In recent years, I have grown increasingly concerned that public health has become too siloed, too dogmatic and too uncomfortable communicating uncertainty. I have seen colleagues on all sides digging in, becoming less willing to engage across disagreement or to acknowledge limits and trade-offs. That retreat may feel protective, but it ultimately undermines trust, both within science and with the public we serve.
It was with that in mind that I took part last month in a Make America Healthy Again Institute roundtable on rebuilding public trust and the future of the National Institutes of Health. There, I joined a small group of public health colleagues alongside NIH Director Jay Bhattacharya and NIH agency heads, MAHA activists and community members.
I want to be clear about my posture going in: I am not ideologically aligned with many who were in that room. As an immigrant physician and scientist, I worry that national funding cuts and policies that make this country less welcoming will deter the next generation of lifesaving talent and leadership from coming to the United States. I understand why many of my colleagues feel frustrated or concerned.
But rather than avoiding the conversation, I decided to lean in. My goal was not to smooth over disagreement, but to understand where critique is ideological and where it reflects real dysfunctions that many scientists themselves have acknowledged for years.
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What I heard at the event was more complex and constructive than much public discourse would suggest. There was a clear appetite for action, for questioning the status quo and for improving systems without dismissing what’s working. There was acknowledgment of the incredible lifesaving research that has happened at NIH in years prior and the outstanding dedication of NIH employees.
Importantly, I come to the conversation not as an outsider, but as an NIH-funded researcher and grant reviewer. Going through that process, I’ve seen extraordinary rigor and commitment. But I’ve also witnessed where the system strains under its own weight. The experience has left me both more invested in the success of the institution and more candid about where it can do better.
Even when I disagreed with some points raised, much of what I heard from NIH leaders at the roundtable had the potential to be genuinely transformative. One recurring theme was the need to rethink how peer-review functions in practice. Agency leaders acknowledged that institutional prestige and entrenched networks can influence funding decisions. This was not discussed as evidence of misconduct but as a structural issue that emerges when many proposals are strong and reviewers need to rely on familiar signals to differentiate among them. That acknowledgment resonated with my own experience as a reviewer. A system designed to reward excellence may unintentionally discourage risk at a time when bold ideas are urgently needed. In addition, instead of asking reviewers to assess every aspect of an application, the process could be modernized by engaging targeted experts, such as statisticians, while using technology to evaluate other elements.
There was also discussion about fragmentation across research. NIH leaders described how, in the absence of shared standards, institutes and laboratories often develop parallel models, protocols and validation approaches, slowing progress and making results difficult to compare or reproduce. To address this, the leaders highlighted investments in collaboration and shared infrastructure. The goal is not centralization for its own sake, but interoperability – enabling work generated in one place to be meaningfully built upon by others.
Agency heads also acknowledged that failure to replicate can often be misread as misconduct, when it more accurately reflects how difficult science is. Experiments are complex, replication is underfunded, and career incentives still reward novelty over verification. Strengthening the incentives for replication work would strengthen the credibility of biomedical research.
The discussion around equity was more nuanced than it often is in public debate. NIH leaders suggested that some mechanisms focused on diversity, equity and inclusion have not translated into desired outcomes, while emphasizing that improving the health of minority and disadvantaged communities remains a core priority. The emphasis was on accountability and measurable impact.
Concerns about concentration of funding resonated most strongly with me. One example captured the issue clearly: If two proposals are scientifically equivalent, but one lab in Boston requires far higher facility costs than a lab in Oklahoma, shouldn’t that cost-effectiveness matter in funding decisions? In practice, it rarely does. Institutional affiliation can influence outcomes even when scientific quality is similar. This reflects a deeper problem in how academic success is defined and rewarded.
NIH leaders also spoke about the need to create a legitimate pathway where negative findings – rigorous work that fails to confirm a hypothesis – are valued rather than buried. I strongly agree. Our system rewards positive results and publication counts, which can discourage risk. Negative findings are not failures; they are essential to progress.
Scientists rightly worry about the politicization of science. But what struck me last month was how much time was focused on practical ideas for making systems more efficient, more rigorous and more supportive of science. There were disagreements, but they were open and respectful.
In the current climate, that mattered a lot. Rebuilding trust will require showing up, listening critically and communicating uncertainty honestly, while supporting reforms that improve fairness, rigor and outcomes. Progress can come only with participation.
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Chethan Sathya is a pediatric surgeon and public health researcher.