BY GREG BROZEIT Just as the swallows return to Capistrano every March, beginning this month medical research advocates can expect to get frantic messages urging them to contact Congress to: a) support funding increases that have been agreed to by advocacy coalitions in Washington, DC and/or, b) oppose cuts. Last year the National Institutes of Health (NIH) budget increased by $2 billion.  This year, the House approved $1.25 billion more, the Senate $2 billion.  All signs point to an agreement of $34 billion for NIH. Taken together, that $4 billion increase spread over two years is still well below the $9 billion that Ronald DePinho, president of the MD Anderson Cancer Center, last year said was needed to get the NIH back to level of research activity of 2003. The National Cancer Institute (NCI), the largest of the NIH institutes, currently has an annual budget of $5.21 billion, an increase of $260.5 million over the previous year.  If this trend continues, we can expect roughly the same this year. But consider, when adjusted for inflation, that the $1.6 billion President Nixon provided for NCI when declaring the War on Cancer in 1971 would equal $14.99 billion today.  We can dream, can’t we? If history over the past 20 years is to serve as a guide, we shouldn’t expect Congress to make any radical increases to NIH and NCI in coming years, even with all the hoopla surrounding the Obama administration’s Cancer Moonshot.  In fact, we really shouldn’t even be optimistic that they will act by the September 30 fiscal year deadline. A more likely scenario will include the following: Congress will again fail to pass most of the 13 “must pass” appropriations bills on time; there will be political grandstanding about issues that have nothing to do with them; short-term band-aid bills will be passed that will hold funding at last year’s levels—known as sequestration—and prevent NIH from making timely, forward-looking plans, and finally; by November or December (for the current fiscal year, it was early January 2016, more than three months late), we can expect passage of a gargantuan omnibus bill that will fund most federal agencies and include a number of hidden, politically-motivated provisions. What advocates aren’t told, however, is that by the time grassroots advocates make noise, most of the big decisions were made long ago.  Now they’re just tinkering around the edges.  There is, in my opinion, a more fundamental reason that medical research funding will likely never be enough to satisfy the market of good, achievable ideas: military spending. The congressional appropriations process funds annual federal discretionary spending, which is just slightly less than one-third of all federal spending.  The other two-thirds-plus is mandatory spending—things like Social Security, Medicare/Medicaid, federal pensions, and interest on the national debt. Discretionary spending, which will likely be between $1.1-1.2 trillion for fiscal year 2017, is divided into unequal pieces between 13 House and Senate appropriations subcommittees.  The largest piece of that theoretical pie, between 53-55%, goes to Defense.  In other words, less than half of annual discretionary spending for every federal agency is divided between the other 12 subcommittees. For the Labor, Health and Human Services and Education subcommittees, that translates to about $161.5 billion for 2017.  The expected $34 billion for NIH will come out of this.  So when one adds all the other functions of those departments—occupational safety, student grants and loans, and disease prevention, just to cite a few examples—there is little room maneuver spending priorities. Instead it will take a reprioritization of macro issues, especially when more than half of the money being spent is off the table to begin with.  This is not a new idea. Almost eight years before President Eisenhower warned the nation about the military-industrial complex, he gave his “Chance for Peace” speech in which he stated, “Every gun that is made, every warship launched, every rocket fired signifies…a theft from those who hunger and are not fed.”  The next two sentences are cited less often: “The world in arms is not spending money alone.  It is spending the sweat of its laborers, the genius of its scientists, the hopes of its children.” [emphasis added] More than 65 years after Eisenhower said those words, it might be time to start to take them seriously.  The United States now spends between three-to-four times more on its military than the second largest in the world, China.  We spend almost ten times as much as Russia. This is having real effects.  I recently had a conversation with one of the leading cancer researcher in the U.S. about medical research in China.  He noted that many Chinese medical researchers trained in the U.S. are returning to China in droves because massive investments are being made in research facilities and scientists are being given carte blanche to pursue investigator-initiated studies.  Similar activities are taking place in Singapore and South Korea. Considering the role that military and national security issues play in national partisan politics, I can already hear many of you who have read this far complain that this is just a bunch of liberal tripe.  But it’s not an either/or question; it’s a question of being smarter. We can reduce our military spending to address other national priorities without putting national security at risk.  And we can geometrically increase medical research productivity to save lives with, when compared to the military budget, relatively fewer dollars. For example, the newest aircraft carrier in the American fleet launched earlier this year cost $13 billion, and that doesn’t include future spending on maintenance and staff.  Remember the $9 billion that was cited above by Dr. DePinho?  This and more can be achieved if our policy makers were forced to think smarter and bolder. In the big picture, a United States leading the world in rapid medical discovery would likely create soft power to further the goals of peace that would at least be the equal of the power of an aircraft carrier. The main point for advocates who strongly believe that medical research should be a major national priority is begin to understand that under the current constraints of the appropriations process, there will only be incremental change. It will require bigger, more effective and persistent coalitions to challenge, influence, and change the attitudes of the public and Congress about fundamental spending priorities; it’s about creating new definitions of guns and butter.  It will require much more engagement than responding to post-Labor Day “calls and letters” alerts. I’ll address some ideas about possible strategies in my next article.