Dr. James Curran

Dr. James Curran

MILLER: This is Dr. Bess Miller, and I'm here with Dr. James Curran. Today's date is February 10, 2016, and we are in Atlanta, Georgia, at the Centers for Disease Control and Prevention [CDC]. I am interviewing Dr. Curran as part of the Oral History project, The Early Years of AIDS [acquired immune deficiency syndrome], 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. I must ask, Dr. Curran, do I have your permission to interview you and to record this interview?

CURRAN: Absolutely, Dr. Miller.

MILLER: Jim, I've known and admired you since the very beginning of this epidemic. You assumed the leadership role on AIDS for CDC from the very beginning. Each and every one of the narrators I've interviewed for this Oral History of the Early Years of AIDS at CDC has expressed their admiration and gratitude to you for how you provided leadership for CDC's response. You served 00:01:00as the Coordinator for the initial Task Force on Kaposi's Sarcoma and Opportunistic Infections in July 1981 and became the Director of the Division of HIV/AIDS in the National Center for Infectious Diseases by September 1989 with hundreds of staff. Currently, in your position as Dean and Professor of Epidemiology at the Rollins School of Public Health of Emory University, you've continued to provide leadership at a national and international level on AIDS. For this oral history of AIDS at CDC, we will be focusing on the early years, beginning in June of 1981 with the publication of the first Morbidity and Mortality Weekly Report on five cases of Pneumocystis carinii pneumonia among homosexual men.

Let's begin with your background. Do you want to tell us a little bit about where you grew up, your early family life, and where you went to college and 00:02:00medical school?

CURRAN: I grew up in a suburb of Detroit and attended college at the University of Notre Dame, where I majored in premed and chemistry, and then went on to medical school at the University of Michigan in Ann Arbor. When I graduated from medical school, my intent was to go into OB/GYN and family planning/population control and get a Masters in Public Health and save the world from overpopulation. That was interrupted, as for many of the men of my generation, by the Vietnam War, and I had an opportunity to serve then as a Commissioned Officer in the U.S. Public Health Service.

MILLER: Who or what influenced you to go to medical school?

CURRAN: I was raised in a family in which my father was a businessman and teacher and my mother was a homemaker. They always admired the family doctor, 00:03:00who was a close friend. I had an interest in a combination of humanities and science and service. I went to a Jesuit high school and that was fostered in my high school era. I thought I would try out premed and medicine and it combined all of those things together.

MILLER: So you were drawn to public health initially, but then reaffirmed by the military circumstances.

CURRAN: Well, I had an opportunity. I was going to have a Commissioned Officer deferment, a so-called CORD deferment for the Family Planning Service, but that program was authorized but not appropriated--a term I wouldn't learn the true meaning of till decades later. I then had a choice of going in the Air Force 00:04:00immediately or seeking out a Commissioned Officer's job in the Public Health Service. That led me to beginning discussions with the CDC. At the time, what was called the Venereal Disease Branch was embarking on an initiative for gonorrhea control. It had been solely a syphilis organization before that, populated largely by dermatologists. Anybody who had even a marginal interest in OB/GYN and the complications of gonorrhea occurring mainly in women was a good fit, so I took that position.

MILLER: Tell us a little more about your main emphasis of work before AIDS.

CURRAN: I began as a Commissioned Officer assigned to the University of Tennessee to study the economic costs of the complications of gonorrhea, and as 00:05:00such I was an instructor in Preventive Medicine. We set up a laboratory and began an elaborate screening process to look at those complications in Memphis, Tennessee. I really liked it, so I said I'm going to give up OB/GYN and just go into public heath. I then applied for career development at CDC, among other options, and was awarded two years of career development.

MILLER: Let's shift our focus to your involvement with what was to become known as AIDS. In the very earliest days of AIDS at CDC, we mentioned that on June 5, 1981, there was the MMWR on five young homosexual men with Pneumocystis carinii pneumonia in Los Angeles. Two of the patients died. Now, you had linkages to the gay community, if we can call it a community at that time, through CDC's work on 00:06:00the Hepatitis B vaccine trials and other sexually transmitted diseases, or STD work. Was there any awareness of these cases, this type of illness, through this channel for you before the MMWR?

CURRAN: Well, I came to Atlanta in 1978 as Chief of the Research Branch of the VD [Venereal Diseases] Control Division, and our highest priority was the funding of studies leading to the Hepatitis B vaccine trials in gay men. Arguably, Hepatitis B was the most important STD in that community at the time, and I believed, and our Division believed, that we should provide the funding to assist the Hepatitis Division, which was then in Phoenix, Arizona, in conducting 00:07:00the trials. So we got deeply immersed in working with the gay community and their providers in five cities in the United States. However, it really wasn't until we saw the draft of that MMWR article, maybe two weeks earlier, that we were able to start making our contacts. And we found when we did that many of these doctors were seeing more gay men with abnormal conditions, not necessarily the serious Pneumocystis pneumonia yet, but they were seeing these lingering kinds of other types of chronic conditions. At the time there were two national STD Control conference meetings, one in Atlanta and one in California. We were armed then with this new MMWR draft to go and talk at those meetings to people who were seeing gay men in their communities--our contacts in the hepatitis community plus others--and that was an opportunity to really get our hands in 00:08:00what was going on.

MILLER: Tell us a little bit about your interactions with the clinicians who must have been the early warners, in Los Angeles, New York, San Francisco, and the other cities that you mentioned. Who were these people and their background, and what were some of the initial hypotheses about this condition?

