Dr. Alan Greenberg

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MILLER: This is Dr. Bess Miller, and I'm here with Dr. Alan Greenberg. Today's date is July 26, 2017, and we are in Atlanta, Georgia, at the Centers for Disease Control and Prevention. I am interviewing Dr. Greenberg 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. Dr. Greenberg, do I have your permission to interview you and to record this interview?

GREENBERG: Yes, absolutely.

MILLER: Alan, you have been a global leader in clinical epidemiologic and laboratory research, as well as program implementation and operations research, in the field of HIV/AIDS [human immunodeficiency virus, acquired immunodeficiency syndrome] throughout your career. You have worked in many other fields, including malaria, tuberculosis, and sexually transmitted diseases, as well. You've also been a leader in training and education in operations research 00:01:00and public health practice and are currently Professor and Chair of the Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, George Washington University.

For this oral history of AIDS at CDC, we are focusing on the early years, beginning in June 1981 with the publication of the first Morbidity and Mortality Weekly Report [MMWR] on the five cases of Pneumocystis carinii pneumonia among homosexual men. But the story of CDC's work on AIDS in Africa began several years later. You served in a critical leadership role in CDC's work on HIV in Africa as Director of Project RETRO-CI-- The AIDS Project in Cote d'Ivoire between 1993 and 1997, and we will put some emphasis on this period of your work as well, during the interview. But let's begin with your background. Tell me 00:02:00about where you grew up, your early family life, and where you ended up going to college.

GREENBERG: Thank you, Bess. Good morning. I grew up with my parents in the Bronx, New York. My parents were both schoolteachers and raised me with a strong sense of social justice. I went to high school at the Bronx High School of Science, as did my wife. The first experience I had with healthcare was during the Vietnam War, actually, where I cofounded and led an organization called the Bronx Science Volunteers at Veterans Hospital. We recruited about 40 high school students who would go to the hospital once or twice a week and fulfill various voluntary purposes, from being candy stripers, to feeding veterans who were quadriplegics, to working in the laboratory, to delivering lab results, to doing 00:03:00whatever the hospital needed. My own job was I taught table tennis, ping pong, to wheelchair patients and went with them to tournaments. That was my first experience with health and really, I think, led to me wanting to become a physician.

MILLER: Where did you end up going to college?

GREENBERG: I was fortunate to go to Amherst College in Massachusetts, and I was actually a premed [premedical] English major. I did my dissertation in Shakespearean literature, about fools and folly in Renaissance literature. But I picked up on that theme of volunteer work at VA [Veterans Administration] Hospitals. The VAs have been a big part of my life. I was director of an organization called the Five College Valley Volunteers at the Northampton Psychiatric facility VA. That was an incredible experience, because we provided 00:04:00basically companionship. At that point, psychiatric hospitals were filled with schizophrenic patients. They were lonely, and we were able to provide assistance to them. So those were the roots of my medical interest.

MILLER: You mentioned something that influenced you to go to medical school. Were there others? Family, other people that inspired you or it sounds like it came from within.

GREENBERG: Yes, I think it did. We didn't have any physicians in our family. I could be wrong, but as far as I knew, I was the first physician, certainly in our immediate family. There were fewer options growing up in the Bronx. Right now, I think our children are aware of so many different career options available to them, (from) the internet. People who did well in school became 00:05:00accountants or lawyers or physicians or business people. I had never heard of public health. There wasn't the full spectrum of choices. If you were doing well in school, the societal or familial expectation is that you would go into one of these specialties. But I think it was my social justice sense during the Vietnam War that I was quite aware. We lived near the Veterans Hospital on Kingsbridge Road, and I was able to get there by myself. I think it was that notion of trying to help that took me into a medical setting. Then I watched the physicians and said, oh, I could be one of them. So I think that's how it started.

MILLER: Where did you end up going to medical school?

GREENBERG: I went to George Washington Medical School, where I now work. It was a great honor to be accepted there. I got a great clinical education. I went to medical school thinking I'd be a family practitioner and a community physician, 00:06:00but a couple of things happened along the way in medical school that changed my life.

MILLER: Tell us about that.

GREENBERG: The first was during, I think, the second year of medical school. We had a lecture on tropical diseases from--I believe his name was Dr. [Jack] Millar. He was a pathologist, and he was showing guys with mosquito netting and scooping up mosquitoes and traveling to foreign places. I'd never really left the Northeast United States very frequently, so to me it was all exotic and fascinating. At the end of his lecture, he said, the diseases I just spoke about are responsible for more mortality in the world every year than all the other diseases you'll learn about in the four years of med school. I'm not sure if that was actually true, but it was an inspirational comment. It might have been true. And he said, but they only give me one hour in a syllabus, and so for those of you who are interested in learning more, please come up to me after 00:07:00class. My roommate and I were young and brave, and we wandered up. He had small scholarships to send medical students to Africa, and that's what changed my life.

It took a couple of years, but as a fourth-year medical student, I had the opportunity to work in--I spoke French from high school, and so they assigned me to a Swiss missionary hospital in Cote d'Ivoire, in Ivory Coast, where I also wound up circling back to many years later. It's in a small town called Dabou, which was about an hour or two outside of the capital in Abidjan. I did a sub-internship as a fourth-year medical student there for two months. I had a little house and cooked for myself, and every day I would go to clinic, largely doing outpatient. I'd sometimes follow the doctors around ward rounds in the evening, but mostly I was doing outpatient general medicine.

Every day there would be lines of people. We'd start clinic at 7:30 in the 00:08:00morning, and by that time, people would come from all the neighboring villages with their own ailments, a wide range of tropical diseases, and then many, many, many mothers with kids with fevers. I mean the line stretched, I'd say blocks, but there weren't blocks, but it just seemed endless. We'd work all day, and child after child had a fever. Many of them had malaria, and we were treating them for malaria and treating them with chloroquine. I remember having a thought, which really changed my perspectives, when I one day thought, I wonder what's at the back of this line. Why are all these kids getting malaria as opposed to just endlessly treating? It was that moment that I really had my epiphany-- that maybe getting into preventive medicine was something I'd like to do. That was a very important moment in my life.

The second thing that happened was other sub internships. My family, as I said, was from New York, and we were in Washington [D.C.], where I also wound up 00:09:00circling back to live as an adult now. But we had the opportunity to do sub internships at other hospitals, to see where we might want to do our internship and residency. So I did two in New York-- one at Lenox Hill Hospital and one at St. Vincent's Hospital [Saint Vincent's Catholic Medical Center] in the Village. St. Vincent's was a community hospital for Greenwich Village. To be honest, I liked jazz and I always thought, growing up in New York, the Village was a really cool place to live and seemed very progressive. St. Vincent's was definitely a place that tried to work closely with the community. So I did my sub internship there, and I do remember that was the fall of 1981. I do remember working in the intensive care unit, and there was a patient who presented with Pneumocystis pneumonia but did not have cancer. Most people with Pneumocystis at that point were immunosuppressed because of malignancies, and I remember the 00:10:00attendings [attending physicians] being a little perplexed and thinking, why would this happen, and wondering whether or not it was related. Actually, I can't remember the risk factors of that particular patient, but it was my first inkling that there was something going on. Then indeed, I loved St. Vincent's. I loved the spirit of the place, so it was my first choice and I matched, much like the EIS [Epidemic Intelligence Service] match. I matched to St. Vincent's and moved to Greenwich Village in the summer of 1982.

MILLER: Tell us more. That was the absolute epicenter of the HIV-infected world, as we know it now, at that time. During your training, your internship and residency, you must have seen a lot of these patients. Can you tell us a little bit about that? What was the clinical care like? What was your reaction to all 00:11:00the illness? You were there.

GREENBERG: Yes, it was ground zero, that's for sure. I guess, like many young physicians who were practicing in the early ‘80s in San Francisco, New York, and L.A. [Los Angeles], we were there at the beginning. As I said, I went in wanting to become a family practitioner or a general community doc, and I walked smack into the beginning of the HIV epidemic. It was very trying and very inspirational at the same time. The number of young men, gay men, who walked into the emergency room with either Kaposi's or Pneumocystis, was extraordinary. I mean, day after day after day, morning report people would throw up the chest x-rays with the Pneumocystis-type picture, and the amount we could do for them was limited. There were aerosolized Pentamidine and IV [intravenous] Bactrim, as I recall. I hope I am not getting my drugs mixed up many decades later. There 00:12:00was treatment but the underlying cause was not even known.

I think at that point it was called GRID, gay-related immune deficiency, in the pre-HIV days. Many of these patients, many of them, got very, very sick, and many of them died. On the clinical end, it was very frustrating being a young physician and taking care of-- you know it's like a battlefield. There were so many young people who were passing away before their time, and although we struggled mightily, there were no antiretrovirals. We didn't even know at that point that it was a virus. It was a very, very challenging time. A lot of the patients were passing. A lot of the staff, because we were living in Greenwich Village, had risk factors as well, and some of them were getting sick. No one knew if it could be passed parenterally. I remember we saw our first hemophiliac 00:13:00with HIV. I remember that patient very well.

