With Sadness and Resolve: Why I Resigned as Chief Medical Officer of a National Institutes of Health Institute and What Comes Next

My time as a federal public servant began July 4, 2009, and I remember that night. I was on the medical intensive care unit in the Veterans Health Administration Nashville. I spent the night caring for a catastrophically ill Veteran and his terrified and grief-stricken family members. Septic shock with multiorgan failure requiring three pressors and an inotrope, severe acute respiratory distress syndrome on maximal ventilator settings, coagulopathy, and contemplating a move for continuous renal replacement is enough to make even a seasoned intensivist take notice, and I was nowhere near seasoned. As scared as I was myself (though I tried not to show it), I was also acutely aware of what a privilege it was to care for this man and all the other heroes in the medical intensive care unit that night. That feeling of proud and grateful service stayed with me for the next 9 years, when every “Thanks, doc” was answered with, “It’s my privilege.” I meant it every single time.

In late 2018, I had the chance to come to the National Institutes of Health (NIH), the world’s premiere biomedical research agency, to serve as a Medical Officer with stewardship over the pulmonary vascular disease portfolio. In this role, I oversaw a clinical trial that led to new Food and Drug Administration approval for a drug/device combination to treat life-threatening pulmonary embolism. I managed the data and safety monitoring boards for clinical trials for therapies for pulmonary hypertension in critically ill babies. I was part of the NIH-side scientific advisory team for an idiopathic pulmonary fibrosis clinical trial. I led a challenge competition to develop new and better ways to deliver home oxygen. My role at NIH served as a bridge between the American Thoracic Society (ATS), federal research, and private industry as a member of the ATS Drug/Device Discovery and Development Committee, including cochairing the BEAR Cage at the International Congress and helping plan several Respiratory Innovation Summit meetings.

As I moved into leadership roles, I was actively involved in the U.S. Government’s responses to coronavirus disease (COVID-19) and long COVID, including direct involvement with the NIH’s flagship programs in each. I have been part of the leadership teams working on data science and artificial intelligence in healthcare and biomedical sciences. I’ve been in the rooms, including rooms on Capitol Hill, to speak on behalf of the science that will serve patients and families with common as well as rare diseases, on behalf of the scientists who bring the breakthroughs, and on behalf of the bedside providers who turn breakthroughs into more and better lives lived.* It was all service on a scale that I had never imagined possible, and it has been the honor of a lifetime.

And now, I have to leave my position as Chief Medical Officer and Director of the Office of Translational Medicine at the National Center for Advancing Translational Sciences. Unlike so many of my friends and colleagues, I have not been fired or forced out. When the first “Fork in the Road” email landed in our inboxes, I said that I would only leave my job in one of three ways: 1) I get fired, a very real possibility; 2) I am on a collision course with burnout, because I am not helpful to anyone if I burn out; or 3) I feel that I am crossing personal moral lines. It turned out to be number three. (Unfortunately, confidentiality requirements prevent sharing specifics.)

21 February 2025

Writing this letter is one of the hardest things I have ever done in my professional life, harder than looking a person directly in the eye and telling them that they are going to die in less than 24 hours (something I had to do as a practicing critical care physician). This letter is my resignation from Federal service at the National Institutes of Health, effective end of day on March 31, 2025. Until that time, I will of course continue to carry out my duties to the level of excellence that I have demonstrated throughout my time at NIH, and I will also actively work to ensure a smooth transition of my responsibilities.

I can no longer, in good conscience, be a part of or lend any kind of support to what I see as increasingly strenuous efforts to comply with each and every immoral and often illegal directive being sent to the National Institutes of Health from the Executive Office of the President, the Department of Health and Human Services, and the so-called “Department of Government Efficiency” (which, as of this writing, is not a duly enacted Department-level unit of the United States Government and does not have a duly appointed and confirmed Secretary-level administrator). Compliance with these directives violates my own morals and ethics and regularly requires me to contemplate behaviors that violate both my Physician’s Professional Oath and my Oath of Federal Service. Furthermore, I do not see those people best positioned to protect NIH and to protect biomedical research offering meaningful resistance or questioning any aspect of these directives in any detailed way. The most common response appears to be to comply as quickly and completely as possible, and to plan ahead for how to comply for any that may be on hold for the time being. I understand the reasons why this might be the position of those making the decisions for the agency, but understanding does not allow me to agree or to capitulate.

