Dr. Gary Noble

Dr. Gary Noble

CHAMBERLAND: This is Dr. Mary Chamberland, and I am here with Dr. Gary Noble at the Centers for Disease Control and Prevention [CDC] in Atlanta, Georgia. Today is Thursday, May 19, 2016. I'm interviewing Dr. Noble as part of the oral history project, "The Early Years of AIDS: CDC's Response to an Historic Epidemic." We're here to discuss your experiences during the early years of CDC's work on what would become known as AIDS [acquired immune deficiency syndrome]. Dr. Noble, do I have your permission to interview you and to record this interview?

NOBLE: You do have my permission.

CHAMBERLAND: Gary, you began your CDC career as an Epidemic Intelligence Service [EIS] Officer from 1965 to 1967. Much of your early work at CDC was focused on studies of respiratory viruses, particularly influenza. Then in the 00:01:00early-to-mid-1980s, you assumed a series of senior leadership positions at CDC. This was during a critical time for CDC's initial response to the emerging AIDS epidemic, which we will discuss in some detail. However, before we go there, let's talk a little bit about your background. To start off, could you tell us where you grew up, a little bit about your early family life, and where you went to college and medical school?

NOBLE: I grew up near Lansing, Michigan, in Clinton County, in the country on a farm, which has been in the family for now five or six generations. I was born in the front bedroom in a house without running water or central heat. It was a wonderful, wonderful place to grow up. I was in charge of my own big garden; I was the third of four children, and I decided although I loved where I grew up 00:02:00and the work I did that I didn't want to be a farmer for the rest of my life. My older brother fortunately was willing to do that. I went to a one-room schoolhouse, red brick, with one teacher for grades kindergarten through eight, and my class was the biggest, with four of us. My sister was a class of one. It was a great place to grow up and with all the wonderful family. My dad's parents and my mother's parents lived within a half-mile or a mile, and we saw a lot of them; we worked very much together as a family. It was a very tight-knit Protestant community. There was one Catholic family who went to a Catholic school, but it was a very typical, Midwestern Anglo-Saxon community.

CHAMBERLAND: You said you didn't want to be a farmer, so you made your way out 00:03:00of the one-room schoolhouse to college and medical school?

NOBLE: My mother was a wonderful person in terms of her aspirations for the children. My brother had not gone to college. My older sister did, but my mother was quite fond of the small, private liberal arts college affiliated with the Methodist church, Albion College. I applied there and went. I didn't really know what I wanted to do, except I started thinking about pharmacy and then quickly changed to dentistry, pre-dentistry. My grades were better than my pre-med classmates, so I decided to switch to pre-med. Albion had a program with the University of Michigan so that if you finished your first three years at Albion, you were admitted to medical school at the University of Michigan in your first 00:04:00year and you would get your diploma from Albion after the completion of your first year at the University of Michigan. That's how I got into med school.

CHAMBERLAND: And then after med school, a residency?

NOBLE: Let me just add that at the beginning of my second year, we didn't have a lot of money, and so a friend and I--I met a classmate in med school--were the caretakers for a house where faculty members lived. It was an old house that had been put into apartments, and we lived in the basement right behind the furnace. One day he said, "I'm going to go apply for a Rhodes Scholarship." I said, "What's that?" He told me, and I said, "That sounds interesting; I think I'll apply too." So we went through the University of Michigan interviews and then the Michigan state interviews, and then two were chosen from Michigan to go to 00:05:00the regional interviews in Chicago. I was chosen; he was not. His girlfriend was quite happy, because you couldn't be married in those days and be a Rhodes Scholar; Cecil Rhodes was a confirmed bachelor. Oxford was all-male back then as well. Anyway, I completed my second year of med school at the University of Michigan and went off to Oxford.

CHAMBERLAND: This is Oxford, England?

NOBLE: Oxford, England, yes, University of Oxford--to one of the largest, oldest colleges. I just went to the 750th anniversary last year of Balliol College. That was a wonderful, wonderful experience for a kid from the farm, being thrown into a mix of people from all over the world. I studied in the Honour School of Mammalian Physiology and got a Masters from Oxford University in that degree. It was just a marvelous experience, rowing for the college; it was great fun.

CHAMBERLAND: So you rowed.

NOBLE: Learning various games that we don't play in the U.S. I'm not very good at cricket, however. Then, because I had somewhat repeated the basic science at Oxford that I'd already had at the University of Michigan, I didn't have the clinical years, so I did a very unusual thing. I went back and completed my last two years of med school after having done the first two at the University of Michigan. By that time all of my friends at Oxford were going back to Harvard or Yale, so I applied and was accepted at Harvard. So, I have a Harvard MD with only two years of tuition.

CHAMBERLAND: That was a good way to do that.

NOBLE: Classmates at Harvard included--not classmates, but people doing post-graduate work, included [Dr. James W.] Jim Mason, [Dr.] Bruce Dull and [Dr. 00:07:00Theodore] Tedd Eickhoff, whom I got to know at some of the clinical rotations.

CHAMBERLAND: Jim Mason, obviously, became a CDC Director years later, and Ted Eickhoff?

NOBLE: Colorado.

CHAMBERLAND: Colorado, very prominent infectious disease physician.

NOBLE: Bruce Dull, Deputy Director of CDC.

CHAMBERLAND: When did the whole idea of getting into public health, coming to CDC, how did that all materialize?

NOBLE: When I matched for internship with the University of North Carolina at Chapel Hill, the Chief of Medicine called us all together about two or three months after we arrived and said, "I can't run a hospital with the draft taking my residents away, so any of you who want to stay here for residency will be given first preference if you've already done your duty or signed up to defer." So I went on and applied to the Public Health Service, hoping to be admitted to CDC, and I applied to the Air Force as a backup. The paperwork was two weeks 00:08:00more efficient by the CDC; otherwise I would have ended up doing two years with the Air Force and going back to a fellowship in nephrology at the University of North Carolina [UNC] under a well-known nephrologist, [Dr. Louis] Lou Welt. I'm so glad I didn't do that.

CHAMBERLAND: As are we.