Not only was it emotionally trying because of the frustration about not being able to help more people, but there was fear among the house staff and among the nursing staff and the technician staff that we could get infected too, and that was realistic. At that point, I don't think the same kinds of barrier protections were in place. We were intubating people, putting A-lines [arterial lines] in, and no one was wearing gloves. We were constantly exposed to bodily fluids from all sorts of patients. I remember actually telling my parents one day, going home and saying, I didn't predict this but I'm in it. I'm trying to be the best physician I can, but there's a chance we could all get it too, and I 00:14:00just wanted you to know that. Don't I get emotional telling your mother that, you know? But there was a bit of, I don't want to talk about myself, but there was a bit of courage that I really admired in the front-line nurses and health staff and social workers and respiratory therapists who were taking care of those-- it was lots of camaraderie.

MILLER: Do you remember having any experience with CDC at that time? Did people look to CDC or even the New York City Department of Health for any kind of guidance at that early stage?

GREENBERG: Honestly, that's a great question, and I honestly can't remember. CDC will become part of the story very soon, but I honestly can't remember those early days. You know, to be honest, you were working-- at that point call was 00:15:00much more frequent. We were on call, I forget her name--Lizzie. There weren't those laws in place yet, and so the months when we were in the intensive care unit (or) in the emergency room, we were on every other night. When you were on the ward, you were on every third night. To be honest, I wasn't really paying attention to the larger world. I was just trying to take care of my patients and trying to--

MILLER: And stay alive.

GREENBERG: --and get some sleep. But on the other hand, I think just to sum that section up before we transition to CDC, I think if there was a positive aspect, it was watching the courage not only of the house staff, but also of the people we were taking care of. It was horrible to be in your young 20's and have this sort of diagnosis given to you and to feel that ill, and so many of them were so courageous. I remember quite a number of them looking at me and saying to the 00:16:00effect of, doc, you may not be able to help me, but help other people, you know? I heard that frequently, the altruism, the courage. I think it was that when I decided to devote my life to HIV prevention.

MILLER: What led you to CDC then? Was it that very thing?

GREENBERG: Inspired by the epidemic as I was, I was going to go do my infectious disease fellowship, as many of my peers in the profession did. Two things happened. One was that I went to the head of the infectious diseases-- his name was [Dr.] Jay Kislak. There were two infectious disease doctors we worked closely with taking care of all the HIV patients. His name was Dr. Jay Kislak. He was the senior physician, and I went and I said, would you give me a recommendation for an I.D. [Infectious Disease] fellowship? He said, of course, but weren't you the guy who went to Africa during medical school? I said, yes, 00:17:00and he said, I have another idea for you. He said, have you ever heard of the Epidemic Intelligence Service [EIS]? I said, no. He said, have you ever heard of CDC? I said, kind of. He said, there's this program where they train disease detectives, and you could get involved on a wider scale. I think with your language skills and with your history of having been comfortable in a developing world before, this might be something you should consider. That was one, and I'll circle back to that.

The second thing that happened was-- and I was contemplating and I was actually named one of the chief residents for the following year. That was going to be my path-- to do chief residency and then apply for an I.D. fellowship. He said that, and then a couple weeks later I was sitting in morning report with the other residents, eating cream cheese on a bagel and drinking my coffee from the Greek diner. I was reading the New York Times, and I should find this article. 00:18:00It was an article in the New York Times where they announced it was vaguely aware that HIV had hit Africa and that CDC had set up a field station in Central Africa in collaboration with the now Congo, but at that time Zaire Ministry of Health and the Belgians. It was in a Francophone country, and their idea was to be first responders to the HIV epidemic emerging in Africa. I remember thinking, that's it. That's what I want to do. It clicked. That was the moment. Then I called CDC, and I made my appointment for an interview. I applied and was asked to come down for an interview, and when I came, I met all the incredible disease detectives. [Dr.] Gail Bolan interviewed me, and I was just--people were traveling all over the world doing yellow fever and GI [Gastrointestinal] outbreaks, and I was just smitten. I called my mother and said, I found my 00:19:00people, I found my people. I'm sure you've probably had that kind of experience too, but it was a real epiphany moment.

I went back to St. Vincent's, and I was supposed to be chief resident. I had to tell the chief of medicine that I was going to pass it up and do EIS, because at that point I'd just found out I'd gotten into the program. I was a pretty good doc and very committed physician, and they were concerned that I was throwing away my medical career. They were being honest, and in some sense it was true. I did a lot less clinical medicine. I did a lot of clinical medicine, but not as much as I would have. They were just mentors saying, are you sure you want to do this, because you'd be a great ID physician as well. I said, I'm sure. I'm not sure I had their total blessing, but I then packed up my bags and moved to Atlanta.

MILLER: Tell us about your EIS training a little bit. Where were you assigned, and did you begin working on AIDS early on?

GREENBERG: Not surprisingly I wanted to work in AIDS. I came down, and they had the famous match, and you have that still. You go through the match process. I went to see [Dr. James W.] Jim Curran, who was the head of the HIV program. I'm not sure (if) I met [Dr.] Harold [W.] Jaffe at that point, but I definitely met Jim Curran. I said, I'm coming from St. Vincent's, and I've been doing HIV care for three years. I probably didn't use (the term) HIV at that point, but I said, I want to work in AIDS. He said, they just started the San Francisco cohort, men's cohort, and they needed someone to work on that. I said, I want to work--I brought out my New York Times article-- I want to work at the field station that you (are) starting, that [Dr.] Jonathan Mann is starting in Africa. He said, that's not what we need. I said-- I don't remember exactly the moment, but I 00:21:00thought to myself, then I should work in tropical diseases because at least that'll get me to Africa. Then I met [Dr. Carlos Clinton] Kent Campbell, who was the chief of the Malaria Branch. He was one of these real globetrotter figures, tropical diseases, like the people in the lecture that I heard in medical school? I said, I want to be like this guy. I was successful. I was fortunate. Malaria was my first choice, and I guess we matched there. It became where I did EIS, where I spent three years. I don't know where you're going next, but it wasn't too many weeks later that my HIV saga began.

MILLER: Tell us about that. Tell us about your HIV saga. I know that you got the opportunity to work in Zaire, on Projet SIDA, during your EIS--

GREENBERG: A couple of things happened. The first thing was that we got a lot of phone calls in the Malaria Branch from clinicians with different cases of 00:22:00malaria who needed advice about how to treat it, because not everyone obviously sees cases of malaria that frequently in the U.S. There wasn't the internet to look everything up. We'd be called upon for consultations, and I was able to get involved with several cases. This is relevant for chloroquine-resistant malaria, where people weren't responding to the usual treatment and we had to help guide their treatment with other medications. That was an important building block when I became, thanks to Kent, very familiar with drug resistance. It had already been prevalent, in my recollection, in Southeast Asia and in East Africa, but it hadn't spread to Central and West Africa. In some of the early publications we were documenting some of the first cases in travelers- not the first, but some of the first cases of documented chloroquine resistance in travelers coming back from West Africa.

The other thing is, I was working with [Dr.] Kirk Miller, who was the EIS officer a year before me. This is, again, very relevant to CDC. The treatment for severe malaria was IV [intravenous] quinine, but that wasn't available at all sites in the United States. The quarantine stations had them, and we literally would have to release the quinine for the different stations and sometimes have it flown to these little towns or wherever the doctor was treating malaria in the United States. It was a great responsibility because it was time-sensitive. We had to get the drugs there on time. So Kirk came up with the idea that IV quinidine, which was available for cardiac purposes, was also effective for malaria, and hospitals had it. He wrote a protocol whereby instead of recommending IV quinine--my recollection and there's articles about this, but it wasn't my study--that IV quinidine was recommended. We would go and fly to 00:24:00cases where sometimes we would go and help and actually go and document the treatment. There was a call from--I think I had been at CDC, they told you to keep your bags packed.

A couple of weeks after I started my EIS rotation, we got a call from Wilford Hall Air Force [Wilford Hall Ambulatory Surgical Center], the medical base there in San Antonio, Texas. We were also doing a protocol with exchange transfusions to try to save people's lives when someone had severe parasitemia. It was a soldier from overseas, and we went and treated him, and the doctors there saved his life. The good thing was he survived, but then we got a call a couple of weeks later that they figured out he was HTLV-3 [human T-cell lymphotropic virus type 3] positive. That's when the question began-- did he get such severe malaria because he was HIV infected? And that was the first part of the story.

MILLER: You get this assignment to go to Zaire, Projet SIDA, during your EIS experience, which is like amazing. Who gets to do that? Tell us about that.

