Dr. Donald Francis

 Donald Francis

MILLER: This is Dr. Bess Miller, and I am here with Dr. Donald Francis. Today's date is October 13, 2016, and we are in Atlanta, Georgia, at the Centers for Disease Control and Prevention [CDC]. I am interviewing Dr. Francis as part of the Oral History Project: The Early Years of AIDS: CDC's Response to a Historic Epidemic. We are here to discuss your experience during the early years of CDC's work on what would become known as AIDS [acquired immune deficiency syndrome]. Dr. Francis, do I have your permission to interview you and to record this interview?

FRANCIS: Yes.

MILLER: Don, you have been a national and global leader in epidemiology, virology, laboratory research, and vaccine research and development throughout your career. For this Oral History of AIDS at CDC, we are focusing on the early years, beginning in June 1981 with the publication of the first Morbidity and Mortality Weekly Report [MMWR] on the five cases of Pneumocystis carinii 00:01:00pneumonia among homosexual men. You served in several critical roles at CDC during these early years, including Assistant Director for Medical Science of the Hepatitis and Viral Enteritis Division, based in Phoenix between 1978 and 1983, where you designed and completed the trial of the newly developed hepatitis B vaccine. You then moved to Atlanta to serve as Assistant Director of the Division of Viral Diseases, where you established the CDC AIDS laboratory. This newly organized laboratory performed much of the early work linking the AIDS virus, which became known as HIV [human immunodeficiency virus], with clinical AIDS.

Let's begin, though, with your background. Would you tell me about where you grew up, your early family life, and then where you went to college?

FRANCIS: Sure. I was born and raised in California, with a strong family history 00:02:00of medicine, with grandfather a doctor, mother a doctor, father a doctor. I really didn't know what I wanted to be in a place like Marin County, California, where we had all sorts of activities and fun. I was interested primarily in competitive downhill skiing, and I decided I wanted to be an orthopedic surgeon. That was going to be my career when I was a youngster.

MILLER: So, who or what influenced you then to go to medical school? Was it the skiing? Was it the family?

FRANCIS: It was really both, together with my early studies at [University of California] Berkeley in science. I'm dyslexic, so I didn't do well in English and reading books. They were always an incredible ordeal for me, so science came 00:03:00easily. Medicine seemed to be logical, and with a family like that it seemed to be--but no one pushed me. There was no pressure at all. As a matter of fact, my parents were told early on, I don't know whether it was in grammar school or high school that I was not a good student and I would never succeed. They never told me that, and so they just carried on. It was kind of the California freedom piece that--

MILLER: Tell us more about your parents then. Your mom being a doctor, you know, wasn't that common in the U.S. in those days. What type of doctor was she?

FRANCIS: My mother, I think, was unique in that she was very bright. I think she was at Stanford [University] at the age of 15 or 16; [she] graduated from Stanford and then went on to the Stanford Medical School. And I think much of her choice of going into radiology was based on [being] a woman in medicine: she 00:04:00could see how tough it was through medical school. So she said that she could control her life if she were a radiologist. Indeed, for much of my childhood and indeed adolescence, she did her office work in the morning and came home with x-rays and read them at home, so the mother was always at home. Not that we bothered her very much, but she had her area in the basement, all full of all the electronic instruments that she needed. So she could be mother and doctor at the same time.

MILLER: What about your dad? What area was he in?

FRANCIS: It's fascinating. My father was an internal medicine doc trained in Southern California and was planning to be a major internal medicine doc in 00:05:00Hollywood. And then came World War II and the draft, and he was drafted into the Navy, but he was stationed in, and our family was, in Colorado of all places, for reasons that I don't remember. He was training other docs, I think. That's where I started my skiing actually, when I was about seven years old. But it was that experience that kept him in administrative positions, and he stayed in the Veterans Administration for his whole career and was the director of the whole western United States in San Francisco. So he was an administrator, interestingly, even though he loved clinical medicine.

MILLER: So then you went to medical school, and where was that?

FRANCIS: I went to Berkeley as an undergraduate and then talked to some 00:06:00wonderful physicians and said, where should I go to medical school? And they asked, what are you interested in? Because of my background at Berkeley, I was working summers and nights at a radiation lab there, and I became interested in research. And they said, well, if you're really going to go into research, the interesting advice was, really get a background in clinical medicine. So I said, where's the best place to get trained in clinical medicine? And they said, Northwestern [University] in Chicago. You know, being raised in California, I just thought the whole [country] was like California. I said, that's fine, I'll go to Chicago. And they said, well, you know, it's cold in the winter. I said, I'm a skier, so I'm accustomed to dressing. Little did I realize that was seven days of the week that were freezing, not the two days of the weekend. It was a shock, no doubt.

MILLER: So you went to Berkeley in the '60s. Were you a radical then? Were you a 00:07:00hippie? How much of that world did you become a part of?

FRANCIS: At that time, everyone was involved in something, and both at Berkeley and ultimately at Northwestern, civil rights was the issue, especially with African American rights. So we were in the street in both locations--and physicians and medical students were. Then came anti-war, and we were in the streets every week. Was it radical? You know, medical student stuff wasn't so radical, but we had lots of meetings and lots of discussions with leftist politics and where it should go and where the political system should go, and certainly where the war effort in Vietnam should go. Now, that was personalized 00:08:00because essentially all physicians were being drafted into the military, and I was refusing to go, which ultimately led to my career at CDC.

MILLER: So were you a conscientious objector, or how did that work out?

FRANCIS: The issue of conscientious objector was key at that time. And so I applied for conscientious objector status. You just sent it in and then when the draft comes, they decide whether they want you to be a conscientious objector. There were a lot of advisors then, and the advisors said, look Don, you're a medical graduate. That's considered a conscientious objector no matter whether you're in the Army, Navy or you know, working at a clinic. So the advice was that it will not work, you'll be drafted. Essentially all doctors were drafted and sent off to Vietnam. So I was planning on moving to Canada and talked to 00:09:00some wonderful physicians in the area of where I should go. Ultimately about this time I was doing my pediatrics [residency] at LA (Los Angeles) County Hospital, and the head of pediatrics, [Dr.] Paul [F.] Wehrle, was a former CDC person--

MILLER: What was his name?

FRANCIS: Paul Wehrle. And he said, why don't you go to CDC for a couple of years as your military service? I said, well, that's a good idea. And I applied and was accepted. Little did I know that that would be a career that keeps on going 'til this day.

MILLER: So that's how you first heard about CDC?

FRANCIS: Yes. It was from a former EIS officer, yep.

MILLER: So you had an amazing EIS experience (Epidemic Intelligence Service 00:10:00being a two-year training at CDC). Tell us a little bit about your EIS experience.

FRANCIS: Well, it's almost comical. By chance they said, where do you want to go? I said California. They said no, so I just chose Oregon as the next state to the north. And with no career, I was doing my military service, and there was no career plan in this at all. So I got in my van, you know, it's the time we all had vans, camper vans, and I drove to Oregon. And before I even got [in] my house, plague broke out, and off I went in my van to see bubonic plague in the United States of America, and it never stopped.

MILLER: Where was that? Where was bubonic plague?

FRANCIS: It was in Southern Oregon. It's always, you know, in the animal population there, and if you're out, as these children were, out in a rural 00:11:00cabin that wasn't necessarily cleaned of animals or fleas, [they] ended up getting infected with plague. Luckily, the doctor saw this big swollen lymph node, called a bubo for plague, and didn't know what it was. The kid had fever and had this swollen lymph node, so instead of just putting a needle in it and culturing, they actually cut it out and had it sent to the laboratory for biopsy. Luckily, the laboratory, looking at it on the microscope, cultured it and got bubonic plague, and that's when I got called down. Here you are an EIS Officer in your little office, and the telephone rings. They said, "You know, we've got a case of plague down here." I said, "You have a case of what?" "You know." And here I didn't even have a--I think I was still in a motel, so I got in my car and just drove south, and it didn't stop. I only stayed in EIS for a 00:12:00year and a half in Oregon, because during that year and a half I was just chasing one thing after another. It was fascinating.

And then CDC calls and says there's smallpox in Yugoslavia, so that was kind of the beginning of the end of my EIS assignment. So anyway, I went off to the epidemic, and it was such a rewarding experience to have one incredible vision of smallpox in these poor people in southern Yugoslavia, which is down in 00:13:00Kosovo. So I came back and--

MILLER: So was that the beginning of the Smallpox Eradication Campaign in the early '70s?

FRANCIS: It was ongoing at that time, and indeed, the head of that campaign had come back from his assignment in Nigeria and was heading up smallpox: [Dr. William H.] Bill Foege. And so I got to know Bill on my debriefing in Atlanta. I said," Bill, that was wonderful public health experience, and if you're ever going to do something big on smallpox, call me."

