Dr. Mary Chamberland

Mary Chamberland

MILLER: This is Dr. Bess Miller, and I'm here with Dr. Mary Chamberland. Today's date is December 9, 2016, and we are in Atlanta, Georgia, at the Centers for Disease Control and Prevention [CDC]. I am interviewing Dr. Chamberland 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, the Acquired Immunodeficiency Syndrome. Dr. Chamberland, do I have your permission to interview you and to record this interview?

CHAMBERLAND: Yes, you do, Bess.

MILLER: For this oral history on the early years of AIDS [acquired immune deficiency syndrome] at CDC, we will be focusing on the first several years, beginning in June of 1981 with the publication of the first MMWR [Morbidity and Mortality Weekly Report] on the five cases of Pneumocystis carinii pneumonia [PCP] among homosexual men. I know you worked on many aspects of the disease 00:01:00after this early period, and we will try to cover a few of those areas as well, but let's begin with your background. Would you tell me about where you grew up and your early family life, and then where you went to college?

CHAMBERLAND: I was born in Hartford, Connecticut. I grew up in Hartford and the surrounding suburbs and was the oldest of four children. My parents did not have the opportunity to go to college themselves, but they were adamant that their four children get a higher education. So after high school, I attended Regis College, which is a small and, at that time, all-women's Catholic college; it's since gone co-educational. I arrived at Regis in 1970 with every intention of majoring in American History or English and being an elementary school teacher. 00:02:00But that's not, obviously, how things played out.

MILLER: How did things change? What changed your mind?

CHAMBERLAND: My first exposure to hospital work was actually in January of my freshman year. The school had organized the academic calendar such that students were free during the month of January to do a nontraditional course of study, and you could actually create your own program of study. With the help of a family friend who was a nursing supervisor at the local hospital, I was permitted to shadow a couple of the infection control nurses at one of the hospitals in Hartford. I kind of liked it; it was interesting. Subsequently, during the next few summers I worked as a nurse's aide at the same hospital and 00:03:00just got increasingly interested in the clinical aspects of patient care. I started to have second thoughts about the elementary school teacher route, but I was thinking initially of nursing and that I would perhaps go to nursing school. I could have transferred out of Regis, but I essentially was just too lazy to think about instituting all the paperwork. I thought, I'll finish Regis and then transfer to a nursing school and get a Bachelors in Nursing. But I thought with that idea that I perhaps needed to lighten up on the Latin and the English courses and change my major to biology. I remember going to the head of the Biology Department and speaking with Sister Cecilia Agnes, or C.A. as she was known to one and all, and telling her of my plan and actually almost trying to 00:04:00have her talk me out of being a biology major. Science had never been my strong suit. I just was convinced I was going to flunk out. So C.A. just looked at me and she said, let's just have you take one day at a time.

I started taking biology and chemistry, and to my great surprise I really started to enjoy science and math. I had a fantastic math professor, Susan Williamson. Susan made calculus and number theory really understandable for the first time. At the beginning of my junior year, I found myself in Susan's office, and she said, hey, what do you think you're going to do? You're going to be graduating in a couple of years. I told her about my plan: I'll finish at 00:05:00Regis and then I'll probably go to a place like Cornell and get a BSN [Bachelor of Science in Nursing]. Susan looked at me dead on, and she said, you don't have to go to nursing school. You can go to medical school. I looked at her, and I said, I was thinking about that, too. She just looked and said, just go do it. At that moment it was like this weight had been lifted off my shoulders, and I thought, I know what I want to be when I grow up. It was just a moment of sheer happiness. I literally skipped back to my dorm, got in my dorm room, and the radio was playing [the song] "I Can See Clearly Now." I thought, this is it! I know what I want to do. So that, through the mentoring of some very caring professors, was how I found myself headed to medical school.

MILLER: That's a great story. Where did you end up going to medical school?

CHAMBERLAND: I had a little bit of a detour. I didn't get to medical school right away. I did apply my senior year and had several rounds of interviews at various medical schools. I encountered the same theme, which was, you're not a great standardized test taker. My MCAT [Medical College Admission Test] scores were fair. They said, oh, Regis College. We've never really heard of Regis. What does an "A" at Regis mean? We don't know what that is. So, I didn't get accepted to medical school. Senior year was coming to a close, and I was feeling pretty rejected and dejected. C.A. came to the rescue and said, look, take a year, start graduate school. I was accepted into Smith College's graduate program in microbiology as a graduate teaching fellow. I started taking courses at Smith, and I got A's at Smith. I went back and reapplied, and I said, okay, you guys 00:07:00know what an A at Smith means. To my great good fortune, I got an acceptance letter from New York Medical College, which was well-timed and spared me the anguish of having to think about writing a graduate thesis in microbiology. So it was at New York Medical College that I ended up .

MILLER: Excellent. How did you get interested in public health?

CHAMBERLAND: It turns out when I was in medical school, I actually did a two-month elective at CDC. This was at the encouragement of an infectious disease physician at the same hospital where I had done this shadowing of the infection control nurses. And it was fun. I got to go out on an outbreak of gastroenteritis at a college campus in New England with an EIS [Epidemic Intelligence Service] officer, and I investigated a mysterious rash illness 00:08:00among hockey players that was afflicting some members of the Atlanta Flames hockey team. I had been assigned to the Special Pathogens Branch, which at that time was headed up by [Dr. David] Dave Fraser, who obviously had a solidly minted reputation as a result of the very successful Legionnaires' outbreak investigation.

I had some vague notion of wanting to return to CDC, but I wasn't just quite sure how that would work out. After medical school I started a traditional three-year residency in internal medicine back in Hartford at a different hospital, Hartford Hospital. I was a pretty unhappy intern. I had a lot of-- it seemed like patients just did not do well. I had attracted patients with medical 00:09:00disasters. It was at the beginning of the second year I saw an advert in the New England Journal of Medicine. The U.S. Public Health Service was actively seeking physicians to get them interested in careers in public health and epidemiology.

At the time, public health and epidemiology were very underappreciated and understaffed disciplines. A career in public health was certainly not on any physician's top 10 list of medical specialties. As a way to try and attract interest in this specialty, something called the Epidemiology Program that was run out of the NIH [National Institutes of Health] was developed. The program was a one-year, fully paid year of study at a school of public health in the 00:10:00United States, and then a two-year "payback" at a federal agency; so CDC, FDA [Food and Drug Administration], and NIH. I applied for the program, and I was accepted. However, the acceptance came two years and two months into my three-year residency in internal medicine, and it was a really tough decision. A lot of my colleagues thought I was somewhat nuts to leave, being so close to finishing the residency. But I packed my bags and drove up to Boston and did a year at the Harvard School of Public Health. Then when it came time for placement, I remember having a conversation with [Dr. Philip] Phil Brachman here at CDC. Phil headed up the EIS program at the time, and he was kind of 00:11:00befuddled. This was all new; he'd never had anybody in this program. After a few minutes of conversation, he said, I'm just going to make you an EIS officer. I said, great! That's exactly what I want to do anyway. So in 1982, that was the year I entered the EIS program.

