The Changing Face of AIDS, 25 Years Later It has been 25 years since the first AIDS diagnosis. On June 5, 1981, the CDC printed a report that turned out to be the first scientific report of what is now known as AIDS. Guests examine AIDS at 25, from treatments that keep the disease in check, to prevention programs, to the changing face of AIDS. Is there any hope on the horizon?
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The Changing Face of AIDS, 25 Years Later

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The Changing Face of AIDS, 25 Years Later

The Changing Face of AIDS, 25 Years Later

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You're listening to TALK OF THE NATION: SCIENCE FRIDAY. I'm Ira Flatow.

We've been talking about a U.N. General Assembly meeting that's been going on and a U.N. report that happened - that came out this week. And the meeting is scheduled to actually conclude today and it has a goal of working out the details of a declaration of commitment on AIDS.

But as the saying goes, you know, the devil is in the details. And that issue is whether to - lots of little details - whether to specify detailed financial and clinical goals such as how much to spend on AIDS by 2010 or the number of people to treat or the number of new cases to be prevented. And, of course, of equal concern, how do you satisfy the various social, cultural, religious taboos among countries that hinder progress in the fight against AIDS.

So, for the rest of the hour, we're going to continue our discussion of AIDS with a report on the U.N. meeting. We'll also get reports from the medical and research fronts. We'll talk about which treatments work, which are showing signs of resistance; how to get life saving drugs to people in poor countries. How to allocate a limited supply of medicine to help the most people. What prevention programs work? And whether scientists are close, or closing in on, a vaccine or cure.

And if you'd like to talk with us, you're welcome, of course. Our number 1-800- 989-8255.

Let me introduce my guests. Dr. Wafaa El-Sadr is the Director of the International Center for AIDS Care and Treatment Programs at the Mailman School of Public Health at Columbia University, and Chief of Infectious Diseases at Harlem Hospital in New York. She joins us by phone from her office there. Welcome to the program, doctor.

Dr. WAFAA EL-SADR (Director, International Center for AIDS Care and Treatment Programs, Mailman School of Public Health, Colombia University): Thank you.

FLATOW: You're welcome. Dr. Rowena Johnston is the Director of Research at AFAR, the Foundation for AIDS Research in New York. She joins us today right here in our studios. Welcome to the program.

Dr. ROWENA JOHNSTON (Director of Research, AMFAR, New York): A pleasure to be here.

FLATOW: Laurie Garrett is the author of Betrayal of Trust: The Collapse of Global Public Health, she's a Senior Fellow for Global Health at the Council on Foreign Relations here in New York. And she joins us by phone from New York. Welcome back to the program, Laurie.

Ms. LAURIE GARRETT (Author, Betrayal of Trust: The Collapse of Global Public Health, Senior Fellow for Global Health, New York): It's great to be with you.

FLATOW: I couldn't help - I just have to, on the side Laurie, I know that you were one of the first reporters to report on GRID 25 years ago. Can you tell us a little bit about that experience?

Ms. GARRETT: Gay Related Infectious Disease, as it was called. And it had other names even before that. Yeah, I was based, for National Public Radio in those days, in San Francisco, right in the heart of the gay community of San Francisco. That's where our studios were in those days.

And it was a time of tremendous terror in San Francisco. It wasn't long before epidemiologists in San Francisco figured out that perhaps half of the gay population of the city was already infected. But as they were figuring that out, there was tremendous controversy with lots of folks in the gay community not wanting to believe that a virus was on the loose and looking for other explanations for why people were sick. It was a very terrifying and deeply sad time in our history.

FLATOW: Mm-hmm. Let's talk a little bit about present times. Are you encouraged by this report - the U.N. AIDS report that's out this week -by the overall decline in AIDS cases even though it might be up in some other countries?

Ms. GARRETT: Well, I think we're looking at a very variegated pandemic. It's not playing out the same way in any two places. That's logical. It all - it started in different times in different places. Uganda is probably the oldest point of the epidemic and, not surprisingly, it's become a more mature epidemic there. And it's still on its ascendancy, in very early phases, in places like Russia, most of the former Soviet Union, even in South Africa and some of its immediate neighbor states.