NOBLE: I got a telegram a few weeks later, saying, "Congratulations, you've been assigned to the prison hospital for the Public Health Service in the Bay of Los Angeles." I said, "That's not what I expected." I called the then-senior person at CDC in charge of the EIS Program and dropped the names of Mason and Dull and Eickhoff, and I said, "I really want to come to CDC." He said, "Well, I don't have the file, but if you want to ask to transfer the file, we'll see what we can do." So I was accepted into the EIS Program. During my two years of residency I was called by CDC and asked [if I] would like to be a physician to 00:09:00the Peace Corps. I would love to have done that, but I chose to finish my residency. So I then ended up with CDC to do my two years of military duty, planning to go back to a nephrology fellowship at UNC. I was assigned to Omaha, Nebraska, to oversee a study of respiratory virology disease in the Omaha Home for Boys. In November, [Dr.] Tom Chin, who headed that program from the Kansas City Field Station, called me into his office and said, "Would you like to go to start a study for CDC among Eskimo children in Alaska?" I said, "Sounds great."

CHAMBERLAND: So that's how you got into the area of respiratory viruses and influenza, just by virtue of your early Epidemic Intelligence Service assignments. Interesting. When you were at Harvard with Jim Mason and Ted 00:10:00Eickhoff and others, did you talk about the Public Health Service among yourselves? Was it something that you all thought was an interesting career path, or was it just a better alternative than being drafted to go off to war?

NOBLE: I had no knowledge of CDC. I was in the library of the West Roxbury VA [Veteran's Administration] one day, and Jim Mason was there. I went and introduced myself and asked him to tell me about himself. He told me a little bit about CDC. When I was told by the Chief of Medicine at the University of North Carolina that we should seek a [draft] deferment, that's where I wanted to be with people, and I got to know Bruce Dull, with his lavender Cadillac.

CHAMBERLAND: Really? Oh, gosh. That sounds very interesting. So you finished 00:11:00EIS, and then after that what happened?

NOBLE: Instead of going back to the fellowship, I called Lou Welt at Chapel Hill and said, "I'm going to extend for a year." I did that two years in a row, and I finally called and said, "Thank you for the fellowship, but I'm staying with CDC." Tom Chin said, "If you're going to stay with CDC for career development, you need a Masters in Public Health. Where would you like to go?" So I'd been there, done Harvard. I could have done [Johns] Hopkins or Berkeley. I went to the University of California in Berkeley during the height of the Vietnam War protest, an interesting time.

CHAMBERLAND: Oh, yes, OK.

NOBLE: Then I went back to the Kansas City Field Station to head up their respiratory virology section. Under the Nixon administration that [unit] was 00:12:00closed. I almost stayed in the University of Kansas in the med school, but I chose to stay with CDC. I looked at various options within CDC, and Walt Dowdle said, "Why don't you come to work for me?"

CHAMBERLAND: At that time Walt Dowdle was ___?

NOBLE: He was Chief of the Virology Division.

CHAMBERLAND: Chief of the Virology Division, okay. So that's how you came to Atlanta and then started your Atlanta-based career in influenza, respiratory viruses. Let's shift now to your involvement in what would become known as AIDS. How did you first learn about the cases of, the early cases of Pneumocystis carinii pneumonia and Kaposi's sarcoma that were reported among homosexual men? I believe you were taking a sabbatical year back in Oxford, England, at the time 00:13:00these first MMWRs [Morbidity and Mortality Weekly Reports] were published in 1981.

NOBLE: Yes. After seven years in respiratory virology [Chief, Respiratory Virology Branch, Bureau of Laboratories, CDC (1973-1980) ] with Legionnaires' and swine flu, I asked Walt, who had just finished his sabbatical in New Zealand or Australia, if I could do something with my then-WHO [World Health Organization] counterpart in London at Mill Hill. He said fine. I called [Sir] John James Skehel, who is a Welshman, head of the WHO Collaborating Centre for Influenza in London. He said, "I'd love to have you, but you really need to work with [Professor Sir] Andrew McMichael at Oxford." I said, "Oh, I've heard of that place." So, I called Andrew, and he said fine. I was coming on a salaried position, so he didn't have to worry about funding. When that year was nearly ended, I was attending the International Congress of Virology in Strasbourg, 00:14:00France, and Walt and I had lunch together.

CHAMBERLAND: This is Walt Dowdle, and he was over attending the conference?

NOBLE: Yes. He said, "Have you been reading the MMWR?" and I said, "Yes." Bev Lawrence, my administrative assistant at CDC, had been faithfully sending them weekly. He said, "You've seen the cases of Kaposi's sarcoma and Pneumocystis pneumonia." And he said, "I think this is going to be something big."

CHAMBERLAND: Quite prescient on his part. Professor Andrew McMichael was an accomplished cellular immunologist, so what a stroke of luck or genius to have that in your back pocket as this epidemic begins to unfold. Were you able to draw on your sabbatical year as AIDS unfolded and cellular immunology obviously 00:15:00was going to be a big part of understanding the AIDS epidemic?

NOBLE: When I came back to CDC, and Walt, by the way, when we were talking about what I wanted to do after Oxford, said, "You can come back to CDC, or you can go to the WHO and work with [Dr.] Fakhry Assaad." That conversation preceded the publications of Kaposi's and Pneumocystis carinii. I was all set to go to WHO and work for Fakhry.

CHAMBERLAND: And Fakhry was the __?

NOBLE: Fakhry Assaad was Director of the WHO Division of Communicable Diseases.

CHAMBERLAND: This would have been in Geneva, a Geneva position?

NOBLE: Yes. My wife and I went and interviewed, and my wife thought Atlanta sounded better than Geneva, although the two kids were quite happy to go to Geneva. Anyway, I chose to come back to CDC, and Walt asked me to head up the 00:16:00Division of Viral Diseases; he had moved on to become Associate Director for Science.

