Sure you "feel for anyone who has AIDS", sure you do.
July 30, 2009
A recent post from Terrified Tabetic (@TTabetic) over at Pull My Finger points to a startlingly idiotic set of comments on federal funding priorities for HIV/AIDS and cancer. Terrifiedtabetic has already pointed out the callous and slightly hypocritical brush-off of “behavioral” causes of cancer while lambasting “behavioral” causes of HIV/AIDS.
I feel for anyone who has AIDS . . . just as I feel for anyone who has cancer. But in the case of those who have cancer, most of them get it due to circumstances beyond their control (yes, I know, some behaviors lead to cancer, like smoking, tanning, eating too much red meat and not exercising). Not the case with AIDS, which is still largely behavioral-intravenous drug use, gay sex, promiscuity (with a few people who got it by accident through tainted blood transfusions).
No, she doesn’t “feel for anyone who has AIDS” the same as she does for people with cancer. Her next sentence makes that very clear. She even acknowledges that, as with HIV disease (which I presume she means when she says “AIDS”-she’s not stupid) people with cancer often have behaviors that led to their disease. What she makes very clear is that sex (especially butt sex) is much more morally abhorrent than smoking (that is, smoking tobacco, because in her dimwittery, nicotine is morally superior to heroin).
I noticed this strange little hateful statement.
And, as we know, AIDS remained confined to gays and needle-using druggies-not the general population which they tried to frighten us into believing would be infested.
“Confined”? Really? but I thought….. hmm, let’s stroll on over to the CDC, shall we? That site quotes a paper.
Estimation of HIV Incidence in the United States
Hall HI, Song R, Rhodes P, Prejean J, An Q, Lee LM, Karon J, Brookmeyer R, Kaplan EH, McKenna MT, Janssen RS for the HIV Incidence Surveillance Group. Estimation of HIV Incidence in the United States. JAMA, August 6, 2008;300(5):520
Said paper estimates about 53% of new HIV infections in the US in 2007 were due to male-to-male sexual contact, 12% to injection drug use and….wait for it…..31% to high-risk heterosexual contact. Another CDC site identifies the same deal in 2006 with 33% of new cases attributed to heterosexual contact. If you ask me, 31% sure as hell does not sound like “confined”.
[UPDATE: Related thoughts on blame-based withholding of health care / research from Pascale Lane ]
DrugMonkey 
July 30, 2009 at 9:41 am
Researchers who work on lung cancer + COPD face similar headwinds.
The diseases are caused (in the most part) by voluntary behavior, so no need to spend money to figure out ways to help people who are suffering.
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July 30, 2009 at 10:20 am
Without sounding like I support that ignorant attitude, there are a couple of points to make as to the basis of their argument.
1) since (depending on estimates) the hetero population outnumbers the gay population between 10-20x, the per capita incidence discrepancy (53% vs 31%) is quite large.
2) the 31% ‘high risk hetero’ probably is mostly included in what that person considered ‘promiscuity’, which they also condemned.
Some people on the other end of the spectrum (not necessarily you) tend to disregard the problems of smokers or drug users (inconsistently they are often more morally critical of smokers than other drug users) also as something they ‘brought on themselves’. Same basic attitude
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July 30, 2009 at 12:38 pm
it’s no wonder that research for certain “non-contingent” diseases (breast cancer comes to mind) are very popular, and we are mostly at the taxpayers’ whim. I do think there is some counterbalance in the sense that HIV work tends to be very popular among researchers due to it simply being a sexy research question. on that note, I always get pummeled at the family reunion for not “curing Alzheimers” and instead picking what is to me a more interesting topic (drug addiction, which according to my family is caused by either not going to church enough, or “those damn w**backs” ).
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July 30, 2009 at 12:55 pm
When it comes to the question of balancing the research expenditure across disease, this is a chronic, remitting / relapsing disorder of scientists and health research advocacy (in general). Even apart from pre-existing socio-political agendas people always want *more* for whatever interests them because of scientific domain, being afflicted, having family members afflicted, affiliating with a group that is disproportionately afflicted…etc.
I have little patience for this, in the broad sense. HIV/AIDS is a classic example, particularly the Congressional mandates for certain agencies such as NIAAA and NIDA to put a large amount of their overall budget into HIV/AIDS work. What goes missed in the usual complaint is the *huge* amount of basic and not-so-basic research that has spill-over benefits into other areas. I.e., into basic virology and immunology, blood-brain barrier function, transcriptional regulation on the one side all the way to sociological and epidemiological factors of disease spread, control, how to educate on health topics, how to instantiate broad-based behavioral change, etc. All of these areas of “HIV/AIDS research” affect broad swaths of other disease categories in the end analysis.
