Dr. Dennis Juranek



CHAMBERLAND: This is Dr. Mary Chamberland, and I'm here with Dr. Dennis Juranek at the Centers for Disease Control and Prevention in Atlanta, Georgia. Today is Monday, July 9, 2018. I'm interviewing Dr. Juranek as part of the oral history project The Early Years of AIDS: CDC's Response to a Historic Epidemic. Dennis, welcome to the project. Do I have your permission to interview you and to record the interview? JURANEK: Yes. CHAMBERLAND: Dennis, you arrived at CDC [Centers for Disease Control and Prevention] in 1970 as an Epidemic Intelligence Service Officer [EIS Officer], and apart from a year of career development at the London School of Hygiene and Tropical Medicine, your entire 36-year career at CDC was spent in parasitic diseases. That's a pretty remarkable run. You had been at CDC for more than ten years when the June 5, 1981, Morbidity and Mortality Weekly Report (MMWR) on Pneumocystis carinii pneumonia among homosexual men in Los 00:01:00Angeles was published. Being in the Division of Parasitic Diseases, Pneumocystis was one of your bugs, so you and your colleagues were involved in AIDS [acquired immunodeficiency syndrome] from the go-get. Before we delve into the details of all of this, let's start by talking a little bit about your background. Can you tell us where you grew up, about your early family life? JURANEK: I grew up in Colorado Springs, Colorado, at the foot of Pike's Peak. I had the mountains to play in on the West and the Great Plains to play in on the East. I was the middle son of three. My father was a paint contractor, and my mother was an electronics technician. She worked assembling motors for Emerson Electric for a long time, and then later soldered circuit boards for Ampex tape recorders, the tape recorders used in the phono and recording industry. 00:02:00CHAMBERLAND: Where did you go to college, and what did you study? JURANEK: I went to college in Fort Collins, Colorado, and got a bachelor's degree in biology there and then later a Doctorate in Veterinary Medicine from CSU. CHAMBERLAND: That's Colorado State University? JURANEK: Colorado State University. CHAMBERLAND: What or who influenced you to be a veterinarian? JURANEK: My grandparents and aunts and uncles lived on farms in northeastern Colorado, so I would spend a lot of my summertime with animals down there and developed an interest in those animals. Then I did basic biology in college and was accepted to the veterinary school and then studied veterinary medicine. CHAMBERLAND: You came to CDC, if I'm correct, immediately after completing your veterinary degree? JURANEK: That's correct. My senior year I had a visitor from CDC by the name of [Dr.] Richard 00:03:00[L.] Parker, who was then the head of the zoonoses unit at CDC. That was my first introduction to CDC and the EIS. He gave a very nice presentation of what the options were and what we could do there. Like most people in my cohort, we were all there at the time of the Vietnam War. Going to CDC offered an opportunity to fulfill our military obligation by doing something really useful, in my mind, rather than just doing meat inspection or candling eggs in the military. That was a big stimulus to go. I had no intention of staying at that time. I was just going to do my two years and get out. Then at the end of my two years as an EIS Officer, I was offered a career development program in which I was allowed to go to London to the London School of Tropical Medicine and Hygiene, where I studied medical parasitology. I got a Master's degree in 00:04:00medical parasitology and then came back to CDC and spent the rest of my career, as you said, here. CHAMBERLAND: Was CDC, by visiting your college campus, excuse me, your veterinary school, were they actively trying to recruit veterinarians to CDC? JURANEK: They were. They were. That was their effort: to get out there and introduce the program to students in their senior year of veterinary medicine. I suspect they were doing something similar for the medical schools, but many of the people in medical schools met people that formerly graduated as EIS officers, so they got both sides. I didn't know anything about CDC at that time. CHAMBERLAND: When you arrived at CDC as an EIS officer, how is it that you ended up in parasitic diseases? JURANEK: There were really only two job openings for veterinarians at that time. One was in the zoonoses unit, headed up by 00:05:00Richard Parker. The other one was in parasitic diseases, headed up by [Dr.] Myron [G.] Schultz. I was assigned to the Parasitic Diseases Division. CHAMBERLAND: When you arrived in 1970, how many--or maybe I should say how few fellow veterinarians did you find here? JURANEK: There were probably three or four other veterinarians at that time. I had a predecessor who was leaving as an EIS Officer, so I was his successor. There were two or three other people that were in different divisions. Some of them were working as clinical veterinarians, but just a few of us as epidemiologists. CHAMBERLAND: Yes, it sounds like a small group. You liked parasitic diseases, hence they sent you on to London to get the master's-level degree? JURANEK: Yes, we had a good run when 00:06:00I was an EIS officer. I got to do several outbreaks, one of which was echinococcosis in Utah. Several patients had big liver infections with that organism. [Dr. Irving G.] Irv Kagan, who was then head of the parasitology laboratory, had developed a skin test for diagnosis, and we were using that. It's like a TB [tuberculosis] test. It's a delayed reaction -- you read it the next day to measure how much swelling there was around the injection site. We found 30 or 40 cases of echinococcosis in young children and adults in Utah. That's a disease transmitted mostly from dogs who eat the guts or offal from sheep and other ruminants. CHAMBERLAND: By sending you to London, I guess the deal was that you would come back to parasitic diseases after you got your master's degree. JURANEK: That's correct. CHAMBERLAND: Before we talk about 00:07:00AIDS, I wanted to see if you could give us a little bit of background about an activity that the Parasitic Diseases Division was responsible for, the running of the Parasitic Diseases Drug Service. This, as you'll tell us, played an important role in the early recognition of unusual cases of Pneumocystis carinii. It would be helpful to get some background about the Drug Service. First of all, could you tell us: what is the Drug Service, and why was there a need for CDC to establish one? JURANEK: The Drug Service was established a few years before I came. It was the brainchild of Myron Schultz, my supervisor. Around 1966-1967 [Dr.] Karl [A.] Western was his EIS officer. Karl wrote up most 00:08:00of the INDs [Investigational New Drug] and put the stuff together. It was done to be able to provide lifesaving drugs for parasitic infections that were acquired by Americans who went abroad and came back. We had movie stars, we had Peace Corps volunteers, we had travelers, we had a variety of people coming back with various infections. The one disease that most people might recognize who have no background in parasitology would be African sleeping sickness, a disease caused by trypanosomes and the bite of the tsetse fly. That happens to be one parasitic infection also treated with pentamidine, the way pneumocystis is. Also pentamidine was useful for leishmaniasis infection, so it was a key drug in our armamentarium. African sleeping sickness and a few others were universally fatal 00:09:00if not treated. You would get the infection, and if there's no treatment available here, by the time you got to the hospital and had it diagnosed, you were fairly far along. Thinking about sending somebody to Europe to get the drugs was not a feasible option. We explored ways to bring those drugs that were manufactured in Europe and used a lot in the European population who traveled to Africa and India and got these infections. The only mechanism that