To answer your question about cell-mediated immunity, there was nothing really happening in the CDC virology lab in that field at the time. It was relatively a new field, cell-mediated immunity. I watched with intense interest all of the work that was being done by [Dr. James] Jim Curran, [Dr]. Harold Jaffe and the whole group working on the epidemiology of AIDS, and I watched with great interest [Dr. Frederick] Fred Murphy and [Dr. Thomas] Tom Spira trying madly to identify the virus and grow it in cell culture. In retrospect, they did see the 00:17:00virus once they had the immune sera and could show it, but they didn't isolate the virus, of course. So, I didn't really work directly on AIDS during that three-year period. I became the Assistant Director for Science in '85, I think it was.

CHAMBERLAND: '83, I think.

NOBLE: '83 to '86. I got a call from Walt one afternoon late in '84, saying, "Would you be interested in chairing a conference on AIDS?"

CHAMBERLAND: Oh, yes, I want to get to that. Can I take us back a little bit, though, first, to your time in the Division of Virology? I wanted to clarify: at the time, did the Division include both laboratory and epidemiologic components, 00:18:00or was it the time-- ?

NOBLE: That was pre, yes.

CHAMBERLAND: Or this was the time when the labs were separate from the Division?

NOBLE: That was the Bureau of Labs, when it--

CHAMBERLAND: So the virology labs were in the Bureau of Labs?

NOBLE: Robinson, Dr. Robinson, Roslyn Q. Robinson and Walt--

CHAMBERLAND: OK.

NOBLE: Yeah.

CHAMBERLAND: Were you yourself doing laboratory work?

NOBLE: We were really primarily the epidemiology, although--that is personally--although there was a very good respiratory virus lab that Walt had created and Marion Coleman had overseen. It was traditional virology: isolation, cell culture, fertilized eggs for influenza and a serology lab doing complement fixation and so on for diagnostic purposes.

CHAMBERLAND: So you were getting, CDC was getting specimens from some of these 00:19:00early cases, and then trying along with many other people--

NOBLE: But they weren't coming into my lab, because the respiratory viruses and AIDS were--

CHAMBERLAND: Right, I see what you are saying. Ok.

NOBLE: --and, what's his name, who had been in the Phoenix Field Station, came to--

CHAMBERLAND: Oh, Don Francis?

NOBLE: [Dr. Donald] Don Francis ended up heading up some of the overall [AIDS] laboratory work at CDC, but Fred Murphy and Tom Spira were the ones doing the electron microscopy.

CHAMBERLAND: Do you think it was pretty early on that many of you started to think that this is likely going to turn out to be a virus? Because early on there were lots of things that were being put out there--bad drugs, poppers. But the virologists quickly came to the conclusion that [it's] likely going to be a 00:20:00virus here.

NOBLE: Yes, I think there was a general consensus, although clearly we didn't have a virus. It certainly wasn't a bacterium that anybody knew, although we learned from Legionnaires' [disease] that you don't always grow the bacterium the first time around, until [Dr. Joseph] Joe McDade did that-- Legionella [bacterium]. We all, I think, many of us in the field of virology, assumed that it must be an infectious agent, probably not a bacterium nor parasite.

CHAMBERLAND: At the time, initially, CDC, I guess until the arrival of Don Francis, really didn't have a retrovirologist on staff.

NOBLE: That's my recollection.

CHAMBERLAND: Whereas other laboratories, such as those at the National Institutes of Health (NIH), and in France and other places did. CDC was a little bit behind, two steps behind in the discovery process. You were more focused on 00:21:00epidemiology, were you?

NOBLE: I wasn't at the time when I was Head of what became--

CHAMBERLAND: You became the head of this Division?

NOBLE: I became the Acting Director of the Division of Virology, yes. There was not really [AIDS] epidemiology [being done in the Division of Virology]; that was being done by Jim [Curran] and Harold [Jaffe].

CHAMBERLAND: The [AIDS] Task Force?

NOBLE: The Task Force, so it was the laboratory work we had at the time.

CHAMBERLAND: What's your recollection about the atmosphere at CDC during these very early days? We're talking 1981, 1982. Do you recall what the atmosphere 00:22:00among people was?

NOBLE: One of intense, long days, weekends, working to understand. We weren't really into the virology per se at that point, but when the laboratory diagnostics needed to be done, the CDC obtained the specimens from [Dr. Robert] Bob Gallo. I understand that CDC provided specimens to Gallo and [Dr. Luc] Montagnier [at Institut Pasteur]. Once the virus was available, then CDC developed the diagnostic laboratory capacities, which was key. We weren't really doing the epi, because that was being done by the Task Force. It was an intense period of time.

CHAMBERLAND: Long days. You then, as you said, were in the Division of Viral Diseases for a couple years. Walt asked you to move on to become CDC's Assistant Director for Science, and that was a position that you held for three years. Can you talk a little bit about your involvement in the epidemic, from the vantage now of this leadership and policy position within CDC that you were now in? You mentioned the AIDS conference; we can talk about that, but I was just trying to get a sense of [whether] you were immediately thrown into issues within the agency and then our relationship with other Public Health Service agencies.

NOBLE: Initially, I was still working on some respiratory vaccine development, not hands-on, but administratively. I was asked to chair an interagency group 00:24:00with the wonderful title of Interagency Group to Monitor Vaccine Development Production and Usage, collaborating with NIH and FDA [the Food and Drug Administration]. I and my FDA counterpart did some trips to Japan to try to figure out why their pertussis vaccine was better than anything we had. So that was a period, and we visited with [Dr.] Lars-Olaf Kallings in that context as well, because the U.S. didn't really have the best vaccine at that time. When Walt called, as I mentioned briefly earlier, one afternoon in late 1984 to ask if I would chair an international conference on AIDS, I guess that's when I really got most involved with the AIDS world.

CHAMBERLAND: Ah, so it was the conference.

NOBLE: I initially said, "No, I'm too busy."

CHAMBERLAND: Oh, you initially said no.Is that allowed?

NOBLE: I called back the next morning and said, or probably walked into his office and said, "Yes, I'll do it."

CHAMBERLAND: The International AIDS Conferences have now [become] an annual event--I think the 21st Conference is going to be happening this July in Durban, South Africa-- but I've always wondered how was it that they came about. You said you got a call from Walt. Was there dialog within the various Public Health Service agencies? Who came up with this idea?

