Dr. Timothy Dondero

Tim Dondero

CHAMBERLAND: This is Dr. Mary Chamberland, and I’m here with Dr. Timothy Dondero at the Centers for Disease Control and Prevention [CDC] in Atlanta, Georgia. Today is Monday, September 19, 2016. I’m interviewing Dr. Dondero as part of the project to document CDC’s Early Response to the AIDS [acquired immune deficiency syndrome] Epidemic. Dr. Dondero, do I have your permission to interview you and to record this interview?

DONDERO: Yes.

CHAMBERLAND: Tim, you first came to CDC as an EIS (Epidemic Intelligence Service Officer) in 1977. It took some eight years before you made your way to CDC’s AIDS Program. Once there, you were a key figure in building from the ground up and then implementing nationwide what became known as CDC’s Family of HIV [human immunodeficiency virus] Serosurveys. Most of these were conducted from 00:01:001988 through 1999.

But before we talk about the Serosurveys, I’d like to ask you a few questions about your background. To start, can you tell us a little bit about where you grew up and about your early family life?

DONDERO: I grew up in a very small town in the Connecticut River Valley, the town of Haddam: very monotonal, not monotonous, but monocultural town, very limited, all white. I think there was one Jewish family in the town; that was as diverse as it got. My father had been a sailor during the Great Depression, [in the] Merchant Marines. I grew up hearing stories of West Africa and South America, and I was always interested in [things] international. I collected stamps, which was my outside world, but otherwise, I was just a small-town kid. 00:02:00I went to high school in a somewhat larger city, Middletown, and then started [to study] engineering. I went to MIT [Massachusetts Institute of Technology] for a year and a half. I dropped out in that third semester, took a semester off, and worked landscape/nursery work. Then I wound up going to Cornell to study the scientific aspects of agriculture, which was biochemistry. From there, I wound up going to medical school rather than graduate school.

CHAMBERLAND: Who or what influenced you to be a physician, moving from engineering to agriculture to medicine?

DONDERO: There was one particular person, a fellow named Dr. John Gallo. My father worked at the hospital; he was the maintenance engineer at Middlesex Memorial Hospital. I was looking at graduate schools for biochemistry, and the 00:03:00young pathologist there, this Dr. Gallo, had gone to one of the schools, undergraduate at one of the schools I was looking at for graduate [school]--it was Johns Hopkins. He had been an undergraduate there. My father knew that, so he said, “Why don’t you go talk with him, and he can tell you what the department was like.” So, we talked for about seven hours. In the course of it he said, “Okay, you haven’t convinced me you really want to go to graduate school. Have you thought about medicine as an alternate way into research?” And I had not. All of a sudden, the light went off. He was a pathologist, and I wound up going into pathology as a way into research, not clinical practice.

CHAMBERLAND: I see. And you did an internship, residency in pathology--

DONDERO: I did two years of residency. The first year in those days was called an internship; anatomic pathology, so I did about 100 autopsies the first year. Then I did the--I never did clinical path, but I did biopsies, cytologies, 00:04:00microbiology, things like that in the second year. Plus, I supervised in the autopsy room. But then I got a postdoctoral fellowship, a hybrid postgraduate thing. I was going to work with host-parasite relationships; it was an NIH [National Institutes of Health] postdoctoral fellowship. It was supposed to be with Johns Hopkins in Calcutta, but because of visa problems I couldn’t get there to do it. I wound up getting switched to the University of California San Francisco program in Malaysia. There, I couldn’t work with hospitalized patients who had chronic filariasis, which is what I was interested in, the host-parasite interaction as part of the pathogenesis of the disease; but rather worked with—I had to work in villages. I got more and more involved with 00:05:00patterns of infection in communities and, of course, epidemiology. So, I sort of backed into epidemiology. I was ultimately in Malaysia for seven and a half years, and coming back to the States I wound up going into the EIS Program as a way of getting into public health, but in the U.S. I had been overseas so long--

CHAMBERLAND: What were you doing in these villages?

DONDERO: Oh, we did essentially complete surveys of everybody, but tested for malaria, which was immediately important to them. I was looking at the filariasis patterns, and I was involved with a group that was ultimately to do filariasis eradication. My boss in Malaysia at the time is now the Grand Old Man at WHO [World Health Organization] who led that, Dr. C.P. Ramachandran, 00:06:00Professor C.P. Ramachandran. But it was that -- seeing you had all these exposures, an entire community exposed to mosquito bites, but only some people getting disease. That’s what was the intriguing part.

CHAMBERLAND: When you were in these villages, you were actually doing, it sounds like, a little bit of epidemiology?

DONDERO: It was epidemiology. It was patterns, and then we worked up the laboratory specimens.

CHAMBERLAND: Interviewing residents of the villages?

DONDERO: Interviewing, a lot of times examining, systematically examining, for manifestations of filariasis, looking for enlarged feet and so forth, taking clinical histories and physical exams. I did finally get to Calcutta, and I did a couple of months’ work there, but only as a TDY [Temporary Duty] kind of thing. That was my first couple of years; that was a post-doc. Then I was obliged to go in the Army. It was toward the end of the Vietnam War. I had had 00:07:00that Berry Plan to go on active duty, but in my area of specialty, which was research in tropical medicine, which the Army of course wanted, with Vietnam. There was an Army Medical Research Unit in Kuala Lumpur at the Institute for Medical Research, where I was based with the University of California. I wound up doing my three years of Army time active duty there, but with malaria and drug-resistant malaria, resistance patterns. I did a lot of mapping of that, which was, again, epidemiologic, and mapping and testing for drug resistance of falciparum malaria all over Malaysia. I actually did some in Indonesia as well. Then I knew I wanted to stay with patterns of disease in communities. I still love the international work.

CHAMBERLAND: How did you hear about CDC’s EIS Program?

DONDERO: Interesting. I was looking for what do after the Army. I had two more years with the University of California, and they needed a coordinator plus part-time research. But I knew, as welcome as I felt in Malaysia, that wasn’t where I was going to be able to spend my career or life. So, I was figuring I’d go to a school of public health in the U.S. I interviewed at several. I went to the Harvard school, and I met with Professor [Dr. Thomas H.] Tom Weller, who had actually gotten a--he had a Nobel Prize for something in tropical stuff, as I recall. I can’t remember what now. He was very, very helpful, and he said, “You’ve already done the stuff that you do in a school of public health. Why don’t you--have you thought about the EIS Program?” Which he had never been in, but from a distance, he had a high regard for. Then I got 00:09:00interested as I learned more about it, and I wound up applying.

I was back in Malaysia and asked if there was some way --you were supposed to come in to Atlanta for interviews --so I asked if there was some way I could possibly do the interview with one of their alumni, the way you could for applications to medical schools or grad schools in those days. I happened to telephone in to the office of [Dr. Philip Brachman, Sr.] Phil Brachman, who was head of the EIS Program at the time, and he was quite--I got him at a good moment, because he said, “You know, the word came out in the office that ’Phil, you have a call from Malaysia, a telephone call from Malaysia.’” Anyway, he was quite charmed. I said, “Is there any--I’m very interested, 00:10:00but is there any way I could possibly do the interview--I could scrape together the money to come to Atlanta, but is there any way I could possibly do it overseas with somebody who has credibility?” He said, “Well, actually, I’m going to be out visiting in Dhaka [Bangladesh]. Let me check that. Yes, I can come back through.” He arrived one afternoon. He wanted to see some things, so I took him out to the Aboriginal hospital where I did a lot of work. I got a Malay driver who couldn’t speak English. Phil and I talked in the car all the time, and I knew this guy, Yakob or whatever his name was, couldn’t understand us, but I could tell him directions because I had fairly good Malay at that time. Phil was enchanted by all this stuff. Then he met my wife and essentially said, “You know, based on your experience, your record, you’ve been in the Army, you’ve got this, that and the other thing. You know, I think you’ll be 00:11:00a good fit.” I said, “Can we offer you some dinner?” He said, “That would be--let me take you out to dinner, but take me someplace--let’s go to someplace where tourists don’t get to go.” We went to street vendors and he was absolutely charmed. He was out the next day, and I was in.

