The new medical treatments that cut AIDS fatalities by 44 percent have forced a dramatic shift in emphasis for the AIDS-service community. But even as treatment takes precedence over providing social services, a leadership vacuum in L.A. County government has thrown the local AIDS community into a crisis that could cost millions in federal funds - as well as people's lives.
L.A. County's Office of AIDS Programs and Policy has been without a permanent director for almost two years, without an AIDS medical director for four years - and county auditors say that applications for state reimbursement of $26 million for prescription drugs are faulty, or haven't even been submitted.
More has been lost than the interest on the stalled $26 million; the county has lost respect in both Sacramento and Washington. Federal AIDS dollars are granted to cities on a competitive basis, and L.A. funding ranks towards the bottom of the nation's cities with major HIV populations. The state has also begun an audit of the disorganized AIDS Program Office.
County Health Director Mark Finucane admitted last month that the Health Services Division has never been particularly "consumer friendly," and reinstated respected AIDS-wonk John Schunhoff as the county's main point person for AIDS.
In the meantime, the search is on for a permanent director of the understaffed AIDS office. Three top contenders for the position - Chuck Henry of the New York State AIDS Institute, and Frank Oldham Jr. and Mitchell Netburn, both with the New York City Department of Public Health - were introduced to local AIDS leaders at a meeting last week, but failed to impress. Commented Ferd Eggan, AIDS coordinator for the City of Los Angeles, "All three are part of the Giuliani administration, which is widely thought of as de-prioritizing AIDS." Few from L.A. are foolish enough to lobby publicly for the county's no-win position.
Supervisor Zev Yaroslavsky has disparaged the interim leaders at the Office of AIDS Programs and Policy as "Keystone Kops," but many in the AIDS community say that that accusation misses the boat. They argue responsibility for the mess lies with Finucane. Many say the health director is in over his head insofar as the entire department faces an overdue reorganization and AIDS has been neglected.
"Mark is just terrible," says AIDS advocate Micki Jackson. "He manages the department by scapegoating and vilifying people. He says he's in charge every 15 seconds, but the minute something goes wrong, he blames everyone."
The county's Schunhoff says he's aware of how difficult it will be to repair the reputation of the county AIDS office: "It's tough job. I know. I had it."
Before Finucane came on board two years ago, Schunhoff led what was then called the AIDS Program Office. Schunhoff managed to mediate between warring AIDS factions - in particular, between the nation's largest AIDS agency, the AIDS Healthcare Foundation, and various members of the county's HIV commission. At that time, AIDS care began to shift from providing services such as transportation, housing and counseling - services that helped people cope with AIDS - to providing drugs and then monitoring how people were taking them.
The HIV commission, consisting of community members, county officials and representatives of AIDS agencies, makes funding recommendations to the board of supervisors as to how federal money gets allocated. It has always been plagued by the politics of scarcity, and conflict of interest.
The way I hear it, Schunhoff got branded as too partisan to the ever-growing and ever-powerful AIDS Healthcare Foundation - whose emphasis lay squarely on medicine and which was often accused of trampling on the toes of other AIDS community groups. And so, in June 1996, Finucane removed the AIDS Program Office from Public Health and had Schunhoff report directly to him. Then, in December 1996, Finucane kicked Schunhoff upstairs to become acting director of public health, cutting his ties to AIDS work.
Finucane says he never intended to undercut AIDS work in the county: "By having the office removed from Public Health and reporting directly to me, I was signaling that it was a personal priority for me."
Whatever the intent, Finucane's move actually isolated AIDS work from the larger county health system. A July 1997 review of public health by the UCLA School of Public Health - an influential document that will guide the restructuring of the Department of Health Services - hardly mentions AIDS. Neither does Finucane's "vision statement" on "The Future of Public Health." AIDS was effectively erased from the agenda.
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According to Al Ballesteros, co-chair of the county's HIV commission, the crisis in direction at the county has raised concern among federal officials that dollars going to HIV social services aren't keeping people connected to medical care. "One of the challenges of leadership at the AIDS office is to deal with the fact that L.A. has been lax on moving the system of care in a direction that is more favorable to Washington. We need to create tighter collaborations between service-provision and medicine."
Ballesteros and others are pushing a fee-for-service system to replace the county's current agency block-grant system, so as to get a better handle on how much each medical intervention costs and create a fairer distribution of resources.
While there is no doubt that lines of communication between the county and AIDS organizations could be better, the city's Eggan thinks the crisis is bigger than Finucane. He lays equal blame on "venal AIDS-service organizations" that are as reluctant to change as is county government. On one level, he's right. AIDS-service organizations that rely more on providing services than medical care must adapt to what everyone considers good news - the falling AIDS fatality rate - or phase themselves out of existence.
Who will set up the new network of care? The AIDS community has never looked to the county for direction - that's why it had to set up its own AIDS-service network in the first place. The question is whether the county, which plays the key role as a conduit for outside funds, can keep its act together enough to avoid derailing a revamped system of AIDS care in Los Angeles.