GREENBERG: What happened was, we had this case of the soldier in our heads about this possible association between HIV and malaria, and things were happening very quickly. Jonathan Mann in Kinshasa published an article in which he was looking at the prevalence of HIV in children. He actually published two sentinel articles. My recollection is the background seroprevalence (of HIV infection) in healthy children was about 1 percent, but among hospitalized children with malaria it was 6 or 7 percent. That was the second piece of evidence that we thought, maybe there really is something going on here. I remember that we had this map of where malaria was in Africa and where HIV was emerging, and they 00:26:00were overlapping. We thought, wow, if these two diseases collide, this could be a major issue. So we went to Jim Curran--Kent and I actually came down here to Clifton Road and met with Jim Curran and said, we have an idea. We'd like to work in Kinshasa, which was my hope. Jim remembered that and worked with Jonathan Mann to do studies to see what the relationships were between HIV and malaria. He called Jon, and Jon said yes. It took a couple of months to get approval from the Zairian Ministry of Health, but it was a public health emergency at that point. It was definitely--

MILLER: I can't believe your good fortune in these difficult circumstances.

GREENBERG: You know, chance favors the prepared. Because I spoke French and because I had worked in French West Africa before and because I knew clinical HIV-- there weren't that many people, certainly at CDC at that point, who had 00:27:00that spectrum. So I was fortunate. But what was really fortunate was that Jon Mann, Jim Curran and Kent Campbell had the vision to support me. I went with my mentor, Dr. Phuc Nguyen Dinh, who was a parasitologist who was an expert field worker and had worked all over Central Africa and Haiti. He went with me on my first outbreak investigation to Zaire.

MILLER: At that point the virus had been identified by the time you got to Zaire?

GREENBERG: Yes.

MILLER: Do you remember some of the projects that you worked on during that time?

GREENBERG: Sure. We had written a protocol to basically go to the emergency room of what was called Mama Yemo Hospital, which was a large public hospital in Kinshasa where Projet SIDA was based. Projet SIDA, again, was put together by 00:28:00NIH [National Institutes of Health], [Dr. Thomas C.] Tom Quinn and [Dr. Henry L.] Skip Francis-- the Belgians, [Dr.] Peter Piot and [Dr.] Marie Laga and [Dr. Robert] Bob Colebunders-- and the US Government and CDC, which was Jim Curran, and Jon Mann was the director. Together they formed the project. I literally flew in in the middle of the night with Phuc, and I remember there were soldiers at the airport. When I saw Jon Mann show up on the tarmac, I was like, oh, thank God. Jon took me in his car, and we drove to Mama Yemo, and it was in the middle of the night. He took me to the Pediatric Ward, which was full of children getting infusions, and lying on the floor were their mothers on blankets. He said, this is the problem you're here to address-- most of the children here have malaria and HIV. I remember it was a dark room, poorly lit, and there were mosquitoes everywhere. One of the issues was, were mosquitoes transmitting HIV? 00:29:00I remember getting bit up, and I said, I certainly hope what we find is that they're not. Anyway, so we then launched into the key studies that I think defined my career. Do you want me to talk about those?

MILLER: Tell us a little bit about Jonathan Mann. I'm jealous that you got a chance to work with him. He's emerged as a larger-than-life figure in the world of early AIDS and all the work he's done there and in WHO [World Health Organization], where he went afterwards. Sadly, he died in a plane crash in 1998. What was he like?

GREENBERG: Jonathan Mann was a great man, and it was indeed a privilege. I knew him well. I was at the project, I think I had five trips in two and a half years, and each one was for a month or two or three. I worked with Jon every day 00:30:00and had the opportunity to watch him and learn from him. He was a visionary. He was prolific. He understood the importance of publishing. He was kind. He was a visionary, and I actually remember when he got the call from--I don't know if it was at that very moment, but I remember the day that he got the call asking him to go to Geneva and work on the global program on AIDS and to found and direct that. I remember he actually asked me, do you think this is a good idea? I said Jon, if anyone can do this, you can. You know these certain people who have that aura and that glow.

MILLER: What was he like? Was he an extrovert? Was he outgoing? Was he quiet? What made people drawn to him?

GREENBERG: Vision. He realized that the HIV epidemic was a crisis. He realized that we were at the very beginning of it and it was going to get worse. He wanted to raise awareness so that the world would react in very much a social 00:31:00justice perspective, as well. Also never underestimate, he set the standard for writing. I think one of the hallmarks of Projet SIDA was the enormous amount of productivity that came out from everyone--not everyone but most people who were associated with that project. He used the published literature as a vehicle to get the message out about how severe a crisis this was. Also I don't know if you ever heard him speak, Bess, but this man could give a speech. Not in the category of a Martin Luther King, but he could get up-- his talks at the International AIDS Conferences would bring thousands of people, literally thousands of people, cheering and to tears, and he could-- you can read some of the texts of what he was saying-- those were events.

I remember there was a story a couple of years later. I was asked to speak at a 00:32:00symposium at one of the international AIDS conferences and there was a room full of people. We were getting ready to start, and then over the loudspeaker they said, Jon Mann is giving a special address in the main auditorium, and everyone left. They said, this session is over, might as well go listen to Jon. I mean, he was a rock star, and he was deeply respected. He loved Toblerone-- he always kept Toblerones in his office. We circled back to him later when I actually got to work with him. He invited me years later, when I left Cote d'Ivoire, to work with him at the Harvard School of Public Health at the FXB [François-Xavier Bagnoud Center for Health and Human Rights] Center he started. When I was setting this up, I flew from Abidjan to Boston and spent the day with him at Cambridge. He imparted many life lessons to me that day, and I was really looking forward to spending two years in Boston with him.

Actually, what happened was, he then became the Dean in I think the School of Public Health [School of Public Health, Allegheny University of the Health Sciences], and he had to tell me he was leaving Harvard, so I never got to work with him. But he came to visit Harvard, and we had lunch together in the School of Public Health cafeteria. I think that was a couple of days before the Swissair crash. But he was, along with Phuc and Jim Curran and Kent Campbell, one of the people who inspired me. He was clearly one of my mentors scientifically and would always sit down and go over my study design and results and was interested and aware. Despite all the million major things he was doing, he kept his eyes on the details. It was a real privilege, and I consider that to be one the good strokes of fortune in my career.

MILLER: You talk about methodology and scientific rigor and writing, and your career has demonstrated how much you've done that and how much you've succeeded 00:34:00in that line. Do you want to mention a few of the projects that you were doing at that time in Zaire?

GREENBERG: Sure. Our original study was, we went to the emergency room and hoped to reproduce Jon's results about looking, because we were actually doing the blood smears ourselves and seeing if we could document the higher (HIV) seroprevalence in pediatric malaria patients. We enrolled-- I think it was a basic case-control study. We enrolled--I had to get the samples--150 kids with malaria and 150 kids without malaria. We were doing all the parasite testing ourselves, the malaria smears, and going to the lab and separating the serum and doing the HTLV-3 testing. The lab would then do those tests. So we were very hands-on. I was seeing all the patients. Then we got the results back. I can't remember the time. It was probably several weeks (later), and we were working very quickly night and day. We hit our sample size results, and it was 1 percent 00:35:00in both populations. I remember calling Jim Curran and Kent Campbell on the phone and saying, I didn't reproduce the results. They said, are you saying Jon Mann's wrong? I said, no, I'm not saying Jon Mann's wrong. I'm just an EIS officer. They said, keep working harder. This is an outbreak-- this is an emergency.

We then figured, maybe we had some sort of selection bias. Phuc and I took all comers in the emergency room. We enrolled over a thousand (patients) and did blood smears and HIV testing on them. Once again we didn't find any association. Then I had this moment where I was seeing all the patients myself and where I put two and two together. There was one 6-year-old boy who had come in with his mom to the first study, who was HIV negative. He came in a couple of days later and he was HIV positive. We retested the specimens and said, how could this have 00:36:00happened? I was going through his medical record, and I realized that in the emergency room he had gotten a blood transfusion that first visit. Then he was sent home and came back and was captured in the second study's catchment. Then maybe it was blood transfusions. I remember I had this realization in the middle of the night. I woke Phuc up, and I said, I think it's the blood transfusions. Because Jon had published that blood transfusions were associated, as well. He said, but it couldn't be accounting for all this HIV. So we went back and did chart reviews in the emergency room and saw that a very high proportion--I forget the numbers--of children with malaria were getting blood transfusions in the hospital. What had happened was--our theory was that chloroquine resistance--circling back to that, had just hit Central Africa. The standard treatment was chloroquine. The kid would get a fever at home, they'd go to the pharmacy, they'd get chloroquine, and then they'd come in, despite chloroquine, 00:37:00with chloroquine-resistant malaria they thought they had already treated. By the time the kids came in, they were anemic, and so they had a fever and parasitemia anemia and were appropriately getting transfusions. We actually looked at the hematocrits, and they were getting appropriately transfused.

Then we did studies of the blood donors. Blood donors were either paid blood donors who were professional blood donors, or family members. It turns out their seroprevalence was--I think about--I can't remember, but I want to say 6 percent but I have to read it. But (there was) a significant amount of HIV in the blood donor transfusions, and no one was screening the blood. We then calculated how many transfusions this one hospital alone could be accounting for, and it was significant. I mean, it was I think five or six hundred cases a year. This was presumably going on at other institutions as well. We then went to the pediatric hospitalized patients and repeated some of Jon's studies, looking specifically 00:38:00at the role of blood transfusions and found there were some children who'd gotten one, two, three, or more blood transfusions. There was a dose-response relationship between the number of transfusions people had gotten and the HIV seropositivity. We actually were able to document to the case, I think 10 or 11 of the HIV malaria patients who had gotten transfused.

