Partial Transcript: Could you tell us where you grew up and about your early family life?
Segment Synopsis: Dr. Auerbach discusses his early life and where he went to school as well as his introduction to the Epidemic Intelligence Service program.
Keywords: Albany, New York; B. Roueche; biostatistics; chemists; D. Fleming; Delmar, New York; English Major; epidemiology; Internal Medicine residency; LA; Long Beach, New York; Los Angles, California; medical school; Minneapolis, Minnesota; P. Brachman; public health; recruits; scientists; Syracuse, New York
Subjects: Annals of Medicine; Centers for Disease Control (U.S.). Epidemic Intelligence Service; EIS; Legionnaire's Investigation; Los Angeles County Health Department; Morbidity and Mortality Weekly Report; New York State; New Yorker; State University of New York; SUNY; U.S. Centers for Disease Control and Prevention
Partial Transcript: I'm just curious what attracted you to a move out west. As you said, you were pretty much an East Coast kind of guy.
Segment Synopsis: Auerbach describes why he decided to do his EIS training on the West Coast and his early work on a new disease.
Keywords: Atlanta, Georgia; Bay Area; blind date; cases; communicable agent; controls; gay; immune compromised; Kaposi's Sarcoma/Opportunistic Infections; KS/OI; Los Angeles, California; national case-control study; New York City; P. Thomas; Palisades Park; potential risk factors; San Francisco, California; Santa Monica, California; Task Force; toxic exposure
Subjects: AIDS; California; CDC; EIS; Epidemic Intelligence Service; hepatitis B; Legionnaire's; MMWR; Morbidity and Mortality Weekly Report; New York Health Department; North America; pneumocystis; U.S. Centers for Disease Control and Prevention
Partial Transcript: How did this all come up for you? It must have been pretty soon after you arrived actually.
Segment Synopsis: Auerbach talk about his training and the implementation the first national case-control study.
Keywords: Atlanta, Georgia; bath house; blood; case-control study; controls; F. Sorvillo; gay community; H. Jaffe; health department; Los Angeles, California; M Guinan; M. Finn; M. Tormey; Omaha, Nebraska; public health; questionnaire; S. Fannin; San Diego, California; San Fernando Valley; San Francisco; sexual activity; sexual contact; sexual histories; sexually transmitted agent; specimens; substance use; surveillance; training; W. Darrow
Subjects: AIDS; CDC; Centers for Disease Control and Prevention; EIS; Gay and Lesbian Community Services Center; Los Angeles County Health Department; MMWR; Sexually Transmitted Diseases; STD
Partial Transcript: You then became involved in another investigation that became know as the Los Angeles Cluster Investigation, which many now flet put some real credibility to this idea of some sort of an infectious agent that was being sexually transmitted.
Segment Synopsis: Auerbach describes how the 1982 Los Angeles cluster study, attempted to trace sexual connections among a number of gay men residing in California.
Keywords: Atlanta, Georgia; case-control study; connections; contacts; gay community; H. Jaffe; health department; infectious agent; interviewing; Los Angeles, California; partners; sexual contact; sexually transmitted; sociology; W. Darrow
Subjects: AIDS; CDC; Centers for Disease Control and Prevention; Cluster Investigation
Partial Transcript: What did you start to find?
Segment Synopsis: Auerbach describes how the linkages between patients in Los Angeles led to finding a geographic center of a cluster of patients. A non-Californian man with Kaposi’s sarcoma was linked as a sexual contact for all these patients. This individual’s status as the “Out-of-California” patient was originally abbreviated to the letter “O,” which in turn was given additional significance when researchers read this as the number “0.”
Keywords: air steward; connections; contact; epidemiology; genetic molecular analyses; geographic center; linkages; Los Angeles, California; molecular biology; New York City; out of California case; Patient Zero; patients; sexual contact; single individual; specimens; Typhoid Mary; W. Darrow
Subjects: acquired immunodeficiency syndrome; AIDS; Air Canada; American Journal of Medicine; California; CDC; Centers for Disease for Control and Prevention; Cluster Investigation; hepatitis B; HIV/AIDS; MMWR; Nature; New York; North America; United States
Partial Transcript: You were involved, I think, in working with pediatric immunologists. Do you remember any of this?
Segment Synopsis: Auerbach describes how one phone call from a pediatric immunologist led to an investigation into transfusions and blood products.
Keywords: A. Ammann; Atlanta; blood; blood bank; blood products; communicable diseases; donor; epidemiologist; etiologic agent; H. Jaffe; H. Perkins; hematopathologist; M. Silverman; mother-to-child transmission; multifactorial; opportunistic infection; pathologist; pediatric immunologist; perinatal transmisson; S. Dritz; San Francisco, California; toxic exposure; transfusion; transmissible agent
Subjects: AIDS/HIV; California; Communicable Disease Control; eryhroblastosis fetalis; hemolytic anemia; hepatits B; human immunodeficiency virus; Irwin Memorial Blood Bank; Kaposi's Sarcoma/Opportunistic Infection; KS/OI; mycobacterium avium; San Francisco Health Department; sexually transmitted diseases; U.C. San Francisco Medical Center; University of California; West Coast
Partial Transcript: Was there an interest in learning more about the donor?
Segment Synopsis: Auerbach describes a donated blood source investigation which led to a man who had no identified risk factors, and how this landmark case unfolded.
Keywords: blood products; case-control study; Castro District; donor; gay; gay district; H. Jaffe; intravenous drugs; IV drugs; M. Guinan; no risk factor; No risk factors; normative human sexual behavior; S. Dritz; San Francisco, California; sexual activity; W. Darrow
Subjects: CDC; Centers for Disease Control and Prevention; gonococcal disease; HIV/AIDS; MMWR; Morbidity and Mortality Weekly Report; Pneumocystis pneumonia; rectal gonorrhea; San Francisco Health Department
Partial Transcript: Did you get drawn into some of that media scrum?
Segment Synopsis: Auerbach describes how an infant transfusion case led to a lot of media attention and misperceptions.
Keywords: A. Ammann; blood supply; blood transfusion; cases; communicable disese; credible; early pediatric; gay population; H. Perkins; Immunologic symptom-complex; J. Bove; Los Angeles, California; mother-to-child cases; pediatric immunologist; perinatal cases; transfusion-related case; transmission
Subjects: American Association of Blood Bankers; Bay Area; Blood Banking; CDC; HIV/AIDS; Irwin Memorial; Los Angeles County Medical Center; New Jersey; New York City; Yale-New Haven Medical Center
Partial Transcript: Are there other aspects of the AIDS epidemic that you were involved in that we haven't touched on that you took part in?
Segment Synopsis: Auerbach explains the issues of explaining the epidemic to other health professionals, the general public and the gay community.
Keywords: 60 Minutes; And the Band Played On; epidemiology; gay community; gay scene; government budgeting; H. Reasoner; heterosexual transmission; mother-to-child transmission; Patient Zero; R. Shilts; sexual transmission; transfusion transmission
Subjects: CDC; Centers for Disease Control and Prevention; HIV/AIDS; Reagan administration; San Francisco Chronicle; UCLA; University of California, Los Angeles
Partial Transcript: Did it ever occur to you to think a bit broader as to how this might unfold-- if this was going to potentially be a huge public health problem - nationally, domestically, internationally?
Segment Synopsis: Auerbach explains his sense of being part of something much larger, an important historical event for a young physician.
Keywords: 60 Minutes; disease; epidemiology; etiologic agent; gay men; gratifying; homosexual; Los Angeles, California; new disease; part of history; public affairs officer; public health issue; serologic test
Subjects: anti-retroviral treatment; California; CBS News; CDC; Centers for Disease Control and Prevention; Disease; Orange County
CHAMBERLAND: This is Dr. Mary Chamberland, and I'm here with Dr. David [M.]Auerbach at the Centers for Disease Control and Prevention in Atlanta, Georgia. Today is Monday, December 11, 2017. I am interviewing Dr. Auerbach as part of the oral history project The Early Years of AIDS: CDC's Response to a Historic Epidemic. David, welcome to the project.