NOBLE: You'll have to ask Walt. Hopefully in his interview he touches on that. This reminds me of how much we all owe to Walt Dowdle as a wonderful figure at CDC. I don't know if Walt had talked to FDA and NIH about that, but FDA and NIH 00:26:00became co-sponsors of the first International AIDS Conference in 1985. We had on the planning committee representatives from many groups around the country, but it was really co-sponsored by CDC, FDA, and NIH, with support from, not financial support, but support from Emory University and Morehouse [College].

CHAMBERLAND: And you were chairman of the program committee?

NOBLE: Right.

CHAMBERLAND: This is 1985, when the conference was actually held?

NOBLE: When the planning began.

CHAMBERLAND: But the planning began a year before?

NOBLE: WNot a year, but it began in late '84 and then was really in full force in early '85. The first planning conferences were held in early '85. I invited the planning committee, but I specifically invited, of course, FDA and NIH and 00:27:00in particular, Bob Gallo from NIH.

CHAMBERLAND: You must explain a little bit about Bob Gallo.

NOBLE: I invited Luc Montagnier, because by then the world was beginning to understand that they had a virus, beginning to understand that virus. Bob Gallo didn't bother to come from NIH, but Luc Montagnier came from Paris. I had drafted a program, an initial plenary session program following Secretary [Margaret] Heckler's opening comments.

CHAMBERLAND: She was Secretary of Health and Human Services, yes.

NOBLE: Then I had Jim Curran and Bob Gallo as the two opening plenary session speakers. I presented that to the panel, and Luc Montagnier said nothing. A week later, Luc called from Paris and said, "My colleagues in Paris think that I 00:28:00should be included in that opening plenary session." I said, "I agree." So I called Bob Gallo and said, "There are now three in the opening plenary session," and he said something I won't repeat about having been asked to do that by Dr. Montagnier.

CHAMBERLAND: Bob Gallo and Luc Montagnier; Bob Gallo is at NIH, Montagnier is at the Pasteur Institute, and these were the two individuals who history often calls the co-discoverers of the virus. At that time [it] hadn't even yet been named HIV or human immunodeficiency virus.

NOBLE: It was called LAV/HTLV-III [human T-lymphotropic virus type III/lymphadenopathy-associated virus (HTLV-III/LAV)].

CHAMBERLAND: Very complicated naming. So Bob Gallo chose not to?

NOBLE: He ended up in the plenary.

CHAMBERLAND: He did end up?

NOBLE: Oh yes. He followed Jim Curran, followed by Luc Montagnier.

CHAMBERLAND: So a lot of -- Besides organizing the program, obviously there were 00:29:00some delicate political issues that you had to navigate around. I'm trying to think: it's April 1985. It's at a time where--

NOBLE: May I just follow one comment?

CHAMBERLAND: Oh, yes, please.

NOBLE: At the end of the opening session, there was a press conference with Secretary Heckler and Bob Gallo and Luc Montagnier. There were lots of questions from the news media, of course. One of the questions was, "When are we going to be able to control this?" If my memory serves correctly, Secretary Heckler said, "I think we'll have a vaccine in five years." That of course has not happened.

CHAMBERLAND: Yes, that was a very optimistic projection. I wanted to get a 00:30:00sense, as the conference is unfolding, people are hearing scientific presentations suggesting -- that there were almost ten thousand cases in the U.S. at the time, cases of AIDS. They're hearing presentations about-- this is the tip of the iceberg; there are likely tens of thousands of more infected individuals in the United States; long incubation period; terrible spectrum of clinical manifestations. Do you remember the mood of participants at the conference, because this was really one of the first gatherings to get all of the people essentially collected in one place to bring the current information together. What was that like?

NOBLE: I think there was just a lot of uncertainty, unknowns at that time, waiting for more information on the virus and trying to understand more 00:31:00completely--which the Task Force at CDC was unraveling rapidly--the modes of transmission, the incubation period, methods of transmission (sexual, blood borne, hemophilia products, factor VIII, and of course needle exchanges). I remember very vividly the ninth, I think it was, International Conference, in Berlin, when Jim Curran and I were invited by the head of the group there in Berlin to be shown around some of the parts of Berlin where AIDS had some of its highest rates of incidence, and they took us to the needle exchange posts. Europe was way ahead of us in many ways.

CHAMBERLAND: This was obviously, certainly a highlight or a big part of your time as CDC's Assistant Director for Science. In your time as CDC's Assistant Director for Science, how were things going in terms of the various Public Health Service agencies, the FDA, the NIH, and CDC. Was there an effort to try and get the agencies to collaborate or coordinate? Did you get drawn into any of this? Was there competition, turf issues? I'm curious how the agencies--it's still fairly early days, how are the agencies interacting with one another?

NOBLE: From my personal perspective, it was always very collegial. You're going 00:33:00to get to this role that I had later on, working in Washington, but it was always this wonderful camaraderie with [Dr. Anthony] Tony Fauci and the colleagues at the National Institute of Allergy and Infectious Diseases (NIAID) and the FDA counterparts; very, very collegial. Very interactive. I think NIH would have been happy if CDC had never been invented, but we are here.

CHAMBERLAND: Yes, that I guess persists to this day. Clearly CDC had done a lot of that and was continuing to do a lot of that initial shoe-leather epidemiology, and NIH was obviously doing some of its own epidemiologic studies and a lot of laboratory work and clinical work. [Is there] anything else that 00:34:00stands out in your mind about that before you headed off to Washington yourself? Any issues, thorny issues that came up that you had to get involved in when you were the Assistant Director for Science, in terms of AIDS? It sounds like a lot of it, the Task Force, was directly-- so you were spared, at least a lot of, some of that, as the Assistant Director.

NOBLE: I got involved in helping to build the maximum security lab at an administrative level.

CHAMBERLAND: Oh, interesting.

NOBLE: Under [Dr. James] Jim Mason.

CHAMBERLAND: Jim Mason, the CDC Director at this time. That's when the discussions about the maximum security laboratory came up?

