A Czar Is Not What the AIDS Fight Needs


July 19, 1993|By DANIEL S. GREENBERG

WASHINGTON — Washington. -- Considering the awful fates of the last czar and many of his predecessors, it is puzzling that the title is invoked as evidence of determination to tackle egregiously difficult problems.

In the case of AIDS, the determination is doubly evident: Congress has decreed the enthronement of what proponents refer to as a czar for AIDS research; meanwhile, President Clinton, fulfilling his czar pledge of campaign days, has appointed a presumably super-powerful staffer at the White House to provide AIDS leadership across the board.

The appointments, of course, feed expectations that the horrors of AIDS will be alleviated faster by centralizing power and authority. It cannot be said for certain that this will not happen. Orchestration has been lacking in coordinating and focusing government-supported programs in AIDS education and services for patients. But some skepticism and recognition of the imbalance between the problem and available resources invites doubt about the potential for czardom in this area.

Since AIDS education and services function mainly at the local and state levels, the enthronement of a White House czar in Washington only begins to approach the problem of how to attain desirable results. Additional federal AIDS money for cash-strapped cities and states is the direct solution.

But the Clinton administration, while more open-hearted and generous than its two predecessors in the AIDS era, has asked for modest increases for AIDS -- sums that cannot support the all-out war promised on the campaign trail. Furthermore, the AIDS czar at the White House is a monarch without troops or money of her own, dependent on proximity to the president to induce the agencies and departments of government to fall in step with her strategy for AIDS. In the history of bureaucratic strife, such arrangements have not often been successful.

The centralization of AIDS research at the government's chief biomedical research agency, the National Institutes of Health, was imposed by Congress over the protests of the mainline scientific establishment. Scientists prefer to keep decision-making at the laboratory level, insulated against distant administrators. AIDS activists, exasperated by the lack of effective treatment or a preventive vaccine after 13 years of research, turned against the research system as hopeless and initiated the drive for an AIDS czar at the institutes.

Generally responsive to the AIDS lobbies, Congress was also drawn to the czar solution by its own preference for administrative tidiness in federal agencies. Congressional power is enhanced when authority and responsibility can be pinpointed in an agency chief who can be called on the carpet.

Prior to the centralization, AIDS research, which is spread throughout the National Institutes of Health, was loosely coordinated by the dual-hatted chief of one of the 16 research institutes in the NIH complex. But decision-making about research goals and resources was spread among the institutes and their thousands of advisers.

Now, by Congressional decree, control will be tighter. Just how tight is not certain, since the legislation still allows a fair amount of flexibility at the NIH -- and scientists there are legendary for saluting the rules and continuing to do things their own way.

The real question, however, is whether scientific understanding of the devilish AIDS virus has reached the point where a directed, engineered approach will be fruitful. Or is it the case, as many scientists contend, that too much remains unknown to lay down a broad research strategy that might inhibit scientific ingenuity or fruitful eccentricity?

The turn to czars reflects understandable frustration and despair. In AIDS education and services, the case for stronger leadership is plausible, though leadership without a great deal of additional money is not likely to amount to much.

However, the attempt to impose centralization on the science of AIDS warrants concern. Scientists, aided by supportive administrative chiefs, can often thrive in difficult circumstances, even though their howls of pain suggest otherwise. But a point can be reached at which scientific productivity is thwarted by misguided direction.

Czars didn't do so well in their original milieu. Why import them into science and the campaign against a deadly disease?

Daniel S. Greenberg is a syndicated columnist specializing in the politics of science and health.

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