San Francisco Chronicle - Monday August 7, 1989
Randy Shilts

The staff for this awesome task: two doctors.

The financing and staff needs of such AIDS battlefields threaten financial disaster for several cities as they try to cope with the rising cost of taking care of poor AIDS patients. With that burden in mind, dozens of doctors and health officials from the nation's hardest-hit cities appeared before Congress last week to plead for federal help.

"In spite of the scientific advances in AIDS therapy of the last few years, in communities such as Harlem, we still find ourselves less - not more - capable of coping with the disease," Dr. Waffa El-Sadr, Harlem's infectious disease chief, told the House subcommittee on intergovernmental operations.

To such pleas for help, however, the Bush administration had one answer: No.

Dr. James Mason, assistant secretary for health, put into words what had long been the de facto policy of both the Reagan and Bush administrations. The role of the federal government, he said, would be to coordinate AIDS prevention efforts and to provide financing for laboratory research into treatments.

Funds to help cities pay for the skyrocketing cost of patient care, he said, would come from "whatever money was left over." And that, he made clear, would not be very much.

With this pronouncement, Mason set the stage for the next great battle over federal AIDS policy.

Although the issue of who pays for patient care lacks the drama of the AIDS testing and discrimination debates, its resolution could well have a major effect on the fiscal solvency of New York, San Francisco, Newark, N.J., and other cities.

President Bush's proposed AIDS budget for the next fiscal year, which was approved by the House of Representatives last week, reflects the administration priorities. Of the $1.6 billion allotted for AIDS spending, 64 percent is for laboratory research, 30 percent is for prevention campaigns, and only 2 percent - or $37.6 million - is directed toward patient care projects.

Programs like the National Health Service Corps, which provides doctors to impoverished communities, have been drastically cut back. In 1986, the corps dispatched 1,200 doctors to poor neighborhoods; this year, there's enough money in the federal program to send only 200.

Just about everybody agrees that a major infusion of money is needed, particularly as the hard-hit cities gear up for the hundreds of thousands of AIDS cases predicted for the next three years. Everybody also agrees that just about the only source of that money is the federal government.

With last week's pronouncement, however, the Bush administration apparently decided that patient care represents a quagmire for federal spending and that the whole issue would be better left untouched.

Mason, for one, voiced fears that attempts to put money into patient care would mean only that money would be taken away from prevention efforts that keep even more people from getting sick, and from laboratory research that can ultimately find a scientific solution to the whole AIDS mess. Such diversions, Mason argued, would be "penny wise and pound foolish."

Few would argue with this analysis. What is needed, most agree, are new federal dollars for AIDS care, not just money robbed from other parts of the AIDS budget.

Neither Congress nor the Bush administration, however, has been eager to provide an expanded AIDS budget. Spending money on things such as outpatient clinics for gay men and black or Latino intravenous drug users simply does not have the political cachet of giving grants to the shiny laboratories of the National Institutes of Health.

Most analysts figure that both Congress and the administration will do this year what politicians usually do when a tough decision needs to be made: put it off.

The expected results, of course, will be huge demands on the already-strained budgets of cities such as San Francisco. In New York, where facilities already are filled to capacity with AIDS patients, many expect to see hospitals begin to declare bankruptcy as they get no relief for providing expensive AIDS care to growing numbers of indigent patients.

The immediate result also is clear. In the crowded halls of Harlem Hospital, patients will suffer because the hospital does not have the staff to provide even minimal care to its burgeoning HIV population.

As one Dallas AIDS expert bitterly told the congressional subcommittee last week, we now live in a society where buying air-conditioned, stainless steel cages for research monkeys has a higher priority than providing beds for those sick and dying of AIDS.

Always watch for outdated information. This article first appeared in 1989. This material is designed to support, not replace, the relationship that exists between you and your doctor.

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