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July 30, 2009 at 1:37 pm
Two words: pediatric AIDS. It’s there punishment for original sin?
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July 30, 2009 at 2:12 pm
The term “31% to high-risk heterosexual contact” still allows the finger wagging scolds to imagine that they are not part of this group. Further that these individuals are engaging in deviant behavior (they will immediately picture unrestrained group and anal sex) and and are, at some level, be punished for their crime.
All of which supports the ‘not my problem’ and the nonsupport of control and treatment effort so as not to ‘promote deviancy’ or ‘stand in the way of God’s judgment’.
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July 30, 2009 at 2:20 pm
To agree with DM (although there should be no need for justification), HIV research has basically revolutionized virology, genetics, infections disease, and therapeutics. There are few areas of medicine and basic biologic research which are unaffected.
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July 30, 2009 at 2:35 pm
PalMD — you could probably say that about any area of research, if it were given 10% of the total NIH budget, including mandatory set-asides in everyone else’s IC.
Drugmonkey — Are you saying that it is OK for AIDS/HIV/LGBT activists to use political pressure to increase HIV-related funding, but it is somehow unseemly for anyone else to engage in research advocacy?
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July 30, 2009 at 2:38 pm
@NC–are you saying the great benefit achieved is illegitimate or less useful because of the money spent? Cuz that seems silly.
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July 30, 2009 at 2:52 pm
Are you saying that it is OK for AIDS/HIV/LGBT activists to use political pressure to increase HIV-related funding, but it is somehow unseemly for anyone else to engage in research advocacy?
Nope. I’m saying I have minimal patience for those that get really bent about some area or other “receiving disproportionate funding” unless they have a really good analysis of how it does not have any spillover into other domains of health interest. Anyone who can’t do “One Aim for Programmatic interest and Two Aims for my real interests” when it comes to grant writing is an idiot.
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July 30, 2009 at 2:52 pm
Well, taken to an extreme…
Is it wrong to feel more job satisfaction for studying a disease that kills about a million children a year (who are mostly poor, brown and from far away) than studying polymorphisms in genetic susceptibility to a disease that kills about a million people (who are mostly rich and white and where the largest etiological factor is one that is both voluntary and something I find personally abhorrent)?
Cause I feel a lot better studying malaria than I ever did studying lung cancer.
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July 30, 2009 at 2:52 pm
PalMD — What an idiosyncratic interpretation of my comment. You are not dumb. You know exactly what I mean.
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July 30, 2009 at 3:14 pm
DM — Your comment is disingenuous. Most people cannot (and should not) toss in an extra aim on their diabetesAlzheimerprostatecancerwhathaveyou grant to appease AIDS activists.
In this thread, you seem to be invested in two highly problematic assertions:
1) The incidence rate of HIV amongst monogamous heterosexuals is not low;
2) The amount of NIH funding devoted to HIV/AIDS is not disproportionate to its incidence in the US.
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July 30, 2009 at 3:17 pm
becca — I think you are going to make DM and PalMD blow a gasket with your reasoning. I am curious to see how they respond.
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July 30, 2009 at 4:20 pm
I’m always surprised at the still “hot-topic” status of HIV research. Instead of the “scourge of God” expected in the early 90s it has shown to be of minor importance to everyday life, life expectancy with treatment is up, transmission outside of risk groups is low, and the risk groups are not really those with high political cloud.
To me it seems more of an undeclared war on a disease where we might win with the combined might of science, a Kennedy-like challenge to the scientific community, with similarly non-proportional funding compared to the potential impact, so with similar advantageous benefits to basic research.
If we study “new” infectious diseases, I’d think something like Ebola, with “black plague” level of death potential, would be of much more importance. But until someone on a flight from Kinshasa to NYC triggers a domestic infection, that seems another “affects only brown people” disease of lesser importance.
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July 30, 2009 at 4:23 pm
Getting back to the original point:
Check the stats on AIDS in Africa–it is estimated to have ~12% of the world’s population but ~60% of the world’s AIDS cases. An overwhelming majority of these cases stem from heterosexual sex trade and the reticence (from ignorance) of using condoms during heterosexual encounters (see the Wiki page on AIDS in Africa for starters but Google will readily yield a ton of refs on this).
From a global standpoint, therefore, spreading the false notion that AIDS is ‘confined’ to homosexuals is highly ignorant, pernicious, and yes, hateful.