MILLER: Wow, that's fascinating and sounds kind of unique.

CHAMBERLAND: It was.

MILLER: You did your internship and first-year residency during the early 80s. Did you see AIDS patients at that time, or patients with the syndrome that would be known as AIDS?

CHAMBERLAND: Actually we did, and this is also an interesting tie to CDC. During my third year, the two months of the third year of my internal medicine residency-- which, by the way, I ultimately did end up finishing some four years later--I was in the ICU [intensive care unit], the medical ICU, as a senior 00:12:00resident. We had a patient in the ICU, a male with Pneumocystis carinii pneumonia, and we had no idea why this guy had PCP. He didn't fit the traditional risk factors, was not a renal transplant patient, didn't have some immunologic disorder. So we were really scratching our heads, as were the infectious disease attendings [attending physicians]. It was 1981, and the MMWR about those first cases of Pneumocystis pneumonia in gay men came out. In those days, the MMWR was mailed in the post, so it wasn't until early July. I was standing at the ICU desk, and the infectious disease attending came running into the ICU holding the MMWR in his hand, and he said, this is it. This is what our 00:13:00guy has. So we went over to the bedside, and of course, none of us had ever thought to take a sexual history. We asked him, do you have sex with men? Yep. Did he have sex with men in New York City? Yep. So this ended up being one of the earlier cases of AIDS nationally, but it was certainly my first exposure to having to treat a patient with AIDS.

MILLER: You came to CDC as an EIS officer in July of '82, and you got matched to a field assignment in New York City. You were one of the so-called field officers, the group of EIS officers that are assigned either to a city or a state health department. Can you describe the setup a bit in New York City for you as a first-year EIS officer? How was your assignment structured, and who 00:14:00were your supervisor and colleagues?

CHAMBERLAND: I remember during that matching process, when the new EIS officers tried to figure out where they wanted to do [for] their two-year assignment, I was really torn. I really thought hard about staying in Atlanta and going to the Hospital Infections Program, with all of this exposure that I had had to infection control. But I remember interviewing with the people from New York City, and [Dr. Pauline] Polly Thomas was the EIS officer a year ahead of me. She had been very involved in some of these early cases of AIDS; she had been one of the investigators for the case-control study of the disease in gay men. I remember really clicking with Polly and liked the idea of coming back to New 00:15:00York; I'd gone to medical school in New York. I ultimately opted for New York.

I arrived in New York in August after the four-week training course that we had in Atlanta that all new officers took. I remember thinking, okay, on the first day I'm going to set up my desk, get to know people and slide into this easily. I got there, and I was greeted by Dr. [David] Sencer. David Sencer was the Health Commissioner for the City of New York. After finishing his time as the CDC Director in January of 1982, he had been appointed City Health Commissioner. I was greeted by Dr. Sencer and Polly with, oh, thank God you're here, we're sending you out to the Bronx. There's been an outbreak of gastroenteritis in the 00:16:00newborn nursery. It's been going on for a couple of months, and we've been telling them we're going to send the new EIS officer. They were kind enough to get me to the Bronx in a City Health Department car, but I was then handed a subway map and told, you can figure out how to get yourself back to Manhattan using the subway, right? I said, yeah, sure. So, I plunged right in. No introductions.

A couple weeks later, Polly and I were boarding a cruise ship docked in New York City harbor that had had a big outbreak of gastroenteritis, again, among the passengers and crew. Polly was nine months pregnant at this point, and we were lumbering up the deck being greeted by this very unhappy captain, who for all the world looked like the captain of the Love Boat, all decked out in one of 00:17:00those white uniforms. We spent a couple of days on the ship interviewing the crew and working with the sanitation department officers at the health department. Finally, it was getting to be the end of August, and Polly clearly had some premonition that the days of her confinement were coming to an end. One night we stayed late in the office, and she just started really cramming in, okay, I've got to teach you about how AIDS surveillance works, how you take case reports over the phone, how you tabulate the data every month for the health department meeting that Dr. Sencer holds for all the clinicians at the end of the month. So I got this crash course, and sure enough, that evening actually, Polly went into labor. For the next two or three months I was head first into 00:18:00AIDS surveillance in New York City.

MILLER: Wow. You would have had a supervisor back in Atlanta as well. Did you have a supervisor that you related to on a periodic basis?

CHAMBERLAND: [Dr.] Lyle Conrad was the head of the so-called Field Services Division, and then under him were a couple of other individuals. They divided up the country geographically. [Dr.] John Andrews was my Atlanta-based supervisor of record and was very helpful. We had to at that time submit monthly reports from the field. There was a format, and you had to briefly outline what activities you had undertaken that particular month, meetings that you'd gone 00:19:00to, any travel that you had done, any media exposure that you had, and any uses of the federal credit card that you had charged. As things turned out, I certainly did have non-AIDS-related activities over those two years, but increasingly, I would say probably a good 85% of my time ended up being on AIDS-related surveillance in particular and AIDS-related investigations. I came to see people like [Dr. James] Jim Curran and [Dr.] Harold Jaffe, who were frequent visitors [as my "supervisors"]. They were frequent fliers to New York City, because in those early days New York and California were where the cases were concentrated, so they were coming up frequently. Particularly for the establishment of AIDS surveillance in New York City, I worked very closely with 00:20:00[Dr. James] Jim Allen, who had previously been in the Hospital Infections Program but had taken on a position in the AIDS Program as the lead for national AIDS surveillance.

MILLER: You mentioned that Dr. Sencer was a big presence, and of course, we know he was a big presence in New York City. Can you tell us a little bit more about what he was like in that role, his leadership style?

CHAMBERLAND: He was a fantastic mentor. As people often spoke about in Atlanta, his modus operandi in New York I think was very similar, which was he roamed the corridors and sought out his staff. Hey, what ya doing, what ya working on? What's new? He was very, very engaged with "his" EIS officers. That first year 00:21:00it was Polly and me. But in 1983 we were joined by a couple of additional EIS officers, [Dr.] Rand Stoneburner and [Dr.] George Rutherford, who had transferred into New York City from other positions. We had David Sencer's ear. He sought us out, and he pretty much had an open door policy. We didn't have to make an appointment. His Assistant Commissioners had to make appointments, but we could go in and talk to Dr. Sencer.

