AIDS Treatment News #163, November 23, 1992
John S. James

Because we could reasonably presume that AIDS will be treated fairly, we discussed medical research overall, not AIDS research in particular. This way we could focus on a universal appeal, since medical research is important to everyone. And this focus opens doors to coalitions with other health constituencies.

In the past, we were advised to soften or omit the problems in medical research -- especially when Congress was considering funding. But now we have the prospect of a serious national commitment to AIDS, as well as a major national policy shift from military to civilian research. As a result, the problems themselves can be an integral part of research advocacy, since they point the way to highly cost-effective management efforts. Correcting key malfunctions which are preventing the translation of research investment into clinical benefits can release unimagined opportunities for achieving the results that count -- better practical treatments for people.

One problem today is the belief in some circles that medical-research progress is a root cause of medical cost inflation, by producing better but ever more expensive treatments -- essentially an argument that in medicine, ignorance is cost effective. A closer look shows that cost inflation reflects mismanagement, not advancing knowledge.

Biomedical research is politically unique because it is personal in a way that other technologies are not. Everyone knows that they and their loved ones may (and probably will) face life-threatening illness some day -- and that medical science could make the difference between life and death, or between recovery and lasting disability. Medical research enhances the security of everyone.

Other technologies also save lives, but the public does not see them the same way. For example, a recent poll of Maryland voters sponsored by Research!America found that 47 percent of voters were willing to pay more taxes to increase medical research -- several times the level of support for space or national defense.

Biomedical research has other advantages:

* If well managed it will reduce the cost of medical care. Treatments which work well are usually less resource-intensive than those which work poorly and require chronic care. Medical cost inflation stems from poor management, from incentives for inappropriate use of technology, not from medical advance itself. For example, in the Reagan-Bush administration, there was no proactive leadership to assert the public interest -- and since price competition in medicine is difficult to arrange within ethical constraints, the commercial incentives were to research and develop the most expensive (and therefore most profitable) treatments, even when less expensive approaches could work as well or better.

* Medical research stimulates biotechnology, a major area of U. S. strength and a key element of the future U. S. economy -- if we do not lose the lead to Japan, which has long been ahead in certain areas, such as fermentation technology.

On the other side, there is public impatience today with cancer, Alzheimer's, and AIDS research particularly, because of lack of productivity in delivering improved treatments and better survival and care. (Some medical fields, such as heart disease and ulcer research, have delivered major benefits.) In AIDS, where we have reported on research and treatment for six years, it is clear that major management problems are inhibiting progress, and that these can be fixed. For example, the biggest single block today to better AIDS treatments is the lack of a workable system for getting the best of the hundreds of promising drugs created in laboratories through preclinical and early clinical development, to the point of the first test of biological activity in 12 to 20 human volunteers. If the drugs could get to that point, it would be relatively easy to find companies to take the successful ones the rest of the way.

Other major, systemic problems in U. S. medical research today include (1) the lack of viable career paths for physician/researchers (who are often required to cash in their M. D. chips due to accumulated debts before completing research training), and (2) the lopsided influence of industry on directing government research money, since almost everybody on the committees which allocate public money has pharmaceutical relationships on the side, resulting in grossly disproportionate research emphasis on large-company drugs already marketed or nearing the market, and no critical mass of advocates to champion newer, emerging technologies. (The latter problem may reflect not so much the excessive power of pharmaceutical companies, but rather the lack of countervailing assertion of the public interest, due to ideological objections in the outgoing administration.) No one in government (or elsewhere) has had the authority to attack these and other systemic problems.

Much progress has been made in basic research, especially in the development of tools and techniques which open doors to progress against AIDS, cancer, and many other diseases. But we have not had the leadership to fix the obstacles blocking the translation of basic knowledge into better treatments and cures. With high-level attention, these obstacles can in large part be overcome, allowing us to harvest the benefit not only of ongoing basic research, but also of the great accumulated research investment already made.

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