MILLER: What was so wonderful about it? What was so big and exciting about it?

FRANCIS: Well, it really was the essence of public health. You had a terrible disease and a mortality of 30 percent, 40 percent, that even if they would 00:14:00survive, they were horribly scarred and often blinded; a very, very bad disease with a very, very simple vaccination that would prevent it completely. And so here I was out seeing all these patients in these hospitals. We had, at that time, the old jet injector, and we were immunizing whole communities in a second, and then the outbreak stopped. So what a simple thing: with a couple of penny immunizations you prevent all this disease. And so I said, "Bill, if you're ever going to do something, I'd like to be part of it, because that was really rewarding."

MILLER: Was that the immediate strategy? Was there numbers counting, surveillance like in typical--or was it already sort of imbued that you see the cases and you start a vaccination campaign? Was it mass vaccination or was it 00:15:00so-called ring-containment vaccination in Yugoslavia?

FRANCIS: Well, it was really mass vaccination at its best or worst, however you want to describe it. But Bill had already come back from his discovery in Nigeria that with smallpox it was very limited vaccination for the people. You know where the patient is and they're exposing them [others] during the rash period, so you really, with a little bit of interviewing, find out exactly who's been exposed and vaccinate them and stop. And that's what Bill did, really out of lack of the system or equipment and everything to do mass vaccination in Nigeria when he was there all by himself. So that's where Bill did the whole thing of figuring out if you really just do good surveillance and vaccinate just those people that are exposed, you can stop smallpox very quickly. I mean, in West Africa, once they started that, it ended it [the outbreak]. Maybe it wasn't 00:16:00weeks, but it was months; every country that took it on. Remarkable.

But Yugoslavia was different, because they had bad vaccine and it had messed the whole thing up. They had infectious people everywhere, and so they had to politically use mass vaccination. And that's where we used the jet injectors to vaccinate the whole country within a few weeks. So it was kind of a different political, not to mention, epidemiologic situation.

MILLER: Well, that must have been pretty heavy, coming into EIS a fairly young person, and here you're controlling smallpox in a whole country. What happened next after that in your EIS?

FRANCIS: I went back to Oregon after telling Bill, if you're ever going to do something interesting, let me know. I went back to chasing bugs in Oregon, from leptospirosis to measles and all sorts of--it was wonderful. And a very good group of people, good health departments; it was a terrific experience.

Then the phone rings again, and Bill and crowd says, you know, we're going to take on smallpox in the last countries having it and wonder if you're interested? I said, "Sure." They asked, where do you want to go? Wherever. And luckily I had taken a fellowship in India right out of medical school for my last quarter supposedly, but then I stayed onwards, which screwed up all my rotations. Everyone in medicine goes July to July, but I always went January to January because I stayed in India for an extra six months. And then literally when I came to CDC I had to do another six months on rotation, and CDC sent me out of the country to work in Africa. So I was experienced there, and when Bill 00:18:00said he wanted to really take this on in a big way, I said, I'll be part of it. And they asked, "Where do you want to go?" And I said, I don't care, send me anywhere, and off I went to what turned out to be, I guess, six months in Sudan and two years in India to take on the big one, and it was very exciting.

MILLER: And what was your role in that? Did you vary roles, or did you end up managing some states, or how did that experience evolve?

FRANCIS: Well, the system was well set up. [Dr. Donald A.] D.A. Henderson, a CDC grad, was the head of the Smallpox Eradication Program for WHO [World Health Organization]. He started recruiting people in for the big battles, which were India and Pakistan and elsewhere, where the residual cases of smallpox were occurring.

MILLER: What was he like, D.A. Henderson? He's sort of one of those larger-than-life leaders. What was he like from your point of view?

FRANCIS: D.A. was remarkable, as everyone knows. His obituary was just in the last few weeks, so it's sad that he is now gone. But he was about as different from Bill Foege as you ever can imagine. Bill Foege was always straight, calm and very organized. D.A. was really a very different personality. And [with] Foege, and in some way, I'm kind of halfway between, we'd learned how to work in WHO, and I would never have predicted. [Dr. David J.] Dave Sencer obviously, thought D.A. could survive in WHO, and he did. He made the Smallpox Program at 00:20:00WHO--sometimes by steamroller versus politics. But he learned very well, even though he was very boisterous and tough and sometimes not so political [laughs].

For example, my first WHO assignment was actually in Sudan, and I was having some real political problems of-- smallpox was really all but ended. We were just trying to get the searches and containment going, and the head of smallpox and I were both having--Sudan was having problems, and so I needed someone to bring it up to the level of the Ministry of Health. I was in contact with Geneva, and I said, you know, maybe D.A. should come down. I don't know what I said, but, you know, beat some sense into this. And the Sudanese were very 00:21:00proper and very nice and kind, and in meetings they will say things that you've got to understand what's harsh and what's forceful. And D.A. comes in, you know, like a football player. I had more problems cleaning up after that than I did before he came. So yeah, that's the last time I invited him down [laughs].

But it was critical to have that force in WHO, which can be very, very soft and silent. An awful lot of people at WHO like their jobs and don't want to eradicate the disease. I mean, look, when you eradicate the disease, you eradicate your job. So D.A. was different and was critical to eradicate smallpox, but boy, you had to be cautious bringing--you want to brief him well 00:22:00before he came into a meeting and make sure he didn't chop peoples' heads off.

MILLER: So did you do the Ebola investigation when you were an EIS Officer, or did that come later in your career?

FRANCIS: Later was the first outbreak of Ebola, and I was, where was I? In some CDC assignment elsewhere, but it was in the Sudan. So they called me and said, we've got a problem in Sudan. Would you be willing to go help? I said, sure, what is it? They said, well, it's this virus; well, it's really a hemorrhagic disease virus. I said, you know, that's a level of containment and laboratory work that I've never been exposed to. They said, oh no, we'll bring you into Atlanta and then you can go off. So I went in with what? Two days with [Dr. Joseph B.] Joe McCormick in the lab, and then I was sent off to deal with Ebola, 00:23:00the first outbreak of Ebola in Africa. It was dicey; it was very dangerous.

MILLER: How so? I think we've learned a lot more about Ebola than we ever hoped to in the last few years, but you were there at an early stage.

FRANCIS: Well, it's classic CDC. This was Ebola, and we had to find out the who, what, where, and why.

MILLER: Why you?

FRANCIS: Why me.

MILLER: Because you knew Sudan?

FRANCIS: I guess because I knew Sudan, and they said that I work with dangerous bugs. I said, yeah, plague and other things, but I had never worked with that class of viruses, not to mention the dangers. I think about me doing a postmortem on the ground outside the hospital in Sudan to get specimens, because we didn't have the specimens. We needed all of that. So here I am with all my 00:24:00respirator and gloves and gowns and such, outside in back of the hospital, because these hospitals were built as temporary isolation units. They were adobe with grass roofs. There was no place to do postmortems.

MILLER: Were you afraid? It sounds like you, at a fairly early age, accumulated a lot of pretty heroic experiences. Were you frightened or excited or all of the above?

FRANCIS: Oh, I think CDC trains you, one, to be excited with something new. But when you see that half of the doctors who took care of these patients are dead when you arrive, then you realize this is a very dangerous bug. CDC teaches you how not to get whatever respiratory bugs or blood-borne bugs or whatever. And so 00:25:00here you are out on the ground in Sudan doing a postmortem with your full respirator, gowns and gloves, and all the isolation equipment, but by that time, you know that sharp instruments between patients that will move blood from one person to the next are what caused it, and here you are with literally blood all over you. You're taking pieces of liver and kidneys and lymph nodes from a patient. You're very careful about what you're doing with these instruments, and when you reach--and here I'm sweating and the heat, and it literally starts raining when I'm out there on open ground. Now I'm starting to see my skin come through my gown as it gets wet, and I've got blood right there.

So you have to be in the middle of this thing, much like we get trained in medicine. You have to be very calm and cool and collected, even when the bad 00:26:00stuff starts rolling towards you. But that is a risk that most people would say, let's stop, the guy's dead, there's no--you can do it later after the rain stops. But you know, getting things like that just organized in a place like South Sudan is not easy. So I just moved on ahead and got it done, very carefully. And then taking off the blood-covered gowns-- luckily, you know, the very good folks at CDC trained me very well and that kind of--

MILLER: Who were some of those? Do you remember who some of the folks--was it Joe McCormick?

FRANCIS: No, Joe was parallel to me. It was the people who preceded Joe. It was a husband and wife team [Karl Johnson and Pat Webb], interestingly, that briefed me. Then, you know, then you go out on your own.

MILLER: And that's a CDC style of working also.