NOBLE: An agency was hired to develop the plans and all of the detailed workings to make the maximum security laboratory safe and functional. The architects 00:35:00recommended the building we now have, which has a very open atrium, and Jim Mason said, "That's a waste of space." But we persisted, and I said, "These people need somewhere to go [when they're] out of their suits in their maximum containment space." So we have that nice atrium in the maximum security laboratory.

CHAMBERLAND: Had CDC been able to do some laboratory work that involved these special pathogens like smallpox virus, and that we had been able to do it, but not obviously optimally?

NOBLE: Yes, and don't press me on what we were doing before the maximum security lab, because there was one memorable lapse where the disposal of some pathogens 00:36:00was not properly done and a couple of our janitorial staff succumbed.

CHAMBERLAND: And this was to?

NOBLE: I don't remember the pathogen that caused it.

CHAMBERLAND: I was wondering, was this one of the rickettsial viruses, perhaps?

NOBLE: Perhaps.

CHAMBERLAND: I'm not sure. We both have to go back and check on that. I think it is time to move on to talk about your tour of duty in Washington, D.C., as National AIDS Coordinator. This takes us to 1986-87, and I want to set the scene a little bit. Ronald Reagan is President when you go up to Washington. [He] has yet to publicly speak about the epidemic, and several landmark reports had been recently issued or are about to be issued. One was that the U.S. Public 00:37:00Health Service had held a retreat with key Public Health Service staff in Coolfont, West Virginia, and had come out with a plan for prevention and control of AIDS. The National Academy of Sciences' Institute of Medicine had published their report, called "Confronting AIDS." The report highlighted and underscored the need for massively increased federal funding for education and research, and last, but certainly not least, U.S. Surgeon General C. Everett Koop had issued his plain-talking report on AIDS. Into this mix, you arrive. You, once again, followed Walt Dowdle.

NOBLE: Yes. Walt had started that.

CHAMBERLAND: He was the first National Coordinator? Did he have any words of advice as he was handing over the reins?

NOBLE: He always had advice. I don't remember specifically, but probably "Have a good time." I was happy to do this. I ended up there with no real staff in the Humphrey Building.

CHAMBERLAND: Is this where Health and Human Services was located?

NOBLE: In the Hubert Humphrey Building, yes, near the Capitol [Building]. I had an office down the hall from Dr. Koop and got to be very good friends with him. Dr. Koop told me that the first he had known that he was going to be writing a report on AIDS to the nation was when he was in the Great Hall of the Humphrey Building and President Reagan was speaking. Apparently, Koop learned that he was 00:39:00being asked by the President to write a report during a speech at that time. Koop took it very seriously and interviewed nearly thirty different groups from across the spectrum of opinions on AIDS; from very conservative to very liberal, progressive points of view, including the AIDS community, the gay community. He wrote the report standing up at a lectern in his house. He had one NIH staffer who supported his work, arranging the interviews and all this sort of thing. He finished his report. The Surgeon General has a very limited budget. He printed I think it was a thousand copies, called a press conference and then left with [Dr. James] Wyngaarden, the head of NIH, for a trip to Europe.

The new Assistant Secretary of Health, [Dr. Robert] Bob Windom, had another NIH 00:40:00staffer who called me in and said, "I've cancelled Dr. Koop's press conference. It should be released as part of my boss's plan for addressing AIDS to the nation." He said, "Gary, I want you to develop a plan and bring it back for Dr. Robert Windom, the Assistant Secretary for Health." That's when I called Walt and said, "Help!"

CHAMBERLAND: Wow, that's an interesting behind-the-scenes story.

NOBLE: There was some initial work at CDC to support that concept [National AIDS plan]. Dr. Koop got back from his trip to Europe and realized his press conference had been cancelled. He went to see Secretary Otis Bowen, the Secretary of HHS, and walked out with approval to have a press conference. Dr. Koop rescheduled his press conference within a week and distributed copies of 00:41:00his report. Previously he had taken copies of that report to a cabinet meeting in the White House, numbered copies, handed them out to the White House Cabinet for their review and asked that the copies be returned. They approved it, and that's when he called the press conference. By the end of the day at the press conference, which was very interesting, because there were tons of questions of Dr. Koop. "When should I tell my children anything about this?" Dr. Koop, a wonderful, wonderful spokesperson, said, "I have several grandchildren." He named one and said his age, and he said, "He's ready to know, to understand some of what's going on, but another child, my grandchild, is not yet ready." It has to be tailored to the individual. By the end of the day of the press conference, having handed out copies to the press and to every member of Congress, there 00:42:00were no more copies left.

Dr. Windom's staffer, whose name I repress, called me in with a staffer, Bruce Artim, who was a friend of Dr. Windom's, and said, "What are we going to do? We have the world clamoring for Dr. Koop's report." I became a little frustrated. I'm generally quite mild mannered, but I put my green-covered notebook down quite firmly on the table with a little audible sound and said, "We'll look into it." Bruce and I went back to my office, called Tony Fauci, and said, we need copies of Dr. Koop's report. He said, Do you have camera-ready material? and I said yes. So we went out on Friday afternoon, Bruce Artim and I, to Tony Fauci's office, and by Monday or so, there were something like ten thousand copies. I 00:43:00don't know, a lot of copies, which then solved the immediate problem of copies of Dr. Koop's report.

CHAMBERLAND: That's a very interesting story. Obviously, Dr. Koop's report was plain-talking. It got a lot of press and interest, as you say, and I think probably caught, even though he had distributed it at a Cabinet meeting, it nonetheless caught the White House and others in government a little off guard. They weren't expecting this, I don't believe.

NOBLE: Right.

CHAMBERLAND: Interesting. So that was some of the problem-solving you had to do. I'm thinking also back to that time to some of the very hotly contested issues of the day. One was around HIV testing. What was the role of HIV testing? There 00:44:00were lots of controversies and issues about testing of individuals. Did you get drawn into any of that, because there were calls for all sorts of policies to be developed? I was wondering.