So, of course, we're seeing a patchwork quilt of what's going on. Some places very encouraging, some extremely distressing.

FLATOW: Mm-hmm. Dr. El-Sadr, do you agree?

Dr. EL-SADR: Yes, I do agree. I think it's - although, you know the report does present a bit of an optimistic view. And certainly we've made a tremendous progress, however, it's very hard to celebrate at this point, knowing that there are still continues to be close to four million new infections every year and millions of people - three million or more, that die every year from HIV around the world.

That tells me that we have a long way to go, in terms of how to prevent transmission of the epidemic, and also how to take care of people with HIV. With the increasing numbers of cases and the needs of people with HIV, I think we have to continue to maintain a very effective, vigorous, two-pronged approach.

Trying to prevent transmission, but at the same time being very cognizant that we must deal with the needs of many, many millions of people with HIV today that are suffering and require care and treatment urgently.

FLATOW: What do you see as the biggest stumbling blocks to achieving that?

Dr. EL-SADR: I think in many ways, I'll start with prevention. I do think that many of us, of course, would be heartened if we had an effective vaccine that worked perfectly all the time, or if we had an effective microbicide material or a substance that could be used by women, for example, to prevent transmission of HIV.

But, nonetheless, we do have - we do know methods that can work and those need to be effective. They need to be utilized widely. They need to be supported by leaders within the countries and leaders within communities. And we need to disseminate the prevention message more effectively to the people most at risk. This often happens to be women and young people in the United States, as well as elsewhere.

I think, in terms of treatment, I think we've made tremendous progress over the last couple of years. I can remember distinctly when we started our own programs to provide care and treatment for HIV internationally, in some of the poorest countries in Sub-Saharan Africa, many were doubtful. They thought this will not succeed. Not only did they think it would not succeed, they thought it was not even advisable.

I think we're in a different place now. I think now there's consensus that yes, we must and we should continue to expand care treatment. It's not going to happen magically overnight, but it requires putting together the pieces in a consistent manner and working with partners on the ground and with the people with HIV themselves so that we can succeed. And even in a short period of time, over the past year for example, we've seen tremendous achievements across the board.

FLATOW: Mm-hmm. Dr. Johnston, a lot has been made of the, quote, “AIDS cocktail" that came out about 10 years - oh, 10 years ago. How has that changed the picture of - the face of AIDS?

Dr. JOHNSTON: Well, it really has been a dramatic change for a person who is HIV infected. Before the combination therapies were available, we did have single, mono-therapies we called them. And they were effective for a very short time, but really, within a couple of months, people were rebounding back to the level of virus that they had before they started treatment.

With the advent of combination therapy, which is taking three drugs or more at one time, you're really attacking the virus from a number of angles at the same time. You're bringing it down to levels where it's more difficult for the virus to mutate and to develop resistance.

And so what we've seen since the advent of combination therapies is that, on average, people can expect to live around 13 years longer than otherwise they would have. And there was a recent study that demonstrated that we've saved about three million years of life by having used combination therapies. So that really is a remarkable advance. And we've done that within a relatively short time of having discovered HIV as the cause of AIDS.

Of course, the news is not all good. People do develop resistance to these drugs. They will eventually run out of options unless we, as the scientific community, can keep coming up with new types of drugs so that we can combat this drug resistance that develops almost inevitable in patients taking therapy.

FLATOW: Laurie Garrett, where do we stand in getting drugs to people who, you know, who can't afford to take any of these kinds of drugs? Where does that stand these days?

Ms. GARRETT: Well, first of all let's keep in mind, we've never before tried, as a global community, to deliver chronic care treatment for life to poor people in poor countries. We don't, right now, treat poor people in poor countries with insulin for diabetes for the most part. We don't, right now, treat any of the standard battery of chronic diseases on a long-term basis and certainly not in some concerted effort that involves the transfer of funds from the wealthy world to the poor world to take care of the problem.

