Dr. James Curran (Part II)

James Curran, Part 2

MILLER: This is Dr. Bess Miller, and I'm here with Dr. James Curran. Today's date is May 3, 2017, and we are in Atlanta, Georgia, at the Centers for Disease Control and Prevention. I am interviewing Dr. Curran a second time as part of the Oral History Project, the Early Years of AIDS: CDC's Response to a Historic Epidemic. Today we are here to discuss your experience regarding CDC's early international work on what would become known as AIDS [acquired immune deficiency syndrome]. I must ask, Dr. Curran, do I have your permission to interview you and to record this interview?

CURRAN: You have my permission and my joyful anticipation.

MILLER: In 1983, that's about two years after the first cases were reported to CDC, there were a number of meetings in Europe in the spring and later in the fall, where European participants presented their cases of this new syndrome. In 00:01:00fact, in November of 1983 an MMWR [Morbidity and Mortality Weekly Report] report indicated that 267 cases had been reported, with 94 from France, 42 from Germany, 38 from Belgium and so on. Can you describe your thinking about these early cases in Europe as you were hearing about them?

CURRAN: The first pattern in Europe beginning in 1981 and 1982 looked very similar to what we were seeing in the United States, [with cases] predominantly in gay men in major cities, but about a year later cases were occurring in people from Central Africa who were going to the original country that they had been affiliated with, mostly Belgium or France, for care. There were people from what was then Zaire going to Belgium and people largely from Cameroon or other places in Central Africa going to France. They were seeing heterosexual men and 00:02:00women who were from Africa being diagnosed with AIDS and being cared for in the capitals of Europe.

MILLER: Following this a year later, [it was reported in the] MMWR, once they had identified ten countries that were being sentinel countries for surveillance, there were 421 cases and, again, 17 cases were reported from Haiti, 39 from Africa, following the pattern you've described. How did your thinking progress, and how was this connected to the U.S. cases? What was the thinking at that time?

CURRAN: In the United States, we'd seen recent migrants from Haiti, those who had been largely political refugees from [Jean-Claude] "Baby Doc" Duvalier, coming to Florida with conditions that fulfilled the case definition. They were 00:03:00diagnosed in a male-female ratio which was precisely that of the ratio among the refugees, that is, about two or three men to every one woman, similar to the refugees, which would imply that there was a new aspect of the epidemic. The new epidemic was also occurring in Haiti, as well as among these Haitian refugees. The cases there were rather similar to the cases among the African migrants to Europe. So it was very compatible with a heterosexual transmission epidemic, but there was yet no real proof of that mode of transmission. There had been clues from New York City earlier, where women who were sexual partners of men with AIDS or of men who were injecting drug users themselves were immunocompromised or had AIDS with no history of drug abuse themselves. I think many of us, 00:04:00particularly those of us with our STD [sexually transmitted disease] backgrounds, felt that this was an early indication of heterosexual spread.

MILLER: How did that affect your understanding of the Haitian epidemic in the U.S.? I know there was a lot of difficulty with the Haitian ministry and so on, of considering Haitians a particular risk group. When did it begin to be even more of a thought that this was a heterosexual transmission epidemic, rather than all of these Haitians being in the closet, men who have sex with men, and so on?

CURRAN: One of the most important things that CDC did in the beginning was accurate surveillance for AIDS with a very specific case definition. When a new pattern came up, since the cause was yet to be found, all you had were the 00:05:00diagnosed cases, and so it was much more difficult to attribute heterosexual transmission unless you had some sort of contact. The cases in gay men were easier to attribute to sexual transmission; they were all in gay men and there were a lot of studies they were doing that suggested that it could be related.

Among the Haitians it was different. The cases in Haitian migrants occurred very soon after there was a refugee migration of nearly 100,000 Haitians from Haiti to Florida. They were not occurring among previous Haitian immigrants in New York, Toronto or Montreal in the northeast, but only among these recent migrants from Haiti. There had been cases of Kaposi's sarcoma reported in the literature in Port-au-Prince earlier, even in the late 1970s, so it was very compatible 00:06:00with such a migration and new occurrence. The relatively equal incidence rate by gender would also be compatible with both the epidemic in Africa, which was starting to appear, as well as heterosexual transmission, as it would be with other STDs. But it was very difficult to prove that, and the coincidence of the autocratic dictatorial rule of "Baby Doc" Duvalier and the political turmoil in Haiti, along with the epidemic of AIDS, was an economic and social disaster for the country of Haiti. [Dr.] Paul Farmer has written in his book that it was wrong for the CDC to identify Haitians as a group who had a higher rate of AIDS or incidence of AIDS and perhaps even to preclude recent Haitian migrants from 00:07:00donating blood. But I thought that we really had no choice. We had to report the data as we saw it, and most of the cases in Florida were among Haitians. So it had to be reported as it came across.