AUERBACH: Thank you, Mary.
CHAMBERLAND: Do I have your permission to interview you and to record this interview?
AUERBACH: Yes, you do.
CHAMBERLAND: David, you were an Epidemic Intelligence Service [EIS] Officerassigned to the Los Angeles County Department of Health from 1981 to 1983. This was very shortly after the publication in June of 1981 of the first MMWR [Morbidity and Mortality Weekly Report] on Pneumocystis carinii pneumonia among homosexual men in Los Angeles. During your time in Los Angeles, you were involved in some of the key investigations of early cases of AIDS [acquired 1:00immunodeficiency syndrome].
Before we delve into the details of all of this, let's talk a little about yourbackground. Could you tell us where you grew up and about your early family life?
AUERBACH: Yes, of course. My family is originally from the Albany, New York,area. When I was young, we lived in a suburb of Albany (Delmar, New York), and my family moved to the southern part of New York State. I went to high school on Long Island in Long Beach, New York, and graduated from high school there.
CHAMBERLAND: Where did you go to college, and what did you study there?
AUERBACH: Yes, I went to college at the State University of New York [SUNY] atAlbany. I was an English major. I took lots of biology as well, but I was an English major. I liked to read and write, and that came naturally to me.
CHAMBERLAND: Who or what influenced you to go on to medical school?
AUERBACH: Yes, I come from a family of scientists, mostly chemists. I think when2:00I was young I aspired to be a scientist, a chemist, and impress my uncles one day. I learned, though, early on that, if I had a talent, it was not that. I think I was looking for a field that combined science or application of science with more humanistic interests, and medicine seemed like a natural fit. I think that was probably a good decision. I'm not sure I would have impressed my uncles anyway, so that was probably a good choice.
CHAMBERLAND: Where did you end up going to medical school?
AUERBACH: I went to medical school at the State University of New York, UpstateMedical in Syracuse, New York -- about 150 miles west of Albany.
CHAMBERLAND: After medical school (when) you did your clinical training, did youstay there or move on?
AUERBACH: Yes, I stayed in SUNY in Upstate for my Internal Medicine residency,3:00which I completed in 1981, just before I started to work for CDC [Centers for Disease Control and Prevention]
CHAMBERLAND: What made you shift from clinical medicine and move towards publichealth, specifically to train at CDC as an EIS Officer?
AUERBACH: When I was young, I grew up reading the stories written by BertonRoueché in the New Yorker under the heading of Medical Detective. Sorry, actually I think it was Annals of Medicine, I believe, was the subhead for his articles. They were fascinating. They involved, most of them involved, investigations by CDC people, and they read like detective stories. They were written in the genre really of detective stories, except they were all true. I 4:00think only the names of patients, no doubt, were changed. The names of CDC personnel were generally used, and everything else was very much true. They were just captivating to me.
When I was, I believe I was a medical student--either a medical student orresident, I think a medical student--Dr. Brachman, Phillip [S.] Brachman gave Internal Medicine Grand Rounds. He was talking about the issue of the moment, which was the Legionnaire's investigation, which had been completed maybe a year or so before that. I thought that was fascinating, too. Dr. Brachman mentioned at the end of his talk that if any of the students or residents were interested in perhaps working for CDC or joining CDC, they should stay after. I stayed after, and one other student stayed after, and we both ultimately became EIS Officers. I think it was probably a pretty good day for Dr. Brachman, in retrospect.
CHAMBERLAND: He got two recruits out of that visit.
AUERBACH: He did, he did, and we got subscriptions to MMWR, courtesy of Dr. Brachman.
CHAMBERLAND: I'm just curious, who was the fellow medical student that also5:00ended up at CDC as an EIS Officer?
AUERBACH: His name was [Dr.] David [W.] Fleming. He was a year behind me atmedical school.
CHAMBERLAND: When you left, or when you announced your intentions afterresidency completion to move on to CDC's training program, do you recall what your colleagues, your peers had to say about that? Did they think it was curious or unusual?
AUERBACH: I think they were mostly excited for me. It was different than whatmost people were doing. They, I think, were intrigued by it, and I was very excited. By the time I finished my residency, I knew I would be representing CDC but based in Los Angeles, with my office at the Los Angeles County Health Department. At that point in my life, I'd never lived outside of New York State 6:00and I'd never traveled west of Minneapolis, so this was quite an adventure for me. After the month, the crash course in biostatistics and epidemiology here in Atlanta, I drove off in my Toyota Corolla in the first week of August of 1981. The car had no air conditioning, regrettably, and I drove across the country to Los Angeles -- I had never been there -- listening to review tapes for the Internal Medicine boards I was about to take in a few weeks. It was quite an adventure for me.
CHAMBERLAND: I'm curious -- as we know, there's an interview matching processfor incoming EIS Officers to land a position, either an Atlanta-based position at CDC or in one of the state or local health departments. I'm just curious what 7:00attracted you to a move out west. As you said, you were pretty much an East Coast kind of guy.
AUERBACH: Right. I laugh about it now. Initially, I was not attracted. They doit with a very gentle hand, and they don't compel anyone to do something that they don't want to do. At some point the idea -- I assumed that I would probably be in Atlanta or perhaps elsewhere, but probably Atlanta -- at some point, I was asked how I would feel about being based in Los Angeles. My initial reaction -- I was reacting I'm sure with a Northeasterner's prejudice at the time -- my initial reaction in my own mind was, absolutely not. If they had said, Northern California, the Bay Area, that would have been fine. I'd never been there either. It was based on image, and I'm not sure what else. But then I thought about it, and I thought that it might be -- after all it was only two years -- how bad could it be? 8:00
Of course, after I arrived, drove out and arrived there, I'd never seenCalifornia, and it was beautiful. I was very fortunate. I got an apartment in Santa Monica -- (it was) notoriously difficult to find an apartment in those days in Santa Monica. The apartment was two blocks from the Palisades Park, overlooking the blue Pacific and was lined with palm trees. The climate was beautiful. Everything was beautiful, and I figured I could probably handle that for two years without any real difficulty. Also, a few months before I moved to California, I had met a woman on a blind date, visiting friends in New York City, and she was finishing graduate school in New York and taking a job in Los Angeles. I looked her up, and we began dating, and we've been married now for quite a few years, so that worked out well too.
CHAMBERLAND: Gosh, it sounds like the stars aligned up pretty nicely, in retrospect.9:00
AUERBACH: It really did. I was very fortunate, that's right.
CHAMBERLAND: As I noted at the beginning, you were part of that first EIS classthat really had any, that actually had to do some work, investigative work around this mysterious new illness. I'm curious: you mentioned that you were in Atlanta during July for the training course that all new EIS Officers undergo. I was curious if during the training course, or before you got in the car to drive cross country, did you have any contact with the, at that time, very new task force that was forming -- the Kaposi's Sarcoma/Opportunistic Infections [KS/OI] Task Force? Any inkling before you landed in L.A. [Los Angeles] that you might be getting involved in this mysterious new disease?
AUERBACH: Yes. My introduction to the whole topic, of course, as everyone10:00else's, other than the people at CDC involved, was that MMWR report on June 5th or 6th of 1981. I remember reading that as I was packing up to leave my residency program and thinking, this is really strange. Pneumocystis was well known at the time, but exclusively in people with some obvious reasons to be immune compromised -- effectively never in previously healthy individuals. Then, of course, the question was, what does being gay have to do with it? The whole thing seemed very odd, and it was. Then when I began the course in July in Atlanta at CDC, of course, I knew I'd be heading out to Los Angeles. I remember there was one meeting during that month in July -- there was one meeting with the Task Force. It was mostly the Atlanta-based Task Force. As I recall, the 11:00other two individuals invited were [Dr. Pauline A.] Polly Thomas, who was about to head to New York, your predecessor in New York City at the New York Health Department, and me. Of course, we were headed to the two locations where most of the now known as AIDS patients were located, so that made sense. It was memorable.
