Dr. Jeff Koplan

Dr. Jeffrey Koplan

MILLER: This is Dr. Bess Miller, and I'm here with Dr. Jeffrey Koplan. Today's date is January 29, 2016, and we are in Atlanta, Georgia, at the Centers for Disease Control and Prevention [CDC]. I am interviewing Dr. Koplan 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. Koplan, do I have your permission to interview you and to record this interview?

KOPLAN: Yes, certainly.

MILLER: Jeff, I've known and admired you since I attended a critical meeting you chaired at CDC in May of 1983 concerning the transmission of AIDS through blood and blood products. You have served in the highest leadership roles at CDC, including serving as the Director of the Center for Chronic Disease Prevention and Health Promotion from 1989 to 1994, and then as the Director of CDC from 00:01:001998 to 2002. 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. You served in several critical roles during those early years, first as chair of the Public Health Service AIDS Task Force convened by the Assistant Secretary for Health, [Dr. Edward N.] Ed Brandt, in 1983, and then as chair of several pivotal meetings regarding the transmission of AIDS through blood and blood products. But let's begin a little bit with your background. Will you tell me a bit about where you grew up, your early family life, and then where you went to college?

KOPLAN: I grew up in greater Boston on the South Shore of Boston, living in the 00:02:00cities of East Braintree and then Quincy, a pattern that I followed after John Adams had done the same thing (beginning in Braintree and ending up in Quincy). I did my schooling in public schools in Quincy and then private school, and then I went off to college at Yale [University]. I did medical school after that, two years at Tufts [University] in Boston and then I transferred to Mt. Sinai [Hospital] for my last two years.

MILLER: What influenced you to go to medical school?

KOPLAN: I think about that periodically. I'm not quite sure, but I suspect it was maybe an interweaving of multiple threads, ending up forming the cloth of medical school. I had a family in which there were no doctors, but there was a lot of illness. So there must be some kind of reaction formation going in that 00:03:00professional direction, hoping that those illnesses will stop and you can be on the other side of the patient-doctor equation. I was interested in medical history early on and read a lot of books about everyone from [Dr.] Harvey Cushing to [Andreas] Vesalius to you name it. I just read a lot of medical history and enjoyed that. Then I was in a high school science program that was sponsored by the National Science Foundation. It was a summer program where you took Advanced Placement-level material and then you worked in a laboratory somewhere. I'd say that was a pretty influential opportunity and immersed me in laboratory work. Now, it was pretty low-level laboratory work. I spent the time swimming mice, meaning I'd drop them in a trough at one end, I had injected them 00:04:00with various pharmaceutical agents and then measured the speed with which they swam the trough. I'm a lap swimmer occasionally myself, and I think this is the payment I get for having done this with the mice. So those I think were largely the things that sent me into medicine. I was committed to clinical medicine and did postdoctoral training in internal medicine and got boarded [board certified] in it. In terms of a career I thought I'd just do something academic, a subspecialty training of some kind. But then I came to CDC and that ended up being the model of what I wanted to do from then on.

MILLER: What drew you to CDC?

KOPLAN: I guess it was a push and a pull. The push was that this was the period 00:05:00of the Vietnam War. Whatever the low level of sophistication I had for politics didn't make this war seem like something I was particularly keen on engaging in. Yet I passed my physical and I was all set to go into the military, under what was referred to at the time as the Berry plan. I don't know the details of it, other than it deferred me until I'd gotten a couple of years of postgraduate training such that I might potentially be more valuable as a doctor with a little more training. But I was enamored of community medicine, preventive medicine, even as a medical student. I started when I was at Tufts in my first two years working on a number of student-led projects, including in a politically active student group called the Student Health Organization. It was 00:06:00an offshoot of the Medical Committee on Human Rights, and I did a program in California where I worked organizing farm workers, organizing them medically and trying to get care for farm workers in the Imperial Valley in California.

Then I came back to Boston and in a multidisciplinary and multi-university group became active in minority admissions for medical school. At any event it was the social medicine side of medicine that I enjoyed early, and I continued that when I transferred to Mt. Sinai, where they had a very active community medicine department. [Dr.] Kurt Deuschle was the chair of community medicine at the time at Mt. Sinai and previously had a very innovative and interesting program at the 00:07:00University of Kentucky, which focused on rural health and rural health needs but in a population basis in a public health manner. I became very close to Kurt as a student, and he said to me, you know, you could have a much better experience than just going in the Army. There's a guy coming up from Atlanta from this place the CDC. He's a guy named [Dr. Philip S.] Phil Brachman, and I've known him for a long time. I'm going to make you his official tour guide when he comes here. We'll have programs set up, but you'll stay with him and go from place to place with him during the day. You'll end up taking him to a clinic that we had established in East Harlem - called the Triangle Clinic because the streets came together in a triangle. So you can be front and center and make a presentation about what we're doing there, et cetera. After that I applied to EIS [Epidemic 00:08:00Intelligence Service] and got accepted to EIS and came for what I thought would be two years of government service and I'd be gone. When I got here, I had pretty good supervisors, [Dr. Stanley O.] Stan Foster and [Dr. William H.] Bill Foege, and I was in the smallpox eradication program. I thought, I've worked with wonderful people in the hospitals, I love clinical medicine and I respect what they do, but these guys at CDC do exactly what I wanted to do, and that was it.