could be established was under the IND process, the Investigational New Drug process, with FDA [Food and Drug Administration], although these drugs were not truly investigational. They had well-established efficacy and well-established toxicity information, but, again, we brought them in as investigational for the purpose of making them available in this country. They were here also because there were so few patients to be treated that it was not economically feasible 00:10:00for any pharmaceutical company in the U.S. to sponsor them through the licensing process. At that time, that licensing process took about $2 million and several years to satisfy all the FDA requirements. They couldn't do that and make any money on three or four doses a year of drugs. That's the basis of why the Drug Service was established. We had probably five or six major drugs that we distributed at that time. Pentamidine turned out to be one of the most common ones, largely because there was a shift in the late '60s and early '70s toward more aggressive treatment of cancers. I'd say the most (frequent) use of the drug was in children with various types of leukemia or other types of childhood cancers. We sent a lot of drugs to St. Jude's [Children's Research Hospital], for example. We sent drugs to people that were receiving organ transplants and 00:11:00who were also immunosuppressed because of those drugs and got pneumocystis. I'd say in most of the '70s we probably only averaged about 20 to 30 pneumocystis patients in that type of population a year. Then it (requests for pentamidine) started to grow in the early 1980s. CHAMBERLAND: Was this arrangement with FDA, as you said, an investigational new drug application, is this a pretty tedious process? Are there a lot of reporting requirements associated with it once the agency is holding this IND? JURANEK: Yes, it's a very time-investing process. The first process is writing the application itself. That entails a total 00:12:00research of the literature, writing down the safety and efficacy of the drug, where it's available, where we were going to get the drug, and how it was manufactured there. Then the reporting requirements for the distribution were first, and you had to have a parasitologically laboratory-confirmed case. We weren't releasing drugs on speculation if a person might have X or Y disease. They had to have laboratory-confirmed infections, and that was a help later on in the AIDS epidemic as well. We collected basic information: patient's name, age, sex, weight, diagnosis, underlying disease that was responsible for the pneumocystis if it happened to be that sort of thing, or the parasitological evidence of infection. This was done by EIS officers and myself. Probably for the first 8 years the number of requests was relatively small. Then as we started getting more and more of the cancer patients with pneumocystis the 00:13:00volume grew, and the number of consults grew. At that time we hired a Drug Service technician, who was [Sandra L.] Sandy Ford, that's been mentioned in some of the literature before. Sandy would take the initial phone calls, record the information about the patients and then share that information with one of us, one of the medical officers and myself, to get authorization to go ahead and release the drug. That's the way it worked. She would then make arrangements for the drug to be shipped out. In the early days it was relatively simple. We just packaged the drug, put it at the CDC front desk, and a courier would pick it up and take it to the airport. On nights and weekends, myself and EIS officers, if we got an emergency call for a seriously ill person, we would have to come in, package the drug ourselves, hand-carry it down to Delta Dash at the Atlanta 00:14:00airport and have it sent off. The third variable was, if the receiving hospital was not near an airport, then it had to be driven by a taxi, or somebody from the hospital would pick it up. In many cases the hospital was actually in a different state. Then we had to make arrangements with the state patrol to take it to the border, hand it off to another state patrol and then get it to the patient's facility. That was a very complex process. CHAMBERLAND: A lot of links in the chain. JURANEK: A lot of links and a lot of effort, but you had a life-threatening infection in most cases. CHAMBERLAND: Time was of the essence. JURANEK: Yes, you wanted to get it there within twelve hours if we could, six to twelve hours. CHAMBERLAND: The drugs that you would be sending out, obviously then, were physically stored on the Clifton Road campus? JURANEK: All of it was stored at the Clifton Road campus until we got into the AIDS epidemic. 00:15:00CHAMBERLAND: I guess you'd have to have some sense of the estimated number of requests that you'd get, because you would have to be importing drugs from these European manufacturers and keeping an inventory that would meet the needs as best you could estimate. Is that how it worked? JURANEK: Exactly, that's the way it worked. For the pentamidine in particular, we got that from a London pharmaceutical company. They only made production runs about every five years. We would estimate about how much we would need based on what we had before and order that amount. About a year before we needed another supply, we would contact them and see when their next run was going to be and put in another order. I might say that that became complicated as we got into the AIDS epidemic. We can discuss that now or discuss it later. 00:16:00CHAMBERLAND: Yes, let's move into the AIDS epidemic, because you outlined very well how the Drug Service worked. It sounds like this was an EIS on-call scenario, although obviously you were long past EIS, so you musthave been back-up call and things of that nature. JURANEK: Yes, we rotated the calls initially just to take a week at a time, and a lot of us went through it. CHAMBERLAND: Let's move to early 1981. As you indicated, your typical request for pentamidine was a scenario of an immunocompromised patient who might have had cancer, whatever, and because of their immunocompromised state (was) developing opportunistic infections like pneumocystis. What started to happen? Some unusual things started to happen 00:17:00about the calls that came in requesting pentamidine. JURANEK: Yes. It was very apparent that we were probably getting one call every two weeks for a young healthy male who had no underlying cause for their immunosuppression, no recognized underlying cause at that time. We were very suspicious about those initially and really wanted to see some of the laboratory confirmations on a few of those. They just kept increasing, from one every two weeks to one a week. Sandy Ford would bring these up, and we would discuss them. She said, "We've got quite a few of these now," and I said, "Let's go ahead and make a line listing like you do as an epidemiologist. Give us the age, sex, location, and what the underlying disease was, and we'll see what we have there." We had probably ten or fifteen of those at the time the MMWR article came out. All the patients in 00:18:00the MMWR were on that list, but we had several from New York as well. So it was starting to be suspicious what was going on. CHAMBERLAND: I'm assuming that Sandy, that you, the other physicians in your group, had a pretty good relationship with a lot of these hospital physicians or even the laboratory staff, because as you said, you were requiring laboratory confirmation before sending out the drug. Were there any doubts in your mind that this was real? Were you able to talk with the physicians or the laboratory people on staff in the hospital and get their thoughts? JURANEK: We talked to a lot of them, and they were puzzled by it, too. They said they just couldn't find an underlying cause, but they had several sputum samples that were positive by silver 00:19:00methenamine stains, and that was as far as you could go. We were not going to withhold drug on somebody that seriously ill. What was really striking to me was some of the discussion about their blood oxygen levels. Some of these guys were down to fifteen or twenty [i.e., partial pressure of oxygen (PaO2) measured in millimeters of mercury (mm Hg)], and I didn't know you could live at that low oxygen levels. They were seriously ill.