MILLER: Now, 18 of the cases came from Zaire and nine from so-called Congo Brazzaville, so Central Africa. Did CDC have staff working in Zaire at the time? What were we learning about this burgeoning epidemic in Central Africa?

CURRAN: Zaire had been the Belgian Republic of Congo and then would become the Democratic Republic of Congo after [President] Mobutu's [Sese Seko] death, but it was the largest country land-wise in Africa and one of the largest 00:08:00population-wise in the continent. It had been a very important country due to mining of minerals, and it had been the site of the original Ebola virus epidemic in 1976, along the Ebola River in northern Zaire. CDC was actively engaged in that investigation. Several people participated in it, including Dr. [Joseph B.] Joe McCormick. Dr. Peter Piot from Belgium was also engaged. So we had done investigations in northern Zaire. Dr. McCormick had very strong contacts with the ministry of health and with the head of the hospital in Kinshasa, so he made a field trip on our behalf with his chief lab technician, who was a crackerjack named Sheila Mitchell. They went over there and were joined by Dr. [Thomas C.] Tom Quinn from NIH [National Institutes of Health] and I believe Dr. Peter Piot from Belgium. They did an initial survey and came back 00:09:00and reported to our very interested group at the CDC.

MILLER: What were some of the illnesses they were seeing, and what led to actually having a field station there, which would be known as Projet SIDA?

CURRAN: The hallmark diagnoses in the United States were Pneumocystis carinii pneumonia and Kaposi's sarcoma. At the time [diagnosing] Pneumocystis pneumonia required an open lung biopsy, and that simply couldn't be done in those types of circumstances in developing countries. More likely the [patients] had kind of a wasting disease, sometimes extensive tuberculosis, and occasionally Kaposi's sarcoma, but often other types of infectious diseases, such as disseminated 00:10:00toxoplasmosis, cytomegalovirus, and retinitis. When Ms. Mitchell and Dr. McCormick were to test their blood for immunologic status, they had a very depleted immune system, so it looked very much like AIDS, other than the specific opportunistic infections that we saw in the U.S. When Dr. McCormick returned, his information, even more than his exuberance, told us that we had to have a presence in Central Africa, particularly in Kinshasa. We didn't have an international budget then, but the budget we did have for research and for investigation about the epidemiology of the disease told us that we should be in Central Africa, where it would be very important not only for those in Zaire, but also for the world. So we vowed almost immediately to establish a project in Kinshasa.

MILLER: In retrospect that seems so totally reasonable. At the time, was there some question as to whether these two diseases or syndromes were related? After all, in Africa there are so many reasons for "slim" disease or wasting diseases. Disseminated tuberculosis, is common. What was pushing and motivating the sense that these were related?

CURRAN: The doctors in Central Africa had a similar feeling about this problem that we had in the United States, in the sense that they had not seen this before. They had not seen people with these types of diseases. Sure, they had seen disseminated tuberculosis, but the other types of wasting syndromes they just hadn't seen, and, furthermore, they were becoming very common. Mama Yemo 00:12:00Hospital, the main hospital in Kinshasa, had wards filled with people, and they were young men and young women dying of AIDS. In Africa people were used to children dying. It was tragic, but AIDS would become the leading cause of death in the continent, eclipsing all the childhood diseases, which had previously been number one. So it was the immensity of it and the unusual type of disease that convinced those doctors and convinced us. And there was a similarity in the faces, a similarity in the syndrome when you saw the patients. They looked the same.

MILLER: To head up this Projet SIDA, you ended up recruiting [Dr.] Jonathan Mann. Unfortunately, Jonathan Mann perished in a plane accident in 1998. Can you tell us about Jonathan Mann? I've heard so many things about him. What was he 00:13:00like? Why did you pick him?