MILLER: Very exciting. So part of your EIS experience was involved in the smallpox eradication program. Can you tell us a little about that? Where were you and...

KOPLAN: That was my EIS assignment, the smallpox eradication program, which was then an entity. That was an organizational unit of CDC before they had bureaus and centers and all that. So my EIS assignment was with Bill Foege as the 00:09:00Director of the Smallpox Eradication program. Stan Foster was my immediate technical advisor, and I had a public health advisor, Jim Hicks, as well. I had a lot of supervisors, and I probably needed them all.

So I did smallpox work. When it started much of the domestic side of it was focused on dealing with the fact that smallpox vaccination had just been taken off the books as a routine immunization for children and adults. This policy decision was based on some wonderful epidemiologic studies done by [Dr.] Mike Lane, who was director of the Smallpox program and later director of the Center 00:10:00for Prevention Services, which had immunizations, STDs [sexually transmitted diseases] and TB [tuberculosis] mixed together. Mike had done these studies which demonstrated that the risk to individuals in the U.S. of getting smallpox was extraordinarily low, much lower than the risk of one to five per million, whatever the numbers were, but low. But still higher was the risk of side effects from the vaccine--greater than the risk of getting smallpox. He made a strong case for it, and, lo and behold, this evidence-based policy changed the requirement, and we did away with routine vaccinations. So I started EIS in '72, and this policy had changed just a couple of years before that. If you meet someone who is born after 1972, the odds are that they didn't get smallpox 00:11:00vaccination unless they were traveling, their family was traveling, they worked in a lab, et cetera.

So my work was often defending the government policy, which is interesting because subsequently our work in immunization often was the opposite. Most often we were proselytizing for the use of a vaccine and decrying people who opposed the use of vaccine, but here we were saying, don't use this vaccine. It was a great vaccine, but you don't need it anymore. And the opposition was saying, how dare you leave us exposed like this? So I, as a freshly minted public health worker, was thrown into speaking to medical groups and answering letters and all that.

At the same time, Stan Foster got me involved in an opportunity to do a clinical trial. I didn't know anything about clinical trials; I probably still don't, but 00:12:00I did one. It was a randomized control trial of an antiviral agent against smallpox in Bangladesh. I spent much of 1973 in Bangladesh, learned functional Bengali, ran a hospital ward, admitted patients. We did a double-blind controlled study of this agent Adenine Arabinoside [ARA-A]. It really didn't work, but our goal wasn't to show that it did work or even have a treatment. Our goal was, if it didn't work, to not give people false hope. We felt it would undermine the successful eradication efforts of people who thought, we've got something we can treat smallpox with, what's the big deal? This trial took that crutch away and focused on the immunization program.

So my first two years were heavily smallpox oriented and included investigating 00:13:00possible cases in the U.S., which fortunately they didn't turn out to be, and included close familiarity with the lab work. I actually did a lot of lab work during that time, and spent as much as half my EIS time working in [Dr. James H.] Jim Nakano's laboratory. I had my own tissue cultures and got involved with electron microscopy when specimens would come in, so it was a very rich experience.

MILLER: Fabulous. Let's shift our focus to your involvement with what was to become known as AIDS. So from 1981 to 1988 you were Assistant Director of the Office of Program Planning and Evaluation and then Assistant Director for Public Health Practice, Office of the Director, CDC. What were you responsible for basically in those positions?

KOPLAN: The position in the Office of Program Planning and Evaluation was 00:14:00largely a few things semi-merged together. One of them was the involvement in various policy decision-making that emanated from that office, which was referred to at the time as OPPE, Office of Program Planning and Evaluation. It had staff, some of whom were former public health advisors, and some of whom were Ph.D. types that were interested in analyzing what do we do, why do we do it, and how can we justify it beyond the science of the individual units of CDC. I came back from career development in Boston at the Harvard School of Public Health and had become very much interested in decision science and how one can quantitatively approach decision-making.

So I came back with a bee in my bonnet about applying that more broadly at CDC, 00:15:00and in particular economic analysis using a decision analytic model. Some economic analysis had been done at the time by a guy named [Norman W.] Norm Axnick, who was the Director of CDC Office of Program Planning and Evaluation. Paul Stang, who was a young staff member at the time, had done a cost-effectiveness analysis of chronic renal diseaese management, I believe, kidney transplantation and dialysis and the cost associated with that. I thought this was an area that CDC really needed to beef up: the economic elements of the public health program. So over the course of my time in that position we started and did studies. One that I started before I came back from career development was onpertussis vaccine, looking at the risks, whatever they were, and at its benefits. It was basically a modified risk-benefit analysis for it, and we 00:16:00published it in the New England Journal of Medicine and made a case that even if you took into account the nay-sayers for the vaccine, its benefits markedly overwhelmed its risks.

