Dr. Dale Lawrence



MILLER: This is Dr. Bess Miller, and I'm here with Dr. Dale Lawrence. Today's date is April 6, 2018, and we are in Atlanta, Georgia, at the Centers for Disease Control and Prevention [CDC]. I am interviewing Dr. Lawrence as part of the oral history project The Early Years of AIDS: CDC'S Response to a Historic Epidemic. We are here to discuss your experience during the early years of CDC's work on what would become known as AIDS [acquired immune deficiency syndrome]. I must ask, Dr. Lawrence, do I have your permission to interview you and to record this interview?

LAWRENCE: Yes, you do.

MILLER: Thank you, Dale. You were one of the original members of the CDC AIDS Task Force on Kaposi's Sarcoma and Opportunistic Infections, as it was known in those early days, (which was) put together ad hoc in the summer of 1981. Your background as chief of the Human Leukocyte Antigen Lab in the Clinical Immunology Branch of the Immunology Division, later named the Division of Host Factors, and as medical epidemiologist in the Division of Host Factors, made you a unique member of this Task Force, with an understanding of cutting-edge aspects of laboratory-based and clinical immunology. You eventually came to focus on investigations of cases of this syndrome in hemophiliacs, in patients who had received transfusion of blood and blood products, and in spouses or partners of these cases.

Let's begin with your background. Would you tell me about where you grew up, your early family life, and then where you went off to college?

LAWRENCE: Yes, happily. My parents were from Northern Kentucky and East Tennessee, respectively. They both had rural family backgrounds and some considerable culture from that community, music and education, but neither of them had gone to college. They married in the Great Depression and moved to the metropolis of Cincinnati, Ohio, for employment, particularly for my father, and some years later, I was conceived there. Unbeknownst to them at that time, my history with infectious diseases began quietly, in the sense that I was living two blocks and playing within two blocks of or nearby to a histoplasmosis outbreak endemic, hyperendemic zone. I know to this day that I have residual of that, fortunately not clinically manifest but quiescent. That and other childhood awareness of personal and family infections keyed me, I think, toward an infectious disease career.

I had an opportunity as a sixth grader to be accepted to a competitive college prep public high school, which had a six-year unified curriculum. This high school had a reputation since the late 1800's of putting out people with stardom in early Hollywood or tennis or, in fact, ultimately [Dr.] Stanley [B.] Prusiner, two classes ahead of mine in the prion science era, and many others. We each felt an obligation to try to exceed. I uniquely happened to meet a classmate whom I liked, a friend, and she, by a miracle of coincidence, was none other than the younger sister of CDC's Dr. Kenneth Herrmann. In fact, she told me to go check with him if I had an interest in medicine or public health that he was working for this place in Atlanta on the then epidemic of rubella. I should go check with him about what he thought of where he worked. In fact, as they say, the rest is history.

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

LAWRENCE: I joined many of the other graduates of Walnut Hills High School who did not go to the Ivy League colleges, which was very traditional, or the small Ohio or other colleges. I went to the University of Cincinnati [UC], which had a formidable program in chemistry, being the home of Procter & Gamble and other major science and engineering firms. I majored as a bachelor of science in chemistry, and together with a colleague or several, we studied toward a BS in chemistry. After three years of that rigorous curriculum, I was ready to go on to medical school and maybe use that year, some other time in my life, for some sabbatical-like experience. Ultimately, that did happen at [University of] Oxford. I was accepted to Duke [University] after three years. I joined some other UC and amazing colleagues at Duke, where I was introduced to the world at large, the international health dimension, the field of epidemiology. I was mentored by Professor Hans Lowenbach, former chair of Psychiatry, who directed me to investigate schools of public health and a career in public health. I could make changes in society that would -- and changes, of course, perhaps to personal medical care, that would help me work out the pain and grieving that had occurred after my uncle became, (after) an industrial accident, an invalid for the rest of his life, for which medical science and research could do nothing. That was my major proponent, prompting me to go on into public health.

MILLER: For your public health postgraduate training after medical school, it looks like you did so many interesting things. Do you want to mention a few of those?

LAWRENCE: Yes. I was frankly motivated by three fields: research and the mechanisms of human biology, under which circumstances I started to take a research training program at Duke, in what we'd call today tissue or antigen differentiation. The other rival thought was public health on a community level. For that, international public health appealed to me, or maybe community public health in the inner cities that I had seen. The third was just excellent healthcare for the marginalized and underserved or international suffering populations, and that particular one came to win out in some respects. I got to go to a mission hospital that Duke supported in Nicaragua. I got to see cases of diseases, be it malaria, diarrhea, dysentery, tuberculosis, Pott's disease, diphtheria, you name it and we had it-- trypanosomiasis, Chagas' disease, and so on, throughout the Americas. That, plus my fellowship and internship residency in San Antonio and at the nearby military medical centers, introduced me to the POWs [prisoners of war] coming back from Vietnam. I had a very intense classical disease clinical encounter.

MILLER: Fascinating. It looks like you also -- maybe this is part of the research -- were interested in genetics, immunology, and laboratory work. Did you get a chance to explore some of that before CDC?

LAWRENCE: Yes. I suspected my future would be -- CDC gave me the opportunity to rehearse my infectious diseases skills toward the boards in infectious diseases, which I ultimately got, as well as internal medicine. As that generalized activity in Miami-Dade, Florida, rounded me out, I had already decided that if I could contribute to the CDC and its research arm, through integration of clinical epidemiology and community epidemiology with human genetics of immune response-- a big new area then, a part of cellular immunology -- that I would have a niche and contribute in ways that my other colleagues like [Dr. James B.] Jim Hughes and others were doing in their own fields of enteric disease or whatever. I came to CDC interested in that, having had two graduate courses. I had studied textbooks of this and talked to people working in that field. I talked to [Dr. Daniel] Carlton Gajdusek and others who were doing studies in Papua New Guinea.

I was nominated to come to CDC, after a deferral for the purpose of hepatitis B vaccine work. Interestingly enough, (that work was) already started by the time I got here and done well by [Dr. Donald P.] Don Francis-- but at the time, that was new. It was Australia antigen that Baruch [S. Blumberg] had identified. There was a field of world health, international anthropology and disease detection that I wanted to be a part of. That was what I was raring to do when [Dr.] David [J.] Sencer said, go to work for the clinical immunology lab. Go see [Dr.] Irving [G.] Kagan and [Dr.] Shirley [E.] Maddison, both in the Parasitology Division, avant-gardes, and then Dave Gordon.

MILLER: Just stepping back a tiny bit, how did you come to CDC initially? There was academia, there was CDC -- you came in through the Epidemic Intelligence Service [EIS]. This was in 1973, right in the middle of the Vietnam War. Did that have an impact? How did you actually decide on government and the CDC?

