Science Correspondent Jon Cohen Sees Perils, Promise in the Fight Against AIDS

Jon Cohen with Sun Fuli in Beijing

[You can see a slide show and a photo essay that accompany Jon Cohen's stories on AIDS in Asia. Read the full set of stories here.]

Jon Cohen arrived at the old Tambaram hospital in Chennai, India, on a Saturday morning last winter and saw sights that he hadn't seen before in Asia. There were five AIDS wards, each with three dozen beds, and each of them filled to capacity. In the past year, he was told, the staff had treated 10,000 patients.

As a long-time correspondent for the journal Science and a leading authority on the global AIDS epidemic, Cohen has traveled the world documenting the human toll of AIDS and the social and medical research being marshaled against it. But he hadn't seen anything as dire as Tambaram since his travels in the AIDS-ravaged lands of sub-Saharan Africa.

"Tambaram is how my mind's eye imagines the Black Plague: long rows of filled beds with dying people," he said in a recent interview. "The clinicians were fantastic: smart, humane, and generous. But this is a nasty virus, and it still takes a lot of money and know-how to keep HIV at bay. As the doctors there stressed to me, they're doing the best they can. I could see that. It's just that the best they can offer right now isn't enough."

Cohen is back in Asia now, joining thousands of health workers, researchers, activists and journalists for the 15th International AIDS Conference in Bangkok, which runs from 11-16 July. The theme of the conference is "Access for All," but in a remarkable series of stories over the past nine months, Cohen has made clear that while there's been great progress, the goal of proper care for all of those in Asia who are HIV-positive or suffering from AIDS remains far off. AAAS and Science will distribute thousands of reprints of his stories at the conference, without charge.

"There are an estimated 40 million HIV-infected people in the world," Cohen said in the interview. "It depends on which equation you use to calculate which of those people need drugs now, but it's a pitifully small number who are actually receiving them."

[See the full interview with Jon Cohen here.]

As the Bangkok conference nears, Cohen sees a world divided into rich nations and poor nations. The rich nations are refining their treatment programs, learning how best to use drugs to combat the virus, and pushing for a vaccine. But in the poor nations, and this includes the nations of Asia, "there aren't a lot of options for treatment," he says. "The big challenge is to get treatment to people, and there is a massive scale-up underway right now. But as of today, very, very few HIV-infected people in the world who are poor receive drugs or have access to drugs even though the price has plummeted."

For years, Cohen says, most of the nations of Asia had been reticent about dealing with the spread of the infection among their people. That's partly a function of denial, he suggests, a response shared by the United States as AIDS hit its stride there in the 1980s, and partly from the fact that the disease is relatively new to places like China. But in the past year, he's seen a change.

"There have been very dramatic commitments from …India, China and Thailand to treat the people most in need," he explains. "I also think that India and China are more forthrightly dealing with their epidemics than they were a few years ago. They're acknowledging the scale and they're also starting to deliver services. But almost every country, and I would include the United States here, is fighting this virus with one hand tied behind its back because of political agendas. That hasn't changed much. It's changing, but it's glacial, it's excruciating to watch…. The virus just doesn't wait for anyone-it doesn't care. It doesn't play politics. It doesn't have a brain. It doesn't have morals. None of that matters to HIV. It just wants to copy itself and spread, that's all it wants to do."

What caused the change in those Asian countries? The factors vary from place to place, he says, but one element is common: Fear. The countries fear the impact on their economies. They fear international disapproval of the sort China faced last year over its failure to respond in a timely and forthright way to the SARS outbreak. And increasingly, he says, they fear the dire impact on their people.

"Think about it—in Asia, who really drives the epidemic?" Cohen asks. "Well, it's driven by sex workers and mostly by their clients—that's what really drives it. And so it's easy for people to be moralistic and to say, 'You got yourself into this—who cares?' Countries come realize then, that, first of all, sex workers and clients are part of the population. They're people too. And much as you might want to marginalize them, they have children, they have spouses, and those people often become infected often having done nothing that any moralist would say is wrong. In India, there's a saying that a woman's greatest HIV risk factor is getting married. Women are largely monogamous there. Many, many women have become infected after their husbands went to sex workers. Countries just start to accept that they can't just put this disease in a corner and say, 'This is something that happens to bad people.'

There is a window of opportunity open right now in much of Asia, he says. And while it gradually is closing, there remains time to save thousands of lives with effective intervention.

"Once you get to a certain level of spread, like South Africa, where you have 20 percent of the adults infected, you can't base your prevention program around targeting those 20 percent of the people," he says. "It's just too large a group. But if you only have, as is the case in China now, somewhere around a million infected people, you can target those people for prevention care. You can target high-risk groups, like injecting drug users and sex workers, and really make a huge difference in preventing a widespread epidemic. That's where Asia sits right now."

Cohen has been covering HIV and AIDS since 1989. He has reported extensively for Science, and his 2001 book "Shots in the Dark: The Wayward Search for an AIDS Vaccine" (W.W. Norton & Company, 2001) won the National Association of Science Writers' Science-in-Society award. His latest book, "Coming to Term: Mysteries, Myths and the Latest Science of Miscarriage" is slated for release by Houghton Mifflin in January. What's striking, in an interview with Cohen, is not only his knowledge and eloquence, but his balance. He has seen the worst of the AIDS epidemic in places like Tambaram and sub-Saharan Africa, he has seen how politics at times cripples the fight against the disease, and yet his perspective retains strong elements of compassion and hope.

"The greatest cause for optimism is that the virus [in Asia] hasn't spread that far yet. So there's a terrific chance to use the new treatment programs to encourage people to receive tests," he says. "If you can offer drugs, there's more likely people will receive a test, because there's something you can do for them.

"And then…on the edge of research, there are some really interesting possibilities. Research equals optimism, to me—that's the whole idea.

"When I work in large AIDS wards, it of course depresses me—and I would have deep suspicions about anyone who didn't feel saddened by the helplessness—but I also feel like, on some level, we are helping. When I go sailing and I'm piloting a boat, the motion of the sea doesn't make me ill. It's the same sort of feeling when I'm at work in a depressing situation: While I'm doing my job, it blunts the dizzying sensation of meeting many, many people in one place who I know only have weeks or days to live. I'm also buoyed by the wisdom that comes with great suffering, and I meet people everywhere who impress me with how well they handle the crises of life with AIDS."

The journal Science, published by AAAS, has the largest paid circulation of any peer-reviewed general science journal in the world, with an estimated total readership of one million. AAAS, founded in 1848, is the world's largest general scientific society, serving some 10 million people through 262 affiliated societies and academies of science. The non-profit association is open to all and fulfills its mission to "advance science and serve society" through initiatives in science policy, international programs, science education and more.

— Edward W. Lempinen

6 July 2004

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