Then I started to work with groups across CDC, and it was a wonderful experience. When I finished EIS, if you had said to me, there's a TB program at CDC, my reaction would've been, really? Where is it and who does it? Many EIS officers, I think, went through their program, and if you had a friend that worked in another program, then you knew there was a possible infection, so you knew there was an immunization program. If you didn't have a friend who worked in it, you weren't aware even then of the breadth of CDC's activities. But with proselytizing doing these economic analyses, I went around trying to make relationships all over CDC. So we did them in TB, and [Dr. Laurence S.] Larry Farer and I wrote a couple of papers together, and I did them with malaria, and 00:17:00Trent Ruebush and I did some papers together. We did multiple analyses for every immunization, with [Dr. Stephen R.] Steve Preblud, with [Dr.] Alan Hinman and Dr. Walter A.] Walt Orenstein, and we did measles and mumps and rubella and combined, and you name it. So it was a very fertile and exciting time for me.

Then we expanded into nontraditional areas, for example, the benefit-risk of physical activity We did a paper on that using data from the Peachtree Road Race in Atlanta and put that into JAMA [Journal of the American Medical Association]. So at the same time we're looking at CDC policy and doing things that were more administrative and bureaucratic at CDC. I was able to keep intellectually stimulated through these studies. Then when I shifted from Office of Program Planning and Evaluation to being Assistant Director of CDC for Public Health 00:18:00Practice, the responsibilities were much more relationships with academia, our links with universities, and, more important, our relationships with state health departments. During that period of time those were my constituency, and I enjoyed getting out to the universities, getting out to state health departments, and being a voice within CDC for their needs.

I continued to do those studies all that time, even while I was doing the other duties. I was responsible for the Preventive Medicine Residency program for some time, early in the period you just described. I was doing it as an assistant to [Dr. Donald R.] Don Hopkins, who was a close colleague and dear friend. Then at one point Don moved on to other things, I think it was when he became Deputy Director of CDC, and I was in charge of the residency program. During that time 00:19:00it became the largest preventive medicine residency program in the country with--I forget the number of people we had, it was 20 or 24 people, and the best performing. The CDC results on the board exams for preventive medicine were the highest of any program in the country. It's got nothing to do with me--we had smart residents.

MILLER: So by March of 1983, with regards to the AIDS problem, there were already 1,200 reported cases and at that time a case-fatality rate of about 60%. This is from the MMWR at that time. Risk groups identified included homosexual men, IV drug users, and Haitians, and 11 patients with hemophilia had been reported. So in 1983 you were asked to serve as chair of the Public Health 00:20:00Service AIDS Task Force that Dr. Ed Brandt had requested. And I guess my first question is, why you?

KOPLAN: I could facetiously say they couldn't find anyone else to agree to do it.

MILLER: Were you surprised?

KOPLAN: Well, I suspect it was Bill Foege just appointing someone who was near him and thought could do this kind of thing. There have always been both incredible cooperation and good work together amongst federal agencies, and there's probably also always been some level of stress and strain because of the different missions and different cultures of the major federal agencies. I knew a lot of people, certainly more at NIH [National Institutes of Health] than at 00:21:00FDA [Food and Drug Administration]. I liked working with people from the other agencies. Maybe that was an attribute that led to having me do it. It wasn't that I had become an expert per se on what we knew about this new immunodeficiency disease at the time, but I had a position whose title lent itself to a broad portfolio. I was comfortable with doing things with other agencies, so why not have me do it.

MILLER: Clearly they thought you could do it and would do an outstanding job, but I'm wondering if it came as kind of a surprise that you were tapped.

KOPLAN: Not particularly.

MILLER: So can you tell us a little about what that committee involved? What were some of the agencies, and are there particular people that stand out in your mind?

KOPLAN: Yes, definitely. The NIH regular attendee, I believe, was [Dr. Robert S.] Bob Gordon, and he had some large responsibilities for infectious diseases across NIH, and a gentleman named [Dr.] Gerald Quinnan, Q-u-i-n-n-a-n, was the representative from FDA, and then from CDC it was [Dr. James W.] Jim Curran. So my long professional collegial relationship and personal friendship with Jim dates from that time, that's when we started to see each other pretty regularly.

MILLER: In '83 so many things happened. Blood transfusion issues, everything AIDS was pretty hot at that time. [Dr. Robert C.] Bob Gallo's lab at NIH and Luc Montagnier's lab at Institut Pasteur were getting close to identifying the 00:23:00agent. Can you talk a little more about the relationship between the agencies? How did they see CDC? Were they competing?

KOPLAN: If I can digress a little, the committee was one of these odd committees that I hope are much savvier today than it was then. At the time, the idea of this interagency committee was a clearinghouse so that people could know what the other groups were doing and make sure we weren't leaving gaps or doing unnecessary duplication, or see if there were differences in findings that required some delving into. I forget the exact frequency of the meeting, but it was frequent--weekly or every other week. There were regular face-to-face in-person meetings in Washington and Atlanta and then occasional phone meetings 00:24:00to supplement those. In looking back, even then we were aware that this was not so much a decision-making committee or a policy-directing committee; it was more of an information-sharing committee In part that was due to the agencies wanting to keep the higher functions of decision making and steering things and setting policy, if not to themselves, at least closer to their directors and closer probably to the ultimate power in the Department of Health and Human Services. So that was okay. We felt we had enough to do, and our meetings were always filled with stuff, but there was also a nagging concern, at least I never felt like all of the information was being shared by all parties. I don't attribute 00:25:00it to any malevolence or innate secretiveness, but rather that in a place where so much was going on in all three of the agencies around this subject, I think it was really hard for even the people representing NIH or FDA or CDC on a weekly or every-other-week basis to have a complete handle on what was happening. You had lab scientists, particularly at NIH, who weren't sharing everything they were doing with everybody. Again, they were busy, it may not have seemed relevant to them at the time, but there may also have been elements of this competitive, who's going to find something out first routine. That meant, why would you want to show your cards early to this committee where you 00:26:00don't even know the people, and they're not world class scientists likeyou are. So we lived with that. I lived with that. You got what information you could. If we weren't sharing something that came from another agency, I can't be responsible for what they bring to the table, but we'll do the best we can in sharing what we know with these three agencies. CDC I think was very open in sharing what they had, and I think probably FDA was also as much as they could be.