CURRAN: The first cases in Los Angeles were reported by Doctors Michael Gottlieb and his colleagues, who was working in the gay community, along with Wayne Shandera, who was the EIS officer at CDC in LA at the time.

MILLER: And the EIS being the Epidemic Intelligence Service.

CURRAN: Yes, the Epidemic Intelligence Service officer in Los Angeles. Dr. 00:09:00Gottlieb had trained in infectious disease and immunology in New York City and was a very well-trained Assistant Professor at the time at UCLA. We made calls to San Francisco to some of our colleagues there, but the first patient I actually saw was in New York. There had been a call and contact with Dr. Linda Laubenstein, who was an oncologist at NYU [New York University]. Dr. Laubenstein, herself a polio survivor, had with her fellows seen cases of Kaposi's sarcoma in a disseminated form and wanted to have CDC assistance. The head of the group at CDC dispensing the drug for Pneumocystis was Dr. Dennis 00:10:00Juranek, who himself was an outstanding epidemiologist and veterinarian. So they asked me to come along as a physician to see this case the week after the first MMWR was published.

I can't help but remember the time I met that first patient. It turned out that we had much more in common than we had differences. He and I were exactly the same age, and we had both gone to Catholic prep schools in Detroit who were football rivals. He might've been a little bit smarter. He had a scholarship to Yale in acting and I went to Notre Dame and became a physician, and he had a scholarship to Yale in acting; he was a handsome actor who had these blotches on his face. And he said, doc, from CDC, what do you think, can we get rid of these, is this going to hurt my career? And, of course, I had never seen a case 00:11:00of Kaposi's sarcoma in my life, and I didn't know what to tell him. Unfortunately, he was treated with very aggressive chemotherapy, which probably hastened his disease course. I had a chance to see him several more times before he died, and actually the week he died in the ICU [intensive care unit] at NYU. What struck me in that first encounter is how similar our backgrounds were and how differently things turned out for him. But for the grace of God and this damn virus, that could have been me.

MILLER: Almost immediately CDC established the Task Force on Kaposi's Sarcoma and Opportunistic Infections, with you as the coordinator. Can you tell us a 00:12:00little bit about those early weeks and months, and who was working with you and how that got organized?

CURRAN: The CDC political background, at least as I remember it, was that Ronald Reagan had just been elected President to replace Jimmy Carter. Some of the stimulus for the election was very high unemployment and inflation rates. In Iran the hostages were taken in the Embassy, and Ronald Reagan rode that to election victory. For the first time there was an organized religious group that was supporting the Reagan administration, following Ralph Reed and Pat Robertson, and so there was a motivation to appeal to that electorate. But the 00:13:00main thing was the concern about a decrease in domestic spending. There was a hiring freeze at the CDC and a freeze on a lot of budgetary aspects of CDC, as well as a commitment to close the Public Health Service hospitals and to cut back on domestic spending, with increased spending for defense in an attempt to vanquish the Soviet Union. So all this was going on in the background when the first cases were reported. CDC had been relatively fresh from an investigation of Legionnaire's disease in 1976 and Toxic Shock Syndrome following that.

We were fortunate to have Dr. Bill Foege retained as Director of CDC through the 00:14:00political transition because of his impartiality and excellence and I think 10,000 bipartisan connections, so that we had that advantage to begin with. Dr. Foege wanted to make sure that we could continue to respond to new threats, even if we had limitations in our budget and travel. One of the really good things is that CDC swarms on new problems with the Epidemic Intelligence Service and the general mentality of responding to a threat. So the Epidemic Intelligence Service officers, which, of course, included you, Dr. Miller, said, we want to deal with this new problem. Despite the financial constraints that we had and the personnel hiring constraints, we had an eager group of people that came from throughout the agency. People working on cancer, people working in virology, 00:15:00people in STDs, people working on environmental issues--all were assigned together to this ad hoc task force that we called Kaposi's Sarcoma and Opportunistic Infections. We wanted people to realize that we considered this not just an epidemic of cancer, not just an epidemic of infections, but an epidemic of a conglomeration of things forming a syndrome, which of course now we know is immunodeficiency caused by HIV infection.

MILLER: How did you come to that decision so early on in the epidemic, the idea that Kaposi's sarcoma and some of the opportunistic infections were linked? That might not have been obvious from day one.

CURRAN: We heard about the Pneumocystis pneumonia because of requests to our Parasitic Disease Drug Service for pentamidine isethionate, and we called around 00:16:00to our physicians who said, we're also seeing Kaposi's sarcoma. And then there were calls from New York City. There was a Dr. Bijan Safai, an outstanding expert in Kaposi's sarcoma at Memorial-Sloan Kettering, who had seen more than a dozen cases. There was a Dr. Greg Ackerman, who was the foremost pathologist on Kaposi's sarcoma at NYU, who had certified all of these cases. They were all in gay men--it only took a few phone calls to find out this was going on, too. Then some of these patients with Kaposi's sarcoma would also get Pneumocystis or they would be immunocompromised. Although the patients were seeing different doctors, the conditions were occurring in the same populations in the same cities.

MILLER: So you called around. I think that's a strength of CDC, but I'd be 00:17:00interested in hearing more about that process. Did you call health departments? You called people who knew people? How did that work?

CURRAN: Well, we had many connections in the infectious disease community. Doctors [Harold] Jaffe and [Mary] Guinan and many others knew people who knew people. We knew people from our Hepatitis B studies in that community, and then we knew who had requested pentamidine. So we made these kinds of connections within the first week or so and made a couple of visits in the first couple of weeks. Then shortly thereafter we dispatched EIS officers to 18 cities to conduct more intensive surveillance in their pathology logs and their infectious disease logs in major hospitals to look for cases.