CHAMBERLAND: Would the pentamidine help them? JURANEK: Yes, for a bit, but most of them were so ill, and you could not correct the immunosuppressive condition at all at that time. Most of those people had died probably within weeks of the infection. With some of the cancer patients and the organ transplant patients, we discussed with the physicians the possibility of throttling back on the immunosuppressive drugs, to let the patient recover a bit if they could. There's 00:20:00a balancing act --fight the cancer or fight the pneumocystis -- but I think most of those people would recover well with the pentamidine use, if you could modify the immunosuppression. Not so with the AIDS patients. CHAMBERLAND: There was another drug available, I think, that became available about 1974, trimethoprim--sulfamethoxazole. Patients were also getting this drug as well? JURANEK: In the early days there was only pentamidine. Trimethoprim--sulfa would have been available for a long time, but only as an oral drug. These patients were too sick to receive any oral drugs. When the pharmaceutical company came up with a parenteral drug, an injectable drug, that was a big boon. I think that was well after '83, '84 or something in that range when that became available. That certainly decreased the demand for pentamidine as a treatment in AIDS. I 00:21:00think it became the first-line drug and also a prophylactic drug in some AIDS patients later on. CHAMBERLAND: Okay, so pentamidine really was the first-line drug of choice for patients in this early 1981 or 1982 (period). JURANEK: '81, '82. CHAMBERLAND: It was, okay. JURANEK: Maybe '83. CHAMBERLAND: Okay. Was pentamidine administered by the intravenous route? JURANEK: Yes. CHAMBERLAND: It was. Okay. Okay. JURANEK: It could be given IM [Intramuscular] as well. Actually, most of it was given IM. CHAMBERLAND: Oh, intramuscular. That sounds painful. JURANEK: Yes. It's a pretty caustic drug. These antiparasitic drugs are like cancer drugs-- it's a contest of who dies first, the patient or the parasite, because you're killing cells that are healthy cells when you're trying to kill another beast inside of you. CHAMBERLAND: To go back a little bit to what you said: you had Sandy and others, I guess, construct this line list. This 00:22:00is before the MMWR came out. You had already started tabulating, if you will. JURANEK: Yes, yes. CHAMBERLAND: Was it just limited to that recent period of time, 1981? JURANEK: I don't think we ever saw an infection in a non-immunosuppressed person prior to 1981. CHAMBERLAND: Okay, okay. When you had this information, what did you do with it? I mean, this was unusual. I'm just curious -- and it was before the MMWR came out -- was this then disseminated within CDC or to other people in your division? JURANEK: It just went up the line, as far as I know. I gave it to Myron Schultz, our supervisor. I assume he discussed it with [Dr. Philip S.] Phil Brachman, the head of the Bureau of Epidemiology at that time. It wasn't long after that that Jim and I, after the 00:23:00MMWR article came out, [Dr. James W.] Jim Curran and I were summoned to the office of [Dr.] John [V.] Bennett, who was then the Chief of Bacterial Diseases. I didn't know Jim at that time. We both showed up at the office, and we looked at each other and asked each other if we had any idea why we were here. Neither of us had a clue why we might be there, especially in bacterial diseases, because we didn't really -- other than in a few diarrheal outbreaks -- we didn't have much in common in parasitic diseases. At that time John said, you're here because we want to find out if this phenomenon is real, the San Francisco clustering and the clustering you've identified in the Drug Service in New York. We want you guys to go up and take a firsthand look, and give us a sense of 00:24:00whether we ought to pursue this more aggressively at CDC. CHAMBERLAND: This meeting in John Bennett's office is after or before the MMWR came out? Or you can't remember? JURANEK: I can't remember, but it was pretty close in timing. We had one day to get ready to go up, so it was a really fast thing. CHAMBERLAND: In terms of the MMWR, that came into CDC probably from the field officer in Los Angeles. [Dr.] Wayne [X.] Shandera had been working with [Dr. Michael S.] Mike Gottlieb in L.A. [Los Angeles] about this publication. Did it come to parasitic diseases for the division's review of it, since it had to do with pneumocystis? JURANEK: It did, and I reviewed it, and it was quite good. They had most of the information there. We made a few editorial things, comments on the editorial comments, but they had it down well. They had the general concept captured, and 00:25:00there was really not much of a question that there was an unusual phenomenon going on and it needed to be further addressed. CHAMBERLAND: Do you know if your division was the first one to receive it? I'm not sure what actually the chain of clearance would be, if you will, for a draft MMWR back in those days. JURANEK: My guess is it came in to [Dr. Michael B.] Mike Gregg, the editor of the MMWR. All of those things then get distributed back out to the respective branches that deal with that organism. CHAMBERLAND: Okay, that would make sense, absolutely. Can you also just remind us about the organization of parasitic diseases, because obviously since the early '80s things have changed. You were a division then. What were the layers above you, the organizational layers above? JURANEK: The top layer was the Bureau of Epidemiology at that time, headed up by 00:26:00Phil Brachman. Below that were branches -- the Bacterial Diseases Branch, Parasitic Diseases Branch, Family Planning Branch and a number of others, viral diseases, and zoonoses. That's what was peculiar when we went into John Bennett's office, because we couldn't figure it out. I didn't really ask at that time, but I can only surmise that maybe Phil Brachman was out of town. He was Acting Director at that time of the Bureau, and that's why he was the one in charge. CHAMBERLAND: That pulled you and Jim Curran together. I see, okay, that's helpful. Parasitic Diseases was actually a branch then and had not attained division status. JURANEK: Yes, there were no divisions in the Bureau of Epidemiology. That was a subsequent reorganization. CHAMBERLAND: This is very interesting that the Drug Service, if you will, is instrumental in identifying 00:27:00an unusual cluster of cases or an increase in cases. Had that ever happened before, that by frequency of requests or patterns of requests for another organism that the Drug Service, if you will, had almost served as a sentinel surveillance site? JURANEK: There's one situation with malaria that came in through that mechanism. It's called autochthonous transmission -- transmitted in the United States rather than acquired abroad. That investigation revealed that a returning serviceman from Vietnam had gone to a drive-in theater with the car open and been bitten by mosquitoes that later bit several other people at that drive-in theater and started a small cluster of five or six malaria cases at that time. That was an interesting concept. CHAMBERLAND: Yes, that is pretty quirky. Who knew a drive-in movie theatre would be a risk factor for malaria? Oh 00:28:00gosh, we're a little bit off the track. To get us back to the story, I think I still want to stay on the Parasitic Diseases Drug Service. Maybe we should go to New York City, because it's chronologic. You and Jim went up the very next day after this meeting. JURANEK: Yes, it was fast. They wanted to make a decision about where CDC should be going. CHAMBERLAND: What did you