MILLER: How was CDC viewed by the agencies? By 1983 there was already a little bit of turf and who's in charge of what.

KOPLAN: I think we had the good fortune in how that plays out is who gets sent to the meeting. It would be quite possible for any of the three agencies involved to pick someone who was more fractious and more competitive and less 00:27:00collegial in that committee setting, and that wasn't the case. So Bob Gordon had worked with some people at CDC before and known a lot of them, if you're in infectious diseases, how can you be at odds with other people in infectious diseases. Gerry Quinnan similarly had a particular knowledge of blood products that NIH has expertise in as well, as did CDC through its hematology and Bruce Evatt's activities then. So there were good parallels. People had worked with the other agencies pretty well before, and so our meetings were not filled with hostility or turf fighting. It was much more, here's what I've learned in the last week or two weeks, here's what's going on now, there's a meeting next month in Salt Lake City, and is anyone going from here. It was information sharing as 00:28:00much as possible, I don't think these individuals came to the meeting, saying I'm not going to tell them about something. They shared what they knew.

MILLER: You mentioned the three big ones. Was ADAMHA [Alcohol, Drug Abuse, and Mental Health Administration], the drug agency, represented?

KOPLAN: Now that you mention it, I think they probably were represented. Whether they came to every meeting or not and whether they had consistently the same person, I think the answer was no to both of those. They were involved periodically. It's the three agencies I mentioned that were front and center all the time on this.

MILLER: So wasn't this a time of budget cuts at CDC and sort of a stressful time for CDC? Did that affect these agency meetings? Did that affect the climate?

KOPLAN: I don't think so much, quite honestly. There are almost always budget concerns and tensions, but I don't remember that as a dominant issue or even a prominent issue in these meetings. I never heard someone say, if only we had more money or if we had another $20 million, we could do this. I just don't remember that as being part of it. Or to put it another way, I don't think it was part of it.

MILLER: Can you speak a little more to the political and social climate at the time? Ronald Reagan was President.

KOPLAN: Sure. I'd say both at the time and thereafter, political activists 00:30:00around the subject [disagreed], and I don't in the least invalidate their concern and their issues and the way they perceive things. From a CDC [standpoint] and from the other two agencies, I thought people were extremely sincere in working on this, were committed to coming to the answers, and were trying to get as much done as possible. If I had been sitting outside and I were an activist and seeing people dying from a horrible disease that we don't know much about at the time, would I have wanted more and demanded more? Sure. I would've happily been taking that side as well. But being on the inside, I never, ever, and this stays with me strongly, felt that anyone working on it was anything less than totally dedicated to the outcome. Most of the folks were 00:31:00either lab scientists or epidemiologists, and they'd all had experience in multiple outbreaks in epidemics before. I've never seen anyone on any subject in an outbreak want to do anything but get to the root cause of it and stop it as quickly as possible. That's a cultural thing that overrides any potential bias or prejudice. So I felt that this was as dedicated a group of people as I'd seen at that point. Now, whatever number of years it is later, 30 years later plus, I still haven't seen anyone more dedicated to the work than the folks that were working on it then.

MILLER: You describe the group as sort of insiders in that they were scientists and laboratorians. What was their understanding of AIDS? Can you remember the 00:32:00emotional response of these folks in terms of the suffering and stigma and fear that this was engendering the clinical world? How did that play out for you and for these others?

KOPLAN: Obviously multiple factors were going on that caused public reaction, political reaction, and reactions by those at risk and those afflicted. To me, there was a major dynamic around not knowing the cause. There was a lot of action and hypothesis testing: is this a toxic chemical, is this something people use as a stimulant or a pharmacological additive to their sexual activities, what defines it, why certain nationalities seem to be involved 00:33:00versus certain lifestyle choices. It wasn't adding up, and there was nonstop discussion. At the end, when you get a group of epidemiologists, which I still count myself as one, it's like we ought to be able to figure out what's causing this. Of course, I think the dominant feeling was that it's an infectious entity, an agent, that we just haven't identified yet. But you didn't want to lose out, like in any outbreak, you're looking for those other pieces that don't fit to help put this together. So that was going on, causing wheels spinning and turmoil and various approaches, inquiries, and pathways to get an answer.