LAWRENCE: I don't think I imagined a career in public health for the federal government when I was facing, as all of us rising medical school graduates (were), the Vietnam Era draft. I had actually taken two years of Army ROTC [Reserve Officers' Training Corps] basic training at the University of Cincinnati. At the time of second-year finishing, I knew I wanted to go to medical school after three. The Army advisor said, don't enroll in the advance corps. If you walk out, you'll be drafted. In fact, another EIS colleague some years later told me he was drafted immediately as an enlisted person when he did that. Nevertheless, I didn't choose that hazardous path. I went on to medical school without finishing Army work, but that factored importantly into my comfort level to work around and with Army and military people, uniforms and regulations and rules and customs. That served me well, both in my later training years at Walter Reed [Army Medical Center] on the staff at Walter Reed, and in my training years under General William Moore in San Antonio, Texas, and Colonel Edgar Ledbetter at the Air Force Hospital nearby at Lackland [Air Force Base, Wilford Hall Air Force Medical Center]. I am glad I had that two-year experience (Army ROTC), but I knew federal public service was my more likely destiny. Indeed, after two years at EIS, (I was) sponsored by some famous people that I'm grateful to and supported by Ken Herrmann, CDC's [Dr. J.] Lyle Conrad, and, of course, the incredible [Dr.] Robert Sharrar, who was then selecting the candidates. This offer came through, and so I chose it instead of Army or Navy.

MILLER: Again, those first few years, you had a field services assignment?

LAWRENCE: Right.

MILLER: How did that come about, and how did you enjoy that? That was the more generic EIS experience.

LAWRENCE: Yes. The selection process, as you know, in the spring was in my case fraught with a number of considerations. One of them was belated at that time, very fresh with me at the time I arrived. My mother had just been diagnosed with disseminated breast cancer, and we knew the end was not too far away. Instead of my speaking with Lyle about Puerto Rico and Hawaii and American Samoa or somewhere far distant or overseas postings, he was very appreciative that I needed to be near a major medical center. That factored into his and my match for field services in the continental U.S., where I could fly back to Cincinnati. Ultimately, I worked so intensively in Miami-Dade [County], both with its senior chief, [Dr.] Milton Saslaw, and Dr. Joel [L.] Nitzkin, that they supported me through this period of bringing my mother to Miami, her death there, the time I had to take off for resolution of her estate and so on. I must say the state epidemiologist and Lyle and others, like [Dr.] Karl Western, enabled me to not only get married in my first weeks at EIS -- to my still wife Trude [Lowenbach] -- but also to have a brief honeymoon. Their understanding of the lives as well as the profession of EIS officers was crucial to my sense that this is a place I want to work. They have family values; they have professional high aspirations.

MILLER: Do you remember what you worked on in Miami?

LAWRENCE: Oh, yes. Of course, I still have copies of most of those files. It was an eclectic thing that we were wrapping up: a typhoid epidemic in the migrant labor camp south of Miami near Homestead. We were wrapping up a cruise ship outbreak that people -- EIS officers like [Dr. James H.] Jim Tenney, [Dr. Michael H.] Mike Merson and [Dr. James R.] Jim Allen, and others had worked on. I then got my own dose of that, with some extraordinary in-cruise investigations. That was the biggest part of my EIS, but it included Haitian immigrants with filariasis and malaria and an extremely famous wealthy scion of a family who were affected by the sinking of the Titanic, and the last survivor of that, who had a very interesting phenomenon from eating raw beef tartare. It was just everything all over the map, and I'm grateful to the wild and woolly experience that represented.

MILLER: Tell us what you did after that. You got some experience in genetics research and clinical immunology. How did that come about?

LAWRENCE: The (research focused on the) mapping of the world's human polymorphisms, as we call them, not just haptoglobin, but which exact molecular structure of haptoglobin could now increasingly be immunologically or immunochemically detected. Those are inherited, and, therefore, if you knew the markers that people carried, you began to see their ancestral relatedness. If they shared diseases in common or were dissimilar with respect to diseases and outcome of infection, then we sought for markers that would distinguish and elaborate the disease susceptibility versus disease resistance. I mentioned about the aboriginal experience with opening the doors to hepatitis B identification, and that was a microcosm of many other investigations going on.

My wife was an anthropologist dealing with health issues, and she was doing her own field work. I decided that after my CDC two years, I would want to propose that I take on this area, which might lead me -- or us -- someday to overseas postings and field trips and investigations. If you can identify, as you so well know, the population who is at most risk of something, then you can understand the unique response they have to, say, live polio vaccine. If they develop paralytic disease and others don't, then you can specify which item is the contributing or major dominant factor. Those were the kinds of diseases we anticipated doing, assessing why some people get lepromatous versus borderline or tuberculoid leprosy, why people get the poliomyelitis paralysis associated with their first receipt of Sabin live polio vaccine--though attenuated--and on and on and on. Tuberculosis, cavitary tuberculosis, Reiter syndrome after enteric diseases, all these we were engaged in ultimately. The South American expedition David Sencer allowed me to go on, as an in-kind contribution to a National Science Foundation field trip to Amazonian populations, really gave me specimen field collection materials and ultimately travel to the lab benches of Oxford, to bring back to CDC both the specimens and that immunology expertise.

MILLER: How did you connect with David Sencer? Was he instrumental in starting an immunology lab at CDC?

LAWRENCE: Yes. He of course, was a pluripotential or Renaissance person, accompanied by great humor, of course, and a personal touch. I've been pleased to hear other people's experience and recollection about that.

MILLER: Was he Director at the time?

LAWRENCE: He was indeed Director at that time. As I arrived here (at CDC in 1973), he was just dealing with the storm of the revelations of the Tuskegee experiments, which, of course, factored into the research of ethics that I did in later years at NIH [National Institutes of Health]. The awareness of that (the Tuskegee experiment) came to his attention and in his corrective action in 1972-197As I arrived, he was very much the Director. He took a very great personal interest in the things that division directors and branch chiefs were in charge of. They were very investing of responsibility in the field officers or the investigative young officers. Every time a cruise ship had an outbreak -- and I think I boarded 18 ships in my two years -- not for pleasure cruises, shall I say -- and during those two intense days or nights aboard coming back to a U.S. port, I worked with Mike Merson or the laboratorians, Joy [G.] Wells or others, to get everything we needed and all the questionnaires and personal patient -- that is travelers' specimens and crew specimens, sometimes not very pleasant experiences for either of them. Those were collated on the same afternoon the ship unloaded at the dock and disembarked. David Sencer wanted to be the one to say, "Yes, that ship may sail," or "No, we don't feel it safe enough." That yes or no, thumbs up or down, would cost a ship in those days a million dollars or more, by my analyses presented at the EIS Conference. Today, it would be a ten million or twenty million dollar decision. He wanted to be there, so he was on the phone with [Dr. Eugene J.] Gene Gangarosa and others to make that decision. And the quarantine station staff I can't have enough praise for, in their ability to support these (outbreak investigations) and help me analyze them on the floor and on the tabletops, sorting the questionnaires quickly.