do? Who did you meet with? JURANEK: We went to New York University Hospital. [Dr.] Linda [J.] Laubenstein was the oncologist there, and she had six or seven patients with Kaposi's sarcoma. We met the patients and talked with them to see if they had 00:29:00any idea what was going on, if they knew any other gay men who had pneumocystis or other diseases, just to get a superficial view if they had any ideas of where things were occurring. The other reason, besides pneumocystis, the other reason I went along was because I had talked to a Dr. Alvin [E.] Friedman-Kien, who was also at that hospital, weeks earlier. In the early stages of this epidemic, probably the most common presentation was a wasting disease and diarrhea. At that hospital they had done stool exams on many of their patients and had found several parasitic infections -- Giardia and E. [Entamoeba] histolytica. At that time they didn't have a test for cryptosporidium, but he was concerned because 00:30:00some of these patients had chronic diarrhea and were wasting. He would have some that they would treat successfully and then come back two months later infected again. One of his theories was that maybe this immunosuppression is being caused by repeated bouts of frequent parasitic infections. I discussed that with him and said I didn't think it was very likely, because people in the tropics deal with these things for a lifetime, repeated infections, and we didn't ever see any immunosuppressive events like this in those areas. But it was something he had seen and observed, and it was good we had a chance to discuss it. Again, we discussed some of those things up there, but it was mostly Kaposi's and pneumocystis that were a primary concern. CHAMBERLAND: Obviously, yes, you mentioned Kaposi's sarcoma. I was curious, thinking back to your line listing 00:31:00that you, Sandy and others had worked on in collecting information about these patients with pneumocystis. Had mention of Kaposi's sarcoma come up, or was this a new one for you? JURANEK: Brand new for me. I didn't see anything there. I don't know if any of those -- I don't think those patients were ill enough, immunosuppressed enough to develop pneumocystis. CHAMBERLAND: Those who just had Kaposi's. JURANEK: Yes, just Kaposi's. I heard later that several of those people went on to develop pneumocystis, but I think at the stage that they were being diagnosed that they weren't that far along in their immunosuppression. CHAMBERLAND: You were going to visit patients you interviewed or patients in the hospital. What were your impressions? What was the clinical condition of a lot of these patients? JURANEK: I think they were very sick, very weak, wasted. Even 00:32:00the Kaposi's patients were just super thin-- they looked like they'd come out of concentration camps in Nazi Germany. They were concerned about their health but still willing to help. That was the other thing I felt very strongly about: that these people knew they were quite ill, and they were doing their best to give us information that might help. They really didn't have a clue. We talked about some of their activities, recreational drug use, sexual contacts, travel. Each one of them had slightly different stories. Their friends had different stories, they said, so they weren't sure what was going on either. But it was there, Both Jim and I knew that this is a real phenomenon. These people are ill, and they're presenting with all sorts of diseases that represent some type of immunosuppression. That's what we told John Bennett when we came back. He said, 00:33:00"We need to start moving on this. One of you guys is going to have to take the lead on this and get it started." To me it was a no-brainer that Jim was the best-qualified person to do that because of his past history in dealing with sexually transmitted diseases. He was familiar with the systems and processes. He took it on, and it was an excellent choice. He just had the right demeanor to handle patients, the politics and the medical community. They couldn't have picked a better person, from my perspective. CHAMBERLAND: When you were up in New York City with Jim for that first trip, I'm assuming you were up there for more than one day. JURANEK: We were up there for just a couple of days CHAMBERLAND: Just a couple days? JURANEK: Because the patients at the hospital, they had them grouped there. They had all the Kaposi's patients in one place and brought them down, so we were able to talk to them as a group in the amphitheater there. CHAMBERLAND: Oh, they brought the patients -- they had them 00:34:00move from their hospital rooms--oh, my goodness. JURANEK: Yes. It was a very efficient way to do it, and we just talked to some of the other doctors there. CHAMBERLAND: It sounds like you were seeing a lot of Kaposi's sarcoma patients. Obviously, it would not have been possible to bring a very ill pneumocystis patient down to an auditorium. JURANEK: Yes, they could barely talk. CHAMBERLAND: So a lot of the focus of the trip was on Kaposi's. JURANEK: Kaposi's, because those people were mobile and could talk and freely discuss things. The other people were just -- the pneumocystis ones were just too ill. I mean, they were on oxygen, high oxygen levels. CHAMBERLAND: Did you go to see any of the pneumocystis patients? JURANEK: We didn't. CHAMBERLAND: Was there an effort made, either by the physicians in New York City, Alvin Friedman-Kien you mentioned and Linda Laubenstein, or did you and Jim play a role in trying to document that these cases of Kaposi's sarcoma were unusual, in terms of the age 00:35:00group that was affected or the frequency? Was there any record review or anything that was done? JURANEK: No. This wasn't really an epidemiologic investigation. It was more just a fact-finding trip, to say did we really want -- should CDC really invest and gear up and do something in regards to this? Is it a true epidemic on the make early on, or should we back off? It was our determination that we really ought to go ahead and start this process. CHAMBERLAND: You mentioned that after your trip it sounded like the Task Force really started to become more formalized. Is that the right word? JURANEK: Yes. There was no Task Force prior to that. I would say within a week Jim had started arranging the group and bringing people in. 00:36:00CHAMBERLAND: Were you part of that group? JURANEK: No, I was not. I worked back in parasitic diseases. [Dr.] Harry [W.] Haverkos came to us as our EIS officer at that time, and he was quickly seconded to the group. That's the way I think a lot of the other branches participated. They had their EIS officer or some of their staff work in those areas for a while. The other major role was later on, trying to identify the intestinal pathogens involved in the chronic diarrhea of these patients. There was a great effort to bring stool specimens back to CDC and do a thorough exam -- viral exam, bacterial exams, parasitic exams, fungal exams, put them through every process that we had, to say what are the bugs here and are there any commonalities in that process. That was a process that went on for a year or so, 00:37:00trying to collect the specimens. CHAMBERLAND: I was going to ask you, because you talked about during the New York City visit meeting with Alvin Friedman-Kien, learning that a lot of these men had had repeated bouts of gastroenteritis related to Giardia and to Entamoeba. Was this something you were aware of previously, because these are parasites? Did any of these other organisms, apart from pneumocystis, require drugs from the Parasitic Diseases Drug Service? JURANEK: No. In retrospect I know we talked to physicians in New York and San Francisco about parasitic infections, but there were commercially available drugs to treat those. Metronidazole was commercially available, Flagyl, if you will. Some of the other drugs for Entamoeba were available, so it 00:38:00didn't require the Drug Service intervention. It was more just a consult: how do we treat these people with E. histolytica cysts, as they were asymptomatic cyst passers even before they got ill. CHAMBERLAND: I was curious if, in addition, as I said, to your pentamidine request, if there was anything else a little unusual that was coming to the attention of people in the Parasitic Diseases Branch, vis-à-vis parasites that people were having. It sounds like pretty unrelenting infections that weren't usual. JURANEK: At that time, working through the Drug Service, I wasn't aware that there were repeated infections. I think that was the new clue that Friedman-Kien brought into the picture. When we checked the history of these patients, probably in the late '70s --'79, '80 -- we were consulted on a number of infections in gay men. That's also when we began to 00:39:00find out some of these people did have international travel to tropical areas, and that's a high risk for some of these parasitic infections, too. That in itself was not too unusual then: to go abroad and have poor sanitation, you're going to likely acquire some of these organisms. That wasn't a red flag for us. It was this whole stuff about pneumocystis in healthy men that tipped the balance. CHAMBERLAND: Let's go back to pneumocystis then, and pentamidine and the Drug Service. Remind me -- you said before AIDS, on average in any given year, how many requests was the Drug Service getting for pentamidine? JURANEK: Probably 20 to 30 per year. CHAMBERLAND: That's 1981, '82, '83. What was happening in terms of frequency of requests? 00:40:00JURANEK: I think probably by the end of '81, we were beginning to assess the need to make another purchase. We did an inventory at that time and said, with the increase in AIDS patients we're running out of drug, and we don't have enough drug to go two years before another run. That became a quasi-CDC emergency of how to deal with that. We got back in touch with the drug company in London, and they said they did not plan to make another run for another three years. We were really concerned about how we were going to provide enough drug. It so happens that in the previous purchase, we not only got the bottled drug but also they had an excess run of 00:41:00synthesized powder that they didn't bottle. They asked us at that time if we wanted that powder, maybe about 10 or 15 pounds of powder at almost no cost. We said, sure, go ahead and send it with the drug. We had stored that in the freezer all that time. When we got to this point, there was not going to be another drug run from the company we got it from. Plus the FDA had stepped in and said, if you're going to do this again, we want one of our FDA inspectors to go over there and inspect the plant to make sure it's doing good manufacturing practices as we do in the United States. The European pharmaceutical companies were under no obligation to do that at all. They weren't selling drugs to pharmaceutical companies in the United States. It would be their gratis to do that, submit to FDA inspection, so another small wrinkle in the process. Then we began to focus on the powder we had left. The first step was to say, is this 00:42:00proper purity? It's been sitting here for three or four years. The CDC labs stepped in and said, we can do that. We can test for purity of this drug. They went ahead and did the purity test, and it was still 99% pure. We discussed that with FDA, and that was okay with them. Then it was a question of, we still have to find somebody that can process this powder back into an injectable drug. That search went on for several months. We finally found a manufacturer in the United States, a pharmaceutical company, that was willing to do that. I cannot remember the name of that company, but anyway they bottled it up. Then we had to write another IND, because (it was) a different pharmaceutical company and a different process. We finally got that IND approved. I think that came out in the MMWR somewhere in 1983, where CDC was distributing pentamidine under IND XYZ. Then 00:43:00the following year, I think in '84, a commercially available source became available from abroad again. They decided to go through the licensing process and get it commercially available in the United States, and we stepped out of the pentamidine business. CHAMBERLAND: Wow, I hadn't heard the details of that prior to this. Did you ever come close to running out? Was this a race against time? JURANEK: Oh, it was definitely a race against time. The number of cases was logarithmically increasing, and our supply was -- I don't know, we probably had maybe 50 to 100 patient-doses left at the time we had to rebottle the stuff, so we were getting pretty close. Of course, at the same time the cost of the drug logarithmically increased, so that was another issue. We weren't getting 00:44:00much support from Washington in terms of extra funding for CDC -- so that had to come out of CDC coffers, to cover the extra expense. When we started the pentamidine distribution, the patient dose was about $5 for the drug itself. It probably cost another $30 to ship it through Delta Dash. I think when it ended up, the cost of the drug was in the neighborhood of $600 to $800 per patient-dose. That doesn't sound like much in these days, but when you think of hundreds of patients, it was another forty or fifty or a hundred thousand dollars of expense that nobody was making up anywhere else. CHAMBERLAND: But were patients charged for the drug when it was under IND? JURANEK: No, no. CHAMBERLAND: These costs -- first of all, the procurement, buying it from the company in England and then storing it and packaging it up and shipping it, not 00:45:00to mention personnel cost-- you've got a drug technician, Sandy Ford, who is doing this as a job -- those were all costs that CDC had to absorb with no extra funding. JURANEK: That's correct, no extra funding. CHAMBERLAND: It eventually became $600 worth of resources. JURANEK: Yes, plus the distribution. We didn't talk further about distribution, but that was another change as the volume increased. We had discussions within CDC, saying, look, is there a more efficient way to get this drug to the destinations? That's when the U.S. quarantine representatives at CDC chimed in and said, we stockpile some vaccines at the quarantine stations around the U.S. at ports of entry. We could also stockpile this in our same refrigerators. All we'd need is an authorization from you guys to release it and where it needs to go. Sometime around that '82 mark, 00:46:00we began to stockpile the drug at U.S. quarantine stations, mostly at the airports around the U.S., the major airports that had international flights. That got the drug to people in just a few hours. That was a nice thing. CHAMBERLAND: The way this came about in Atlanta, did you start brainstorming this with the quarantine stations? Had somebody thought of this as a possibility? You made it sound like the quarantine stations volunteered. JURANEK: We had representatives here. John DiAgnes was one of them, and I think [Joseph] Joe Giordano had worked at quarantine, I believe. He was Assistant Chief of the Bureau of Epidemiology. Between him and John and a couple of other people, this came up at an informal meeting. They said, I think we can do this. So it got set up, and that was a good solution to the quicker distribution. 