As the epidemic unfolded, it was-- the burdens of work just multiplied, and we really sought out his support, his guidance. His Deputy Commissioner was [Joseph] Joe Giordano, [a] longstanding CDC Public Health Advisor, and the two 00:22:00of them were a pretty strong team. Dr. Sencer was really engaged in wanting to share experiences or opportunities. I'll never forget: I was working late one night in the health department office, and Dr. Sencer shows up. He said, hey, come with me, we're going in the car to Gracie Mansion. Gracie Mansion is where the Mayor of New York City resides, and at that time it was [Mayor Edward] Ed Koch. The first cases of tampering with bottles of Tylenol had occurred, and, as you may recall, I think it was like little needles or sharps had been placed in these bottles. There was going to be a news conference at Gracie Mansion about this. He said, get in the car. I sat in the back of the Green Room and watched Koch and David Sencer engage with the press in an ad hoc press conference.

Another opportunity: there was a Public Broadcasting System [PBS] program called 3-2-1 Contact. It was very much an educational program but pitched to younger kids. They had contacted the New York City Health Department because they wanted to know, they were going to do a program on disease detectives -- and who could Dr. Sencer recommend in Atlanta that they could speak to. He said, go no farther. We have disease detectives here in New York City. So he got Polly and me engaged in filming a sequence of the show that actually centered around one of my early outbreaks, a hepatitis A outbreak in a pizzeria in New York City. 00:24:00They built up the story line about this, and the kids were customers at the pizzeria. The kids, who were actually eighteen years of age but looked much younger, all had scripts and dialog. They would set up the scene, and the kids would say their lines, and then they'd say, okay, Polly, Mary. Roll 'em. We had to ad hoc improvise this dialog. Thank you, Dr. Sencer, for some impromptu media training. He was a fantastic mentor.

One final thought: I was retiring from CDC. I was actually being seconded to the health department in London in the United Kingdom, and there was a retirement party or a going-away party for me. I didn't know this, but Dr. Sencer had been 00:25:00invited. There was a presentation, speeches or whatever, and Dave Sencer got up and presented me with a silver pin in the shape of an apple. He said, Ed Koch gave me this pin, and I'm passing it on to you. It took my breath away. That's the kind of guy Dave Sencer was.

MILLER: Great memories. In June of '82, just before you arrived in New York City, the MMWR reported 355 cases of Kaposi sarcoma and serious opportunistic infections in the United States occurring in previously health persons 15 to 60 00:26:00years old. Now, New York was reported as the state of residence for 51% of the homosexual males, 49% of heterosexual males, and 46% of the 13 females. Can you tell us a little bit about the atmosphere in the health department with regard to this new disease? What was the early thinking as to its cause? What were they hearing from clinicians managing these cases? What was it like then?

CHAMBERLAND: It was a pretty intense experience, because, as the figures that you just recited indicate, New York City was a real epicenter for this new disease. There was an intense amount of work associated with doing some of the 00:27:00very early investigations such as the case-control study and the lymphadenopathy study that you worked on, Bess, with New York City clinicians. People were just very committed to doing whatever they could to find out about what was going on. It was still very early days. I think by '82, by the time I'd arrived, as a result of the case-control study, people were really getting their heads around the idea that this was looking like a sexually transmitted disease [STD]. It was looking like hepatitis B in its modes of transmission. But it was still at a time-- and it's hard to remember that there was a time when we really didn't know for sure that transmission was occurring via heterosexual contact, via transfusions of blood or factor VIII concentrate, or that there were cases 00:28:00occurring in children, pediatric cases.

Before I arrived, as I said, Dr. Sencer started as the health commissioner in January of 1982. Within three months he established a meeting on a monthly basis, the last Wednesday of the month, that was open to all of the clinicians and academic researchers in the city. As you might imagine, obviously it was an academic environment. People were pretty competitive; they were wanting to publish about these new cases and whatever. But he was able to galvanize among the academic and clinical community a real camaraderie. So they came. Fifty, sixty of them would come every month to the health department, and the deal was 00:29:00that the health department would start each meeting with a summary of the national statistics and the New York City statistics on cases. In turn, one of the attendees from the clinical or research side of things would do a presentation, and people would talk. They would share, hey, have you seen this? We're seeing this.

It was a lot simpler time in terms of data analysis and presentation. The analysis of cases was being done in New York City at that time manually, by hand. We had our little calculators, and we tabulated and added up these 300-plus cases every month. We hand-drew epidemic curves and bar graphs. Polly's 00:30:00husband was an architect, and he had established a template for us, using that very nice printing that architects somehow know how to do. I remember carefully tracing his template to label the various graphs and figures that we had. It was an invigorating but very intense period of time in New York City and with the health department.

MILLER: It was still pretty early, and we know that it was a competitive publish-or-perish environment. Was there a lot of fear at that time?

CHAMBERLAND: There was certainly fear that was palpable, I would say, in the community at large, in the City of New York. As more information became 00:31:00available and the media started picking up on these stories, there was certainly fear out there in the community about the transmissibility of the disease and all sorts of wild ideas. Among people in the health department, the EIS officers and a whole cadre of public health advisors that we worked with, I don't think any of us were afraid. I remember talking to [Dr.] Donna Milvan, who was the head of infectious diseases at Beth Israel Hospital, and this was a hospital that was seeing a lot of cases of AIDS. She said that some of her newer house staff or other house staff or people in the hospital were very fearful, and they 00:32:00said, you know, but we look at you, Donna -- and Donna was actually also pregnant during this time --and she said, you go and you touch the patients, you examine them. She said that, in her hospital at least, provided a lot of reassurance to people. It was a time when there was a lot of not just fear but stigma and discrimination associated with cases of AIDS. A diagnosis of AIDS for some people meant the loss of their job, getting kicked out of their apartment, losing their health insurance and the like. It was a time that again, is hard to recall, because it now just seems so foreign an idea, since AIDS, sadly, 00:33:00regrettably, has become an established disease in the population. But in those days it did engender in people a lot of fear.

MILLER: You had a lead role in developing and implementing the first AIDS surveillance program in New York, and I believe this was the first in the U.S. as well. Let's talk about that a bit. Just to start out, surveillance is the basis of all work in public health. Can you tell us a little bit about what surveillance means and the different types of surveillance, before we get into some of the details of the one you worked on?

CHAMBERLAND: Sure. As you said, surveillance is essentially the tabulation of cases of disease and following trends in disease. As you said, surveillance 00:34:00really underpins a lot of public health. It allows you to establish trends over time. For various diseases you get to know if there is an increase in cases that appears out of the ordinary. Surveillance for most diseases is of a passive nature, which means public health authorities wait to hear about cases reported by physicians or others. You get an alert physician or hospital infection control nurse who calls you up and says, hey, we're seeing a lot of cases of whatever; it seems kind of unusual. So it can serve, as I said, as an early warning signal.