MILLER: What was the response to that? They weren't ready to do HIV testing of blood products, but how did the community respond immediately to this finding?

GREENBERG: Immediately. I remember in the JAMA [The Journal of the American Medical Association] paper, there was actually a curve in the number of transfusions. I think they were transfusing with a hematocrit of 30 or below, and they immediately reduced that to like 20 or below, so there was a great drop-off in the number of transfusions. This could be wrong, but my recollection is that Phuc went to WHO, and--I can't remember--but certainly we came back with 00:39:00the results to CDC. The blood screening, HIV screening, HTLV-3 screening of blood units became a real priority pretty quickly. I had the opportunity at the third International AIDS Conference in Washington, DC, I had an oral presentation. It was my first major talk and, you know, thousands of people were sitting there, and I had to go out and present this story. I remember my knees were clacking together. Dr. Kapita Bila, who was the head of Pediatrics of Mama Yemo, was the moderator of the session. He said "courage pour les enfants," “courage for the children.” That was picked up on NPR [National Public Radio], and the word got out about the importance of blood transfusions, which Jon had already documented, but the severity of it hadn't really. That was the 00:40:00immediate public health link-- that children with presumably resistant malaria, which we then documented, were coming in with fever and being treated with malaria but leaving the institutions with HIV.

MILLER: What an incredible EIS experience.

GREENBERG: If I can just, if you don't want me to go on, but there was a whole other line of work. Jon's successor was another great figure, [Dr. Robert] Robin Ryder. I worked with Robin for the last year and a half or so, and to my knowledge, Robin did the first mother-child transmission study of HIV.

MILLER: Yes, we've had the opportunity to interview Robin.

GREENBERG: Oh, you did?

MILLER: Yes.

GREENBERG: We did a malaria sub study of that cohort, because he had a matched cohort of mothers with HIV-positive and -negative children. We were able to--every time those children got a fever, document that and do a malaria smear on them. We were able to look at the incidence and response to treatment and the 00:41:00severity of the parasitemia in children with HIV versus not. That was an incredible experience, working on that study, which, again, we'll circle back to.

MILLER: Wow. Before we move on, I'd like your thoughts about the origin of AIDS. What was your thinking at that time about the origin of AIDS being in Central Africa?

GREENBERG: I remember a couple of stories. My recollection--and again we're going back 35 years--is that there were two sentinel articles published. One (was) by Peter Piot's group in 1984, documenting what they thought were the first cases of HIV in Central Africa, and then the second by--there was a group led by [Dr. Joseph B.] Joe McCormick, if I recall. Joe McCormick went with Jim Curran and Tom Quinn to Kinshasa. I wasn't there, I came along about a year later. They were the ones who together decided to start Projet SIDA and then 00:42:00hired Jon to run it. Then Skip Francis from NIH and Bob Colebunders were assigned by (the) Institute of Tropical Medicine in Belgium to be the first scientists there. In terms of origin of AIDS, while I was an EIS officer, the year after me came another one of my great mentors and friends, Dr. Kevin [M.] De Cock. Kevin was in the Viral Special Pathogens Branch, working with Joe McCormick, to my recollection. Kevin published a very well-known New England Journal of Medicine] article where they went back to--I'm going to forget the name--Yambuku?

MILLER: In rural Zaire.

GREENBERG: In rural Zaire, where there had been an outbreak and specimens were collected many decades ago. They were able to look at the origins of HIV. Kevin's paper was also one of those sentinel papers.

MILLER: Yes, it was the Ebola outbreak in rural Zaire that had the blood 00:43:00samples, so yes.

GREENBERG: Right, so they went back, Kevin went back. I remember we presented back-to-back at the EIS conference my second year.

MILLER: How exciting to have actually gone as an EIS officer to the site of it all. That's just amazing.

GREENBERG: It was. It was the greatest privilege of my career.

MILLER: Then you moved on, a big drastic shift from Central Africa to the New York City Department of Health, Office of AIDS Surveillance. At this point, there were reported over 82,000 AIDS cases in the U.S. and about 14,000 cases reported in New York City. This was before HIV test reporting of AIDS "disease" reporting. What were your main emphases at that time? What did you get involved with in New York City?

GREENBERG: The story was that I had been on the road for three years back and forth, trying to publish all these papers. I missed home and I missed my family. I went to Jim Curran many times in my career. He had this pivotal influence on me, but I said, I want to go home. I'll come back, but I want to go back to New York for a couple of years and be closer to my family. Do you know of any opportunities, even outside of CDC, where I could work in Public Health in New York? He said, it just so happens that yesterday he had gotten a call from [Dr. Stephen C.] Steve Joseph, the Commissioner of Health, who said that they were looking for someone to be assigned by CDC. He said, are you interested? I said, when does the bus leave? Yes. So I went with Harold Jaffe. Harold and I flew up to New York, and we met with Steve Joseph and I believe [Dr. Steven] Steve Schultz. We went to lunch, and they basically agreed that I'd be detailed to the New York City Department of Health as a CDC assignee. [Dr.] Martha Rogers was my 00:45:00supervisor in the Epi Branch. I largely worked on--I reported to [Dr.] Polly Thomas, who is another great mentor, about how to move ideas through organizations. Polly was the Director of Surveillance, and I was the head of, I guess, the Research Unit within surveillance. Polly went on leave, and I actually was the Acting Director of Surveillance for about half a year during my period there. I largely worked on the completeness of AIDS case reporting, which I think we published in JAMA, and the spectrum of HIV disease that didn't meet the case definition, which I think we published in AIDS. Those were my major responsibilities, being involved in routine surveillance. It was a very tumultuous time.

MILLER: What was going on in New York at that time? We're talking you were there in the late '80s, early '90s, before very much HIV treatment (was) available.

GREENBERG: Right. I think AZT [azidothymidine] was monotherapy. I was also seeing patients at Beth Israel Medical Center. It was the AZT monotherapy era, 00:46:00where our patients were taking two pills every four hours and having to wake up for the 4:00 a.m. dose. Many of them responded and it was a miracle for a while, but I guess we weren't aware it wasn't lasting long. They were getting resistant to monotherapy. That was a very difficult time clinically, but we were trying our best, I remember, at that point. Then at the Health Department there was quite a lot of activism about the HIV epidemic, and quite a lot of it was directed at the Health Department. It was an interesting time.

I'll tell three quick anecdotes, and then I think we can move on. The first is that we used to have a monthly surveillance report, where the Health Department would report back to the community and to the press and to the clinicians who were taking care of patients about how the AIDS epidemic was going. They'd been doing that apparently since the start. Then [Dr.] Isaac Weisfuse and I actually were assigned to take over that, and there was a lot of understandable anger and 00:47:00why aren't people doing more? We were the frontline people giving those reports and trying our best to answer questions.

The second was, of course, Act Up [AIDS Coalition to Unleash Power], which was a very important voice in bringing HIV care to the fore. I had great respect for a lot of the people, and I actually took care clinically of some patients who were Act Up members. Some of my friends were Act Up members, so I had great respect for what they were doing. But on the other hand, they were really angry at the federal government and the local government. They raided our offices once. I remember when New York City lowered the estimates of the number of HIV-infected patients, they did this campaign saying that the blood of hundreds of thousands of New Yorkers were on their hands, and there were these handprints of red paint 00:48:00put all over the city.

Then also at that point, it was the era of the four H's, where there was a lot of stigma of heroin users, and homosexuals, and hemophiliacs, and Haitians, and it caused terrible stigma in these populations. There's a very large Haitian community in Brooklyn, and I remember we were at the Health Department and there was a big march. We could see out the window the Brooklyn Bridge, and they were coming towards the Health Department. There were mounted police with the Health Department, and it was a very challenging time. On the one hand, we were representing the federal and local government in our professional capacities, but of course, from a social justice point of view, we could certainly identify with a lot of the people who were protesting us. I really think that the mutual respect that was developed between the public health professionals and the activist community over time was really instrumental in us hearing them and 00:49:00respecting their input, and, as you know--you know the story probably better than me, Bess--it had an incredible positive influence on clinical trials and bringing HIV medicines to the fore. I still know some of these people to this day, and those were tumultuous times.

MILLER: What were some of the things that you think either CDC or you, as a federal assignee and other federal assignees in the New York City Health Department, what were some things that you think worked that made things better?