On the topic of funding balance, let me open this can of worms—given the stats on AIDS in Africa, does AIDS not remain a high priority for funding here as well? Or is it OK to idly stand by while a continent slowly perishes? Do you think we will be insulated from the devastating effects of what’s happening in Africa? I realize that Becca’s point on malaria will also be pertinent to my last statement—but isn’t it interesting in this regard that it is at least in part from this global health view that The Gates Foundation pours in a ton of money into malaria research?
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July 30, 2009 at 4:33 pm
In this thread, you seem to be invested in two highly problematic assertions:
1) The incidence rate of HIV amongst monogamous heterosexuals is not low;
2) The amount of NIH funding devoted to HIV/AIDS is not disproportionate to its incidence in the US.
Careful there N-c, the “c” is interfering with your reading comprehension again. with respect to 1) the motivating line was a comment that “AIDS remained confined to gays and needle-using druggies”. This is as false as false can be and was the subject of the post.
regarding 2) I did not say this at all. What I said is that I have no patience for the idea that funding attributed to a specific disease category can be trivially assigned to “disproportionate” without consideration of the impact that whole body of research has on other disease categories.
becca@#11- actually I have no problem on the topic of what anyone finds compelling as a research question. unless I am being specifically asked to make decisions in the course of grant review :-), in which case I very much enjoy reading people’s justifications and arguments.
and believe it or not I am open in theory to arguments that we spend too much money on topic X. I just find that in most cases such arguments ignore the spill-over into other topics, perhaps intentionally.
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July 30, 2009 at 6:04 pm
Anonymoustache @16 — Your “can of worms” was already addressed — to the tune of $61 billion — by the evil George W. Bush and his nefarious African AIDS initiative.
DM @17 — My point @8 above is that any research area that is given massive saturation funding would have all sorts of interesting spillover effects. Why should it be this one?
Total annual AIDS deaths worldwide: ~2million (~75% in sub-Saharan Africa)
Total annual AIDS deaths in US: ~15,000
Total annual cancer deaths worldwide: ~8million
Total annual cancer deaths in US: ~550,000
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July 30, 2009 at 6:06 pm
This reminds me of a comedian who was doing a stand up routine early on in the HIV/AIDS years in the US. He got on a riff and said something along the lines of “name one person who wasn’t doing something disgusting when they caught this virus. Someone who wasn’t having inappropriate sex or shooting something up.”
Someone in the audience yelled out “Ryan White” and the comic had to leave the stage.
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July 30, 2009 at 6:09 pm
“shown to be of minor importance”? WTMFRUBBQ?????????
You DO realize that HIV/AIDS has been changed from something that could very well formed a plague of biblical proportion to your “of minor importance” through 1) scientific understanding of transmission and 2) the creation of modern HAART therapy?
This didn’t just turn out to be better than anticipated as with avian flu, swine flu, etc. It very likely would have been a disaster without the progress of science in understanding the virus and the disease.
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July 30, 2009 at 6:41 pm
oooo, oooo, I got one:
Smoking deaths run about 440,000 in the US per year. loss of productivity plus related health costs is estimated at $167 Billion.
Alcohol kills another 167,000 people in the US, WHO estimates 2 million worldwide.
and of course, your “cancer” figures includes a greater diversity of pathological processes than does HIV/AIDS or probably even all of substance abuse (given current understanding of final common pathway type theories).
so yeah, you can knock around these numbers and all you come up with is that they are significant health problems that affect a boatload of people. After that you are going to have a damn hard time convincing anyone of the ROI for putting cash into research where success is basically unknowable at the start. A failure to cure what afflicts 100,000 people is a bad investment whereas a cure for 10,000 is relatively speaking a good one.
Our (successful) bias in the US has been to put money into essentially every disease category. This is a good model and a conservative investment strategy. I imagine you agree with the principle (?)
Nevertheless you are intentionally refusing to grapple with the real point which is research which involves the other disease categories where the virology, immunology, etc all the way up to social interactions and behavioral change can be deployed. It is disingenuous to call all the studies that apply broadly “HIV/AIDS funding” if you do not also include those “other” disease categories in your death stats.
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July 30, 2009 at 6:49 pm
It is irrelevant if the particular kind of sex is abhorrent or not to the fact that AIDS is associated with certain sexual practices (and certain culture of promiscuity).
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July 30, 2009 at 6:55 pm
Sure but the original punditard is an idiot on both counts BTC so what is your point?
“associated with” is not equal to “confined to”.