I think back to that meeting, and I think back to the speculation about whatmight be causing this new disease entity. I think it was fairly clear that it was indeed new, not just newly reported or newly noted, as for example, Legionnaire's, which was just newly noted, but not new. I think back to that day, and I'll speak for myself. If you had asked me to guess what the cause 12:00might be, let's say, a new communicable agent -- infectious disease versus some sort of toxic exposure, I think the betting might have been on a toxic exposure. After all, I think a completely new disease entity, infectious entity, in North America would be virtually unprecedented in modern medicine. On the other hand, the chemical industry turns out new compounds by the thousands, no doubt every year. Some were used as street drugs. I think that might have been where the betting was. Not too long after that it became quite clear that we were dealing with likely a transmissible agent, transmitted in a way very much similar to hepatitis B. But at that moment, it was not obvious at that moment on that day. I remember that.
CHAMBERLAND: Certainly one of the first things that CDC did to try and identify13:00potential risk factors for this new disease, as you say, to try and sort through possible exposures that could be resulting in it, was to do a national case-control study in which gay men who had the disease -- the cases -- were compared to gay men who were like the cases, but appeared apparently healthy, the so-called controls. We now know in retrospect that many of the controls themselves were likely infected, but there was no agent, there was no test. The study took place in four cities -- New York City, San Francisco, L.A. and Atlanta. Now, I believe you were part of a pretty large team of people that were involved in interviewing cases and controls. I just wanted to have you tell us a little bit about how you got involved in that. Was there any 14:00special training, since there were going to be so many people involved in interviewing cases and controls around the country? How did this all come up for you? It must have been pretty soon after you arrived, actually.
AUERBACH: Yes, it was. That's a good question. There was some training. In fact,I remember this: that all of us who were going to be involved in the case-control study -- those of us not based in Atlanta -- were brought back to Atlanta for a day of training. Before I came into Atlanta, I remember wondering whether this was completely necessary. But it was necessary, I think, in order to do a study that was valid and as reliable as possible. What I remember, in particular, (was) there was a long, fairly long questionnaire, and the questions were about the things that you would guess -- substance use, sexual activity and so forth.
I remember there was a session where there was a kind of role-playing thing,15:00where the rest of us watched two individuals, one playing the interviewer and one playing the interviewee. The question was, how do you do it in a standardized way. How could we learn to do in a standardized way, ask questions about number of different sexual contacts. I remember the way that we were advised to do this was to ask people to place themselves at times in their life. Maybe the person was living in Omaha for these years and they had very little sexual contact, and then they moved to San Francisco and maybe started going to bath houses. "How many times a week did you go to the bath house?" "Two or three." "And each time you would have contact with about how many others?" Do that and break it down, do the arithmetic, and we were instructed to do that in a consistent way. It's very logical-- it makes sense. It's not entirely 16:00intuitive, and I'm sure if left to our own devices, we would have done it in somewhat different ways. That would have meant the study would have been less reliable. I was really very impressed with how methodically the whole thing was implemented.
CHAMBERLAND: I'm sure, based on your clinical years of experience you had, inthose days certainly, physicians really weren't even taking sexual histories from patients for the most part. I'm sure this was fairly new territory to be asking a lot of very explicit questions about sexual activities, drug use activities.
AUERBACH: You know, I'm trying to remember. I think we did some, often, askquestions about sexual history. I can't remember really if we got much instruction in that in medical school, or we just learned it as residents, I'm not sure. I spend a lot of time now teaching medical students, and it's very 17:00much a part of the curriculum. I've been doing that for a long time. It certainly didn't have the emphasis that it does now. I don't remember how much attention was given to that when I was a medical student, though.
CHAMBERLAND: Tell us a little bit about how the mechanics of this study worked.You flew back to L.A. from Atlanta after the training session, and what were your instructions? First of all, you had to find the men, the cases --
CHAMBERLAND: Presumably who had been reported to the health department to date,and then controls. Were you involved in trying to find controls for these case-patients, and then where did you interview them? How did this all work? I'm just curious about the logistics of doing this.
AUERBACH: Yes, of course, I had a list of the cases. There weren't all that many18:00at the time in Los Angeles when I first arrived. Maybe there were eighteen or twenty or twenty-five-- not more than that, I don't think, that we knew of, anyway. Not all were still alive, of course. The controls we got from various sources. I remember one, and I'm sure I had help from CDC and CDC contacts here in Atlanta and also at the Los Angeles County Health Department, where I was based. They had roots in the community, and people were knowledgeable about the community. One location in particular was very helpful. There was a, I think it was called the Gay and Lesbian Community Services Center, I believe was the name of it, or very similar to that. They were the source of finding controls that we could use for the study. There was a Director of the Center, whose name I don't 19:00recall at the moment, who was very helpful in cooperating and helping us identify appropriate controls that would meet our needs.
CHAMBERLAND: Where would you interview cases and controls? Would you go to theirhomes? Would they come to the Health Department?
AUERBACH: Usually, I would go to their homes. I think some of them were done atthis Gay and Lesbian Community Center. We would do it where it was convenient to do the fairly long interview. I think it was twenty, twenty-five pages of questions. It took a little while to get through that. I believe I also drew their blood to ship back to Atlanta. For some of these (interviews), I was joined by my colleague, [Dr. William W.] Bill Darrow, who was wonderful. That's pretty much how we did it. 20:00
CHAMBERLAND: Yes, there were a number of different types of specimens involved.There was certainly blood drawing and I think swabbing, maybe oral/rectal swabs.
AUERBACH: I don't remember that. I remember drawing blood. I don't think therewas anything besides a blood draw.
CHAMBERLAND: Did that make you nervous at all, drawing specimens?
AUERBACH: Honestly, I didn't know enough to be nervous. I don't think any of usdid. I mean, I tried to be careful. I don't think I wore gloves, I don't remember. I don't think many people wore gloves drawing blood in those days. I was careful and never had a needle accident, but, of course, we didn't really know what we were dealing with.
CHAMBERLAND: What about the men that you were interviewing? As you've said,you've got a really long questionnaire. It's pretty detailed in terms of explicit sexual practices and frequency and the like, some of these being 21:00illegal activities. Were they cooperative? Were they engaged? Here you are from the U.S. government. What was your sense of the men?
AUERBACH: They were very cooperative. I don't remember anyone who refused tocooperate. I mean, understandably, the gay community became well informed about this before most other nonmedical people. They had an obvious reason to be interested. They wanted to cooperate. They wanted answers to be found, and they knew this was the way to do it. They were very helpful and cooperative, by and large. I don't remember any problems doing that.
CHAMBERLAND: Did your interviews only take place in L.A., or did you get involved22:00in going up to San Francisco as well, to interview for the case-control study?
AUERBACH: I did go up to San Francisco a few times, and San Diego as well. Ithink that was mostly not as part of the case-control study, but for other reasons related to the AIDS investigation. I don't believe I did any interviewing outside of Los Angeles.
CHAMBERLAND: Since it was a multicenter study, with lots of people involved, doyou recall if there were any opportunities for group conference calls, or did people from Atlanta-- you had Bill Darrow with you from the Task Force, but I was just curious if there were periodic group conference calls where you would check in with each other, learn what different kinds of experiences people were having, and share stories about what seemed to work well or not work so well? 23:00
AUERBACH: I think there probably were. There must have been some groupconference calls. What I remember more were just bilateral, two-way phone calls, either with Bill Darrow or [Dr.] Harold [W.]Jaffe. Those were probably the people I spoke with the most regarding AIDS who were Atlanta-based. There must have been some conference calls. I'm sure there were, but it was mostly, I mostly turned to Bill or Harold, and [Dr.] Mary [E.] Guinan occasionally. I'm sure there were some others I'm not thinking of at the moment who I would talk to regularly.
CHAMBERLAND: You alluded to the fact that at that time, 1981 and early 1982,there's a pretty small number of cases, recognized cases, in L.A. I'm curious if 24:00the health department, if the county health department had instituted any sort of formal or informal program of surveillance. Were physicians calling up the health department and saying, "Hey, I think I got one of these." Because the MMWR did serve -- it was good at, I think, nationally calling attention to the problem, and physicians started to think about, "Hmm, interesting case that I saw that I never quite knew what was going on. It could have been one of these." I was just curious what L.A. was doing.