CHAMBERLAND: That has to go down as one of the more interesting EIS interviews--

DONDERO: That was an easier, less bureaucratic one. Maybe that one shouldn’t be on the record.

CHAMBERLAND: Needless to say, you were accepted into the EIS Class, and you were assigned to the Tennessee State Health Department.

DONDERO: I chose a state purposely. I had worked with a categorical couple of parasitic diseases; I wanted broader public health experience, so I wanted a state assignment so that I could do whatever came up. I had all sorts of things. The big ones turned out to the Legionnaires’ disease, but I had plenty of food 00:12:00poisonings in nursing homes and daycare centers and pesticide exposures and sudden deaths on the job and this kind of thing to deal with.

CHAMBERLAND: So the classic, well-rounded state experience?

DONDERO: Yes, and I dealt with the media directly, too. That was very, very useful.

CHAMBERLAND: Now, one final question before we shift our gears to AIDS: I did really want to follow up and ask you a bit about the investigation of the Legionnaires’ disease outbreak in Memphis, because my sense is that your investigation really nailed the association of the outbreak with contaminated air conditioning cooling towers. The original outbreak investigation in Philadelphia had been really unable to find a source. Can you tell us a little bit about that?

DONDERO: Yes, there had been the Philadelphia outbreak one year just before I came into EIS. In my first year in EIS, there was a Legionnaire’s disease 00:13:00outbreak in Kingsport, in upper east Tennessee near the Virginia border, the tri-cities area. It happened mostly at a hospital, including some people who had visited the hospital and some people that had been patients, including a couple of staff and a couple of people who had walked by the hospital. We never could find a source. But at that time, they were still pinning down--they had the organism and they had a serologic test, so we actually did a survey in Bristol, Tennessee, as a comparison, as well as in Kingsport, Tennessee, and we found just as much in the comparison city. So it looked like something that was sort of endemic or quasi-ubiquitous.

The following year there was an outbreak in Memphis at the big hospital, and it was almost a “gift.” There had been a flood, as I recall; it was in August, 00:14:00very hot summer, Memphis, humid and the river. The air conditioning had been knocked out by the flooding. They ran one auxiliary unit, which was based in a different part of the hospital, and limped along for a month before their regular ones came back online; then they took that [auxiliary unit] offline. The cases started about six or seven days after the flood, and they ended about 13 days after the auxiliary air conditioning cooling tower was turned off.

In the meantime, the pathology department had isolated the organism from water from that auxiliary cooling tower through, it was either a hamster or guinea pig they injected, old-fashioned stuff, and they’d isolated it. It wasn’t the first successful environmental sample, but it was the first one that was 00:15:00actually in a place related to an outbreak. I think it had been isolated from a stream somewhere else [in the United States]. We were, with an engineer from here [i.e., CDC Atlanta], able to pin down the-- we knew it was in that cooling tower. The engineer was able to figure out where the air intakes in this old hospital that had multiple-- they had all these different air channels to different parts of the hospital. It was like the London water supply in the classic cholera epidemic.

Sure enough, the attack rates were much higher in the people who had been in the rooms that had the air intake [from the auxiliary air conditioning cooling tower]. So, we had that epidemiologic evidence. The organism had been isolated from the water in the cooling tower, which hadn’t had biocides. Generally, the service people would put biocides, just to keep algae down, [but] they had happened to miss this one. There it was —the spray was there, you could see 00:16:00it, it was right outside the office we were working in. We had the organism from the thing [i.e., water from the auxiliary air conditioning cooling tower], and we had the cases linked epidemiologically to the vapor from the cooling tower. The next outbreak was somewhere else [in the United States], and I think they found it in an evaporative condenser, but then sprays and-- but yes, the Memphis investigation was the one where it was pinned down. I got the Langmuir Prize for that baby, and also my only New England Journal publication, first author publication.

CHAMBERLAND: Very elegant work. Very elegant work. Your EIS ended in ’79 in Tennessee, and it--

DONDERO: Oh, and then I was supposed to go overseas. I was going to go to Cameroon, where there was an immunization and internationally quarantinable disease surveillance thing. It was part of the old, what became [the] 00:17:00International Health Program Office, [Dr. Stanley O.] Stan Foster’s project. Then the fellow who was there decided he was going to extend for one more year, [Dr.] David Heymann, who had been the Ebola person at WHO. Anyway, I had one year to kill, so I came into Atlanta and worked in the epidemiology group in support of the field-based EIS Officers. During that time, there was a big crisis of all of the Vietnamese boat people, the refugees out of it, and then fairly shortly thereafter the Cambodians coming out into Thailand into refugee camps. I had worked in Southeast Asia for seven and a half years. I had worked in Malaysia, and my wife had grown up in Thailand. The island, I love the 00:18:00islands where the refugees were coming [from]. I had already worked in these areas, and I was relatively free in terms of job activities. I was the one that worked with our Quarantine Division on initially coordinating the response and getting people out to --young epidemiologists --out to the refugee islands and camps. That was that year. Then I went to Africa for two and half years of work. When I came back, I was with the International Health Program Office and AIDS was coming up in Africa during this time. I had seen plenty of STDs [sexually transmitted diseases] in Africa and risky behavioral patterns. You could just see it coming. I wound up joining the AIDS program in 1985. I had been back about two years from Africa before starting with AIDS.

CHAMBERLAND: How is it that circumstances arose that you made your way to the 00:19:00AIDS Program?

DONDERO: The International Health Program Office wasn’t--I didn’t see that as a long-term career thing. I wound up doing a lot with disaster relief, and there were droughts and civil wars in Africa in ’84, I guess. I was the lead epidemiologist on that before that was picked up over in what became the disaster relief group. But it was run by public health advisors, and they occasionally would tap an epidemiologist, me, for particular tasks. I could see that there wasn’t a career for me to get into that, as much as I would have liked it. After two years and having to do a lot of fairly bureaucratic backstopping work in the International Health Program Office, I wound up thinking I needed to change into another category. I had been to a management course; I had been with [Mr.] Wilmon Rushing, who was also taking one. I had 00:20:00worked with him a few years before actually, on a detail in Washington, D.C., interpreting the medical reports coming out of the refugee camps for the State Department. So Wilmon and I were up in Washington, and we got to know each other and hung out a bit. Now he was at this management course along with [Ms.] Frances Porcher, who was the editor and I guess MMWR [Morbidity and Mortality Weekly Report] person at the time. The three of us talked a lot, and I was interested--here’s a chance to learn something about AIDS--

CHAMBERLAND: Because Wilmon was, at that time--

DONDERO: Wilmon was there, and he was--

CHAMBERLAND: He was the public health advisor—management officer of the AIDS Program.

DONDERO: Had time on his hands. Yeah.

CHAMBERLAND: --working closely with [Dr. James W.] Jim Curran at the time.

DONDERO: Yes, he was. Then a month or two later, after I got back from this management course, I started looking at things differently, from a more management perspective. I said, “There’s not really a job for me in the International Health Program Office.” I mean, it was run by other people. The 00:21:00niche I wanted to do wasn’t the programmatic stuff; I wanted to work with disaster relief, and it just wasn’t there to be done. I started looking around, and I thought, “Oh, let me go back and talk to my friend Wilmon.” I talked to Wilmon, and apparently there was a need for somebody. Wilmon said, “Yes, let me talk with a couple of people.” Next I came over to talk with [Dr.] Harold Jaffe, who was the first one I spoke with. Then with Jim Curran, and this was at the time when the antibody test had just been licensed. I think it was somewhere around April of ’85.

CHAMBERLAND: Yes, March/April 1985.

