1180 6 DECEMBER 2019 • VOL 366 ISSUE 6470 sciencemag.org SCIENCEL
ast week, Dutch farmers across the
country parked their tractors along
highways in the third such protest since
October, when they jammed traffic
while driving en masse to The Hague,
the nation’s center of government.
They are protesting a Dutch high court
decision that in May suspended permits for
construction projects that pollute the atmo-
sphere with nitrogen compounds and harm
nature reserves. The freeze has stalled the
expansion of dairy, pig, and poultry farms—
major sources of nitrogen in the form of
ammonia from animal waste. Also blocked
are plans for new homes, roads, and airport
runways, because construction machinery
emits nitrogen oxides. All told, the shut-
down puts some €14 billion worth of proj-
ects in jeopardy, according to ABN AMRO
Bank. “It has really paralyzed the country,”
says Jeroen Candel, a political scientist at
Wageningen University & Research.
The government is preparing to enact
short-term measures, including lowering a
highway speed limit, which could reduce
nitrogen emissions a sliver. To make a sig-
nificant dent, many experts say the coun-
try’s farm animal sector—the densest in the
world—must shrink and recycle more of
its nitrogen. Last month, farmers asked for
nearly €3 billion over 5 years to help pay
for more environmentally friendly ways to
deal with manure. Although agriculture is
a large source of nitrogen emissions, other
sectors will have to rein in their pollution,
too. “Those are really tough political deci-
sions that have to be made,” says Jan Willem
Erisman, a nitrogen expert at the Louis Bolk
Institute in Bunnik.
Nitrogen, a key nutrient for plants, is
also an insidious pollutant. Fertilizer wash-Ecological damage from
manure fumes triggers
calls for drastic change to
livestock industry
ATMOSPHERIC CHEMISTRYBy Erik StokstadNEWS | IN DEPTH
lawmakers barred the agency from making
cost comparisons while mandating that its
board include stakeholders representing
industry, insurers, patients, and physicians.
They also gave it a name that did not men-
tion comparative research, but instead re-
flected a less controversial goal: putting the
needs and interests of patients first.
Figuring out what “patient-centered re-
search” meant took time. “Nobody really
knew what it was or used [the term] in
their own way. In fact, PCORI defined it,”
says Ellen Sigal, chair of Friends of Cancer
Research, a Washington, D.C.–based patient
group. PCORI-funded researchers must try
to include patients every step of the way,
from enlisting them in study design to, at
times, including them on the research team;
patients also help PCORI review research
proposals. The requirements “have been an
adjustment” for many scientists, but worth-
while overall, says health services researcher
Michael Fischer of the Harvard University–
affiliated Brigham & Women’s
Hospital in Boston, who has
worked on PCORI projects.
PCORI says patients have sug-
gested changes to studies, such
as emphasizing the ability to
live at home as a treatment out-
come and changing how a study
is explained to them. PCORI
has inspired U.S. agencies, drug
companies, and health care
organizations to incorporate
patient-centeredness into their
work, says Marc Boutin, CEO of
the National Health Council in Washington,
D.C., which represents patient groups.
But developing methods for involving
patients and setting up review panels was
time consuming, and PCORI’s first con-
tracts only went out in late 2012. Many
early projects focused on patient education
and engagement, such as evaluating “deci-
sion tools,” or brief information sheets, to
help people and their caregivers choose be-
tween treatments. The institute also spent
time and money to build PCORnet, a clini-
cal research network that pools electronic
health records for millions, which aids in
comparisons of treatments and recruit-
ment of patients for clinical trials.
PCORI eventually ramped up its sup-
port of comparative effectiveness research,
which has consumed 73% of its total award
commitments to date, the institute says.
Published findings include that oral anti-
biotics are as helpful as intravenous ones
for certain children with serious infections,
and that type 2 diabetics who aren’t on in-
sulin don’t need to test their blood sugar
every day. Some results have found their
way into practice guidelines, and PCORI is
now funding efforts to get physicians and
health systems to adopt its results.
There has been “substantial disappoint-
ment” in the slow pace, however, says bio-
ethicist Ezekiel Emanuel of the University of
Pennsylvania, who helped craft the PCORI
authorization as an Obama official. By now,
he adds, it should be able to “rattle off five or
10 things” that have had a major impact on
medical practice. Emanuel contends that its
patient engagement efforts went “way over-
board.” He also faults the institute for shying
away from large-scale drug comparisons for
fear of “antagonizing” the drug companies.
“They weren’t bold enough,” Emanuel says.
Health insurers, too, feel that PCORI
“hasn’t really informed our decision-
making as of yet,” says Kate Berry, senior
vice president for strategic partnerships
for America’s Health Insurance Plans, a
lobbying group in Washington, D.C.
PCORI’s defenders say its critics have “an
unrealistic understanding of how rapidly
you could implement large
scale trials. Then there’s the
lag at the other end—how slug-
gish the adoption in health
care is,” says PCORI interim
Executive Director Josephine
Briggs, a former National In-
stitutes of Health (NIH) offi-
cial who replaced its founding
director Joe Selby last month.
She also defends its decision
not to fund more of the long-
term drug comparison studies
more typically done by NIH.
Their cost “could absorb our budget and
keep PCORI from doing more of the very
practical stuff,” she says.
Although PCORI still has funds left to
administer ongoing grants and make a few
additional awards, it has no money to initi-
ate new rounds of funding. A search for a
permanent director is underway, but Briggs
expects any candidate will want to wait to
see whether reauthorization goes through.
Two bills approved by House panels
would renew the institute for only three to
seven more years and leave its operations
largely unchanged. A bill introduced in the
Senate would give PCORI another 10 years,
creates an advisory panel to identify high-
impact research areas, requires more short-
term projects, and allows the institute to
consider treatment costs—all changes that
Berry’s group and other insurers favor.
Although PCORI’s supporters expect
a compromise bill to pass in the coming
months, they are watching the process anx-
iously. After nearly a decade spent building
a new patient-centered way to fund health
outcomes research, “it would be such a pity
if this were to dwindle away,” Fischer says. j“They have
picked up speed
and set up
more effective
s t u d i e s .”
Ross McKinney,
Association of American
Medical CollegesNitrogen crisis
threatens Dutch
environment—
and economy
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