First Opinion is STAT’s platform for interesting, illuminating, and provocative articles about the life sciences writ large, written by biotech insiders, health care workers, researchers, and others.
To encourage robust, good-faith discussion about issues raised in First Opinion essays, STAT publishes selected Letters to the Editor received in response to them. You can submit a Letter to the Editor here, or find the submission form at the end of any First Opinion essay.
The story
“The NIH ordered me to stop my ‘dangerous’ gain-of-function research. It isn’t dangerous at all,” by Sarah Stanley
The response
I have been working for well over a decade to raise awareness about, and increase restrictions on, the small subset of microbiology research that could lead to a large outbreak or pandemic, through accident or deliberate misuse. This type of research, which has had different names through the years, is called “dangerous gain-of-function” (DGOF) research in President Trump’s executive order. It is defined as research “that could result in significant societal consequences and that seek or achieve” one of seven types of changes to infectious agents like increased transmissibility or virulence.
I remain in favor of tighter restrictions on such research and contend that there are only very rare instances where such work can justify the risk. Alternative, safe scientific approaches nearly always exist that can achieve the public health goals of proposed dangerous gain-of-function studies, and we should support these safe alternatives instead of the DGOF approaches.
Unfortunately, Sarah Stanley is right that the implementation of this executive order has targeted entirely safe and important research that doesn’t even meet the definition of DGOF in the executive order. This implementation does little to make us safe. Instead, it has canceled experiments, including hers, that pose no risk of widespread infection even in the event of an accident, and which are part of basic science that is essential for new cures and prevention measures for tuberculosis.
Though I probably favor tighter restrictions on some experiments than professor Stanley, I believe that arbitrarily restricting safe and productive scientific research increases, rather than reduces, the risk we face from infectious diseases. Restrictions should be focused on the tiny subset of research that actually creates outbreak or pandemic risk, leaving the vast majority of microbiology to proceed.
— Marc Lipsitch, Harvard T.H. Chan School of Public Health
The story
“The U.S. experiment with profit-driven health care has failed,” by Steffie Woolhandler, David U. Himmelstein, Adam W. Gaffney, and Danny McCormick
The response
While the authors make great points, they overlook the largest problem: the irrational expectations of the public. We are entitled to every possible care option. And it shouldn’t cost us anything. Every other existing health system would be unacceptable to Americans as they apply cost-benefits constraints, especially in late-stage care, which explains a lot of our higher costs per capita vs. Europe. But we’ll scream “death panels” and find scapegoats to avoid dealing with realities of an unhealthy and aging population with increasingly expensive ways of treating their conditions.
— Robert Merold
The response
The authors are right on target. The main reason health care in the U.S. is unaffordable and inaccessible is ownership of hospitals, practices, and long-term care by disinterested investors. The profit they earn should be going into health care, not dividends. When one of us is sick, all of us are sick. We learned that lesson painfully during the last pandemic and surely there will be another one. The goods of health care are public goods. They should be allocated according to need and paid for according to ability. Our current health care system (if you can call it that) and the resources required to manage it are irrational, dangerous and unjust. The problem is that we have no operative notion of the common good in the United States. We prefer to see everything through the lens of merit and private ownership. If we don’t dump our current system and envision a new one through the lens of the common good, the problem will get worse and worse until it collapses entirely.
— Father Charles Bouchard, Aquinas Institute of Theology
The response
The authors are correct in describing the failures the U.S. health system and the role of corporate takeover in siphoning money and priorities toward profit rather than improving care. However, it is in many ways worse that they have described. To mention one example: primary care, where we have a national shortage and crisis in access and cost. At Mass General Brigham we have more than 15,000 patients on the waiting list for primary care — patients of ours whose doctors have left and there are no PCP appointments available. I recently learned of a patient who was just discharged from the hospital and given the earliest available PCP follow-up appointment — December 2026! The problems have been well documented and studied with multiple commissions in Massachusetts and from the National Academy of Medicine. But since it is not profitable to invest in primary care, the needs of patients (and PCPs to improve their work processes) go unaddressed.
