Big Shot: Passion, Politics, and the Struggle for an AIDS Vaccine (review)

Vaccines are miracles of medicine. An AIDS vaccine would save untold numbers of lives and billions of dollars for our embattled earth, where each day 16,000 more people become infected. An effective vaccine would offer promise of universal protection, whereas treatment of those infected is an expensive proposition, likely to benefit only the financially fortunate, thereby widening the gulf between prosperity and poverty that breeds rage, hopelessness, and terrorism. With what it costs to treat one AIDS patient, 10 children could be put through primary school. An AIDS vaccine could help save the youth and productivity of young people, especially in the world's most populous countries, where the epidemic is growing most rapidly. With a need so urgent, the fact that 20 years after the identification of HIV there is still no viable hint of a vaccine ready for distribution is one of the moral outrages of 20th-century medicine.

Fifteen years into the epidemic, the question of why we still had no AIDS vaccine began to haunt Patricia Thomas, an accomplished medical journalist and former editor of the Harvard Health Letter. She set out to answer this question in 1996, and produced Big Shot: Passion, Politics, and the Struggle for an AIDS Vaccine five years later. Still there is no vaccine.

Thomas's answer to the question "Why not?" reveals important realities about the politics of biomedical research, the federal bureaucracy, and the international pharmaceutical scene. The science, which she explains with admirable clarity and liveliness, provides a partial answer. The complicated machinations of the human immunodeficiency virus have eluded scientists. HIV conforms to no previously known pattern of infectious disease, its subtypes differ around the globe, and it continually produces new strains.

The complexity of the science, however, is only part of the problem. In Big Shot Thomas shows how self-serving politics and the lack of adequate funding have stalled the development of an AIDS vaccine. Some of the roadblocks are structural and generic; they result from a bad fit between the goal of an AIDS vaccine and an organization's mandate or mission. Biotech start-ups could not afford to share discoveries while trying to stay afloat. Scientists on corporate payrolls were directed to concentrate on the company's main technology rather than exploring new, less lucrative potential approaches. Large pharmaceutical companies chose to invest in drug products that would require multiple treatments over a lifetime rather than a cheap vaccine that is given once. The needed funding for large clinical trials has been held hostage to the paralyzing deliberations of federal agency committees. And AIDS activists, outraged by governments' slow response to the plight of those already suffering and dying of the disease, have diverted attention and spending from vaccine research. Other delays and obstacles are the legacy of highly placed individuals and their jockeying for power and position. The AIDS vaccine is not the only "big shot" in this story, andThomas astutely recognizes and portrays how arrogance and its common flip side, a fragile insecurity, have undermined progress in vaccine research, development, and testing.

The pivotal moment in Thomas's chronicle of the quest for an AIDS vaccine is the 1994 meeting of the AIDS Research Advisory Committee at the National Institutes of Health. The committee's decision not to fund Phase III trials for the recombinant gp120, the most promising of the vaccine candidates, nearly killed the prospect that gp120 would ever reach the market. These expanded trials, required for FDA approval and licensing, are so lengthy and massive that they seldom occur in the absence of federal funding. Yet through the fierce determination of Don Francis and Robert Nowinski at a small biotech firm, gp120 has gone to Phase III clinical trials both in the United States and in Thailand. Whether it will become the initial AIDS vaccine...