DONDERO: It was for use in screening blood for blood banks. Then there was a conference on that, and Jim Curran thought, “If it can actually screen for the infection, not just for the advanced disease, isn’t there some way to put that 00:22:00into a surveillance kind of thing and figure out how much infection is increasing in the country before the disease starts?” --because there had been this very dramatic upward rise in cases. I had gotten partly interested in AIDS, though, because already there were reports coming out of Africa about how quickly it was increasing in the female sex workers and some other groups. It got me back to what I had seen in Africa. So that’s how I wound up coming into the AIDS Program.

CHAMBERLAND: You came on board as a medical epidemiologist initially. Were you tasked with advancing Jim’s idea, this idea of how can we use the antibody, the HIV antibody test, to--

DONDERO: Yes, to figure out, to figure out how much infection there is. That was a simple question. I figured we’d need to be doing sentinel surveillance. I 00:23:00had worked with sentinel surveillance on vaccine-preventable diseases in Africa, where you couldn’t get an absolute number, but you could get a trend. You could get patterns. The big question was, is this AIDS epidemic going to get huge, as it appeared to be, or is it leveling off, or is it going down? Is there some way we could tap into available blood samples to look at patterns in the country? I also fairly quickly wound up in charge of, for a brief period, AIDS Surveillance.

CHAMBERLAND: Chief of the Surveillance Branch.

DONDERO: Chief of that, and that was a limited period of time. I think [Dr.] Meade Morgan had been running that, but he was also doing all of the IT [information technology] and the statistical things. I had that for a while, and when we got the serosurveillance going, then the two of them became, you know, 00:24:00too much to run, so it [the branch] was split into a case surveillance group and the serosurveillance.

CHAMBERLAND: Indeed, about the time you became Chief of the Surveillance and Evaluation Branch in June of 1986, that was coincident with the Public Health Service Conference that was held at Coolfont, West Virginia. It was the work of Meade Morgan and others that reported at the Coolfont meeting that they were projecting that in five year’s time, 1991, the number of AIDS cases reported in the U.S. was going to be something like 270,000, at a point of time when there was only 20,000, only 20,000.

DONDERO: Yes. I joined when there were 13,000. People used to note how many cases had been reported at the time they joined. I joined, because I was fairly late among the early peak group.

CHAMBERLAND: Obviously these overwhelming numbers didn’t scare you off from taking the job.

DONDERO: No, it seemed like an interesting challenge. A couple of things to note: I had worked with sentinel surveillance in Africa, where you couldn’t count on, you know, all the measles cases to be reported. On the other hand, working with a few places, you could get patterns, and you could get increases and decreases. But I also knew about this trick with the blood, sampling blood that was already available for some other reason, because that had been done with the arboviruses in Tennessee. They would watch for West--and there wasn’t West Nile at that time, but Eastern equine encephalitis, that was the big one, also Rocky Mountain spotted fever. They would simply get a certain number of blood samples, every tenth blood specimen submitted for fever, and they would test it. Then they could see when seasonal Eastern equine encephalitis activity 00:26:00started in Tennessee.

CHAMBERLAND: These two things that you’ve just mentioned, the concept of doing sentinel surveillance and a methodology for sampling, these are obviously--

DONDERO: Yes, using existing specimens.

CHAMBERLAND: Existing specimens. These were going to be the same core features of this program. I do want to explore that in more detail with you. Let’s just try and set the scene a little bit more here, and discuss why was HIV serosurveillance really needed? After all, there was national AIDS case reporting that had been in place since ’81. As you mentioned, with the availability of the antibody test, we had several large groups like blood 00:27:00donors, the military, another group called the Job Corps, people who were trying to get into this Job Corps program--

DONDERO: CDC, by the way, did not have those data.

CHAMBERLAND: At the time.

DONDERO: At the time. I went to Walter Reed and used my old--

CHAMBERLAND: Oh, your military connections.

DONDERO: Army connections, yes. I had been with the Walter Reed Unit in Malaysia, and I went to Walter Reed. They were very cagey [about the HIV screening results] because they wanted to do research on them, and there were some pretty active people. We made a deal that we [CDC] would not be doing research on veterans, but we could follow test results for patterns and trends. But there was clearly a bias there, since two of the principal, known at the time, modes of transmission were discouraged or banned from the military. So, you’re going to have a lower risk population group in terms of the specific [risks].

The Job Corps we got onto because that was tapping into a group that didn’t have any behavioral restrictions. You could have been, in the past, a drug user, but as long as you were clean, you could go into Job Corps. You could have exposures out in society. Those groups were available, and the blood donors. But the blood donors were specifically screened on all sorts of things that might be associated with increased risk. We wanted to look at everything that was out there.

CHAMBERLAND: Let me ask you a little bit about--I want to follow back on a couple of things now that you’ve just said. The military, as you said, had implemented HIV screening of not only its new applicants, new recruits, people that were interested in joining, but also active duty. As you said, male-to- male sexual contact and intravenous drug use were obviously activities--

DONDERO: They were exclusionary at the time.

CHAMBERLAND: Exclusionary activities.

DONDERO: Including in the recruiting process.

CHAMBERLAND: In the recruiting phase. So, in your early discussions with colleagues at Walter Reed, is this where the initial brokering [took place] of an arrangement where the military would share its seroprevalence data with CDC? Is that where that was brokered, courtesy of you?

DONDERO: Yes, it was. I had Jim’s encouragement, but I went up to Walter Reed and I met with people, some of whom I knew from my Army time. They weren’t concerned about sensitivities, political sensitivities or [any] other. There were some who realized they were on a treasure trove of--and they had a lot of 00:30:00young research-oriented medical people in the military. There always have been. A lot of CDC was set up by people who had military experience. They saw this as a window on the U.S. epidemic, and they wanted to be the ones to do the research on it. They were okay with us using it for more surveillance purposes, and they couldn’t ultimately say “No” to CDC, but there was a lot of negotiation on who could do what with the data.

CHAMBERLAND: As you say, [the military was] obviously a select population, not anything that would--

DONDERO: Yes, the lead guy in the Army, and I’m blocking on his name, went to the University of Maryland and became very, very involved with the research there in AIDS. [NOTE: The name of the referenced individual is Dr. Robert Redfield.]

CHAMBERLAND: I’m blocking on his name as well. Similar, over time, similar arrangements were made with the American Red Cross, again, for them to at least share--

DONDERO: Yes, but they didn’t have a lot of HIV infection. The Job Corps came a little later. In the meantime, we had gotten the--those were passive surveillance, harvesting existing data. We started the more active [approach] to go out and seek out blood specimens that were available and actually physically test those.

CHAMBERLAND: Just to sum up, the feeling was that the serosurveys were needed, because obviously AIDS case surveillance was just telling you about transmission patterns that had occurred years ago.

DONDERO: Right.

CHAMBERLAND: Obviously, because there was, at that time, there were several 00:32:00years, easily, people had recognized between the initial infection and the development of end-stage AIDS. So, AIDS cases are--

DONDERO: Yes, and they were already figuring out what the median length of time was. The median was somewhere around ten years. Of course, there weren’t interventions in those days. Therefore, you could not tell if there had been some radical change in the past year or two, because that wouldn’t have shown up yet, couldn’t have shown up yet.

CHAMBERLAND: So we really didn’t have a window into real time, what was happening almost in real time with the epidemic.

DONDERO: Right.

CHAMBERLAND: As you said, there were real concerns. There were real questions with these projections that had been put out there--

DONDERO: Oh, at Coolfont. And from the other side, of a much more conservative political side, it was a feeling that this was being way overblown. There were 00:33:00elements within the administration that thought that this was being built up --that the public health people were feathering their own nests and they were building their job security.

Also, there was another very political element, and that was that this [epidemic] was establishing visibly that there was a large gay male population. Of course, they voted in this country, and this was giving them, in the view of some of the conservatives, undue political clout. They felt that the AIDS epidemic was a very indirect way, you know, if you’re basically a conspiracist, that the AIDS epidemic was a way that the gay community, and their fellow travelers, were building up the idea that there are really many more gay men out there than was thought. These were background things, but also there 00:34:00were just budgetary issues, and it was at a time when the President didn’t even mention, publicly, AIDS.

