Gay Men's Health Crisis: Treatment Issues, Volume 8 no. 3 - May, 1994
Derek Hodel

AIDS research advocates have long been frustrated by the difficulty in attracting world-class virologists and immunologists to AIDS research. They considered Paul's appointment a strong signal that the Clinton administration and NIH leadership view AIDS research as a top priority, with the OAR playing a central leadership role.

Paul's decision to accept the appointment was widely credited to arm-twisting by Harold Varmus, M.D., overall director of the NIH.

The search for a director began in November, 1993, as a result of the NIH Revitalization Act of 1993, which strongly enhanced the authority of the OAR. The central mandate of the reinvigorated OAR is to develop a strategic plan for AIDS research throughout the 21 institutes, centers and divisions of NIH, all of which currently conduct AIDS research.

The strategic plan will be closely linked to a consolidated, bypass budget estimate submitted directly to President Clinton. The "bypass budget," similar to that of the National Cancer Institute (NCI), will permit the OAR to publish the official justification for its "professional judgment" budget, a valuable lobbying tool. The consolidation of the AIDS budget will mark the first time that the $1.3 billion program will be evaluated and prioritized as a unified program across institute lines. As director of the OAR, Paul will also convene a new advisory council and administer a discretionary fund that currently amounts to $10 million. The OAR also will establish coordinating groups in major disciplines (pathogenesis, epidemiology, vaccine development, drug development and behavioral research) to evaluate the AIDS research portfolio.

Since 1970, Dr. Paul has been the Chief of the Laboratory of Immunology at the National Institute of Allergies and Infectious Diseases (NIAID), an NIH subunit. Though Dr. Paul has little direct experience in AIDS research, many feel his work on the regulation of T-cell function and on the molecules by which the immune system recognizes "self" from "non-self" make him an ideal appointment for the position.

Some activists have expressed reservations about Dr. Paul's long-standing insider status at the NIH and his association with NIAID chief Anthony Fauci, M.D. Dr. Fauci was the director of the OAR before its reorganization.

Others point out that NIH laboratory chiefs like Paul direct largely autonomous fiefdoms. And, while Dr. Paul, as director of the laboratory of immunology, did report to Dr. Fauci, he was considered an independent force within the NIH hierarchy. Dr. Paul's immediate challenge will be to establish his office's authority, a process that may be hindered by daunting bureaucratic obstacles at NIH. Because of the complex NIH budgeting processes, three fiscal years interact at any given point: the budget we are now spending (fiscal year '94), the budget we are now fighting about (FY95), and the budget under development (FY96). At the time of this writing, the FY96 AIDS strategic plan and budget was due to be submitted to Varmus - thus, AIDS research planning and budgeting for the next two years is nearly a fait accompli. To leave a mark, Paul will have to move quickly.

Paul got high marks in his first month in office, however, by convening on short notice a group of outside experts (extramural scientists and community representatives) to review the FY96 strategic plan from top to bottom, one week before it had to be submitted upstairs. In government circles, the move was considered courageous, and a strong signal of Paul's determination to wrestle with the inertia inherent in the system.

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