So we're in the midst of something utterly revolutionary without any precedent in world history. Where we stand on the ground is that the optimism that many people felt about executing large-scale treatment on a sustainable basis is evaporating in many areas as people are realizing, hey, we have a global, acute shortage of healthcare workers. We're short some 4.3 million healthcares in the world.

Sub-Saharan and Africa alone has a deficit of one million. Not only that, that shortage, that deficit, is expanding because healthcare workers are, themselves, dying of HIV AIDS in many countries in the world. And we, in the wealthy world, are getting older. So we want nurses desperately to take care of us.

And we're offering huge financial incentives. We've even put through a bill in Congress to make an exception for nurses in the otherwise anti-immigration package just to suck them in from the poor countries at this critical time.

So what we understand right now is some key countries, notably Uganda and Botswana, Brazil, have done an outstanding job against all odds of rolling out these drugs and getting everybody pretty much that they know of who needs to be on the drugs, on them.

But, it risks being at the expense of other health programs. It risks sucking the health talent, away from other sectors of public health needs, to HIV. And what we're now seeing is a turning point where more and more people involved in the battle against HIV are coming right back to realizing, hey, we're in a battle against all of the primary causes of death and disease.

We have to take it all on together.

FLATOW: Dr. Johnston?

Dr. JOHNSTON: There's another important challenge in getting anti-retroviral therapy out to all these people in the developing worlds. We have to keep in mind, that here in the United States, patients have access to 20 or more anti- retroviral medications.

And so when they take their first-line regimen, after a few years that might fail, and they have the opportunity to switch to another combination of drugs that will be effective again.

For most of the developing world where we are supplying drugs, they have a choice of only three drugs. Those are the three drugs they get. And if and when those drugs start to fail, these people don't have any options.

What we really need to be doing is making sure that we understand it is a lifelong commitment. If you've decided to treat people for HIV in the developing world, you have to understand that you're going to be treating them for the next 50 years.

You have to have Plan B in place before you roll out Plan A.

FLATOW: Dr. El-Sadr, Paul De Lay was on earlier, talking about a very cheap way of treating women with a dollar drug - if you gave them, I think he said, while they were pregnant, before delivery. What about mother-to-child transmission? Why can't we have something like that and eliminate - would that eliminate a problem of transmitting disease?

Dr. EL-SADR: Well, certainly the discovery of this very inexpensive and easy- to-take medication that does decrease the transmission of HIV from a pregnant woman to her baby, is a remarkable discovery. And this medication is given once during delivery, during labor, and once to the baby.

It does decrease the transmission by about half. But it doesn't eliminate it completely.

And as was - as Laurie was mentioning, it sometimes - although it is a very simple intervention, it is complex to implement these programs. For example, you have to bring in all pregnant women into antenatal care so they can get tested for HIV. That is possible in some countries. In other countries, only as little as 20 percent, one in five pregnant women, ever reaches antenatal services.

Then you have to provide the testing. You have to then provide the counseling. You have to enable the women to agree to the test, and so on. And then you have to, most importantly, I believe, offer these women something.

Unfortunately, it was assumed, that if you just offered the women to prevent transmission from themselves to their baby that this would solve all problems. These programs did not offer anything to the woman herself with HIV.

We've tried and been working and we've built a very interesting program and quite effective program called MTCP-Plus(ph) Initiative, where we are engaging these women who are HIV infected themselves, during pregnancy or after they deliver, and we're providing them with the medication to prevent transmission to their baby.

Not only that, but we're also offering them, as well as their families, their babies and their children, their partner, their household members - we're offering all of them comprehensive HIV care and treatment.

And our goal is to transform the way that people look at HIV - that families will come together, women will be able to disclose to their partners at home about HIV - and they'll be able to all get the care and services they need together.

And, you know, we hope that - and what we've seen - is that over time, these women are actually able to bring in their partners. They're able to bring in their other children. Sometimes they're able to bring in their sister, or their brother, or the second wife in the household, to be able to engage in HIV care and treatment.

So, I think as we - we're learning as we go about the complexities of even trying to put in place the simplest of programs, that it's not as easy as a pill. And I think that's the message, is neither HIV prevention nor HIV care are going to be simple.