MILLER: That's how you got connected to Dave Sencer?

LAWRENCE: Yes. He got to know me very well, and I guess trust my analytic and investigative talents. I came in the end of my first EIS year and said, "I think I want to stay here. Could I maybe do a preventive medicine residency with a goal to integrating immunology, cellular immunology --which is the new field, three years old really-- and genetics, which is only one year old?" He said, "Go off to your conferences that you want to go to on your own." Next year, we're going to have you meet and deal with these people. I think you'll have a nest in the clinical immunology lab or division." That's where I was welcomed and further trained, as I said.

MILLER: Can you say a little bit more about CDC's interest in immunology and lab immunology? Was that competing with NIH? What was the aim there, to try and get expertise in that area?

LAWRENCE: NIH was, of course, at the front of immunology research, as were many -- or let's say, a few dozen avant-garde places in the world at that time. Ultimately the Nobel Prize for immunogenetics work was won by two investigators, [Dr. Rolf M.] Zinkernagel and [Dr. Peter C.] Doherty, whom I got to know. Before that, immunogenetics and cellular immunology (were pioneered) by other investigators of that early era. David Sencer was open to new ways in which CDC could be at the forefront of having the resources to carry out its mission in epidemic interception and control. When people on his staff, be they Bureau of Labs, with worldwide Supreme Court-like analytic capability for microbes or who had advanced immunology diagnosis of parasitic diseases, when they had new techniques, he supported them.

A discovery I made, perhaps about the time I came to CDC, was that there were three different parasitic disease expertises. One was clinical diagnosis, and you found these in schools of tropical public health and so on. Then there was the histopathology, and that was at the Armed Forces Institute of Pathology, and then there were the molecular characterization, beginning on the actual microbe. It was CDC who had the (expertise in) diagnostic parasitology using immune methods. The handful of the immunologists, primary from parasitology, said, let's have a weekly meeting and have presentations -- you know, a journal club. People with leprosy background, like [Dr. Charles C.] Charlie Shepherd, [Dr. Thomas J.] Tom Spira, [Dr. J.] Steven McDougal, of course Dave Gordon the head, [Dr.] Irving [G.] Kagan, [Dr.] Steve Shore, and many, many people, including vaccinologists, would come and listen and present to that.

We were a chomping-at-the-bit group, ready for what turned out to be HIV [human immunodeficiency virus]. We had those CD4 [cluster of differentiation 4 -- T-helper cells] and CD8 [cluster of differentiation 8- T-suppressor cells] markers. We were already using them. We had the half-million dollar FACS-4 machine for a Fluorescence Activated Cell Sorter, that was a major purchase authorized by Dave Sencer and then ultimately Dave Gordon, and perhaps by then [Dr. William H.] Bill Foege. We were well equipped to be right at the top when this outbreak occurred. We didn't have to get resources and start learning.

MILLER: That is just so interesting. Let's move on, then, to your work on AIDS and the very exciting aspect of it that you got to be involved in. On July 16, 1982, there was an MMWR [Morbidity and Mortality Weekly Report] on three hemophilia patients with Pneumocystis carinii pneumonia. Again, we didn't quite have the cause of the disease, which had not been identified. That first case had been reported in December of '81. You were involved in investigating these cases. Can you tell us a little bit about these investigations?

LAWRENCE: Those investigations followed the pattern that CDC tried to emulate over its recent decades of history, namely, to work through state health departments and local health departments, and the local health departments worked through clinicians. If there's a step or oversight or bypass at some point, (we) try to connect the dots again and get everybody on board and get this evidently interstate disease dealt with here at CDC. We became then the resource to go to, the location for assimilating, accumulating, and then investigating these cases, beyond what the state or local health department could do. That meant putting state-of-the-art immunology resources in their hands and at the beck of the clinician, if he didn't have that or she didn't have that.

Sometimes, those clinicians -- and not at the very beginning -- but some of the clinicians were very academically oriented and wanted to publish their novel case and didn't really want to share much with CDC other than what it took to get medicines for the disease from the Parasitic Diseases Drug Service, that our Division of Host Factors then controlled. When those reports would come in and we realized there was someone coming in the back door for that (drug) on a responsible clinician's basis, we would then backtrack and try to fill in those gaps, and then get permission from the state health department and keep them informed as we went out and investigated it. A whole pattern then emerged of an extremely rapid turnaround time. [Dr.] Bruce [L.] Evatt might hear from the Parasitic Diseases Drug Service. He let the Task Force know. They'd record some tentative information, then he'd call me in or he'd call [Dr.] Janine [Jason] and me in. Janine would then maybe be the one who would tell me, and we would take off on -- or I would take off on a field trip and --

MILLER: The drug in question was --

LAWRENCE: Mostly pentamidine. There were some other drugs that were needed for other opportunistic infections, but for the most part, the necessary drug that would treat the acute pneumonia form of Pneumocystis carinii, now (called) Pneumocystis jiroveci, was in fact pentamidine. I might add, as a parenthesis, our own EIS colleague, now the assistant director for NIAID [National Institute of Allergy and Infectious Diseases] in Bethesda, [Maryland], Dr. Karl Western, was in fact the originator of that, the implementer of that in the late '60s, I think it was, and so --

MILLER: Implementer of?

LAWRENCE: Of the Parasitic Diseases Drug Service. He was a parasitologist. We are building on incremental elevations, over decades, of credibility established by CDC of international commitment, such as [Dr.] Bruce [G.] Weniger evidenced in Thailand. The worldwide outreach to Africa, for example, or the Americas, presentations in Europe, Australia, Canada, and so on. I came in with a relatively focused and remarkable opportunity, but I was interconnected with and supported by immense resources and history.

MILLER: The request comes in for pentamidine. How was it connected that these are hemophiliac patients?