00:47:00CHAMBERLAND: There's a finite number of these quarantine stations. JURANEK: Almost all of them receive international flights. All the East Coast and West Coast places: New York City, San Francisco, LA, Chicago. You had a pretty good bunch. If you've got an international flight direct in, then you had a quarantine station. CHAMBERLAND: Given what you described in terms of the trials and tribulations of getting the manufacturer based in the United States to take the powder-- obviously I'm making it very simplistic, and essentially mix it up with some sort of -- JURANEK: Diluent. CHAMBERLAND: Diluent, thank you. I was searching for the word there. Were you relieved when pentamidine became 00:48:00available on the open market in the U.S.? JURANEK: It took a big burden off of us trying to get it out. Also, by that mechanism they could position it throughout their pharmaceutical range to make it more available to people. They could stockpile it at various hospitals. It wasn't any longer an emergency situation for the distribution part of it. It was still an emergency for treatment. CHAMBERLAND: Obviously, it was a better situation for patients and physicians, although the patients were probably going to have to pay for it now. JURANEK: Yes, that's true. CHAMBERLAND: Interesting thought, because this is happening in, I think about 1984, so three years or so after the initial recognition of an unusual occurrence. I'm assuming the Parasitic Diseases Drug Service was still keeping track of numbers of requests, obviously, and the line 00:49:00list. Had the pentamidine requests become sort of a surveillance system in itself, that you could cross-check with case reports that were coming in through other channels? JURANEK: I don't know how useful it was. I initially thought, working with Harry, that it might be very useful, in terms of not only a surveillance tool but getting back to people and doing investigations. In fact, most of those patients had died soon after receiving the drug, so we weren't very successful in trace-back. We had their name, we had the hospital, we had the doctor, but calling the doctors after these people had already passed was probably the saddest part for anybody participating in this investigation. You meet people, and three months later they're gone. Just a very fast thing. In terms of looking at reports for CDC, yes, it was useful for a short while, but 00:50:00as soon as the trimethoprim sulfa became available and commercial pentamidine became available, really (there was) nothing coming back, (there were) no requests back to us. CHAMBERLAND: Let me pick up on what you just said a little bit. From a personal perspective for you, for Sandy, you were on the receiving end of a lot of calls from probably pretty desperate physicians. The clinical community was reeling with the impact of such seriously ill young patients. I'm just curious, what impact did it have on you, Sandy, and others in your group from a personal perspective? JURANEK: I think from the volume of calls and consults, it certainly increased during the daytime. The hardest part was dealing with the after-hours and weekend calls. That put the burden totally on 00:51:00staff and EIS officers. It went from the guard calling us with a call, to wearing beepers and getting called at 2:00 in the morning, and getting up and going down to the airport. It was a real struggle for quite some time. People put a lot of effort into doing it, but again, we all felt this was lifesaving stuff. It wasn't something that could wait three weeks and you could send it out. It was emergency response. CHAMBERLAND: Yes, indeed. All of that just stopped once the drug became available -- JURANEK: Yes. That part was nice. We had very few calls after that late at night. We still had the occasional African sleeping sickness and the occasional other thing, but it went back to one every six months. CHAMBERLAND: I want to ask you about some other HIV-related 00:52:00parasitic pathogens, but before I do that, I do want to ask you: somewhere along the way the organism named Pneumocystis carinii underwent a name change. If I'm correct, it is now called Pneumocystis jiroveci -- JURANEK: jirovecii, I think. CHAMBERLAND: Can you explain why the name change? JURANEK: Yes. We had the organism in our branch because it was considered a parasitic disease. It was a peculiar disease, and it only got pigeonholed in that category because it did not look like a bacteria under microscope, it did not respond to antibiotics, it didn't look like a virus. It might have-- could have been a fungus, but it didn't respond to any of the antifungal drugs. By default it got targeted as a 00:53:00parasitic disease, but it didn't have the classic morphology of a unicellular organism with organelles inside. Then later, with the advent of molecular biology, being able to test DNA of organisms, type them out, it was shown to be much more closely related to fungi than to any parasites. Thus the name change. CHAMBERLAND: When did that happen? Did it obviously within CDC get moved from parasitic diseases over to fungal diseases? JURANEK: That molecular tool stuff really didn't develop until the '90s, so I think that was a rather late, late change. It had very little effect on what we were doing with the pneumocystis. 00:54:00We still consulted on it in the '90s by telephone calls. CHAMBERLAND: I'm just thinking, (it's) a bug that has been, for decades, slotted into a certain division within CDC. Then because of these advances in immunologic or genetic testing, it is found to actually represent an entirely different class of organism. I'm thinking that would be very difficult to move an organism, okay, no longer a parasite, a fungus, and to have another organizational entity within CDC to take responsibility, without any of this background --decades worth of background -- and expertise. Did that actually happen? JURANEK: Not to my 00:55:00knowledge. CHAMBERLAND: It's still within the parasitic division. JURANEK: I don't think there is a specific parasitic disease division [Division of Parasitic Diseases and Malaria] now, I don't think. I think they're wrapped up in a broader group of diseases. CHAMBERLAND: Ah, with one of the more recent organizations within CDC. JURANEK: Yes. Certainly none of the people from fungal diseases came knocking on our door and said, we really want this organism, especially in the days when it was a burden to carry it. But I don't think those DNA tests were available until quite recently. I'm guessing probably in the late '90s, maybe early 2000s, we were just doing that sort of work with some of the other parasites in that decade, malaria and diagnostic stuff with the DNA testing. I don't think that affected the early pigeonholing of the organism. 00:56:00CHAMBERLAND: Let's talk about some parasitic infections apart from pneumocystis. You mentioned some in passing, Giardia, Entamoeba, these were pathogens or opportunistic infections that were being seen in AIDS patients. You also talked about the very striking wasting syndrome and that a lot of these patients had diarrhea. You mentioned this very comprehensive effort to have stool specimens brought to CDC and put them through a lot of testing. What did this yield? Were there any new surprises, information about old pathogens, that you gleamed as a 00:57:00result of the AIDS epidemic or anything else? JURANEK: Not really. From a parasitic point of view, I don't think there was any large grouping of organisms that would explain anything in particular. I think the thing that I walked away with is that there were two organisms that were recognized later on. One was an organism called Entamoeba dispar, and it was important. This was a discovery made by [Dr. William A.] Bill Petri, [Jr.] at Uniformed Services University [Uniformed Services University of the Health Sciences] back in the '90s. He discovered that this organism was morphologically identical to E. histolytica, the pathogen that we were all dealing with from the tropics and other places. He had developed an immunodiagnostic test to differentiate it from E. histolytica, 00:58:00and that organism was found in several AIDS patients that he had looked at. I'm now thinking in retrospect that many of those repeated infections reported as E. histolytica, quasi asymptomatic, in patients back in the '70s and '80s were probably this organism, and we just could not make a distinction on morphological grounds. We had this whole population of infections that were designated as asymptomatic cyst-passers, passing E. histolytica cysts. Some of that had to do with AIDS, but a lot of it didn't have anything