At the same time, you had groups who felt they were maligned, groups who felt they were on the fringes of society and not of their own choosing, and groups 00:34:00that were beset by social problems, economic problems, societal position problems, a range of things. That includes the drug-using community, if you can call it a community, the gay population, the Haitian population. Now it seems so ancient to think a group of people from a given country was targeted, when it became a worldwide phenomenon. But by the same token, from both an epidemiologic perspective and from a public health perspective and just from some sense of how communities work, people were afraid and concerned about exposure and what level of interaction could they have with someone who represents one of these groups. Then someone from those groups felt that they were already at risk, already 00:35:00under great strain, and now people were treating them as a pariah with no justification epidemiologically. So you couldn't put it all together in one package. There's a lot of ferment and turmoil going on but, you know, that's public health.

It was and is a defining disease for the last 40 years and will be for some time to come. But we just had an Ebola outbreak and a lot of people's reactions to that, we've got a Zika outbreak going on right this minute and we haven't seen, even the frosting on this thing. There's going to be a lot more that we learn and have reason to be concerned about, and that's public health. It goes with 00:36:00it. You can't say, I don't want to deal with this political stuff; a stigma, that's for someone else to deal with. It's part of public health.

MILLER: Before we leave that, I'm interested in your own emotions at the time. You were kind of brought in, so you hadn't been steeped in it every day like someone like Jim Curran had been. Do you remember what you felt about it at that time: this is different, this is more scary, this is more suffering, or again, no, this is a problem and we've seen things like this before. Did the AIDS exceptionalism aspect of it strike you at that time?

KOPLAN: Probably both the things you described. On the one hand, it was a classic epidemiologic problem, seemingly infectious, but we were not assured of 00:37:00that fact. It was one where you had enough inklings that you thought, we ought to be able to sort this out and solve it, but we weren't quite there yet. And then there was obvious human suffering and concerns and overlap of this disease in so many areas of life, whether it was school kids not being allowed to come to school, or people losing their jobs, or a community losing by death its most important members. There was all this turmoil going on.

MILLER: Did you have friends or relatives that died of AIDS at that time?

KOPLAN: I had friends from CDC who died, but it may not have been in those early years. Over the next few years it happened, and fellow EIS officers died from AIDS. In a later period people were able to be tested and see whether they were 00:38:00carriers, so that was going on as well. So yes, it wasn't like this was an outbreak that was totally external to my life or my friends' lives or the community's life. At first you might have thought of it as a minor overlap or just touching each other, and the touching involved the professional versus patient end, but in short order it became: these are people we know and care about as well. That's going to be true of any outbreak when it starts. If it's people you know, when friends are in West Africa on the Ebola outbreak, you suddenly are worried about them. When there's a terrorist attack in a place where you've got colleagues working or they're staying in the place where the 00:39:00attack occurs. It's hard to be as distanced from it as you might have been before.

But like other things in medicine, it's important to keep some emotional distance from what's going on, particularly if you're involved in policy formulation, recommendations for decision-making or resource allocation, et cetera. You can't just throw your hands up and let your emotions run wild. Much as when you're taking care of a patient as a physician, you can be sad and you can be compassionate and you can care. But if you're the person taking care of the patient, you've got to back up from that a bit and try to do the right thing on multiple accounts, and maybe that's the answer to this, too. You want to do the right thing on multiple accounts, but you need to focus on what you're responsible for and try to do the best job you can while everything else is swirling around you. To my mind, there's no better example of that than Jim 00:40:00Curran during this period, because he was under huge stress from different sides, and he often was the target of, seen as a force of evil, when this guy was devoting everything in his professional and often personal career to doing as much as he can to alleviate this. Never once in several years during that period of almost daily interchange with him did I ever, ever hear him express anything than total commitment to this and total, both emotional and personal commitment to it. So Jim is, to me, a great hero in this regard.

MILLER: Well, if chairing the Task Force wasn't enough, in January of '83 CDC hosted a national conference to determine blood bank policy regarding screening 00:41:00out individuals at high risk for AIDS from the blood donor pool. So at this time the virus had not yet been identified, and there certainly was no serologic test. And as a background to that, in the summer of 1982 there were three cases of Pneumocystis pneumonia among patients with hemophilia, and then in December of '82, a 20-month-old infant developed AIDS following multiple transfusions, including from the blood of a male who developed AIDS. So here again, Assistant Secretary for Health, Ed Brandt, convened an advisory committee to address questions regarding transmission of AIDS through blood and blood products, and you were asked to chair this meeting. Can you tell us a little about the meeting, who attended? It was sort of a watershed meeting I think in many ways, 00:42:00in terms of the entire AIDS issue opening up and needs for prevention and needs for decisions before you have an agent. Do you remember that meeting?

KOPLAN: It was a hell of a meeting. It involved the program, I don't have it in front of me, but I can remember it pretty distinctly. We went through a series of presentations on the overall epidemiology of what was being referred to at the time as Gay Related Immuno Deficiency, GRID. We went through the overall epidemiology and the surveillance work that was being done and then the investigations of these individual cases with the lab work. It was very much an intense look. There were three cases at the time that were probably Factor VIII [an essential blood-clotting protein] related. For us it was Factor VIII-related 00:43:00transmission; for many of the visitors it was potential concern about Factor VIII. We had very clear-cut groups with known strong differences of opinion.