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July 30, 2009 at 7:10 pm
DM@21 — I have “grappled” with the issue two times already in this thread.
Spending on any disease category will always have spillover effects in other categories at the level of basic processes, novel methods development, health care delivery models, etc.
This is especially true precisely because “cancer” encompasses such a diversity of pathophysiologic mechanisms.
You do not yet explained why you think HIV/AIDS is privileged in this regard, nor why it deserves much more per incident case and per US/global fatality than (e.g.) cancer or even the other causes of death you cite.
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July 30, 2009 at 7:26 pm
Becca –
I am not knocking your preference for studying malaria, so please don’t get me wrong here.
But the majority of smokers are actually the poor and poverty ridden. Not sure about the race end, but there are a hella lot of smokers who are also minorities. And it should also be noted that the vast majority of people who have been diagnosed with bipolar type’s I&II, schizophrenia, severe adhd, severe unipolar depression, OCD and a great many other neurological issues, also smoke.
As a smoker who is working his way towards quitting, I find smoking personally abhorrent as well. It is reasonable to say that it was a bad decision on my part (made when I was fourteen) to start. It is not even unreasonable to blame me for not quitting – I so very desperately need to. But please keep in mind that statistically speaking, it was considerably more likely that I was going to become a smoker (and abuser of other substances, for that matter) than it was that I would never light up. And keep in mind that managing to get where I have – down to less than five per day – and ultimately quitting, is even less likely than my avoiding smoking in the first place.
And again, please don’t get me wrong, I am not trying to excuse my smoking. With bipolar II and ADHD, I had and have better odds than someone with bipolar one or worse, schizophrenia. I just want you to consider that there are people who aren’t making rational decisions over all, when they make the decision to smoke. I know that I was rather prone to exceedingly irrational decisions at that point in my life and ultimately have only started dramatically improving on that front, over the last few months, since I’ve been on meds. Consider how much harder it is on someone who is barely capable of formulating a coherent thought, who is barely capable of making decisions that are even in the ballpark with irrational/rational.
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July 30, 2009 at 7:27 pm
You do not yet explained why you think HIV/AIDS is privileged in this regard,
I never said this. Where did you get that impression? I think it does have good spillover but this by no means is saying that it is the only disease category that is similarly “privileged”.
nor why it deserves much more per incident case and per US/global fatality than (e.g.) cancer or even the other causes of death you cite.
Again, this very rationale is what I think is a dumb one. Until and unless you account fully for spillover of beneficial effects and/or the full population of disease sufferers that is reached. If you aren’t willing to do the full analysis you have no business trying to argue that HIV/AIDS funding or cancer funding or Alzheimer’s disease funding is over or under represented in federal expenditures. This is the part I find you failing to admit that you udnerstand.
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July 30, 2009 at 7:37 pm
Mu –
Minor importance hell! Do you know anyone who’s positive? Do you know anyone on those peachy fucking cocktails? Drugs, btw, that run several grand a year. I do – had a roomie who was positive and volunteered with an organization for a while, that provided help to people who were positive or who have full blown AIDS.
I have helped clean up fecal matter, because someone forgot to wear an adult diaper to bed – or couldn’t make it to the bathroom fast enough. I have cleaned up vomit, because the projectile vomiting wouldn’t stay confined to the fucking toilet, or the bucket that lives by their bed.
Not everyone’s experience, to be sure – some people manage better than others. But that is very similar to the experience of most people who are positive and virtually everyone who has full blown AIDS. Things are exponentially worse in the developing world, where the drugs to treat it are rare.
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July 30, 2009 at 8:40 pm
DM @26 — My point is that it would be virtually impossible to perform such an analysis. At the very least, it would require a full study with heavy support from NIH/CSR. Not something for a blogger, much less a commenter. Your insistence on such an analysis therefore seems to be merely a tactic to shut down debate and preserve the inequities of the status quo.
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July 30, 2009 at 9:46 pm
HIV disease a minor inconvenience??????????????
wait…
???????????????????????????
OK, look. When HIV came on the scene, after we stopped burning down people’s homes, chasing kids out of town on a rail, firing people who even got tested…once we got over that, we had what might arguably be the most productive decade in medicine and biology—due to HIV research.
I diagnose a number of HIV cases every year, and I’m not even a specialist. I diagnose diabetes and hypertension every day, and treat them, thereby helping save life and limb. But the research into HIV has turned a death sentence into…well, not an inconvenience. A very serious disease that doesn’t normally kill you quickly.