GREENBERG: I think one of the themes that I saw both domestically and internationally and something I really respected that CDC as an institution has always done--I don't know always well, but in my experience well--was to provide technical assistance and work with and for the local public health authorities. 00:50:00When I was working in Zaire, we were reporting to the Ministry of Health. We weren't just parachuting in and being, you know, U.S. Government Scientists, but we worked in collaboration with and for (the local authorities). I was assigned Dr. Nzila and Dr. N'galy as my partners. For the famous lecture in CROI [Conference on Retroviruses and Opportunistic Infections], (I was) the opening lecturer after Dr. N'galy and Dr. Mann. It was the Mann-N'galy Lecture. But we were counterparts. I think when I was assigned to Zaire, it was very clear that we were there at the invitation of the government, and we had to regularly report to the government. I'll talk about that when we get to RETRO-CI. We weren't just there in isolation. We were working for the Ministry of Health. I think similar to CDC's relationship to the states, we had to be invited in by the New York City Health Department, and then I reported very clearly to Polly Thomas who reported to Steve Schultz. We were welcomed in, but with the very clear understanding that we were working for them and with them, not apart from 00:51:00them, not with our own agenda. I think that's been one of the great, in my career, one of the great privileges to see how CDC does that and doesn't impose its will but works very closely with local or international health authorities. That's my answer.

MILLER: With regard to surveillance, can you say a little bit more about that? Was there the beginning of electronic reporting at that time? Were you still having the telephone call and the forms? What was reporting in New York City consisting of at that time? For future viewers, I think people can't believe that there weren't always computers for these huge outbreaks.

GREENBERG: Right. I have several memories of technology emerging during that time. One was that there was no email. Every day I remember going to lunch, and the secretaries would take messages on those little pink slips. I'd come back 00:52:00from lunch, and sometimes I'd have 20 or 30 phone calls to return. I spent my mornings doing work and my afternoons returning phone calls. I remember when we registered for the Florence AIDS conference, it was the first time I ever saw a fax machine. They had just bought a fax machine, and I didn't even know it existed. I said, do we have to mail these by airmail to Italy? They said, no, no, you just put it in this thing, and it comes up in Italy. I'm like, really? It was a different era and a lot more manual work. There certainly wasn't electronic lab reporting in those early years that I recall. My recollection--and again, the New York City Health Department would be better to answer this than me, but my recollection is that there were over 80 reporting hospitals plus private physicians. Different public health workers were assigned surveillance duties who would visit and get the case reports and record them onto the CDC forms.

MILLER: Handwritten.

GREENBERG: Yes, I think so. Again, I'm on camera, and I may be making a mistake but--

MILLER: No, I think that's right.

GREENBERG: There were no iPads to put it into, so it was brute force.

MILLER: Let's move on to your time in Cote d'Ivoire as Director of Projet RETRO-CI, which was from 1993 to 1997. This was a pretty prize position to get as Director of Project RETRO-CI, the HIV/AIDS Field Station in Cote d'Ivoire. You were Dr. Kevin De Cock's successor, as the project was initially set up in '88 and initially placing emphasis on studying HIV-2, a second retrovirus that was prevalent in West Africa. Can you describe the field station when you 00:54:00arrived? Number of staff, colleagues, your relationship with the Ivoirian government. What was that like? That had to have been a big move.

GREENBERG: It was a big move, and that's when I made the transformation in the same way that I'd transformed from a clinician, even though I still practiced AIDS medicine until a couple a years ago as a voluntary physician for my whole career. I transitioned my primary occupation from a clinician to an epidemiologist, and then in Cote d'Ivoire that's when I started transitioning from an epidemiologist to more of a manager of science and moving into leadership roles, which I have been in since then and actually getting formal training in management.

I remember at one of the international AIDS Conferences being interviewed for the position by Kevin himself--the great Kevin De Cock, whom I knew from EIS, but he's really one of the leading scientists. He's a good friend, but respectfully, he's one of the leading HIV scientists in the world, and 00:55:00succeeding him (was) little ol' me. It was pretty big shoes to fill. I remember I flew to Abidjan when he was still there, and we spent three or four days (with) him orienting me. He had a little shack on the beach. We went there, and he gave me these life lessons on how to be a good director. Then a couple months later I moved there with my--I was married at the time and (am) still married-- I had gotten married, and my wife and I moved to Abidjan together.

I remember showing up the first day on the job--I was a little more jovial in those days--and meeting Professor [Auguste] Kadio, who was the Director of Infectious Diseases. He was my boss and became my mentor there. I remember he looked at me and said, so you're the one who's going to replace Kevin De Cock. I said, yes, I'm going to do my best, Professor Kadio. I'll never be Kevin, but I'll try my hardest. Thus launched the incredible experience. Kevin had modeled 00:56:00the structure of Projet RETRO-CI after Projet SIDA, and I'm sure he probably told that story. It was, again, a partnership with the Ministry of Health and the Ivorian, many Ivorian physicians who Kevin had in leadership roles. The Institute of Tropical Medicine and Peter Piot had [Dr.] Peter Ghys, who's now head of surveillance at the UNAIDS [The Joint United Nations Programme on HIV and AIDS] and was the assignee from the Institute of Tropical Medicine in Antwerp. Kevin also involved the London School, where he became a faculty (member), and [Dr.] Alison Grant represented the London School [London School of Hygiene & Tropical Medicine].

It was this United Nations, my recollection by the time I left--again, I don't have my data--but I think there were about a hundred staff from 14 countries. I remember we once did a survey on how many languages (were spoken by staff), and there were something like 50 to 60 languages that were spoken. There were people from all over West Africa-- Benin, Togo, Ivory Coast, Burkina Faso, Uganda--. 00:57:00Just on and on. It was an incredibly vibrant and interesting place. It was francophone. All business was conducted in French, and it was very exciting. There were fleets of vehicles. I think there were 10 or 12 vehicles. There were gardeners. It was built in a renovated section of the Infectious Diseases Department of Treichville, which is like Mama Yemo, one of the larger, if not the largest, public hospital in Abidjan. So it was quite formidable walking in there.

MILLER: By that time, what were some of the critical research and problematic questions that you focused on, or that you and your colleagues focused on? How was that moving forward?

GREENBERG: The way the project was structured is, we created sections. There was 00:58:00the (administrative) support section, the laboratory section, the section l'Informatique, the data management section, and then four scientific sections that were actually doing the studies. Each had a major project. There was mother-child transmission, clinical, tuberculosis, which was the major opportunistic illness, and sexually transmitted diseases. The major studies were--at that point, my recollection is that until '96 there was dual therapy in the United States. Antiretrovirals were just trickling in, so it was still the pretreatment era. The desire to do something about the epidemic was to intervene as much as we could, was really the driving force. The first (interventions) were the adaptation of the AZT regimen--076 had been shown to be successful, but 00:59:00that was a very prolonged therapy and had intravenous--

MILLER: For reduction of mother-to-child transmission?

GREENBERG: Mother-to-child transmission. The ministry was very keen on trying to see whether or not we could come up with a quicker low-cost regimen that could be implemented much more quickly. Those were the short-course AZT trials, which worked. Then the second series of studies was trying to lower morbidity and mortality using Bactrim prophylaxis in HIV-tuberculosis patients, which was also published in the Lancet, along with a French group who actually worked on both issues, as well.

MILLER: Now, that one ended up having a huge impact in terms of implementing Cotrimoxazole [Bactrim] preventive therapy throughout Africa, isn't that correct?

GREENBERG: I'm not on the programmatic side, so I don't have any data, but I do think those results were picked up and disseminated and were very--

MILLER: I think they were hugely impactful over there.

GREENBERG: It reduced morbidity and mortality. My recollection was, it had 01:00:00impact on malaria and different infectious diseases.

MILLER: Can you talk a little bit more about why Cotrimoxazole-Bactrim was identified as a key preventive strategy?

GREENBERG: [Dr.] Stefan Wiktor was the PI [principle investigator] of the two trials. Are you interviewing Stefan as well?

MILLER: Yes.

GREENBERG: You can certainly talk to him. My recollection was that Alison Grant, who was working in the London School along with [Dr.] Gaston Djomand from the Ministry of Health, had published a spectrum-of-disease project. We did an in-depth laboratory investigation of the spectrum of HIV disease and looked to see other (manifestations) than what people were getting hospitalized and dying from, and published that. The thought was, which I think that our French 01:01:00counterparts also had, was looking at the spectrum of disease that Bactrim had the potential for preventing morbidity and mortality, and it worked, so--

MILLER: Why TB patients? They were the early patients identified? They presented with higher CD4 counts, and so they were sort of like the canary (in the coal mine)?

GREENBERG: I think TB was the most common opportunistic illness that we were seeing, and Cote d'Ivoire had a tremendous screening (program). You probably remember the screening program for tuberculosis. They had eight what were called Centres Anti-Tuberculeux [CAT] scattered throughout the country, two of which were in Abidjan. They saw a large number of patients, and for one of our other projects, we set up HIV screening in all eight of them around the country. We knew that these were HIV-TB patients who were accessible and were fairly 01:02:00advanced in their [HIV] disease. In the pre-antiretroviral era, it was an opportunity--my recollection is--to provide some reduction and help to them.

MILLER: That was also pretty amazing. Over time we did a lot of work on trying to get HIV testing in TB clinics, but I think yours in Cote d'Ivoire was one of the early ones where they actually did it in a very large scale. Do you recall any of the issues that (were) concerned in terms of who was going to do the HIV testing or how will that work in a TB clinic?

