Throughout the world respiratory research is underfunded with a large discrepancy between the proportion of patients suffering from lung diseases and the amount of research funds awarded by our national agencies.^1–4 In fact, many governments—including the current British government—acknowledge this and are committed to directing more resources into an area where the diseases often affect the most vulnerable in our society. In this editorial I have attempted to analyse how we have got into this “Cinderella” state, and try to propose practical approaches to help us get more funding into respiratory research. The discussion focuses on Britain, but it is hoped that some of the suggestions might resonate with respiratory colleagues in other countries where similar underfunding is in danger of undermining valuable clinical strengths that have been nurtured over many years.

This article predominantly assesses the state of affairs in the more basic science, but it is hoped that it will also promote debate around more clinical and translational research which is so central to progress in patient care. In this area it is my sense that the respiratory community still has a strong reputation. However, whereas in the past these studies were predominantly supported by government agencies, the recent trend is for more and more dependency on pharmaceutical companies. This may be inevitable—and even desirable—as we seek new drugs and refine old ones, but at the very least the trend requires analysis.

WHY IS RESPIRATORY RESEARCH CURRENTLY UNDERFUNDED?

There has, for as long as I can remember, been a feeling that respiratory research is poorly funded compared with other disciplines where patient numbers are comparable. This feeling is also borne out by the numbers provided by the major funding bodies such as the Wellcome Trust and the Medical Research Council. For example, while deaths from respiratory disease accounted for 13% of all deaths in England and Wales in 2002, funding for respiratory research claimed only 2.8% (£11.4 million) of the MRC’s total expenditure in 2001–2 (£412.9 million).^5–7 Why should this be the case? When you challenge the leaders of the funding bodies their response is almost always that “we need to look at ourselves, not them”. They point out that all their grants are peer reviewed in the same way and that, if grants in respiratory medicine were as highly rated as grants in other areas, they would also get funded. Let’s accept this for a moment and try to analyse why. One possible answer lies in history. In the late 1970s, in Britain at least, respiratory research was confined to a few centres and was largely of the “measure and correlate it” type, with the main aim to monitor response to treatment rather than elucidate mechanisms of disease. At this time, research in other areas (cardiology, neuroscience and oncology, for example) was already embracing the new opportunities provided by progress in cell and molecular biology. This yielded strong progress that laid the foundations to establish many centres throughout Britain where the next generation of people are now benefiting. The respiratory world needed to catch up and, to a great extent, it has now done so.

My sense is that this discrepancy between respiratory medicine and other disciplines applies to most countries, although the time scales are different. In the US, for example, there was a concerted move to embrace molecular biology at least a decade before this occurred in Europe. However, even in the US it could be argued that we let our colleagues in other areas of medical research get the jump on us, and this may partly explain why the impact factors of specialist journals in many other areas are often higher than those in respiratory medicine.⁸

The last 25 years has seen unprecedented growth in basic respiratory research, particularly in key centres. This growth explains the current status of the many groups who are now recognised as world leaders in medical research. Nevertheless, not all of these centres are well supported by the established funding bodies. One possible reason for this is that we are, despite progress, still not writing grant applications of the highest calibre. I will return to this later. Another possibility is that the peer review process in the respiratory world is leading to lower rating not based purely on the quality of the science. In other words, as a community we set the bar higher than our colleagues in other medical disciplines and look for reasons not to fund. This is hard to assess objectively but it is certainly my sense that, in Britain at least, we are a very critical community. For example, there is no doubt that in some areas such as asthma research we are worldwide leaders by any standards, but this may work against us as competing asthma researchers sense (often incorrectly) that there is a limited cake to be portioned among their peers.

THE WAY FORWARD

Lobby the funding agencies

All of us leading research need to coordinate with each other and provide a strong lobby for government support, both at national and international levels. Combating lung disease is central to our government’s goals as outlined in the “Health of the Nation” document published in the first term of the current Labour government. We need to lobby for support and seek special initiatives to target the areas of respiratory medicine in which research is urgently needed to match our community expectations.

