Simmons: Political agenda blocks HIV name reporting (The Washington Blade) 10/26/01
GLAA slams mismanagement, lack of oversight at D.C. Dept. of Health
Gay and Lesbian Activists Alliance of Washington, DC
PO Box 75265
Washington, DC 20013
PERFORMANCE OVERSIGHT HEARINGS
DEPARTMENT OF HEALTH
Committee on Human Services
Council of the District of Columbia
March 6, 2002
Chairman Allen, Members of the Council, and Fellow Citizens:
My name is Bob Summersgill. I am the President of the Gay and Lesbian Activists Alliance of Washington, DC (GLAA), the nation's oldest continuously active gay and lesbian civil rights organization. We will be celebrating our 31st anniversary with a reception at the Hotel Washington on Thursday evening, April 18. Full details are available on our web site, www.glaa.org. Invitations are going out shortly, and I hope all of you can attend.
Today I will focus on the HIV/AIDS Administration (HAA), a division of the Department of Health. While we are told that HIV infections are increasing, and DC has the highest AIDS rate in the country, HAA operates without effective management, without accountability, and without oversight. HAA is a floundering agency with no real idea of what it is doing. The failure to supervise HAA's operations effectively has resulted in spending without accountability, an epidemiological system designed to fail, and a bumbling excursion into patently unconstitutional activities.
Structural mismanagement can clearly be seen in the organization's leadership. Mr. Ronald Lewis is both the Director of HAA and the Deputy Director for Health Promotion. This means that Mr. Lewis is his own boss. The practical effect is that there is no management oversight of HAA. Mr. Lewis reports to Dr. Ivan Walks, who is enmeshed in the massive responsibilities and problems of the Department of Health. Since Dr. Walks refuses to respond in any way to us, and is slow or unwilling to respond to the Council, we have no reason to believe that he has provided any sort of personal oversight of HAA. We can only hope that his replacement will provide the accounting and managerial leadership that has been lacking at the Department of Health for many years.
HAA's budget has received almost no scrutiny from the Council. The budget provided by the administration covers HAA in just two paragraphs. With a relatively small budget of $58 million, HAA is lost in the $1.3 billion budget of the Department of Health. And since approximately 85% of HAA's budget comes from the federal government, the Council has really only checked to see that federal dollars keep coming in, and local dollars are sufficient to meet federal maintenance levels. The result is that HAA has operated in almost complete budget secrecy since it was first created in 1986 as the Office of AIDS Administration.
Councilmember Jim Graham began asking at public hearings in 1986 for an accounting of how the agency spends DC appropriated dollars. On August 24, 1993, when he was Executive Director of Whitman-Walker Clinic, Mr. Graham stated that unlike other cities, the District government has never issued a public accounting of how much it spends on its numerous AIDS programs. The AIDS budget, Mr. Graham said, has become almost meaningless because no one knows whether or how much large portions of the money appropriated for the budget are spent.
He has continued to ask for the same accounting since his election to the Council. In March 2000, he finally received partial accountings for fiscal years 1996, 1997 and 1998. He has been promised the budgets for 1999 and 2000 but has not yet received that information. Unfortunately, despite Mr. Graham's efforts, we still don't have that public accounting and the Council has failed to conduct an oversight hearing on HAA since July 18, 1998.
We were alerted last year by one AIDS service organization that they were unable to figure out where all the money was going. They added up all of the contracts that they could identify, and found it to be significantly short of the total Ryan White Health Care money that was being given to DC from the federal government.
Last year we requested HAA's detailed budget for 5 fiscal years and an accounting of to whom, for how much and for what purpose contracts were issued. In May that turned into a Freedom of Information Act request after hearing no response at all. A partial response was finally provided in time for a Washington Blade reporter's deadline on the failure of HAA to comply with the FOIA request. We are still waiting for an accounting of how HAA has granted or contracted for services, although we receive periodic assurances that they are putting the information together.
The budget information provided to GLAA is incomplete, and at odds with public statements and information provided to the Council. At another oversight hearing conducted by Councilmember Catania on February 25, Mr. Lewis claimed a budget of $6 million for the AIDS Drug Assistance Program (ADAP). However according to the budget provided by the Department of Health, $53,390,315.00 is budgeted for fiscal year 2002. This is a discrepancy of over $47 million dollars in an overall budget of $58 million dollars. Either Mr. Lewis has no idea what is going on, or he is deliberately hiding misspending. Either way, we see gross mismanagement.
Part of the problem may be that the HIV/AIDS Administration is unable to explain the difference between their "Responsibility Centers". According to the glossary of financial codes provided with the budget, center 3070 is identified as the "AIDS Drug Assistance Program." Center 3060 was not identified at all. When I called Mr. Lewis on November 5 to find out what responsibility center 3060 is for, I was told that he would get back to me. In December, Ivan Torres replied with an email that 3060 is for the AIDS Drug Assistance Program. When I asked if there is a difference between 3060 and 3070, and why two different responsibility centers refer to the same program, Mr. Torres promised I would soon receive a timeline for a response. We are still waiting for the timeline for a response, as well as an answer.
