director for AIDS research, to consider such questions as the effectiveness of NIH's use of advisory groups in the AIDS program. The general idea was to examine the NIH approach to AIDS research after five years of intensive activity. Headed by William Danforth, chancellor of the University of Washington in St. Louis, the 15-person IOM committee met five times between October 1989 and September 1990 before issuing The AIDS Research Program of the National Institutes of Health in 1991.

The report recommended that the period of rapid buildup in AIDS research, which led to expenditures of $805 million in fiscal year 1991, or nearly 10 percent of the total NIH budget, should give way to long-term planning. In terms of emphasis, the committee suggested that NIH should increase its activities in behavioral science, basic science, patient care research, and vaccine development. As William Danforth explained to a congressional committee, major progress depended on "better understanding. The best way to increase this understanding is to provide support for scientists studying how viruses work.... Such basic research may not be glamorous but it is our only real hope." In the meantime, according to Danforth, the nation was forced to depend on "behavioral change" for improvements in mortality and morbidity related to AIDS; therefore the country needed "to know more about human behavior and how it might be modified." The committee estimated that implementing its recommendations would lead to an increase of 25 percent in the NIH budget for AIDS but cautioned against siphoning resources from other parts of the research program. Hence, any budget increases should be "new funds."50

The 1991 report amounted to a synthesis of the IOM's AIDS concerns, as developed in its 1986 and 1988 reports, and the IOM's traditional interest in improving the management of the NIH and insulating it from politics. The IOM approved of the way in which NIH organized its AIDS activities. Despite the size of the problem, NIH chose not to create an AIDS institute. Instead, NIH managed the program as an "institute without walls" from within the Office of the Director, with an associate director for AIDS research, a national advisory council, an executive committee of senior program representatives, and an executive office for staff support. Such an approach meshed with the recommendations of the 1984 IOM report on the management and organization of the National Institutes of Health, which had cautioned against creating new institutes. In the 1984 report and elsewhere, the IOM had tried to cushion NIH from the yearly vicissitudes of the budget process and from political directives that disrupted the orderly conduct of research. In this



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