Surveillance for AIDS had been passive, and cases were being called in 00:35:00principally by physicians at the time, outpatient physicians as well as hospital-based physicians. There were indications that a year into this already we were seeing so-called "reporting fatigue." First of all, docs were really busy, and to phone in a case of AIDS was probably a 15- to 20-minute phone conversation to provide all of the information on a case report form that we were collecting: demographic information, information about the disease, testing, laboratory testing data about the opportunistic conditions, because still at this time no virus had been discovered. We were seeing the period of time begin to lengthen from when a case was first diagnosed to when it was reported to the health department; three or more months were beginning to elapse. Also, I think among physicians the novelty of it began to wear off ,and 00:36:00it was kind of acceptable, yes, this is now an established thing. Certainly, mandatory reporting had not yet been established by the state health department.

For a variety of reasons, people in Atlanta, people in New York, were really thinking that we needed to develop a more active approach to detecting and reporting cases of AIDS. Hence, CDC awarded in September of 1982 the very first cooperative agreement for active surveillance in the United States to the New York City Health Department. It was for a whopping $150,000. The whole idea of active surveillance is that, instead of passively waiting for a phone call, you, 00:37:00from the health department, go out and seek the cases. We spent a lot of time figuring out how we would go about doing this. [James] Jim Monroe was a public health advisor in New York City at the time, and he was the project director for the cooperative agreement. I was the physician director. The money allowed us to hire ultimately about six new public health advisors to staff up the office, because basically it had been Jim Monroe and myself and Polly that were doing all of AIDS case surveillance. Jim Allen was our Atlanta-based liaison, and Jim spent a lot of time in New York. Together we hammered out a generic protocol. 00:38:00The idea would be that we would pilot active surveillance in a subset of New York City hospitals for about six months, and then we would assess, revise as needed, and broaden the sample, and then we would evaluate the system. After it had been in place for about ten months, we would evaluate how complete active case surveillance had been.

New York City has seventy-five hospitals. How do we go about selecting what we thought would be fifteen? Jim, with his Hospital Infections Program background in Atlanta, calls upon the Program, and a second-year EIS officer, [Dr. Steven] Steve Solomon, was charged with pulling together an analysis of New York City 00:39:00hospitals for us. He produced this lovely ten-page report drawing on AIDS statistics, American Hospital Association statistics, and he characterized the hospitals. We knew already that the vast majority, about 75% of cases of AIDS, were already being reported by a small number of hospitals, the big, large teaching hospitals, about nine of them. While we wanted them to certainly form the bulk of our pilot, we wanted to expand beyond that, because the question was out there, hey, are there cases of AIDS occurring in smaller hospitals that are just not being recognized, not being reported?

Ultimately, with Steve's help, we selected a sample of 15 hospitals. As I said, most of them were the big teaching hospitals, but we had representation from 00:40:00hospitals in all five boroughs of New York. We had private hospitals, public hospitals, and VA [Veterans Administration] hospitals in our sample size, and we set off. We decided that it would be very important to visit personally each hospital, and this is where Jim Allen was just invaluable. He was another one of my fantastic mentors. With his background in hospital infection control, Jim knew everybody in New York City. All of the infectious disease docs, infection control people, the glitterati. Jim and I were going to a Memorial Sloan Kettering meeting with [Dr. Donald] Don Armstrong, the head of ID [Infectious 00:41:00Disease]; Donna Mildvan at Beth Israel; and [Dr. Lewis] Lew Drusin at New York Hospital. We would present the protocol and then figure out a way to tailor the protocol to the specific hospital. At the end of the day in each of these active hospitals, it was typically an infection control nurse who was designated within the hospital to whom all the cases of AIDS should be reported. On our end at the City Health Department, we identified a public health advisor who was their liaison.

For active surveillance to really work, the public health advisors would go out to the hospital every week, meet with the infection control nurse, and assist in the completion of the case report forms, because it often involved a lot of medical record review to get the details of the information that were required on the case report form. That was how active surveillance worked. We didn't 00:42:00completely want to ignore the remaining 60 hospitals, so we identified another 20 as what we termed "augmented passive" surveillance hospitals. The public health advisors called the infection control nurses typically once a week, every two weeks, but never went out on site to actually assist with case [report] completion. Then we tried to raise awareness among all hospitals in New York City through stories that we wrote in the monthly newsletter that the health department put out. We had a continuing medical education lecture for all of the infection control nurses in New York City and then the monthly meetings that I mentioned earlier. That was another venue that we could get the word out about case reporting.

MILLER: Sounds like it was a very impressive functional health department.

CHAMBERLAND: It was, and it's very interesting, because I hadn't appreciated it at the time, but David Sencer took charge of the health department at a time when the health department had really fallen on hard times. It had been decimated. There had been really severe budget cuts, and I subsequently saw a quote that Dr. Sencer -- attributed to Dr. Sencer because I guess a lot of his peers thought he was crazy to take on the health department commissioner job since it was in such dire straits. He said, when you're at your low point, this is a good time to build. And that's what he did.

MILLER: What did you do for the case definition for this surveillance activity? 00:44:00This is done before the cause of the disease is known and you don't have the virus, you don't have a test for it. You have a lot of diseases, but where do you draw the line? How did you come upon a case definition?

CHAMBERLAND: The case definition had pretty much been established before I arrived. I know that Polly had had interactions with some of the key clinicians in New York City, and they had had discussions in New York City about a case definition. But my recall is that for surveillance purposes a national case definition had been more or less established that health departments were using. It was, as you suggested, really based upon the diagnosis of a number of 00:45:00opportunistic infections or diseases. These conditions would not occur in an individual with a normally functioning immune system, and they had to occur in individuals who didn't have another reason or explanation for an immune deficiency. Obviously, it excluded people that had cancers or some of these classic immune deficiency diseases that had been described. We were using diseases such as Kaposi's sarcoma and Pneumocystis carinii pneumonia, and as the spectrum of diseases became better appreciated, more were added: CNS [central nervous sytem] toxoplasmosis, cryptosporidiosis, Cryptococcus, etc. I know [Dr.] 00:46:00Richard Selik in particular and others in Atlanta were very careful to establish diagnostic criteria for each of these conditions. It couldn't be, well, it looked like a classic picture of Pneumocystis on an x-ray. There really was, again, in these early days an effort made to use definitive methods of diagnosis, be it biopsy or serology.

MILLER: As months and then a year or more passed, were new diseases added? Was it a shifting case definition? Did that cause any problems in trying to assess trends?

CHAMBERLAND: Certainly as time went on, yes, conditions were added, and the AIDS 00:47:00case definition continued to evolve. For decades later the definition has continued to evolve, as more information has become known and the availability of virus testing and the like. It has always presented a challenge for analyzing disease trends over time. I don't think it was a particular problem in '82 and '83. Things were not shifting that dramatically then.