So you've got a group of CDC scientists that included laboratory people and epidemiologists. Jim was prominent, [Dr. Harold Jaffe] Harold was prominent, [Dr. Donald P.] Don Francis was present, [Dr.] Janine Jason, I think, gave a presentation, and [Dr. Thomas J.]Tom Spira gave a presentation from the lab side. So it was held in what was historically the CDC auditorium, I think it was in Auditorium A that we had this meeting. It was a pretty good-sized room, set up with a rectangular table. We had members of the blood banking community 00:44:00present, so that's the American Red Cross and the American Association of Blood Banks. There may have been a couple of other folks present. Professor Bove, [Dr.]Joseph I believe, was there from the Red Cross. At any event, there was the hemophilia organization, the National Hemophilia Foundation, and the representative of that was their chief medical officer, who happened to have been a professor and teacher of mine in medical school, [Dr. Louis] Lou Aledort, who I had always liked and gotten along with and respected. He was there. And then there were activist members of the gay community, including a couple of physicians who were present. I'm sure there were a lot of other people present from CDC who just wanted to see this slam-bang event. We knew ahead of time this was going to be fractious--that this would be difficult information, and the 00:45:00blood banks did not want to be messed with.

MILLER: Why was that?

KOPLAN: The blood banks felt they had enough problem getting blood, period. Their job was to make sureif I had my gallbladder taken out or whatever, that they've got two units of blood that matches me and that can be given and it's safe and appropriate, and when they need platelets for someone with leukemia, they've got them. They had a tough enough job in the current system to get the blood that they needed to do what's supposed to be done. Then for us to start saying, you can't draw blood from these folks and you can't do it from these and you need to ask these questions, it was like--we've got a hard job already and you're making it harder. So we knew this was a problem, but as an epidemiologist, when you heard there are three cases now and it's related to 00:46:00this thing--we've all been at outbreaks and arrived at different times. If you do enough outbreak investigations, as soon as you hear, this is really rare and this is occurring in association with that, your antenna go up and you say, what do we do now? Usually it's, you damn well better do something about this, because it's only going to get worse. You can wait until there's a hundred cases or a thousand or ten thousand, but my view was, this is enough evidence right now to do something with it. That view was shared by virtually all the CDC folks who were present and certainly articulated in the most impassioned way by Don Francis at that meeting.

MILLER: How so?

KOPLAN: Don is an old friend, and Don was always a passionate advocate for the area he worked in. Now, regarding your earlier question about adequate 00:47:00resources, Don was someone who probably was yelling whenever I saw him, that we need more money and they need more to do this and they need more to do that, and he was probably right. But also I'd heard that from him no matter what he was working on, for a long period of time. If you walked up to people at CDC who were working on polio or immunizations or tobacco or whatever, if they were that personality they'd grab you and say don't leave us out, et cetera.

So back to the meeting. Those were the presentations, and then there were reactions to presentations by all the other players present, the two representatives of the gay community, the...

MILLER: That must have been complicated. What was the stance of the gay 00:48:00community at that time?

KOPLAN: Interesting. I think there were definitely different voices being heard. It was similar voices to the folks who were saying, shut the bathhouses because they're facilitating spread and we should shut them down. You heard that from some members of the gay community, and then you heard others saying, don't mess with our culture and lifestyle. You may not like it, but there's no proof, and this is just an example of your stigmatizing us and trying to oppress us more than we were before. So I think there was some of both. I don't remember exactly at the meeting whether both of those views were expressed, but my vague memory is both of those strains came out. That gets translated in the blood donation area to you're going to stigmatize us further if you say all of us can't give 00:49:00blood, it doesn't make sense, you can't prove that we're all at risk, this is a stretch too far. The same would be true if you said it about Haitians or about drug users. For drug users you could make a better case because of the link with hepatitis B, and there it may be a little more nuanced. So there was that view being voiced as well. There were people at very different places as to what should be done next.

MILLER: Now, there were a handful of cases among hemophiliacs. Was there yet any sense of a long latency period and that there may be people who are affected by this but not yet showing it? Did that come into play in terms of trying to convince the audience that this is a bigger deal than a measles outbreak?

KOPLAN: Yeah, I think all that stuff came into play, but it wasn't telling, so that the people who were resistant would come back over and over again.:you had a handful of cases, whatever it was. It was first three and then four and then five, and to me, when you went from three to four to five, it was just sealing the deal. It was like, this is crazy. This is a problem, and what's your number? Is it a thousand you want to go to, or how high do you want to go, because this is enough for me, right? This isn't the brilliance of hindsight, this is just the epidemiologist speaking. It's not hindsight because at that time we voiced every speaker, some more stridently, like Don, and some in a more calm tone 00:51:00said, you know, this is what we do and this is what this looks like. It's only gonna get worse, and the better part of valor would be to take some steps here.

MILLER: Now, blood and blood products are under the purview of FDA, I think. Why wasn't this meeting held at FDA? Why didn't FDA take a lead role in this?