AUERBACH: Yes. There was surveillance, but I don't remember how active it was. Idon't know if there was some kind of outreach. There were certainly physicians, especially ones who were providers in the gay community, who would call, and 25:00they'd give us information and were generally very helpful out there. There was one in particular, I believe his practice was in the San Fernando Valley. He was a very astute clinician, and he was very helpful, he was very helpful. I don't remember his name.
CHAMBERLAND: It sounds like the health department had some pre-existingconnections with the gay community or gay physicians at the time, which, as you say, would have been helpful. Who were you working with at the L.A. Department of Health? Who were your supervisors or others, colleagues, that you were working with? Were they involved in some of these early AIDS investigations, or was it pretty much, "Oh, that's the EIS Officer's job?"
AUERBACH: No. There were others involved. My supervisor in Los Angeles wasShirley Fannin, Dr. Shirley [L.] Fannin. She was terrific. She was a very astute 26:00physician, pediatrician and public health official, and she was certainly very helpful. The director of the county health department was Dr. Martin [D.] Finn. He was in charge of the department. I had wonderful colleagues, [Michael] Mike Tormey, Frank [J.] Sorvillo and others who were involved. I am sure I turned to them for assistance with AIDS and, of course, many other things that I was also working on at the time. They were all very supportive, very knowledgeable, very skilled professionals, who were available to help me and give me advice, and I'm sure I needed lots of advice in those days.
CHAMBERLAND: It's interesting. The case-control study pooled all of the datafrom all four of the cities and was written up. You were a co-author, and the writers were a little cautious, I think, in their conclusions. The case-control 27:00study found that (case) gay men certainly tended to have higher numbers of sexual partners, and were more likely to have various STDs [sexually transmitted diseases] than control gay men and the like. There was still some caution in the way the conclusions were drawn, about saying this is definitely looking like a sexually transmitted agent. It was certainly out there, but I think there was still a sense of not having really nailed this.
You then became involved in another investigation that became known as the LosAngeles Cluster Investigation, which many now felt put some real credibility to this idea of some sort of an infectious agent that was being sexually 28:00transmitted. Tell us a little bit about the L.A. Cluster Investigation. I am just curious how this all started. I think you were very much a very early focal point for getting this investigation under way, based on information you were hearing in Los Angeles?
AUERBACH: Right, right. I believe I got a call one day -- it must have beensomeone in the gay community or perhaps in the health department or a gay community center, I'm not sure, mentioning somewhat anecdotally that there were a number of then patients who had had contact either with each other or with another individual -- a single other individual -- and that led to the Cluster 29:00Investigation that you're referring to.
CHAMBERLAND: You heard this. I don't believe the case-control study asked peoplefor partners, if they had had partners with anyone with the disease.
AUERBACH: No, no.
CHAMBERLAND: This is-- hmm, new information, a new lead. When you heard this,what did you do?
AUERBACH: Let me take that back. The case-control study, when we did theinterviewing, I believe we, I think we did ask about contacts. I don't remember how that was recorded or if there was a single methodology for doing that, but I think we did ask for contacts, I believe. I'm sorry, your question is?
CHAMBERLAND: You're on the receiving end of this initial phone call that'ssaying, "Hey, there are several of these patients with the disease that appear 30:00to have had sexual contact with each other or another intermediary." What did you do when you heard that? Did you pick up the phone and call Atlanta?
AUERBACH: I must have spoken probably with Harold Jaffe or Bill Darrow. I musthave discussed it with them, and then it was decided that we would pursue this. Specifically, Bill would come out to Los Angeles, and we would work together on this. Bill was terrific in every way. Bill is not a clinician. His graduate degree is in -- he has a Ph.D. in sociology, but really to the point, Bill was probably the most naturally gifted interviewer I've ever worked with. He had this way of drawing people out, putting people at ease. He also was familiar 31:00through other academic work he had done, his contacts, he was very familiar with the gay community. He also had a memory that approached photographic. It was really astonishing. If we heard information -- these people mentioned names of people they had sexual contact with, Bill could remember that that person had sexual contact with another person, who had contact with another person and going back multiple iterations to another -- finally connecting to another patient. He would make those connections, and he would mention that to me, usually as we were leaving the interview. He'd say, "David, did you catch that?" I'd say, "Catch what, Bill?" Then he would describe this whole sequence, and I would say, "Bill, you are totally making that up." We'd go back to my office and look in my files, and he was not making it up. He was right. He just had an astonishing memory for these things.
CHAMBERLAND: Your objective was to go and basically interview all of the living32:00patients with AIDS, at that time, all gay men, and ask them essentially, among other questions, to provide names of their sexual partners?
AUERBACH: Yes, that's right.
CHAMBERLAND: OK. Were people able to do that?
AUERBACH: Not always. There obviously is a certain amount of purely anonymoussexual contact, but in some instances, they were when it was a sexual relationship over a longer period of time. Of course, we had to do that. They understood we had to do that. How else would we make these connections that would infer transmissibility of a disease? Again, there must have been some who were reticent, but I don't remember any, or maybe there was some initial reticence that was quickly overcome, perhaps. Again, the gay community was very 33:00informed very quickly. This was in their press. I was asked to speak to community groups and medical groups too, and later on more general community-based groups, but the gay community was very well informed very early on.
CHAMBERLAND: Did you and Bill do all the interviews together, or did you splitup and divide and conquer?
AUERBACH: Did we do all of them together? I think for the case-control studies Idid those myself, I'm pretty sure. For the Cluster Investigation, I probably did a few myself, but more often than not, Bill and I were together, and that was very helpful. That's my recollection, anyway.
CHAMBERLAND: At that time there were twenty or under twenty patients that you34:00were visiting. How long did this take? Were you doing more than one a day?
AUERBACH: Some days we could (do one) or even maybe two or three or more. Iremember we spent a lot of time driving around Los Angeles looking for homes. Usually, we would interview people at their homes. How long did it take? It must have been over at least a few months, I think. I can't remember exactly, but probably over a few months that this unfolded, until we could interview everyone that we could.
CHAMBERLAND: Your goal was to get names, and then you were cross-matching thenames to see if there were any linkages. What did you start to find?
AUERBACH: We started to find that, in fact, there were linkages between these,at least some of the patients. Also notably many of them had contact with a 35:00single individual not from Los Angeles, who became known as the Patient Zero. In retrospect, perhaps the designation was unfortunate, although I don't think we could have anticipated that. The Patient Zero was -- I think the article in the American Journal of Medicine makes it very clear that this Patient Zero was at the geographical center of a cluster of patients. Nowhere does it even imply that he was a point source or the unfortunate term later that was used, I think was the "Typhoid Mary of HIV/AIDS." There is no suggestion of that. Honestly, if we had to do it over again, we probably would have started the sequence with ABC 36:00instead of 0,1,2,3. But it was zero only because zero comes before 1, and it was at this geographical center. There was nothing more that was implied or intended to abide by using that designation.
CHAMBERLAND: So, Patient Zero, also sometimes referred to as the "out-of-California" case. Tell us a little bit about Patient Zero. He's an individual whose name keeps popping up during some of your interviews. Tell us a little bit about his background, because, as you said, he was not from California. He was actually an early New York City case. His occupation and --.
AUERBACH: Patient Zero was no longer alive by the time this began. Bill Darrow,I believe, had met and interviewed him in, I think, New York City. I never met 37:00him. He was no longer alive by the time the Cluster Investigation began.
CHAMBERLAND: You were hearing about him through some of his sexual contacts thatwere in L.A., and he was an air steward. He flew for Air Canada, I think it was.
AUERBACH: Right, right.
CHAMBERLAND: Did you and Bill -- this in a sense is what you're looking for -- Imean, did you have any sort of big aha moment about--wow?