CHAMBERLAND: That was President Reagan.

DONDERO: But there was to be--they decided they wanted to have a national survey that was going to be a big Gallup-type survey or some national sampling with blood testing. I thought this was going to be disastrous, and fortunately for us, CDC directly didn’t get the task. It went to NCHS, which did a whole series of surveys.

CHAMBERLAND: The National Center for Health Statistics.

DONDERO: Yes.

CHAMBERLAND: At that time, NCHS was not a part of CDC, I believe.

DONDERO: Right. But they got the survey task, and of course they couldn’t make it work, because it was not workable. In the meantime, we came in with these [sentinel surveys], lesser ones, the “Family of Surveys.”

CHAMBERLAND: Let’s talk about the “Family of Surveys.” All of the surveys, and we’ll talk about some of them, I think, in a little bit more detail, were done in an anonymous and unlinked fashion.

DONDERO: Yes.

CHAMBERLAND: Can you explain to us what that entailed? What does it mean to anonymize and blind a survey?

DONDERO: All right. There was some precedent for this, and we had to go through a lot of legal discussions with the legal office here. I wasn’t a lawyer, but I felt I was having to become one. The idea was, if there were blood specimens that had been collected for correct, normal clinical purposes--complete blood counts, everybody at the hospital got one, for example--that the leftover specimens, if you could permanently eliminate any identification and linkage to 00:36:00the person from whom the specimen came, that could be tested then, for the greater good of public information, surveillance and knowing where the epidemic was-- and it would not hurt individuals. At that time, you certainly could not--you still cannot--forcibly test someone for HIV or test them without their permission. If you ask permission, there would be some people who would say “No.” You’re going to have a participation bias, and that would defeat the purpose.

But there were other examples. I’ve worked in pathology, you know. I trained in pathology, and there were always the tissue banks at the hospital. There are always specimens, which you brought up for teaching purposes, for comparison. CDC benefited from [these specimens]--and Legionnaires’. There were blood 00:37:00specimens in the freezer from pneumonias of unknown etiology and outbreaks where they couldn’t find the agent. They went back to those specimens and documented that, wow, a lot of the pneumonias of unknown etiology, in fact, the severe ones, were Legionnaires’ disease, and it was sporadic, it was everywhere. So that pattern was there. I checked with the legal office, it went through IRB, too--

CHAMBERLAND: The Institutional Review Board.

DONDERO: It had to go through the Institutional Review Board, and it was proved that it did no harm. There was no harm to the individuals from whom the specimens came, because there was no way of linking them. Now, there was the other--the challenges were not that there were missed opportunities. That came 00:38:00later. The challenge was that autonomy has been violated; that a person should have control over what happens to something that came from that person. There are certain countries, particularly post-World War II, countries like Holland, who had felt so violated during the Second World War that they had--people had strict control over anything that came from them. An anonymous unlinked survey could not be done in that country.

But there was an ethical debate, and there were the ethics on the side of knowing what’s going on, when we may have an absolute major epidemic here. The argument used to be, that I made, was somehow that ignorance is unethical, when you have the opportunity without hurting anyone to learn what’s going on. But 00:39:00it was always debated.

CHAMBERLAND: Who were some of the individuals involved in these discussions, and were they just contained within CDC, or were these discussions that took place--

DONDERO: Oh, no, no. They were ethicists from outside. It was Bayer, Ron--

CHAMBERLAND: Oh, [Dr. Ronald] Ron Bayer from Columbia [University]?

DONDERO: Ron Bayer. He was, at the time, in New York at some institute there.

CHAMBERLAND: Columbia, I think.

DONDERO: Columbia, yes. He bought into this, and he saw on balance that this was the ethical thing. There were also in the newspapers, was it Jeff Levi? One of the early AIDS activists, with the gay activists, saying, “This is a way, yes, the information is important, it’s important to our community, it’s important to the country, but we can’t--we’re not just going to force people to give blood specimens.” There had been those sorts of murmurings that they weren’t going anywhere, we’ll just put people in a quarantine camp--we’ll 00:40:00just go and test them. We’ll just force them to be tested. This was a way that would defuse that. It would get the information without hurting individuals. But there were people who were against it, and I’m trying to remember who specifically. There was a prominent editor somewhere.

CHAMBERLAND: Did CDC actually bring in a group of external experts for a meeting about this, or were these informal--

DONDERO: There were some [meetings]. I’m not sure of the timing. I think we were already going on that, on the survey. I think they did get it reviewed, but I’m a little, a bit fuzzy on that.

CHAMBERLAND: Yes, because obviously, as you say, having the surveys completely delinked from the test result, there was no way to get back to an individual to give them their test result.

DONDERO: Right.

CHAMBERLAND: When you’re in that sort of a situation, obviously it becomes impossible to--people don’t necessarily know their status, and they don’t have access to information as to potentially how to reduce their risk of transmitting the virus to others--

DONDERO: Right. And then later came treatment drugs.

CHAMBERLAND: Right, AZT [azidothymidine]. FDA [Food and Drug Administration] had licensed AZT as the first HIV drug in March of ’87. All of that is happening about the same time.

DONDERO: But there were already test sites--they were initially called the “alternate test sites.” It was a place for people--

CHAMBERLAND: Counseling and testing sites.

DONDERO: “Counseling” --that was the later term. The “alternate test facility” or “alternate test site” or something like that, which was a way--there was a fear that some people would want to know their status, who maybe were worried about it and [would] go donate blood for the purpose of learning, because that was the only way you could get tested. This was a way that you could go to the health department, not donate blood, but get yourself 00:42:00tested. That then became counselling and testing. But they were [called] alternate test sites, initially.

CHAMBERLAND: I forgot about that term; you’re right.

DONDERO: There was the opportunity to get tested. Now, we didn’t know at the time that if you knew you were infected, that behavior could be changed in a beneficial way. There weren’t yet early treatment drugs and stuff like that. There wasn’t really much you could do for anybody except give them bad news. That changed later, and it changed as soon as you got into the mothers. Then there were issues of --but as drugs became available, as more became known about preventing mother-to-child transmission, then that got increasingly complex.

CHAMBERLAND: Okay. Let’s then get ourselves back to the beginning. There’s obviously been a lot of discussion about, as you say, the ethical considerations, the legal considerations, a lot of work to get that sorted. Let’s talk a little bit about the logistics of implementing the surveys. The first one was--

DONDERO: The first one was the sentinel hospitals, and that was directly patterned after my experience in Africa with sentinel surveillance of the vaccine-preventable diseases, and what I knew from Tennessee with how they tested the bloods from fever cases for the arboviruses at the time. We set up--we did it through contracts. We had to find hospitals that would agree to 00:44:00this, and that they would select the kind of specimens we were looking for, the ones that wouldn’t suggest AIDS, risk factors or related conditions. It’s the reverse of when you’re looking to see if Eastern equine encephalitis is coming through, you test the fever patients. This is the one where you didn’t test anybody that had fever or an infectious disease that might be associated with AIDS, or sexually transmitted diseases, or drug overdose patients and stuff. We worked with, particularly looking at orthopedic, general surgery, and other things that would be bland in terms of AIDS –that would just be the things that anybody could get. You could include people who had HIV, but 00:45:00excluding the infectious diseases--

CHAMBERLAND: You were wanting to avoid oversampling, inadvertently oversampling patients with HIV.

DONDERO: Yes, right. And we didn’t, because the hospitals are obviously going to get sicker patients; if people got Pneumocystis pneumonia they are going to come to the hospital. We didn’t want the pneumonia patients, or any infectious diseases. We were looking for the average citizen in an un-enriched sample. We had criteria for what specimens. I have forgotten how the pay was done, but we had a couple of public health advisors and contracts and stuff like this.