MILLER: You mentioned before that fortunately Polly's husband had some architectural capabilities to help you with reporting. Tell us a little bit more. This was still the era of paper-based reporting, the Stone Age to the current EIS officers at CDC. How did that work? How did reports come in to the 00:48:00health department, to CDC Atlanta, and then how did you report out without just having the advantage of pressing a button and having a nice report?

CHAMBERLAND: It was the age of paper and pencil. When I first arrived in New York City, they were still using a case report form that was typed up on the IBM Selectric typewriter. There were actually versions of this case report form that were manually printed out, but I think it had progressed to the point where there was a typewriter version of the case report form. As I said, prior to the establishment of the active surveillance program, case reports were being called in. You got a phone call, you were on the phone, and you wrote down the information on the report form. Then, once a week, the forms were mailed to 00:49:00Atlanta, and not just by us, but by every health department in the United States that was seeing cases. They were carefully reviewed, particularly by Richard Selik at CDC, who was just an incredibly diligent reviewer of forms and a real stickler for details. Inevitably, every week to ten days, we'd get a letter in the mail from Richard, and in it, in Richard's perfect block printing style, would be a series of questions about ten or fifteen cases that we had submitted: You left this blank; can you specify what diagnostic criteria were used for 00:50:00this? It was hard work to make Richard happy. Sometimes the information just didn't exist. So there was certainly that element of it.

We also, as I mentioned, we hand- tabulated the information; your basic demographic breakdown, men, women, by risk group, and age group. We hand-drew the bar graphs and the like. It wasn't until the beginning of 1983 that the first Wangs, or word processing machines, arrived at the health department, and it wasn't until later in 1983 that I think the cooperative agreement monies allowed for CDC to provide the health department with a personal computer. Pretty primitive times.

MILLER: What did you do about names in this reporting? Were you able to protect the confidentiality of patients' names? Certainly to receive a diagnosis of AIDS was very harmful to persons, as you described before. What did you do about names?

CHAMBERLAND: By the time I arrived, this was August 1982, my recall is that name- based reporting was still very much in place, and so was the procedure, not just for New York City but for all health departments. Somewhere along the line a national case form became available, and we all began to use the same form. The report form would have a patient's name on it, and we assigned a New 00:52:00York City ID number. Then these forms with names on them would be mailed in the U.S. post to Atlanta. Then Atlanta would assign them a national case number. Each case would have a national number and a city or state health department number. This continued until probably sometime in early 1983, when issues about confidentiality really started to percolate in New York City, but in other places as well. Members of some of the community groups that were impacted were clearly very worried. They were worried about the strength of confidentiality 00:53:00protection for this sensitive information. What levels of protection did a health department or the federal government have, if you will, to resist potential subpoenas or whatever for case names? There was a real concern about this. In early 1983, the decision was made that the New York City Health Department would black out the patient names on the case report forms, and we would send the case report forms in an envelope to Atlanta, identified by a New York City number. However, in a separate mailing we would include the New York City case numbers linked to a name. Atlanta was still getting names, albeit not 00:54:00on an individual case report form, but they had the linkage.

One of the reasons for this was there was a real concern about duplicate reporting. It was still at a time when there were probably close to a 1,000 cases of AIDS or so, but there was probably on a national level 10% to 20% duplication of case reporting. Atlanta had figured that out, because patients were mobile. For example, a patient might be diagnosed in his hometown and seek care out in a place like New York or San Francisco, where there were obviously many more clinicians familiar with the disease.

As the concerns became more vocal about this, Dr. Sencer called a meeting of the health department Institutional Review Board (IRB). I remember I was at that 00:55:00meeting. Jim Allen came up from CDC Atlanta and David Sencer and others from the health department, and we talked about the reasons why named-reporting certainly was very essential for the New York City Health Department. Dr. Sencer made the decision to establish a subcommittee of the IRB that was called the Confidentiality Committee. It would include members of the health department, but also it would include members from each of the affected communities. There was representation from some of the gay men in the community, IV [intravenous] drug users, Haitians, transfusion recipients, etc. A series of meetings began in May and continued on through the summer.

At the first meeting, the community groups presented their concerns, and there 00:56:00were several. They were very concerned about the flow of information from the health department to CDC, and obviously, the reporting of names to the federal government. They were also very concerned about just case reporting in general and the idea that this sensitive information was being collected as part of a routine case report. For many of them, they thought that informed consent was needed from the patient to consent to the reporting of this case. This was connected to the idea, is surveillance research, and if it is, certainly informed consent would be required. They were also very concerned about reporting by name to the health department; they didn't clearly understand why 00:57:00that would be needed or would be helpful. At subsequent meetings we worked through some of these issues. I think it was about the third meeting or so, in very early July of 1983, Dr. Sencer announced at the start of the meeting that by executive order, with immediate effect, the health department would no longer be sending names at all to CDC. All case report forms would go with a New York City number and no subsequent name reporting.

It was in a very short period of time, two to three weeks later actually, that on a national basis a new system of reporting was established. On a national level names were no longer being sent to CDC; a system referred to as Soundex, which was an alphanumeric way of coding people's names, [was used]. The code 00:58:00began with the first letter of someone's last name, and then there were these very arcane rules for how you transformed consonants and whatever into numbers or letters. That actually was done manually. The coding of names was done by our public health advisors. Obviously, over time, computer algorithms could be used or whatever. So it was in 1983 that name reporting on a national level stopped.

The health department made its case, however, that name reporting was still, to the City, very important. We emphasized that case reporting was not a static thing. The receipt of a case report was not where things ended. As new diagnoses 00:59:00became available or patients died, we needed to update case status and whatever, and that required a name to be able to do that. One further step that was taken by Dr. Sencer was to amend the health code so that AIDS case reports were afforded the same level of confidentiality protection as were cases of sexually transmitted diseases and information about substance abuse. They had a higher level of protection, and the code was amended to include AIDS cases in that same category.

MILLER: You've mentioned many times the public health advisors. CDC has a long history of placing assignees, and they were usually in that cadre of public 01:00:00health advisors to state and local health departments, to assist with disease detection and control. Over many decades this was primarily immunizations, tuberculosis programs, and sexually transmitted disease programs. I think they started placing public health advisors for this new syndrome very early on in the process, maybe late '81. Can you tell us a little bit more about this grouping? You've mentioned them for different projects, but it sounds like they were quite a presence in New York City.

CHAMBERLAND: The public health advisors, they made surveillance work. Much of the AIDS activities in New York City was very much as a result of their hard 01:01:00work, their know-how, their technical expertise. I think some of it might have reflected that in Atlanta -- and I think this was also replicated in many health departments -- that the initial investigations about cases of this new disease came about as an outgrowth of the sexually transmitted disease sections of health departments and certainly here in Atlanta at CDC. Early members of the task force, the core members, were drawn from CDC's sexually transmitted diseases group, and the public health advisors played a very prominent role in tracking cases of sexually transmitted diseases and their contacts. This was a 01:02:00very helpful skill to have in trying to track down cases of AIDS, and as we began to investigate in more detail unusual cases of AIDS, the public health advisors were just great at doing this.