MILLER: Can you say a little more about the top priorities of the Task Force at that time, surveillance or looking for cases, or the case definition? Can you 00:18:00speak a little more about those aspects?

CURRAN: Well, the important thing about investigating a new unknown condition is to get a handle on what you're really investigating and to find out if it's new, who gets it, and is it going up or down. These things can help lead you to finding out what the cause is, because ultimately you want to find the cause and then how to prevent the condition. But you have to get a handle first of all on what it is you're really studying. In order to do that it's important not to be too limited in your knowledge of where you think it's going when you don't know what it is. So we spent quite a bit of time, meaning days to weeks, making sure that we had a handle on a very specific case definition. We were aided with this 00:19:00definition because the conditions were so rare and so remarkable. Men with Kaposi's sarcoma in its advanced phase or Pneumocystis pneumonia were often cachectic, were often like the sickest of cancer patients or disaster survivors. They were very, very, very ill. Any doctor who saw one patient would remember it. They would say, oh my God, this is remarkable. One of our EIS officers, Dr. Harry Haverkos, saw one patient during his fellowship and said, I want to go work at CDC and figure out what is this and what causes it, because it was so remarkable. Also, cases could be diagnosed by definitive means through open lung biopsy for Pneumocystis pneumonia and through a skin biopsy or tumor biopsy with 00:20:00Kaposi's sarcoma, or other definitive means for other fatal opportunistic infections.

We knew, as you did from your work, Dr. Miller, that this was the tip of the iceberg. What we were measuring, because we wanted to be very specific, missed a lot of other things that were lesser conditions that were less specific: lymphadenopathy syndrome, thrombocytopenic purpura, other types of cancers all occurring in the same people. But we wanted to know who was getting this syndrome, not what other nonspecific symptoms the people who were getting it also got. We had a very specific case definition and conducted active surveillance using it, which allowed us to go backwards in reviewing records and to go forward in determining whether this was increasing and whether it was affecting new populations. Perhaps the most important thing we did was establish that case definition.

MILLER: How was it that you knew this was the tip of the iceberg?

CURRAN: We had many connections with doctors. I had a very good friend who was a physician caring for people in the gay community in New York. I spent 40 weeks in New York the first year, and I would have dinner with him once a week. He would tell me about his practice and I would tell him about CDC. He had formerly been at the health department, and he would tell me about the kinds of patients he was seeing in his office and how he essentially had to open up on weekends. He was so busy because he had all of a sudden this large number of gay men coming to his office with a variety of conditions: sinusitis that couldn't be treated, just a variety of things that were related to this diminished immune system people had. We had that experience in talking with physicians, so we knew 00:22:00that there were other people with the syndrome.

Of course, what we hoped was that these other conditions, for example, oral thrush, implied that the spectrum was caused by a virus like hepatitis B, which would include short-term infection and natural immunity. We were enamored by the Hepatitis B model. We thought that this looked like it was transmitted like Hepatitis B, and we hoped that the natural history would be like Hepatitis B: that people would either have no symptoms or they would have minor symptoms, they'd develop an antibody response to whatever it was and then we could come in and develop a vaccine and end the epidemic. That's what we wanted to do.

MILLER: Was that the thinking very early on?

CURRAN: That was hopeful thinking. Of course, in the absence of the true known cause, it's impossible to know.

MILLER: So for the case definition you wanted to be inclusive but not too 00:23:00inclusive. Can you recall some of the thinking on that? Did you include the sinusitises and the thrush or did you only include the more--

CURRAN: We wanted something to be very specific, and so we only included culture- or biopsy-documented life-threatening opportunistic infections or Kaposi's sarcoma in people under age 60. There were a few cases of Kaposi's sarcoma in men over 60, a few hundred per year, reported in the United States. We didn't think that had anything to do with this, so we limited the definition to people under age 60, and then we would investigate every case. Was this happening in women, for example?

The other part of the case definition that was very important is that there had to be an absence of a known cause for immune suppression. So if somebody had an underlying cancer, if they had an immunodeficiency disease or they were taking 00:24:00steroids for their asthma or something else, then they would be eliminated from consideration. When the first two cases in women were reported after 150 cases in men, the cases turned out not to meet the case definition because the Pneumocystis, for example, would be diagnosed before the cancer. Dr. Guinan and others would rush off to the city and investigate the case, obtain specimens, do questionnaires, and then maybe it wouldn't turn out to be a case. But when the first case in a woman was reported and the first case was documented in a 00:25:00heterosexual man, they were extremely important clues. The woman, I believe, was the female partner of an injecting drug user, and there had been men who were injecting drug users reported. Again, this fit the Hepatitis B model of transmission: blood-borne and also sexually transmitted in gay men and heterosexuals. This case definition was extremely important because it was so specific, and the cases kept on increasing and being recognized in more areas.

MILLER: Following up on that, you did a case-control study during that first year. Can you say a little more about that? A case-control study is a very standard operating procedure at CDC. How did that go? Was it accumulating cases? Who were the controls? The thinking there was critical as well.