Science and medicine have been my passion for all my learning and working life. Both are about improving the lives of all people, whoever they are and wherever they are and however they might be helped in their time of need. Both are about service—science being service to knowledge as best as we can understand it, and medicine being service to other people and their health. Both are about telling the truth. These core values of my two greatest professional passions have been so beautifully united and harmonized and amplified for most of my time in public service. But now, they are under intense daily assault. People are being systematically and deliberately excluded by the very entities that have sworn to care for them. Service to knowledge and to other people is being cast aside and replaced by service to a political agenda. Telling the truth is increasingly not permitted, either outright or through such distorting restrictions that it ceases to be the truth. I must push back against this assault, and I cannot do that from my position at NIH.

This is also deeply personal for me. I cannot be at peace with being a part of an administration that is openly and with what looks like gleeful cruelty seeking to erase the identities of people I love with all my heart—cherished friends who are transgender themselves or have transgender loved ones, family members who are nonbinary, beloved friends and chosen family who are immigrants, and so many others. This will never be okay with me, can never be. My own partner is alive today because one person not even 100 years ago was able to flee a regime seeking to erase their identity through wholesale murder. My partner should have had many great-aunts and great-uncles and scores of cousins, but their great-grandmother and great-great-aunt were the only survivors of eight children. The others died in the camps. Yes, this is deeply personal for me.

Public service at the National Institutes of Health has been one of the most important things I have ever done and likely will be one of the most important things I will ever do. I will relentlessly continue to try to do good in the world in all the ways I have been trained to do, as I have always tried to do. I will always be a partner and an ally to those who also seek to do good in the world, as I have always tried to be. I truly hope to return to Federal service one day, when the mission of the government returns to one of service and truth for everyone. Until then, I will never stop trying to make that real from wherever I am. I am heartbroken that I can no longer do so as a proud member of the Federal workforce at the National Institutes of Health.

With sadness and resolve,

Joshua Fessel, M.D., Ph.D., A.T.S.F.

I have realized that the major work of the remainder of my career—and that of many others—will be the repair of biomedical research and public health in the United States. And as one must always plan for healing even during initial stabilization, damage control, and resuscitation of a patient, so we need to prepare for institutional rebuilding now. Here are a few thoughts based on where things are right now and where I think they might go.

First, we must limit the damage. We must preserve as much of the critical institutional scaffolding of the scientific enterprise as possible. Scientific networks and communities are an indispensable component of the scaffold, and they will require deliberate nurturing and growth as the actual doing of the science gets harder. Many of us are used to putting our energy toward funding and doing the science, and the networks and communities coalesce almost as a byproduct. I think we need to be more intentional than that, starting now. Connect with your biomedical science and public health colleagues around the world even when there is not a specific project or grant or initiative as the reason for the call or meeting. The reason is to talk about how to preserve biomedical research, and to connect as human beings. When safe for you and your family, go to conferences in person even if you are not presenting data; if you can, advocate on behalf of those for whom it is not safe. Stay visible and stay part of the conversations.

Second, we must tell the stories of science and scientists, of public health and the professionals who work to keep us all healthy. Tell those stories in ways that are true and that are accessible and compelling to many audiences. This is easier said than done, because sometimes we are really good at talking to other professionals and less good at talking to people with whom we disagree. But it is vitally important because it is all about building back trust. The work of repairing and rebuilding will go much better if the scientific and public health communities have the trust and the support of the American public, of journalists, of universities, of elected officials at all levels, of as many people as possible. For the pulmonary/critical care/sleep medicine community, this can start by reaching out to the organized communities of patients and families who have pulmonary diseases. Work directly with these organized communities to craft the stories of how biomedical research and public health directly benefit the members of the communities. Then, work with the community members to find or create the venues for telling the stories. Patients and caregivers are also members of many other communities both personal and professional, and those networks are vital to trust-building storytelling.

Third, we must protect the next generation of leaders in the biomedical sciences and public health like your life and theirs depend on it, because they do. Academic medical centers and doctoral training programs are facing open existential threat, particularly programs that seek to ensure excellence by bringing in the best new voices. This matters because we all go to the same schools, whether we follow career paths into basic research, clinical research, teaching, regulatory science, clinical practice, academia, industry, nonprofit, government, consulting, you name it. The ripple effects of the damage done to our early-career colleagues could be massive, long-lasting, and far-reaching. The leaders of tomorrow are in a crisis today. They must be protected. Universities will need to be more flexible than they are used to being when supporting and retaining early-career faculty. Creative funding and support models will be needed, such as exploring partnerships with the private sector to support training programs or even individual training positions. Universities will need to enact values to support excellence even if they can not, for a time, get a federal contract to support those values. I do not know how different the landscape for supporting trainees and early-career colleagues will need to look, but I do know what it looks like if we fail to be creative in how we protect the biomedical research and public health workforce of the future.

I am so sad that I cannot do the good that needs to be done from within the NIH right now. But I am resolute that this good work will be done, and we are just the people to do it. Together, in new ways.