They're going to require a lot of attention to the details, a lot of attention to programming, a lot of building of coalitions, a lot of partnerships with people with HIV and with community-based organizations, a lot of thinking about the models of care.

It's going to take, take a concerted effort to make these programs succeed - even the simplest of interventions - to make them succeed.

FLATOW: Yes. Talking about HIV AIDS on the 20th anniversary year, this year, on TALK OF THE NATION SCIENCE FRIDAY from NPR News. 1-800-989-8255.

You touched a little bit about the stigmatism here. And the more I talk to people who deal with the epidemic, the more they talk about it's really the empowerment of women. And Kofi Annan said it this week - he said that when women are more empowered then this epidemic may start going away.

Do you agree with that?

Ms. GARRETT: Who are you asking?

FLATOW: Laurie, go ahead.

Ms. GARRETT: By the way, it's the 25th anniversary, not the 20th, which…

FLATOW: What did I say? I said 20th? 25th. I'm sorry.

Ms. GARRETT: Yes. You know, I always remember - every time I hear people talk about abstinence and faithfulness within marriage as solutions - I think about the time I sat in a room with 61 women, every one of them HIV positive, just outside Kampala, Uganda - every one of them married, every one of them had been loyal to their husbands. Not one of them confessed to having ever had an affair of any kind with anybody else.

In fact, most of them were virgins when they married and had never in their lives had sex with another man. And here they were, dying of HIV AIDS, dying because their husbands were having affairs. And that is the accepted norm.

And, by the way, not affairs, but multiple sexual partners, 12, 15 happening in the same time period of a given month or something of that nature.

So the real problem is that there's nothing right now, a married woman of any age can do to protect herself, when she is in most of the kinds of marriages that we're talking about around the world, where there's this sort of peril.

FLATOW: All right, Laurie, hold on to that thought because we have to take a break. You know the radio business. We'll come back and pick up on that because it is a very important point, and we want to discuss it in greater length.

So stay with us. We'll be right back talking about HIV AIDS on this 25th anniversary on SCIENCE FRIDAY. Stay with us.

I'm Ira Flatow. This is TALK OF THE NATION SCIENCE FRIDAY from NPR News.

(Soundbite of music)

This is TALK OF THE NATION SCIENCE FRIDAY from NPR News. I'm Ira Flatow. We're talking this hour about AIDS with my guests, Dr. Rowena Johnston, director of research at AMFAR, The Foundation for AIDS Research in New York, also talking with Laurie Garrett, author of Betrayal of Trust: The Collapse of Global Public Health, and she's also senior fellow for global health at the Council on Foreign Relations, and Dr. Wafaa El-Sadr, director of The International Center for AIDS Care and Treatment Programs at Mailman School of Public Health at Columbia University. She's chief of infectious diseases at Harlem Hospital in New York.

Our number, 1-800-989-8255. And when I rudely interrupted Laurie, she was telling us about how women, you know, are just not in control of their lives in the spread of AIDS here.

Ms. GARRETT: Well, I mean, the bottom line is the only prevention tool we have right now that works to intervene with sexual transmission is the condom. But the condom is controlled by the man. And unless the man is agreeable, the condom is not going to be there.

So, until we come up with something, and there is research going on that I know Rowena can tell you about for trying to come up with a microbicide, a sort of a vaginal foam that women could use. But until something like that is really available, and not just available but dirt cheap, women will be in a very vulnerable state.

And the sort of judgmental messages that imply that you have AIDS because you misbehave morally - you had too much sex, you were wrong, you were bad - is very, very cruel in the face of the real data.

And by the way, the group at highest risk, in the world, on a biological basis - meaning the person most likely to become infected with any single act of exposure - are teenage wives; meaning young girls or very young women - depending on how you want to refer to them. Thirteen, 14, 15 year olds, that are getting married, and their first act sexually, may very well involve sex with an HIV-positive new husband.

