Washington Perspective

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Washington Perspective Clintonian

woes

for biomedical research

Always tense about money and Presidential recognition, the managers and practitioners of biomedical research have become unnervingly concerned about both since Bill Clinton took office. The President aims to expand the Government’s support of various fields of research as part of his design to invigorate industry. Biomedical research is not among them. Bereavement is not in order, since the principal federal agency in this sector, the National Institutes of Health, is budgeted by Clinton for a world-leading$10-6 billion. But growth, rather than scale, is the heartfelt measure of success in science, where an inexorable ratchet effect means that a repeat of last year’s bonanza would be this year’s calamity. And the budget proposed by Clinton for fiscal 1994 (which begins next Oct 1) allows only a 3% increase for NIH, not enough to match inflation or finance new ventures without cannibalising ongoing work. In other areas of research, however, Clinton favours robust growth, seeking, for example, a 26% increase for computer-related activities and 29% for transportation R&D. The President’s budget calls for an 18% increase for NIH’s companion agency, the National Science Foundation, which supports academic research outside of the health area. The miserly increase for NIH is even skimpier than it appears, since virtually all of the growth is allotted to AIDS and breast cancer research. These are worthy fields, but their favoured treatment must be credited to politicians sensitive to public concerns, rather than researchers knowledgeable about opportunities for scientific progress. If the budget is enacted as proposed, several hundred grants would have to be dropped from the NIH research portfolio, a planned inflationary allowance in grant funding would be eliminated, and over 600 staff positions would be eliminated on the Bethesda, Maryland, campus. At a recent meeting with reporters, questions on these matters were addressed to the President’s Science and Technology Advisor, John Gibbons. "Take out AIDS and breast cancer, and it’s actually a cut", a questioner observed, adding: "Can you explain why biomedical research isn’t one of the Administration’s priorities?". For the guardians of biomedical research, Gibbons’ reply was a chiller: "NIH has been moving along pretty well", he said. "There’s no retreat from interest in NIH, especially biomedical and biotechnology [research] at NIH. I think we

ought to grow."

look

to

the ’95

budget to

see

how that’s

going to

The next chapter in the NIH budget saga will be written in Congress, with the outcome due late this summer. Under a venerable tradition, presidents have sought minor growth for NIH in the confident expectation of Congressional generosity. But last year, for the first time in about two decades, Congress stuck close to the President’s request, leaving NIH with an essentially static budget. Given the anti-spending fervour that has unexpectedly stalled the Clinton economic programme on Capitol Hill, there are few expectations of a miracle for NIH. While our biomedical leaders lament the budget situation, they also must consider another affront. Mrs Clinton hasn’t invited any of them, or their disciples, to the great planning exercise she presides over for remaking the economics and administration of health care. The 500 or so people summoned to that task were publicly identified last month after the Clintons’ attempt at secrecy broke down and names began to leak around the capital. Most are lawyers, economists, and apparatchiks of one sort or another from government agencies and Congressional committees, with a sprinkling of academics and specialists from the administrative side of the health-care industry. If there are any physicians or laboratory researchers among them, they are well concealed. The high command of the Clinton health-care revolution has not explained its choice of recruits. My speculation is that doctors and scientists are regarded as among causes of the problems, rather than as guides to the solution. The normal difficulties of running NIH, as well as other government research agencies, are now compounded by a grandstanding White House edict that requires at least a one-third reduction in the membership of advisory committees by September 30. Intended to demonstrate Clinton’s dedication to lean government, the reductions strike at a peer-review system that is sagging under the load of applications. The reviewing job is now handled by 100 study sections, of 18 to 20 members each, that assemble three times a year at NIH for meetings that usually run two or, at the most, three days. At a typical meeting, a section evaluates 75-80 applications, each with a 25-page maximum for the research plan, but no limit on appendices. The reviewers receive modest travel expenses plus$150 per day while at NIH. The financial savings from the mandated reduction will be trivial. The detrimental effects might be serious. The workloads of the study sections have become so onerous, and the professional frustrations caused by limited resources so great, that willing recruits have become scarcer.

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political strength of biomedical research in Washington suffers from the Clinton administration’s incredible tardiness in filling senior positions. Still vacant is the top policy position for the Government’s health research agencies in the Department of Health and Human Services, Assistant Secretary for Health. The choice for that position, Philip R. Lee, director of the Institute for Health Policy Studies, University of California, San Francisco, was announced in March. But, as of mid-April, his nomination had not been sent to the Senate. The explanation for this and similar delays is that the FBI is heavily burdened with the background investigations required for all Presidential appointees. Pending nomination and confirmation by the Senate, Lee has been working at the Department as consultant, a nebulous status that precludes official acts, public statements, or open involvement in controversial The

issues.