And their training-- They had a lot of interview skills and techniques. They were very good at being able to put patients at ease to share very sensitive and confidential information. The ones that I worked with in New York City, many of them came from the STD [programs], but as our staff grew, many of them came from immunizations [programs at CDC and state and local health departments], and from tuberculosis [programs at CDC and health departments]. Jim Monroe was just a 01:03:00standout. He was the lead public health advisor at the health department -- I think he had come from immunizations [program]-- and they made things work. I learned a lot from the public health advisors, because I didn't know any of this.

MILLER: What were the key findings of the surveillance activity in New York City from your perspective? With the benefit of 35 years of experience, how do you look at it now?

CHAMBERLAND: As I mentioned, after we implemented active surveillance and it had been in place for about ten months, we felt it was important to validate that system. To validate the system, you have to utilize a different method than your case finding. We validated the system in 12 of the 15 pilot active surveillance hospitals and in three of the augmented passive surveillance hospitals. Again, 01:04:00similar to when we had implemented active surveillance, we went and visited every hospital and spoke with heads of departments from microbiology to pathology and hematology. The whole idea was to find the diagnostic records for a subset of the opportunistic conditions. We selected six of them: Kaposi's sarcoma, Pneumocystis pneumonia, toxoplasmosis, Cryptococcus, cryptosporidiosis and atypical mycobacterium. We looked at a period of time before we had implemented active surveillance and then after. Hospitals didn't have computerized records either, so this meant combing through pieces of paper, 01:05:00laboratory slips, laboratory reports, pathology reports, and log books. We hired three or four professional medical record technicians, and each of them went with the designated public health advisor to that particular hospital and in one month went through 350,000 pieces of paper in these fifteen hospitals. We had developed a typewritten data collection form, and we had all agreed that for confidentiality to be strictly maintained, personal identifiers would never leave the hospital, nor would the health department bring its personal identifiers, its case files to the hospital.

The way things worked is, we had developed a prototype spreadsheet, if you will, on a legal piece of paper, a big piece of paper, where initially the record technicians would record a patient's name and accession number, medical record number, every time they found one of these diagnoses, [as well as] record some additional information. Then, the public health advisor for that hospital would pick up the telephone and call a contact in the New York City surveillance office. Over the phone they would try and reconcile records to see if this patient with a diagnosis in this hospital of Kaposi's sarcoma had previously been reported to [the] health department. It was time consuming, because sometimes the demographic details didn't quite match and sometimes it had been reported from another hospital, whatever. All of this was done over the phone, 01:07:00the matching. Every night, the technicians would hand in these legal-size pieces of paper to a designated point of contact in the hospital, who would lock them up. Every morning they'd be unlocked. When we finished at a particular hospital, the identifying information had been recorded on the left-hand side of the piece of paper. We literally took scissors and we cut the left-hand side of the piece of paper off and left with the hospital the names and medical record numbers, with no indication to them whether or not these were indeed cases of AIDS. We left with the right-hand side of the paper, which had the New York City case number.

Our findings demonstrated that prior to active surveillance being established, there actually had been pretty complete reporting, 90-plus percent. It improved 01:08:00with active case reporting, and also what dramatically improved was shortening the period of time from diagnosis to case report. I think it ended up we went from about 50% to 75% being reported within one month. Also, the process of active surveillance recovered a whole backlog of cases that had been somewhat incomplete or whatever and were just in a holding pattern. It verified that among the active surveillance hospitals, we really were seeing most of the cases, and even in the modified passive surveillance hospitals, we were getting most of the cases. That was good news.

It also verified that [for] these smaller hospitals that we had included in the 01:09:00pilot that weren't reporting a lot of cases, that was actually true. We didn't uncover any new cases. It set the pattern, and for many years active hospital-based surveillance became the national norm. It made sense at the time, because most patients ended up in a hospital as their AIDS progressed and they required treatment for these opportunistic diseases. Obviously, as antiretroviral therapy became available and AIDS essentially became a chronic disease, this type of surveillance system doesn't work. It's been changed dramatically over the decades, but at that point in time a hospital-based system was pretty effective in capturing cases.

MILLER: Moving away from the surveillance, you also did work, for example, on AIDS in prisoners in New York City, Rikers Island. Do you want to tell us a 01:10:00little bit about that? I think you actually did develop a surveillance system for the prison also.

CHAMBERLAND: We did, we did. I had several encounters with Rikers Island. The first was a Dr. Sencer Special. I was in my office, and Dr. Sencer came in, completely unannounced, ad hoc. Mary, I need you to go to Rikers Island. The guards are kind of agitating. They are really concerned about getting AIDS from the prisoners. I've arranged for a car, and you're going to go over to Rikers with people from the Department of Corrections, the medical director. "Really? Okay. What am I going to do?" "You're just going to inspect the place and reassure everybody." So, I got in the car. It's summer, I was thinking, oops, wardrobe malfunction. I was wearing sort of a sundress. It had 01:11:00sleeves and it was long, but it had slits on either side, big slits. This was not what I would choose to wear to Rikers Island, but there was no time for a change of clothes. So, we drove over Rikers Island bridge to get to the prison, and what an eye opener. We were in an official Department of Corrections car. We got stopped, and the car was searched. Security personnel pulled out the back seat of the car, they opened up the trunk, they looked under the car. Each of us was patted down; we were frisked just to make sure that we were not bringing any contraband into the prison. We got there, and I was asked to tour the facility.

AIDS patients at the time: they had at any given time two, three, or four 01:12:00prisoners with AIDS, and they were always in the infirmary. I looked at the infirmary and met with the infirmary staff and went through how they were dealing with issues that might involve blood and body fluid contact; how they managed laundry and drinking and eating utensils and the like. I went and saw other parts of the prison, such as the day room and the exercise area. It was pretty sobering. To get to different parts of the prison required the guards to unlock a series of two or three doors, one right after the other. They had these big key rings with keys that unlocked each of these doors. The doors would slam 01:13:00shut, and I remember thinking, Oh wow, this is really chilling. Talk about being deterred from any thought of a life of crime. It was a very stark, chilling environment. So the guards -- we had a number of recommendations to make: no, you didn't need to wear gowns and gloves when you drove a prisoner in a prison van. No, you didn't need to do special things with the laundry or the eating utensils. So things quieted down.