to do with AIDS, just populations in general, populations in orphanages and other facilities that took care of young children and had poor sanitation. We actually used that test 00:59:00on a water-borne outbreak of amebiasis in Tbilisi, Georgia, trying to make sure that what we were seeing in patients there was really E. histolytica and not [E.] dispar. Ours turned out to be E. histolytica. Those patients had liver abscesses and intestinal disease associated with that outbreak. But it was a new concept, that you could have an organism that's morphologically identical to E. histolytica and not be a pathogen. He (Petri) had seen this many times in Central and South America when they were doing studies down there. The other organism that cropped up on the screen is cryptosporidium, and that's an important story to tell. If it had not been for the AIDS outbreak, we would have never known that cryptosporidium could be a human pathogen. I think that's one important point to make. We knew, probably in the '60s, that cryptosporidium was an important cause of diarrhea in calves in the veterinary world, and a lot of 01:00:00activity was undertaken to try to control it in dairy herds and dairy calves and so forth. But until the AIDS epidemic came along, we didn't think of it as a human pathogen. For a while we just thought it was one of those opportunistic infections, again in immunosuppressed individuals, because that's where it was seen. Then a microbiologist by the name of [Dr.] Pearl Ma at New York University developed a modified acid-fast test. It was a great improvement over the old stain, which required a lot of heat and a lot of extra work. She began using that (new) test for AIDS patients at their hospital. One week, for about a 2- to 3-week period, they were having an outbreak of diarrhea in the hospital's daycare center. Staff would be able to bring their children in and leave them there and have good childcare services. They had looked for all sorts of 01:01:00bacteria and viruses, the usual suspects that might be responsible, and just weren't finding anything. She decided one day, I'll just try this acid-fast test and see what comes up. Several of these children had cryptosporidium, and they weren't immunosuppressed at all. It was the first recognition that this could be in a healthy individual and cause chronic disease. From that point on, people began using that test, including us at CDC. Probably within six months of that occasion, we started investigating several diarrheal outbreaks in daycare centers in the Atlanta area and found cryptosporidium. Then it became a big question of, how do you control this sort of thing. Usually you would wait until the children clear the parasite. That would be the recommendation (before returning to daycare), but we didn't know how long this parasite stays around. 01:02:00We began doing stool tests on children that were left out of the daycare center, saying, okay, before you return, the stool must be negative times three, to make sure that they're parasite-free before they go back in. When we did that, we found out these kids would still be passing oocysts occasionally 30 days out, 40 days out. We had to change our public health policy about keeping kids out of school. We had to think about something other than that, because what were these parents doing if they couldn't get back in their daycare center? Just put their child in another daycare center and start the problem all over again? It became a public health policy to simply wait till the diarrhea had disappeared, caution management to be very careful in diaper changing in those facilities, and keep the infected kids separated as much as you could. The other phenomenon that occurred at the same time was, in 1986 we had a water-borne outbreak of 01:03:00cryptosporidium in Carrollton, Georgia, just west of here 70 miles. That was initially responded to by the bacterial diseases folks, or viral diseases folks, because it presented with diarrhea, low-grade fever, some nausea and vomiting. They were working it up and weren't finding much. We had already made agreements between the viral, bacterial and parasitic diseases groups, that when an officer went out to the field, we would all back each other up with laboratory tests to make sure we were dealing with the right organism. Specimens came back to us and were just loaded with Cryptosporidia. This is a story that then launched us into water-borne cryptosporidiosis. Then a recreational water outbreak of cryptosporidium occurred at Whitewater Park in Georgia, with kids in a swimming pool getting infected. The common theme that links all this water stuff and the 01:04:00daycare center stuff is disinfection. They all have in common that they use chlorine, dilute chlorine for disinfection. The drinking water industry uses this, the swimming pool people use this, and the daycare centers squirt down the changing tables with chorine disinfectant. The concentration used in drinking water and recreational water and the changing table is about 1 to 3 milligrams per liter of chlorine. Laundry bleach contains 50,000 milligrams per liter. When researchers want to do infection studies in animals, they soak the cryptosporidium in laundry bleach to kill off all the bacteria, fungus and other 01:05:00organism, but all the cryptosporidium oocysts are still infectious. That told us that disinfection as we were practicing it, both for community drinking water and for swimming pools, was not going to touch that organism. It opened a whole new door for the need to change regulations and processes in the United States when dealing with water-borne disease and water treatment, all based on what evolved out of the AIDS outbreak. CHAMBERLAND: That's quite a story, that in the context of the AIDS epidemic a pathogen that had not really been on the scene or recognized becomes one of the opportunistic infections that cases of AIDS are getting. Because they're immunocompromised they're clearly not able to clear it. 01:06:00Really for a lot of them, their GI [gastrointestinal] symptoms persisted-- this was part of the wasting syndrome complex. Then it leads you to all sorts of other populations, risk groups, or risk factors associated with the infection. Now what you're saying is there's not really an effective way to treat infected water. JURANEK: There is, and that changed regulations in the way a lot of people operate. For the daycare centers, hydrogen peroxide is a more effective disinfectant, but we learned you can't just squirt it on the table and wipe it off, like you would do in any exam room. You've got to leave it on there and have a little contact time, maybe for several minutes, before it's really clean, kills the organisms. In the drinking water industry, there are two layers of 01:07:00treatment. One is the filtration part, and one is the disinfection part. In the filtration part we found that this organism was getting through some filters, as would some bacteria and viruses. If the bacteria and viruses got through, you had the disinfection waiting for it to finish it off, so it wasn't a big deal. For cryptosporidium that got through (the filtration), there was no safeguard left. The bigger utilities have moved on to either UV [ultraviolet] radiation of the finished water, which is highly effective against cryptosporidium, or a process of membrane filtration with reverse osmosis, and that would actually remove the organism. The EPA [Environmental Protection Agency] had to change their filtration guidelines for water treatment plants with respect to how well the water is filtered. Filter performance is measured in turbidity units, how 01:08:00much turbidity is coming through the water after treatment. Start with the Chattahoochee [River] that's red and muddy, and you come out with clear water, but there are different levels of turbidity there. The smaller utilities were often just barely meeting the EPA standards. The bigger utilities had qualified engineers trained to manage that much more effectively. They would get the water turbidity filtration down probably ten times better than the EPA required, sometimes 30 times better than EPA required. EPA then eventually had to say, okay, we've got to change our filtration regulations for smaller treatment plants, and we've got to start thinking about better disinfection. They also had to start thinking about sewage discharged into the rivers, because people were boating and playing in those rivers and streams around the country. That's still an issue that has to be addressed effectively. CHAMBERLAND: Is there treatment for cryptosporidiosis infection? JURANEK: There is Nitazoxanide. 