Other basic accounting problems riddle the budget. For instance, how is object class 32 differentiated from object class 30? 30 is listed in the glossary as "Energy/Rent" and 32 is listed below as "Rent". What determines which object class is to be used? Mr. Lewis and Mr. Torres have been unable or unwilling to answer.
In FY1997 $15,694,000 55% of the total HAA budget was spent on Health Services under the object class 40, "Other Services". In FY 1998 this was $27,834,000 67% of the total budget. How was this money spent? How can the single largest line items two years in a row be "other"? How will federal auditors view that accounting practice?
Health Services responsibility center 3020 was eliminated in FY 2000. This was the largest part of HAA's (or at the time Agency for HIV/AIDS) budget. It was replaced with the AIDS Drug Assistance Program. While drugs are critical to preserving life and quality of life of people with HIV, it must be accompanied by frequent blood tests and doctors visits to monitor the activity of the virus and the body. How do people accessing ADAP drugs receive the medical attention that must accompany the drugs? And what medical services were eliminated in FY 2000 with the elimination of the Health Services funding?
According to the budget, the prevention budget was on a slow decline through FY 1997 through FY 1999, despite reports of rising rates of new infections. In FY 2000 it was eliminated entirely. Why was this critical activity completely eliminated? In FY 2001 it was restored at less than 25% of the FY1999 levels. FY 2002 did see a small increase. Interestingly, this information is at odds with the prevention budget provided to Councilmember Jim Graham. According to that budget, DC has appropriated $1.5 million for FY 1998 through FY 2001 with an additional $5-6 million from the Centers for Disease Control. Clearly, HAA is providing false information to the Council, or in response to a FOIA request, or both.
The failure of HAA to provide basic accounting information is more serious than the commonplace incompetence that we have grown used to for years in the District Government. In addition to the failures of the health care system and lives cut short, we are at considerable risk for losing federal funding.
As a result of widespread fraud and theft of federal HIV/AIDS funds, the federal Department of Health and Human Services is beginning performance audits of all federally appropriated HIV/AIDS expenditures. AIDS activists have been lobbying Janet Rehnquist, Inspector General of HHS to make DC a high priority, specifically pointing out the lack of audits in DC, failure of contract compliance officers to do their jobs and the unresponsiveness of DC health officials.
Federal investigations have found $2.2 million in Puerto Rico alone was redirected to a politician's reelection campaign. In Florida, a bookkeeper was found to have embezzled hundreds of thousands of dollars. An audit in California found half a million dollars in federal AIDS funds were misspent and more than two-thirds of contractors were providing services "at levels below contract requirements." A North Carolina agency director used federal money to write himself generous personal checks. Illinois auditors recently concluded that a controversial South Side gay minister who opened an AIDS center last September has misspent at least $68,000 in state grant money the clinic received. Other thefts have been found in Texas and Nebraska. We don't know of any thefts in DC, although unlike these states, we haven't conducted the audits to find out.
However, the DC Office of the Inspector General has provided an audit, conducted by Gardiner, Karnya & Associates, of the HIV Community Coalition of Metropolitan Washington, DC (HCC) for the year ending December 31, 1998. In the 'Summary of Audit Results,' point #7 states: "HCC was determined to be a high-risk auditee."
The audit cites numerous incidences of poor management and accounting discrepancies at HCC. We have been assured that HCC has corrected their accounting problems, yet the Office of the Inspector General has no more information on file since the 1998-99 audit. In other words, even after finding problems, the District government has failed to insure that those problems are not continuing. There is no evidence that other contracts don't have similar problems.
The evidence that our funds are not being stolen would be provided by a detailed and public audit of HAA and the contractors. This must be done, and inappropriate expenditures must be found and corrected before the federal government does it for us. The likely result of the federal government finding inappropriate spending, or outright theft is loss of funding and further encroachments of home rule.
HAA is unable to provide any reliable information on HIV rates in DC. AIDS cases are reported to HAA and are probably reasonably accurate, but the number of HIV infections is just an educated guess. The Centers for Disease Control and Prevention (CDC) has pressured all states and DC to begin tracking HIV infections as well as AIDS. The CDC suggested two systems as being acceptable for HIV tracking. Names reporting, as we do with AIDS and many other diseases and a unique identifier system. Both systems are only as accurate as the number of people who get tested. The CDC estimates that 25% of all people with HIV have not been tested and do not know their status. A study by Kaiser Permanente found 40-42% of people who test positive for HIV wait until they get sick, and miss years of life-extending treatment. Therefore, any system must encourage people to get tested, or at least not discourage them from doing so.
In 1999, The DC Council recommended to the Mayor that a unique identifier system be established to protect the confidentiality of people who test positive and to maintain public trust in the health care system. Unlike most other diseases, HIV disease carries great stigma, and extra protections for privacy are warranted. Mr. Lewis led the fight to oppose unique identifiers, supporting names reporting. Mayor Williams wisely chose unique identifiers, but left Mr. Lewis in charge of implementation.