NOBLE: During that year working for Bob Windom, there were, I think, weekly meetings in Dr. Windom's office with Tony Fauci and FDA people to talk about a variety of issues. That was just an ongoing debate and I don't remember any particular focal point reaching a crisis. Yes, there were a lot of questions about who should be tested [and] when. If I could just jump briefly forward for a short point: when I left CDC and was recruited to work for Johnson & Johnson for a start-up company that offered, planned to offer, an opportunity for a 00:45:00person to go and buy a kit in a pharmacy, prick their finger, mail in dried blood spots with an ID number, that was hotly contested by two groups. [First,] the state health departments, who were reimbursed by the federal government based on the number of AIDS cases they had. If they didn't know a case, that was money lost. [Second,] the AIDS community was concerned that people would be jumping off bridges because of the intense stigma.

The lack of good treatment--any treatment--early on was a major concern. I believe there were enough people who would behave responsibly with the knowledge and try to avoid infecting other sexual partners, etc., that it was a worthwhile idea; that eventually of course was approved by FDA. It didn't make enough money 00:46:00for Johnson & Johnson [J&J], so they closed the doors and I stayed on at J&J.

CHAMBERLAND: In your year up in Washington as the National AIDS Coordinator, what were some of the other activities or issues that you got involved in and some of the people that you worked with? Does anything stand out in your mind?

NOBLE: I'm unclear [about] the timing of some of these events, because when I came back from the role up there and Jim Mason asked me to become the [CDC] Deputy Director [for HIV], there were lots of things going on that were very contentious. During my year there as the AIDS Coordinator for the Department, Dr. Bowen, Secretary Otis Bowen, a physician from Ohio I believe, asked me to go 00:47:00with him to a meeting of the White House Cabinet, where there were two items on the agenda. President Reagan was chairing. I sat behind Otis, Dr. Bowen, and there were two items, as I said, on the agenda. One was, should people with HIV be allowed into the country, and [the other was,] should there be a plan to educate the public about HIV/AIDS? The Chief of Staff, whose name I also repress, said to the Cabinet members, "There's no need to discuss the question of whether we should allow people with HIV infection or AIDS, the diagnosis of AIDS, into the country, because of course that won't happen." That ban wasn't repealed until President Obama repealed it.

CHAMBERLAND: So there was very little discussion, no discussion.

NOBLE: There was no discussion. On the question of educating the public, there was discussion. Knowing that President Reagan was good friends with Maggie [Margaret] Thatcher, the Prime Minister of England, I had obtained just the week before the copy that the British government had sent out to all of their people. During the discussion, President Reagan asked if there were questions. Being the timid soul I am, I raised my hand, and he pointed at me. I stood up and said, "Mrs. Thatcher has issued this report to the nation [the United Kingdom]." I put it on the table and pushed it across the table to him. The outcome was, of course, the national mailing that occurred when I got back to CDC.

CHAMBERLAND: I'm struck by this story and have to ask you: here you are a 00:49:00trained scientist, a very technical person, and you're operating in a political arena. Obviously to take a decision to ban the entry of anyone with AIDS into the country certainly would have been thrashed around at CDC and NIH as a very science-based discussion. What was that like? Did you sometimes wonder, "Where am I?"

NOBLE: Unfortunately, that is so often the case. Ignorance creates bias and prejudice, and there was an amazing amount of ignorance for so long about this. The political environment was not to my liking. Gary Bauer was one of the spokespersons for the Reagan Administration and on AIDS, and he and I would 00:50:00occasionally end up on a platform speaking together, and we didn't exchange many pleasantries.

CHAMBERLAND: It only lasted a year, and you came back to CDC. This is now taking us to 1987. You took on a newly created position as the Deputy Director for HIV.

NOBLE: Right.

CHAMBERLAND: Is that correct?

NOBLE: Jim Mason called me one afternoon and said, "I would like you to take over the oversight coordination of all the components of CDC that have been working on AIDS." By that time, [that included] not only the Center for Infectious Diseases, but the Center for Prevention Services, the Center for Environmental Health, NIOSH [National Institute for Occupational Safety and Health]--worker safety, [and] a number of components of CDC's adolescent health 00:51:00programs. I called Walt as soon as Jim Mason was off the phone and said, "Walt, do you know about this?" because Walt was the Deputy Director of CDC. I didn't get an answer clearly whether or not Walt could answer that question.

CHAMBERLAND: This was a second Deputy Director position that was being created specifically. I think that the term that was used was "matrix manage." There were something like nine or ten centers / programs at CDC at that time. As you say, they're all working on some aspect of AIDS. What's that like, herding cats?

NOBLE: It was interesting; a little like herding cats. Eventually, with Walt's initiative to recommend Bill [William] Parra, who was at WHO; Bill, a master of 00:52:00[a] Public Health Service Advisor by training, a master administrator, created this wonderful matrix management program with all of the dollars--almost half of CDC's dollars came into our matrix-managed program--and the FTEs [full-time equivalent positions]. Our program was responsible for trying to manage the resources among the various components. The weekly meetings of the staff started out with a little of polite kickback: "I don't need you, Gary Noble, calling these meetings."

CHAMBERLAND: Because you're now another layer. Your office is another layer.

NOBLE: Yes, of course.

CHAMBERLAND: And with the dollars.

NOBLE: It worked fine. CDC is a remarkably outstanding organization, and 00:53:00personal views are seldom surfaced.

CHAMBERLAND: You're matrix-managing the various centers and programs, but there's another big aspect to that job: the office that you were heading up was the National AIDS Education Campaign [for] Prevention.

NOBLE: NAIEP, National AIDS Information Education Program, already existed when this was created.

CHAMBERLAND: How did it actually come about that CDC was designated to be the lead for providing education?

NOBLE: I remember doing my year in Washington, the National AIDS advisor attended that [NAIEP] conference, and Paula Van Ness was there speaking. She was a very activist person promoting the importance of education, and I think Walt probably hired her, I'm guessing, to initiate that program. We'll watch Walt's 00:54:00interview and see what that history was.

CHAMBERLAND: That program had been established by the time you got back to Atlanta, with Paula Van Ness in place. But you must tell us about the centerpiece of what came out of the office: the "America Responds to AIDS" information campaign, and I know it had multiple components. Tell us a little bit about America Responds to AIDS.