CURRAN: The case-control study was led by Doctors Harold Jaffe and Martha Rogers, and many of us participated in it. In terms of supervising it, Harold, who has been a very close colleague for many years, was in California while I was in New York, in order to assure there was a standardized way of conducting the study. Since most of the cases had been in gay men, we wanted to find out how the gay men who had this disease differed from other gay men in their areas. We didn't want to find out that they were all from New York or California. We knew that already. We didn't want to find out that they were a little bit older, that they were average age 35. We knew that already. We wanted to find out how 00:27:00they were different from other gay men. So we matched them with controls by city, by age, race, and sexual orientation.

Where could we find controls? Well, much more than nowadays, the gay community was closeted. Certainly we were decades away from gay marriage and decades away from the kinds of protections that we now have in many states and the federal government to protect against disease. So we had to rely upon sources of available patients: STD clinics, private doctors' offices, and friends who were not sex partners of controls. We would match them by age, city of residence at 00:28:00the onset of the patient's illness and of course, sexual orientation. We knew that the patients who were controls were highly sexually active, more so than the average gay man in those cities, since they were going to STD clinics. They either suspected or had a sexually transmitted infection or they were going to a doctor's office, often because of a sexually transmitted disease. We even knew but couldn't quite figure out whether some of these people who were controls might've been in the iceberg. So we knew we were over-matching in a variety of 00:29:00ways. If we were to find a difference between the cases and the controls that was related to sexual behavior or possible exposures, then the study would be even more robust because you wouldn't expect it to be that way. Indeed when Doctors Jaffe and Rogers and their colleagues finished the study and all the analyses, they found out that almost all the variables that differentiated the cases from the controls were related to sexual activity, lifetime numbers of partners, mean numbers of partners in the past year, partners from bathhouses, and serologic evidence or personal history of STDs. In retrospect, now we know that the gay men who were first infected with HIV and who first became ill several years later had to have more chance of exposure, simply because the 00:30:00virus at that time was rare compared to now. So in a sense it was very compatible with this.

MILLER: To interrupt the flow a little bit, when do you think you realized that this epidemic was huge, was going to be something very big? Was it yet at this early stage?

CURRAN: The difference between this and other epidemics CDC investigated was that the numbers of cases began slowly, kept increasing inexorably, and the condition seemed to be inevitably fatal. So we weren't talking about something that lacked in severity. We didn't know how large the iceberg was or how many 00:31:00people were affected, but we knew that the people reported were progressively getting worse and dying, and it was unremitting. When there were ten cases and then 20 cases and then 40 cases and then 80 cases, doubling every few months, we knew that this doubling resulted in people who would die. We knew that the longer they had it, the less likely they were to live. The average person would live a year after they were diagnosed and reported. So we were dealing with something very, very serious.

Now, we would estimate how many cases would occur in the future in the first year or two, and I can remember two things about the estimates I or others at CDC would make in public or with the press. One is that we would say that this is getting much, much worse. Second, I can remember also saying we're probably underestimating it. I would provide a large estimate and then a few months later 00:32:00an even larger estimate. I was being questioned by the people in the Reagan administration, and they were saying, why are you alarming people by saying there are probably hundreds of thousands of people who are affected? I'd always say, I'm probably underestimating it. I didn't know if I was or not, but turned out I was underestimating, and we were all underestimating it. We could never have thought that this would affect a hundred million people in our lifetime and result in 40 or 50 million deaths.

MILLER: We talked about the Reagan era in Washington and some of the funding cutbacks. Do you think the funding issues in the early years affected CDC's 00:33:00response to AIDS?

CURRAN: I think that there were biologic and social factors which impeded our response. The most important factor was the virus itself. We now can estimate that when those first five cases of Pneumocystis were reported, there were likely already 250,000 gay men infected with HIV, and there was no really good treatment until 1995. Almost all of those men have now died. So the biologic nature of the virus itself and how hard it is to deal with was a major factor, and we still have no cure and no vaccine. So you always have to take "could we have done better" in the context of how terrible this virus is and how difficult 00:34:00it is. Having said that, there's no question that this condition occurring in gay men in New York and California primarily to begin with--states that didn't vote for Reagan--did not cause a major radar blip in the White House. In fact, President Reagan said almost nothing at all about AIDS for many, many years, despite of course knowing people in Hollywood, knowing Rock Hudson, knowing people in the Joffrey Ballet (where his son was a dancer) who were dying of AIDS. So we know that there was not-so-benign neglect. I mean the band did play on, there's no question about that.

What difference would it actually have made if the NIH [National Institutes of Health] could have done more? Certainly there could have been stronger and 00:35:00earlier communication and sympathetic warnings from the President and the Adminstration early on. I think certainly we could have used more research money earlier, we could have used a lot more sympathy from the American public toward the gay community. I think if we'd had gay marriage in the 70s, it would've been helpful. I think that the political administration was part of where America was then. I wish the response had been better. I wish it had been much better for injecting drug use and needle exchange and other things that we didn't do, but the virus itself is formidable.

MILLER: Did you feel supported by CDC's leadership? I think initially it was Dr. Bill Foege and then in 1983 Dr. Jim Mason. What was the relationship with the activity and CDC's leadership?

CURRAN: Despite the financial constraints of the Reagan administration, we had a 00:36:00couple of very fortunate leaders. One was that Dr. Foege, who had been Director of CDC under President Carter, because of his relationship with Senator Richard Schweiker, who became the Secretary of HHS, was able to remain on as Director of CDC. We were also fortunate that a very knowledgeable M.D., Ph.D. biostatistician named Ed Brandt, who was a loyal Republican and an outstanding academic and physician, became Assistant Secretary for Health. That position and his relationship with Dr. Foege were very important in the public health and medical and scientific response to the epidemic, particularly in the absence of additional resources. But there was a conscience and there was a communication 00:37:00at that level that Dr. Foege brought to Dr. Brandt that helped to counter any negative vibes that were going on in the Administration.