GREENBERG: Yes, we worked with the Director of the National Program, who was Dr. Coulibaly Issa-Malick. He and I literally went around the country and visited--with my wife and at that point our first baby in the back of a car. He basically said he would teach me how to work in these environments. He was my mentor. We would travel to all far reaches with strategic positions all over the 01:03:00country, so (we spent) 12-14 hours in a car with a screaming child. The first thing was to get local buy-in, so we met with the local governors, the political representatives, the local physicians groups, and the tuberculosis control people. Very importantly, we met with the local tribal leaders, and those were fascinating meetings. These are very respected and powerful leaders of their communities, and Issa-Malick taught me how to meet with them. For example, in most cases you couldn't address them directly. You would address their intermediary, who would then translate what you were saying for them. There were gifts that had to be given, small gifts, laundry detergent, you know, it was symbolic. It wasn't anything of more than a couple of pennies in value, but you 01:04:00had to show up with soap, actually. Who knew? But Issa-Malick knew. The idea was to make sure that the local, both tribal and governmental authorities, were supportive and saw this as value, because obviously, this screening would allow people to, hopefully, link to services that they wouldn't have otherwise-- and prevent their loved ones from getting HIV, as well.

MILLER: In so many countries there was this fear of dual stigma, that if you start testing for HIV in a TB clinic, the word will get around that you have AIDS if you have TB. Did you have to deal with that at that time?

GREENBERG: I wasn't on the front lines, but my recollection is that it was handled confidentially and respectfully. Again, Stefan would be the person to recall more of the day-to-day of this, but I don't recall any major 01:05:00controversies emerging. I think it was--

MILLER: How was HIV/AIDS looked at in the Ivoirian culture? Was it stigmatized in a major way, as it was in so many other countries in Eastern and Southern Africa?

GREENBERG: I think because there was no treatment readily available at that point, it was largely quiet. You would hear that someone died or there were many, many funerals, and it was often unspoken what they died of. I think, yes, there was stigma associated with it, and people largely kept it to themselves and their families. It wasn't--without treatment--

MILLER: Were there a lot of issues around divorce or rejection of partners that were HIV-positive?

GREENBERG: I think you did hear both-- everywhere in the world you did hear stories like that.

MILLER: But it doesn't sound like it was big and in the front.

GREENBERG: Oh, it was very much in the press, yes. I think that's why the miracle of PEPFAR [President's Emergency Plan for AIDS Relief] was such a welcomed relief. People became increasingly aware, especially since the government was so proactive and we were publishing our results, and there was a very vibrant media that Kevin and myself and others, especially our Ivorian counterparts, were talking to. I think the depth and breadth of the problem was emerging. Every month I had to go see the Director General, the person who reported to the Minister of Health. I'd go up to the Ministry of Health and take this private elevator to the top and have to report everything we were doing. Then he would bring that to the minister. It was very much a public health issue 01:07:00that people were increasingly aware of, and I think, hopefully, laid the foundation for the receptivity to the PEPFAR program. Again, as you know, I didn't work in the PEPFAR program, but the opportunity to treat people has been the game-changer for the epidemic everywhere. Certainly if you talk to people who have been involved in the program, it was well positioned to take advantage of that, because there was HIV screening and there was good access to care in some sectors.

MILLER: You were doing randomized controlled trials, short-course AZT, Cotrimoxazole. Did the Ivoirians buy into the randomized control approach? Were they comfortable with placebo? Was there any data safety monitoring or group 01:08:00representing the Ivoirians? How did that go for you?

GREENBERG: Yes, definitely there was the Ministry of Health institutional review board that monitored the trials. My recollection is that the Ivoirians wanted things that could help them, help their people. I think that was their primary motivation, because there were no ARVs [antiretrovirals] available widely to develop interventions that could be cost effective. At that point there was no PEPFAR, things they could afford and implement. I think that was their desire and to know that they worked in their context. That was a very, very important point. Their impression of scientists, there are so many variables and a different sense of issues in every different environment--they wanted to know that these things could be shown to be effective in Africa and in their own country. So they were very supportive and encouraging to try to do things that 01:09:00we could do quickly and prove to be effective. That was true for AZT as well as Bactrim.

MILLER: What about the placebo control? The issue of not treating some of the moms with a short-course AZT 076 trial? Was there concern? You know, over the years there have been concerns over placebo-controlled trials in many different settings. What was it like then? We were still early in the AIDS epidemic, but there was information that AZT short course can work. How did that go with the Ivoirian government?

GREENBERG: Again, my recollection is their position was that 076 required--my recollection is pre- and post-oral (treatment before and after delivery of the baby) and then intravenous therapy as well with AZT. They felt in that context that it was not reproducible. At that period of time, they couldn't afford it, 01:10:00they didn't have the facilities for it, and they couldn't scale it. So they wanted to come up with a short course. There were many scientific meetings about it. Most of the transmission occurred around the time of labor and delivery, according to the scientific information that was available. They thought we could capture a lot of it by administering an oral drug for a very short period of time, which turned out to be true. The controversy was largely not within Cote d'Ivoire. It largely came from outside of Cote d'Ivoire, and there was quite a lot of discussion about it in the international media.

MILLER: About what aspect of it?

GREENBERG: About the choice to use placebos.

MILLER: And--

GREENBERG: I remember CDC had a post hoc consultation with a number of 01:11:00ethicists. Were you at that meeting? It was very interesting.

MILLER: I'm aware of it.

GREENBERG: They brought in the leading ethicists for that, and the conclusion was that ethically--my recollection is that ethically it was justifiable, but CDC could have been more public about it early on. No one was trying to hide things or doing things surreptitiously. It was the honest feeling of not only the Ivoirian scientists, but many African scientists published it. At that point in the pre-PEPFAR era, there was an emergency to come up with randomized clinical trial data for things that could work for their people in that context.

MILLER: The current strategy was no treatment, so that the placebo wasn't going against what was standard approach.

GREENBERG: Right. Standard of care was just documenting the transmission rates. I mean, it was nothing.

MILLER: Right. So that took some guts to do those.

GREENBERG: Yes, and I think the valuable lesson that institutionally was learned is when there are things that are controversial, to bring them out for public discussion and for scientific discussion, which I think had been done in the public health world but not in the mass media world. It was certainly a very important experience in our careers.

MILLER: You had a family. You've already said that one of your children was screaming throughout the rides around Cote d'Ivoire.

GREENBERG: Poor thing. They were long rides.

MILLER: Can you tell us a little bit about that? Is that where you actually had your children? Were they born in Cote d'Ivoire?

GREENBERG: I met my wife in the New York City Health Department. She was an epidemiologist there, and then she went back and got her Ph.D. when we were in New York. Her father was a travel agent and did safaris to Africa, so she also spoke French and she also had a love for sub-Saharan Africa. So we went 01:13:00together. There's this famous family story where we went to our check-in physical at the embassy. You know, they draw blood, they do physical exams. You are also part of a walking donor bank for the U.S. Embassy population, so they had to blood type you. The nurse came out and said, you're both healthy, and by the way, Mrs. Greenberg, congratulations. We had been to Abidjan for a week, and we said, what? She said, you're going to have a baby. I think I fainted, is the story. So we had our first pregnancy in Ivory Coast. Our second pregnancy, as well. Our two daughters--we actually Medivaced [Medical evacuation] the mothers six weeks before and six weeks after back to the U.S. for delivery, and 01:14:00the husbands three weeks before and three weeks after, so both our daughters were born in the Bronx. By the time we left Abidjan we had a 3 and a 1-year-old there. Michele likes to tell the story that I was so happy to become a new father that I announced to the Ivoirians and to the Projet RETRO-CI staff that if I had a healthy, live child I would throw a big party for everyone. They held us to it, and we had two of the most incredibly meaningful nights of our lives. We have it on video with African dancers. I remember we had like six goats. They brought the whole goats with foil on the legs, and they carved the goats up and 50 chickens. We had a hundred-plus people at our home. We did two of these with speeches and great merrymaking, being thankful for healthy children. Then our third child was born later on when we were in Boston, our son. Those were some 01:15:00intense times for childrearing.

MILLER: How did it go with your work demands and family demands?

GREENBERG: The spouses of those-- we were working very long hours. I mean, the obligation to run a project of this magnitude, continue to be productive scientifically, and trying to have a personal life was all bound up. We socialized a lot with each other. Those remain some of our closest friends. The other is John Nkengasong, who is now head of the African CDC. That's a good story when we hired John--if we have some time. We were working really hard. Michele likes to tell the story that Peter and I were talking to our wives once and said, you know, we're really busy now, but in April things are going to calm down. It was like January or something. We really think once we get to April it will calm down. I think the joke is that 30 years later, they're still waiting 01:16:00for April. These are not positions that require a small amount of work and I think require a good amount of family support.