NOBLE: There were multiple meetings, traveling around the country, addressing people's concerns. Ogilvy & Mather was hired, a major national ad agency. A gay man incidentally, coincidentally, Steve Rabin, headed the Washington office 00:55:00of that at the time. They recommended various things, which had to pass through various levels of review. They would have focus groups to develop the public service announcements and the various information tools to see how it was viewed by the public, was it understandable; did it educate and convey important information. Those public service announcements would be done in storyboards.

CHAMBERLAND: In the initial phase?

NOBLE: In the initial phase, and then [they] would be presented to various groups; ultimately to Jim Mason, who sometimes didn't think the country was ready or Washington was ready for that perspective. Condom use was one of the touchy issues.

CHAMBERLAND: You're trying to develop public service announcements for radio and television. You're trying to get across messages about safe sex and IV drug use. I'm thinking this has got to be tricky to do, because clearly there were some constraints to what you could and could not say?

NOBLE: Yes, there had to be. I had hanging over my desk at that time, as the Deputy Director for AIDS, one of the posters, and it was simply a big, black square with a little balloon and an arrow down to the middle of the black square, saying "Here, let me help you with that."

CHAMBERLAND: So a lot [was] unsaid, but presumably people understood.

NOBLE: That was the hope.

CHAMBERLAND: That was the hope.

NOBLE: I'm sure a lot of people didn't.

CHAMBERLAND: These signs being cleared by Dr. Mason, did these have to go then up to Health and Human Services, the White House? Were you under a lot of oversight?

NOBLE: I think that Mason was the final clearance, to my knowledge.

CHAMBERLAND: OK. Then these ultimately started to go out on the airwaves, TV, print media. Were you able to get a sense of their effectiveness, because there were still a lot of misconceptions about the virus and how it was transmitted and all that? Did you ever get a sense of how effective [the ads were]? Could you gauge in any way their effectiveness?

NOBLE: I honestly don't recall surveys to test the impact of that. It's hard to do when you think about it, because what's your control group? You can have it 00:58:00before and after the campaign, but other things were happening besides the campaign to change people's attitudes and knowledge, so I don't think it was a very tangible opportunity to really measure the impact of the campaign.

CHAMBERLAND: Now another component of the campaign was the brochure that was developed to be mailed to every household. You must tell us this story as well, the "Understanding AIDS," I think it was called, brochure.

NOBLE: It was developed, again, by the ad agencies and with input from a lot of people [and] with photographs of various members of the public representing the people who would be reading this. But again, because of the views from above in Washington, it was going to be in the U.S. mail, and kids were coming home from 00:59:00school with their parents working or teenagers coming home from school with nobody in the house. Did we really want them reading this kind of salacious material? So it was sent out with three-side tear off. It couldn't be opened. The brochure couldn't be opened unless you bent and tore off all three sides of the brochure.

CHAMBERLAND: To try and make it kid proof?

NOBLE: Yes.

CHAMBERLAND: Was CDC responsible for developing the content? OK. It was supposed to be, again, a plain-spoken thing. Ultimately, it went out, though, with Surgeon General Koop as the spokesperson.

NOBLE: Right. Obviously, it had to have approval at that level because nothing that important to everybody in the nation; referring back to the White House 01:00:00Cabinet meeting where this idea of, how do you educate the public was first raised. There was a lot of, as you were saying, Mary, the government and the President didn't really utter the word "AIDS" very much early on. There was a lot of pushback. It was considered-- you even heard comments like, "Gay men deserve this."

CHAMBERLAND: Do you have a sense that the response by the U.S. government would have been different if this were a disease that hadn't affected homosexual men and IV drug users?

NOBLE: Of course. If it had been a group of veterans at a meeting / convention in Philadelphia who came down with pneumonia, it would have been very different.

CHAMBERLAND: But the brochure went out to-- I guess there were a hundred million or so of these printed, so it really was delivered to every household.

NOBLE: There's a question of how many actually went out or were received, but yes.

CHAMBERLAND: Coming to the end of our time here a bit, but I really wanted to ask you a couple of personal questions, in the sense that you were a part of something that changed history and the course of public health. Now you can reflect back, decades later. How did that change you personally and professionally?

NOBLE: Because I had such strong feelings that public health needed to be primary, the hell with the political correctness. When I was finishing my two 01:02:00years, what turned out to be two years, I could have stayed on as head of the legislative office [CDC Government Affairs Office] in Washington. After I was in the Deputy Director position, [Dr. William] Bill Roper [Director, CDC] asked me to go and head up the Washington legislative office [as] [Dr.] George Hardy was retiring. I dealt peripherally with these issues while I was still there as the head of the CDC legislative office in the Humphrey Building. It was to deal with all of CDC's issues, not just HIV/AIDS, but clearly there were opportunities for testimony and other things, because I was the man on the spot, so to speak, in Washington.

I had decided long ago that I wanted to do something in my career after being a 01:03:00Commissioned Officer [in the U.S. Public Health Service], so when I reached the magic thirty years of full retirement credits, I was interested in doing something else-- being an academic, going to a school of public health. George Hardy called me and said, "You're going to get a call from a head hunter who is looking for somebody who knows something about AIDS to launch a test for HIV." Shortly there was a call from a major head-hunting firm, and they came and talked to me in the office. They said, "We're interested to know if you'd like to work on this test that you can obtain in a pharmacy and learn whether or not you're HIV positive anonymously."

I felt strongly, as I said earlier, that that was an important tool, so I went 01:04:00through the interviews with the man and his wife who had sold the idea to Johnson & Johnson. The head hunter wouldn't tell me who the company was, but he said, "Dr. Koop thinks it's a good idea." So I said to Dr. Koop, whose office was down the hall, "What do you think?" He said, "Oh yes, that's a good idea. I'll put in a good word for you at J&J if you want." Despite the fact that I would not have chosen to work for the two individuals who had sold the idea to J&J--if that hadn't been a part of J&J, if it had been a stand-alone company, I don't think I would have taken the job. But I figured with J&J behind it, it had some possibilities.