KOPLAN: They have a blood and blood products committee, which was having its own meetings during this period. Why that didn't suffice in and of itself, I think was because the investigation of these cases had been done by CDC, and so immediately it was an opportunity to begin a policy conclusion by involving the 00:52:00various pieces of the pie. In addition, I'm not sure whether my view of this was more strongly formulated months and years after this event, or whether I held it at the time of the meeting, but that entity in the FDA was heavily influenced by the blood banking members. Yes, there is a group of professional scientists and administrators at FDA, much like at CDC, who have responsibility for a given subject, in this case blood banking, but their meetings involved bringing in a dozen or eight, whatever, of distinguished blood bankers from outside. So that 00:53:00created a very different dynamic around what decisions got made. Probably there was a conflict of interest even within the individuals, because the blood bankers come wanting to do a good job of blood banking, but none of them would have an underlying desire to spread a disease through blood banking, it's just it was, in fact,

MILLER: A decision analysis.

KOPLAN: It is a decision analysis, and at that meeting I did refer to it, I think it's denial behavior. It's like, I don't want to hear about those cases, we've got to do what we've got to do, don't tell me about that stuff. And the extension of don't tell me about that stuff is, yes, yes, I hear you, but it's just a few cases and it can't mean anything.

MILLER: It sounds like it was a pretty difficult meeting, maybe one of the more difficult meetings you've chaired.

It prepared me for others.

MILLER: So what was the outcome of the meeting, the immediate outcome?

KOPLAN: The outcome of the meeting was that we did not reach consensus. So the goal was everyone was going to see this for what we thought it was, and now we can all go and formulate something together. That outcome was much more deferred, in the sense of, we hear you and we'll think about it, because they didn't have to do anything we said. We'll discuss it with our colleagues at the FDA. Okay, that keeps it in a Public Health Service framework.

In short order, more and more cases were occurring. I don't have the epi curve in front of me now, but if you look at hemophilia cases and then add in the transfusion-related cases, they were going up. You do what we always do, which is draw an epi curve. You've got time and the curve and it's going up. So I 00:55:00smile about it now, but at the time it was like, we can prevent these cases from occurring. The other piece of it, to be fair, is that the Factor VIII and Factor VII, and the various factors that get used for folks with clotting disorders, are a lifeline. Prior to the existence of pooled Factor VIII, and it was relatively recent then as a therapeutic intervention, because it's both preventative and therapeutic, these folks just had no life. They couldn't go out, they'd lose limbs, they were swollen, their lifespan was limited. It was 00:56:00incredibly limiting and debilitating. Lou Aledort, I remember, at this meeting, was describing this and presenting it. So anything that limited that supply or tainted it was terrible from their perspective. My remembrance of Dr. Aledort's reaction was, by the same token, having that supply contaminated for our life-blood substance isn't good for us either, so let's figure out how we can get it and get it safely. If that's the source of what's going on and it's because it's contaminated by something in some way by somebody, whatever we can do to return it to its lower risk status is in our best interest.

MILLER: So a couple of months after the meeting there was an MMWR, just 00:57:00suggesting that members of groups at increased risks should avoid donating blood. But it would really be two years before definitive action was taken. So in January of 1985, by then you had an ELISA test and you knew the organism. Provisional PHS [Public Health Service] recommendations for screening donated blood were established. So in those two years a lot of hemophiliacs and other recipients of blood transfusions were infected, and I've seen numbers like thousands, tens of thousands. With the luxury of hindsight, now that you've got it, could we have responded differently? You've chaired a million groups since then; you've led so many things.

KOPLAN: With the luxury of hindsight well, actually I can't say the luxury of hindsight. We felt strongly about it then. I should be transparent: I've served 00:58:00as a historical witness and as an expert witness in several transfusion-related AIDS cases, all of which were found in favor of the defendant, which was the American Red Cross. But I felt strongly enough about this and what I saw as an obstruction to good public health practice. This was after I left CDC government service that I actually testified in those cases to the effect that...

MILLER: For the plaintiffs.

KOPLAN: For the plaintiffs, that this could have been dealt with sooner and that this should have been avoided. So the legal side can argue that I was wrong because they weren't found guilty, but I felt strongly then and still feel 00:59:00strongly that, yes, more could have been done. It couldn't have been done by us. I mean we made our statements relatively, not even relatively, we strongly expressed our view that this relationship was with the donors and that if there were donors who were at higher risk than the larger group of donors, then it was worth trying to remove them from the pool, to be reinstated later if that was feasible. It was important to preserve the safety of the blood supply.

MILLER: So you've been on so many groups and chaired and led and tried to persuade. What do you think about in terms of, how does one persuade, how does one affect decision-making? This has been written up as a big critical 01:00:00decision-making in some of the things that may not have gone as well as they should have. What do you think about that now? Are there lessons to be learned in terms of how to persuade groups, or do we need to wait years and years, with tens of thousands of people getting ill? Are you smarter now?

KOPLAN: Probably not. I've had more experiences, but I'm probably not any smarter. Was there something administratively or decision maker-wise that could have been done? While no one at CDC was in a position, if you think of any of the big outbreaks that CDC is involved in, CDC is rarely in the position of saying, you better close that plant or that restaurant. CDC can make recommendations, like if you're traveling to the following countries you 01:01:00shouldn't be pregnant or get pregnant. Would ideally something much more stringent and draconian and dictatorial be appropriate? It may in some instances, but were there elements of, you're not sure, and were there elements of individual rights? That complicates it, no matter what the disease is or what the circumstances. That was true then, and it's true now. I wonder whether this would be a role for the Assistant Secretary for Health to step in, and that may have been something that I needed to transfer or get the CDC Director involved in the transfer.