CURRAN: Jonathan and I did not know each other. He was recommended, I believe, by [Dr. J.] Lyle Conrad at CDC. He'd been the EIS [Epidemic Intelligence Service] officer in New Mexico and then became the state epidemiologist. He was well known for a number of things. One was his ability to make a difference and to do hard work and very constructive important public health work. He was very articulate, and when he was a student at Harvard College, he took a semester a year abroad in Paris and became fluent in French and married a beautiful French woman. He had retained his fluency in French, which was the major language in Zaire, and he was looking for something different to do. I thought it was certainly worth the chance to call him. We had a chance to meet, and he 00:14:00volunteered on the spot. I insisted that he and his family visit first, so that they knew what they were getting into and that they were happy to do it. And they did, and then they made the decision to move there.

MILLER: Just to hold on to discussing Jonathan Mann more: what was his leadership style in Zaire? How did it turn out for him in Zaire?

CURRAN: During Joe McCormick's visit there had been an almost simultaneous visit planned by investigators at the National Institutes of Health and the Institute of Tropical Medicine at Belgium. Rather than go with competing trips at the same time, they elected to go as a team. We made the first move to establish a 00:15:00project there, but the NIH and the Institute of Tropical Medicine wanted to be part of it as well. The thought was that we would send an investigator from each of those two units to be part of a three-person team to found Projet SIDA. Jonathan Mann was the project director. That was as much part of the fact that we paid about 75 or 80 percent of the budget, and we insisted that he be the project director. The laboratory director was [Dr. Henry] Skip Francis, who came from the National Institutes of Health, and then there was a clinical researcher named [Dr.] Robert Colebunders, who was the clinical person from the Institute of Tropical Medicine. But, again, we had about 80 percent of the budget, and 00:16:00Jonathan Mann had about 110 percent of the control. He was an electric figure, larger than life, and was really unbelievable.

MILLER: How so?

CURRAN: He was absolutely fluent and oratorical in both French and English. He could be gracious, he could be overwhelming, he could be filled with ideas. He was very bold in all his approaches, and he worked with certitude. The other colleagues worked closely with him, but he was clearly the leader during his time period, his short time period, in Zaire. There were times when there was 00:17:00some rustling around about who's in charge and who gets permission to do what. All of them, as anybody in global health knows, have the tyranny of their home agencies to deal with and the expectations that they're showing their own agency that they're making a contribution. Jonathan Mann was the type of person--he was there for two years and that goes from moving there, and setting up a laboratory--and he was not a laboratorian--, using experimental HIV [human immunodeficiency virus] tests, because they were not yet licensed, and working in conditions he'd never seen before, both physical conditions and hospital and medical conditions. And he went and [got results] and published 22 or 23 peer-reviewed articles in that first two years. He just took over and did it; he hired a hundred people. He was a force of nature.

MILLER: How did it go with regard to the Zairois, the Congolese ministry and hospital leadership? What the relationship with Projet SIDA and the country?

CURRAN: The key representative was Dr. Bila Kapita, who was the chief of medicine at the Mama Yemo Hospital. A well-respected cardiologist and a visionary who welcomed us with open arms, provided space and provided some political cover. It was a difficult country because of the tyranny of Mobutu, and there were people around who were hangers-on of Mobutu. People that had to be feared but not trusted. So there was a lot going on in that part of the country, but I think in general Dr. Mann and his successor, Dr. [Robin] Ryder, 00:19:00were able to scoot around that pretty well. When Dr. Heyward took over, it was beginning to crumble, and the country fell apart. Eventually the project had to close.

But they were able to deal with the ministry of health pretty well, and the talent that they could recruit among the Zairois -- [they] eventually recruited two or three hundred people who were native Zairois, and the physicians that they recruited were absolutely top notch. When you have natively very intelligent people with no opportunity and you provide opportunity, you really get the very best people and the most motivated people. One doctor, his chief, a young doctor I remember, I met him, he had spoken five languages but not 00:20:00English. We challenged him to give the--Jonathan Mann gave the first talk on AIDS in Africa at the first international conference in Atlanta. Then there was the next conference in Paris. We challenged the Zairois doctor to give a keynote speech in English in the first year he learned English, and he was terrific. Unfortunately, shortly thereafter he died in an auto accident (and there was speculation that maybe it wasn't an accident).

