The New York Times - August 2, 1983
Lawrence K. Altman, M.D.

Hundreds of AIDS victims have wasted away, while doctors could do nothing for them but treat each bout of opportunistic infection as it came along, give overall supportive care, and watch the sufferers slowly die. It is only natural for the friends and families of the victims, or people at risk of AIDS, to wonder sometimes whether society is really investing all it might in the search for the cause, cure and prevention of so grim a disease. Sometimes the question is really an accusation that lack of research money, or lack of sufficient interest in conquering AIDS, have held back some otherwise attainable breakthrough on the AIDS problem.

Unfortunately, money alone seldom solves scientific mysteries. The lavish expenditure of enormous sums over many years has not conquered cancer or cured multiple sclerosis. Still, the United States could hardly have developed the large corps of doctors who have devoted their careers to research and given the country world leadership in scientific medicine without the enormously increased financial support taxpayers have provided in recent decades.

AIDS research so far has followed orthodox precedents. It has been no exception to the rule that the initial reports of any new disease focus on its clinical descriptions. In AIDS these included the wide variety of opportunistic infections and a rare type of cancer called Kaposi's sarcoma; these were tipoffs that something was wrong with the immune defenses of the patients.

Within days after doctors first recognized that they were dealing with a strange new syndrome in 1981, immunologists, microbiologists and other scientists entered the research picture. Thanks to the flexibilities that are built into the American research system, these scientists went to work not with new grants, but through existing ones from the National Institutes of Health - the N.I.H.

The institutes, a Federal organization, are the main financing body for the nation's army of medical researchers. They support work not only at the N.I.H. campus in Bethesda, Md., but also at medical schools and teaching hospitals throughout the country. Under normal circumstances, medical researchers apply to the institutes, as well as to other Federal and private organizations, for "investigator-initiated research grants" to pursue the aspects of research that most interest them. The institutes place high priority on these grants, whose scope is broad enough to permit some holders to search for the cause of a new disease, or to respond to other medical emergencies when they arise.

New York University-Bellevue Medical Center is one of the hospitals that first recognized AIDS and began the fight against it. An immunologist there, Dr. Fred T. Valentine, is one of the many N.I.H.-financed scientists throughout the country who quickly responded to the new medical emergency by shifting the focus of their research to those areas of AIDS that fell within their particular expertise.

"That's the beauty of these N.I.H. grants," Dr. Valentine said. "You are free to pursue the new directions that turn up during the course of your research because if we didn't have this flexibility, we might not discover anything. If you could always predict what was going to happen, by definition it wouldn't be research."

As a clinical researcher, Dr. Valentine works in both patient care and laboratory research. His team's basic interest is studying the ways the human immune system responds to infections and to cancer. The laboratory is headed by Dr. H. Sherwood Lawrence, internationally known for his discovery of transfer factor, a natural immunological substance that is used to treat some unusual infections, and is being evaluated for use in cancer.

As Dr. Valentine and his colleagues examined dying patients on their rounds at Bellevue in 1981, they quickly saw that AIDS was producing a medical catastrophe. Nature had produced in human beings the very combination of infections, cancer and impaired immunity that they were trying to create under artificial conditions in the laboratory.

Dr. Valentine could and did begin working on AIDS without having to seek approval from the National Institutes of Health, though he informed them of his activities through periodic progress reports. Otherwise, several months, at least, would have passed before the handling of a new grant could have been completed. Meanwhile, the institutes themselves appealed to medical researchers to apply for new grants and to join the battle against the disease.

Because most AIDS cases have occurred in New York and California, researchers elsewhere who might otherwise have been able to contribute to the solution of the disease have had little chance to examine cases. For some such researchers, the existence of a problem they have only heard about may not have been sufficient to motivate them to make major diversions in their research efforts without such an appeal. Dr. Valentine was one of those who was successful in getting one of the new grants for AIDS.

Medical researchers must have worthwhile ideas before they can do worthwhile investigations, and such ideas take time to develop, particularly when a new disease emerges. Unless researchers are trying to answer the right questions, money is of little help.

Dr. Anthony S. Fauci, an immunologist at the National Institutes of Health who began working on AIDS early in the epidemic, said earlier this summer he disagreed with colleagues who argued that they would be well ahead in AIDS research if only more money had been available earlier - an argument that is arising in current Congressional hearings. But, he said, when he has asked such critics what they would have done with more money a year or two ago, he usually "finds the ideas weren't there."

Dr. Fauci's position is bound to "create resentment," he said. Still, he maintained: "If someone had given me a lot of money a year ago, I wouldn't have known what to do with it. Right now, I need money and I am getting it. I probably will need more money next year. I hope I will get it."

There does come a time when the number of researchers interested in a problem increases, ideas mount, and additional money is needed for extra technicians, more reagents and equipment. Many feel researchers are now at that point in the case of AIDS. For example, it costs several hundred thousand dollars a year simply to keep the specimens from AIDS patients in freezers, ready for testing when new developments arise.

Nevertheless, it is hard to choose which research projects to finance, largely because with a new disease like AIDS, no one knows where some crucial clue may come from. It could well derive from research on some obscure virus, rather than direct work with AIDS patients.

The approach to medical research must be pluralistic. Money is required for the proposed experiments to solve the next obvious research step. But support is also needed for the wild ideas, the long shots that might win Nobel Prizes - if they work. Many knowledgeable scientists complain that officials responsible for deciding which research projects get financed are willing to make only the sure bets, not to gamble for long odds.

The early stages of investigating a disease of unknown cause are apt to resemble a scientific fishing expedition. Even so, there is room for legitimate worries that speeding up the Federal financing process will lead to lower standards in selecting researchers. Dr. David Axelrod, the New York State Health Commissioner, in a report to Governor Cuomo, criticized some scientists for being "opportunists" in trying to get grants for AIDS. Others, too, are concerned that a sudden influx of funds might make researchers less meticulous than they otherwise would be, because they felt they would get their money easily because of the medical emergency.

Dr. Richard M. Krause is director of the National Institute of Allergy and Infectious Diseases, just one of the N.I.H.'s member institutes that have appealed for more AIDS researchers. Dr. Krause said he has shifted money away from other projects to finance some AIDS research because it was so pressing a problem.

But he also expressed deep concern that unless more new funds become available for AIDS, valuable projects involving other diseases might not be done. The tragic possibility exists, he said, that "the answer to AIDS may come from the kind of research activity in basic virology and immunology that might go unfunded."

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