MILLER: Was Dr. Bill Foege still the Director then?

KOPLAN: Yes. Of course, Bill was present to kick off the meeting, Bill was there 01:02:00at the end, and we debriefed with everybody, our whole team, on what could be done.

MILLER: And then did it go back to Dr. Ed Brandt?

KOPLAN: Yes. So all this was out there.

MILLER: Presented to him. Did he have a major impact on the decision-making process?

KOPLAN: I think probably his impact was not on the decision-making process that we had in our group and at those committee hearings. There were no imposed-from-above conclusions or thoughts in that direction. But at the end of those discussions, what had been discussed and the pros and cons certainly had made it up the food chain. I think I, or even the CDC Director, was in no position to say to FDA, you'd better do this. CDC interacts with FDA daily on a 01:03:00million topics, and that relationship is, here's what we've found, and from our perspective you ought to get those sprouts off the market or don't sell the raspberries from this source. When that works well, FDA says, we agree and we'll take care of it. Or FDA pushes back and says, it's not quite that simple for this reason. There's a professional interchange. It's a bit of hindsight to say that more firm measures should have been taken and by whom, but from my epidemiologic science end, the case was made that it was only getting worse.

MILLER: So were you disappointed and frustrated?

KOPLAN: Well, what happened was there were the two committees. The first one focused on hemophilia and concentrated clotting products, and the second, which 01:04:00was transfusions in general, was merely an extension of the first. That presented an even broader problem, because the number of hemophiliacs is much less than the number of people getting transfusions all the time. It was really the same discussion magnified. I believe it was at the second meeting where one thing we did get through was renaming the disease. Gerry Quinnan from FDA seems to think that I proposed the name, but I actually don't remember. It was a group process. Calling it gay related made no sense epidemiologically, and certainly from a stigma perspective it was not a good idea and detrimental to the public health. So it's Acquired Immuno Deficiency Syndrome.

MILLER: And there had been a weight control tablet called AIDS. I don't know if you remember that and that it quickly went off the market.

KOPLAN: Yes, it's probably no loss either.

MILLER: Well, I guess in conclusion, we've talked about so many things.

KOPLAN: Can I interject one thing?

MILLER: Yes, please.

KOPLAN: I'm thinking about analogous subsequent parallel events. I'm sure I'm not thinking of a hundred that are appropriate, but one that springs to mind is the Tylenol scare, when some malevolent being was contaminating boxes of Tylenol off the shelves in stores. Johnson & Johnson's reaction was to pull them immediately. They didn't quibble that this is just a few events. You can claim, 01:06:00well, that's crass business. It isn't, it's smart business practice. If your business is producing blood products for people to use, and the attraction of those products is that they improve your health and that they're safe, and the question is going around that they don't seem to be safe, there's a real risk involved. Johnson & Johnson didn't wait for 50 more cases or 100 more. They pulled all the boxes and probably destroyed everything they pulled and then took steps to make sure you couldn't tamper with the stuff. I don't think they ever found the culprit, but they took steps to make sure their product was safe. They didn't deny something was threatening their product and say, we're not going to worry about that. What we're going to do is pull off anything that could be contaminated and let the consumer know that we're doing everything we can to 01:07:00ensure its safety and that you'll know it when you go to buy it. I think that's not a bad way to behave in a situation like that. But there are costs to it, and where you stand depends on where you sit, as they say.

MILLER: So how would you say your work at this, 1983 was pretty intense for you, although looking at your CV, many years were intense. But how do you think the work on AIDS affected you personally? Do you have any recollections of that? Did it affect you personally? Did it affect your subsequent work or decisions?

KOPLAN: I recognize all the tragedy and grief and sadness and the huge loss of life worldwide. A terrible thing. But in a glimmer of light that shines through, 01:08:00under and around this curtain, lies the fact that there's been a huge expansion of knowledge about immunologic processes, and antiviral agents have been improved and created that never would have seen the light of day before. Scientific knowledge, trust, commitment, development have been remarkable and pushed by this terrible outbreak. Unfortunately vaccine development hasn't been as quick and is much more complicated. It raises the issues of marginalized communities. It raises a lot of social science and behavioral issues that I think can affect any disease or health issue we work on. It has made us 01:09:00hopefully more enlightened and more sympathetic and more compassionate towards these things. It's not for me to comment on it, but from my humble and maybe naive and ignorant lay opinion, it's empowered the gay community in ways political and social that might not have happened before. It created a stronger sense and maybe moved the whole population's conception about sexuality and lifestyle choices into a much healthier realm in general. So we live in a different environment today, and our kids live in a very different one than we had and our grandparents had, and I think that progress is real progress. It would be great if hundreds of thousands of people didn't have to die for that, 01:10:00and I don't see it as a one-to-one relationship. But amidst all the horror of it and the terrible aspects of it there have been some good things that have come as part of the process.

MILLER: Thank you very much. This concludes our interview.

KOPLAN: Thank you.

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