01:09:00CHAMBERLAND: Obviously the key is prevention through the methods you described, in terms of water, filtration (and disinfection). JURANEK: The key is prevention. The problem with treatment in the otherwise healthy individual is that you would have to probably do it at the first sign of diarrhea. It's like the common cold: it's going to be self-limiting. In 7 to 10 days most people are going to get well and going to get over it. You wouldn't probably use this drug unless there was some reason to intervene very early to shorten the course of diarrhea, but most people are going to self-cure. That's probably why we didn't recognize this years earlier. You might have had water-borne disease forever, but diarrhea is such a common thing -- in the office physicians say, I don't know what it is-- 01:10:00it might be some virus going around. You could have hundreds of thousands of people infected that way. CHAMBERLAND: That is a very interesting story. Let me tie up a few things here. When I asked you a little while ago about further involvement with the Task Force after your initial visit to New York City with Jim Curran, you mentioned that your EIS officer Harry Haverkos was involved in work related to the Task Force. I'm thinking you had to have some peripheral involvement with the ongoing epidemic, given your subject-matter expertise in parasitic diseases and the development of guidelines about treatment of these diseases and whatever. Is that fair to say, that you did have? JURANEK: We had informal discussions. I don't think I ever attended a formal Task Force meeting. 01:11:00The questions that came up in that period of time, both with physicians at hospitals and with Harry and a few other people (were), what do you do when you have five patients with pneumocystis in your hospital? Do you do respiratory isolation? Do you leave them in the same room? Can you put somebody with pneumocystis in a room with an AIDS patient that doesn't have pneumocystis? It became a very difficult problem for most hospitals, how to bed these individuals safely, because there's always some concern about respiratory transmission of pneumocystis to somebody that didn't have it. We really didn't understand the true epidemiology of pneumocystis at that time. I'm not sure we still have a great handle on it, but there have been efforts in animal models to use immunocompromised nude mice and infect some with pneumocystis-- you can do that 01:12:00with a droplet inhalation or nose-- put them in cages upstream of a stream of air and put uninfected animals downstream and see if you get respiratory transmission. Just we were not able to do that. It just didn't seem to work. Yet, I said, if I were an AIDS patient without pneumocystis, I wouldn't want to be in a room with somebody that did have it. It just doesn't make any epidemiologic sense or medical sense to me-- you have to have the space to accommodate them. Later on, again, with molecular DNA analysis, there were some papers that suggested there might be respiratory transmission in hospitals, but (we were) still not very sure. At the time we were doing this, I was thinking that pneumocystis is probably like many fungi: it might be environmentally common all over the place. We all might be exposed to it from time to time, but with intact immune systems we're fine. If you happened to get immunosuppressed 01:13:00and you have that in your lungs, you might develop disease. The molecular tools are starting to tease that out a little bit, so maybe there will be some evidence of direct transmission. CHAMBERLAND: It sounds like, while you may not have been a formal member of the Task Force, clearly over the ensuing decades, 10, 20 years, your expertise in parasitic diseases was still something that was very much helpful in consultations related to infection control or treatment or prevention guidance. JURANEK: Yes. We haven't talked about Toxoplasma, but that's another one that came up occasionally (in discussions of) how to manage those things. It was an epidemic that involved everybody's time and attention. A 01:14:00lot of it was directly on the Task Force and going right out and dealing with patients in all the states, but there's a lot of background work still being done at CDC between the patient interfaces. CHAMBERLAND: AIDS actually was a part of your extensive career at CDC. Obviously your career at CDC included quite a diverse range of pathogens and problems and whatever. I'm curious, given that you had an intense early experience and then maybe some ongoing intermittent consultations related to issues that cropped up about AIDS, did it nonetheless have any lasting impact on you, those early days? When you think back to them, was there anything else comparable that came up in your career? 01:15:00JURANEK: Oh, nothing comparable. I think it was the epidemic of the second half of the 20th century that without a doubt was career-defining for many people at CDC. Even if it wasn't part of your career endeavors, there were very few people who weren't touched in some way by this epidemic. It didn't matter if you were in the lab or you were a secretary, you were doing something sometime, budgeting something, administratively working on something that had to do with AIDS. It was an all-hands epidemic. You got seconded to do this or that, and what was amazing to me is that nobody complained. People said, yes, this is real, we're going to contribute our part, do what we can and go on. CHAMBERLAND: This has been very interesting chatting with you, Dennis. Thank you so much. Any closing thoughts, anything we haven't covered? 01:16:00JURANEK: Not really. I think the only thing that did strike me and really had a lasting effect was in the early days at the American Society of Tropical Medicine meeting. I can't remember which city it was in, but Jim (Curran) was speaking there, as well as [Dr.] Anthony [S.] Fauci and a lot of other AIDS researchers. We had just got started in the program, and the program got disrupted by Act Up folks. They came in and disturbed the whole process. This was my first exposure to that type of activity. Now in retrospect I can see why they were upset, because the government politicians were just ignoring it. They wouldn't speak about it 01:17:00politically. None of the congressmen would ever say the words, and the President [Ronald W. Reagan] wouldn't. But it struck me as really sad, because I knew all those people at the meeting were working their ass off to try to help them, and they were disrupting discourse. That left a negative taste in my mouth for that activity. It wasn't until later on that I came to understand why they were frustrated, but they happened to hit the wrong group. They aimed their comments at the wrong group, because everybody there was seriously trying to help. That was also my first foray into realizing how politics influences public health. It was a really difficult time in the beginning to get any political support, any funding for the AIDS outbreak. I thought that was extremely sad, given the amount of effort that people were putting into this on their own, their own 01:18:00funds. CHAMBERLAND: Dennis, as I said, it's been a real pleasure chatting with you. Thank you so much for coming and talking with us this morning. JURANEK: Thank you. I enjoyed it. 1