In 1993, dozens of AIDS organizations and hundreds of AIDS researchers joined together to push for reforms in management of AIDS research at the National Institutes of Health (NIH). For several years leading up to 1993, the NIH AIDS research program was criticized by many, including the Institute of Medicine of the National Academy of Sciences, the scientific journal Nature and many AIDS groups, for a lack of coordination and overall leadership. That year, a bipartisan group of Federal legislators led by Senators Edward Kennedy (D-MA), Nancy Kassebaum (R-KS), Orrin Hatch (R-UT) and Representative Henry Waxman (D-CA) introduced measures into the reauthorization legislation for the National Institutes of Health which finally set up a command center for AIDS research by beefing up the already existing NIH Office of AIDS Research (OAR).
The new Office of AIDS Research was given the mandate of leading the disparate AIDS programs of the NIH's 24 individual and independent-minded institutes. Each year, the new OAR was to construct and implement an NIH-wide strategic plan and budget for AIDS research. To give the new OAR some teeth to do its job, the Congress authorized the new Office to receive all monies allocated for NIH AIDS research each year and to distribute the funds to the institutes according to the NIH-wide strategic plan for AIDS research. This feature of the new OAR never sat well with the Directors of the NIH's 24 separate institutes, who were used to being lords of their own manors and didn't feel they needed to answer to anyone. The Congressional framers of the legislation giving the OAR its new powers realized this was precisely the point.
In order to effectively shape the 24 separate programs of AIDS research at the NIH into a coherent and efficient whole, the Office had to have some clout in dealing with the Institute Directors. Without some kind of budgetary authority, the new OAR Director would rule like a British monarch: a mere figurehead with the capacity to advise. Pomp, but no circumstance. With control over funds allocated for AIDS research, the new OAR Director became a modern leader with real executive authority over the NIH AIDS program.
In 1994 NIH Director Harold E. Varmus appointed the world-renown immunologist, William E. Paul, to be Director of the OAR. Because of his standing in the scientific community, Dr. Paul was able to enlist some of the most talented scientists in the country to help him re-shape the NIH AIDS research program. Some of these researchers, although they were leaders in the fields of virology, immunology, or molecular biology, had never set foot in AIDS before Dr. Paul's request for assistance. This year, Dr. Paul has commissioned Arnold Levine of Princeton University, a noted molecular biologist, to lead a unprecedented, wholesale review of the NIH AIDS research program. In turn, Dr. Levine has assembled a group of over 100 leading scientists and AIDS community members to evaluate the NIH's entire portfolio of AIDS research and to come up with recommendations for change.
Although this may sound somewhat incredible to anyone who has closely followed the progress of research throughout the epidemic, Dr. Levine's review offers hope for real change in the direction of AIDS research. Turning around the NIH's AIDS program might be likened to turning an ocean liner 180 degrees--it moves slowly and only with great effort and still takes a while to get anywhere. For once in the epidemic, however, fate has temporarily conspired with us, instead of against us. While the logic behind the strengthening of the OAR was extremely compelling, it took a lot of hard work and an unusual bit of luck for activists and scientists to convince Congress in 1993 to overhaul the management of AIDS research at the NIH and create a real command center for research on the disease. While Dr. Paul has said that its was a humanitarian concern that drove him to accept the position of OAR Director, a little bit of luck was again involved in convincing him to put his illustrious scientific career on hold and lead the new Office of AIDS Research.
The scientists assembled by Dr. Levine are composed of some of the brightest of the generation of AIDS researchers that came of age during the epidemic, supplemented by powerhouse researchers from other fields. There isn't a better group of people to craft a frank assessment of the NIH AIDS research program, and Dr. Paul is committed to implementing their recommendations. If the OAR's review of the NIH AIDS research program under Dr. Levine offers hope for real change, it comes to us within a narrow window of opportunity--a window that may slam shut before the panel's recommendations can be acted upon.
Right now, there is a move in Congress to revoke the budgetary authority of the OAR. The House Appropriations Committee, doing the bidding of the NIH institute directors, has voted to remove the NIH AIDS research budget from the OAR, and for the first time since the early 1980s completely eliminate designated AIDS funding at the NIH. Funds for AIDS research under the House Republicans' plans will become simply a part of the general pot of money given directly to the 24 NIH institutes. If House Republicans succeed in getting their way in the final version of the spending bill sent to the President, and the OAR no longer receives all monies allocated to the NIH for AIDS research, the Office could become a paper tiger, putting the successful implementation of the Levine panel's recommendations into jeopardy.