FLATOW: First Lady Laura Bush, who was in New York today addressing the U.N. conference, and she said that she called on countries, and I'm quoting from the A.P. here, to improve literacy. And she said this, she said, more people need to know how AIDS is transmitted. Every country has an obligation to educate its citizens.

You seem to be saying that education is not the problem here.

Ms. GARRETT: Wait a minute, no. I think, in the big picture, education is a problem. One of the reasons women are so vulnerable is that in many countries in the world, women don't have cash so they cannot walk out of a dangerous marriage.

There's no such thing as opting for a divorce to protect yourself, even if you're very well aware of your husband's activities.

Education is a valuable tool. And we do see, across the board, not just with HIV but virtually every infectious disease health problem you can think of. The survival of children and mothers is enhanced by maternal education.

FLATOW: But you're also saying, if I heard you correctly, you can be as educated as you want but if you don't have that condom to use, it's not going to help you.

Ms. GARRETT: That's true.

FLATOW: Do you agree, Wafaa?

Dr. EL-SADR: I think it's - I agree and I also think that complexities of the issues is paramount. I think education by itself certainly would be very - is necessary.

I do think, though, that beyond education, it's almost transforming societies and cultures to be able to appreciate and value women, to be able to appreciate and value individuals within the site, appreciate each other and protect each other from threats like from HIV.

I am encouraged, though. I do - although stigma is certainly a huge problem, both remains in our country as well as overseas, I'm beginning to see some evidence of, you know, of the beginnings of a change. It's small, but it's happening.

I've just come back from a trip to Africa and was heartened to see women and women's groups and who are speaking up, women with HIV who are taking leadership positions in programs, who are able to challenge the establishment. I was able to see women who are now able to tell their partners that they have HIV and demand the rights and demand the rights for their families. I was also able to see, you know, clinics that, everybody knows in these facilities that this is where HIV infected individuals are getting their care. But nobody really seems to care. People come to these clinics, they flock, once they know that there's treatment there, they come. And that's telling me there's something that's happening, something's changing, that people are coming because they suspect they have HIV, but they also that there's something we can offer them.

FLATOW: Mm-hmm.

Dr. EL-SADR: And I think that all of these factors are going to, are coming together to demonstrate that maybe there is a change. It's a small change, but it's the beginning of something new...

FLATOW: Interesting...

Dr. EL-SADR: And I think it bodes well for our ability to deal with this epidemic.

FLATOW: Dr. Johnston, what can you offer some - in terms of new medicine for people who might be coming to the clinics of today or tomorrow?

Dr. JOHNSTON: Well, we have triple combination therapy available, certainly in the developed world. And it's increasingly becoming available in the developing world. Triple therapy will probably do good for people, especially who are starting out therapy for quite a time to come, unless they're unfortunate enough to have been infected by somebody who's already drug-resistant, because if drug-resistant virus gets transmitted to you, then you start off really a long way behind the eight-ball where your treatment options are limited.

Researchers are in a constant race against this virus. This virus moves very fast. It's a very fast-moving target. And so, researchers need to always be coming up with different classes of drugs, that is, drugs that operate in entirely new ways and attack the virus from completely different angles. We have, for example, a group of drugs called receptor blockers. It seems likely that they may become available within the next one or two years, and not far behind those might be integrase inhibitors. There's a number of different types of drugs that are in development that are starting to look promising. You know, unfortunately, for every new drug that you think might look good in pre-clinical development, you may well reach a point where it's too toxic or it's just simply not going to be suitable for human use.

FLATOW: Well about microbicides, where a woman could take it herself if her husband is not...

Dr. JOHNSTON: Well, I was very, right, I was very interested to hear both Laurie and Wafaa talk a lot about the social and economic vulnerability of women, and certainly that's very true. But it's important to point out that women are actually biologically far more vulnerable to HIV than are men just by the nature of their bodies. And in terms of biology, scientists are developing a new intervention called microbicides. It's not yet available.

But you know, people are optimistic that it may actually become available in about five years, say. And it would be a gel, or a cream, or a foam, or - nobody knows what exactly the formulation might be at this point. But it would be applied internally and it could protect a woman from her male partner if he happens to be HIV positive. And also, what's also important is, depending on what the compound is, the active compound is in a microbicide, it may also help the woman to protect her male partner if she's HIV positive.