LAWRENCE: The requesting physician, or if the notification was a death in a hemophiliac or simply an illness in a hemophiliac, for which maybe no drug was yet appropriate for that illness-- those two pathways, whether going up through state health department from a clinician or coming in to the Parasitic Diseases Drug Service in retrograde notifications, they came to CDC and needed investigation. As I mentioned, those intermediates that I worked for would ask me to get out there and see the case, perhaps while still alive, perhaps verbal, perhaps the --

MILLER: Was your group looking at blood issues in general? Why clinical immunology and the Division of Host Factors for the--

LAWRENCE: In the unfolding history of the clinical immunology lab, after the departure for academia and private practice of Dr. Gordon, Steven McDougal rose. I had been initially asked by Dr. Gordon in the summer of '81, when the first MMWR article came out, to get involved, at least informally. He thought my mix of epi [epidemiology], tropical medicine, opportunistic infections, ID [infectious disease], and laboratory immunology benchwork would help, and it, of course, did in the long run. I took a backseat to persons such as yourself and [Dr.] Harry [W.] Haverkos and others who were flying around the country and doing things appropriate to that unfolding stage. I was in the lab doing some studies that later were published by immunogeneticists on susceptibility to one or more of the manifestations of what we call HIV infection today, including the unique Kaposi's sarcoma.

As I was doing lab work but going to those (meetings), I was staying informed. Others who were attending in those early days, like Dr. David Morens, now of NIAID, were also quite [involved], you know, taking careful notes and so on. The case in Miami, Florida, was brought to my attention of a hemophiliac, who by then had died, who was quite elderly and whose use of factor concentrate had been heavy as long as it had been available. He was up in years, probably then younger than me now. He had developed an immunologic syndrome that didn't quite fit our case definition but was very close, and he had no other explanation for immune deficiency. The astute clinician epidemiologist, a senior "dean" in that community in Miami, Dr. [Nathan Joel] Ehrenkranz, said, "CDC, I think this is an AIDS case." And that link of hemophilia and AIDS followed the report through Tom Spira, to Bruce, to me. Then I really went to work on it, because I knew the clinician and the family.

MILLER: Say a little bit about what was involved then. I think finding that report was a watershed event for us at CDC and the country, to understand a new aspect of how AIDS was transmitted.

LAWRENCE: As often happens with, so to speak, watershed events, you don't fully appreciate what you've got in hand until the second or third or beyond cases occur, and suddenly a pattern is emerging. We were wrestling with what had been an immune deficiency but with a follow-on immune manifestation not typical of AIDS, which can be a signal of a different pathway of pathology. We were holding that case in abeyance until June 15 approximately of 1982, when Bruce called me and said, "You've got to go to Colorado. We've got a case in the ICU [intensive care unit] there. They've called for pentamidine. He may not be alive much longer. Please try, if he's not on a respirator, interviewing him and talking to his wife." I raced out there, and that became an intense week-long investigation that has been chronicled pretty well by the author of the book And the Band Played On, Randy Shilts. In there, he describes how I tried my best to interview him. I did not wear a spacesuit during that, because I already had faith in the CDC's experiences with this, that this was not an easily transmissible disease.

I got all the factor concentrate records from that person and 60 others. I put them on a giant spreadsheet: all the blood work, clinical studies, and factor concentrates. I talked to his wife. It was a tragic story of, I think, a heroic woman who had married a greatly invalid man whose only employment for the family was as a janitor, with his handicapping conditions of crippling arthritis from his lifelong hemophilia. I saw them as heroes in their own right. I collected, of course, blood specimens and so on, with permission, and brought that information fully to the attention of the Hemophilia Treatment Center, whose records I was borrowing or recording, and to the clinician and ultimately back to CDC.

(I went on) a similar trip to Ohio only three weeks later over the July 4th weekend, to Northern Ohio. Harry Haverkos, my colleague, flew out for another Ohio case. There was a St. Louis case that led to me going to a family over a late-night trip through the Southern Illinois rural areas, to a farmhouse with ten grieving family members, nine of them adopted children and one, the wife, and racing those specimens back to the airport. It was just a mind-boggling cascading intense event, where you knew you were making history and you had to do it right at every step.

MILLER: At that time, again, we don't know for sure that it's an infectious agent. It's still about a year away from the French identification of LAV [lymphadenopathy-associated virus], although there was a lot of work that was being done that was pointing in that direction. What was your thinking, what was CDC thinking then, as you're seeing these cases in hemophiliacs?

LAWRENCE: As has been said by others, we all felt that training in infectious disease, experiences such as CDC and the academic world and international historians had seen, that it was entirely possible to have an early exposure and a very much later -- say two, three, or more years -- latency of a disease that had begun a bit earlier in a quiet, silent, unnoticed setting. Hepatitis B is famous for this, because of its three or more week incubation period. Then, of course, hepatocellular primary cancer of the liver can occur years and years later, as has been mentioned by many people.

I personally felt even more strongly it was an infectious disease, not only because we had the models of hepatitis B and certain conditions like syphilis, where tertiary or even secondary syphilis may be months to years after the primary infection that might have gone unnoticed or certainly unreported. I had worked in leprosy already, both lab work and clinical work in epi, so a seven-year incubation period for Mycobacterium leprae was not at all a surprise to me. I had met the man who worked on Kuru. My wife had introduced me to the anthropological thing of Kuru in Papua New Guinea, where cannibal diets of '40s and '50s led to neurologic dementia and paralysis. So I was open to a long incubation period disease. All of us felt -- I don't think we can really characterize (how) we felt -- but what I had in hand that was dramatic to me was that the Colorado hemophilia spreadsheets showed that many of those hemophiliacs, though not all yet AIDS cases, had lymphadenopathy already for months and months and had declining T cells, absolute T cells, for two years.

MILLER: Was that on the spreadsheets? That had been documented?

LAWRENCE: Yes, yes, but there was a sense that there is no other therapy (for hemophilia) that can come close to being effective, fast, efficiently administered in the home, for example, like factor concentrates. It's not labor intensive to administer and has been approved by FDA [Food and Drug Administration] for the requisite heat treatment that the manufacturer has been approved for. So we're watching this unfold. We know each of these patients. Practically all of them (who were) heavily treated were hepatitis C positive, because though it was not identifiable as an agent yet, we knew it wasn't hepatitis A or B. We knew there was hepatitis C throughout the population, so we worried what shoe was going to fall next. We felt it was falling, but what do we do? There's no agent. There's no -- is it even AIDS? And many immunologists felt there was no such (AIDS) syndrome yet.

MILLER: How come?

LAWRENCE: To name a gifted and generous, kind academician, Dr. Robert Good, it took the International Congress on Immunology in 1983 -- a triennial meeting -- for him to hear the immense accumulating information before he said, "Maybe this isn't just a concatenation of different, in fact, even late presentations of congenital immune deficiency. It can't be a unified syndrome." But he heard it, and his conversion, so to speak, was a boon to the whole immunology field. The world at that Congress, I think, woke up. Our Dr. Tom Spira, together with [Dr.] Susan Zolla-Pazner of New York University, chaired the session. The audience overheated the room and overflowed the room and were mesmerized by this. So it finally clicked, I think.