MILLER: When Dr. Mason came in, which was a little later, how did that fare?

CURRAN: Dr. Mason had previously been Deputy Director of CDC. He was an outstanding public health figure and an M.D., Ph.D. who rose through the ranks at CDC very quickly. He left CDC to head the health services in the Mormon Church and then become the State Health Commissioner in Utah. He was very close to Senator Orrin Hatch and was appointed as Director of CDC by the Administration; he came with a deep knowledge of public health and a deep 00:38:00knowledge of how CDC works, and an extraordinary work ethic. So we were fortunate to have someone like him, despite his strong loyalty to a socially conservative Administration. He was then followed by Dr. Bill Roper who, again, was a political appointee and also was very deeply committed to the fundamentals of public health.

MILLER: You mentioned you spent a lot of time in New York City that first year: 40 plus trips to New York. Dr. David Sencer, who was previously a CDC Director, was serving as the Commissioner of Health for New York City at that time. There were EIS officers: Dr. Polly Thomas was there and Dr. Mary Chamberland was 00:39:00seconded there for quite a while. There were a lot of clinicians and academicians. The Gay Men's Health Crisis was established in 1982. Can you tell us about your work and experiences in New York that first year?

CURRAN: I think we were fortunate for these leaders. The only unpleasant aspect of traveling to New York so much the first year was that it coincided with the air traffic controllers' strike. It made traveling anywhere in the United States in 1981 very difficult. Two-hour trips turned into 12-hour trips. But we were very fortunate that Dave Sencer, who had been Director of CDC for many, many years and a mentor to many of us, had just assumed the directorship of the New York City Health Department. He was an enormously talented guy who loved public 00:40:00health and loved the CDC and loved relationships with the CDC, so he would try to strengthen those relationships as much as he possibly could. He and I talked in the beginning about what the health department could do. At the time there was a citywide infectious disease conference headed by Dr. Don Armstrong at Memorial Sloan Kettering. He would gather infectious disease clinicians and scientists every week or two to talk about emerging threats. I would go to those meetings. In talking with Dr. Sencer, we said perhaps the health department could have regular meetings on this new topic and be the center of focus. He immediately instituted that, and the health department then got very much involved with all the academic medical centers and all of the people. It was an open meeting . The press could be there as well, and it was a chance to really 00:41:00focus communications from the very beginning. So working with Dr. Sencer and also his staff in terms of the case-control studies and reporting was a delightful thing and a fortunate aspect. I think it's something that is a real strength of the CDC and that is the relationships with state and local health departments. It really shows up when an epidemic occurs.

MILLER: Can you tell us a little more about what was coming to light with the academicians as the case numbers were going up and there were frequent meetings? What was the atmosphere among the clinicians?

CURRAN: When the epidemic first occurred, it's hard for us to remember that 00:42:00almost all the cases were from California and New York. Doctors in 90% of the states had never seen a case nor heard of a case in their own community. There were only a handful of people who had any clinical experience with this epidemic. And there was not any press coverage to speak of, except in the gay press in New York and California. But there was a cadre of infectious disease doctors and sometimes oncologists or dermatologists who were seeing these patients, and they felt so passionately about them that they were calling attention to their colleagues through papers in the peer-reviewed literature. They were reporting at meetings, and so there was a buzz in that community. I had one memorable occasion. There was a scientist here named Al Balows, a senior 00:43:00microbiologist who was doing a planning session for emerging diseases at the ICAAC meeting [Interscience Conference on Antimicrobial Agents and Chemotherapy], the infectious disease meetings in Chicago, and he asked me if I would do a late-breaker on Kaposi's sarcoma and opportunistic infections at the annual meeting at the Conrad Hilton in the grand ballroom. There were maybe 10,000 people at this meeting. So I went up there toward the end of '81, thinking, oh my God, this is just another group who doesn't care. First there 00:44:00was a Legionnaire's disease presentation, a Lyme disease presentation, which was relatively new, and a Toxic Shock presentation. The ballroom was perhaps a third filled, seating four or five thousand people, and it was now 9:30 at night. Everybody was tired from the long day at the meeting, and there was a little poster saying that I was going to be speaking last as a late-breaker. And the ballroom started to fill up at ten o'clock and by the time I got up to present the 40 cases, there were 5,000 people in the ballroom. I knew then that other people realized that there was a strong academic community recognizing the importance of this epidemic.

MILLER: There was a more organized gay community in New York City than other 00:45:00areas and, again, they formed the Gay Men's Health Crisis to begin to address this in 1982. Can you say a little bit about your relationship with this community during that first or second year?

CURRAN: The first organization of the medical gay community I believe was in San Francisco. It was the Bay Area Physicians for Human Rights. Drs. Bob Bolin and Neil Shram and others eventually were in that group. They formed in the 1970s to deal with STDs and other health problems in gay men, including hepatitis; we'd had some contact with them. There was a Los Angeles gay community center where the first hearing was held with Representative Henry Waxman in 1982 in Los 00:46:00Angeles. In New York City there was a very strong advocate named Larry Kramer and a colleague of his named Paul Popham, who was a publishing executive. Paul and Larry formed the Gay Men's Health Crisis, the first NGO solely to deal with this epidemic in the United States. Actually, it was a model for all the other organizations in the United States, including AID Atlanta. So that was the formation that really began to address that problem.