Now, if we could come up with a formulation that is not contraceptive, that might even be better, because I think another one of the obstacles to getting people to use condoms is, if you want to get pregnant then condoms are not the option for you. So, if we can come up with a product that can protect you from HIV but still allow you to become pregnant, I think that would be fabulous.

Dr. EL-SADR: I think another strategy that is often forgotten when we think about sort of prevention of transmission of HIV is if we can get populations and groups at large to know their HIV status. Because HIV is transmitted from someone obviously has the infection, and I think over the past several years and maybe, especially in the past year, there's been a recognition that more widespread availability of testing, so that people know their HIV status, would really be a step forward to stemming the tide of transmission of HIV.

FLATOW: Do we have the…

Dr. EL-SADR: I mean, it's estimated…


Dr. EL-SADR: …that, you know, less than half of people who are HIV infected know that they're HIV infected. And that actually is an issue in this country, in the United States, as well as, obviously to a much greater extent overseas as well.

FLATOW: Yeah. Do we have, Dr. Johnston, cheap diagnostic HIV kits, so to speak?

Dr. JOHNSTON: Ah, diagnostics? It depends what you're asking here. Um, we can test people for HIV relatively inexpensively. Voluntary counseling and testing is being rolled out in the developing world. One problem that kind of touches a little bit peripherally on this issue is, once you've discovered that somebody is HIV positive and you want to start treating them, what you need to do is closely monitor how well they're doing on their treatments. You need to be measuring how much virus do they have in their blood and how well is their immune system doing, their CD4 T-cell count.

You need to know those things, because you need to know how well the drugs are working, whether they need to switch to another strategy or whether this is working at all. Those tests are actually quite expensive, and really are only available on a very limited basis.

FLATOW: Mm-hmm.

Ms. GARRETT: One of the things though - this is Laurie Garrett - one of the things that's exciting that's going on right now is, actually thanks to our great advances in basic molecular and genetic research, scientists have come up with some pretty revolutionary designs for rapid testing. Not just for HIV, but for a whole host of infectious diseases that would no longer require that we withdraw blood.

One really big problem with all the diagnostics that require drawing blood is those needles get reused and spread other disease, and you don't want the reuse of needles. There's a lot now beginning to come out of the research part of the pipeline. The problem is translating that into mass production on a scale that is affordable and has sufficient volume to be useful in developing countries. And that's a step where we at the Council on Foreign Relations have been very active, because right now, lots and lots and lots of things that could save lives - not just for HIV but for tuberculosis, malaria, and a host of other diseases - are stymied at that point. Because industry can't see how they could profitably manufacture something that's going to go to a country that spends $15 per capita per year on healthcare. We have to get over that hump.

FLATOW: Mm-hmm. Laurie, where do we stand on a vaccine?

Ms. GARRETT: We're not in great shape on the vaccine front. On the one hand, there's a tremendous amount of intellectual energy on the problem, and we do have a lot of money thrown at the vaccine question now. Not just by our NIH, our government-sponsored funding, but private industry is in the game all over the world, and there are a lot of foundations, like the International AIDS Vaccine Initiative.

The problem really for the vaccine front is an intellectual one. We are really stymied by a virus that not only infects the immune system directly and manipulates it to its needs, but also hides inside of our genes, in our DNA. It's really tough to come up with a way to vaccinate against that.

The other thing that makes this virus even harder on top of all I've already said is that when it's in the human bloodstream, it coats itself in our sugar, in the kinds of sugar molecules that routinely are drifting around inside of our bodies. So, when our antibodies look at it, they see a ball of sugar, and we certainly wouldn't want our antibodies to say, uh-oh, bad ball of sugar, must kill it, because then those same antibodies would start destroying very vital things all over your body. You begin to understand we're up against it big-time on the intellectual level with this virus.