MILLER: There was a lot of important work accomplished in Zaire. Are there some aspects that stand out in your mind of some of those early findings of Projet SIDA?

CURRAN: It seems easy, now that we know so much about how HIV is transmitted, to 00:21:00think about how you could learn about it when you didn't know the cause. There were a lot of concerns about household contacts, and there were studies done among household contacts who were not sexual and not birth contacts of AIDS. [These studies] showed no evidence of immunosuppression in large numbers of households where there were both mothers and fathers who had AIDS. There was also the relationship between HIV and malaria, which was first explicated by Dr. Alan Greenberg, who was an EIS officer traveling from the Malaria Branch and working with Jonathan Mann. It had been found that childhood malaria was closely associated with HIV, but when they did a study, they found out that it was closely associated with receiving blood transfusions, which then caused infection with HIV. That led to a great concern about blood transfusions for 00:22:00malaria in the developing world. The lack of evidence of arthropod-borne transmission was documented in Zaire. [These studies gave us] terrific information on sexual contact of HIV and sexual transmission from women to men and men to women. And then [there were] large numbers of cohort studies of opportunistic infections and other things.

MILLER: In terms of CDC's support of this international work or the HHS [Health and Human Services] support of this international work, was that an issue at that time? Were you using domestic funds? How was this received from the OD [Office of the Director] at CDC?

CURRAN: We were unfortunate to come into the AIDS epidemic early in the 00:23:00[President Ronald] Reagan administration, when there was a hiring freeze and essentially a funding freeze at the CDC. But we had an enthusiastic group of people who jumped on the problem, even though we didn't have much money. We were short of hard-to-fill positions like statisticians. We couldn't really hire people, but we could detail EIS officers like yourself and others to work on a problem, because it was obviously important. We didn't have much money, but then money did start to flow in 1982 and then a little bit more and more later. But it was largely for epidemiologic investigations and surveillance initially. I made the argument, I think quite successfully, and [Dr. William H.] Bill Foege was our director, that our epidemiologic investigation money would be well spent in Zaire, that more could be learned there for the same amount of money that we would spend in the United States. So that's how we started it. It wasn't "don't 00:24:00ask, don't tell," but it also wasn't advertised as an international project.

MILLER: Moving to a second international site, and that was Projet RETRO-CI, which was a site in Côte d'Ivoire. In 1987 you and Joe McCormick and [Dr.] Kevin De Cock went to the third international conference on AIDS in Washington, and there were a lot of presentations on different retroviruses and diseases in West Africa. Can you tell us a little bit about that and what led to the idea of actually having a second site in Africa?

CURRAN: When the virus was discovered in mid '85, a blood test was developed which could be used to screen blood donations, and it was able to screen out 00:25:00HIV-1 from the blood supply. When a second, similar but totally different virus in a way, HIV-2, was found in north and western Africa, Senegal I think, Côte d'Ivoire and other places, there was a big concern that this might be a different epidemic and that also it wouldn't be-- it couldn't be screened out from the blood supply or eliminated as a diagnosis for people who might be ill. So we felt that we had to learn much more about HIV-2, and that was reason number one that Côte d'Ivoire was an appealing site for studies. Reason number two was the potential instability of our project in Zaire because of Mobutu and the increasing political instability in his regime.

By then, Dr. Mann had gone on to found the World Health Organization Global Program on AIDS, and Dr. Ryder had replaced him in Zaire. Dr. Kevin De Cock, as an EIS officer, again I believe in malaria, had worked with us in Zaire and worked with Dr. Mann. He had gone back to the village in Zaire where the Ebola outbreak was to do a survey, because we discovered in some of the blood samples stored in 1976 a viable virus of HIV that had preceded the epidemic. He went back in '86, ten years later, and found the prevalence to be almost the same. So he had a strong affinity for working in Africa and was an outstanding scientist. During an earlier phase of his life, he had met and married a wonderful African 00:27:00woman in Kenya, and he was the right guy to go to Côte d'Ivoire at the time. He had some training not only in Belgium and the United States but also in London, and he brought a very esteemed colleague of his, [Dr.] Sebastian Lucas, who was a tuberculosis expert and pathologist, down to do some seminal studies in Côte d'Ivoire.

MILLER: Once again, was there support from your superiors, from the OD, to form this second site?