— Gordon Schiff, Brigham and Women’s Hospital
The story
“Corporate support cannot make up for threats to the NIH budget,” by Jerry Avorn
The response
Professor Avorn raises a crucial issue — but reaches the wrong conclusions. Between 2010-2019, 83% of National Institutes of Health grants (totaling $156 billion) were for basic research and 17% ($31 billion) were for translational research.
How can we explain this yawning chasm in program funding? The Occam’s razor explanation is that the NIH can only approve grants that they are asked to review. In other words, the overwhelming number of grant requests are for basic science research. Another way to define “basic science research” is research that isn’t only exclusive to academic researchers but that purposely excludes intramural cooperation with the biopharmaceutical industry.
Such puritanical attitudes are churlish, outdated, and contrary to the scientific tenet of cooperation. Why aren’t more academic researchers seeking more translational program funding partnerships from potential industry partners? One reason is that they haven’t had to. Until recently, with every doubling of the NIH budget, the incentives for translational industry partnerships decreases. Academics were fishing where the fishing was most abundant.
Avorn fails to consider the broader ecosystem. Even when NIH funds grants for translational research, many of which include human trials, they often fail to reach out to the FDA to vet the prospective grantee’s technical assumptions — decreasing the ability to validate relevant findings and, potentially, putting clinical trial participants at risk. Other areas of relevant but siloed knowledge include the FDA’s expertise in biomarkers, real world evidence, and benefit/risk analysis.
Since interagency cooperation isn’t succeeding organically, it’s time for top-down initiatives led by a Health and Human Services “innovation czar.” Such cooperation will act as a force multiplier, helping to make the recipients of NIH grants more likely to succeed.
A good first step would be for the NIH to consider mandatory cross training for their internal teams and external grantees in the processes, procedures, and evidentiary standards of the FDA. Potentially fewer NIH-funded grants and lower reimbursement rates for indirect costs are both very unsubtle signals that academic researchers should look to sources other than NIH for project funding.
The obvious opportunity lies with more and more regular partnerships with the biopharmaceutical industry. It should also drive innovative thinking inside the NIH grant-making apparatus. Perhaps the NIH should create a category of “matching grants” whereby government support is contingent on an applicant’s first receiving equal support from private sources (such as foundations and the biopharmaceutical industry).
Such a paradigm shift requires abandoning the shibboleths of traditional research purity. It takes two to tango.
— Peter Pitts, Center for Medicine in the Public Interest
The response
Thank you for this thoughtful and 100% accurate opinion piece. Everything you said is what I know to be true; is what I studied as a graduate student in a science, technology, and public policy program at George Washington University; and is what I experienced firsthand when I worked at the NIH/CC and the FDA and presently working for a pharmaceutical company. Your words are compelling, but I fear only to those who already understand and value how biomedical research is conducted in the United States.
Let us hope that people in positions of power will recognize what is at stake and take heed of your sage warning.
— Julie Zawisza
The story
“The origins of Covid and public health’s uncertainty problem,” by Michaela Kerrissey and Richard J. Tofel
The response
Public health scholars Michaela Kerrissey and Richard J. Tofel recently argued in STAT that students should study the unresolved debate over Covid-19’s origins as an exercise in grappling with uncertainty. Their impulse is admirable.
But there’s a danger here that echoes an earlier chapter in American science education: the “Teach the Controversy” campaign of the early 2000s. That movement, led by advocates of intelligent design, urged schools to “teach both sides” of evolution, presenting it as an open question rather than a foundational fact of biology. Within evolutionary virology, evidence for a zoonotic spillover from the wildlife trade in Wuhan remains far stronger than evidence for a laboratory accident. The latter is not impossible, but it is highly speculative and unsupported by data. Treating these as equivalent “scientific hypotheses” risks reproducing the same false-balance dynamic that once let pseudoscience sneak into biology curricula under the banner of fairness. Uncertainty in science is not the same as controversy in politics. Every field of research contains unknowns; that’s why science progresses.