I'm getting mixed up. My last two years at CDC as head of the legislative office 01:05:00and then my next opportunity in AIDS, you asked me how it changed my views. That's one way it changed the views: wanting to continue to do something useful in this field. AT J&J we got FDA approval to test markets, and did some test markets in two different sites. We didn't have the uptake that J&J thought it needed to sustain commercial viability, so they closed the doors and laid off some ninety percent of the staff. We had a marvelous national group put together in this company, a subsidiary of J&J, called Direct Access Diagnostics, based on the CDC program, based in North Carolina. We used CDC's model to create our own in-house counseling referral service. We had data from every state health 01:06:00department for referrals to people who called, and we did counseling anonymously over the phone, one-on-one with trained interviewers, trained counselors. It was sad to see it fail. It was subsequently picked up, the idea, by another smaller company in Chicago and went on from there to continue the idea of this anonymous testing.

CHAMBERLAND: These home testing kits?

NOBLE: Right, right.

CHAMBERLAND: So J&J never got theirs?

NOBLE: No, they got approval and did test markets and decided it wasn't profitable.

CHAMBERLAND: To pull out.

NOBLE: Yes. I ended up as a spokesman, as Vice President for Medical Affairs, in Medical and Public Health Affairs, on the corporate staff at Johnson & Johnson for the rest of my ten years there.

CHAMBERLAND: You stayed on for a good amount of time. Looking back with hindsight, which is a luxury, can you think of any aspects of CDC's response 01:07:00where you thought maybe we could have done a better job, and conversely, where you think CDC really did an outstanding job?

NOBLE: In the climate and at the time, I think CDC did an outstanding job. If there hadn't been the bias, prejudice against the largely homosexual initial population, without recognizing that heterosexual transmission was also [occurring] early on [but] was not recognized as important, I think we could have done more to try to sway the political opinion, but CDC directors at the time were appointed by a Republican administration. Dr. Mason, a lovely man, a 01:08:00good friend, was answering to Washington, and Bill Roper was a White House fellow and became the next CDC Director. Again, another wonderful guy, but they had their chains of command and had to please their bosses in [Washington] D.C., so there was that constraint to what CDC could do.

CHAMBERLAND: Some people have said that the AIDS epidemic politicized CDC in ways that it hadn't had to operate before, and you're nodding your head vigorously, "Yes."

NOBLE: CDC didn't exist in the Washington sphere; it was down there in the South somewhere. Legionnaires' [Disease] made it more apparent. They finally figured out who we were and--

CHAMBERLAND: What we did?

NOBLE: Yes, what we did. Did CDC take any hits, so to speak, for being this wild-eyed liberal organization down there in Atlanta? Yes. I don't think that it hurt us. To the extent that the CDC directors are able to voice their opinions, it may be easier in a Democratic administration than in a Republican administration, just because of who we are as a nation. But we don't control that, the voters do.

CHAMBERLAND: One more good story to tell us about your time at CDC? It doesn't have to be AIDS, Gary.

NOBLE: When you asked the question about CDC and its political fit in the 01:10:00environment: this wasn't really political, but my comment was CDC management always had your back, my back. When I was head of the Influenza Branch and swine flu came along, an eighteen-year old Marine recruit at Fort Dix, New Jersey, died. The health officer from New Jersey called and said, "I can't identify this virus, it's an influenza." He said, "I'm sending it to you." It [the specimen] came and [Dr.] Alan Kendal, who was head of the diagnostic part of the influenza lab, came back and said, "I can't type it either." Coincidentally, the health officer from Wisconsin some weeks earlier had called me and said, "We have tested a man and his son who were on a pig farm and had respiratory illness, and 01:11:00they have antibodies to swine flu." So they were tested, there was no spread of that, but when Alan Kendal came in and said, "I can't type it," I said, "Try it for swine flu." He came back on a Thursday and said that it was swine influenza, so-called swine influenza. We don't have the isolate that caused the huge pandemic of influenza in 1918-1919, hundreds of thousands, millions of people around the world dying. If you look at a mortality curve, you can see the blip for that period of time caused by swine influenza.

So I called Walt Dowdle, and on Saturday, in the conference room was [Dr.] David Sencer---

CHAMBERLAND: Who was the CDC Director.

NOBLE: --[and also there] was a spokesman from NIH, from Walter Reed Military 01:12:00Institute, and FDA. The question was, we have a U.S. Marine recruit who died of this influenza that killed millions back in 1918. What are we going to do? It was a general consensus that there would be full speed ahead to develop a vaccine using this isolate. It went into another period, somewhat like HIV/AIDS, where there was just no sleep. I'd come home at night and the family would be in bed.

The press never got to my level down in the laboratories, because Don Berreth [Director, Office of Public Affairs, CDC] usually dealt with the press. The phone rang and it was a reporter, a science reporter, for The New York Times. 01:13:00She said, "I understand you know something about how influenza vaccine is made and tested." So I went through all this. I was late for another meeting about cases of putative influenza in Japan. I talked and kept looking at my watch and told her how influenza vaccine is tested and how effective it was. I said it depends on how close the match is between the vaccine virus and the circulating influenza virus in the community. I said the efficacy varies from maybe 30, 40% to maybe 80%. She said, "But President Ford just said we're going to protect the entire U.S. nation by giving them swine influenza vaccine, and you've just told 01:14:00me that it's not 100% effective. What do you have to say to that?" I said, "Well, the President made things sound a little rosier than they really are." That appeared on the front page of the next day's New York Times, which my wife had laid out on the breakfast table when I got home and she was in bed.

I walked in the next morning to Walt's office, and he just looked at me and smiled. Nothing was said. I wasn't fired, but some weeks later Dave Sencer's brother was in town, for Thanksgiving perhaps. In a senior staff meeting Dave Sencer, without looking at me, said, "My brother's visiting from Michigan. He 01:15:00works for Ford Motor Company." He said, "If someone said something quite derogatory about the president of Ford Motor Company, he wouldn't be working there anymore." Again without looking at me, Dave Sencer said, "I told my brother that's the difference between CDC and Ford Motor Company." That was the question of how I was working for CDC, and at CDC, in general, Directors have your back.

CHAMBERLAND: Glad that you weren't fired and went on to have an illustrious career at CDC. Thank you for that vignette, Gary. Again, it's just been great talking with you. Thank you.