CURRAN: They either urged us to do it or we convinced them to do it, but it was not at all secret or anything. You know, it's a major commitment to establish a project like that, because you have to have the resources to guarantee the ministry and renovating the lab space and a lot of work. It's a major 00:28:00commitment, and it's a major commitment to the staff that you send over there. So it has to be done with a sustainable plan.

MILLER: Was this one in collaboration with other agencies, or this was only CDC?

CURRAN: I think it was predominately CDC, but there were collaborators from other countries who were there. I mentioned Dr. Lucas from London, and I think there were also collaborators from either Belgium or France. Dr. De Cock can tell you for sure. There was the Institut Pasteur in Côte d'Ivoire, and I know that they worked closely with Institut Pasteur offices in Côte d'Ivoire but whether they were directly involved in the project, I don't know.

MILLER: What happened to HIV-2? Was it found to be less significant, less 00:29:00virulent, more localized?

CURRAN: It was less virulent, less transmissible, and less prone to epidemics than HIV-1, and so what you think might happen happened. Initially when HIV-2 and HIV-1 were in Côte d'Ivoire, HIV-2 and HIV-1 were approximately equal in prevalence, and mortality was unknown. As it was shown that HIV-1 was growing very rapidly, HIV-2 stayed more stable, and eventually HIV-1 overwhelmed HIV-2 as the epidemic pathogen. But that wasn't known then, and it also wasn't known the range of HIV-2 viruses from which you might want to protect the blood supply, for example. So there was a need to have quite a few isolates and to do 00:30:00quite a few studies both in the laboratory and also for developing tests.

MILLER: So those were some of the important works done in Côte d'Ivoire. Other things--Can you tell us a little bit about the sexual mores in Côte d'Ivoire-- how that might have compared to those in Zaire?

CURRAN: In my impression, Côte d'Ivoire and [its capital] Abidjan was more of a tourist town. Some people have called it the Paris of West Africa. No one has called Kinshasa the Paris of West Africa. It was more of a large, bustling but less diverse town. I remember visiting both the staff in Kinshasa, which had grown to be quite large, and the growing staff in Côte d'Ivoire. In Kinshasa 00:31:00there were perhaps 10 or 15 expatriates and 200 Africans, almost all of whom were from Zaire. When we went to Côte d'Ivoire, there were maybe a half a dozen expatriates, and there were Africans from 10 or 15 different countries in the staff. They'd moved from Ghana, they'd moved from Cameroon, they'd moved from Nigeria, all other countries, and they had migrated to Abidjan as a place to live and a place to be. There were gleaming expressways. It was more of a destination it felt than Kinshasa. Now, all urban areas are destinations, but this was more of an international destination. The spread of the virus was much faster in Abidjan than it was in Kinshasa.

MILLER: Why was that?

CURRAN: It began with a low prevalence, much lower than in Kinshasa, and in a 00:32:00few years it was double Kinshasa's prevalence. It relates, I think, to the-- well, who knows for sure what it relates to, but it relates to the type of environment that the city had, of migrating populations and tourism and a variety of things. Special it is.

MILLER: It sounds like the collaboration with the Zairois was very good; similarly with the ministry in Côte d'Ivoire.

CURRAN: It was excellent in both countries.

MILLER: Why do you think that was? Would that be the same today if the United States wanted to set up a field station?

CURRAN: Of course the CDC and PEPFAR [U.S. President's Emergency Plan for AIDS Relief] have been setting up projects throughout Africa, I think largely with great success and great collaboration. I think that that has always been the 00:33:00experience of people from CDC working in Africa, that there are willing partners to deal with problems that affect their population.

MILLER: I guess that reflects on CDC's reputation, and I guess at that time CDC already had a reputation.

CURRAN: A reputation from working in Africa since its beginning, [with] the eradication of smallpox and problems like Guinea worm and the immunization programs that were going on in Africa, and consultations in a variety of other diseases.

MILLER: Moving along, in 1990 CDC formalized an existing relationship with the government of Thailand to form the CDC/Thai HIV collaboration. Can you tell us a 00:34:00little bit about the origins of that collaboration? Why Thailand?