But not every unknown deserves to be framed as a live dispute between co-equal camps. When instructors or journalists collapse that distinction, they can inadvertently validate manufactured controversy and erode the public’s sense of what counts as reliable knowledge.
A better way to teach the Covid-origin debate is to flip the frame. Instead of asking students to weigh “lab leak versus market spillover” as if they were symmetrical, ask them to examine why the lab-leak narrative spread so powerfully despite limited evidence. What roles did media incentives, algorithmic amplification, and partisan polarization play? How did uncertainty become political currency? These questions illuminate the sociology of knowledge without confusing it with the science itself. The point isn’t to suppress skepticism or close debate. It’s to teach the hierarchy of evidence and the anatomy of misinformation at the same time.
Students can and should learn how scientists assign confidence to hypotheses, how peer review works, and how data can overturn consensus. But they should also see how disinformation campaigns exploit the normal self-correction of science to suggest chaos or deceit where there is merely complexity. Framed that way, the Covid-origin discussion becomes a lesson in epistemic literacy — how to know what is known — rather than another installment of “teach both sides.” It arms future public-health professionals not just with facts, but with the intellectual tools to recognize when a controversy is genuine or manufactured.
— Philipp Markolin
The story
“The radical democratization of academic medicine,” by Jonathan Avery
The response
Jonathan Avery’s essay is exactly right that the center of gravity is shifting away from the old guard. But let’s be honest about why that shift is overdue. For decades, academic medicine has fetishized “R01 + NEJM” over real-world adoption metrics. The system has rewarded incrementalism, risk aversion, and gatekeeping disguised as rigor. NIH paylines typically range from 10–12%. The median age for a first R01 is 43.
That is not meritocracy. It is a system optimized for endurance, not discovery. Those who came up under that structure have enormous intellectual investment in preserving it. They chair review panels, sit on promotion committees, and guard the methods they were trained in. But as Byrne Hobart and Tobias Huber argue in “Boom: Bubbles and the End of Stagnation,” and as Alexander Karp and Nicholas Zamiska warn in “The Technological Republic,” Western science has been trapped in a culture of safe excellence. Brilliant at refinement, timid at risk.
Meanwhile, the next generation is building in public: open-source datasets, artificial intelligence tools, educational videos, and digital health pilots that reach more people in a week than a print journal does in a decade. These are not distractions from “serious” scholarship. They are modern expressions of it. I once received a grant review that asked, “Where is your power calculation?” for a computer vision proof-of-concept. That moment captured the mismatch between our methods of innovation and our methods of validation. Democratization is not dilution. It is correct. Rigor still matters, but rigor today means reproducibility, transparency, and usability, not gatekeeping. The future academic physician will publish tools, data, and ideas that move faster than bureaucracy. Academic medicine’s credibility problem is not that it is losing its hierarchy, it is that it mistook hierarchy for quality. The new generation of scholars is not asking for permission. They are rebuilding the architecture of impact itself.
— Matthew Crowson, Mass Eye & Ear and Harvard Medical School
The story
“The long history of euphemisms around the use of animals in lab research,” by Melanie D.G. Kaplan
The response
Melanie Kaplan’s recent opinion piece, an excerpt from her new book, “Lab Dog: A Beagle and His Human Investigate the Surprising World of Animal Research,” raises an important truth: Language shapes how the public understands science. The research community hasn’t always done enough to explain the words we use or the safeguards behind them.
However, the excerpt’s claim that this language “hides” reality to be secretive overlooks important context and may lead readers to misunderstand its true purpose. In animal research, terminology is not about softening or “soothing” reality; it’s about precision and accountability. Words like “euthanasia” and “animal model” have specific scientific and legal meanings that trigger defined welfare standards, training requirements, and oversight mechanisms. For instance, when a protocol lists “euthanasia,” it activates a chain of mandated veterinary review, approved methods, and public documentation.