AUERBACH: I think there were multiple moments like that, where we would heareither his name, the Patient Zero's name, or the name of someone else that we knew to have had what came to be called AIDS. There were multiple instances of that. Remember, it was relatively a small population that we were working with. 38:00If I remember, there were, I think there were nineteen known patients in the Los Angeles area. We could interview thirteen of the nineteen. The others, I think, were no longer alive. Of those thirteen, there were connections among nine of those thirteen. The Cluster was later extended nationally and included a population of ninety. Of those ninety, I believe forty had links among each other or to multiple others within that group. That's how it began, yes.
CHAMBERLAND: Your characterization of this Patient Zero I think is very apt. Youcalled him a geographic center or geographic linkage, because he's in New York, 39:00you're in California, and all of a sudden there is an individual who's got connections to cases on both coasts of the United States.
AUERBACH: Right, right.
CHAMBERLAND: I think that must have been viewed as a breakthrough in time.
AUERBACH: It was. Of course, even then this does not exclude other theories. Ifall of these individuals were drawn together because of a common interest, hypothetically let's say a common interest in using a certain substance, that might also explain it. On the other hand, other possible theories aside, this did, I think along with the case-control study, add to the evidence that this was a transmissible agent, likely a virus, that was transmitted, again in a way very similar to what we knew about the transmission of hepatitis B. 40:00
CHAMBERLAND: Your view of the Cluster and particularly this individual that wasuniquely linked to cases on both coasts -- you said very clearly that people at CDC never viewed this individual as the person who brought AIDS to North America.
AUERBACH: No, not at all. Honestly, I don't think that ever came up. First ofall, just given the nature of this epidemic, the idea that there might be in effect a point source in a population as large as North America -- the notion of a single point source is ridiculous, really. No one had that notion. Of course, 41:00then there were also the vagaries of case finding. Yes, this happened to come to our attention. There were, no doubt, many other instances of individuals, perhaps very, very similar to Patient Zero, who we did not know about and still don't. You have to be a little bit modest, I think, about what you can possibly know. Sure, I got a phone call one day about this one instance. How many phone calls did I not get about far more instances of individuals who might have been responsible for transmitting the disease? Remember, of course, often these people were transmitting disease at a time that the disease was not identified or at least not understood. Trying to attribute responsibility to people in retrospect is unfair and certainly pointless in any case.
CHAMBERLAND: As you know, this moniker, "Patient Zero," and this idea that42:00somehow this was an individual that brought the virus to North America or whatever, persisted for a long time. It was only recently, in fact October of last year, that using some very advanced genetic molecular analyses that looked at specimens that had been stored for all these years that were obtained from this individual that really, very clearly from a molecular point of view established that, while certainly an early case of AIDS in the United States, he certainly was not carrying a virus that was one of the earliest. When this was published in the journal Nature, it really got a tremendous amount of attention in the print and televised media, you know, "Patient Zero exonerated. " Were you 43:00perplexed or surprised by the reaction to this?
AUERBACH: Yes, I was. I think I had two reactions to that. On the one hand, it'sa marvelous paper. It serves as a tour de force of epidemiology and molecular biology and even history, and that's all wonderful. It's a contribution to science, there's no question about that. On the other hand, when it comes to a matter of what was being refuted here, those of us who were involved early on never suggested, implied or even thought that he was the source. What was being refuted was a misunderstanding, a misinterpretation of what in print is really very, very clear. I think it probably was necessary to refute the folk wisdom, 44:00the folk knowledge, or misunderstanding of what was found early on by CDC. That was probably necessary, no doubt. On the other hand, you're refuting a misunderstanding in the popular press. It's important in my mind that it did not seem that important. It's kind of refutation of a straw man in a way, and that did not seem important.
The science of it is still quite marvelous -- of the Nature article that you'rereferring to. I guess that maybe it does raise the question of, what responsibility do you have if you're writing an article? What responsibility do you have for the misinterpretation of what you're writing it on? Maybe it sounds 45:00defensive, but I think the answer is, not much. We did our best to be clear. I think even now, if you read the article it's very clear. I never would have imagined that Patient Zero would be focused on and described as the point source, the Typhoid Mary of HIV/AIDS. That didn't even enter our minds. I don't see how we could have guarded against it. In retrospect, sure, maybe we would have started the sequence by using A, B, C, D, E, but could we have anticipated it? I don't think so. At least I would not have been clever enough to have done that.
CHAMBERLAND: The case-control study that you were a major contributor to, the L.A.Cluster Investigation, comes out, first in the MMWR and then, as you've said, in the American Journal of Medicine. People are probably by this time getting more 46:00and more convinced that sexual transmission is an important mode of transmission for this, as yet unidentified postulated agent. It's hard when you look back to imagine that there were times, there was a time when we didn't know how this agent was being transmitted. But you found yourself really very much involved in a couple of other types of investigations that looked at yet other different modes of transmission. I think one of these was working with others in California to examine mother-to-child transmission, perinatal transmission. You were involved, I think, in working with pediatric immunologists. Do you remember any of this?
AUERBACH: Yes, you're referring, I think, to the San Francisco case. Let me just47:00say this. In some of the speculation at the time about what might be causing the disease, I remember -- even putting aside the toxic exposure idea, I think that was not thought to be relevant fairly early on -- there was some prevailing notion -- the term was "multifactorial" -- that being exposed to lots of sexually transmitted diseases and maybe some substances and not getting enough rest or proper nutrition, on and on -- and I must say, I never bought that idea very well. It seemed to me even then, and even more so looking back on it, that when you don't really know what's going on, life always seems multifactorial. Then when you find the etiologic agent, life looks very unifactorial. I think a 48:00lot of us had that insight, even while we were in the middle of it. The case you are referring to was really a very exciting moment. We understood, or we believed we understood, we believed that this was a transmissible agent, transmitted again in a way very much analogous to hepatitis B virus, which we knew quite a bit about. It would be predictable that we would perhaps ultimately hear about a transfusion-related or perhaps maternal-fetal transmission, but there were no instances, no specific instances for a long time.
I think the way this began was, I believe Harold Jaffe got a phone call from avery astute pediatric immunologist at U.C. [University of California] San 49:00Francisco, named [Dr. Arthur J.] Art Ammann, A-M-M-A-N-N, I believe. Dr. Ammann told Dr. Jaffe that he had a patient, an infant on his service at U.C. San Francisco Medical Center, who had erythroblastosis fetalis, Rh incompatibility, and had received a great many transfusions of blood products, red cells, platelets and so forth. The infant developed an opportunistic infection, Mycobacterium avium, and on investigation this infant had a cell-mediated immunity. I believe what he told Harold over the phone was that this infant had some form of acquired cell-mediated immunity that he had never seen before. Coming from one of the true experts on pediatric immunology, that meant a great deal. Dr. Ammann, of course, being in San Francisco, was well aware of the 50:00epidemic, and like many of us he anticipated the possibility of a transfusion-related AIDS or HIV [human immunodeficiency virus]. Again, the agent had not been identified at the time, of course. That no doubt prompted his phone call to Harold in Atlanta. Harold called me and said, "Why don't you go up to San Francisco and meet with Dr. Ammann and pursue this." That's how that episode began.
CHAMBERLAND: Ah, OK, all right. You're the go-to California guy, I'm getting thesense, because you're based in L.A., and obviously there is a lot happening in San Francisco. They would have you fly up?
AUERBACH: Right. It was very exciting. I was really the only person working forCDC based on the West Coast at the time, at least in this area. I'm sure there were others doing other sorts of things. Yes, I wasn't too far away, so I could 51:00fly up there.
CHAMBERLAND: You were asked to go to San Francisco. What did you do when you gotto San Francisco? How did you begin to pursue this?
AUERBACH: Right, right. This is very memorable and very exciting. I mean,horrifying in another way, but as a physician and epidemiologist, exciting in the insight that was available through this episode. I flew up there, and I had arranged first to meet at the San Francisco Health Department with Dr. Selma [K.] Dritz, who was the Director of the -- perhaps she was in charge of communicable diseases, because the person in charge of the Department was Dr. [Mervyn F.] Silverman, I believe. But Dr. Dritz, maybe she was in charge of 52:00Communicable Disease Control, similar to the office I was based in, in Los Angeles. She was well known and very respected in the community. I met with her, and she provided me with a list of names of all of the known patients with what we were calling it then, KS/OI, I suppose. It was not a very long list. It was maybe less than two hundred, I think, approximately less than two hundred.