MILLER: Can you describe some of what was going on in the gay community at that time in terms of lifestyle, before and then during the early weeks and months where AIDS was becoming a reality: the bathhouses, the multiple partners? What 00:47:00did you encounter when you got there? Was that a surprise to you or had you seen that through your hepatitis work?

CURRAN: My introduction to CDC and to public health was in the area of STDs in the decade of the 1970s. That was the decade of the so-called sexual revolution. Oral contraceptives were recently introduced to the market; antibiotics could cure gonorrhea. Chlamydia was not yet readily diagnosed, but there was a huge gonorrhea epidemic and a herpes epidemic among heterosexual populations, as well as gay populations. Following Stonewall in 1969, the gay community joined the sexual revolution en masse, and there were hundreds of gay men at STD clinics 00:48:00every day in San Francisco and New York City [seeking treatment] for gonorrhea and syphilis and amebiasis, and then Hepatitis B of course followed.

So there was a sexual revolution in the United States, and the gay community was right there with very, very high rates of STDs. We were aware of that, and we were doing studies and trying to have programs to deal with it. The way syphilis had been dealt with in heterosexual communities wasn't working very well in the gay community. It was much more educationally and economically diverse and closeted. So CDC was aware of these things, and therefore it wasn't a total surprise. We had a lot of work going on in New York City in a lot of these control areas.

MILLER: And can you discuss a little bit about the controversy that went on 00:49:00between the urgent public health mandate of closing the bathhouses, changing behavior, and the other side, which had just felt liberated. Did you experience much of that in New York with Larry Kramer and others?

CURRAN: It's hard to categorize public health approaches to deal with problems of disadvantaged populations, and the gay community was clearly a disadvantaged population in terms of popular respect at the time. People were discriminated against based on sexual orientation. In general, people with STDs were shunned because of the shame, and then, of course, HIV scared people. If you want to 00:50:00work effectively with populations, it's a balance always between what is the intellectually most important approach and what is the approach which will engage the community to participate. For example, you can have rules, but if no one follows the rules, then they're simply on the shelf. It always made sense, once the virus was discovered, that people should know their status and that people should avoid transmitting to others. But it was equally important for people who were infected with this fatal condition to have access to medical care. So you had both issues to deal with in the people who were tested.

I always used to use the example of mammography. What if you had a situation where you said everybody should get a mammogram, but we don't have the resources to treat anybody who is positive. How would you ever get anybody to do it? HIV 00:51:00was the same way. We had to have connections with the healthcare system. We had to make sure that people weren't discriminated against if they tested positive. We had to work with the concerns of the community. But we did have the underlying principle that people need to know their status. That was very, very important.

Before the virus was discovered, we made recommendations that people should avoid having multiple sexual partners and should use condoms. We knew that the sexual revolution and sexual freedom and liberation were leading to the kinds of excesses which were contributing to this epidemic. We also had to have the gay community working with us. The first proposal to close the bathhouses came actually from a gay physician in San Francisco working with then Mayor Feinstein 00:52:00and with Health Commissioner Merv Silverman. I was asked to come out and consult on this problem. I couldn't, as a federal official, make a pronouncement in a state and local matter. But I went to consult in a late-night meeting at the health department, at the request of the mayor and the health commissioner. As I got off my plane about 8:00 pm in San Francisco, I was met there by Randy Shilts from the San Francisco Chronicle, who said are you here for the secret meeting? So the press was engaged to begin with in this deliberation about closing the 00:53:00bathhouses in San Francisco.

MILLER: Can you mention a little about the bathhouses. Were they baths, were they rooms for sex? What were the bathhouses?

CURRAN: I think that like massage parlors nowadays or like bathhouses, some people use them to get a massage, some people use them for sex, and they have a great deal of variation. The bathhouses in the 70s were quite elaborate, some of them, and many people could go and meet private partners and go into a private room and do whatever they wanted to. They got to be very popular with many people in the gay community and some in the straight community. But if you have a new epidemic of a new infection that's unknown, that's the perfect kind of environment to facilitate behaviors involved in transmission.

MILLER: So what happened at the meeting?

CURRAN: Some of the people who were originally encouraging this measure, including Dr. Marcus Conant, didn't show up. So the consensus was shredding a bit. It was difficult for Dr. Silverman and Mayor Feinstein to be as definitive as they wanted to without losing some of the political base for the decision. But ultimately they did place restrictions on the bathhouses in San Francisco.

MILLER: And in New York?

CURRAN: I believe the same thing was done in New York. I'm less familiar with how that actually occurred. There were a lot of controversial issues that dealt with the ability to protect the privacy concerns and health concerns of people 00:55:00with HIV or at risk and also the public health concerns. A lot of times if you could get them to align, it would work a lot better. Now that we have good therapy for HIV it's a lot easier to convince people that testing is extremely important, particularly if you can link people up to care.

MILLER: In those early years there must have been a lot of morality discussions, you know, these people are getting what they deserve, the moral thing to do is to reduce the number of partners. Do you remember that issue and how you dealt with it? What was your thinking on it?

CURRAN: In the first 6-12 months of the epidemic, virtually nobody seemed to care about it. That meant that nobody was opposed to it, nobody was offended by 00:56:00it, and nobody was excited about it, and no one was funding it. When it became clear that it was in the blood supply and that it was actually caused by a virus and that many, many more people might have it, that changed the dynamic. First of all, it became much more of a news item, and that attracted all types of people, including the press and including politicians, and also there was panic. We used to say that we had a barometer at CDC from panic to neglect and from fear to complacency, and that we had to monitor that barometer. When there was excessive fear and panic, everybody would want to stop going to restaurants with gay waiters, or they wouldn't let their kids come home, or they would have just 00:57:00horrible kinds of discrimination.

