One of San Francisco's most famous AIDS organizations is accused of mismanaging public money earmarked for people with AIDS. For more than a decade, Shanti has offered emotional support, practical help and housing to people with AIDS. It is a national exemplar. Now, with some $200,000 unaccounted for, city auditors fear Shanti's books are so botched that the mystery of where the dollars went will never be solved.
But the ramifications of Shanti's debacle reach far beyond one organization in the epicenter of the AIDS epidemic. They suggest that the public-private partnership for AIDS care, commonly known as the "San Francisco model" and widely emulated, needs an overhaul.
From the earliest days of AIDS, San Francisco officials worked with mostly volunteer groups like Shanti, which mushroomed to fight the epidemic. Because these grass-roots organizations are less rule-bound than health departments, they could react quickly and emphatically. And because they are grass-roots organizations--to which, nationwide, tens of thousands of volunteers have contributed uncounted millions of hours--they could be run more cheaply. There are now more than 200 such organizations in San Francisco alone, from the AIDS Action Project, which educates gay men to stay in the safe-sex lane, to PAWS, whose members walk the pets of people living with AIDS.
This approach took off nationally in the late 1980s, when the R.W. Johnson Foundation distributed $20 million to cities battered by AIDS, to help them launch their own public-private partnerships. Federal money began flowing after passage of the Ryan White Care Act in 1991. Organizations once staffed almost entirely by volunteers now have 100-plus employees and $5-million budgets.
With the money has come mounting charges of financial irregularities. A few years ago, board members of Project Open Hand, a high-profile AIDS group that distributes meals, accused staffers of pilfering money. There have been persistent complaints that the AIDS Walk, which annually draws more than $1 million, spends too much on overhead and too little for people with AIDS. And last month, the city's AIDS Office cut off public funds for AIDS Indigent Direct Services, which manages the funds of people with AIDS, when it discovered that the agency was using clients' Social Security checks to meet its payroll.
The San Francisco model is developing other problems as well. The "We're in this together" attitude, so evident a few years ago, has been undercut by ethnic and ideological rivalries played out inside AIDS organizations. The biggest ones, including the AIDS Foundation and Shanti, have been accused of insensitivity (read: racism and sexism). As a result, many new organizations have been started up for those who felt left out--African-Americans, Latinos, Asians, leathermen and lesbians--and these groups have squabbled over turf.
The let-a-thousand-flowers-bloom approach means that, in the competition for AIDS funds, political clout--not strategic priority-setting--mostly determines winners and losers. Among the losers are gay white men, politically passe in funding circles, though still the overwhelming majority of AIDS cases in the city. And not much attention is being paid to gay teen-agers, many of whom operate on the deadly misconception that they are invulnerable, sexually speaking, as long as they don't trust anyone over 30.
All this tells a sad, if familiar, tale in the annals of community groups. Grass-root organizations frequently lose sight of the altruism that initially powered them. Volunteers suffer burnout and compassion fatigue. Some founders grow into tyrants or cult leaders.
But the Shanti accusations ought to be a wake-up call. Even if no out-and-out crookedness surfaces, it's to be expected that, in groups like Shanti, the books will sometimes be badly kept by people who lack the training and patience to do the job. The multiplicity promoted by the San Francisco model almost assures inefficiency and needless competition.
Government can't--and shouldn't--deliver all the sought-after AIDS help, from hand-holding to dog-walking. But a little more bureaucracy wouldn't be such a bad thing. There's no reason for cities to underwrite every splinter group or to let fiscal matters slide for as long as they did at Shanti.
Public dollars are becoming scarce in this second decade of AIDS, even as the need for care grows. No cure is in sight. More soberingly still, no sexually transmitted disease has ever been wiped off the planet; there's no reason to believe AIDS is any different.
All this makes the San Francisco AIDS model, which was just right a few years ago, now seem an unaffordable luxury. Cities should be using their fiscal influence to encourage AIDS community groups to merge into a handful of organizations that will work with one another and one government. If that reassertion of public purpose doesn't happen, taxpayers and politicians will start getting skeptical about where all their AIDS dollars are going. Those who may be hurt most will be the very people--the people with AIDS--whom the San Francisco model is supposed to be helping.