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Goedert: Yes. I did hear about it. It was a spin-off from that NRC report that basically said that AIDS has not had much of an effect on the social institutions in the United States, except maybe in New York. This is a higher-powered microscope look at New York. They say AIDS incidence is not even in all areas of New York. It is only high in some of the zip codes in New York?
Harden: Yes. In fact, in the New York Times they published a zip code map of New York, showing that there were probably seven or eight zip codes where the infection rate was extremely high. We are awaiting the arrival of the NRC report to read it in more detail, but the idea is that education efforts and other programs could be concentrated in very highly infected areas, and by this means, the incidence of the virus reduced so low that it would not be a factor in the larger population. Would you respond to this possibility as an epidemiologist? Is it a reasonable tactic?
Goedert: No. I think it is wrong. I think the horse is out of the barn. Do you know if the maps are related to recent infection rates, as opposed to AIDS rates and so on?
Harden: I think it is infection rates, but I do not know how recent they are. I see your point..
Goedert: If you did a map of AIDS cases in New York, you would find all these places in lower Manhattan where all the AIDS cases were in gay men. There are very few new infections going on in gay men. It is not zero. But I assume that is not what the report is talking about. It is discussing some of the minority populations in the Bronx and the like.
Each community obviously has to identify what populations are at highest risk and develop a culturally appropriate, but pointed education effort to get information to those people. But there is very substantial HIV incidence, which is new infection rates, going on in rural America. To have said in 1982 that all education efforts should be concentrated among gay men in New York, San Francisco, and Los Angeles, when there were not only enough infected gay men living elsewhere but there was enough mobility within that population, would have been ludicrous. Think of Bel Glade, Florida. In Bel Glade, Florida, a substantial portion of the infected people was migrant farm workers. Are you going to target your effort to Bel Glade, Florida, and believe you have taken care of the problem? Those people go elsewhere and harvest crops.
No, I do not think that approach makes any sense. If the people in communities in Texas feel that farm workers are a group at high risk of becoming HIV positive or spreading HIV, then they should certainly concentrate on the farm workers and not worry much about the school children who live there all the time. But to think that you could come up with a geographic map and focus on a certain area, that does not make any sense. There is too much mobility. In fact, even in areas like Florida and Texas, migrant farm workers probably go back and forth to Puerto Rico frequently and there is a raging epidemic in Puerto Rico.
Rodrigues: I notice from your curriculum vitae that you made a presentation to the Presidential Commission. Was that the Watkins Commission?
Goedert: Yes. That was on the “What is Safe Sex?” thing we just talked about.
Rodrigues: Thank you.
Harden: Would you like to add anything about where you see this epidemic going and what your prognosis is for the future?
Goedert: On a personal level, AIDS has been great for careers, and mine in particular. But on a public health level it has been a disaster, and continues to be so. There are many frustrations and I think the institutional sluggishness is a serious frustration. The timidity of people who get involved is a frustration. The politics are necessary to a point, but it is again a major disappointment that politics so much impedes efforts to try and improve what we see as our mission [at NCI]. That is improving the health of people, reducing their risk of disease, cancer, and death.
Harden: Will it help reduce the sluggishness of research to move all NIH AIDS grants through the Office of AIDS Research? Or do you think it will add another layer of bureaucracy?
Goedert: I think it is worth trying. Those of us in the Cancer Institute are very fearful that we will get left out. I think it will depend on the vision, open-mindedness, and willingness to take chances of the person who takes that office. The office, quite frankly, is set up as a consequence of political pressure. If it is used as a tool of the interest groups, it is asking for trouble. It is not the most expeditious way to get the job done.
The reason I am in cancer epidemiology is to try to prevent people from getting cancer, and that means that our success is in cases we never see and diseases you never see. The Hippocratic Oath, and simple decency, calls first for taking care of people who are sick or dying, but it is clear that the interest groups have that as almost their sole interest. I am here to try to prevent many, many cases from occurring. I do not think you can do the most good for the most people by focusing a grotesquely disproportionate amount of your resources and efforts on treating people. Treatment research only helps people who have or get the disease, but preventing the disease, in this case preventing HIV infection, will do much more good for many more people. How can infection be prevented? That is what vaccine research, epidemiology, and behavioral research will answer. But it is the people who have the disease that mobilize the Congress and the money. It is now true for breast cancer, of course, and I understand it completely. I have dealt closely with people with all those diseases.
I think that the person who takes that Office [of AIDS Research], will only be a success, in terms of ultimately dealing with and controlling this epidemic, if the person has enough wisdom, a broad enough view, and enough strength of character to resist the political expediency of pouring more and more money into treatment of the comparatively small number of people who are now sick, as opposed to the much larger number of people who are at risk.
Let us hope that whoever gets in there has enough wisdom to help us. One of our immediate concerns–it has been immediate for a while–is to understand the cause of cancer and, ultimately, how to prevent it. We are using this as a way to understand the cause and prevention of AIDS-associated cancers and, obviously, cancer in general, without HIV infection.
Harden: One starts to see all sorts of areas of research coming together in cancer, AIDS, and the whole immunological understanding of the body. Immunology seems to be taking over everything in one sense as a fundamental discipline.
Goedert: Yes. It is quite fascinating in terms of neurologic diseases and the like.
Harden: Thank you, Dr. Goedert. We certainly appreciate your time and your comments.
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