She gave me that list, and then I remember I took a taxi over to U.C. SanFrancisco Medical Center, and I met with Dr. Ammann, Art Ammann. As I recall, he took me to lunch at the faculty club, and he told me about this patient and explained the circumstances and how it appeared to be a new entity. Then he 53:00walked me over to the blood bank at U.C. San Francisco Medical Center, and I met with the people at the blood bank there. I wrote down the serial numbers corresponding to all of the units of any kind of blood product that was transfused into this infant. I'm quite sure the infant had died by that time. In fact, I'm sure that's the case. It was a very long list of blood products that this child had received because of the hemolytic anemia, of course. I had the two lists -- the list of patients in the Bay Area from Dr. Dritz, and I had a list of the serial numbers corresponding to units of blood products that had been transfused into that infant.
Then, I took a taxi over to the Irwin Memorial Blood Bank, the blood bank that54:00serves the San Francisco Bay Area. I met with, I remember, two pathologists. The pathologist, hematopathologist, in charge was Dr. Perkins, [Herbert] Herb Perkins, I believe. There was his younger Associate Director, I believe, a younger pathologist. I explained my interest and what we were looking for. I've got to say, they responded like consummate professionals. I knew I was handing them the headache of a lifetime from the perspective of a blood banker. But they also understood the importance and the need to pursue this. I gave them those two lists. The list from the San Francisco Health Department and the list of 55:00units of blood products corresponding to units that had originated, of course, at their blood bank, at the Irwin Memorial Blood Bank. Obviously, we were looking for a match. They accepted those lists and assured me they would be looking for a match as quickly as possible. I don't think it took that many days before they in fact did find a match.
CHAMBERLAND: Did they notify you, or did they notify the health department?
AUERBACH: No, not me. They must have notified the health department, and Iprobably heard about this from Harold Jaffe, I believe. I was not notified directly, I'm sure of that. It probably went from Irwin Memorial to the health department and then to the CDC, and I probably heard about it that way.
CHAMBERLAND: So, there was a match? There was one donor?
AUERBACH: There was a match-- there was one donor. I remember there was a -- I56:00remember seeing there was a press conference in San Francisco, and the press interviewed at the same time Dr. Dritz and Dr. Ammann, I believe just those two. They explained about this episode and the fact that this was a new instance of something that had been anticipated perhaps, but there had not been an example of it, yes.
CHAMBERLAND: Now did you get involved in following up (to find) more informationabout the donor? Was there an interest in learning more about the donor?
AUERBACH: Yes. As it turns out, I had already met the donor. I didn't know it,but I had. This is really a remarkable instance. By then, of course, I had the name of the individual who had donated the blood. I should explain, the man who 57:00donated the blood products was healthy at the time that he donated the blood. He was not ill. AIDS was not a known entity. These are volunteer donors-- they're not paid, and this man thought he was no doubt being a good citizen. That was his only motivation. There was no other reason for him to do that. He was not being irresponsible in any way at that time.
At the time that this connection was established, this man was no longer alive.The way I came to know him is that I got a phone call, again probably from Harold, explaining that there was a patient in San Francisco who seemed to be the very unusual, perhaps unique case of someone with this disease syndrome who 58:00had no risk factors. He did not use drugs, IV [intravenous] drugs or any other kind of drugs. He wasn't gay. He had no reason to be immune compromised. He had an episode of Pneumocystis pneumonia and recovered from it. He later had a second occurrence of Pneumocystis pneumonia, and he died from that later. Again, as it turned out, he was the source of those blood products that had been transfused into the child. By that time, he was no longer alive, and he did not know -- he wasn't ill at the time he had donated the blood. Between the time when he first had Pneumocystis pneumonia and the second time that proved to be 59:00fatal for him, he appeared to be a patient who had this disease syndrome that we were all investigating, with no risk factors.
Harold asked me to go up there and interview the man, draw his blood and soforth. This would not have been part of the case-control study, but I remember I used the same form just for information-gathering purposes. I remember I met this man at his office. He was a very well-educated, sophisticated man. He understood the importance of what we were doing. I went through the whole questionnaire. He seemed to be very forthcoming. I should explain he was perhaps in his, I'll say, mid- to late-forties, I think. He was single. He'd never been 60:00married, and I thought that maybe some of his answers were a little bit -- I don't think he had much sexual activity of any kind until my notion of a little bit later in life than is customary. Then again, you might ask who made me an expert in normative human sexual behavior, and the answer is nobody. I guess, my impression was that he was being forthright and candid with me. That was my impression, with a few small qualms perhaps, but in general that was my impression.
I remember calling Mary Guinan, talking to her on the phone about it, and I61:00explained that I generally believed the guy, although, with some qualms, maybe partly related to the fact that he was mid-forties or later and had never been married. I remember Mary telling me, "Well, you know, Dave, I didn't get married until I was" -- I think she said about forty. That settled me down. I mean, he was probably being very truthful with me. Then I called Bill Darrow, who had this innate sense of whether people are being truthful. Bill was a remarkable guy. I told him the exact same facts, and Bill immediately said, "This man is gay, David--what don't you understand here?" It was obvious to Bill. I said "Okay." I said, "I'm not repeating Mary's explanation." Bill said, "Mary just got married late in life. This man is gay." I said, "Okay, Bill, I would never 62:00doubt you, Bill." In retrospect, of course, Bill was very much right, and this man was the source of the blood products from the first identified transfusion-related case.
CHAMBERLAND: Your interview of him took place in the context of this effort togo and look at all cases very carefully that had "no identified risk."
CHAMBERLAND: You interviewed him, and there were perhaps some strong suspicionsor some suspicions, but on the books, he was still listed as a "no identified risk" case.
AUERBACH: He was, that's right, and there was a footnote. Dritz CHAMBERLAND:Then, I don't know, months later, his name pops up as the one donor who matched San Francisco's case list, cross-matched with the list of donors to this infant.
CHAMBERLAND: Was there an effort to resurrect -- he's now deceased -- but was63:00there an effort to resurrect the investigation, if you will, and try and find out more about this gentleman, if indeed he might have had some risk factors for AIDS?
AUERBACH: Then what happened, he died, of course. As I recall, it must have beenSelma Dritz who had spoken with this man's personal physician, who was also a family friend, and who assured Dr. Dritz that this man was not gay. He often saw him on social occasions with an attractive woman in his company, and besides being his doctor, he was something of a friend of this man and was sure he was not gay. But then after he died, I heard that a surviving brother went through 64:00his papers. He must have again notified the San Francisco Health Department, I assume probably Dr. Dritz, who passed the information along to Harold Jaffe, the information that he found some papers. The papers included some bills to a physician -- not the known personal physician that I mentioned, but to a different physician in the Castro District, whose office was in the Castro District of San Francisco, the gay district of San Francisco. Harold called me with this information, and this was after the fact, but I don't think I made a special trip. I was going up to San Francisco fairly regularly, so Harold asked me when I was going to go up to San Francisco next to go to this doctor's office and ask the doctor if I could see those records. I think it was as informal as 65:00that. And I did. I probably arranged this in advance, or maybe more likely perhaps the San Francisco Health Department arranged for me to meet this doctor at his office. I reviewed those records, and this doctor had treated this man several times for rectal gonorrhea. That's the conclusion of the story, really.
CHAMBERLAND: That provided evidence after his death that he was someone havingsex with men?
AUERBACH: Yes, and it provides further evidence of how astute Bill Darrow is inhis intuitions.
CHAMBERLAND: That's right. Obviously this is a big deal. It gets published inthe December issue of the MMWR, December 10, 1982. This gentleman, as you said, 66:00was a very altruistic individual, (who) donated blood.
AUERBACH: Partly, no. I should say yes, the publication and this episode got ahuge amount of press. This episode, the connection to the reputedly "no risk factor," that -- I've never seen that in print. It was known to a few of us.
