Washington. -- Is AIDS consuming a disproportionate share of federal money for health research and patient care?
Sen. Jesse Helms received a deserved barrage of opprobrium last week when he said the disease results from "deliberate, disgusting, revolting conduct," and that funds for treatment under the Ryan White Care Act should be reduced.
The cruelty and absurdity of his remark is evident in the fact that the law, which authorizes $880 million a year for patient care, memorializes a dead teen-ager who innocently acquired the AIDS virus from a blood transfusion, as have many thousands of others.
But the question of appropriate shares of federal money for patient care and research long precedes Senator Helm's vulgar outburst, and it is likely to linger on.
The federal Medicare program provides for care for the elderly and disabled, regardless of their ailments or how they acquired them. But AIDS is the leading killer in the 25-44 age group. The majority of those infected with the virus are too young for Medicare. If they're poor enough, they probably qualify for assistance under the federal-state Medicaid program, but many don't.
As an alternative to many of the uninsured dying in ghastly circumstances, the Ryan White program was designed for those who don't meet the poverty-line criterion for Medicaid assistance. In this respect, AIDS is unique. Similar federal assistance is not provided for those dying of cancer, accidental injuries or other fatal conditions.
In dollar amounts, federal expenditures on AIDS research appear to be very high in relation to spending on other diseases and their patient loads. But the significance of numbers is easily distorted and adaptable to misleading and inflammatory political purposes.
The great majority of federal research on AIDS is either conducted by the National Institutes of Health in its own laboratories or financed by NIH in universities and hospitals. This year, NIH is spending $1.3 billion on AIDS research and $2.2 billion on cancer research. Heart research is third, with $817 million, followed by diabetes and Alzheimer's, with about $310 million each.
Do the numbers suggest too much for AIDS, as Mr. Helms and others contend, or too little, as AIDS activists insist?
If spending is matched with the number of people afflicted by the diseases and the death toll, AIDS is clearly over-financed. Figures for 1992 -- and they have changed little since then -- show 35,351 deaths from AIDS, 538,000 from cancer and 721,000 from heart disease. In death rate per 100,000 persons, heart disease causes about 225, cancer 174, AIDS 8.3.
Why, then, does AIDS, so low on the list of fatal diseases, command such a hefty share of federal research spending?
The agitation of AIDS activists cannot be discounted. They have been effective in commanding public and political attention and in stimulating and accelerating the flow of federal research money -- from $700 million in 1990 to nearly double that amount at present.
In years of life lost, a commonly used measure in public health statistics, AIDS goes to the top of the charts. It's a disease of the young, whereas heart disease and cancer are concentrated in the later years of life. But more important, AIDS is a sexually transmitted disease that is invariably fatal -- a combination that fully warrants alarmed concern.
In the United States, the disease was initially identified with homosexual sex and intravenous drug use, leading to comforting conclusions about the risks to the straight population.
But in recent years, there's been an increase in heterosexual transmission -- the infection route that has decimated populations in several African countries. Complacency is unwarranted about the disease being confined to the social margins in the U.S. for all time.
The question of how much is enough has no real answer. But in looking at the puzzle of disease and dollars, it's important to recognize that budget boundaries are for the convenience of politicians and bookkeepers and frequently have little to do with the realities of modern basic biomedical research.
Some research, of course, is actually pinpointed on specific diseases, with wondrous results. But the often-rewarded promise of basic medical research is that it pays off in understandings far beyond its budget labels.
The immediate danger in medical research is that all areas of disease studies are on the way to being crimped by misguided reverence for reducing federal spending.
Daniel S. Greenberg is editor and publisher of Science & Government Report, a Washington newsletter.