CHAMBERLAND: How did you select the hospitals, and was it difficult to get them on board?

DONDERO: We put out the word. It was a--what do you call it?

CHAMBERLAND: Solicitation for proposals?

DONDERO: Yes, for proposals, and I can’t remember if we knew a couple of places that people knew and tried to encourage them to do it. But there were 00:46:00places that--we had enough places that were from different parts of the country, because the typical CDC thing is, you bring in whoever is going to be the PI [Principal Investigator] at that place, and the infection control nurse or head of the lab or somebody would come in, and we’d set out criteria. Meade Morgan, of course, worked on a lot of the logistics on this stuff. That was--was that 1986?

CHAMBERLAND: I think that was about September ’86.

DONDERO: ’86, yes. I had joined in a little over a year before then. It took a while to get the concept and develop the concept. Then, pretty quickly, we realized there were some higher-risk groups that we also specifically wanted to check, such as STD clinics. You particularly wanted to include the men who had sex with men at STD clinics and drug treatment centers. Then we got into the 00:47:00fancier--. the blood spots from the heel prick of the babies, where they were being tested for, all newborns were to be tested for some of the--

CHAMBERLAND: Metabolic diseases.

DONDERO: Metabolic disorders that you could intervene with. The leftover specimens from there were actually a measure of the mother’s antibody situation. That was always, of course, the one that got the most difficult ethically.

CHAMBERLAND: Yes, we’ll go back and talk about that one.

DONDERO: So we had STD clinics, we had drug treatment centers, and I remember [Dr.] Eugene McCray did the STD clinics. Then we got into--by this time we had gotten the Job Corps data, but they were screening anyway. We didn’t have to test. They were already being tested; we just needed access to the data. Then the other one that was sort of cute was getting the blood samples from the college health services, and [Dr.] Helene Gayle was in charge of that one. We 00:48:00were looking at the rate of HIV infection in college students, and it really wasn’t very high, as I recall. It was hard to get lots of the specimens, but the rate was very, very low [in] college students, but it had to do with the age. The college students that did have the infection tended to be the nontraditionals, so they were the 28-, 34 year-old that kind of thing, who had come back to college. It wasn’t the Joe College, Jill College classical undergraduates.

CHAMBERLAND: It sounds like there was a real mix of survey populations, some you would have expected to have elevated rates of infection, like the STD clinics.

DONDERO: Right, STD clinics and drug treatment centers.

CHAMBERLAND: Then as you were saying, the university student population--

DONDERO: Well, there was worry. Were they spreading it fast?

CHAMBERLAND: There was a worry. What was the thinking? Why did you want to get so many different types of--

DONDERO: The model was the-- what did it use to be called? It was a thing used by the stock market where the leading--something about leading indicators. That term isn’t around anymore, but they had all these indicators--you had employment rates, you had this, that and the other thing. You had a whole series of different indicators, and then you --triangulate is a little bit elegant term --but you got a feel for it; a series of imperfect things that you could see the picture and watch trends. We felt we were better off if we could control the sampling conditions, that we could at least get trends that paralleled what was going on in society.

CHAMBERLAND: You mentioned a couple of times the Job Corps, so I feel like we should follow up about that. Can you explain a little bit about what the Job Corps was about?

DONDERO: Yes.

CHAMBERLAND: And who these people were? How was it that they were being tested, and how did CDC fit into the picture?

DONDERO: Okay, Job Corps was set up, I think it was in the mid-‘80s, somewhere around there. It was a training program for young people, I don’t know if you had to be under 19 or under 20 or something like that, who were from usually poor backgrounds, who had not done well or had dropped out of education, who were training in job skills where they could support themselves. So a lot of mechanical things, they did training for forklift operators and heavy equipment operators and things like this, and skilled crafts. It was set up purposefully for the poorest and the most disadvantaged of society. It included lots of 00:51:00minorities and included a lot of poor white people too. It was just a sampling of poor, young people, many of whom had dropped out of school because they were using drugs and other things. You couldn’t come in currently using drugs, as I understand, but you could have had a fairly active history of drug use. As long as you were sober at the time, you could join. So that it was a sampling of risks and there were no restrictions on sexual behavior and things like this. It was, in part, a sample of that part of society that, --they were already being tested.

CHAMBERLAND: So the Job Corps--

DONDERO: The Job Corps was testing.

CHAMBERLAND: Had on its own initiated testing of its entrants.

DONDERO: Yes, yes, and when we found that out, we quickly got hold of that information. It had an interesting side effect. When the distribution along racial lines became more apparent, there’s always these claims, ah, but it’s poverty, poverty is driving all this. Then you could look and say, well, anyone 00:52:00in the Job Corps has poverty and under-education and all these socio--what do they call them? The social determinates of health. They had all the bad things, and you could still see racial and ethnic differences. So it actually helped answer that question.

CHAMBERLAND: In preparing for the interview, I came across some statistics that I think give some hint of the magnitude of the task that you and your team were embarking on. You were establishing cooperative agreements to provide technical and funding support to 30 major metropolitan areas. In these 30 cities, there were more than 400 clinics and hospitals that were enrolled. By September of 00:53:001989, so roughly about a year, a year and a half, after things started rolling out, sentinel surveillance for HIV was going on in 41 states, the District of Columbia, Puerto Rico and 38 metropolitan areas.

DONDERO: I remember us being busy, but I didn’t realize it was that busy.

CHAMBERLAND: It’s a bit breathtaking to consider how much was rolled out in such a short period of time.

DONDERO: It was. We had great support, and I got--first, Wilmon Rushing made sure that this—and I had [Mr. E. Thomas] Tom Starcher, as I recall, who was a master--

CHAMBERLAND: These are two public health advisors.

DONDERO: Two public health advisors. They were the people who got stuff done. I mean, they used to say CDC was the docs and the public health advisors; the docs maybe came up with the ideas, but the public health advisors got them carried out. And we had people out in these places, too. We had our own reps in a lot of 00:54:00places as well. We were quite large at the time. They also covered surveillance issues, too.

CHAMBERLAND: What was the general plan then about how the project was going to be organized and managed? You had an Atlanta contingent, and it sounds like there were people stationed in the field--

DONDERO: In the field keeping them going. That’s the old public health advisor model, that you’d have your immunization reps and stuff. We had our surveillance reps. They already had them in important places.

CHAMBERLAND: So people, CDC assignees to do AIDS surveillance, were then also asked to tack on--

DONDERO: Serosurveillance.

CHAMBERLAND: Serosurveillance--

DONDERO: Right. There was a little bit of institutional resistance for a while.

CHAMBERLAND: I was going to ask you, what were some of the challenges, because, again, this is a pretty large scope of work.

DONDERO: Yeah.

CHAMBERLAND: Do you remember what some of the hurdles were?

DONDERO: Internally, I remember there were three public health advisors who worked with the surveillance. By this time, surveillance was, and this is by 00:55:00’86, surveillance had been going on for five years, it had become an--

CHAMBERLAND: AIDS case surveillance.

DONDERO: AIDS case surveillance had become a major institutional thing. There were careers being made in it, especially out in the states. There were patterns that they were starting to be comfortable with: the reporting systems were there, they were getting increasingly computerized --that’s what kept Meade busy. All of a sudden you want to add these surveys at hospitals in some of these areas, and the guys are thinking, that’s kind of frivolous.--you know, we have our job, because it was already, I guess comfortable would be the term.

CHAMBERLAND: They were in their comfort zone.

DONDERO: They were in their comfort zone. They could do their familiar stuff. We wound up adding a lot of people.

CHAMBERLAND: I was going to ask you, when the project started, do you have any 00:56:00recall about what your staffing level was and how it had to grow?

DONDERO: Yes, it was me at first, coming up with the idea of sentinel hospitals.

CHAMBERLAND: And were you personally the architect of that protocol?

DONDERO: Yes.

