Good Intentions: How Big Business and the Medical Establishment Are Corrupting the Fight Against AIDS.

Good Intentions: How Big Business and the Medical Establishment Are Corrupting the Fight Against AIDS Good Intentions: How Big Business and the Medical Establishment Are Corrupting the Fight Against AIDS. Bruce Nussbaum. Atlantic Monthly Press, $19.95. In critiquing the medical-industrial complex and the orthodox old-boy AIDS network, Good Intentions adds to the history of AIDS, bringing to life the people who shepherded the drug AZT from laboratory to patient. Nussbaum thoroughly records their smelly backroom deals, bureaucratic botchings, conflicts of interest, and peccadillos. He also chastises the powers-that-be for ignoring (and deep-sixing) drugs other than AZT and toasts the researchers and people infected with the AIDS virus who bucked the system and started their own community-based drug trial programs. And Nussbaum's business writing seems largely on the mark, which is to be expected from a veteran BusinessWeek hand. He convincingly shows how the Food and Drug Administration (FDA) favors pharmaceutical giants like Burroughs Wellcome over underfunded startup companies that have interesting products but can't afford the regulatory process. The way Burroughs's David Barry sailed AZT through the regulatory doldrums of the FDA, his old employer, is a classic it's-who-you-know tale. Yet Nussbaum undermines his credibility with error after error, sullying the genuine facts in the book.

The biggest hoot comes early on. "It is a polite finction that scientists at the NIH [National Institutes of Health] and the drug companies work for the public health," Nussbaum posits. "They really work for credit and cash." As Nussbaum himself might say in the flabbergasted voice he maintains throughout Good Intentions: Shocking.

While NIH scientists should always put the public good above their own gain, since when are drug companies held to that standard? Burroughs Wellcome's original $10,000-a-year asking price for AZT was offensively high, but so are the price tags on plenty of other drugs (cyclosporin, which prevents the rejection of transplanted tissue, costs $13,000 a year). The fact is, in the U.S., health care is a for-big-profit industry. Nussbaum doesn't analyze whether this is good or bad, opting to attach the symptoms rather than the disease.

Three pages later, Nussbaum gets his medical history wrong. "In the fifties," he claims, "it was polio that received the big government research bucks." Not so. In the fifties, as Jane S. Smith details in her new book Patenting the Sun: Polio and the Salk Vaccine, the National Foundation for Infantile Paralysis/March of Dimes funded the bulk of the polio research. She cites congressional testimony in which an NIH director noted that in 1953 the NIH spent $72,000 on polio research, while the private, volunteer National Foundation spent nearly $2 million. Indeed, the National Foundation deserves most of the credit for "conquering" polio. Nussbaum's mistake is not a minor historical inaccuracy: The private funding of polio research raises an intriguing, big-picture question about the role of the federal government in the search for a cure for AIDS, a question he skips.

But time and again a scientific--not a historical--error breaks the book's momentum. This is just a further reminder of how, because complicated topics are easy to screw up, science has long been the journalist's bane. Many major dailies now assign MDs and PhDs to their medical beats. Some publications with long lead times have researchers vet their science articles. And reporters often read or fax technical passages to their subjects before going to press.

Nussbaum's science reporting fails on two levels: when he does it and when he doesn't. For most of Good Intentions, Nussbaum assiduously avoids the wily nature of the AIDS virus and the obstacles that drugs combating the microbe must overcome. The strategy might work for an article in a business magazine, but for a book recounting scientific tales, it chips away at his authority. More troubling still, when Nussbaum does delve into science, he's often embarrassingly wrong on important issues.

According to Nussbaum, the scientists at Burroughs Wellcome, the company that marketed (and, depending on your point of view, developed) AZT, "didn't know" how the drug worked. Says who? While Burroughs Wellcome may have had difficulty proving exactly what AZT did in the body, to say the company didn't know how the drug worked is hyperbole. Human immunodeficiency virus (HIV), the causative agent of AIDS, infects cells and then replicates. There are 15 steps in this process, one of which AZT interrupts, stopping HIV's replication. To spare you the details, scientists have a solid idea which of these steps AZT interferes with and how the drug does its thing. As Nussbaum even reveals at one point, the scientist who invented AZT in the early sixties, Jerome Horwitz, had a good hunch about the drug's mechanism of action--though he couldn't prove it in cancer cells back then. "The way we hoped the drug would work against the cancer cell is just how it works against the AIDS virus," Horwitz recently told Discover.

Nussbaum says Kaposi's sarcoma, a rare cancer among the general population that afflicts many HIV-infected people, is an opportunistic infection. But no one has identified an agent that causes Kaposi's sarcoma, a requirement for calling it an infection.

Similarly, Nussbaum claims that the drug CD4 operates like AL 721, an experimental drug made from eggs and marketed by a small company. Incredible. The theory behind AL 721 is that it disrupts HIV's membrane, hindering HIV's ability to bind to cells and infect them. Though the drug CD4 and AL 721 have similar objectives--they're both trying to prevent T-4 cell-HIV binding--saying the two operate in similar ways is as meaningful as saying soccer and baseball are similar because both require moving a ball.

Nussbaum, in fact, has a book-sized chip on his shoulder (OK, half a book) about AL 721. He journeys through the arcana of how the drug never received a fair trial by the AIDS doyens, many of whom were hired by Burroughs Wellcome to test AZT. "What happened to AL 721 is a said, sad story," laments Nussbaum. "The fact is that the people Americans look to for health protection blew it. They fouled up on a spectacular scale."

Though Nussbaum never produces a smoking gun, assume he's right--assume the apparent conflicts of interest indeed colored the AZT crowd's judgmnet. Granted, this a sad, sad story. But it says more about the players and the system than the drug. Nussbaum's enthusiasm for AL 721 clouds this point, leaving the reader with the impression that a great drug is being ignored. If AL 721 is so promising, Nussbaum doesn't convincingly make the case. "Scientific research continues to show efficacy," he proclaims near the end of the book, describing positive results from a test-tube experiment. "Efficacy" is a loded word in science, typically reserved for the final phase of drug tests in humans.

As it stands, we're never given sturdy evidence that AL 721 is any more effective against HIV infection than dozens of other compounds that look interesting in the test tube. When Nussbaum ridicules NIH AIDS bigdome Tony Fauci for wanting to "debunk" AL 721 because he feared it was keeping people away from other, more promising drugs, it's easier to side with Fauci than Nussbaum.

The ultimate insult caused by Nussbaum's disregard for science is that he fails to inform the reader that the deck is stacked against every potential anti-HIV drug. The villain? Not the cadre of AZT cheerleaders. Not the NIH, the FDA, the White House, or the Congress. Sure, the slothful government should act less like, well, the government. Sure, the product from the small drug developer should receive the same attention as the one from the mammoth pharmaceutical house. But Good Intentions accords these factors too much import. HIV and its evil ways are to blame. Blast all the wrongdoers to hell and ship in the most brilliant, incredibly imaginative scientists on earth: They'd still have a vexing, humbling problem to solve. Good intentions notwithstanding.