CHAMBERLAND: I see.
AUERBACH: My description here may be the first recording or documentation of it.But that was not -- widely known.
CHAMBERLAND: I think this MMWR alluded to the fact that he had rectal -
AUERBACH: Maybe. Maybe.
CHAMBERLAND: gonococcal disease.
AUERBACH: Perhaps not the connection to the question of whether he was a zerorisk factor (case).
CHAMBERLAND: Exactly, yes.
AUERBACH: Yes, right. The case itself got a huge amount of attention.67:00
CHAMBERLAND: Did you get drawn into some of that media scrum?
AUERBACH: I did, I did. I think it's fair to say that when the generalperception was that the disease was confined to this one subpopulation of gay individuals, it did not have a great deal -- it had some traction, but not, I think, the attention it deserved. Once it became clear that, like every other disease, there is no disease confined to one (population) -- certainly no communicable disease. Health professionals always knew that, but once it became more generally understood that the disease would not be confined, then there was a great deal of interest, of course. This transfusion-related, apparently transfusion-related, case was maybe one of the landmarks on that road. 68:00
I remember I was asked to be interviewed after this case by one of the majornews networks at the time. I had plenty of time to think about my answer to the obvious question. I was asked on camera, "Does this mean that this illness can be transmitted by blood transfusion?" My answer was that, of course, this was one instance. My answer was that I thought this gave us very strong circumstantial evidence that in fact, this disease could be, was transmitted by blood transfusions. That was my answer. I think the phrase I used was "very strong circumstantial evidence." Looking back on it now, I guess it really 69:00depends on what kind of evidence you're looking for, and if one is not -- may not be completely conclusive.
On the other hand, given the whole context, I think most of the rest of thegroup at CDC was convinced that that was the mode of transmission in that instance. This was recorded, and my characterization of strong circumstantial evidence, that was recorded. That evening, I, of course, I watched it on the news. I read long before that, that television is very much a visual medium, not so much what you say as how you look. What I looked like at the time: I was a young physician. I had certainly a fuller beard at the time. I looked young, 70:00because I was at that time. They cut from my answer to a different response from someone who looked far more credible, I will admit. I remember the man sitting in front of the television camera was a very distinguished gentleman, wearing a white coat -- I was not wearing a white coat. He was wearing a white coat, and he looked like the distinguished doctor out of central casting. On the screen below it identified him as Dr. Joseph [R.] Bove. It said he was the Chief of Hematology at Yale-New Haven Medical Center and President of the American Association of Blood Bankers. When he was asked the question, "Does this suggest that this disease is transmitted by blood transfusion?" he said, "Absolutely not. There is not a single, credible shred of evidence that that is the case." What was funny is that just given the medium, I guess, I was inclined to believe 71:00him, even though the person who he was disagreeing with was me, actually, which was sort of funny.
CHAMBERLAND: You were on the right side, though.
AUERBACH: I think so.
CHAMBERLAND: You had the right answer.
AUERBACH: I had a certain perspective because of where I was sitting that wasvery helpful.
CHAMBERLAND: As you alluded to at that moment in time, there is an "N" of one.There is one instance in which an individual subsequently diagnosed with AIDS, as you mentioned, was not ill at the time, asymptomatic at the time of his donation. Subsequently he becomes ill and appears to have transmitted through a transfusion of a blood component to this infant. Certainly, he had other blood products that were derived from his donation. Was there any effort to track down 72:00other recipients who had received blood from this donor? Did you get involved in any of those investigations or follow-ups?
AUERBACH: In the Bay Area? I don't recall being involved in that. The otherrecipients from that same individual? I am quite sure I was not involved in that, at least not in any substantial way. I know that it was done, I believe, probably by the health department, unless CDC was involved. I'm not sure. I don't believe there were other cases, although I'm not sure about that.
CHAMBERLAND: So, your part in the investigation was really restricted tofacilitating the identification, the cross-matching of the two lists and then doing some follow-up to nail down as definitively as could be done that the 73:00implicated donor had a risk factor. Did you ever have a chance to talk again with Dr. Perkins, Herb Perkins at Irwin Memorial?
AUERBACH: No, I did not.
CHAMBERLAND: To get a sense of -- you felt what you were asking him to do, itresulted, as you had predicted, in a really big headache, to put it mildly.
AUERBACH: Huge headache.
CHAMBERLAND: I was just curious if you'd ever had any more contact with him.
AUERBACH: No, I never did. I couldn't help but think very highly of him for hisresponse and how professional he was. No doubt (it's) easy to-- the expert from Yale comes to mind -- it's easy to understand how someone might be defensive or maybe in a bit of denial. They're doing good work, essential work, life-saving work in blood banking. It's essential for them to have a safe blood supply. They 74:00need people who are willing donors, and willing recipients, for that matter. On the other hand, certain realities present themselves occasionally, and Dr. Perkins did not hesitate to pursue this and pursue it to a conclusion or an answer that was very important. But, no, I've never talked to him again.
CHAMBERLAND: I want to circle back to Art Ammann, the pediatric immunologist,who was the astute clinician in this instance to recognize that he was seeing a new immunologic symptom-complex in a child not previously described and making the connection to "Hmm, looks like AIDS." He was also involved, along with physicians, pediatricians, in New York City and New Jersey, in recognizing some 75:00of the very early perinatal cases of AIDS -- mother-to-child transmission. Did you get involved in any work with him in investigating any of these early pediatric mother-to-child cases?
AUERBACH: No. I certainly did not work with him on that. I think I may have beeninvolved, maybe somewhat peripherally, in Los Angeles. There may have been some cases at Los Angeles County Medical Center perhaps, I don't remember. I think I knew about a few cases. I may have been involved, but not very actively in the maternal-fetal transmission cases.
CHAMBERLAND: What you describe, what we've been discussing, was certainly a lotto have transpired during an EIS Officer's two-year assignment to L.A. Are there 76:00other aspects of the AIDS epidemic that you were involved in that we haven't touched on that you took part in?
AUERBACH: Yes. I remember thinking at the time it was all aspects of the AIDSinvestigation that were so interesting. The science, the epidemiology was very interesting, but also the communications issues, the issues of explaining this to other health professionals, the general public, the gay community. That was also very interesting in all of its aspects. For example, I remember after And The Band Played On, the book by Randy Shilts, was published, that re-invigorated 77:00a great deal of interest in all of this, including the Patient Zero. Randy Shilts had interviewed me about that episode, and I remember by that time, I think by the time I was even interviewed I had completed my two years of working with CDC. He interviewed me. I recall, I was doing some additional training at UCLA [University of California, Los Angeles] by that time, and of course I was still at UCLA when the book was published.
I remember, for example, when Randy interviewed me, he knew the name (of PatientZero). My colleagues and I at CDC, even after the name was published, I think none of us used his real name -- it just was not comfortable to do that. Randy 78:00Shilts, he went and interviewed me. He knew the name. He covered the gay scene for the San Francisco Chronicle. He had his resources and his sources, and (he was) a very astute person, very knowledgeable, of course. He knew the name. He got the name, I'm sure, from the community that he was very much involved with and part of, in fact. I remember urging him not to use the real name. Patient Zero was, again, no longer alive, and I know people who are no longer alive don't have many legal rights of privacy or confidentiality. I believe he had a surviving mother, and really, was it necessary to use the name to make all the points. At the time, I didn't think he was going to pay attention to me, and in fact, he did not. 79:00
Then, the book was published, and it got a great deal of attention. Again, I wasstill at UCLA at the time, so I got a message that 60 Minutes was doing a segment on And The Band Played On, based on that, and they wanted to interview me. I said, "Sure." I think it was arranged through the Public Relations Office at UCLA. I remember I was in a conference room, and there was a producer there. The interviewer was Harry [T.] Reasoner, I remember, who at the time was a well-known personality on 60 Minutes. (It) was widely watched, I watched, everybody watched it. I don't think Mr. Reasoner was especially knowledgeable, but he had been prompted. Remember, there was a producer who was very 80:00knowledgeable, and who no doubt wrote the questions.
