ARPA-H must think differently and leverage technology

The Biden administration has announced the formation of the Advanced Research Project Agency for Health (ARPA-H), an organization that will be housed within the National Institutes of Health (NIH) with the mission of bringing to medicine the kind of breakthrough research ideas and methods that led to the advent of the internet and GPS. 

While innovation is desperately needed in medical care — and DARPA, the U.S. Department of Defense agency that ARPA-H is modeled after, offers a compelling model — the past two years of the pandemic have revealed that the focus of ARPA-H should be radically different than what is being proposed. 

While nascent, the current plans for ARPA-H are to invest in research for cancer, Alzheimer’s and diabetes, among other illnesses. This disease-oriented approach may yield new drugs, detection methods, and therapeutics for conditions that already have significant research funding and investigation underway at the NIH. It would not change the sobering fact that the United States ranks 42nd in life expectancy worldwide, has the highest suicide,  infant and maternal mortality rate among industrialized nations, and has alarming disparities in health among Blacks, Hispanics, Indigenous Americans, and other marginalized communities, with a 20-year longevity gap based on where you live — your zip code, not your genetic code. In fact, as we saw with the groundbreaking COVID-19 vaccines, medical innovations on their own — without the public health infrastructure in place to effectively deploy them — risk leaving vulnerable communities behind and worsening health inequities. 

Instead, ARPA-H must fund breakthrough public health technologies that can improve health outcomes and equity today and modernize our public health infrastructure for decades to come. Here are five such examples: 

1. Pandemic response and surveillance: A key to mitigating COVID-19 was “last-mile” delivery innovations such as drive-through testing and pop-up vaccine clinics, but we could go much further. Right now we lack accurate COVID case counts because at-home tests are costly and lack connectivity to public health departments. ARPA-H could fund second-generation at-home tests that are far less expensive to produce and are connected. It could also fund new vaccine delivery modalities such as vaccine patches that could be self-administered, simplifying their administration and potentially decreasing vaccine hesitancy. 
2. Mental health crisis: Less than half of people with mental illness receive appropriate treatment ), and deaths of despair including drug overdoses, suicide, and alcoholism are leading causes of mortality in the United States, with alarmingly high rates in young people. The PHQ-9, the most widely used screening tool for depression developed over two decades ago, fails to diagnose 12-15 percent of people with this illness and requires a healthcare professional to administer, a barrier for at least one-quarter of Americans. ARPA-H could fund breakthrough technologies to analyze data collected from smartphones, voice calls and text messages and generate signals that people may be depressed, anxious or at risk for suicidal or homicidal behavior. It could also fund new interventions that improve mental health resilience and help address mental illnesses such as depression, PTSD, schizophrenia and bipolar disorder using technologies such as digital avatars and mental health coaches trained with evidence-based best practices to help augment our depleted mental health workforce. 
3. Disease prevention and behavior change: The tripling in obesity rates over the past two decades may result in the first generation of Americans who are not as healthy as their parents. ARPA-H could address obesity and type 2 diabetes at a population level by funding artificial intelligence (AI) chatbots for health designed for and by vulnerable communities and, for individuals on the other side of the digital divide, community health workers who support people in their homes and neighborhoods using advanced decision support software. 
4. Social determinants of health: Forty percent of health outcomes in America are driven by social determinants of health — factors such as education, housing, transportation and food security that are upstream of the traditional healthcare system. The problem is multifactorial, but one challenge is matching an individual’s needs with available social services. During the pandemic, we learned that we can program mRNA into vaccines but can’t help people figure out where to get vaccinated or tested in their neighborhoods. The same kind of information gap exists for finding housing and legal aid, food banks, low-cost transportation, and medication assistance programs. ARPA-H could invest in mapping community resources digitally so accurate data is available to any healthcare provider or person looking to address an individual’s social needs and help overcome barriers to healthcare.  
5. Public health communication: COVID-19 exposed how mistrust and misinformation can hinder the most advanced medical breakthroughs. ARPA-H could invest in harnessing new social media tools and advanced analytics to help public health professionals identify and break chains of transmission and contain “outbreaks of misinformation” while delivering effective prevention messages at scale. Additionally, there is an estimated 17-year science-to-service gap in the dissemination of research findings into clinical practice. In the Digital Age, this should be a nanosecond. ARPA-H can develop innovative strategies to speed the adoption of best practices.  

ARPA-H holds tremendous promise but as COVID-19 has laid bare, we can’t afford to keep doing more of the same. NIH should adopt more of DARPA’s high-risk, high-reward strategies for transformative solutions in funding some of its disease-oriented research. However, by focusing on underfunded problems that impact health across multiple diseases and require cross-agency as well as cross-sectoral collaboration, we can put the “H” in ARPA-H and advance health for all. 

Shantanu Nundy, MD, is a primary care physician in the safety net and Chief Medical Officer of Accolade. She is the author of “Care after Covid: What the Pandemic Revealed is Broken in Healthcare and How to Reinvent It.”  

Susan J. Blumenthal, MD, MPA, is the senior policy and medical advisor at amfAR, The Foundation for AIDS Research, a senior fellow in health policy at New America, a visiting professor at the MIT Media Lab, and a clinical professor at Georgetown and Tufts University Schools of Medicine. She is a former U.S. assistant surgeon general and a retired rear admiral.