MILLER: Wow! I guess we'll move on, but I could hear a whole lot more about this. I remember those days, and we haven't heard that much about the immunology community. Not terribly long after this, you began receiving reports of cases of what seemed to be AIDS in blood transfusion recipients, so you were starting to look for transfusion-associated cases. On December 10 of '82, there was a report of a possible transfusion-associated acquired immune deficiency case in California. Here's where the 20-month-old baby had died of AIDS after receiving multiple blood transfusions due to Rh incompatibility with the mother -- and here a donor with AIDS was identified. Can you tell us a little bit about your investigation of these cases, both before the donor was connected with the child and where the blood banks were concerned about looking for donors? How did that come about?

LAWRENCE: Because we felt this disease had many parallels with other blood-transmissible -- likely sexually transmissible diseases, be it syphilis or hepatitis B or others -- we were all on the edge of our seats. That's, of course, [Dr. James W.] Curran and [Dr. Harold W.] Jaffe and myself and Bruce Evatt and so on. Bruce was, as you know, a professional hematologist already and inherited the Division of Host Factors, which was fortuitous for the population that became involved -- the hemophilia population, for whom he could speak and interact with professionally. He and Curran and others wanted to be ready for the first blood transfusion case, because it was just bound to happen, if our hypotheses were correct about transmission routes. I don't recall when the 20-month-old baby was diagnosed, but I do remember that in July of '82, shortly after my trip to Northeastern Ohio, the call came from combined Bruce and Jim Curran to go up to New York and investigate a possible blood transfusion case. We were tipped off, you might say, that this was probably a blood transfusion case in an adult who had seemingly no risk factors but was now in the ICU, no longer coherent to be taking an interview. Drs. Robert Holzman, Shelly Gordon, Fred Valentine, and H.S. [Henry Sherwood] or Sherry Lawrence, long-time "dean" of Infectious Diseases there at Bellevue Hospital, called us and said, "We think this is a blood transfusion case." I've often credited them with that.

We went -- I went, and to get ready to go, of course, the typical preparation of a shoe-leather epidemiologist, whether EIS or alumni, is to hand them a bunch of papers on blood-transmissible diseases or hemophilia care in the modern era. Bruce had Ms. [Rosemary B.] Ramsey prepare me in both fields. Bruce being a hematologist, he knew all about transfusion, so he fully wanted to share in the transfusion field. Jim knew it was hierarchically crucial to all the other sub-branches, of which the Division of Host Factors certainly owned the hemophilia and spouse pairs and children thereof who might be hemophiliacs. I was working across the Task Force and the Division of Host Factors and keeping both of them apprised at 9 o'clock from New York City every night after a day-long wild experience in the Bellevue Hospital environment. (I was) helped immensely by David Sencer, who took me physically in the Department of Public Health limo to the hospital to have me welcomed to the medical records department and the wards and so on and so forth --

MILLER: Dave was the Commissioner of Health in New York City by that time.

LAWRENCE: Yes, he was. By that time, he had left CDC in the aftermath of the swine flu vaccine and the unfortunate Philadelphia Legionnaires' disease syndrome. He had either gone directly there or perhaps through an intermediate position. I feel it was a blessing he was there, because he gave - those of us who were working there he considered his children -- guidance, direction, and facilitation. He opened doors for me that might have been already closed, but every door that he could open was opened. I worked diligently, keeping my staff here informed.

MILLER: What were you doing now? You've got a case in someone who has received blood transfusions. What's the process? The blood banks at that time did not want to share any information on donors. What were you doing when you were investigating?

LAWRENCE: As usual, the case investigation always involves starting with clinical information -- when was the onset of illness -- so you can call that the incidence date. Then at least relevant to other cases you know of, either in that same community or elsewhere, (that date is) the beginning of an epi curve. You start putting on a calendar the St. Louis case that came later, the Ohio case that came before that may be blood transmissible, and the baby in San Francisco that had been reported, and you start creating the epi curve across the nation or right there locally. That concept then causes you to say, as I investigate and interview the patient, clinicians, family, or other source of information: can I find a realistic source that, if this matches HIV, as we later know it, immunodeficiency, then is there another cause? Was the gentleman having a secret life on the outside unknown to his wife? Did he use injection drugs? He lived in a very marginal, almost impoverished environment on the western tip of Long Island, not otherwise now named, and the answer was no, no, no.

As Randy Shilts described my work about this case in his book , I looked at everything from airflow and staffing of ORs [operating rooms] during the man's cardiac bypass surgery, during which he had gotten 20 units of blood. Then I got the records of what units and where they came from. Twelve had come from the New York Metro area, not all from New York City, and eight had come from a U.S. Army donation site for the Red Cross over in Germany. I now wanted to follow those, either the federally collected cases or the local ones. I'd start with the local, because there was no outbreak yet in Europe but there was in the New York Metro area, people we thought had this syndrome. If I could follow up on those twelve donations, absent any other causation coming to light, I would maybe find that one or more of the donors was an IV [Intravenous] drug user, would permit specimens, and would show an immune deficiency. We could bank the serum for later, someday, testing.

I got the addresses of the donors from the New York Blood Center, and I wanted to go see them, perhaps in their home or perhaps call them in to a health department facility like the Chelsea Clinic, which was later used. I was told in no uncertain terms by the blood bank representative on duty that day that I could not actually contact the blood donors. This was a forbidden territory by their own agreements of privacy and respect for the donations. Dr. Sencer was aware of that and I think had to accept that at the time. I had to accept that, CDC had to accept that, but all that information, of course, was saved and shelved, ready to go on a minute's notice. As it happens in the movie version of And the Band Played On, I think at this point, I am shown in a very vigorous debate with [Dr.] Joanna Pendyck, the former director of the blood bank at that time. I had no such verbal outburst with her, and she was helpful later, but her representative on the day I got there in July said, "You may not go further, but here's as far as we can help."

On December 10, I'm doing a grant research review at NIH in my genetics field; I was proud to get to stay with that field, although I was getting constantly pulled out into what I would never leave ultimately -- HIV/AIDS. I get a call from [Dr. Walter R.]Walt Dowdle and Bruce Evatt and Harold Jaffe, and Harold says, "Dale, you remember that baby case? We've just made a connection, and it's going to press. As soon as that hits, we've shared all this, as we did every epidemic report, investigative report, that would be an MMWR article -- we cleared those with the FDA and other agencies and HHS [U.S. Department of Health and Human Services]. So when it hits the press -- and they know it's coming, and the blood bankers have been primed -- they'll open their doors. Dale, it's Friday afternoon. Can you be in New York City Monday morning mid-December?" I said yes. I reversed from Bethesda, got home, thought I had collected enough warm clothes but hadn't, and went to mid-December New York City to follow on. I mention that because none other than our own EIS officer there, [Dr.] Mary Chamberland, directed me to a place to get some warm clothing at a menswear or something in Manhattan.