NIH Director Harold Varmus says that he will ensure that the Levine panel's recommendations are followed--no matter what happens in Congress. Unfortunately, though, without AIDS research dollars flowing through the OAR, the implementation of these recommendations becomes a big horse-trading session between Dr. Varmus and the lords of his 24 institutes with priorities other than AIDS entering the calculus of decision-making. The implications of the House Republicans' move are rendered even more chilling by a recent report by Nobel Prize winner, Michael Bishop of the University of California at San Francisco, and Paul Calabresi of Yale University, on the National Cancer Institute (NCI).
In their report, Bishop and Calabresi discovered that a major portion of the NCI's AIDS research monies were being spent on work that could only--by the greatest stretch of the imagination--be considered AIDS research. Importantly, the Bishop-Calabresi report recommended that the OAR help re-program these funds to support high-quality AIDS research. Without any control over the AIDS research budget at the NIH and no designated funds for AIDS research, no one is going to be able to assess--or rescue the fate of--research dollars supposedly being spent on AIDS.
The House Republicans' action weakens the authority of the OAR and its leadership of the NIH's AIDS research program and leaves the institutes free to do whatever they want with monies formerly devoted to AIDS research. We can only hope that history of AIDS funding at the NCI is the exception rather than the rule among the other institutes.
The moves in the House of Representatives are being fought vigorously by an unprecedented coalition of AIDS groups and scientists. Every major national AIDS organization, including the American Foundation for AIDS Research, National Minority AIDS Council, AIDS Action Council, Human Rights Campaign Fund, Gay Men's Health Crisis, Mobilization Against AIDS, AIDS Action Baltimore, Mothers' Voices, and the Treatment Action Group has put the restoration of the budgetary authority of the OAR at the top of their agendas. Hundreds of scientists too, including three Nobel prize winners, have joined the AIDS community's appeal to Congress. In July, two of the country's top scientists, Nobel Prize winner David Baltimore of the Massachusetts Institute of Technology and eminent AIDS researcher David Ho of the Aaron Diamond AIDS Research Center in New York City, joined forces and co-authored an Op-Ed piece in The New York Times to rally the scientific community and the public to the defense of the OAR.
This pressure has, in part, born fruit. If only in its rhetoric, the House Appropriations Committee softened its opposition to the OAR in its bill which includes funding for the NIH. While still revoking a single, consolidated budget for NIH AIDS research for the OAR, the House Appropriations Committee maintained in the fine print of the bill that it still supports the OAR and its mission, singling out the Levine review of AIDS research for special praise. In the fine print of the bill, the House Republicans also give NIH Director Varmus the ability to construct an NIH AIDS budget, with OAR Director Paul acting in consultation with him or as his agent. In the final analysis, however, the fine print intentions of the House Appropriations Committee are contradicted by the actual statutory language, which appropriates all funds for biomedical research--without any designated AIDS research monies--directly to the NIH's 24 institutes. Who is in charge of the NIH AIDS research program under the House Republicans' vision? Who has the power of the purse? Is it the triumpherate of Congress, the NIH Director and the OAR Director? Or is it the 24-headed hydra of NIH institute directors?
The OAR was strengthened in 1993 in order to provide clear and unambiguous leadership for the NIH AIDS research program. Both the scientific community and AIDS groups think the House's actions have undermined the OAR's bipartisan mandate and are continuing the fight to restore the OAR's single, consolidated budget for NIH AIDS research.
The battle now moves to the Senate, where scientists and AIDS groups will try to convince the leadership to maintain a single, consolidated appropriation for AIDS research. If that is successful, efforts will then be made to convince the House Appropriations Committee to cede to the Senate's wishes when the final version of the spending bill is hammered out in a joint Senate-House conference committee later in the fall. Already, three Nobel laureates, David Baltimore and Philip Sharp of MIT and Torsten Wiesel of Rockefeller University, have appealed to Speaker of the House Newt Gingrich to heed the advice of the scientific community and restore the consolidated AIDS research budget to the OAR. If all else fails, President Clinton has said he will veto a spending bill that does not include the OAR's consolidated AIDS research budget. (That and a token will get you across town.) Stay tuned.