FRANCIS: Clearly a CDC tradition that you have been briefed on a new disease, you don't know what it is, but you've been briefed by the appropriately trained people. As CDC would tell, one, it's unknown, so we need specimens, and get them to us so that we can diagnose this disease and figure out what to do with it in terms of transmission. That was your job as an epidemiologist, to take the laboratory and the epidemiologic settings and join those two together to figure out, with a new bug, what it is. It's [the process is] very well worked out, even though it's an unknown bug, so when you're out there you know what you're doing.

You don't know the real transmission yet until you do the epidemiology. But you 00:28:00do know that an awful lot of people who have been taking care of patients are dead. The nurses and doctors, half of them were dead by the time I arrived. The rest essentially left the hospitals, so the patients often were at home dying. So that's a situation I guess you have to be ready for, because I was not the first person who was sent on this. There was a CDC person sent on this before, who turned around in Geneva and came back home--probably a wise person. When I got the call, they said, don't turn around if you're going to go. I said, "okay." And I went.

MILLER: So after EIS you went on to do an infectious disease fellowship and then began and completed a doctorate in virology at Harvard School of Public Health under [Dr. Myron] Max Essex. And before we get into that, what prompted you to 00:29:00do that?

FRANCIS: The question is, what prompted me to go to Boston for my subsequent training and to say that I wanted to go to Harvard School of Public Health.

MILLER: You were a California boy. What happened?

FRANCIS: My Oregon girlfriend was at Harvard, [laughs] that's what happened. And so I asked to go to Boston to get my training and also be with her. Then I broke up with the girlfriend quite quickly afterwards, [laughs] interestingly, and here I am on my own in Boston. But it was a very interesting process. When I had 00:30:00come back to CDC, on one of my home meetings from India, I asked CDC to send me up to Boston to at least talk to the School of Public Health. They were very kind and had me rotate around the various departments and ask what was going on. Ultimately CDC agreed to send me there, but what would I be doing? I interviewed with a guy named Max Essex, who was in the Department of Microbiology at Harvard, and he had this fascinating disease of cats. He was a vet actually, a PhD vet.

MILLER: Max Essex was a PhD vet?

FRANCIS: Yeah, and he was looking at a disease called feline leukemia. He was doing all the laboratory technical stuff. He had these houses, [with] fascinating people who liked cats and had lots of cats, and especially two in 00:31:00the Boston area that he was following. Max provided them with freezers. So when the cats died, they threw them in the freezer and then he would do the postmortem from that. He really thought that someone like me would be interested in combining virology with epidemiology and figure out the transmission of this disease and the natural history. So it was a wonderful opportunity.

MILLER: So you had done infectious diseases, you had done CDC, you could have come back and made CDC your home career, you could have gone back to the West Coast, which you love, and been an ID [infectious disease] Doc and epidemiologist, but you instead went--was that a real change in trajectory or was that just a spur of the moment, this seems neat, or--it's an unusual direction.

FRANCIS: Yeah, it was an unusual direction. Was it a spur of the moment? I mean, I went there for a girlfriend, so at first it wasn't necessarily a career plan. 00:32:00And CDC sent me there for two years to do my ID fellowship.

MILLER: And did you get them to pay for the virology doctorate?

FRANCIS: Well, yes, that's where Ebola comes in, because they called me during my second year. I'm doing all my lab work--really Harvard was very good, you could do [both] your ID fellowship and your lab work, they expected you to really understand something in the laboratory. Then Max said, you know, with just another year you could get a doctorate here too, instead of just an ID fellowship. So I was taking the classes for a doctoral degree, which were very good, too, to really get me solid into microbiology and the understanding of virology. But then Ebola came and "sacrificed" my second year of my 00:33:00CDC-sponsored fellowship training. I said, well, you know, you did pull me out, and I was even thrown in quarantine for two weeks, not to mention the whole month and a half I was gone in the field. So could you give me another year so I can finish what you sent me here for? CDC can be very good about things like that, and they said sure. So that allowed me to complete all of my laboratory research for my doctorate. Then they were nice enough afterwards to really bring me to Atlanta and let me do most of my writing for my thesis and get all the research published and written. CDC was very good, and that ultimately allowed me to get my doctorate.

MILLER: So why was that interesting? Cats and cat viruses--was Max Essex 00:34:00exciting and charismatic and was he the draw, or just did you like cats? How did that work?

FRANCIS: Well, I went into cat leukemia, not for the liking of cats. I'll tell you, bleeding a cat in these houses was not fun. Here I was, trained as a pediatrician, so I knew how to get blood out of funny places and small critters. But your key person in the cat-bleeding business is the person holding it, because you go down for the jugular veins on a cat, which is right at the business end of a cat. If the person who's holding this cat slips, it comes at you with not a positive feeling towards the person who's sticking the needle in their external jugulars. That aside, we ended up with a very good team and could 00:35:00really do the epidemiology of this disease. The combination of my epidemiologic interest and Max's virologic interest, together with the people in the lab with different experiences, turned out to be a remarkable team.

Here we had a disease transmissible by close contact in cats that produced immunosuppression and cancer. When I finished, there was no such disease in humans. The closest were the hepatitis viruses in terms of their transmission pattern and what they did, because there we're talking about, again, a long incubation period for the hepatitis, relatively long, and then years for primary hepatocellular carcinoma in hepatitis B virus-infected people. So it was not a 00:36:00bad match, to be honest.

MILLER: Is that where you got involved in retroviruses? This [feline leukemia] was a retrovirus. Was that something unusual to be working on in virology? Why all of a sudden did retroviruses become of interest? Were there new methodologies to study them? How did that come about?

FRANCIS: The major interest in retrovirology at the time was really animal oriented, because of the cancers of animals. These were mostly laboratory animals, where you could get cancer by injecting these various viruses into mice and chickens and not much higher than that, interestingly. And it was relatively dull. It was really looking at the cancer virology: how does the transformation 00:37:00in cell culture happen. As a result, these viruses became very, you know, laboratory-selected ultimately, very different than what we do at CDC.

But the cat thing was different. Max was not studying viruses that had been selected to give cancer in mice and rats and chickens in the laboratory. This was an actual history. He was looking at the natural virus. I was looking at the natural history of this virus in a population. So it was a very different situation. And who would predict that we would have a retrovirus causing immunosuppression cancer in humans not too many years after.

MILLER: Now why was he doing that? In the field of retrovirology, why would he want to look at the natural history of a retroviral disease? How did that fit in 00:38:00either with the virology, the virologic interest, or was it the manifestations of cellular immunity interest?

FRANCIS: I think Max Essex really recognized that, instead of the very laboratory-concocted virology that most retrovirologists were working on in mice and rats and others, this was a very different situation. And here he was a vet from the outside--

MILLER: What was his work before he worked on feline leukemia virus? What were some of his other--

FRANCIS: He was working in general virology. The other thing that he was--interestingly, I should point this out--Max developed a remarkable allergy to cats [laughs]. And so he couldn't work with the cats and so, again, bringing in doctoral students like me was very helpful because we could bleed cats and 00:39:00didn't sneeze afterwards for weeks. But he was a very good virologist and saw this opportunity when he uncovered these clusters. He was a vet, and so the local vet would call him and say, you know, I have this household that has lots of feline leukemia in it. So he was stimulated really by the fact that it was in front of him, very clever. Then he found these two houses where these people wouldn't [euthanize]. Everyone with feline leukemia by that time in the vet field would say, you've got to put the cat down because it is transmissible and you don't want to give it to other--so they would euthanize it. But the owners of these cats would not euthanize anything, and so we had a natural history that was set. We would go down and bleed them every four to six months--bleed all the cats and look at the natural history. It was a wonderful opportunity, and Max saw that this was an opportunity.

So he became the virology part and I was the epidemiology part; putting the two 00:40:00together was wonderful. And we had others --there was a vet that helped us out down there. He would do postmortems on all the cats, so we knew exactly what the cats died of, immunosuppressive disease and cancer. But after I finished, I had to find a job at CDC. There was no such immune suppressive viral disease. The closest were the hepatitis viruses, which caused chronic diseases that had an inflammatory erosion of hepatic function and ultimately would produce cancer of the liver. So here I am working in that disease arena. There was a new vaccine that needed to be tested, so it was not a bad match.

MILLER: Fascinating. So then you moved to CDC, and you were in Phoenix where the hepatitis--now, why was the Hepatitis Division in Phoenix instead of Atlanta?