CHAMBERLAND: You were, okay. You and--

DONDERO: I’ve forgotten who else. The other thing started, my first year we got the Army data, and we started getting a couple of people who could work with the data. I was never that good on the computer with the large numbers and things. We had people who could do that. I’ve forgotten who they were now. But, with the sentinel hospitals, oh, I got a--he was [Dr.] Lyle--

CHAMBERLAND: Peterson?

DONDERO: Peterson was my public health resident--

CHAMBERLAND: Oh, Preventive Medicine resident.

DONDERO: Preventive Medicine resident. He came in from Connecticut.

CHAMBERLAND: So, two years--after finishing the EIS two years, many went on to do a third year.

DONDERO: He came in; he was going to do two years. Instantly, you know, we got this going, and all of a sudden, he was in charge of a whole bunch of the surveys. The sentinel hospitals came on, and he got [Dr. Robert] Rob Janssen in, who were--.and we had this German intern [Dr. Bernhart Schwartlander], and he worked with the things for a while, too. In the meantime, we were able to get [Dr.] Ida Onorato, who headed up the clinic-based surveys, and she got people in who were really good. We had actually great people. I’ve since been supervised by many of them. They were always nice to me.

CHAMBERLAND: What was the atmosphere like?

DONDERO: It was lively. It was lively all over the place. When I first joined the AIDS group, I remember that in ’85 you’d see the cameramen just lined up in the hallway we were talking about, you know, the sub-sub basement.

CHAMBERLAND: Of Building Six.

DONDERO: Of Building Six, and there would be cameramen in there. We used to say, you know it’s going to be a bad day when the 60 Minutes crew is waiting outside your office. They’d be waiting there, be waiting for Curran.

CHAMBERLAND: To interview?

DONDERO: To interview. Then they got people like [Dr. William] Bill Darrow and others. Jim arranged that we all have media training to be able to speak with the [press]--and I had, fortunately for me, done a lot of that in Tennessee as the EIS Officer. You’re not sheltered, you’re not the low person on the totem pole, you’re the big person on the totem pole. So, I had already been speaking with media on all kinds of things. But the training Curran arranged was particularly good, and the person that they brought in as the trainer also trained people who were political candidates and things like this. He had his Ph.D. in theatre from the Yale School of Drama, and his thing was, how do you 00:59:00present yourself? How do you, ultimately, use the opportunity of speaking with the media to get the public health message out when their agenda is something else? You know, whatever it is, not necessarily bad, but its selling time and catching eyeballs and stuff. And you’re trying to use them. [President] Donald Trump is probably the master at using media. But using the media to get the public health message out. Anyway, we had drama training.

CHAMBERLAND: Did you feel, did you personally or did your team, did you feel like there was a lot of pressure on you to deliver? Were there a lot of expectations that were being held within CDC, outside of CDC?

DONDERO: So many new things were being tried then, some of which succeeded. You got involved in one, “Project Iceberg.” But there were lots of initiatives, 01:00:00and not everything would work, but there were always so many new things. I don’t think there was ever a feeling of, I must accomplish this thing. You’re looking at more shotgun and lots and lots of things going out.

CHAMBERLAND: Now, as you also touched on earlier, it was soon after the surveys got up and rolling, this is when AIDS case surveillance and seroepidemiology formally split into two branches.

DONDERO: Right. It was just too much for one person.

CHAMBERLAND: So you became Chief of the Seroepi [Sero Epidemiology Branch].

DONDERO: Seroepi, and the case surveillance, which was also expanding. They were formalizing things, and they were upgrading all their reporting systems, because I think those reports used to come in on paper at one time.

CHAMBERLAND: Yes, that’s right. And then eventually [came] electronic reporting.

DONDERO: Of course, they’re cranking out research out of it and learning what you could from all of these things. I don’t know how many hundreds of 01:01:00publications [Dr.] Richard Selik has, but he was always putting them out.

CHAMBERLAND: I want to go back to the survey of newborn infants in a bit more detail, because we’ve touched on it a couple of times. To start us off, can you expand a little bit on your earlier comments and describe in general how was this survey conducted and what was actually being measured?

DONDERO: Okay. All infants in this country, at least that contact the medical system when they’re born, get a heel-stick blood specimen on filter paper for testing for these metabolic disorders.

CHAMBERLAND: Right in the delivery room, I suppose?

DONDERO: Yes, it’s routine. But there are some delivered at home, and they bring them in and then they get the specimen taken. It’s a virtually universal sample of newborns. The mother’s antibody is in there, and so you had the 01:02:00chance to test for infection in the mother. It didn’t tell you anything about the baby, and they hadn’t by this time come up with ways of preventing mother-to-child transmission. But with those specimens, they’ll tell you, [it’s a] 100% sample of the newborns and therefore, of women delivering babies. There was always some leftover specimen so you could test that for the AIDS antibody, I mean the HIV antibody.

CHAMBERLAND: But it reflected the mother’s status, because the--

DONDERO: The mother, yes. The babies were, maybe a quarter of them wound up getting the infection without any intervention.

CHAMBERLAND: Because they were, these antibodies, I think the term is passive--they were passively acquiring their mother’s antibodies.

DONDERO: They were passively transmitted antibodies.

CHAMBERLAND: Whether or not the babies were truly infected, only time would tell.

DONDERO: Right, as they essentially get all the mother’s--they just share the mother’s antibodies. You could measure--but here were the samples, they were 01:03:00already at the hospitals, so you just had to harvest those up or get the states to harvest them up. And the states bought into this. Some states went really vigorously; New York was a real leader on it. They were testing them, they weren’t sending them [to CDC]--our lab did a lot of the developmental work on those.

CHAMBERLAND: Yes, I was going to ask you, because--

DONDERO: [Mr. Charles] Charlie Schable in particular.

CHAMBERLAND: --because obviously, most HIV testing was happening from a blood sample that was drawn from a vein. Did this require some rejigging to be able to test blood off a filter paper?

DONDERO: I don’t know the details on that. Charlie Schable is the person I contacted and, of course, other technicians in there, but they had it worked out pretty fast. They felt that it was not a problem, and apparently it is not a problem. They can even get nucleic acids off filter paper.

CHAMBERLAND: You’ve mentioned a couple of states that were-- New York State came on board very quickly.

DONDERO: They were very research-oriented.

CHAMBERLAND: The State of Massachusetts, I believe, was the one that had first implemented [testing] on their own.

DONDERO: They may have, yes.

CHAMBERLAND: A survey. And I was just curious if they had engaged with CDC in the development of the survey?

DONDERO: I’m trying to remember. Maybe it was a researcher from there. There was somebody from one of those states; I had forgotten this part, there was somebody, and it may have been Massachusetts. They were testing for other things too. This is somebody who was interested in infectious diseases, and they used this--they may have started with the HIV, I’m not [sure]--but there were certainly some studies of other infectious diseases that had epidemiologic patterns that you might want to know about from a public health standpoint.

CHAMBERLAND: This survey, ultimately, I think was called the survey of 01:05:00childbearing women. How important a survey was this?

DONDERO: I thought it was essential, because it was a sample of the non-MSM--

CHAMBERLAND: Men who have sex with men.

DONDERO: Yes, men who have sex with men. It was the women, half of the population and not enriched with drug users. There were certainly some drug users, but it was a sample of the younger childbearing-age women population, and particularly younger women. There was some predominance, I don’t know, the median may have been in the early 20s or something. So, it’s a sample of the country basically, with specimens that were available everywhere. You didn’t have to do anything other than pay for them to be mailed in or pay them [state labs] to test them. So, it was a logistically relatively easy one to do.

It turns out the testing was easy, and the complexity then became on the ethical side. Once there were things that could be done, how could you test a specimen where you might have been able to--of course, it was after the baby was born, so you couldn’t intervene prior to it, and they didn’t know of postexposure prophylaxis at that point or the newborn prevention at that point. But it was becoming problematic. On the other hand, they were trying to get--here’s what it drove, it indicated how high the infection prevalence was and where, and it forced the issue of pushing for the interventions as soon as they were available. I’ve forgotten when, 076 was the…when was that?