She and I went out to the Chelsea Public Health Clinic, where they had already called in the twelve regional donors. We systematically reviewed them, looked at the questionnaire form from CDC, the permission to draw blood. As it happened, she and I sat in the room, as we are now, when one of those donors confessed a bit sheepishly that, yes, he didn't want to tell his employer he couldn't really participate in the blood drive safely, so he went ahead and donated. That donation had really not been too long since he had shared needles with a man who had a strange blood disease that the doctors couldn't diagnosis that they thought might be some kind of weird leukemia, but that's all he knew. Mary and I realized we were probably --indeed, he had immunodeficiency, not yet AIDS. As we gathered that, reporting it back here, of course, we began to accumulate a consistent package, a handful and then more handfuls of true transfusion-associated cases. That subcategory grew over the next few months by leaps and bounds, and by twelve months later, we had almost twenty of them.

MILLER: Was there any work at that time being done on the immunology from a laboratory point of view on any of these patients?

LAWRENCE: Yes. CDC had, as I said, with visionary foresight been prepared for exquisite immunologic assessments by Sencer, the parasitology division, and others supporting -- Dave Gordon and Steve McDougal, etc., the rest of us. Because they had done that, every single one of these cases was able to be tested. Funding somehow found its way to Steve McDougal's lab and his staff, [Dr.] Janet Nicholson and David Cross, Dr. Linda Martin and others. As we had our own hands on those test results, we could be credible in national and international fora, that this was a syndrome of commonality of immune deficiency of radical nature like none normally seen before, and that even if it involved subpopulations as dissimilar as babies of drug addicts and hemophiliac elderly men, this was the same immune deficiency with a spiraling toward zero of the T cells.

MILLER: Was that the main clinical test that you were using basically -- and it wasn't that easy until the FACS counter [enabled you] to differentiate between the CD4s and CD8s -- was that the primary test that you were doing of a clinical nature?

LAWRENCE: Yes. The lab had emerged from the very earliest exciting era, when, oddly enough, a T cell could be identified by the fact that, if you separated it from all the rest of the white cells and red cells and plasma, you could dunk it in some sheep red blood cells and little rosettes, a little collar of red cells from the sheep would form. That odd correlation based on some attachment marker was our functional marker for T cells. If they disappeared or if they're cytotoxic and dead, that was an immune deficiency of T cells. We migrated from that over a very short span of time, already by '80 to that predecessor of CD4 test. It was called OKT4 and OKT8, but that (was the) CD4 test and CD8 test, and those tests were at the forefront of diagnostic testing. They were only being correlated with clinical disease, and as we spoke, we were making history with that. I don't recall at that moment if FDA had approved them as diagnostic tests legally, but they were fortunately being funded and were making history in our lab, and of course by Dr. [Anthony] Tony Fauci at NIH, who spearheaded their effort.

MILLER: What's your thinking about the work that was being done in the immunology lab under Steve McDougal and others? Do you feel like it was essential to the investigations that you did?

LAWRENCE: Absolutely yes, is the short answer. Had we not had that opportunity, I find it hard to believe that CDC would have been able to do what it did for the rest of its contributions in this incredible global pandemic. We absolutely needed that. If we had had to borrow those resources from research grants and other universities, or as Don Francis had to do, working with the French transatlantic collaboration, (we couldn't have done it). In retrospect, it may have been easier with NCI [National Cancer Institute] and Dr. [Robert C.] Gallo or the Japanese with their HTLV-1 [human T-lymphotropic virus, type I] work -- if we had had to reach out to far-flung labs, we couldn't have done it and we couldn't have had the credibility. We moved to the absolute front of the line, and it was only years later that the phenomenal character that Steve McDougal was as an immunologist could be seen for what he was.

MILLER: Can you tell us more about him? He died in 2014. He's a legend. Can you say a little more about Steve McDougal?

LAWRENCE: Yes, I believe he came to CDC as a [U.S.] Public Health Service officer, as many other gifted Public Health Service officers did, during the Vietnam era. Even if they were not EIS, they got EIS training, and then they went to their respective lab or other assignments. He came in 1974, as I recall, at the invitation of Dr. Gordon. He was highly trained already, but I don't recall where. He was an absolute quintessential laboratorian. He was soft-spoken, had a wry humor, would toss in little jibes throughout the day. When it was lunchtime and he wanted to let some cell culture incubate or some centrifugation happen while we went off to lunch, he would say "Manger?", French for "shall we eat." Otherwise, I didn't hear him speak French. We would all troop off and have a fun lunchtime in the cafeteria. He would come back with his white lab coat on, back to his beloved lab work, and he spent many hours in the cold room with the so-called Sephadex columns that were filtering various serums through and purifying things and so on and so forth, that were at the state of the art of immunochemistry, using things to filter out and get pure specimens or to concentrate and get what you want. He was the key laboratorian; he trained me, enhanced Tom Spira's training, and along with [Dr.] Linda Martin, taught many of us how to do this.

He would not shed his white lab coat. In 1987, he stood before the CDC director in Auditorium B, I believe it was, and he received the year's award for the laboratory manuscript of the year, the publication of the year. That publication had put him on the international stage and put CDC on the international stage for having found the exact attachment of HIV the virus to the target CD4 T cell, how they connected, and why that cell suffered. That was big news in science. He at that point anticipated and maybe predated the work even by NIH and others. When he walked to the podium to get that award and accept it, he had only walked out of his lab, wearing his white lab coat, and then walked back to his lab. You know: get the award, praise his colleagues, they get recognized, and he's back to work.

There are many favorite stories, but one small one is that in those journal clubs I referred to earlier, he always sat in the back unless he was presenting. He was quiet and soft-spoken and rarely said anything throughout the presentation. When the chalk marks or the white-board work was finished or the slides or whatever presented and speaker finished, he would sit back and he'd say, "Could I ask you, Dale, to go back to slide 2. Is it possible that the publisher transposed the last two data columns and that T cell or that immunoglobulin value should have been in the other column?" And we looked, and he was right. There had been a misprint in the original article that we hadn't picked up. That was the astute insight and just gentle corrections that made him a legend.

MILLER: That's a great story. You were involved in a number of other studies, but I would be interested in hearing a word or two about those looking at the -- trying to get a sense of the magnitude of this problem, so looking at the prevalence of immune deficiency and clinical abnormalities in hemophiliacs using HTLV membrane antigens, looking at infection in spouses. Can you tell us a little bit about some of those studies that were done to begin trying to get a sense of how broad based is this issue?