Continue to attract the best scientists and physicians into respiratory research

It is my sense that we have not always got the top of the crop into respiratory research, from the pools of both medical and science graduates. Furthermore, this is a vicious circle—if we don’t have the funding we can’t attract the best people who will in turn attract the best grants to allow them to flourish. We need to be more proactive in providing incentives and good career structures for our young talent. Furthermore, once we get people into respiratory medicine we must mentor them carefully. They need to be advised on how vital it is to obtain degrees of the highest quality and to perform their studies in the best laboratories worldwide. With this grounding, they will be in a position to compete with the very best graduates across the disciplines and obtain appropriate funding to fuel their desire to make important discoveries.

The long term career structures in academic medicine also need to improve along with financial incentives at least comparable to those in full time clinical practice. Equally, we must give scientists working in respiratory medicine an opportunity to rise to the very top of our medical schools and direct their own departments and research centres. Of course these are big issues, but the senior people in respiratory medicine must continue to make the case to their deans, vice-chancellors, provosts, and NHS chiefs.

Write better grant applications, recognising the need to take a multidisciplinary approach

We can all work on improving our grant applications. Rightly or wrongly funding is, to some extent, blind to the past. Track record is still very important but, if you do not write a grant with the key elements of novelty, focus, clear hypothesis and testable aims, you are probably sunk. Furthermore, if you avoid the trend to take a multidisciplinary approach, attacking a problem with all the tools available, you are also likely to fail. If this cannot be done within the confines of your own centre, then look for collaborators outside. One piece of practical advice: write your grant applications early and then take counsel from colleagues on how to improve them. Good grants need time to gestate.

Be better referees

All of us has a duty to the funding bodies to provide objective and impartial reviews. If we do not believe we can do this, we should return the grant applications and say so. We should also, when we review our peers, begin with the strengths rather than immediately attack weaknesses (which are inevitably present). We should first highlight the importance of the research area. Are there any areas of respiratory research (from the common airway diseases through to the orphan diseases) that are not worthy of support? Say So. Secondly, begin with the strengths. Many of our centres are led by extremely talented individuals who often have first rate international reputations. These strengths should be stated. In many cases we also have state of the art science faculties linked to unique clinical resources. These strengths should also be acknowledged. Simply stating a list of criticisms of experimental detail is, on its own, not appropriate. Of course, if there are fatal flaws in experimental design then this should be stated and the grant application should, quite rightly, fail.

Our grants committees usually recognise that a balanced judgement based on input from multiple referees is essential for fair grant assessment. This by and large works well but, in Europe at least, respiratory grant applications are often assessed by multidisciplinary panels representing all areas of medical research. It is therefore vital that we have good representation on these committees and we must be proactive in ensuring this. In the US, where respiratory funding is usually decided by individuals who are themselves involved in respiratory research, this is much less of a problem. Perhaps this is a better model for other governments and funding bodies to consider.

CONCLUSIONS

The last 25 years have seen huge strides in basic lung research and we have reason to be optimistic about the future. The products of this research are beginning to be realised.⁹ We also await translation of others through to clinical practice and, in this sense, it is vital that researchers in all areas of respiratory medicine work together to optimise the fruits of their outputs.¹⁰ In Britain and elsewhere we have many established centres and new ones are arising around the dispersed talents. The existence of strong basic science programmes supported by strong clinical research should engender confidence in physicians and scientists considering entering respiratory research and seeking funding for their work. However, at times I hear colleagues express a sense of nihilism regarding funding, partly arising from the observations that some of the very best groups are inadequately funded from these sources. We must work at eliminating this. Let’s continue to attract top young scientists and physicians into respiratory research. Let’s lobby our governments in a coordinated and constructive way, as is currently seen in the US. Finally, let’s continue to be positive, submitting the very best grants we can and being balanced referees for our talented peers.