The article lays out a major issue with the concentration of extramural funding at a few elite institutions. One additional reason that the geographical and ins

The article lays out a major issue with the concentration of extramural funding at a few elite institutions. One additional reason that the geographical and institutional concentration of extramural funding is so harmful is the 'brain drain' effects at research institutions that face uphill climbs to access funding. A significant part of every grant application is the institutional support, which lists core facilities and other resources that are funded by the indirect cost recovery from government grants. This creates a positive feedback loop where grants fund resources that enable grants to be awarded. You can imagine how institutions without large amounts of NIH research can struggle with this. Then you have to consider that many of these institutions are Universities with undergraduate populations. Undergraduates are engaged more and more in research exposure, which is becoming a significant prerequisite for graduate school and medical school (and especially for combined degree programs like MD/PhD programs). At universities without lots of external funding, such as NIH or NSF funding, it doesn't take a lot to imagine that there are knock on effects creating geographic and structure imbalances in the education that can be offered at a state school in say Wyoming or Nevada. Measures, like the Grant Support Index, would have curbed the worst excesses of this imbalance, by preventing super start researchers from effectively 'renting' out their name as a co-PI for research they were tangentially involved in. Likewise, NIH could recognize the need for biomedical investigation to be a 50-state wide enterprise leveraging institutions across the country rather than something to be pursued by elite institutions, many of which concentrated in a few metro areas. I have no evidence, but I do wonder that when we concentrate this knowledge and learning in a few metro areas, is it really a surprise that scientific literacy and health literacy can be quite low in the same areas we are failing to invest in?