CURRAN: It was evident that Thailand was seeing an explosion of HIV in their heterosexual populations. The CDC had a long-time collaboration in Thailand, as did Walter Reed [Walter Reed Army Medical Center] and the U.S. Army and the National Institutes of Health. We had an energetic young doctor, [Dr.] Bruce Weniger, who had been there with the Field Epidemiology Training Program and who knew the people in the ministry of health and the NIH of Thailand. It was suggested that we might once again learn an important part of the global AIDS epidemic. Thailand was quite different from the African sites. First of all, [it was] more of a mid-range income country, with a lot more capacity medically and 00:35:00capacity clinically to deal with things, a higher educational system, and a very good reputation for conducting studies. They'd been doing many vaccine trials and much work with Walter Reed for decades on a lot of tropical diseases. So they were keen to do it, and we were keen to work with them.

MILLER: Why the explosive epidemic in Thailand, and was it just serendipitous? Would you have found that in Vietnam and Cambodia if you had looked? What was special or different about Thailand?

CURRAN: Eventually, of course, it did go to Vietnam as well, but Thailand was close to the Golden Triangle, where there was a lot of drug use, with part of 00:36:00Szechwan China and Burma. There were epidemics there in injecting drug users that had been studied early on, and that was a major concern in testing the blood supply in those countries. From there, there was a situation where they jailed many drug users in Thailand, then released them. Following the release there was kind of a heterosexual epidemic going on, that was linking the widespread brothels in Thailand to military recruits and others who had been tested.

Thailand had a long history of open sexuality and common brothel use, but they also had open communications. They had a famous minister who had done terrific 00:37:00work in population control, who was really the king of family planning in Thailand when they chose to try to reduce the population growth. His name was Mechai Viravaidya, and Mechai was so successful in condom distribution and family planning. He would give all of the beggars condoms, and then whenever they got money, they would give people condoms. He became so well known that the nickname for a condom in Thailand was Mechai. So people would ask each other if they'd used the Mechai. When he saw the AIDS epidemic, he volunteered to the princes and to the head of Thailand that he would be the cabinet minister for AIDS. Thailand immediately did that, and they had TV shots every hour on the hour about AIDS education and condom use. They went to all the brothels, and 00:38:00instead of saying, we're closing you down, they said, we will close you down if you don't use condoms. They taught all men not to have sex without a condom.

They also had very good laboratories, so they learned-- they were the only country to learn from HIV prevalence, before people got sick, what was going to happen. The Thais did serosurveys and found that there was increasing incidence in the military, increasing incidence in other populations, and in commercial sex workers, and they said, we've got to do something about this before our hospitals get filled up. So they appointed Mechai as a cabinet member, and he took over and said, we're going to prevent HIV from occurring. And they greatly reduced the incidence. A remarkable story, really. They're not totally out of the woods, but they did a terrific job, and CDC was part of that, and we were 00:39:00there, with Dr. Weniger.

MILLER: So much important work was done in Thailand, [such as] prevention of mother-to-child transmission and others. Can you reflect on what you think some of the highlights of that were?

CURRAN: There was anxiety. From 1993 there was the AIDS 076 Trial, which was a collaboration between NIH and INSERM [the Institut National de la Sante et de la Recherche Medicale], [Agence Nationale de Recherches sur le SIDA [ANRS] of France] and the Canadians, to show that AZT [azidothymidine] given during the last stage of pregnancy, during labor and then to newborns, would reduce perinatal transmission from something like 25% to 8%, or two-thirds. Then the question was, what would you do in a developing country where most people don't deliver in hospitals, or when people can't be given drugs during the last stage 00:40:00of pregnancy, and you may not give it to the newborns? Could there be a simplified measure? In what was a very controversial study in Thailand, the next year a very large study was done, giving a simplified regimen with a placebo control, showing that would work.

The placebo control itself was very controversial and evoked commentary from the New England Journal of Medicine, [Dr.] Marcia Angell. defended by [Dr.] David Satcher, who was Director of CDC at the time, as well as the Director of the NIH. And at that point in time [the study] produced very important information, which people could move forward in developing countries with. In today's backdrop, with large AIDS programs around the world and the use of highly active antiretroviral therapy by everybody, particularly pregnant women, it's hard to imagine that study even being contemplated or being seen as important or being 00:41:00tolerated. But it was a breakthrough study at the time, conducted by CDC and the Thai government, but under a certain amount of scrutiny.