There was one question, I thought of this as "the" question, because I had itposed many times. What was funny to me is every time I was asked this question, I had the impression that the interviewer felt that it was an original question, that they were the first one to think of this very clever question. The question came in various forms, and Mr. Reasoner posed the question as well in one of its many forms. His question basically was something like, "Tell me, Dr. Auerbach, if this disease entity had primarily affected affluent, suburban businessmen, would it have gotten more attention than it did from the government and from investigative resources?" I suppose it's one of these things where you put like 81:00a balloon above your head -- "your thoughts?" I suppose the answer is, the short answer is "Yes, of course." It's a rhetorical question, really or should be.
My answer -- which I think, was more appropriate and more fair and maybe morereality-based -- my answer was that I certainly cannot speak for resource allocation at the higher levels of the Reagan administration. That's not something I had any particular insight into. I was just a front-lines person at the time, working for the Centers for Disease Control, and from my perspective, CDC responded very quickly. I remember hearing very quickly that there were more than fifty people involved (in the response), and then maybe more than a hundred people involved. As I said to him and as I would still say, they were not only a fairly large number, they got up to a hundred quite early on, but those 82:00individuals were really among the most energetic, talented, smart people I've ever worked with in my career. Again, you have to realize, of course, that CDC cannot possibly have budgeted for something that didn't exist. I don't know too much about government budgeting, but it cannot include budgeting for things, problems that have not materialized. From my point of view, CDC responded very well, and I was then and remain very proud of having been part of it.
CHAMBERLAND: I want to ask you -- you characterize yourself as a "front-lineperson," and my goodness, in the two years that you were there, you were working through sexual transmission, transfusion transmission, although, maybe not directly hands-on involved, but were also learning about transmission from mother-to-child, heterosexual transmission. Did you, while this was all 83:00unfolding in your young years of your career, did you have any sense of a bigger picture? Did it ever occur to you to think a bit broader as to how this might unfold -- if this was going to potentially be a huge public health problem -- nationally, domestically, internationally?
AUERBACH: I think we did know that, and again, this was not a matter of beingespecially astute on my part. I think those of us who were involved, it was really very clear that this would become a very important public health issue. Again, we all knew that a disease like this cannot be confined to one subgroup 84:00-- that's not the way human infectious diseases work -- and that it would become a major issue. I think that was very clear early on. No doubt, I was not involved except as a spectator to basic science, but even now when I think back on it, the time between noticing a new disease entity, understanding the epidemiology, understanding it well enough to give intelligent advice to avoid the transmission of the disease, and then finally finding the etiologic agent, finding serologic tests for the etiologic agent and ultimately finding an anti-retroviral treatment for it -- you look at that timeline, and as a matter of medicine and science, it is breathtakingly fast. It's really astonishing and 85:00quite wonderful.
It's still a terrible disease with terrible impact for a great many peoplearound the world, but the progress that was made very quickly is really very remarkable. To answer your question, I think those of us who were involved, because of our perspective and where we were sitting at the moment, we did understand that this was a very important thing. I have in my career, I have never before or since had the sense that I was going to happen to be sitting in the middle of history being made around me. It was a very exciting time. I was a young physician and a neophyte epidemiologist, and it was very exciting. The whole thing was exciting.
I think back to those days, and one of the impressions and memories that stays86:00with me is it was very gratifying to be part of something that was much larger than myself. Physicians, I think, have a self-regard as being independent, single operators. In many ways, they are, and that's not necessarily a bad thing, although I think that attitude has evolved, and that's also a very good thing. But to feel like you're part of something that is important and much larger than oneself, at least for me, was a very gratifying sensation.
There were many other interactions, human interactions, that were memorable andvery rewarding. There was one that I think about fairly regularly. I remember, I was asked to give talks to various groups, and that accelerated as the interest 87:00grew. Initially, it was mostly gay groups, and then there were often medical groups, medical grand rounds, that sort of thing. Then later on, even more general public sort of thing. Early on, it was people with a particular interest in this, either because, well often because, they were gay groups. I remember early on I was invited to give, this being Los Angeles, I was invited to give a talk to an organization of gay physicians. Again, this was very early on. I remember being invited to give this presentation, and, as I recall, it was a Sunday afternoon at the home of one of the physicians in this organization. I was new to California, I remember driving -- and this is also before Google Maps 88:00and so forth -- I remember driving looking to be at this man's home in, I think southern Los Angeles County or maybe even into Orange County. I was driving around there, and it was again, early afternoon at his home. There were maybe fifty or so individuals, physicians in this organization. I had my slide set from CDC, of course, and I gave my talk. You always have to adjust your explanations and descriptions for your audience. If it was a lay group, of course, I would use a certain way of describing things. This was a group of physicians, so I spoke in the language of clinical medicine and epidemiology. I didn't have to really change much of anything, it being a group of all doctors, after all.
I gave my talk, and afterward there was a coffee hour, so I stayed around and89:00chatted with a few of these people who were in attendance. This one young physician -- they were all very appreciative and thanked me -- this one physician came up to me, and again, he thanked me, he liked my talk and all that. Then he said something like, "Obviously you yourself are straight." I should maybe add, as an aside, there's always a certain, maybe when you're speaking to a group that you're not part of, there's always a concern that you may inadvertently say something that is offending. I was conscious of that, and I was quite sure I hadn't said anything offensive, but I couldn't help but ask him. I said, "You're right, but how would you know that?" Again, I had been using the language of clinical medicine and epidemiology. I was really not 90:00talking about my date the night before. His answer was, "Well, it's obvious." He said, "No gay man would use the word homosexual." We both knew he was doing me a favor, because he knew -- this was the very beginning of my time in Los Angeles working for CDC -- he knew I'd be giving lots of talks and presenting to lots of groups, including gay groups. I think we were tending to use, I'm guessing, I'm sure it was in the CDC slides, the term "homosexual" -- it seemed more clinical, objective, something like that. I'm sure he's right, and so that was no doubt the last time I used the word homosexual, as opposed to the word gay. Again, it was very clear to both of us that he was doing me a favor, and I've always been grateful to that man for his advice or his assistance at that moment. 91:00
CHAMBERLAND: It sounds like being a part of something that changed the historyand course of public health -- as you said, it was in many ways a once-in-a-lifetime opportunity -- it no doubt impacted you professionally and personally, as you've just related. It's been fascinating hearing some of your stories from those very early days, and I'm pleased that we could do this. Anything that we haven't covered, any closing thoughts?
AUERBACH: Maybe one footnote to my Harry Reasoner interview. They did not usethe segment -- maybe that goes without saying. That's just as well. I remember during the basic training course that CDC puts you through during the month of July when you first start to work with them, I remember there was a public affairs officer for CDC who gave us all the advice. He mentioned that he had 92:00noted a tendency among people who were being interviewed for television to want to say something that will ingratiate themselves, that will get them on television. Of course, often what they're looking for is something that is short and simplistic and maybe misleading, but dramatic. And he said, "Don't do that." I remember keeping that in mind, and it was helpful. I was not going to say something that would sound foolish. That was his advice, and I really didn't care one way or the other if they used that interview with me. Of course, with my answering the question as I mentioned, it was no doubt predictable that they were not going to be putting that out. Maybe I didn't say this, but after my comment about I didn't have any insight into the operations of the Reagan administration, I said that at those levels of the federal government, no doubt the interest will follow the amount of attention that issues receive in the 93:00press. I suggested that he look into CBS news files for the amount of attention that CBS news gave to this topic in, let's say 1981 and 82 and early 83. I think that pretty much nailed it that I would not be seeing myself on 60 Minutes, which is just as well.
CHAMBERLAND: But we've had a chance to capture you here today, and we're veryglad that we could.
AUERBACH: Yes. That's right. I've enjoyed it.
CHAMBERLAND: Absolutely. David, thank you so much. This has really been, as Isaid, a real privilege to chat with you and get the perspective of someone who was on the front lines in L.A., one of the very, very early epicenters of the disease, and we're very happy that you agreed to do this. Thank you.
AUERBACH: I've enjoyed it, Mary. Thank you very much.