Meanwhile, a search committee is looking for a new director for NIH, to succeed Bernadine Healy, who, upon rejection by the Clinton administration, said she will leave by June 30. Healy expressed hope that NIH will be spared another interregnum-20 months preceding her arrival in 1991. But given Clinton’s torpid pace of appointments, no one

is

counting on it. Daniel S.

Greenberg

Round the World WHO: Continuing

unease

On May 5, representatives of WHO member states are scheduled to vote on whether or not to endorse the executive board’s decision to let Dr Hiroshi Nakajima remain as director-general for a second 5-year term. The vote will be by secret ballot in closed session. With western nations, the US and the European Community in particular, prominent among his critics, the developing countries’ habitual resentment of any such observations from that quarter has been combined with the pragmatic consideration of not getting into Japan’s bad books. Western diplomats, accordingly, have no great hopes for acceptance of proposals, as stipulated in the constitution, for a preliminary vote on whether the issue is sufficiently important to require a two-thirds, instead of a simple, majority. The WHO legal adviser opposes such a move as establishing a precedent too

easily susceptible to unjustified exploitation. Western diplomats also do not think there is much chance of the agenda order being changed so that substantive discussion by the assembly of the irregularities described in the external audit report (see Lancet April 10, p 949) can precede the crucial vote. Authority to rearrange the agenda is vested in the steering committee, which meets for the first time on May 3. While the DG’s tacticians are poised, it is said, to oppose any major rearrangement suggested at that meeting, they may offer a "compromise" of an hour or so’s discussion of the audit report immediately before the vote. While leaving much unsaid because of the time restriction, the discussion could possibly be the occasion for Nakajima replying, as promised and no doubt at length, to criticism. There has, of course, never, as yet, been an instance of the World Health Assembly rejecting an executive board recommendation relating to a director general. Short-lived too, was any hope that the recent trip to Washington, Geneva, and London by Haruhiko Shibuya,

organisations department at the Japanese Foreign Ministry in Tokyo, might indicate that his Government was contemplating some decisive initiative. Although he did inform Nakajima that US views on his unsuitability were unchanged, their 2 hour meeting did

head of the UN

be ascertained from either WHO or diplomatic sources-produce any tacit understanding on how a sorry situation might be expeditiously resolved. Still, it was at least a sign of unease in Tokyo at the disclosure of patent wheeling and dealing before the executive board’s not-as

far

as can

January meeting. Although details of these dealings are there for all to see in the external auditor’s report and, rather more prominently, in leaked letters from senior WHO officers, the question is how may of WHO’s membership have given those documents anything remotely resembling the serious scrutiny accorded them in Japan. How many governments now believe that a further 5 years with Nakajima in charge would leave WHO hardly more than limping along-as some of its staff so obviously fear? There is even talk of a "climate of fear" within the organisation, conversations on "the situation" being conducted in low tones during a walk in the grounds or over a doubly-defiant cigarette on the open-air rooftop terrace-where smoking is still tolerated. Particularly significant among those letters is one addressed to Mr D. G. Aitken, assistant director for administration, in which the writer deplores the disregard of regulations governing WHO contractual arrangements with persons or organisations conceivably useful in the context of the DG’s second-term aspirations. These included US$300 000 paid to Hoffinan and Hoffinan, a US public relations company. The letter also deals with the$150 000 grant to the Intercare Research Foundation, Manila (a contract given special attention by the external auditor) for the preparation of a case study on the development of the Department of Health of the Philippines. This job, the letter observes, "could no doubt be done by any reasonably competent journalist for a fraction of the cost". It describes the contract as constituting "a flagrant breach of a whole series of WHO manual provisions". After referring to other such instances, the letter says, "In closing, let me also inform you that I have been in WHO long enough to be fully conversant with the various mechanisms and ways sometimes resorted to in order to deal with difficult situations as the ones outlined above, i.e. sudden reassignments and transfers to regional or country postings; ’reorganisations’ in order to neutralise one’s functions; abolition of posts; suspensions etc...". Addressed directly to Shibuya at the Tokyo Foreign Ministry-with copies to various governments-was a letter from a Japanese doctor for many years with WHO who worked under Nakajima when he was director of the WHO Manila regional office for the Western Pacific. Citing examples of the DG’s inappropriate managerial methods, including arbitrary transfer of anyone daring to disagree, the writer expresses apprehension that WHO "may become the next Unesco". Posts that Nakajima may have decided to abolish-he can also, of course, create a few new ones-may include that of deputy director general, its most recent, perhaps last, incumbent being Dr Mohamed Abdelmoumene. He was abruptly relieved of his post last August after deciding to run against the DG for the top position. On an unpaid election sabbatical until February, he has since been on full salary but is still without a job. Taxpayers of the world please note. Alan

McGregor