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

Jim,

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Speaking of plagues, I received your entry last night after watching the BBC World News. The night sky over England's farm country is burning hell-fire red, lit up by flaming pyres of pigs and sheep who are suspected of having the virally conveyed infection known as hoof-and-mouth disease. A bad patch--and a marketing disaster--indeed, after the recent bad publicity about mad cow disease. The Britons are moving with dispatch because the contagion among the animals threatens their economy. Those blazing pyres on the evening news are meant to ensure beef-eating Europe (which is already buying its steaks elsewhere) that the herds will soon be put right. Talk about unanimity of civic intent ...

I share your take on contagion among human beings. Things do indeed "get serious" when, as you say, self-interest is involved and "people think that regardless of station in life or individual precautions, they all might be struck down." But we yawn and go back to sleep when the much-feared disease narrows its interest, taking those with whom we have little in common. But there is more to self-interest than personal safety with respect to a dreaded disease. The broader, civic self-interest is important as well. Those of us who live in clean, comfy neighborhoods can look with yawning disinterest at the AIDS epidemic that is still ravaging the inner cities. But the costs of the disease will come home to us very shortly. We care for the sick and dying in public hospitals. We feed, attempt to educate, and lodge in very expensive jails the damaged, parentless children they leave behind. We pay taxes to subsidize the policing and social work that goes into supporting neighborhoods that fall to pieces in every conceivable way as the epidemic takes its toll. This extended civic interest applies internationally as well. The relentless march of AIDS across sub-Saharan Africa is breaking down societies, cultures and nation-states, creating a grave threat to international harmony and security. I am sure you agree that "self-interest" needs to be broadly defined in cases like this.

Who woulda thunk that a pesky little bug that prayed mainly on homosexuals, junkies, and hemophiliacs would be such an enormous threat in Africa and Thailand today? The point is that you never know, Jim; best to marshal your forces and get to the barricades as quickly as possible. In the worst-case scenario, you forestall disaster and save mankind. In the best-case scenario, you end up with a nifty little fire drill that shows where the hoses, hydrants, and the exit lights need to be. From the standpoint of dress rehearsal for a broader medical disaster, the AIDS epidemic has not been inspiring. The NIH sat around stroking its chin and smoking its pipe. The big vaccine companies with the most resources and experience sat out the dance, fearful of liability, fearful that the potential market was too small. Congress was primarily interested in directing AIDS money to favored lobbyists. The work of finding a vaccine, as Cohen so pointedly explains, was left mainly to small start-ups with shallow pockets and used-car salesman CEOs who were more interested in shilling "discoveries" to their investors than in rigorous trials that would had produced a viable product. For this group, self-interest was defined in terms of venture capital raised and promised return on investment.

Yes, as fire drills go, this was a bust. Government failed. The vaunted "market" failed, too. What in heaven's name will happen with the next great plague, Jim--and rest assured, it will come. Will we watch with yawning disinterest as it first devours some disfavored group, then turns hungrily toward the rest of us? Will we be able to martial an urgent, activist response? Or have we forgotten how to do that? These thoughts came into my head while reading Shots in the Dark.

Now, on to your questions. What is the next step? Test the vaccine. Set up the necessary infrastructure to allow its distribution. Does Cohen favor pure science or crusaders? I would be happy to hear from him. But as I read Shots in the Dark, he favors neither the pure scientists nor activists but sees that both are needed to get things done. His most piercing critique of the NIH effort is basic Science 101: that Fauci and the others failed to create a series of experiments across which results could be sensibly compared. (This is what we learned to do high school.) Cohen favors sound, careful science ... but prefers it in the form of an independent agency that could have moved swiftly toward a possible vaccine or some other purposeful goal. Am I right, Jon Cohen, or am I missing something?

Brent Staples

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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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