Kevin once made a speech where he said, you need three things to succeed as a Projet RETRO-CI director. Let me see if I can remember-- a big heart, a good mind, and a strong spinal column. I'm glad I was young when I did it, because it took quite a lot of long hours, and trying to be a good father and a good husband at the same time, you have so much professional responsibility. On the other hand, I grew up. It really was a life-changing experience for me. I remember waking up one day--I was 35 when I started and always felt like I was 01:17:00still an adolescent, but one day I was sitting there looking at my wife and two kids and a hundred people looking at me and I said, I think I just grew up. Indeed, when I left the Ivory Coast, there was a ceremony at the Ministry of Health where the minister said, Alan, tu as fait deux enfants ici, you've made two children here. You've become an Ivoirian. He said, now you've become a man. So there was this notion that it was a very maturational experience, both as a scientist and as a human being.

MILLER: What were some of the most pressing management issues you had to deal with?

GREENBERG: Management always comes down to fiscal and HR [Human Resources], right? Number one, compared to PEPFAR there weren't huge amounts of money, but 01:18:00it was still millions of dollars, and (I was) trying to absorb the weight of being responsible for that much taxpayer money. At that point, it was a huge amount of money, and (I was) trying to make sure we were fiscally prudent and responsible and that we knew where every dollar was, which I think we largely did, and absorbing the responsibility, which I have to this day, of managing government funds well. I think that's part of it.

The other big challenge is HR. When you're running, you know, a bit of a Tower of Babel. There were people from so many different cultures, and (I was) trying to create an environment of respect and where diversity is celebrated and where people from different cultures feel comfortable and feel like they are valued. I think (I was) learning to be a manager not only on the fiscal side and also 01:19:00trying to pick people who fit. Anyone who works with me knows I have a very simple mantra, which is hire smart and nice. You know, keep it simple. Try to not only hire the smartest person you can, but people who you want to see at work every day. So there were a lot of, for lack of a better word, smart, convivial people who worked in the project that Kevin had hired, and then I tried to continue that tradition. I think all those things are easier said than done.

You have to take the time to know Excel and know where the dollars are and watch over that yourself and have a hand in the hiring of people so you can create a certain kind of--and leadership. I think learning to give big speeches, which I'd never done in my life, and be more charismatic than would necessarily come naturally and learning to be a public figure, learning to speak to the media, and learning to deal with controversy and also being an assignee. Again, at that 01:20:00point email was there, but communications weren't quite--there was no face chat, you know. It still wasn't the same, and having the responsibility of a lot of U.S government resources in a far-flung part of the world. Now there are many, many people at CDC who've had that privilege through the PMI [President's Malaria Initiative] and through PEPFAR, but (then) there was just a field station in Thailand and the field station in Kinshasa and the field station in Cote d'Ivoire. There was Lassa fever that Joe McCormick ran in West Africa, but there weren't dozens (of field stations). You know, there was a handful.

MILLER: Who was your "control officer" in Atlanta? Who did you look to for support?

MILLER: [Dr. Timothy] Tim Dondero. Tim was another amazing--I've been blessed, you know, to have worked with all these great figures. Tim was the head of global HIV branch. I think it was called the International AIDS Branch. He was 01:21:00my direct supervisor, so I had to keep him and his--and [Dr. Phillip] Phil Nieburg was a deputy. I had to keep them closely informed. That's another challenge of the job, having a lot of bosses. I reported on the Ivoirian side to the Director General of the Ministry of Health and to Professor Kadio. They definitely, as you said, with their engagement in the design of all these trials and handling the media, they were not passive partners. They were very much engaged both scientifically and policy-wise. Then I had my boss at the Embassy because I was head of agency, so I reported to the U.S. Ambassador. We had to keep the U.S. Embassy--I'm sure all the PEPFAR people have gone through this, but at this point it was all new to me. Trying to make sure the U.S. Embassy, which was supporting us, supporting our homes and supporting our families, were quite aware of what we were doing and could report back to the State Department about what we were up to and then reporting to CDC. Because after all, we were 01:22:00CDC assignees and reporting to DHAP [Division of HIV/AIDS Prevention], and they very much wanted to know what was going on. Science, management, money, hiring, leadership, it's all challenging, and those of us who were privileged to be given those opportunities, I think we all take it seriously. Nothing's perfect, but you try to do the best you can and contribute as much as you can for as long as you can.

MILLER: The political landscape of Cote d'Ivoire has changed over the decades, and there have been a lot of periods of fighting and danger in different parts. You described driving pretty much throughout the country with Dr. Coulibaly 01:23:00Issa-Malick. What was the political situation during the years you were there? Was it fairly calm? Was there a good relationship between the North and South?

GREENBERG: My recollection is there were the founding days of [Felix] Houphouet [-Boigny], the father and first president of the country. The government changed while we were there, and I remember the first transition of--I have to look this all up, Bess, so I apologize, but my recollection is that there was concern about the hand-over of power. I remember we were confined to our houses for a couple of days by the Embassy, but I think things went relatively peacefully. I left Cote d'Ivoire, and then after I got my Master's in Public Health. I was the Epi [Epidemiology] branch chief for HIV for many years. I went back to Ivory 01:24:00Coast for a meeting actually to open a vaccine research center is my recollection, and we were in the Hotel Ivoire. I got a call at 3:00 in the morning from Marie Laga who was there, saying, look out your window. It's 3:00 in the morning, and you could hear and see gunfire. That was, I think, the first outbreak of what became the widespread conflict in the country. Some of my colleagues lived through a lot more. We then left in '97 and I don't have the whole history in my head. We were not there during the crisis, but many of our friends were, and certainly many of our Ivoirian colleagues were.

MILLER: Did you have any concerns about your safety and the safety of your family while you were there?

GREENBERG: There were always health concerns. We loved Ivoirian food, and so we were out eating at local restaurants very often and had quite a number of cases of food-related enteric illnesses. I was hospitalized with cerebral malaria during one of my latter years there.

MILLER: Were you taking malaria prophylaxis?

GREENBERG: I was, but--

MILLER: And your family, as well?

GREENBERG: Yes, but you know largely we were in air-conditioned settings, and so you could get away in Abidjan with personal protection because the mosquitoes were largely biting in the evenings.

MILLER: So you would go through periods when you would not take malaria prophylaxis?

GREENBERG: Early on, until I got malaria.

MILLER: Then you got a real--you were severely ill?

GREENBERG: I was hospitalized, yes. I think there were concerns about--and what happened was, I was traveling on these tuberculosis--I wasn't always the best 01:26:00patient. You'd think I would have been, but--

MILLER: I'm just hoping you didn't call your mother when you were hospitalized?

GREENBERG: No. Actually, my wife was attending her cousin's wedding in Italy. I wasn't feeling well, so I called [Patrick] Pat Whitaker, who was the head of the data management section. He came over and said, I think we'd better get you to the hospital. So I went to Pisam, which is a hospital in--I said, I'll be all right. And they said, no, you won't. I actually don't remember being in the hospital, but I remember Angie, who is Peter Ghys's wife, was a nurse. Apparently she came and was with me for a couple of days while I was out. When I woke up, she was sitting there in a chair smiling, and she said I'm a nurse, remember? She goes, your wife wasn't here, so I took over. I was quite ill.

In terms of physical safety, we lived in U.S. Embassy housing, so we had guards and had very secure facilities. We had a hundred people on the project, so you did hear of issues. There were house break-ins, there was some street crime, dealing with staff, trying to support staff. We'd been through difficulties. Some of them were able to handle it well, and some of them were affected. So there was definitely physical--

MILLER: Was there anti-American feeling at that time, or not really?

GREENBERG: No, I don't recall being stigmatized as an American. Because it was French West Africa, there weren't that many Americans who would be there and work there. There was the Embassy, but it was largely a French-dominated--it was 01:28:00a French colony and they had their independence, I think, in 1960. My recollection is, when they thought of the West, they thought more towards Europe than they thought towards the States. I don't remember any-- I could be wrong, and my colleagues, if they are watching this, could be correcting me, but I don't remember any anti-Americanism being an issue. I think we were viewed as trying to help.

MILLER: Before we move towards conclusions, can you just tell us in a few words about your career since then? You've had a long and a very full career in HIV/AIDS since then. Do you want to just give us a few words about what that's been like?

GREENBERG: Sure. I'll do it in a quick paragraph, because I know the time is short. After I left Abidjan, I remember going to [Dr.] Helene Gayle, who was the 01:29:00Center director, and I said, Helene, I had this incredible experience being a leader of a project, but I'm at a career crossroads and I need your help. I said, either I'm going to be a scientist at CDC or a manager of science, and if I'm going to be a manager, then I really think I'd benefit from training. She supported that, and so I went to the Harvard School of Public Health to work with Jon Mann. As I said before, I didn't wind up doing that because he left and then passed away, unfortunately. But I studied. I was on the Health Policy and Management track. I took as many courses on Organizational Strategy and Structure as I possibly could have. I really tried to sort of cross-train and understand more.