FRANCIS: Yes. The Hepatitis Division of CDC was in Phoenix. That’s interesting historically, because hepatitis A was a major problem in the Native American populations, and Phoenix was, you know, in some ways the medical head or at least [had] a collection of experts in the Native American populations. There was an old facility there that had both offices and laboratories that CDC had established for Indian Health Service issues. Then ultimately, when hepatitis became such a major problem, they started working on hepatitis and then ultimately became the Division of Hepatitis. So people literally moved out of 00:42:00Atlanta and collected there. Now for me, not thinking about a career, but you know, being a Westerner, I said, gee, that's great, and it fits well with my interest in virology. [Dr. James] Jim Maynard, who directed it, heard that there was a guy who had epidemiologic experience and had a doctorate in virology, or almost a doctorate in virology, and he was perfectly happy to let me work for the first four or five months getting my thesis done so that I would have--

MILLER: What was your thesis on, by the way?

FRANCIS: It was the natural history and outcome of feline leukemia virus [FeLV] in real life settings. At that time, you know, Harvard was wonderful because the structure of the thesis was straightforward. You'd write the introduction and then tell what you did, and then you'd literally staple all of your reprints in your thesis, and then you would have a conclusion to fit it all together. So the 00:43:00thesis was really meant to be real scientific; even though it's a book, it was not some thesis of theoretical stuff. It was real, if you had published papers, put them in there and staple them and introduce what's going to come, and then where that led you on to the next thing. So the FeLV discoveries made a very interesting story, actually. I was very fortunate to stumble into Max's lab and then to have Harvard have that kind of a process that was quite practical. Before, students just took all of their published papers and put them into words in a thesis. That was really silly. Harvard was very practical and indeed encouraged that, if you get them published [the papers emanating from the research], then let the value of a published paper stand in your thesis. And so it was relatively easy to put it all together ultimately.

MILLER: So now, what did you work on when you got to Phoenix? You were there for about five years. What were your areas?

FRANCIS: Well, the big thing at the time was a vaccine that looked like it may work to prevent hepatitis B. The question was how to do a phase III study of that, and how would you design it so that you could have at-risk people that were--I mean the more at-risk, the fewer you'd have to do in your phase III design.

MILLER: So the phase III being?

FRANCIS: The actual efficacy of the vaccine in a real-life setting, where you take a group at risk for the disease, in this case hepatitis B, and some of them get vaccine and some of them get placebo. On an informed consent, they all come into the study. I had not done a phase III trial of a vaccine before, and this was a major challenge. But interestingly, the group at CDC in Phoenix had been 00:45:00doing an epidemiologic study of hepatitis B in gay men in five cities, and so the suggestion really made by Jim Maynard was, “Can't we do a phase III trial of the vaccine there?” So I then met with Merck to see would they provide vaccine and indeed placebo, and then I went out to these five sites to see if they were interested, and they were.

MILLER: So it was all gay men?

FRANCIS: It was all gay men, and the challenge, in a way,[was that] for a vaccine you want gay men who had not had hepatitis B yet. I mean if they're already infected, what's the vaccine going to do? And so we knew that well above 00:46:00half of the gay men who came into these studies were already infected with hepatitis B. So we had to, you know, ultimately bring all of these field experts into our headquarters and talk about how to do this study. Then we had to design the protocol, get the approval of the various committees at both ends, get the money to do it and the budget that it would take. Luckily, we were fortunate that we could put all that together and do a study of the efficacy of Hepatitis B vaccine in a natural setting. It turned out to be a remarkable vaccine. This was the old plasma-derived vaccine, taken off of carriers of hepatitis B virus, human carriers, and then inactivated. Ultimately, it led to--when the recombinant technology came in, then one could do the same thing, make the surface protein of the virus by recombinant technology, and we had to do 00:47:00follow-up studies of that. But this study was of the old plasma-derived vaccine. It turned out to be very effective in preventing hepatitis B.

Then we expanded that, looking at some studies outside the United States. We collaborated with various groups to see the efficacy in--the real challenge of Hepatitis B [was in] preventing mother-to-infant transmission. This was important, because if the mother is a carrier of hepatitis B, the infant had a very high probability of being infected. And that is the kid that ends up with cancer of the liver twenty, thirty years later. So that was a critical study to do, and we ultimately found folks in less developed countries who were interested in doing these studies. In these we did the phase III study of perinatal infection by vaccinating the baby as soon as his little butt would 00:48:00come out. There was remarkable success there in preventing infection and ultimately cancer of the liver.

MILLER: So even if the mother was hepatitis B positive, you could get the baby and prevent hepatitis.

FRANCIS: We knew at the time that these babies were not infected when they are born. They are exposed during the birthing process; it's not transplacental. So soon after they were born, they would become infected. A high percentage of infected babies would ultimately become virus carriers. Then twenty, thirty years later, these are the kids that develop chronic hepatitis and hepatoma. So it was absolutely essential to see whether the vaccine could prevent mother-to-infant infection. If you couldn't prevent that around the world, including the United States, but certainly in the developing world, the vaccine 00:49:00wouldn't have much value. But the ultimate success of this approach set the stage for newborn immunization of hepatitis B and the elimination of it.

MILLER: So were a lot of the studies then done in Asia or--

FRANCIS: Then the major question was: is it practical to immunize all kids. We collaborated a lot in the People's Republic of China and Thailand on how best to immunize kids in the newborn period. Ultimately that became the standard of practice, and as a result it essentially eliminated the terrible diseases of hepatitis B--remarkable.

MILLER: So was CDC doing much international work at that time?

FRANCIS: Well, look at my experience. I ended up working in the United States, 00:50:00let's say, for the gay male study, but doing an awful lot of my hepatitis B work outside, advising WHO and ultimately doing the phase III studies of perinatal transmission in China and Thailand.

MILLER: So CDC had quite a presence really, internationally?

FRANCIS: Oh yeah. I mean if you think about my work with CDC, it was often international. CDC had a very close relationship with WHO and also had its own collaboration around the world. So CDC was remarkably effective worldwide. Early on I was quite naive about how effective CDC could be. We never had lots of money and had to beg and borrow and push here and there. But I think Washington saw how productive CDC was and added support. Then until leaders like Bill 00:51:00Foege, who eradicated smallpox, and thus they saw what we could do, and so they could really--

MILLER: Think big.

FRANCIS: Think big. And then the history gets more difficult with HIV, because the politics got in the way.

MILLER: Let's move on to HIV AIDS. So while you were still in Phoenix, you became a member of the newly created CDC so-called Task Force. It wasn't called AIDS; it was Kaposi's sarcoma and opportunistic infections, KSOI, in 1981. So can you tell us about that early experience, those early years where you're in Phoenix but you're on the Task Force. What was your role, and what were some of the early hypotheses? How did that come about?

FRANCIS: Well, this was a new disease that affected a group that [Dr. James W.] Jim Curran and I had considerable experience working with. Jim Curran collaborated with us a lot; he came from sexually transmitted diseases and I from hepatitis. With our HBV [hepatitis B virus] vaccine studies, we used the STD [Sexually Transmitted Diseases] clinics in the United States. So I knew Jim very well, and so he called me straight away.

MILLER: And Jim, Dr. James Curran, was the head of the Task Force?

FRANCIS: Right. He was the head of the Task Force from sexually transmitted diseases, because with AIDS we had a serious disease of gay men that looked like it was sexually transmitted. And Jim knew my background and he said, you know, this looks like a transmissible agent that's causing immunosuppression and cancer, and didn't you do something like that in cats? He knew me well.

MILLER: Was it that early that you had those discussions?

FRANCIS: Oh, yes. You see the pictures of that early Task Force, and there's not a person in that circle that didn't think this was caused by an infectious agent. We were rather biased, coming from CDC's infectious disease side. We had little problem suggesting an infection that caused immunosuppression and cancer. But, you know, I remember our early meetings. I would just take the combination of hepatitis B virus and feline leukemia virus and say, “There's your virus.” I don't think there was a person in the room that didn't think that this was a transmissible agent--I mean, after all, all these people in the room had worked with gay men having sexually transmitted diseases. So what are the odds, given hepatitis or gonorrhea or syphilis or whatever you want, herpes, viruses, bacteria. They had all of it. It was not--I mean, it sounds remarkable 00:54:00now, but at the time everyone had that bias. Now, there were other hypotheses, but the dominant one was infection.

MILLER: What were some of the other hypotheses? And controversies.

FRANCIS: Well, there were others. One of the major hypotheses here was that there were drugs or medications or whatever that these people would take that may be the cause. Some gay men, in order to have increased sexual activity, took stimulants. Many already had remarkable sexual activity. All males have limits. So if they continued to want to have sex, there were these various drugs, inhalers that they were using, that were sold with various remarkable names on the street. And so some of the hypotheses that were--

MILLER: So those were the poppers--

FRANCIS: Were the poppers, yeah.

MILLER: And nitrates.

FRANCIS: Amyl nitrates and uh--

MILLER: Isobutyl?