Neuroconservative, I didn’t misread your comment—it was inane. If you are saying that any particular disease, were it to receive a huge sum of money, would have led to similar advances…well, who the fuck knows? Could be, but wasn’t. We spend a gazillion dollars on various cancers, and we’ve made huge progress, but people don’t perceive it as much as they do with HIV.
But HIV was unique in some ways…the confluence of ID, immunology, oncology, virology, genetics, genomics…a perfect storm, both of pathology, and of opportunity.
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July 30, 2009 at 9:49 pm
This is something I’ve never understood about the argument in favor of studying very basic biological science. I love basic biology. I think it’s totally cool and I want to make sure some people can do it. But why should we fund people doing it more than we fund, oh, say, theoretical mathematicians?
Well, presumably because basic biological research has spillover effects on things that have turned out to be incredibly critical for human health… but that’s the thing. Doesn’t research on one disease often have spillover effects on many others? Why are spillover effects assumed to be greater for some topics than others? Why is it assumed that some things are “fundamental” and will affect lots of fields, and other things are not?
If spillover effects were equally likely (or at least equally difficult to predict) in any given set of studies, why doesn’t it make more sense to work on areas where we can make the biggest dent on human suffering with the direct angle, and just keep an eye out for spillover stuff?
That said, I don’t think anyone has a good formula for how a given scientist can maximize their impact on minimizing human suffering- so I’ll have to remember DM’s line about not taking issue with what anyone finds compelling as a research question.
@DuWayne- I was not aware of the data on smoking rates among those with severe unipolar depression (do you have a citation, by chance?), though I’d heard about the schizophrenia connection
Just to provide some context, both of my parents smoke and have smoked a lot (e.g. two pack a day of Camels) for decades. I don’t find smoking abhorrent because it’s not rational, I find it abhorrent because of some incredibly strong gut emotional rejection of it (maybe I’m afraid of my parents dying- your psychoanalysis may very).
Also, I’m not knocking the suffering of people living in poverty in industrialized nations… but there is ‘USian poor’ and then there is ‘typical malaria victim poor’… it’s the difference between having money for cigarettes and not having money for food.
@Mu- although hemorrhagic fevers like Ebola probably are understudied, the odds of one evolving to be contagious with that high a fatality rate are (one hopes) pretty low. You can’t transmit a disease that kills you before you get on the airplane.
Not that they aren’t scary, and that there aren’t scenarios by which they could wipe out humanity. But I don’t want to see an enhanced virulence MDR TB or airborne severe immunodeficiency virus, either.
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July 30, 2009 at 10:08 pm
PalMD — As always, your measured, reasoned approach contributes greatly to the conversation. As to your last “point”: was it really a “perfect storm” of opportunity — or of opportunism?
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July 30, 2009 at 10:15 pm
Jeezus Kriste, NC, could you be any more of a tool?
“Opportunity—or opportunism?”
You should be writing for the Daily Show.
Opportunism? Are changing your mind here about the advances from HIV research? Or are you just upset because you forgot to write relevant grants?
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July 30, 2009 at 10:46 pm
Get a grip, Pal — You’re embarrassing yourself. If you are unable to tolerate alternate points of view, you should stick to your own blog. The grown-ups are trying to have a conversation here.
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July 31, 2009 at 2:20 pm
@NC
HAHAHAHAHAHAHA!!1!
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August 6, 2009 at 5:14 pm
becca: This is something I’ve never understood about the argument in favor of studying very basic biological science. I love basic biology. I think it’s totally cool and I want to make sure some people can do it. But why should we fund people doing it more than we fund, oh, say, theoretical mathematicians?
I’d argue we fund very little “basic biological science”. All the money is for biology that is at least rationalized as very close to translation.
We should not justify spending for basic science by some foreseeable side effect — the scale of the side-effects are massive, but completely incalculable and unpredictable.
Research for “close to translation” should be privatized (although the funding for areas that are not fundable via capital markets, such as malaria, should continue). The “Academy” is just not terribly good at it — just like private organizations are terrible at real basic research.
And yes, we should give a hell of a lot more money to mathematicians. Everything, in the long term, depends on mathematicians — without the mathematicians working out formal systems in the pre-WWII period, we’d be at just about the same levels, scientifically, as the 1950’s.
Separately, anyone else note in the AIDS rant the one major group ignored as unworthy recipients? AIDS rates among minorities are vastly higher than among “whites”. World-wide, AIDS is a disease of poor brown countries. Yet that most salient of facts is ignored — you aren’t allowed to publically spew racism anymore. I suspect that the psychological driver isn’t “butt sex” but “brown sex”.
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