CHAMBERLAND: I think it was 1994, the Clinical Trial 076 that was the one that--

DONDERO: That was the one that showed that AZT dramatically cut down--

CHAMBERLAND: Dramatically reduced the likelihood that a mother, an infected mother, would transmit to her infant.

DONDERO: Right. All of a sudden, once there was an intervention, we already had the data there to show how much infection there was, and it made it real to the obstetricians and that sort of thing. I think it was a major way, it was a good indicator of what was going on in the “general population.” But it also drove that very important intervention, which is one of the great prevention successes. They were already screening the blood and blood products and things like that. Factor VIII concentrate and things like that had been the early terrible things and had already been dealt with through biomedical intervention. 01:08:00But this then, we had the data to say how bad the mother-to-child problem was. So, I thought it was essential.

A similar thing has actually been used and is just about finished in developing countries, but it was promoted by the World Health Organization. Then the subsection of that became focused on AIDS, the joint “whatever.” They would use the specimens, the prenatal specimens, collected from pregnant women who were being tested or supposed to be tested for syphilis and standard [things], sometimes iron. They tested for other things as part of their prenatal care. They started using that internationally. Now, that was at a time when there was an intervention, so that [the ethics] became dicier. You had two ethical--and of 01:09:00course, we [Division of HIV/AIDS Prevention] didn’t do the international work. Global AIDS Program did support those surveys, though, but they had to be reviewed carefully, and they tried to do them only where there was diagnostic testing available and interventions available.

But on the other hand, if you didn’t look because a place hadn’t set up mother-to-child transmission prevention, if you didn’t document that it was high, there was less incentive to--by showing there was a problem, you could force the prevention to take place, the prevention programs to take place. The policy makers had to deal with it. I was an activist in that way, in terms of having the data not just to monitor forever what was going on but to indicate where there was a need for an intervention. We also were the ones that--by this time I was with the international work, and we actually led the charge on 01:10:00testing a workable version of 076 internationally. That became more problematic in terms of dealing with the ethical aspects than the other surveys.

CHAMBERLAND: So, domestically, the serosurvey of childbearing women-- soon after the results of that clinical trial demonstrated that AZT could really dramatically decrease the likelihood of transmitting HIV to--

DONDERO: We already had data by the time that came along.

CHAMBERLAND: Yes. Domestically, I think it was within months--

DONDERO: The survey had told you what the extent of the problem was.

CHAMBERLAND: But the survey in the United States stopped soon after.

DONDERO: It stopped fairly soon after because they were getting a very high rate of testing as part of the prevention of mother-to-child transmission. You 01:11:00didn’t need anonymous surveys anymore. And that was always the ideal: if you could use specimens that were collected as part of clinical service and they were being tested anyway. First of all, if they were being tested anyway, all you had to do was harvest the data. We had done that with the Army, with the Job Corps, blood banks, anywhere where testing was being done for service purposes, we were interested in those data. We didn’t have to bring those specimens in and test them.

CHAMBERLAND: It’s interesting that you--because by this time when the 076 trial data was available, and then the following year the domestic survey of childbearing women is discontinued, by this time you had--

DONDERO: I was already with the international group.

CHAMBERLAND: --moved to the international studies activity within the Division of HIV/AIDS.

DONDERO: We were still dealing with it internationally.

CHAMBERLAND: This actually came around in that international position for you 01:12:00that you had to revisit these issues and--

DONDERO: And the World Health Organization, and it was [Dr. James] Jim Chin, who was their advisor who had worked on this stuff in California. He had been part of the one--because he had been in Malaysia in the old group [University of California San Francisco] that I was in. He had been there before I was, but he was an alumnus and so it was an extra bond. He was the one that helped formulate this family of surveys. I used him to run ideas by. He was now advising WHO, and they wound up with a thing that was parallel to the family of surveys in WHO. In England, Scotland and Wales, they instituted a family of surveys. In fact, their whole team came over for about three weeks, seeing how we did it. They set up a 01:13:00similar thing, and WHO adopted it quite shortly after that.

CHAMBERLAND: So you consulted with Jim Chin very early on?

DONDERO: Early on.

CHAMBERLAND: To develop the whole survey idea.

DONDERO: Yes. Particularly not so much the sentinel hospitals, I think I had already done that, but particularly when it was set up in clinics.

CHAMBERLAND: In clinics, okay.

DONDERO: Because he worked with --the hospitals weren’t under the health departments --whereas the clinics all were--.

CHAMBERLAND: Okay, and Jim had--

DONDERO: And Jim had already been dealing with that. We had that other connection: we both had been part of the so-called Hooper Foundation with the University California San Francisco in Malaysia.

CHAMBERLAND: Do you remember you, people at CDC, people in the state and local health departments, when the results started coming in from the surveys, the childbearing women, some of these other surveys, were people surprised by any of 01:14:00the data results? Do you remember any sort of shock-and-awe moments where people said, “Gosh”?

DONDERO: There were some things. The fact that it was not roaring upward the way the cases were, because the cases were catching up to what had happened already with the spread of the virus; the fact that the prevalence wasn’t moving up fast. The fact that we could show that, at STD clinics around the country, that the prevalence of infection in sexually active gay men, who were showing up at STD clinics at least, was 25-30 percent. And in the drug users, it was very high, relatively high in the East Coast and very low in California and stuff like that. Those were somewhat surprising things.

The reactions, an interesting reaction --I’ve never told anybody this --I got 01:15:00on the first of the surveys when there was a--the professional survey people were outraged that this amateur ragtag of convenience surveys that were willing to look at a sentinel, to look at patterns over time, even if they weren’t exact numbers. But the professionals really wanted to pin down--there was a conference in Washington of these people. It wasn’t headed by the government, but it was prominent university survey people. I was linked in by phone and they were poo-pooing this sentinel hospital idea, that it really needed to be this major national survey, and do it right and not have a bunch of amateurs messing around, when they were the experts kind of thing. I remember being on [the 01:16:00phone] there, and they started criticizing. I said, “I’m sorry, I can’t see into the room, I can’t tell who is there, I gather that most of the people there are professional survey statisticians and performers. Is there anybody in the room, since this is about surveillance, who has done surveillance of a disease in order to combat the disease?” There wasn’t a single person. They were talking about a methodology that was being applied for surveillance purposes for disease control, and they didn’t have a single surveillance, they didn’t have a single surveillance person. I said, “I’m rather shocked, actually, that such a group would --on the subject of using surveys for surveillance purposes --and you haven’t thought to bring in a surveillance person, other than perhaps myself, and I’m appearing as sort of a witness here. I frankly don’t think you people understand what the issue is.” I 01:17:00didn’t spend a lot of time talking with them. A year or two later, after we had published the first results, I had met a woman somewhere, and she said, “I was in that room; I was in that room and I tell you, people were really outraged by what you said, and I was at the time, too, and I’m very glad you guys made it work.” I have forgotten who she was.

CHAMBERLAND: Some nice feedback.

DONDERO: It was nice feedback, anyway.

CHAMBERLAND: Just a couple more questions here, and then we’ll wrap it up. You were the lead author for a December 1987 MMWR supplement publication called “HIV Infection in the United States: A Review of Current Knowledge.”

DONDERO: Yes, I did that alone.

CHAMBERLAND: You did that alone. It’s quite large and very lengthy. The report 01:18:00is prefaced with a notation that it was prepared initially as a report to the President, as in President of the United States, and the Domestic Policy Council and was presented to the Council on November 30, 1987. I was a little bit curious about the origins of this report and the meeting.

DONDERO: No, that was 198--

CHAMBERLAND: 1987.

DONDERO: 1987, okay. Yes, I gathered all [the data] I could, I started--

CHAMBERLAND: This was a specific request that came to CDC from the White House?

DONDERO: Yes, I went up and talked.

CHAMBERLAND: At this Council meeting?