FRANCIS: Isobutyl. So there were several drugs that these guys were taking, so that had to be tested in the overall early epidemiologic studies of causation. Jim Curran and Harold [W.] Jaffe, et al., did these epidemiologic studies very early and showed that it didn't look like any specific “drug” was associated, because the control groups were taking the same amount of drugs as the cases of KSOI. It didn't look like the drugs were a key piece in the evolution of this disease towards the whole KSOI outcome. So it looked like there was a new bug. From the natural history of these young men, they had clinical signs of disease long before the fatal forms of Kaposi's sarcoma and 00:56:00the Pneumocystis [carinii pneumonia] and all the other immunosuppressive diseases came along. Also we knew from the clinical researchers working on it that this disease was associated with a decline in some of the very specific lymphocyte populations of these cases. So it looked like something had occurred long before the onset of disease. So now, we're back to this acute infection with a disease manifestation months to years later.

MILLER: Now, was feline leukemia virus a piece, a lymphocytic cytopathic infection?

FRANCIS: There’s very, very limited cytopathology with feline leukemia virus. It ultimately just caused immunosuppression of specific T cells, but not as dramatic as you saw with AIDS. But ultimately, these animals died of their 00:57:00infections, so it was a piece of it, but not as dramatic as we saw with AIDS. Interestingly, it was often the dermatologists, like [Dr. Marcus A.] Marc Conant in San Francisco and others in New York, who said, I'm looking at these guys, and suddenly they come in with these Kaposi's sarcoma lesions, because often they came to the dermatologist first. And then someone suggested to look at the immunologic makeup of them, even though they were, except for these red bumps on their skin, otherwise healthy. But their immunologic function was not. Then if you followed them a dramatic picture would emerge. These docs were very clever, both in New York and San Francisco; they continued to follow them. Using 00:58:00monoclonal antibodies that could subtype the subsets of blood cells in the body, they could literally see the decline. So the natural history of this was really very, very well worked out, even before we identified the causative virus.

MILLER: So now, the cell counters, the ability to differentiate between CD4 and CD8 cells [t-lymphocyte subtypes], was that a relatively new technology in terms of, certainly in terms of clinical use, but even research?

FRANCIS: In the early days of AIDS, it was the laboratories that had these remarkable instruments that poured blood in the top and it would drop individual cells through a reader hole, and they could tell whether it was a different 00:59:00[subtype], you know, B cells, T cells, and ultimately subsets of those cells. By putting monoclonal antibodies on them that would light up and tell us which one [subtype] it is. This is really the combination of technologies we saw with vaccines. Here the technology and physics come together, with the electronics of instruments that allowed us to make vaccines and allowed us to do subtyping of cells in the body. So in all of our field, public health, an awful lot of the stuff we use comes from intense laboratory work and engineering. And it allows us to just gallop ahead and understand a new disease.

MILLER: Now, where was CDC on this? So, I guess let's move you to CDC now in Atlanta. I guess that was in '82 or '83 that you became the Assistant Director 01:00:00for the Division of Viral Diseases and coordinator of all of the AIDS lab work. What was the status of CDC labs vis-à-vis this type of work? Was it sophisticated? Was it spotty? What did you find when you got here?

FRANCIS: Well, here I had come from the Hepatitis Division. Jim Maynard, who headed it, was very interested in supporting the laboratory aspects of the disease, and so we had some very good PhDs that did the hepatitis virology work. Then I started initially commuting from Phoenix to Atlanta and leaving my family alone in Phoenix, while I started working on what do we do with the laboratory at CDC. I met with [Dr. Walter R.] Walt Dowdle and [Dr. Frederick A.] Fred 01:01:00Murphy, and they said, I think you should go down and see the laboratory that you have. Phoenix was, you know, not the Rolls Royce, [but] it was a very good laboratory because Jim Maynard was very aggressive in fighting Atlanta for money and successful in building a laboratory, which was essential for these modern virologic studies. Hepatitis virus didn't grow well in the laboratory, so you had to figure out laboratory techniques to identify them. So Walt brought me in and--

MILLER: Now, Walt was the Division of Viral Disease Director? [By then Dr. Dowdle was Director of the Center for Infectious Diseases.]

FRANCIS: Correct. Walt Dowdle and Fred Murphy were--

MILLER: CID, yeah Head of CID. [Dr Murphy was Director of the Division of Viral Diseases.]

FRANCIS: CID, right?

MILLER: Center for Infectious Diseases, yeah.

FRANCIS: And so they said, why don't you go down and look in the lab. And it's, you know, in the movies of this--and the drama, but it was just about as bad as 01:02:00has been portrayed in the movies.

MILLER: The movie, And the Band Played On?

FRANCIS: And the Band Played On, you know, where the cabinet falls on top of me when I walk in the lab. It was just about that bad. It was very primitive. [Dr.] Paul Feorino, the poor guy, who came out of EBV [Epstein–Barr virus] type work, was working on this. We had very good electron microscopy showing these viruses and stuff, but the rest of it was really crude. We had to build a new laboratory with no money, and so it was all patched together. I wasn't going to tolerate any compromise of safety here. If we didn't have to work on it, fine, but if we're going to work on it, I don't want any of my laboratory people to get a 100 percent fatal virus. You know, just because it had a long incubation 01:03:00period, don't kid yourself. This bug is very dangerous, and to prevent any aerosol, we had to work in cabinets. We had to treat this as a very dangerous bug.

MILLER: What was your strategy for strengthening the lab? What's CDC's role? Is it to link epidemiology with clinical specimens? Is it to identify the virus? What were your hopes for the lab as you're trying to put it together?

FRANCIS: I think the remarkable thing about CDC is the historical integration of laboratory science and epidemiology. If you do that, you can discover new bugs and understand the natural history far faster than specific research labs at the NIH [National Institutes of Health] level. I mean, they are very good getting sequencing and all that and understanding some of the cellular level, and that's NIH's role in it and it's terrific. But CDC’s responsibility is to understand 01:04:00the disease so you can prevent it with whatever tools you have at the time. There was a strong tradition of doing this at CDC, of integration of the laboratory into the mainstream. For example, I came out of the Hepatitis Unit, and that was laboratory and epidemiologist really in the same offices, the same building. And that's the way it was supposed to be. But unfortunately, the closer you get to Washington, D.C., the more difficulty CDC had in getting the budget to continue to support all of these activities. And so when I came and saw the laboratory that I was supposed to build in Atlanta, it was just a shock, because compared to what we had out there in the bush in Phoenix, it was nothing. So it had to be built from the bottom up.

MILLER: And what did you want to build? To what capability?

FRANCIS: Well, at this time, to identify and figure out what this virus was. The 01:05:00basic epidemiological, virological interaction to understand the transmission and develop tests of the bug so that you can figure out where it is and where it's going epidemiologically. And then ultimately, to understand enough about it so you understand the immune response, and can you make vaccines and preventions and treatment and the like? Frankly, CDC has done that for many bugs since it came [in] to existence.

MILLER: For viruses?

FRANCIS: Well, viruses were-- I mean you're not putting them onto agar plates like bacteria and being able to see it [growth]. Parasites are difficult, too, so CDC had this experience from viruses to bacteria to parasites.

MILLER: But was this going into sort of new territory in some ways, from a 01:06:00laboratory point of view, to have CDC actually identify a retrovirus? Well, you didn't know it was a retrovirus, so yeah.

FRANCIS: Was it new for CDC to discover new bugs? No. CDC had a long history of it. But it was confusing from the politics and the fiscal standpoint. They said, “NIH does that kind of research.” But CDC had a long history of being part of this and collaborating with NIH. In addition, CDC would have the epidemiologic specimens. You need the person who has the disease and a control who doesn't have the disease if you want to check them for whatever bug is in your hypothesis. And CDC had a long history of that [case-control studies]. Unfortunately, this was a time when the politicians didn't understand what the responsibility of government was in public health. So it was a very, very different time than my previous experience at CDC.

MILLER: Did you feel supported by your superiors or some of your superiors? How did you approach the issue of, we don't have money, we can't do what we need to be doing?

FRANCIS: Well, when you're at CDC, you have a lot of experience in saying, we don't have any resources, so how are we going to get it done? Let's all work together to get it done. You know, the early Director of CDC was Bill Foege and then Walt Dowdle for Center for Infectious Diseases, and we all knew that we would have to work on these budgets, put them together, and fight and push whatever buttons we could in Washington and the like. That had been common practice and not the best way to run public health. But there was usually 01:08:00somebody in Washington who understood. CDC's office in Washington knew the ways to work these things, and then we would push them with data and presentations and such.

This was not just an interesting research project like those at NIH. This was a disease that was killing lots of people. We, you know, very soon, even before we had the virus and the serologic tests to see where it was, we were very concerned by what we saw. We and others were collaborating to do these large bleedings of gay men and looking at the level of immunologic damage. We had an idea that there was a huge group of people who were probably destined to move have serious and deadly disease. We had worked with dangerous bugs around the world, but our eyes were wide open that this was something very, very bad.