We did work with the Department of Corrections and established an active system of surveillance at the prison, as well as a couple of the hospitals that treated prisoners when they required medical care. I also had a second visit to Rikers about a year later, when the guards, as well as the residents of Queens, were 01:14:00very agitated about the prospect of mosquito-borne transmission of AIDS. The thinking was if AIDS is transmitted by syringe and needle, how is that different from a mosquito biting a prisoner who has AIDS and then flying over the East River into Queens and biting a resident of Queens or biting one of the guards in the exercise yard? The guards were wanting all prisoners with AIDS to be indoors at all time. That was another interesting visit to Rikers.

MILLER: How did you address that concern? There was a study on that in Belle Glade, Florida. Had that been done by the time you went to Rikers?

CHAMBERLAND: No. This was all pre-Belle Glade. I remember we asked CDC Atlanta for help in pulling together a statement or documentation. It was pretty 01:15:00minimalistic: to our knowledge, no, cases of [AIDS] would be unlikely. It wasn't the level of scientific rigor that you would like. That would come much later, as you said, with the studies that took place in Florida, where they actually looked at the ability of various insects to transmit AIDS, which obviously was not a mode of transmission.

MILLER: You were working quite a bit in uncharted territory here.

CHAMBERLAND: We were, we were. It was, as I said, it's hard to remember a time when these were viewed as real concerns and questions about modes of transmission. We were always looking for potential new modes of transmission, and a lot of that was happening in New York City. The first cases of pediatric 01:16:00AIDS were described in New York City. I remember visiting with Polly Thomas, who was a pediatrician, [Dr.] Arye Rubinstein in the Bronx in November of 1982. He sat down and described ten kids with disease, severe immunodeficiency, unlike anything that he had ever seen before. Infants, young children born to mothers, most of whom were IV drug users. What was this all about? It wasn't anything that had been previously described. We got calls from the infectious disease team at Montefiore [Hospital], also in the Bronx. They treated a large number of IV drug user AIDS patients, and [they were] calling up and saying, Hey, we have these women [who] swear on a stack of bibles they don't shoot drugs, but they have husbands or sexual partners who shoot drugs. Could this be heterosexually 01:17:00transmitted? We worked with [Dr.] Dale Lawrence at the end of 1982, investigating one of the very early cases of transfusion AIDS. This was about the time that the first MMWR came out about transfusion AIDS. These were all, as you say, uncharted territory, figuring out what this disease [was] and who the populations at risk were.

MILLER: As you look back on it, how did you experience all of that? Was it exciting? Was it anxiety provoking? What was your feeling about all of that work? It was so unique.

CHAMBERLAND: At the time, I'm almost embarrassed to say I found it exciting. I was a brand-new EIS officer, a real newbie. Hey, not too many people have brand-new epidemics drop on their doorstep with a new reveal. It seemed almost 01:18:00every week there was something new going on in New York or somewhere else. It was really incredibly exciting to get to work with such a wonderful team of investigators, both in the City, the clinicians and the investigators in the City, as well as people in Atlanta. Honestly, it was only decades later that I really came to appreciate the enormity of what was unfolding. I had really no idea. Thank goodness there were smarter people like Jim Curran, Harold Jaffe and others, who really, quite early on I think, saw where this was going. They saw that this was not going to go away, that it was going to be a disease that would 01:19:00establish itself and become entrenched. I didn't have any of that insight in those days. I look back and it is with profound humility and a sense of real gratitude that I was able to be at a good place at a good time with good people.

MILLER: There's one more group I wanted to ask you about. During this period, mid '82 to '83, the risk groups for the syndrome appeared to be, as you've mentioned, homosexual or bisexual men, intravenous drug abusers and their partners. Confusingly, Haitians, and those receiving blood or blood products were beginning to be recognized, but there was always a group with so-called no 01:20:00identified risk. You were involved in investigating this category and later directing a national surveillance and investigations for these [cases]. Can you tell us about those? It's sort of a basket category. Was that a large group, and what can you tell us about it?

CHAMBERLAND: There was a keen interest in the so-called "no identified risk cases;" cases that were reported without the already identified risk factors that you mentioned. A lot of energy and effort was spent, both in New York City and then nationally, in investigating these cases. The concern being, are there other modes of transmission that we don't know about that we should uncover? The 01:21:00proportion of overall cases of AIDS that fell into this group pretty much settled out at about 5% of the cases. Maybe in the early days it was 10%. It was never a big proportion of cases. When you analyzed the data, the vast majority of these cases had demographic characteristics that were very similar to the major risk groups. There were a lot of white males, young white males, and also individuals that demographically looked like and provided you with information that made you suspect that potentially drug use had been involved. I was involved in a number of investigations in New York City, most of them centered 01:22:00around transfusion cases.

When I left New York City and came to Atlanta and, as you said, worked on the national surveillance of no identified risk cases, I had a number of interesting cases that we assisted state health departments with. There was, gosh, I think it was in 1986 that we were contacted by the U.S. military because the Armed Forces had suspended distribution of a lot of RhoGAM [Rho(D) immune globulin]. This is Rh immune factor that's given to women who are pregnant who do not have an Rh antibody. If the child they are carrying does, it can set up an immune reaction and be very detrimental to the unborn fetus or the infant after its 01:23:00birth. RhoGAM was an immune globulin product made from pooled plasma from lots of donors, thousands of donors. An active-duty woman had been identified during routine testing for AIDS that the military had instituted of all of its active-duty personnel. She turned up positive, and it was a month after she had received this injection of RhoGAM during her pregnancy. They got very concerned, and out of what we would now say an abundance of caution decided to just discontinue use of the lot. This resulted in a series of phone calls with CDC and the FDA and the manufacturer of the product and the U.S. military.

It was decided that CDC was invited to participate in the epidemiologic 01:24:00investigation aspect. I was sent to a military base in the United States to interview this woman. She was amazingly cooperative. I was able to establish a good rapport with her, and she was very open to me about the full extent of the answers to questions that I posed to her about potential ways that she could have acquired the infection. She honestly had no idea about potential exposures that could have resulted in transmission of the virus to her. In addition to the interview with her, I reviewed her medical records and the records of her infant, and other clues started to emerge. Ultimately, this was a fairly 01:25:00complicated investigation that required the assistance of a couple of state health departments. We accrued enough data where we felt very confident that we had identified a risk factor for this woman.

This was ultimately published in the MMWR. It was a fairly brief report, but we felt compelled to publish it, because word had percolated out and people started to express concerns about these pooled plasma products. As we noted in the MMWR, a detailed investigation had identified a probable risk factor for this woman, and that's where things were left. To my knowledge, there were no additional problems with the use of RhoGAM or whatever. This was one of the more interesting and one of the more satisfying investigations, because so many times these investigations led to dead ends. You had strong suspicions about a risk 01:26:00factor, but you couldn't nail it down.