On the other hand, people would say, this isn't a problem at all, it's not me, we don't have to worry about it, and complacency would reign. When AIDS got to be recognized as a serious public health problem, people started to worry about it and then there was funding for it, then many state and local legislators got into the act. We had sometimes some of the negative aspects of our federalism in that there were 600 to 700 bills and legislaions that were rather punitive toward AIDS at a given time. And we were going around sometimes trying to stamp out forest fires with our public health colleagues.

MILLER: As evidenced today, you've always been a great speaker and communicator. A critical role you took on early on was interacting with the press about AIDS, both print and televised. Can you tell us a little bit about what that was like 00:58:00for you? You were catapulted into a very highly visible, high-pressure role. What was that like?

CURRAN: I was fortunate to be able to be involved in the public communication aspect. From the beginning we knew that it was very important to get public support and that people needed to learn about this, but there was a general reluctance on the part of the press. Randy Shilts claims he was the only openly gay reporter at a major newspaper in the United States in 1981. Outside of California and New York, there was almost no coverage in any kind of local media. So we relished the idea of doing this and doing it right, with the idea that we needed to call people's attention to the problem without scaring them. 00:59:00That's a difficult thing to manage. How can you be accurate and honest without being overly alarming? You want to be a voice of reason, not simply a loud voice. And that was something all of us who were involved struggled with. As press articles became more common, we found ourselves sometimes reacting to what other people were saying about this, and that's a different type of tactic.

But we were fortunate that people often looked to the CDC to find out what was going on with this epidemic and many others, and this was a very important news item for five years at CDC. Virtually every day there was something. We had Don Berreth as the head of communications at CDC at the time, and he was excellent. 01:00:00We could always get advice from him on what to do and what not to do. But it was an honor to do this. We were so starved for attention to this problem initially that I can remember the first chance for national TV was "Good Morning America." Frank Gifford was substituting for the host, and he had a friend who had pneumonia in the hospital in Los Angeles and he asked to have somebody come and talk about this. So though the CDC had no money for travel, and we couldn't take ABC's money, we said this is so important that Jim Curran will fly to New York and be on the show for 15 minutes. I got there and met Frank Gifford. Fortunately and unfortunately, that was the day that the Iranian hostages were 01:01:00rescued, so the 15 minutes turned into three minutes. But Frank Gifford had more personal time with me. I spent a lot of time talking with him and he threw away all of his questions and his only question to me at ABC was how come nobody's paying any attention to this? That allowed me to go on for a minute and a half in a soliloquy. That's how he and others realized that this problem was actually much worse than recognized.

MILLER: What do you think the impact of the press was overall during maybe the first two years?

CURRAN: Well, the press I think would probably get a D for the first year because of lack of coverage, and then they got to be much, much better. There were a lot of very good examples of in-depth coverage in the print media, as 01:02:00well as on TV and others. Many people who are chronicled who've been very good at this got to be experts. There should be experts in public health and health in the newspapers and press like there are with the state department and defense issues. We should have reporters who are knowledgeable enough not to ask the dumb question that comes from the false report. We saw that really picking up quite a bit in the ensuing years from say '83 on, so I think that the press did quite a good job overall after the first couple of years.

MILLER: A critical role for CDC during these early years and continuing was to liaise with the other federal agencies, including the National Institutes of Health, which included the National Cancer Institute and the National Institute 01:03:00for Allergy and Infectious Diseases, as well as the Food and Drug Administration and ADAMHA, which was then the Alcohol Drug Abuse and Mental Health Agency. Can you describe a bit about the relationship between the agencies during those early years?

CURRAN: Well, our first contact at CDC was with the NIH, in particular the National Cancer Institute [NCI]. That came across, I think, serendipitously because there was a dermatologist named Alvin Friedman-Kien in New York City, who had been a fellow at NCI in the Virus Cancer Program. He became aware of Kaposi's sarcoma and called his friends at NCI. They had had a program in Uganda studying Kaposi's sarcoma and other problems in-country, and they had a very big 01:04:00interest in viruses and cancer. So we were in contact with the National Cancer Institute very, very early, the first of the NIH agencies. One of my chief residents in medical school turned out to be the project officer there at the time, and we initially set up a small scientific meeting, paid for by NCI, of interested people from California and New York and CDC and NIH. That meeting stimulated the NCI in its interest in this problem. The National Institute of Allergy and Infectious Disease [NIAID} initially had relatively little interest in the problem. Their director was not particularly interested in it at the time. Dr. [Anthony] Fauci was then an intramural scientist in the labs, and it was really when he got interested several months later that they became a very 01:05:00important player and remained a very important player in the AIDS epidemic. NIAID played a very strong leadership role.

MILLER: What about the FDA, and, maybe before we move towards conclusion, mention all the issues around blood and blood products as a means of transmitting HIV. So the first hemophiliac cases and then a transfusion case were reported in 1982. Then in January of 1983, one of the early meetings to discuss these cases at CDC in Atlanta, the FDA and the blood banks were there. But I think to the surprise of CDC, there was not agreement on how to manage this in terms of restricting blood donations. Can you comment a little on that 01:06:00and the extent of the impact and the relationship with FDA.