Far from being euphemisms, these are terms embedded in a regulatory framework designed to protect animals and ensure consistent, humane care. Animal research is among the most scrutinized areas of science in the U.S. Institutions using regulated species are inspected by the Department of Agriculture — often unannounced — and those reports are posted publicly. Federal agencies publish annual counts by species and pain category, and most major programs also undergo voluntary Association for Assessment and Accreditation of Laboratory Animal Care accreditation, adding yet another independent welfare audit beyond what the law requires.
Specialized language isn’t unique to research or animal-related fields. In aviation, for example, a pilot might use terms like “controlled descent” or “runway incursion” — not to downplay a problem or avoid plain words like “crash” or “near miss,” but because those phrases are standardized codes that precisely define the risk and corrective process. They enable experts, inspectors, and regulators to communicate effectively, allowing every event to be traced, measured, and corrected under federal oversight, ensuring the issue doesn’t happen again. Animal research terminology works the same way: it ensures that welfare and procedural standards are met, not masked.
Nonetheless, the research community can and must do more to communicate transparently. Scientists, veterinarians, animal care professionals, and compliance experts share a duty to proactively explain their work and the compassion behind it. Clearer dialogue that is grounded in facts, not fear, will strengthen public trust and safeguard the scientific progress that benefits both human and animal health.
— Naomi Charalambakis, Americans for Medical Progress
The story
“Parents of children with rare diseases ask: How long until our CRISPR miracle?” by Celena Lozano
The response
Lozano’s perspective as both a scientist and a mother is a timely reminder that progress in rare disease research requires urgency from researchers, policymakers, and the biotech industry. Precision medicine should start at birth. Today, most families still endure diagnostic journeys that can last years, delaying care and causing emotional and financial devastation. According to the European Journal of Human Genetics, nearly 70% of rare diseases begin in childhood, with over 80% of those being genetic in origin. Meanwhile, experts estimate that rare diseases cost the U.S. health system approximately $1 trillion annually.
Luckily, we’re starting to see progress that meets the urgency Lozano is asking for. BEACONS is the first U.S. multistate genomic newborn screening program, funded by a $14.4 million NIH award. The program will enroll up to 30,000 newborns in an effort to determine how whole genome sequencing can be responsibly integrated into public health newborn screening programs. Research like this promotes a future where every child has the chance to live a healthier life starting from birth, while arming parents like Lozano with the information they need to advocate for their children.
Early diagnosis is only part of the solution. The current ecosystem isn’t built for the pace of genomic innovation or the urgency of high unmet medical needs for pediatric patients living with rare diseases. There is no reason families should be waiting decades for an accurate diagnosis that could improve a child’s health outlook. Lozano and every rare disease parent like her need our system to change. Research like BEACONS is a crucial step in finding answers and treatments our system needs.
— Katherine Stueland, GeneDX
The story
“What RFK Jr. gets wrong about medical school and nutrition education,” by Tiffany Onyejiaka
The response
Bravo to Tiffany Onyejiaka for highlighting the enormous, science-based role that nutrition plays in the patient’s prevention and treatment of many chronic diseases as well as identifying the registered dietitian nutritionist (RDN) as an important member of the interdisciplinary health team. While I welcome a higher level of nutrition education in the medical school curriculum, I would advocate this for only one reason. Medical doctors should be educated that RDNs are well-trained in personalized medical nutrition therapy so they should refer their patients to these nutrition professionals.
An orthopedic surgeon knows the value of physical therapy in the pre- and post-treatment of their patients. They do not, however, provide this therapy. Rather, they refer them to the expert physical therapist. RDNs are the nutrition experts and an invaluable member of the team.