As you might imagine, the military had a lot of trouble finding risk factors among cases that occurred in its population. As I said, they had an active program of testing for HIV [human immunodeficiency virus] among all active-duty personnel. They would report cases among their personnel to the national surveillance system. We had a lot of no identified risk cases in the military, and they demographically looked very similar to some of our major risk groups. I'll never forget-- I had established a lot of contacts with some of the military public health people that were responsible for these investigations and 01:27:00for doing surveillance and epidemiologic studies among their populations. They were just really frustrated by their inability to get risk factor information.

I was invited to come to the Pentagon and talk to them about how we did no identified risk investigations nationally and in local and state health departments. I remember that there was a big discussion before I went. Jim Curran was involved and others about whether Mary should wear a uniform to the Pentagon, because by this time the wearing of Public Health Service uniforms had been instituted. We were doing it on Wednesday of every week, I think [that] was uniform day. I was petrified. Please, please, no. I don't want to go to the 01:28:00Pentagon wearing a uniform. I'm not at all versed on military protocol, and people will be saluting me and I'll have no idea what to do. The decision was made: don't wear the uniform. I remember checking in to the Pentagon, going through the security screening and the metal detector. I was met by one of the people that I worked with, and he was pretty high ranking. He said, Oh, I see you didn't wear your uniform. I said, Yes, there was a lot of talk about that, and [it was] decided I shouldn't." He said, It's probably not a bad idea. You're going to be meeting with a lot of high-level people, generals, , very-high ranking people. At the time I probably was a Lieutenant Commander or Commander, so [Department of Defense Pay Grade] 0-4 or 0-5. And the way things, I later learned, in the military, the way they work is people just look at how many 01:29:00stripes you have on your shoulder board. They said to me, If you'd gone in wearing a uniform with such a low rank, they would have immediately discounted anything that you had to say, because you would just not have been viewed as a senior-enough person. But coming, as you will, as a civilian with this supposed expertise in no identified risk investigations, at least I was able to get their attention and be able to chat with them about their situation.

MILLER: Through these various circumstances, did you get involved with the press at all during your experiences?

CHAMBERLAND: I did, and boy, it was trial by fire, learn by doing. And not doing 01:30:00a very good job of it, I might say. You didn't get media training. I think now EIS officers get media training-- no, no. Again, Dr. Sencer came into my office one day and said, "Mary, there's an interview with one of the local major affiliates." I don't know, NBC or ABC had scheduled an interview with Dr. Sencer about AIDS, an update on AIDS. He said, I can't do it. Something's come up, so I'm going to have you do the interview. Really? So [it was] another wardrobe malfunction study. It was another summer day, and I was wearing this polo shirt, one of the Lacoste polo shirts that were popular at the time, white, and some sort of skirt. I was taken to a room in the health department where they typically filmed these interviews. This very New York City newswoman came in and 01:31:00said, I'm looking for Dr. Chamberland, and I said, That would be me. And she said, Oh. She of course was dressed to the nines; high heels, very hip. She proceeded to look me over from toe to head at what I was wearing, and she turned to her cameraman and she said, Just shoot her from the neck up. I really obviously needed to get my act together in terms of wardrobe. I was actually surprised when I went back in preparation for this interview and I looked at some of my monthly reports that I was submitting every month to the Field Services Division. Every month there were numerous interviews with the New York Times, Bill Moyers, the New York Native, whatever.

But there's one more story. I think by this time I was in Atlanta, and I was scheduled to do a presentation at the Third International AIDS Conference in Washington, D.C. I guess this was about 1987, maybe. I was doing a presentation on heterosexual cases of AIDS. [These were] heterosexuals who had no use of drugs, the so-called "heterosexual contact" cases. Most of these were cases among partners of IV drug users or individuals with other risk factors. But there were some that we didn't have any other kind of known exposure. There was a growing sort of drumbeat among the so-called "general population" about what their risk of AIDS might be, and this almost hysteria that was beginning to percolate along about the risk of AIDS to all heterosexuals. I was doing a 01:33:00pretty straightforward surveillance data presentation on this particular group of individuals. I was in my hotel room, and it was the morning of my presentation. I was getting ready and I had the television on, and it was one of those morning news programs, Today Show, whatever. The news report came on, and I was getting ready, and I heard "and today federal health officials are going to be reporting about the growing cases of heterosexual transmission among the U.S. population." I listened to it, and I realized, they're quoting data from my abstract. I thought, Oh my gosh, I think he's talking about my presentation. Needless to say, this was a little worrying. I did the presentation, but afterwards I remember being surrounded by a scrum of media. Good ol' Kent 01:34:00Taylor, who was from the CDC office, as it was called then Office of Public Affairs, was at the conference. Kent was a really big guy, over six feet. Kent came over and just literally ran interference for me and got me out of a situation that I was clearly being overwhelmed by. So, not so memorable media.

MILLER: In closing, I just would like to ask you a few questions about the personal aspects or impact of this work on you. You were a part of something that changed the history and course of public health. How has that affected you personally, would you say?

CHAMBERLAND: As I said earlier, it's only with the passage of time, decades, that I've been able to look back and realize what I was a part of. [I had] a 01:35:00pretty small part but something that I was very privileged to be a part of. I look back with enormous gratitude to so many people that took the time to mentor me and to show me the ropes and provide me with skills that I continue to use to this day. I remember sending first drafts of manuscripts about no identified risk cases or about the surveillance system in New York City to Jim Curran, and they would come back-- these were typewritten manuscripts, no word processing-- with red ink all over them. Jim always started off his comments with "good start," and then what followed was a long list of "I think you should do this; 01:36:00try this; shorten, but add more data." I just remember being so taken aback by all of this, but obviously, with people that take the time to spend on a manuscript like that, you learn. Again, it was only with the passage of time, when I found myself being a supervisor to a very junior epidemiologist, [that I] realized the hours of time it took to really go through a first draft of a manuscript and provide comments that would be constructive to the individual in developing the next draft. It certainly gave me a great start for my career skills that I continue to hone and use for years after.

It also left with me a very great sense of the value of teamwork, because I 01:37:00think so much of public health is teamwork. Despite some of the jostling with the academics in New York City, who were certainly out there to publish or perish, through Dr. Sencer's efforts, through the efforts of people here at CDC, I think we came to realize that AIDS was bigger than any one of us. It was really only through an intense collaboration and teamwork that we were going to be able to solve this, to make some progress in this. It affected me profoundly, and still does, for my career in public health to have been exposed to this at such a young and tender age.

MILLER: Any closing thoughts, Mary?

CHAMBERLAND: No, I think you've done a great job of pulling out some of the stories. It was, as I said, an exciting time, and it speaks a lot to the value of public health, to the scientific method. The fact that we really were able to elucidate the epidemiology of this disease before a causative agent was discovered, before a test was available. The epidemiology was pretty much mapped out, as were the early guidelines and recommendations about prevention of this disease. They really stood the test of time. It says a lot about the power of epidemiology.

MILLER: Thanks, Mary.

END.

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