Race for Medical Cure Also a Contest for Funds : Research: The federal government spends $2 billion on AIDS, the same as cancer, and perhaps it should. But arriving at a decision is as much a political choice as a scientific one.
Does the government spend too much on AIDS? Too little on cancer?
Donald Poppke gets those questions so often he can wheel around with hardly a look and put his hands on the right manila folder, the one with “AIDS vs. cancer” written across it in big black letters.
Poppke is chief of the Public Health Branch Office of Budget in the Department of Health and Human Services. His folder contains some interesting statistics:
* For research, prevention and treatment combined, the federal government will spend virtually the same this year on cancer and AIDS--$2.05 billion for cancer, $1.97 billion for AIDS.
* Last year, the government actually spent about $100 million more on AIDS than cancer.
* The government is spending 2 1/2 times more on AIDS than on heart disease, which is by far the nation’s biggest killer.
Precisely comparing federal spending for various diseases is difficult. The U.S. Public Health Service provides the totals but concedes that it uses different accounting methods for AIDS. AIDS advocates contend that the government underestimates what it spends to treat cancer, heart problems and diseases other than AIDS.
But is spending on AIDS and cancer too high, too low or just right? Poppke’s folder cannot answer the question, and neither can he.
“There are a lot of compelling reasons why we should be spending more or less on AIDS,” Poppke said. “But the fact is that these are the two diseases we are spending the most on, and they are the two diseases people are most concerned about.”
Just how much research is too much--or too little--is as much a political question as a scientific one. That is why single-disease pressure groups, such as the AIDS and breast cancer lobbies, have been so successful in getting more money for their causes.
And because the decisions are political, rather than based on some dispassionate formula, people can disagree. And do.
“There is more money going into AIDS than any rational distribution would come up with,” said Dr. David Denhardt, chairman of biological sciences at Rutgers University in Piscataway, N.J.
“Definitely AIDS is getting more than its fair share, no doubt about it,” contends Lloyd Ney, president of Patient Advocates for Advanced Cancer Treatments, a prostate cancer group.
Others, however, including those who have the disease or have devoted their scientific careers to it, contend that the level of AIDS funding is barely enough, or maybe even too low.
After all, AIDS is a clear health emergency. It is a contagious disease. Its victims are young. And by going all out to attack it now, it may be possible to find a cure or prevention before it seeps too deeply into the population.
“Some might say it’s too much, but I think it’s right,” said Dr. Paul Skolnik, director of AIDS research at New England Medical Center. “This is an epidemic. Money has to be targeted to a public health scourge that is still increasing exponentially.”
An Institute of Medicine report last year also called AIDS funding “adequate.” However, AIDS advocates argue that it is still too low, a point frequently made by Earvin (Magic) Johnson, the HIV-infected basketball star.
In the statistics they cite to answer questions about research funding, federal health officials rarely mention how many are actually dying of the diseases they are trying to control.
Heart disease this year will kill about one-third of all Americans who die and cancer one-quarter. AIDS, by contrast, will kill 1%. Some contend that the burden of disease should be a primary, and perhaps the overriding, factor in setting the federal government’s research agenda.
“The rest of us will die from something else,” not AIDS, said Joel Hay, a health economist at Stanford University. “Why aren’t the National Institutes of Health funding what the other 99% of the population will die from?”
To those who feel their causes are being shortchanged, one frequently mentioned idea for setting federal priorities is a dollars-per-death formula.
“There is no criteria that determines what disease will get more money than another,” contends Ney. “It should be predicated on the number of deaths that the disease causes every year.”
Currently, the government spends about $79,000 for every American who dies of AIDS. It spends $7,300 per death from cervical cancer, $6,300 for diabetes, $5,100 for kidney disease, $2,800 for breast cancer, $1,100 for heart disease, $800 for prostate cancer and $600 for lung cancer and stroke.
Certainly, AIDS lobbyists believe dollars per death is a bad way to set priorities. AIDS this year will kill about 25,000, while heart disease will kill about 725,000.
“The deck is always stacked against us when we talk about body counts,” said Carisa Cunningham of the AIDS Action Council. “Everybody dies of something. Most die from heart disease, cancer or stroke. Every society values young life. Focusing on diseases that take young lives is a defensible choice.”
Many in the federal research establishment agree that the amount of money spent per death cannot alone be the guide.
“That’s a dangerous way of looking at it. What would happen to orphan diseases (those that affect small numbers of people) if we thought that way?” asked Francine Little, assistant director for budget at the National Institutes of Health.
In fact, some of medicine’s biggest successes have been in controlling diseases with small numbers of victims. Among the cancers, for instance, federal research funding was important in learning to control testicular cancer and childhood leukemia, both rare diseases.
Dr. Samuel Broder, director of the National Cancer Institute, said decisions where to spend medical research money are based on the availability of scientific opportunities, judgments about the probability of success and the magnitude of the problem.
“The magnitude of the problem is in part defined by what the public wants,” Broder said. “We have to be very sensitive to the expectations and demands of the public. They are who we work for. The public has a right to express its overall priorities.”
Many agree that decisions about scientific research are simply too important to be left up to scientists. And even though this means that diseases backed by the most persistent activists may draw more research attention than those that are not, that is one price of an open, democratic system.
Dr. Robert Wachter of the UC San Francisco School of Medicine, is a critic of disease activists. But even he says these decisions are too important to be left to the experts.
“It is not the scientists’ money,” he says. “It is our money, and we need a role.”