A lot of physicians manage intuitively and from their experiences in the clinical world or at CDC, and it really helped me. I learned how to do strategic 01:30:00planning and, you know, Harvard's famous for their case studies. Many, many issues that have come to me subsequently, I said, oh, I already studied about that. It gives you some basis so that you're not managing intuitively or based on your own experience, but managing in ways that you've learned about. So that was a life-changing, career-changing experience for me.

Then halfway through that time in Boston, Kevin De Cock became the Division Director of DHAP. Once again he reached out to me and said, I'd like you to be Chief of the AIDS Epidemiology Branch. I said, but I'm living in Boston. He said, well, commute. So I then was the Chief of the HIV Epidemiology Branch from 1998 to 2005 when I retired (from CDC). We won't have time today, but that was an incredibly rich experience because we worked in dozens of states and ten countries around the world. We had the privilege of supporting some of the most 01:31:00amazing scientists who to this day have gone on to do wonderful things. So that was very prideful.

I retired from the Commission Corps in 2005 at my 20-year anniversary, and I was recruited back to my alma mater by the then- Dean Ruth Katz, who was I think on the CDC Advisory Board of Emory. She has an Atlanta connection, and she knew I was retirement eligible. She came down and got me with the tagline-- how would you like to move back to your alma mater and help build a school of public health in the nation's capital? I remember thinking that my wife said, that sounds like you. So we moved three generations of our family from Atlanta to Washington, and I'm now starting my 13th year. I'm Chair of the Department of Epidemiology.

I have three jobs basically. I'm Academic Chair of the department, which is related to, but very different, than being a branch chief at CDC, in that at CDC 01:32:00you have some line authority. Of course, you report to the Division Director, but the tables have turned. I report to the faculty. So it's very interesting, managing in an environment where you're more a managing partner than you are a supervisor. I certainly don't supervise the faculty. Of course, we have the wonder of being around young scholars in their 20s and doctoral students and young faculty and the privilege of mentoring EIS officers, mentoring the next generation of epidemiologists. We don't have time today, but it's grown dramatically and we have our own building now and an endowment and a great dean, and it has really been a privilege to do that.

My second job is, you know, the AIDS epidemic in Washington, DC, was considerable, and despite having such a severe epidemic, there had never been 01:33:00what's called a Center for AIDS Research, an NIH-sponsored CFAR-- Centers for AIDS Research in the United States. GW, the university where I work, wasn't large enough and didn't have enough grant money to qualify. I always say, other than marrying my wife, the only good idea I've ever had in my life was, I thought if we could get everybody in the city to work together that we would qualify and have not a university-based CFAR, but a citywide-based CFAR. So dot-dot-dot, we started an AIDS Institute, and we were then funded by the NIH for a developmental CFAR. Since 2015, we're a full CFAR, and we now have 235 faculty members from eight institutions-- GW, Georgetown [University], Howard [University], and American University, Children's National Medical Center, the VA Medical Center in D.C., the very well-known Whitman Walker Health Clinic, which is a very large community-based clinic, and the DC Department of Health.

MILLER: And the mandate of that CFAR?

GREENBERG: Our mission is to support HIV research that will contribute to ending the AIDS epidemic in Washington, D.C., and beyond, in partnership with community and government. If we had more time I could talk about what that means, but we work very closely with the community and government. Indeed, AIDS cases have fallen from-- I think there were 1,350-ish in 2007, and we're now I think in the low 300's. So there has been a 70-plus percent reduction in the number of HIV cases. How that was done is a whole 'nother story, but it's really been a privilege to work with the local government and the NIH and the community to help contribute to that change. Of course, led by the Health Department. They deserve most of the credit for coordinating the response.

Then my third job is as an HIV researcher. We're a member of the HIV Prevention Trials Network. We have a clinical research site where we do interventional trials to prevent HIV in high-risk populations. Intramuscular prep, for example, 01:35:00being one of the studies we do now. We have a large cohort study of consenting HIV patients, participants from 14, soon to be 15 HIV clinics. We do a monthly electronic medical merge, which is an IT [informational technology] challenge but we figured out how to do it. We're starting to publish--characterize this population very well and trying to bring interventions to the population, which is very exciting, and improve clinical care and other studies, as well.

MILLER: Excellent. You've certainly had an amazing career. Before we conclude, any general thoughts on your work for CDC and in the various settings and the various topics you've covered? Any further thoughts on your work with CDC?

GREENBERG: Sure. First, it was an absolute privilege--it remains a privilege to work with the CDC. It's an incredible organization filled with-- I think now that I'm an academician in a much smaller environment, (I'm in awe that) you walk around these hallways, and there's not just dozens of epidemiologists but thousands of epidemiologists. I don't think when I was here I quite realized how unique-- I realized it was great, but I didn't realize how unique it was. I mean, there's probably nowhere in the world that has such a confluence of public health experts on such a wide range of diseases. There couldn't be.

As you know, Bess, I've had the privilege to serve on advisory boards for CDC, advisory committee to the director, and chair that for Dr. [Thomas R.] Frieden, and that was an incredible experience. I continue to be wowed by CDC's response to Ebola. I mean, it's just an amazing place, and I think that's the first 01:37:00(thing), is just how respectful and in awe I am, and how awed that I had these opportunities in one lifetime.

The second thing is mentorship. As I've tried to explain today, I've had the benefit of amazing mentors. In malaria, Kent Campbell, [Dr.] Joel Bremen, Phuc--and then in the Zaire days, Jim Curran, Peter Piot. These are giants. Kevin De Cock, Robin Ryder, Jon Mann, Phuc Nguyen Dinh in malaria, and Polly Thomas. They all took way extra time probably away from their families to review my manuscripts, to review protocols, to help. Helene for the vision to send me for management training, which was so transformational in my career. I think that was a second lesson learned.

What I've tried to do, I actually wrote an editorial in AJPH [American Journal of Public Health] about it this month, is do that myself and mentor as many 01:38:00people as I could, help when I could, and I am so proud of some of the people. I mean, success has a lot of mothers, so you're not solely responsible. At one point or another I hired and gave some input into amazing people who've gone on,--Stefan Wiktor, who was head of Hepatitis C for the World Health Organization-- Dr. [Rene] Ekpini in Abidjan, who was Mother-Child for UNICEF-- Peter Ghys, who now is the head of surveillance and a very senior member of the leadership of UNAIDS in Geneva. [Dr.] Shannon Hader was my EIS officer, and she's now head of Global AIDS for PEPFAR for CDC. John Nkengasong, whom I hired 01:39:00from Belgium --I had the good fortune to hire John, who has now changed history in his work in Africa and around the world through PEPFAR. He now is the founding director of the African CDC. We've been emailing yesterday. I'm still in touch with all these people. I could go on and on. I'm sorry if I'm missing anybody, but I've had the opportunity to hire and help evolve the careers of so many people who've gone on.

I've had an incredible career, but the achievements of the people I've had the opportunity to mentor and now doctoral students and young faculty, far outstrip anything I've done. It's the single thing I'm proudest of when I look back at my life. It's the people I've trained, not to mention the Ivoirian scientists who we worked with. One after another and now there's so many who work for CDC or international organizations. For instance, I just got an email from Dr. 01:40:00[Mamadou] Diallo, who has worked with Peter Ghys. He's going to be a country director for the President's malaria initiative. I mean on and on and on. That's the second thing I think I took away.

The third is what I was talking about before, which is the way CDC works, which both has lessons in that you don't fly in and take over-- you fly in and support local people to do it. That institutional lesson, which I've already talked about, applies personally as well in my professional life. You don't tell people what to do, you get their good ideas and help them fulfill their dreams.

MILLER: You have so many wonderful things to say about CDC. Is there anything over the years that you feel that CDC could have done better?

GREENBERG: I don't know the whole of CDC, so.

MILLER: In your experience?

GREENBERG: I don't want to be a Pollyanna, but CDC did a lot with a little amount. When I think of the budget of DHAP, I don't know what it is, but it was hundreds of millions, not billions. The incredible things they've done with those resources and internationally, CDC's role in the PEPFAR program, which I wasn't privileged enough to have the opportunity to work in directly, but so many of my close colleagues have, and they put up those slides with the lives saved. [Ambassador] Debbie Birx--I mean it's incredible. You know, the 35,000-foot answer to that is, I'd have to think about it, because nothing's perfect. All in all, when I think of CDC, it's an organization shining on a 01:42:00hill. It's not, “well, we gotta get rid of that one,” you know? It's the leader in public health and prevention. When I was fortunate enough to serve on the advisory committee and learned about the breadth of what goes on here, I was so busy doing what I was doing, even now I work so hard I don't even often know what's going on the floor below me or above me. I should, but then I couldn't do all the things I do. When I served on that committee, you hear about seatbelts and you hear about violence prevention and you hear about immunizations, and you hear about TB and you hear about STD [sexually transmitted disease] and surveillance and responsiveness. It's incredible. There are plenty of other things to criticize but CDC is doing pretty well, I think.

MILLER: It has been a real privilege talking to you. Thank you.

GREENBERG: Thank you, Bess. It's been a great honor to have this opportunity to share the first half of my life story.

MILLER: Thank you.

END.