuing to monitor the impact recent cuts are having and possible implications for our country’s unique innovation ecosystem.” PhRMA did not respond with a statement about the new study in time for publication.
Sanofi and Novartis did not respond to requests for comment.
Brian Druker, M.D., the developer of Novartis’ Gleevec and current leader of the Knight Cancer Institute in Portland, Oregon, told Fierce that his work on the drug would have been impossible without the foundation laid by preceding NIH-funded research.
“This includes the discovery of BCR-ABL, but even that took contributions to chromosome banding, the discovery of oncogenes, the ability to map genes to specific chromosomal locations, gene cloning and the discovery of kinases,” Druker said earlier this week. “NIH-funded research is essential for the pipeline of drugs that are developed by industry.”
Azoulay believes the industry understands the importance of NIH funding for their business, “but I also think they've been quite cowardly in the past few months,” he said.
“I think they don't want to attract the ire of Trump or RFK,” Azoulay said, referring to Department of Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. “They have left academia to fend for itself. That's pretty disappointing, as far as I'm concerned.”
Changing times, changing questions
Trump’s proposed budget for 2026 includes a nearly $18 billion cut to the NIH, and, although Congress, which has ultimate control over the government’s purse strings, has shown no desire to implement those cuts, the federal health apparatus has still been upended during Trump’s second term.
The HHS has been hit with mass layoffs, hundreds of millions of dollars’ worth of NIH grants have been canceled and NIH Director Jay Bhattacharya, Ph.D., has threatened to terminate any research that doesn’t align with new agency priorities.
Azoulay and the same team of collaborators had previously shown in 2019 that boosting NIH funding supports patents in the private sector, but he told Fierce this prior work focused on “small changes at the margin” of the agency. With the reelection of Donald Trump, the question no longer became about the impact of small changes but that of “nuking the NIH budget.”
To address the potential impact of this “nuking” and build the alternative history, the researchers took advantage of data from 1980 to 2007 that demonstrated the funding priority for all approved NIH grants. The team then estimated what would happen if those grants at the bottom 40% of the pile had never been funded, which they assumed would be the case if the agency’s budget was 40% smaller at the time.
While it’s impossible to say for sure what would have happened with a smaller NIH budget in the past, Azoulay said their analysis is the best they could do with the data they had.
“There are shortcuts here, and we're very open in the paper about what those shortcuts are,” he said. “But I think people should take the analysis seriously, even if they don't take it literally.”
Numerous other studies have highlighted the importance of the NIH for the private sector. A 2018 study found that NIH-funded research supported every single one of the 210 new drugs approved by the FDA from 2010 to 2016, and a March analysis found that every $1 spent on research by the NIH in 2024 produced a return of $2.56.
Should the NIH’s budget actually be cut, Azoulay worries it would be very difficult to restore the agency later on. He and his collaborators have previously identified the time lag between when research is done and when benefits from that research actually manifest, which he says means that cuts to the NIH might not have consequences until years down the line.
“Cuts today are going to have effects starting 15 years from now, roughly, and then accelerating from there,” Azoulay said. Since World War II, support for the NIH has enjoyed bipartisan consensus, he said, but “what's been playing out is the fraying, or end, of this bipartisan consensus. I'm not sure we can wind the clock back.”