MILLER: Somewhere around the early '90s, you actually created an international activity in your AIDS division. What led you to that, and was there support for that in the agency?

CURRAN: Well There were a couple of things. One was that we were always anxious to support these studies, and the studies required a different type of support than domestic studies. There were concerns about currency valuation and exchanges, and concerns about visas. We often wanted to have people with different expertise from different parts of CDC assigned or working in those 00:42:00areas, and we needed a focus in our Atlanta office to manage that. In addition, we had opportunities to go to do short-term consultations internationally in units that were not supervised by us. So it was a focus both for our own staff and for staff of others to get involved in protocol, development and conducting studies.

MILLER: Did you have support from your supervisors and from the offices of the Director of CDC?

CURRAN: I don't remember ever not having support from those people.

MILLER: The joys of getting older.

CURRAN: There were times when our views might have been thought of as controversial, but I felt like I was always defended pretty well. We had some 00:43:00bumps in the road and everybody has regrets, but I think the support from the higher-ups at CDC, particularly for these types of things, was quite good.

MILLER: Over time you worked quite a bit with the World Health Organization. Any thoughts about CDC's collaboration with WHO during some of the early years?

CURRAN: We were fortunate that CDC had been working with WHO essentially since CDC's beginning in malaria control and other areas, so that there were many contacts. A very important one for us was Dr. [Walter R.] Walt Dowdle, who was actively engaged in the work with WHO in the STD area. Dr. Mann was then recruited to WHO by the Director General of WHO, Dr. Halfdan Mahler, and to work under Fakhry Assaad, who was Dr. Dowdle's good friend. Fakhry then passed away 00:44:00almost immediately, and Dr. Mann grew the global program on AIDS over the next four years into the largest program in WHO's history.

MILLER: Someone said that CDC's AIDS work and its international AIDS work changed the face of CDC. Can you comment overall on that and on CDC's international work on AIDS in particular?

CURRAN: CDC has always had a stronger international influence and interest than its budget would indicate. Periodically people at CDC who were scientists or staff or field workers would get engaged in international epidemic problems. As I mentioned before, the beginning of CDC was malaria control efforts in the late 00:45:001940s, which, of course, was a disease largely not domestic. It was of concern in the southern United States, but it couldn't simply be looked at as a United States problem.

Smallpox eradication was central to CDC's work, and many people at CDC worked on smallpox eradication. One of my colleagues, [Lawrence D.] Larry Zyla, would almost break into tears, saying that in his career he worked on the ending of one disease and the discovery of a new disease, both smallpox and HIV. It was kind of in the lifeblood of CDC employees to want to do global work, and, before many of their U.S. citizen counterparts, to see the world as a global world. I would say AIDS itself changed global health more than it just changed CDC, but 00:46:00CDC was a byproduct of that. Because AIDS was first recognized in the developed world and then in the developing world, there were so many thousands of scientists and workers who were knowledgeable about this new disease and concerned about it. That concern and knowledge migrated to Africa and other parts of the developing world and led to worldwide advocacy.

I think anybody who worked in global health before 1975 would never have imagined something like PEPFAR, where you'd have a global program largely supported by the United States and other countries, which would involve diagnosing and treating millions of people indefinitely as a commitment. That was not in the formula for international health work or global health work. So to some extent AIDS changed the view of global health. At the time the world was 00:47:00becoming smaller and smaller, and it made people think differently about it. CDC then developed a global AIDS program, which included TB and malaria as bigger efforts. It joined with its immunization efforts to really greatly expand not only CDC's presence but also CDC's commitment to global AIDS and responsibilities for global AIDS, because these were budgeted international efforts. These were not like our original ones, which were kind of begged, borrowed and rationalized from domestic funds. These were efforts when people said, here's money, CDC, go do this. And that changed the way we had to look at it. This was probably part of the reason for the commitment by Dr. [Thomas R.] Frieden to have a Center for Global Health.

MILLER: Any parting thoughts?

CURRAN: As we mentioned earlier, a lot of it's been reflecting back on the beginning of AIDS, and it starts with me by thinking of people: where were you in June of 1981? Where were you in '81? For those of us old enough to remember and who were engaged in it, we have to acknowledge how the AIDS epidemic not only changed the world, but how it changed each of us in so many ways. It's not something you walk away from or you underestimate its presence in your life.

MILLER: Thank you.

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