After an 18 month delay, HAA convened a working group to help design the unique identifier system. GLAA was invited as the only community representative which did not receive funding from HAA. A few doctors and academics, who did not represent patient groups, also do not receive funding. The original unique identifier plan was crafted without HAA input. However, HAA staff insisted that the proposed identifier be modified to include the last four digits of the patient's social security number. Arguments noting the inherent problem of including the partial social security in terms of immigrants without a number, people mis-reporting the number, and general mistrust of the government collecting the information were ignored.
Information provided to the working group from the CDC explained that the failures of the unique identifier systems in Maryland and Texas were directly related to the inclusion of a partial social security number which were only 50% complete. In two evaluations of unique identifier systems conducted by the CDC in Los Angeles and New Jersey, found the social security numbers to be available in less than 20% of all cases reported. The CDC requires 85% reporting completeness for the system to meet minimum performance standards. First names, which HAA prohibited from being included, are 97.2 - 99.9% complete. Use of the first, or the first two letters of a person's first name as is done with last name would distinguish between two people born on the same day with similar last names.
Failure to implement a workable HIV tracking system will result in the loss of federal funds and in wasteful expenditures based on mistaken notions about which populations are currently in greatest need of resources. If the system HAA has foolishly imposed does in fact fail, Mr. Lewis will be quick to claim that he was right all along and that we need to convert to a name reporting system.
Bill 14-0326, "HIV Unique Identifier System Amendment Act of 2001," was introduced by Councilmembers Phil Mendelson, Sharon Ambrose, David Catania, Kevin Chavous, Jack Evans, and Jim Graham and co-sponsored by Adrian Fenty to correct the problems with the unique identifier system. Unfortunately, this committee has refused to schedule a hearing on the bill, and Ms. Allen, you have failed to respond to our letter of January 28 asking for a hearing.
A further failure of the HAA is in HIV prevention efforts. Prevention of HIV has been demonstrated through education and condom use. However, HAA support of education and condoms seems to be on the decline.
Condoms have all but disappeared from the bars and clubs. While bowls of free condoms and lubricants were once commonplace in gay bars, we have been reduced to a hit-or-miss program of outreach workers distributing prevention materials at random. Recently, condoms have become available in machines at just 6 bars. Condoms are not expensive. Commercially, 1000 Lifestyles non-lubricated latex condoms cost $70. 1000 Wet LightFoil water-based lube packs cost $140. We should be able to purchase condoms in bulk for far less.
GLAA spearheaded the condom availability project that led to an executive order in 1992 to make condoms availability in schools. Yet 10 years later, with an apparent rise in HIV infections among youth, students are limited to just one condom per month, if they are available at all. The Department of Health is responsible for HIV prevention efforts and controls the distribution of condoms in public schools through the nurses.
There is not one HIV prevention poster or brochure, and not one free condom or lube packet at the Income Maintenance Center where thousands of DC's most vulnerable residents visit every week for food stamps, Medicaid, welfare, and other survival services. When asked at a press conference in November why condoms weren't being made available at the Income Maintenance Center, Mr. Lewis replied that there wasn't any prevention material to distribute with the condoms, and in any event they didn't want to offend any of the religious groups that oppose condom distribution. In short, the 15 year old HAA doesn't have HIV prevention literature, and takes direction from religious groups instead of complying with District law and policy.
Mr. Lewis' lack of understanding of the separation of church and state became clear last year as ACT UP discovered that HAA was distributing a pamphlet titled "A Christian Response to AIDS." Once the Washington Post reported on the unconstitutional pamphlet, Mr. Lewis admitted it was illegal, but no one was ever held responsible or disciplined and the cost of the pamphlets, $560, was never recovered. That could have paid for 8,000 condoms.
HAA has found the time and money to buy and give away numerous tchotchkes. ACT UP has collected tote bags, water bottles, key chains, hair clips and beer bottle openers with the HIV/AIDS Administration name and logo. Beyond the complete waste of money that these trinkets represent, the beer bottle openers represent a violation of the purpose of HAA and an encouragement of HIV transmission. As has been known for more than a decade, and recently reconfirmed by an HAA-sponsored survey conducted by the Whitman-Walker Clinic, people are more likely to engage in risky sexual behavior after drinking. Handing out beer bottle openers instead of condoms encourages HIV transmission.
The management failures of HAA, the failure of basic accounting, the failures of the administration and Council to provide adequate oversight and the failures to provide even minimal levels of HIV prevention must be corrected. We can wait for the federal government to do it for us, as seems to be the current plan, or the Council and the Administration can shake up HAA while we have a window of opportunity with the resignation of Dr. Walks. At a minimum, the Council needs to ask for a complete performance audit of HAA and its contractors by the Inspector General, and passage of the HIV Unique Identifier System Amendment Act of 2001.
Thank you. I am available to answer any questions that you may have.