— Joan Salge Blake, Boston University
The story
“An insurance company is introducing a new threat to American medicine,” by Ryan Nadelson
The response
One aspect I appreciate about Ryan Nadelson’s article is that he cited a study to demonstrate his point of view on physician burnout and burdensome paperwork. His citation makes his view credible. If Cigna cited any objective study to support their view, that physicians are upcoding medical visits falsely, we don’t learn about such studies in this article. I would like to know what is the source that supports their claims.
In today’s political climate, legislators will freely accuse legitimate users of government services of fraud and other misdeeds, without substantiating those claims. Cigna may not have followed this page from the conservative politicians’ playbook, but if they did, they are importing weak government tactics into the arena of health care decision-making. Whether the group making these accusations justifies their assertions as efforts to save taxpayers dollars or get investors a better return, the public who is affected by the consequences of draconian policies deserves better documentation of the fraud they are being accused of. If doctors become victims of loose claims of fraud, the public has reason to view doctors as untrustworthy. Cigna’s charges, substantiated or not, seriously undermine the bedrock relationship of trust between doctors and their patients. I find this issue to be very unsettling. Thank you for covering it.
— Marty Perry
The response
The thoughts laid out in this opinion piece are woefully one-sided. Yes, health insurers are getting more innovative. But guess what? So are providers — doctors, caregivers, etc. Just as an example, more and more providers are doing their medical coding and billing using AI. After copious amounts of dollars lost (and upset shareholders), the insurers looked to the claims they were sent and realized that there was a trend of high-level submissions among certain doctors. These doctors coded and billed using AI agents and those submissions were incorrect, bordering on fraud. Naturally, health insurers are now actively combing through claims, and as this article stated, are downcoding where applicable.
Just wait until insurers start the claims approval process via AI to combat the AI generated submissions. The headaches that will cause the general populace will be legendary.
— Christopher Aliprantis, health insurance IT expert
The response
I read with concern your recent reporting on Cigna’s new policy to downgrade physician billing based on peer comparisons. As an independent physician in a small practice, I’ve seen firsthand how insurers exert outsized control over reimbursement—with little transparency or accountability.
Beginning this July, both Cigna and Aetna abruptly began paying me about two-thirds of the contracted rate I had been receiving, without warning or explanation. At first, when my billing team called, we were told: “Our mistake, we applied the wrong contract — submit an appeal and wait 30 days.” After multiple appeals, audits, and hours on the phone, the story shifted: Suddenly, these lower payments were supposedly the “correct contracted rates.” But that makes no sense — especially since reimbursements for the same evaluation and management codes vary widely across claims, and this inconsistency only started a year into my new practice.
The reality is that insurers hold all the power. There is no mechanism to hold them accountable for unexplained payment delays or underpayments — problems that can destabilize a small practice’s cash flow overnight. To keep my practice afloat, I’ve had to shorten appointment times again, directly impacting patient care. When large insurers like Cigna or Aetna can unilaterally alter physician reimbursement without oversight, patients ultimately lose. Transparency, consistency, and accountability are badly needed if independent practices are to survive — and if patients are to keep access to personalized care outside of large hospital systems.
— Gordon Hill, M.D.
The response
Good for Cigna! As a veteran clinical neurologist and as a patient I have witnessed excessive upcoding by too numerous physicians to count. I have seen physicians pop their head into an exam or hospital room while I am doing a full exam on a patient and charge them as a four or five level visit. Disgusting! This has gone on for years. How can these physicians sleep at night? Sometimes I have discussed this with friends after looking at their explanation of benefits after witnessing these brief clinical encounters and then later assessing the charges. I can personally say I have not been a perpetrator of med insurance fraud like this.
Somehow these physicians rationalize it. Their thinking probably goes like this: “Well, they aren’t paying me enough for a level one or two visit so I’ll upcode.” I say to physicians out there: Prove it. Prove you have spent the time you spent with the patient and prove the complexity of your decision making and management. Cigna would not have to do this if physicians were honest.
— Robert Feldman