DONDERO: Yes. I presented, and I met two characters --I don’t know if this is appropriate --there were two individuals who were in the administration; one who was generally disapproved of, at least by the more liberal parts of the country, the Attorney General, [Edwin] Ed Meese, and then there was the Domestic Policy 01:19:00Advisor, who was [Mr.] Gary Bauer. Gary Bauer was--they still wanted a survey, he was one of the ones who was convinced that this AIDS epidemic was way overblown, and wanted to show that this really was just trumped up or just fear-mongering or something and wanted to show that it was really very low and marginal. Meese listened. Meese was courteous. Meese was --I liked Ed Meese and I had my opinion of him. I had never met him before and never since, but I actually liked the man. The other one, I had a different reaction. I started just figuring --there were all these bits and pieces of reports, there’d be somebody at a hospital who had tried a sample here, there were these bit and pieces of surveys, and so I learned how to use a spreadsheet and just--because 01:20:00[in] my day in EIS you used the line list--

CHAMBERLAND: The paper line list.

DONDERO: Yes, the line list. You could do it with a spreadsheet. And then look for patterns and yes, I wrote that.

CHAMBERLAND: Yes, that was it was a massive amount of information that was pulled together, and it was just as the serosurveys, many of them were starting to roll out.

DONDERO: Yes.

CHAMBERLAND: Before we finish up, I must ask you about the moniker, “The Family of Seroprevalence Surveys,” that’s how the program became popularly known.

DONDERO: And it had its own line-item budget.

CHAMBERLAND: How did that name come about?

DONDERO: Okay, we had this group of things, and I was seeing them as like the leading economic indicators, a series of things that measured bits and pieces. 01:21:00You know, a bunch of blind men touching the elephant, and you try to look at it in a vague but continuous sort of way. I had met up there, I forget the exact timing with regard to that time I was at the White House, but the pressure was on to do the national survey, which the National Center for Health Statistics got stuck with and it never wound up being able to be done. But in the meantime, we came in with this alternative, which CDC was doing, and we actually were starting to grind out some numbers. I had pulled together whatever survey stuff was available, and that document is what came out of it.

But a lot of the issue of family: there was always the term “family of 01:22:00curves,” which had been used in mathematics and things like this, and so it was a “family of.” I did biochemistry, and there are families of compounds, a lot of anthocyanins, for example, it was a family of anthocyanins and things like this, so it fit with a family. Then, of course, humor always came into it. The administration, which was resistant to a lot of things, was always proclaiming to be very family friendly, so how could they resist--we’ll do a “Family of Surveys.” They couldn’t resist it. The CDC Director at the time, [Dr. James] Jim--

CHAMBERLAND: Mason?

DONDERO: --Mason was extremely supportive. He was an old public health --I don’t know what his politics were --but he was an old public health practitioner. I think he had been an EIS Officer, but he was Health Commissioner in Utah, and he had a sense of dealing with reality and making the best you can 01:23:00out of the limited information you can get. He was extremely supportive, and he went for it. He was initially “Yes Sir” on doing the national survey, but very relieved that it was another institution that wound up with it. [NOTE: the NCHS became part of CDC in 1987.] So that’s how the family came out, and then it just caught on as a term, and we actually had a budget for the Family of Surveys.

CHAMBERLAND: So it follows that you are the father of the Family of Surveys.

DONDERO: Or the midwife or something like that.

CHAMBERLAND: Are there any aspects of the family that we haven’t covered that you’d like to mention before we wrap up here?

DONDERO: It’s just that the family--maybe it’s always done this way at CDC, but my experience with management, at which I’m not very good, is from Army 01:24:00experience. You have responsibilities that are defined and never shared by two people because that doesn’t work --”Oh well, he was supposed to do it.” So, there were people in charge of each subsection of the thing. The STD clinics had their chief, the survey in childbearing women, the college health office thing, they all had their individual people leading them. Then there were a couple of people: Lyle Peterson led the broader group and Ida [Onorato] led the clinic-based ones. Virtually all the people who headed up those different surveys went on to quite prominent things, some of them in HIV and AIDS, some of them elsewhere. The last-- two of the Division of HIV/AIDS Prevention [DHAP] directors were heads of important surveys. The DHAP [director] was somebody I 01:25:00hired for our project in Uganda, [Dr. Jonathan] Jono Mermin. I had been supervisor, at one time, of all of them. But people like Helene Gayle were in there, who went on to great things. Ida was a champion, and [Dr.] Marta Gwinn has done very well. There were just really good people there.

CHAMBERLAND: You continue to work to this day on HIV/AIDS.

DONDERO: I’m cruising on my laurels. It takes a senior person to tell somebody “Uh, that’s not very well written, that’s not coming across clearly.”

CHAMBERLAND: Have you ever reflected back on how these years that you’ve spent working on AIDS have affected you professionally and personally?

DONDERO: I haven’t really thought of it quite that way. It did get me back into international work, yet again, after the time with the serosurveillance. By the way, when I formed that, there was a gaping need for somebody with the international activities. Helene Gayle had run it, and she was called to Washington, as I recall, and it went unfilled for a while, so it was drifting.

But things were changing with the serosurveys by this time. There were new things coming in, there were new initiatives that needed doing, so it was good for somebody new-- and the other stuff that I had worked on was pretty well 01:27:00established. But I did get back into the international work, which I’ve always enjoyed and I keep coming back to. The last time I was overseas, other than Canada, the last time I was overseas was in Madagascar. That was getting HIV surveys going in Madagascar. I thought the time in Africa was good. One of my kids went in the Peace Corps there. She met her husband, who was also in the Peace Corps there, and one of his buddies wound up marrying another of my daughters. I guess it’s--

CHAMBERLAND: International--

DONDERO: Family connections.

CHAMBERLAND: Connections, rubbed onto your children. Tim, thank you very much for sitting down and chatting with us and sharing your stories as to how the Family of Seroprevalence Surveys got up and running. Thank you.

DONDERO: Thank you. Oh, I did notice--

CHAMBERLAND: A closing thought.

DONDERO: One of the most complicated things is getting those tables out. After all this work--

CHAMBERLAND: The data tables.

DONDERO: The data tables. I used to see that with the surveillance people. They are more polished at it now. Checking across is just horrendous work. Now that I’m reviewing rather than creating research work and I see these things, I’m just in awe of what other people have done--because I know what went into it.

CHAMBERLAND: Yes, and when you think back, it was still fairly early days, the late 80s in terms of all things IT. It’s been a revolution in terms of number-crunching and data output. Doing this in the late 80s was a challenge 01:29:00from an IT perspective, and still pen and pencil was probably used--

DONDERO: It was pen and pencil. For my early journal articles, including the one in the New England Journal, when I was an EIS officer in Tennessee, I had to draw the graphs. I used a drafting table over at Vanderbilt; I was able to go in there. I had done mechanical drawing in high school, so I had to draw those and you had the stencils for labeling. Now, you just put it up on the computer.

CHAMBERLAND: I’m thinking [about] all of these many threads, your engineering experience, your Army Medical Corps experience--

DONDERO: That turned out to have been very--

CHAMBERLAND: Your pathology experience.

DONDERO: Yes.

CHAMBERLAND: All of these threads, these strands of your training and background, actually ended up making you a good fit for the Family of Seroprevalence Surveys.

DONDERO: Yes. Surveillance. When I was an EIS Officer I used to think, eh, how 01:30:00boring. Then when I got to Africa and saw that they had no idea what’s going through and how much disease they’re seeing and being able to actually see it. And tracking a cholera epidemic by measuring vomiting without fever, and the clinic rate just going through, and you can see when the epidemic went through. And then surveillance in refugee camps, and just death, something as fundamental as death surveillance, just counting deaths. And immunization status and that sort of thing, all of these surveys. I became a great enthusiast for the need for surveillance. It’s never fun, but it’s essential.

CHAMBERLAND: Thanks so much, Tim.

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