LAWRENCE: Having already essentially convinced ourselves that it had to be the factor concentrate accountable for most of the severe hemophilia patients' AIDS cases, and having already appreciated the statistical rarity that elderly hemophiliacs presented first, long before the teenagers and the young boys typical of hemophilia with AIDS, we felt that the harbinger, the sentinel cases were these elderly hemophiliacs with a less-than-robust immune system who, once infected, along with many others, would be first manifest. The question was, would we study those collections of hemophilia patients treated at, say, Emory or in a New York setting or Colorado setting? Would we focus on studying those where there had yet been no cases reported, presumably they being behind in their exposure as a group to factor concentrates and the viremia inherent in them? Or should we start with those communities of hemophilia patients such as Denver, where it's clear it's already rampant in the body, ([with) the immune hematologic findings I cited a few minutes ago and by the clinical lymphadenopathy and so on.

It was primarily Bruce's decision that, working with colleagues that he knew extremely well, both at Emory and in the New York area, we would get some places that weren't already manifestly prevalent, and he chose those. He first authored those, as I recall, and he showed that it was already there, at least by immune deficits that we and the university clinic labs could test for. We had aliquots -- at least aliquots -- of their sera or plasma, and we would ultimately be able to test them when and if an agent's identity came about and the serologic detection technique (was) formalized and made widespread. We were ready to then be definite, but we couldn't yet. Don Francis had worked with the people at Harvard in the laboratory of cancer biology there, and [Dr.] Max Essex, his former feline leukemia colleague, and others were exploring this Japanese finding of HTLV or Bob Gallo's finding of HTLV and a possible virus. That had a serology. That serology cross-reacted with this other responsive reactive mystery agent. When sera lighted up from our seemingly ill or immune-deficient patients and not really from the others, we knew we were in the right ballpark if not at the right seat. It was explosive news. That was really spearheaded by Bruce and Don Francis and their colleagues and others.

MILLER: So that was the HTLV--

LAWRENCE: It was then only called HTLV-1 or -2 membrane-associated antigen. It was Dr. Gallo later, who in competition with the French, chose to try to call his [isolate] HTLV-3 and their (the French investigators') original name LAV [lymphadenopathy-associated virus]. The commonality of serologic cross-reactivity is what led us to feel we've got an agent out there by the tail, not by the head. We're going to keep looking.

MILLER: Wow. When you did look at the prevalence in some of those early '70s, was it --I guess it depended on the population you were looking at. Were you finding higher levels than anticipated?

LAWRENCE: It was a spread. As we feared, it was widespread in some communities that had certain products made by certain manufacturers with a lesser rigidity but FDA-approved technique, and perhaps even at a correlation with where that plasma processed into the factor concentrate had been collected. Those centers that were maybe using product from another manufacturer that was heat treated or otherwise treated in some other way -- let's call it more stringent -- might have been later and behind. At that point, it was hard to say if any heat treatment had anything other than a retrospective ability to assess its safety, not really a prospective. The dilemma was that the plasma collection network throughout America or the world pays for donations from down and outers who are in inner-city urban areas and desperate for cash. I've known many of those, and they donate for small amounts of cash and donate as often as they can, because they get the red cells back and the plasma gets kept and processed and, therefore, they'll make more plasma over the few weeks until they do it again. That plasma may have the horrific viremia of their first HIV encounter and viremic state, and that virus may not be yet detectable by anything we have. The antibody in fact wouldn't have been detectable even in the early weeks or months, so they shed a burst of virus that isn't totally (detectable) into a pool of 20,000 units, pooled into a vial or multiple vials. It's inescapable that on a thermodynamic probability basis, some people with high needs and high usage and maybe certain corporate or processing techniques are going to get that virus unforeseen.

MILLER: You were often asked to meet with families at the National Hemophilia Foundation regional meetings. Can you tell us a little bit about that, about the human side of this?

LAWRENCE: Yes, my career and life and even later life have been associated with appreciating the impact on families with disability in members of the family. It started with the occupational injury of my uncle, whose illness motivated me to go into research and medicine. I was happy to share what I had learned straight from an up-to-date, inside the CDC, so to speak, horse's mouth -- direct information -- with those to whom it mattered most, the patients, their mothers, their spouses or children, and their treating caregivers who come to these regional meetings. I felt a mission to do that, not only to share the facts but to share them with an empathy that they could recognize I had as a family member. When I shared with them the information, I never wanted that message to be one of future fatalism. I wanted them to see what we were doing and the intensity of what CDC and others were doing on their behalf, so that they could sense that they were part of a process to block, stop, prevent, or otherwise move on this tragic avalanche. It was not good news always; it was sometimes delivered in very somber settings in the middle of the winter after snowstorms, impeded plane landings and so on, but I had the opportunity and the honor to be the human face of our endeavors.

MILLER: We've touched on latency a bit in talking about the hemophiliacs. You were involved in developing and elaborating on this concept of the long AIDS latency period, which was such, again, a landmark issue that would come to have huge implications. Can you describe some of the work that led to this finding, and then your collaboration with statisticians to try and get a sense of the impact of this finding?

LAWRENCE: I haven't mentioned in this setting yet the fact that there were coincidences that occurred. I had knowledge of, let's say, pairings of cases where the donor was perhaps still healthy at a time when the baby and immunologically still young and immature exposee developed AIDS, but then weeks, months, or years later, the donor who was in perfect health gets AIDS. We know that the donor had it long before the baby was exposed. The baby has a short latency; the donor has a longer. Even if the donor can never know when he, for example, got infected, we know the date of the baby's (infection) and we know the date of diagnosis. That's an interval or incubation period or latency, so we knew there was a tremendous span.

The same thing was true with the first documented hemophilia spouse pair, two elderly married people in South Florida. The husband gets AIDS. I interviewed the wife with the help of the treating doctor. She turns out to have only had a not-so-distant sexual exposure to him in their late years, and now she has overt AIDS. It was really, again, a pairing of wide range of incubation periods. Then we look at the blood transfusion information, which I had co-spearheaded with Harry Haverkos and then ultimately [Dr. Thomas A.] Tom Peterman and the statisticians, and I said, we've got the handle on this.