The interesting part politically was not just the risk groups involved (which was difficult to an extent and got worse with time), but it was the slowness and the long incubation period. For years, we had been working with hepatitis B. We could see these little kids who were getting infected in the newborn period, and they would have cancer of the liver twenty-thirty years later. So for us, at CDC we were already familiar and practiced with long incubation period diseases. Long incubation period phenomena, associated with acute infections, was part of our vocabulary at CDC at the time. We didn't have any trouble. But we had to translate that politically, and here we had practice. We had been working with gay men for hepatitis and sexually transmitted disease at CDC for decades. But we didn't really understand going to Washington to say, well, there are gay men 01:10:00and IV drug users with this bad disease, and we've got to do something about it. We would say, “This is a population in our society and we know that you get sexually transmitted disease in gay men that goes to other people. It doesn't just sit there, and it's not an island in the middle of a society; it is part of society.”

But by this time, we had a Republican director of CDC and all the Republicans in both executive and legislative branches. This was really a Republican-Democratic issue: Republicans wanted to stop spending money in the government. And we, with our and some Republican helpers, but primarily Democrats, who understood that the society that takes care of itself will save money and lives in the long run. So let's understand the disease and do something about it. Don't tell me that 01:11:00they’re gay men or IV drug users. We know that there are sexual contacts or family contacts of these that will get the disease, and it will spread. But some of these guys were just terrible.

MILLER: So these guys were the Reagan Administration?

FRANCIS: This was Ronald Reagan and his group of conservative Republicans. I’m sure that within the Hollywood side of Ronald Reagan, there certainly were enough gay men (with Rock Hudson and all of this stuff, who could talk to them and be friendly with them). But there was a whole group of--I don't know where it would come from, but it comes from this anti-gay thing that made just no sense at all. Maybe it was just the convenience of saving money. [The politicians said, we don't need to deal with the gay men, because it's not a big political [issue]--without realizing how many gay men were in their staffs and other elected officials around them. We all in this game became politicians who started to understand this.

Our history in public health dealt with people, recognizing when some people in a society get an infection it goes to other people in society. And so we did all we could to understand who were the people at risk for a new disease. Here we had a new disease that was in gay men and IV drug users, but we also knew that it was in the sexual contacts of heterosexuals. It fit with all of our other diseases we dealt with at that time. So there was not an issue of a gay disease or a straight disease.

We had a really bad disease that, unfortunately for politics, yet good for the patient, had a long incubation period between the time of infection to the time of disease. So people lived for years with a slow decline of their immunologic function because of the replication of this virus. We said, there's X number of 01:13:00people with this infection, and they're all going to get disease. But the politicians said, “No, you only have this small few thousand cases, so why are you so worried?” And then we'd say, “Well, it goes into all populations.” “No, they are all gay, and they are IV drug users.” So the politicians ended up with the ability, with the long incubation period phenomena, of saying, you know, if I'm elected for two years or four years or six years, why do I care about a disease that you guys say it looks like it's ten plus years away? I can say no, and it's a group of people that I don't know they exist. I don't want to know. And you guys are just government asking for more money. Right now, you have elected officials who don't want to spend more money, who say we want to decrease the amount of money in government. And we would say, but only 01:14:00government does this. Government does public health. You're not going to get the private sector to move in on it. But none of this worked at a national level. And so I was asked by CDC to at least push the process. I made this initial plan and the multi-million dollar budget.

MILLER: Now this plan was for prevention or for strengthening laboratory?

FRANCIS: This really was for prevention, which required a lot of laboratory strengthening. The plan was called Operation AIDS Control, and Walt Dowdle and [Dr.] John [V.] Bennett asked me to write it, and so I gave it to them and we passed all around. We all agreed on the wording of it, and it went to Washington. And John Bennett called me in his office one day. John Bennett was 01:15:00not, in general, an emotional person; he was very technical. But when I walked in, something really bad had happened, and he was very angry. And he said, Don, we just got the news back from Washington about the funding of Operation AIDS Control. They said, we're not going to fund it. The quote, as close as I can make it, was, "Look pretty and do as little as you can." You can imagine John Bennett and Walt Dowdle's reaction to that kind of thing. They were furious, and everyone else was furious.

Soon thereafter, I said fine, if that's the way the government wants to do this, I cannot work here ethically, because my responsibility was to control this disease, and the politicians will be long gone when a million people die of it. Others will look back at us and say, you guys didn't do your job. So I literally 01:16:00got on the telephone and called the State Epidemiologist in California, [Dr. James] Jim Chin, and asked if he could use someone on AIDS, and he said sure. I went back to Walt and John and said, will you guys send me home to work on AIDS? They said “yes,” and I packed up my family and moved to California.

MILLER: CDC had a Division of Communications, I think that given 30=plus years has become much more sophisticated, and communications itself has changed tremendously. Do you think it could have done more? Was there a failure of knowing the language that would be understood in Congress and in the Reagan Administration, or was it way beyond that?

FRANCIS: I think CDC was very sophisticated, and you know, the Washington Office 01:17:00and people here had been fighting for years. They were moderately successfully in getting some programs. Maybe slower and maybe less money than we wanted, but we had been around the world eradicating diseases. Although it wasn't perfect, it was tolerable.

MILLER: This was different.

FRANCIS: And this was different. This HIV was a very, very bad virus that was invading our population, not to mention we had data from around the world; we went back to our freezers and found HIV all around the world in specimens from our various studies. We were a group of people who had worked with very, very dangerous viruses around the world, and this one really got our attention and our concern: the long incubation period and the ability to transmit sexually and 01:18:00by sharing of blood. And we saw evidence of it everywhere. WHO and our collaborators said, look, we can see this too. Almost everyone was very concerned. And then to have the Republicans in Washington say, "look pretty and do as little as you can," was unbelievable to us. Although we could often tell there wasn't great support for these kinds of things in the past, but the system would respond. But when we brought the AIDS data to them, you'd think that they would be wise enough to open their eyes and say yes, for the health of this country and our responsibility as government. But they said “no.” It was like talking to a bunch of doofuses, whose political beliefs and biases led them astray from their responsibility as elected and appointed officials.

Unfortunately, that influence came to the then-Director of CDC, who came from a 01:19:00background that was not perfectly suited to deal with this new epidemic in gay men and IV drug users and their sexual contacts. So it was the combination of politics, the long incubation period, and the people who were the primary source of infection in the United States (but all pointed out that it was heterosexual around the world). This was a huge, huge problem. These “leaders” were such politically twisted individuals that couldn't understand their responsibility as public health officials. This included, ultimately by that time, the Director of CDC, who became Assistant Secretary in the Department of Health and Human Services. These biases became universal.

But the dominant issue in the government was to cut the budget; the bad thing was you need a new budget to deal with a huge epidemic. So “fix it.” That's what we did in the past. They just found every excuse not to, and that's when I asked to be transferred to California. There I became a spokesman in the political realm of California, raising money in the Senate and the Assembly of California. Here I was a trained virologist and epidemiologist, and I'm testifying in front of politicians, successfully. But given government funding procedures, this meant that a response was another two years later, and another thousands and millions of people became infected. So it was. There I was having a background and training perfectly suited to deal with a disease like this. And yet--

MILLER: Terribly frustrating.

FRANCIS: And it was horribly frustrating and incredibly dangerous, and millions of people died around the world because of it. The world looks to the United States, in many ways, to CDC to set at least some parameters of response to new epidemics. And this time they were told to "look pretty and do as little as you can."

MILLER: So, moving in that direction, before you left, in July of 1982, three cases of this syndrome were reported in patients with hemophilia A. Then in December of '82, the MMWR published the report on the first "possible transfusion-associated AIDS case," which was from California. So this was a 01:22:0020-month-old infant who developed AIDS following multiple transfusions, including from the blood of a male who had developed AIDS. Can you tell us a little bit about that? What effect did this have among the major stakeholders in thinking about blood-borne transmission of AIDS? So you and your colleagues had already, I think concluded that, but here it was right in your face. What were the initial reactions?

FRANCIS: Well, the initial reactions to transfusion-associated AIDS at CDC were very different than, again from the outside. [Dr.] Bruce [L.] Evatt here had been working with the hemophiliac community since the early years of AIDS. And then the transfusion cases came --as expected, to be honest. If you're talking about a disease, like hepatitis B, that has a long incubation period, and it's 01:23:00transmitted by sex and blood-sharing, these cases were all expected to come in, and indeed our feelers were out very early on. We let the state and local health departments know to keep their eye out for these cases. So when they came, it fit the picture and we were ready to blast away at ways to prevent it. Before we had the test for the virus, we suggested using CD4 counts of people who are donating blood, and just ask them about their sexual activity. Again, CDC was all prepared; we had meetings, these incredible meetings that had been well 01:24:00described in the lay press and stories in the history of AIDS. And we were ready.

