NO HEALTH problem in a generation has caused as much concern or generated as much press attention as the disease known as AIDS. While relatively few Americans have actually been afflicted, it is believed that more than a million are now infected with the AIDS virus and that many, if not most, will eventually develop the disease. Even more disturbing is the lack of certainty that persists about how the virus may be transmitted and what portion of the population may eventually be at risk.
Fortunately, few people now believe that efforts against the disease should be less than wholehearted. The same White House that rejected a 1983 appeal from the Centers for Disease Control for $12 million to track the spread of the disease is now asking Congress for $766 million for efforts to combat AIDS in the coming fiscal year -- nearly $300 million or about 60 percent more than we are presently spending. Of that sum, $423 million will go to the National Institutes of Health for biological research on various aspects of the disease. A broad consensus appears to have evolved that we should do everything possible to combat the spread of AIDS and find more effective means of treating its victims.
There is, however, something deeply disturbing about the underlying philosophy of the administration's AIDS-research request and the attitude it reveals toward medical science and the way we combat dread disease.
First, The amount being requested for research specifically directed at AIDS is quite large -- so large that it may be difficult to find ways to spend it effectively. Under current plans, more than 40 percent of the real-dollar increase in directed research on AIDS requested by the president for NIH would be spent under contract. There is considerable skepticism within the scientific community that a sufficient number of high-quality research opportunities specific to the HIV-3 virus exist at present to get a full return on such an investment. In addition, such heavy reliance on contracts by NIH rather than the more traditional investigator-initiated research grant proposals, is by itself an indication that the universe of expertise on AIDS-specific issues is being overtaxed. Of further concern is the fact that contract research is designed by the in-house staff at NIH, rather than the investigators themselves, and is not subject to the same rigorous peer-review process as are basic research grants.
Moreover, the funding increase requested by the administration would come entirely out of the budget for more basic biological research about cells and how the human body functions. The president is in fact asking Congress for considerably less in new appropriations for biomedical research in the coming year than is presently available, even when the large increase for AIDS is included in the total. It would appear that a judgment has been made by someone within the White House that we already have a fairly thorough knowledge of the factors involved in the causation of AIDS and must now simply proceed to apply that understanding toward prevention and treatment.
Nothing could be further from the truth. AIDS, like cancer, may be nearly as complex as the biological mysteries of life itself. One of the principal conclusions that can be drawn from the applied research already conducted is that, more than most diseases, AIDS will require a substantial expansion of our overall knowledge of human biology before prospects become good for the development of a vaccine that will prevent infection or drugs that will provide effective treatment of victims.
But efforts to expand that basic knowledge would be slashed dramatically if the president's budget were adopted. The administration's total request for new funds for the National Institutes for Health for fiscal 1988 is $5.6 billion, $550 million below the amount appropriated last year. That represents a cut of almost 10 percent in nominal dollars and of 18 percent below the NIH estimate of what will be required to offset inflation and maintain current services.
That cutback would fall primarily on the funding of new research grant proposals -- proposals submitted by scientists from around the country and funded competitively on the basis of careful review by scientific panels. These "basic" grants represent not only the bulk of all NIH activity but the major effort being made anywhere in the world to understand the human body and cope with dread disease. The grant proposals deal with such questions as how chemical changes within nerve cells allow an image seen by the eye to be transmitted through the optic nerve to the brain, or how the more than 20 specialized subgroups of cells in the human immune system communicate with one another to launch a systematic and orchestrated attack on infection. The results of this basic grant research are the building blocks on which many new medical treatments are based.
During the 1970s, up to 60 percent of the approved grant proposals (those which scientific reviewers determined to have significant merit) were funded in a given year. That percentage has declined steadily over the past decade. This year we will fund about 35 percent. The president's request would cut the figure to only 10 percent.
The House of Representatives has adopted an appropriation for NIH which adds more than $1 billion to the president's request and would thereby maintain funding at a level that will support the same number of new grants in fiscal 1988 as we are funding in the current year. Even so, the number of basic research grant proposals approved by the scientific-review process but left unfunded will go up if the amounts in the House-passed appropriation become law.
Many of the grants that are now going unfunded are of a scientific quality that would have virtually ensured their funding even in the leanest years during the decade of the 1970s. During that time period it was rare for any grant proposal with a score of 2.0 or better on a 5-point scale (with 1 being the highest) to go unfunded.
Between 1980 and 1986 the number of proposals submitted to NIH grew by 35 percent, from 14,142 to 19,119. In 1980, fewer than 300 grants with a score of 2.0 were not funded. By 1982, more than 1,000 proposals with a score of 2.0 or better went unfunded; by 1986 it was more than 2,700. NIH estimates that that number will go up again in fiscal 1988 even at the approximate funding levels contained in the House bill.
A review of grants now pending at one institute, the National Insitute of General Medical Sciences, indicates that about 200 highly evaluated research proposals in molecular and cell biology, pharmacology and biophysics (which have long-range relevance to the understanding of how the AIDS virus causes disease) will go unfunded at the level contained in the House bill. Those proposals would be roughly divided among the following areas:
Determination of the structure of cell-membrane receptors.
Definition of the relationship between the structure of a molecule or virus and how it binds to cell receptors, and how such binding might permit the design of antiviral drugs.
Synthesis of antiviral chemicals, which not only block viruses but assure that their activity is not inhibited by the immune-deficient state.
Structural aspects of proteins involved in the immune response.
Even at present levels, we are wasting far too many high-quality basic research opportunities to allow us honestly to claim that we are declaring all-out war on this disease. If the Senate swings more toward the priorities established in the president's budget when it considers the appropriation for NIH, the final product will be a funding level that will cause the number of wasted research opportunities to grow dramatically beyond present levels; and the pace at which we put together the pieces of the AIDS puzzle will be markedly slower.
The mistake we are making is not unlike the one we made in the early years of the so-called "War on Cancer." As one scientist commented at that time, "We began this as though we had all the basic underlying knowledge and simply needed to make the right application. It is something like what would have happened if we had decided to launch a campaign to go to the moon during the 1920s by spending millions to improve ladders, hot-air balloons and propeller-driven aircraft."
Our best defense against AIDS and all other disease is the expansion of our knowledge about basic human biology. When we fail to support the research necessary for that expansion to take place, we do not have an effective program or strategy to combat AIDS because we are trying to build walls and windows while failing to build a foundation.
Dave Obey is a Democratic congressman from Wisconsin.