CURRAN: One of the strengths of the federal government is that we have a lot of depth in many areas in many agencies in health and human services. That can also lead to territories that are independent. The Assistant Secretary for Health, Dr. Brandt, and then eventually Surgeon General Koop would have weekly meetings on AIDS, which would include all of the agencies in the Public Health Service and the Assistant Secretary's office, to communicate and coordinate and deal with what was going on with AIDS. But there was clear territory set aside. I think the CDC and NIH had a different definition of their role. NIH was clearly a research definition; the CDC was tracking the disease and prevention. We shared commonalities, but there wasn't always a clear delineation. ADAMHA had 01:07:00responsibility for drug use control, and the FDA had responsibility for the blood supply in blood banks. I think that it was more difficult to coordinate in those areas in ways that weren't as productive initially as they could have been.

My biggest regret still is that we were so slow in dealing with the epidemic in injecting drug users. I think we could have done much more years and years earlier, even after the virus was discovered, to reduce the amount of transmission in drug users, particularly through needle exchange and expanded drug treatment programs for people who are positive. If CDC had been in charge of all that, I think we might have fought harder. Maybe not successfully, I don't know. But with the pattern of AIDS occurring in sexually active gay men, 01:08:00injecting drug users and their partners, it was expected that the infection was in the blood and therefore would be in the blood supply.

Initially we would have these case reports that had no known risk, called Non-Identified Risk. As many as 4% or 5% of cases reported to CDC would have no risk, but about 30% of that group would be different from the others. The others looked like the people with risks, and maybe the risksweren't identified. But 30% were often elderly men who'd had cardiovascular surgery, and all had had dozens or more of blood transfusions. So we thought, well, this really looks like a transfusable disease just like in injecting drug users, just like Hepatitis B. We initially had difficulty getting the National Heart, Lung and 01:09:00Blood Institute and FDA and the Blood Products Advisory Committee interested in this. We couldn't investigate these initial cases due to blood bank resistance. It wasn't until there were three cases reported in people with hemophilia who automatically had received transfusions from hundreds of thousands of people (the perfect canary in the coal mine for a new blood-borne infection) that 01:10:00blood-borne transmission was convincing. Once those three cases of AIDS in persons with hemophilia were well documented by CDC's Dr. Dale Lawrence, then everybody recognized the causative agent of AIDS was likely a virus and in the blood supply. I can remember a case associated with transfusion investigated by your husband, Dr. Steve Solomon, who wasn't so sure he believed this himself. He found himself in the middle of the South in a rural area with a blood donor he finally tracked down who had lymphadenopathy syndrome and immunologic abnormalities, and he thought, oh my God, this is really true. They were right in that once it was shown to be true, that transmission by blood was possible, there was panic. People were afraid to give blood. Blood donations went down. Of 01:11:00course, there was no risk to donating, and it resulted in more shunning of gay men.

MILLER: So that was in '82, and then in January of '83 there was a meeting to try and come to some agreement on what recommendations should be given, and the surprise--or was it a surprise?--was the blood banks were not ready to make strong statements against donation of blood.

CURRAN: The first cases of person with hemophilia were in the middle of 1982, and that's when we adopted a recommendation accepted by the medical community that we start to use the term AIDS instead of Kaposi's sarcoma or opportunistic infections. In a meeting in Washington we asked a physician to recommend that to 01:12:00a meeting chaired by Dr. Koplan. He raised his hand--we knew he was going to say this because we planted it--we named this AIDS. We thought it was much more descriptive, and also frankly we did really want an acronym that we could use that would be memorable.

We started to investigate the transfusion cases. We wanted to call together people to come up with consensus recommendations which we would make by March of 1983. Our first big public meeting was in January of '83 here at CDC, which included the blood banks and many people from the gay community and scientists and others. At that time the blood banking representatives still remained rather intransigent about making any types of recommendations. The gay community, conversely, unlike the movie [And The Band Played On] presents them, was already 01:13:00on board, and the major gay organizations were going along with the restriction of blood donations. The recommendations made in March of '83 contained the endorsement from the American Red Cross and the American Association of Blood Banks, as well as all the Public Health Service and World Health Organization and others. Those blood donor restrictions did a great deal to protect the blood supply and saved thousands of lives, two years before the antibody test for HIV was available.

MILLER: And those recommendations basically asked for voluntary restriction of donors.

CURRAN: Yes. But then the FDA codified that into questionnaires for all donors coming into blood banks. So the FDA gave guidance to blood banks to query people about sexual contacts and about injecting drug use, et cetera.

MILLER: In coming to the close, I'd like to ask you about leadership. You are 01:14:00clearly seen by your peers then and today as really a great leader in this area for CDC and for Emory University and for the world. Can you comment about what you think it takes to be a leader, and what maybe the challenges were for you?

CURRAN:I think one of the actual and important aspects of the CDC is that there is a widespread recognition of the importance of group effort. We can't respond to an epidemic of AIDS or Zika virus or Ebola or anything else if we just say doctor so-and-so gets all the credit and is in charge. There has to be organization, there has to be recognition of strengths, there has to be 01:15:00transparency. There has to be a way to articulate the vision and encourage people to work hard together to meet the goals. Anybody fortunate enough to be in a leadership position has to be willing to do it and has to be willing to recruit and enlist the others to be involved and to share the credit as well as the blame for what goes on. I was fortunate to be asked to do this. I was fortunate to be involved in leadership at CDC for 15 years with this epidemic. I learned how wonderful the people were at CDC to work with and how important it was to work with both the community of scientists and advocates and affected people to deal with the problem.

MILLER: Thank you very much.

CURRAN: Good talking with you, Bess.