FLATOW: Mm-hmm. We're talking about AIDS this hour on TALK OF THE NATION SCIENCE FRIDAY from NPR News. Let me see if I can quick a phone call in from Ned, in Denver. Hi, Ned.

NED (Caller): Hi. Thanks very much for taking my call. It's a great show. Just for background, real quickly, my wife and I just moved back to the United States after spending 16-and-a-half years in southern Africa, in Mozambique, South Africa, and Zimbabwe. And we, I work in the water and sanitation sector, and she works in the HIV and AIDS sector. And I must say the discussion you're having is really interesting. But from a kind of field-based perspective, it seems like another universe in many senses. I think the one good thing that's happening in the AIDS sector right now that doesn't get a lot of play is I think there is a growing realization that looking at the broader development issues around the people who have, who are HIV positive, is a very good thing.

So, for example, the Gates Foundation right now is doing a lot of work in HIV/AIDS, but they're now also starting to explore whether they should be involved in the water and sanitation and other things, because they're realizing that a lot of people who are HIV positive, even if you get all the staffing issues right, which you rarely do, and even if you get medicines out there, which is very hard, you really struggle because the environments around them are so bad and so peoples' immunity is so bad anyway.

I think the other issue in the sector that rarely gets a lot of play is I think there might actually be too much money, and I know that's heresy. But I think the incentives in some senses are wrong, and you have a lot of money going into, still going into conferences and very high salaries, and things like that that have nothing to do with the development sector. But there's very little looking at questions of impact, you know, what will your program, you're getting all this money, what impact did you have? Are salaries, all these conferences, and everything justified...

FLATOW: Ned, Ned we're running out of time. Let's see if we can get an answer for you.

Ms. GARRETT: Well, I love what Ned is saying, and it's very much in synch with what I was trying to get across. Yeah, what's the point of taking an antiviral drug if you drink it down with a cup of water that has cholera in it? What's the point if you have no water? And, or if, while you're deathly ill, you have to walk, 15, 20 kilometers to get to a well and then carry a giant jug of water on your head all the way back home. And that's a bitter reality that has to be faced.

And, yes, he is echoing exactly what I was trying to get at about skewing our health resources so heavily to one disease, by not only funding the HIV effort but paying higher salaries to healthcare workers and giving them options to go to international meetings and travel by getting involved in AIDS care. And what do they do? Well, of course they abandon the dire real disease programs, the very unglamorous child health programs, and we're already seeing this happen and it's quite dramatic and very disturbing. Indeed, at the Council on Foreign Relations we're on record saying we very much are concerned that the net impact, if we don't do this differently from how we're doing it right now, the net impact of the fight against AIDS could be an overall increase in mortality in many countries because of the abandonment of child health programs.

Dr. EL-SADR: Another way…

FLATOW: So what's the, Laurie, what's the answer?

Dr. EL-SADR: Another way of looking at this maybe is, and I tend to think of it in, come at it from a different direction, is that this is a remarkable opportunity. I think the investment that many countries around the world are putting into HIV programs, similar to investment our own government here has put into HIV programs, has transformed the way we provide healthcare services.

Think back a few years ago, when we thought, you know, we didn't know that people with asthma and diabetes needed to be taken care of by multi- disciplinary team, that they needed social support, and that they needed community outreach. HIV paved the way. And I feel that HIV can do the same in the poorest countries in the world. For example...

FLATOW: Well, we've run out of, Dr. El-Sadr, we've run out of time. I'm sorry.

Dr. EL-SADR: That's okay.

FLATOW: It was an interesting, you made an interesting point and I think we understood what you said, but unfortunately the clock is the master.

Dr. Wafaa El-Sadr, director of International Center for AIDS Care and Treatment Programs at the Mailman School of Public Health at Columbia; Laurie Garrett, author of Betrayal of Trust: The Collapse of Public Health, and she's also a senior fellow for Global Health at the Council of Foreign Relations. Dr. Rowena Johnston, Director of Research at ANFAR, the Foundation for AIDS Research here in New York. Thank you all for taking the time to be with us today.

GROUP: Thank you very much.

FLATOW: You're welcome.

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