I had had an insight from an Emory University after-hours private course I was taking on epidemiologic methods. I went to statisticians at Emory who used to work at CDC. They had a very gung-ho, can-do, action-oriented style they carried from CDC, and when they told me I needed -- My concept was bona fide, that we (CDC) were vastly underestimating the average incubation period by only seeing the cases that were manifest early in their cohorts, early hemophiliacs, early blood transfusion. We had no idea yet how many had been infected, nor where the halfway point would be. I was looking at where the halfway point is and where the inflection point is in the curve, and so on. Each year (the numbers were) getting bigger and bigger, cohorts of transfusion, AIDS in New York, and so on. They said, you need mathematical modeling, so I turned to the CDC statistician who had done a remarkable job, a very young early careerist named Dr. Kung-Jong Lui, originally from Taiwan. He had worked on the linkage between clusters of blood transfusion cases with their respective donors. He showed in that statistical argument that, if you take all the AIDS cases and all the infected suspected donor clusters, they shouldn't distribute where one AIDS case was always associated with ten, twenty, or more blood transfusion donors, only one of whom had the risk factor of immune deficiency or IV drug use or gay lifestyle.

He had done a really statistically remarkable thing that we later published and presented. I went to him, and I said, "I don't know if this is in your field. It's way beyond my minor in mathematics. Help me here." He looked at it, and he brilliantly chose from all statistical models one that had never been used before for health issues, only in industrial application, little known to us statisticians at CDC, called the Weibull distribution. I would not want to try to explain it now. As the originator of the concept that he then made manifest and as an epidemiologist of the Task Force, I could be the interlocutor with the Task Force meetings and with ultimately, of course, Bruce and hemophilia presentations and ultimately, the International Conference on AIDS, where it was very fully presented and well covered by the press. The outcome of that, to my surprise, only a short while later was considered so well known that the columnist, I think Ann Landers, was putting it in her advice column to the world that we must recognize that it could be a long time between exposure and actual AIDS manifestations.

The horrifying thing was that the model said that, based on only twenty or twenty-one cases then, none of whom had over five years, at most two or three years, that we were looking at a disease (latency) of five years or maybe ten on average. What does that mean the future holds? I realized that we were riding a tiger, that the world, including sub-Saharan Africa, that the gay population and the artistic population of our country, (and) the hemophilia patients that I had been facing with incremental news, we were facing a national calamity that would change public policy, public insurance funding, the arts and sciences. This was a revelation without an ability to prove it. There was no serologic test, and (it would be) unaffordable to test everyone in America. We were really caught, tragically, until further cases came. Thank goodness, a serological test became available that could cement the facts.

MILLER: Well stated. Very, very frightening. It sounds like you hit a lot of the high points in the work at CDC. How did your experience with AIDS at CDC end up affecting your future career choices? Eventually, you left CDC.

LAWRENCE: Yes, perhaps I haven't said it explicitly, but the watchword for all of this was teamwork. While here, as each of these dramatic stories was unfolding, from those in early '81 through the work you were doing in '81, '82 and the hemophilia in '81, '82, '83 and so on, each was cascading at an explosive rate that I can only liken to maybe a few other outbreaks, Ebola and otherwise, SARS [Severe Acute Respiratory Syndrome] and Zika and so on that we know of today, or the Space Shot or World War II -- things that had to come together across all disciplines to quickly combat a threat of global immensity.

LAWRENCE: As the team worked, without there being hardly any egotism at a pathologic level, we were called on to really implement each action as seemed right, then necessary. We had the CDC can-do atmosphere from past outbreaks and past issues of national importance. I thought in 1981 that I would be spending a career in academic public health-- epi interface, clinical interface, of understanding why disease manifests in some people as scarlet fever and in others as just the sniffles, or death from measles in Africa and only a rash in the United States, or permanent arthritis as an outcome of certain infections, while other people had had only a little rash and then over time, it was gone. I thought I would be dealing with genetics of immune response and why our human family around the world is both dissimilar and similar and how that spoke to the epidemiology that CDC was avant-garde in.

No, that era ended. My lab space had to go for T-cell testing and other testing. My career in publications of everything, on to even mitochondrial DNA [deoxyribonucleic acid] and Amazonian Indians and Siberian people, all that stopped. The issues of the antiquity of humanity, all that stopped, and it was AIDS, AIDS, AIDS, which ultimately carried me toward NIH and AIDS vaccine work. My other work was here at CDC and the then-new exciting work of cellular immunology, comprehensive immunology, and vaccines. We had big exciting projects right up there with NIH and academia, but our influenza and pneumococcal studies, as vast as they were, had to stop for AIDS. I had to go around the back to get into vaccines again years later, but everything built on another thing. As I've often said, those projects you really didn't want to do, when you get into, you wound up gaining another insight or credential that prepares you for a future opportunity.

MILLER: You have had the opportunity to see both agencies. I won't ask you to compare them because they're so different, but when you look back at CDC's response, you've had so many positive things to say about how CDC works and how it was perceived. Were there any aspects of the work you were involved in where you thought maybe CDC could have done a better job?

LAWRENCE: I would say, none that I can feel confident to make. For every possibly negative insight I might have on operational things that took place at the time, there was some antecedent reason why we did it that way. It may have been our budget was so constrained we couldn't have done more or funded more, or that it took another several months for the unfolding epidemic to demonstrate that a new construct of response team, be it Task Force or new laboratories, etc., be assembled and staffed.

The saddest thing, I think, is that we didn't have the almost instant availability to bring on line here, the way we had the antecedent T cell work and immune deficiency work, bring on line the retrovirology or lentivirus expertise that ultimately led those devoted to that, be they France, Netherlands, and certainly Dr. Gallo and others, to break open this disease. There were inquiries I made to the lab of Dr. Gallo early on, when I saw that he was following or leading some of the work done by the Japanese in adult T cell leukemia and lymphoma virus. I felt he had the lab resources, but I was an unknown from CDC, and he was busy in the lab. He didn't return the call, although I gratefully learned others tried to solicit his involvement, I think Jim Curran and others. We didn't have that lab, so Don Francis had to reach out to his Pasteur Institute colleagues.

My real sadness is that --best is that the skills happen in the labs best prepared to do it. Clearly, history unfolded to make those labs produce for the world's benefit. CDC had done such an investment and credible job that, I believe, had a nascent protocol we began here in February of 1983, nine months or six months before the French announced at the Kyoto meeting that they thought they had something, and certainly, a year and a quarter before Dr. Gallo announced his significant finding. Had we gotten beyond the first snafus or problems in our lab benchwork that I and Steve McDougal and [Dr.] Paul Feorino attempted to isolate that virus, I think CDC might well have been a contender, so to speak, with that. Had they done that, a lot of the acrimony of Nobel Prize work and attribution and so on and so forth, that we weren't even a part of but had to be proud did get done by someone. We might have been a part of that, and I think it would have been nice if the late Steven McDougal and our colleagues of that time had truly been able to claim small credit for the actual discovery. We were close.

MILLER: Thank you so much.

LAWRENCE: You're quite welcome.