MILLER: Let's talk about one of those. The first one was in January of 1983. So at CDC's request, the Assistant Secretary for Health, [Dr. Edward N.] Ed Brandt, convened an advisory committee to address questions regarding transmission of AIDS through blood and blood products, and that included the blood banks, the Red Cross, Hemophilia Foundation, infected patients, NIH, and FDA [Food and Drug Administration]. So my first question is, why wasn't FDA in charge of this meeting? FDA, if blood banks and blood transfusions are under their purview, what happened with that right from the get go?

FRANCIS: CDC and the FDA decided who would sponsor this meeting. This was early 01:25:00in the game of AIDS, and so it seemed perfectly appropriate to have CDC do this, but it was not without the collaboration with FDA. There was a major person in the FDA who was involved in this all along.

MILLER: Do you remember who that was?

FRANCIS: Yes. But this person happened to be gay, and he was very, very good at blood banking and knew it well. I think there was some, maybe personal discomfort, but he was very collaborative. There was not a fight at all here. And I worked with him a lot; he's a very good guy. And so it was not the fact that CDC was doing it. We had most of the data on the disease, so it was fine 01:26:00and FDA was here. But the outcome, it goes back, there's something about this disease and the long incubation period that allows people to deny it. So the outcome of this first meeting was so extraordinary that my quiet self pounded the table. Literally pounded the table!

MILLER: Did you really pound? I've read that in so many--I didn't know whether that's apocryphal or--

FRANCIS: No, I pounded.

MILLER: I've thought of you often when President Obama talks about gun violence. I think, gee, we need Don Francis to pound. And what did you say when you pounded?

FRANCIS: I just said, this is so straightforward. You can't walk out of this 01:27:00room saying we need more research, that we need more studies of this. We have the issue of gay men donating blood that's causing death, and it's straightforward. There were some objection in the gay community, but I had worked a lot with the gay community and that objection you expected. Why are we being prejudiced? I literally said there's not a right to donate blood. This is not a constitutional right, and we screen out people who have hepatitis B and all these other things. So for you to receive blood or for your family to receive blood, you want it to be safe as possible. So that argument was just nonsensical. In this case, the blood banks were the evil people, and it didn't really make any sense.

MILLER: Well, where were they coming from? We know that there were a lot of concerns that it would dry up the supply of blood and--

FRANCIS: There was some truth to that, because gay men were very good donors of blood. But with the publicity that these meetings had stimulated with just a minimal amount of coordination, you could get every female donor from Nebraska to donate blood for the rest of the country. It was just a silly thing. If the CDC and the FDA and blood banks called for donors, they would come in by the droves because we have this disease and we have to be overly cautious. [We could have said,] “I'm sorry, we can't use these donors today, but maybe tomorrow we can when we understand it better.” It was not an issue. And these blood banks, from the public health standpoint, I mean, here we have these biases, and you just assume logic will follow. I've been working with blood transfusions and 01:29:00hepatitis B for years and worked with blood banks and-- ** MILLER: Were you surprised by this?

FRANCIS: Yes, and shocked. Why would you even consider not acting? What was the rationale? I think it was just inconvenience. Well, I'm sorry.

MILLER: Now, what could CDC have done differently? We always look at what, you know, what is it about communicating health risks that is often difficult?

FRANCIS: If we had all the budget in the world and staff to do all of these things, then you could have your public relations and marketing team advising us doctors. Instead of being so reticent, you would have a “go get 'em” thing. We could do this politically, so we could all understand and get all the backing of that. If we had those kinds of resources, we probably would have done better, 01:30:00no doubt. But we didn't have any resources. I mean, look, every one of us was stolen from some other part of CDC, and we didn't have any money for AIDS specifically. We didn't have time for this. We were doing all the research and putting all this data together and trying to get support out there to understand the disease and to treat it and do whatever was necessary.

There are dozens of things needed to deal with a new outbreak. CDC should have had millions and millions of dollars to put on it right there and then. We could have had a whole group working on the transfusion side, which was just one-two percent of all AIDS cases. Again, this was a management issue at the government level, where they essentially said, “CDC, you're not going to have resources to do this and that we don't”--I don't know what their logic was -- “that you don't need public health.” “We don't need government in this,” is what they were saying. I mean, I had never seen this in all of the countries in which 01:31:00I had worked around the world. And here, in my own country with a very, very bad epidemic, these doofuses said, “we don't need your efforts, and you don't need any money to do what you think is necessary.”

MILLER: Now, had there been agreement to have some type of screening, what was some of the thinking on hepatitis B core antibody, CD4 counts? What were some of the proposed screening methods?

FRANCIS: The proposed methods for blood transfusion were really quite straightforward. Indeed, there were blood banks in these meetings that reported that they were already doing CD4 counts on donors. Now that's a fairly elaborate laboratory technique, but it was perfectly reasonable to do. The other thing [was] that we had data from the AIDS cases that 70-80 percent of them were infected with hepatitis B virus because of the same sex--transmission risk. So 01:32:00we were recommending screening out the blood for Hepatitis B virus infection. This was done already for the virus itself, using the HBsAg test. But why not just use the antibody test, which would get the other 70-80 percent, and it would decrease, at that time what we called non-A, non-B hepatitis (hepatitis C). It would reduce 30 to 40 percent of non-A, non-B and 80 percent of HIV. So we thought that this approach was very straightforward, and we presented all the data at the blood bank meeting. But these blood bankers said, “What? Why would we do more tests, and then we would have to go find more donors?” It just was--

MILLER: It must have been very, very disillusioning at the end of that meeting.

FRANCIS: I don't think there have been very many meetings where I pounded tables with my fist. And this wasn't a frustration with our limited resources and all 01:33:00the other difficulties we had with the early days of AIDS at CDC. It was, this is your responsibility. This is not our area. You are the blood bankers, you know what to do. It was not a difference between FDA and CDC. We spoke the same language. It was straightforward. We knew that these people with AIDS had a very high prevalence of hepatitis B infection. We had documented this with all of these studies that Bruce Evatt and others had done, including finding the donors to these cases. And we could screen out, just using antibody to Hepatitis B. It was about 80 percent effective in screening out infected donors --which would not be bad. The thought was we could do the T4:T8 ratios in addition. But that required an expensive machine that blood banks were not going to have. Hepatitis antigen testing was being done, so to add antibody testing was nothing. It would 01:34:00cost a couple of dollars a unit extra.

MILLER: So before they even identified the virus, by March of '83, CDC, FDA and NIH agreed on some guidelines in the MMWR, that members of groups at increased risk should avoid donating blood. Then in December of '83 the Blood Products Advisory Committee of FDA met to discuss options for surrogate marker testing. So, was that effective? Voluntarily telling people not to donate blood? What were your thoughts on that, and how did the gay community respond to that?

FRANCIS: There were, at least in one meeting, there were some minor objections. One PhD gay man had been involved in science and understood the issue. But he 01:35:00was very politically active from California and gave some objections in a meeting. But I knew him well and I just said come on, don't have the gay community be blamed for this through transfusions. Then he and others said, we understand, just do it, you know. As a matter of fact, very soon thereafter the gay community came forth and said, “If you are gay, do not donate blood.” Later, blood banks finally came around, but it was slow. It took time.

MILLER: So with all of these years passed and you look back at it, first of all, how many lives were lost on the basis of that as far as one can estimate?

FRANCIS: Of just the blood trans--

MILLER: Thousands? Tens of thousands?

FRANCIS: Well, if you think about prevention from the behavioral side and 01:36:00prevention from blood transfusion around the world, it's millions. Certainly in this country it's tens of thousands. This is a relatively difficult bug to get. [It can be prevented] with things like condoms and some sexual caution, blood transfusion screening, clean needles and syringes, all the things that we ultimately used in places like California. But that kind of action takes months to develop and put in place. CDC could have come out with it straight away and let the states work it out on their own. If that is put in place, you don't have to go through what I had to do when I left Atlanta and went to Berkeley, to do all the politics in California. It took months to develop these things and then getting budgets to deliver them. You know, budgets don't come quickly 01:37:00state-by-state. The former Director of CDC was Assistant Secretary [Assistant Secretary for Health] and could have rapidly gotten the few millions of dollars. I mean, this is nothing, but it is equivalent to a war. The Defense Department does this kind of thing and rallies forth; we should have been able to do it too. But these people literally stood in the way.

MILLER: There were a lot of trials around these transfusion-associated AIDS cases. Did you testify at any of these, and what was the outcome of those trials?

