Shots in the Dark: The Wayward Search for the AIDS Vaccine

Greetings, Brent (and Jon),

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Thanks for these posts. I am sorry that we're at the end of this process because just now some issues are coming up that we should probably go back and forth on.

Let me respectfully but firmly object to an implication of your last message, Brent. The implication is that it is bloodless and inhuman to notice the economic fundamentals of pharmaceutical research, as Jon Cohen lays them out--and more generally that if I had New York outside my window, rather than the San Francisco Bay Area, I would recognize that this shouldn't be judged as just another nonfiction chronicle but instead as a moral appeal. I object for a variety of reasons. Such as: San Francisco is not exactly the place you'd choose if you wanted to overlook the consequences of AIDS. But the one I'll stress is that I think this misconceives the role of Cohen's book.

There is a legitimate place for writing whose explicit purpose is to heighten and focus moral outrage. Quite a bit of what appears on an editorial page has this as its goal. Time's recent special issue on African AIDS, which I mentioned at the start, was a dramatic gesture in this direction--and a brave one, since they must have known it would tank on the newsstands.

But pure "consciousness raising" is not what Cohen is up to--nor should be, in my view. His subject is a large-scale human catastrophe, and one whose effects are far more horrifying in Southeast Asia (where I have seen them) and of course Africa (where I've only read about them) than anyplace in the United States. But his ambition, as I understand it, is less to bewail the absence of an adequate response than to explain authoritatively why it has not occurred. A clear explanation would presumably build pressure to remove the obstacles that have led to a wasted decade in the search for a vaccine.

At the tactical level, I've had various complaints about how concisely Jon Cohen lays out this explanation. But strategically, I think he's taken just the right approach--that of showing the combination of scientific, cultural, economic, and bureaucratic factors that have thwarted the creation of a vaccine. And by the end of the discussion, we're left with three inescapable realities that have made this search hard:

• Drug companies are companies, and for business reasons they won't invest in the search for a vaccine. The potential market is small, as I pointed out yesterday in the passage you objected to. Perhaps more important, the potential liabilities are vast. If an AIDS vaccine were 99.9 percent safe, then in theory it could still cause one case of AIDS for every thousand people who were inoculated. From a public health point of view, using such a vaccine on high-risk groups would save many more lives than it would put at risk. But because of the legal exposure, drug companies would rather spend their money on other projects. To observe this is not to be complacent about the fact. It is to conclude that this is a market failure in the classic sense--like the fact that you can't rely on corporations to supply good child care. A solution has to come from outside the market, with public money for research and some public protection against the legal risks.
• Societies inevitably respond faster when they perceive a threat to the general public than to problems that are far off or contained. You can call this immoral or callous. I am submitting it as an observed historic fact. The crusade against polio was possible not just because FDR was in a wheelchair and not just because of the organizational factors Jon Cohen analyzes. It was seen as a general threat, requiring general response. As the worst effects of AIDS have become distant (Africa) or ghettoized (in a literal and a figurative sense within the United States), the likelihood of general mobilization has ebbed. This makes it harder to correct the market failures (above) or to face the worst dilemmas of risk (below).
• The "empirical" or "crusade" approach, which holds the best prospects for near-term discovery of a vaccine, also poses the most difficult ethical challenges. Jon Cohen explains these well in his latest post. In the absence of the wartime, general-threat mentality I mentioned before, it's hard for me to imagine how we could even discuss these choices.

For instance, suppose a vaccine shows, in animal trials, that it will probably be 99 percent effective and 99 percent safe. The first time it's tried in humans, the 1 percent for whom it's not safe will develop AIDS. How is the press going to handle that fact? My guess is that it would be treated as a shocking exposé, and Cohen has a depressing real world example confirming that fear.

Suppose these trials don't happen within the United States, but instead in Rwanda, or Burma, or some other place where infection is so rampant that even a 70 percent effective, 70 percent safe vaccine would save millions of lives. As Cohen shows, the governments of such countries have actually been eager to run human tests since the alternative is an ongoing holocaust. But can you imagine how this would turn up in the headlines: "THIRD WORLD GUINEA PIGS: Millions in Africa, Asia exposed to vaccine outlawed in the U.S./Vaccine subsidized with public funds tried out on illiterate peasants," etc.

The message I take from this book is worse than moral despair about the impact of the disease. It is that for commercial, technical, and legal reasons, the vaccine problem is almost insoluble, unless the warlike mood of a generalized crusade recurs. Maybe his book, by doing its job of explanation, will make that more likely.

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This week, our critics tackle Jon Cohen's Shots in the Dark: The Wayward Search for the AIDS Vaccine. (Click here to buy it and here for an explanation of our format.)

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