FRANCIS: Well, they asked me to testify, and then it just became, I mean it was endless. So I told all of the legal folks who were taking these blood banks on, to come into one room with cameras and tape recorders and ask me any questions 01:38:00they wanted, because I wanted a single interview. I didn't have time. I didn't think it was an appropriate use of my time to be testifying in all these cases, even though I thought my opinion would be important in pointing to where the liability was. So I did that once. I don't know, there were a dozen or 20 attorneys, and they all had these cameras. We recorded the whole thing, and then they used that testimony for their trials.

MILLER: Did a lot of those people win their case?

FRANCIS: I think eventually. Ultimately there was a fund set up. This was terrible. These people were killed for no reason; especially later on after we said that donors needed to be screened. There were many horrible cases that were totally preventable.

MILLER: Before we move towards closure, you were closely working with Max Essex. 01:39:00In late '83 and early '84 there were several groups coming close to identifying the virus. That was [Dr. Robert C.] Bob Gallo at NIH and the French Luc [A.] Montagnier's lab and [Jean-] Claude Chermann and Francoise Barre [-Sinoussi], and you worked with them providing specimens from CDC. Can you tell us a little bit about the controversies there, and the role that CDC played in providing specimens and in other efforts to identify the virus?

FRANCIS: Clearly, it's CDC's role, not to mention their history. When you have a suspect new infection, one needs to bring both the lab at CDC and the 01:40:00collaborators outside together as fast as possible to find the bug. We were quite limited in what we could do in Atlanta because of budget. But we also had a very good idea where this bug resided and what could be done and, with our experience in retroviruses, the ways to identify it. But we needed really good virologic labs to do that. There was the group at NIH, but there was a challenge. The director of that group, Bob Gallo, was not an easy person to collaborate with. He was known to be a very hard guy to work with. But I knew the French from my past and--

MILLER: How was that? How did you know the French?

FRANCIS: I had worked with the Institut Pasteur on things before.

MILLER: Okay.

FRANCIS: And so Francoise Barre called me on the telephone and we talked. She wanted specimens, and we were more than happy to give her specimens. I was going to Europe for a WHO meeting, and I carried specimens and stuff to Paris and spent a couple of days with them. They had grown and identified the virus themselves. They sent it to us at CDC, and they also kindly sent it to Bob 01:42:00Gallo's lab and to other labs. Then the sad thing that came out of Bob Gallo's lab: he announced that he had the cause of AIDS. This was just before the French had all the data that we provided them, showing that they were the first to uncover the cause of AIDS.

Ultimately the virus that Gallo “discovered” was sequenced, and it ended up to be the French virus that they had sent him in the post. He had thrown it into his cultures, expecting that it would be mixed with other viruses. But this virus was already lab adapted, and so it just took off like crazy and outgrew all the other ones he was trying to hide by mixing. But that took years to settle and was a very, very unfortunate chapter. Unfortunately it took the 01:43:00National Institutes of Health, ultimately the Director, who was a good guy, to move Bob Gallo out, because he did not follow common ethical scientific rules of the trade. He went on to do his thing elsewhere. But it was a very sad thing for the U.S. government.

CDC is obviously a part of the U.S. government, and to have that conflict [was sad], especially when the government decided to put Bob Gallo on the stage as the discoverer of the AIDS virus. We saw the conflict coming, and we talked to the Assistant Secretary's Office and said, this is a very poor idea because we've got information that the French were the true discoverers of the virus. We 01:44:00had been working with the French, and we had that virus growing in our lab. We had all our hepatitis B studies and were grinding out tests using it 24 hours a day. But the silly politicians in Washington wanted credit for the discovery. Because they were getting so much criticism for their lack of federal response to AIDS, they wanted to declare that they found the cause and would make a vaccine tomorrow. So it was just another sad chapter, and here we were at CDC with all the information and a limited amount of resources, fighting all this stuff, only to have our colleagues in Washington make it more difficult.

MILLER: So now that we've got about 30-35 years behind us, what are some of your thoughts about that time? Are there things we could have done differently? Was 01:45:00it just bad luck? So many millions of people have been infected since then.

FRANCIS: Some of it is bad luck that this bug, I hate to say, is clever, but it is certainly a great nuisance, a well-designed nuisance for a society. Our system is changed by these long incubation period phenomena. Look at our response to pollution in the United States. It only takes seconds to dump it out, but it takes years for the diseases to occur from this exposure. Thus, the impact on plant and animal species is delayed. We have a very hard time in our 01:46:00system to respond to such slow-moving phenomena. So we need to address that. We need to get a system where CDC has an alarm ability to say, this is a long incubation period situation. Be careful because we get suckered in by these bugs.

Another factor with AIDS was the initial population at risk. This factor was trivial to us at CDC because we knew that in the rest of the world the bug was heterosexually transmitted. Homosexually transmitted, IV drugs, transmitted by dirty needles, that doesn't bother us at CDC. The leaders in Washington should listen to people at CDC, because they know about these things. CDC should be allowed to come up with recommendations that need to be followed. But the 01:47:00current structure of the U.S. government and CDC's location in that structure of government make it impossible for CDC to operate appropriately on these kinds of things. There needs to be a way that CDC has the equivalent of a national board of health or a representative system where they can speak the truth. CDC needs to be able to recommend what is needed to combat these diseases without having somebody like these conservative Republicans up there saying no. We do have that independence in our banking system. It's interesting we do not do it for our public health system. There has to be--

MILLER: How so for the banking system? The Federal Reserve --

FRANCIS: You have the Fed Advisory Group that says this is what interest rates should be, and some people make a lot on that, and maybe it should go down, some 01:48:00people are going to lose money on that. There's a lot of pressure in terms of financial loss and gain, and yet, the financial community has said that we need an independent group to do that, so that we don't have some political forces that interfere. We need exactly the same thing in public health. You can't have CDC be tied by this interference. CDC has had very, very good people, but when you see Directors of CDC leaving because of the political interference, then you know your replacement director is not going to be quite so independent of whatever party is in charge. The Director of CDC should speak for the health of the people, and the politicians be damned. And the country must follow what the CDC says, because they're the experts.

So do we need a larger board or advisors or something to insulate it? It's not going to work the way it is today, I can assure you! I have written this in the 01:49:00literature and have gotten lots of support. But so far, we do not have the political force in the elected officials or the President to say, “we cannot do this anymore because people die because of it.” Very simple. Some of that is the result of people dying of these long incubation period diseases. Today’s Director will be out of office, and all will be able to say, that damage was not on my watch. So especially with these long incubation period phenomena, you do need a wise group of people to help support CDC's expertise and translate that into political activity of the positive nature and not this negative stuff. Same actually goes for acute diseases too.

MILLER: How did your early work on AIDS affect you personally?

FRANCIS: In several ways, I mean, the worst thing for me with AIDS was I knew 01:50:00these people.

MILLER: The people that were dying?

FRANCIS: Right. I didn't have that experience from Ebola or whatever else. These were acute diseases. But for AIDS, I had met them before and knew many well. Many were my friends and colleagues. I stopped going to funerals in California because I knew so many people, really good friends of mine, who were really wonderful people in the AIDS community that did great things, that were now dying. I couldn't deal with it. There was so much death, and with this disease they're now my colleagues and friends that are dying. I just stopped going to funerals because I had to keep functioning. I had worked around the world on all of these bad diseases, but nothing like this, where now I was dealing with it personally, with lots of really good people whom I knew that died of this disease.

That downside of AIDS work was followed by the frustration of going to Genentech and starting work on an AIDS vaccine. That was frustrating because it was difficult scientifically. But that was part of the battle, that you know, and I could accept. But the lack of resources given by our society to make a vaccine I couldn't accept. It's been very difficult to get sufficient resources to work, I mean for an easy vaccine it would have been fine, but for a difficult one for a virus like HIV, that changes so much, this is not straightforward. To me, the HIV vaccine effort has been really left only partially done because of the lack of resources.

MILLER: So you've stayed working on AIDS for all of your career?

FRANCIS: Our staff at Global Solutions for Infectious Diseases works on the AIDS vaccine stuff, and I do dengue and other things outside the country. I don't 01:52:00work in the United States anymore. I have so many years left to contribute. So I'm going to work on things I can get done, and if the United States wants to trip and stumble on itself, so be it. I've got a lot of other countries that could use our help. So things like a dengue vaccine will be out. Some good NIH people developed that, and we're testing it now in Brazil. You watch, we'll get a dengue vaccine before there will be an AIDS vaccine.

MILLER: Yeah. Any other concluding thoughts?

FRANCIS: A concluding thought for me for the United States of America is to look at the AIDS model and develop a new system in which organizations like CDC can 01:53:00operate that will prevent deadly diseases coming into the United States. And have it be free of the political influence of these elected officials who have little or no idea of the consequences of their inaction.

MILLER: Thank you.

FRANCIS: My pleasure.

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