Dr. Walter Dowdle

ï"¿Dr. Walter Dowdle

MILLER: This is Dr. Bess Miller, and I'm here with Dr. Walter Dowdle. Today's date is January 14, 2016, and we are in Atlanta, Georgia, at the Centers for Disease Control and Prevention [CDC]. I am interviewing Dr. Dowdle as part of the Oral History project, The Early Years of AIDS: CDC's Response to a Historic Epidemic. We are here to discuss your experience during the early years of CDC's work on what would become known as AIDS [Acquired Immune Deficiency Syndrome]. I must ask, Dr. Dowdle, do I have your permission to interview you and to record this interview?

DOWDLE: Absolutely.

MILLER: Dr. Dowdle, I've known and admired you since the very beginning of this epidemic. You have served in the highest leadership roles at CDC, with responsibility for many different aspects of AIDS. These include serving as Director of the Center for Infectious Diseases from 1980 to 1986; Coordinator for AIDS Activities for the U.S. Public Health Service, where you served in Washington, D.C., in 1986; Deputy Director of CDC for AIDS between 1986-87; and Acting Director of CDC in 1989. For this Oral History of AIDS at CDC, we will be focusing on the early years, beginning in June 1981 with the publication of the first Morbidity and Mortality Weekly Report [MMWR] on five cases of Pneumocystis carinii pneumonia among homosexual men, and including a discussion of your year in Washington.

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

DOWDLE: Yes. I grew up in a small fishing village called Bayou La Batre, Alabama, which was well known in some of the movies at some times. This was a very small town. I went through high school there, and from high school I went to Spring Hill College with the idea of going into medical school eventually and going into premed. But [I had] no money, so I ended up in the services at that time to take advantage of the GI Bill. I did the Medical Corps, first in the Berlin Airlift and then Korea. It was four years before I finally got out of the military. At that time I had decided that I was more interested in science and did not pursue the medical career. I ended up at the University of Alabama and then finally the University of Maryland, and then from there to CDC.

MILLER: How did you get interested in public health, or did you before you came to CDC?

DOWDLE: Well, my stint in the military-- I was a corpsman in Korea, but the last year of my military time I was in California at an air force base, where I was in charge of a large outpatient clinic. There I decided that science was more interesting, to be honest with you, and so it was a wonderful experience. Somehow I just gradually evolved into more of the scientific thinking rather than the clinical thinking. Had I known, had I had the right mentors and known what options would have been available, then I think I may have continued on with medical studies. That's why it's so important to have the right mentors and really knowing what's available for you out there.

MILLER: So you went to graduate school, and your area of expertise was--

DOWDLE: Microbiology. Chemistry and microbiology.

MILLER: So how did you get to CDC?

DOWDLE: There again, it's a fairly long story, but back in those days fluorescent antibody was a big deal, and that was the hottest thing. I did studies with that at the University of Alabama, and this other fellow graduate student and myself had developed a process for fluorescein isothiocyanate in large quantities, it made us very attractive to other schools. So we were actually given a grant-- I was actually given a grant at the University of Maryland for a project with the armed services at the time. So I didn't have too much of a problem finding a place to go. I already had everything with me, so I was actually recruited by several places. Pure luck.

MILLER: What was your main emphasis of work initially when you came to CDC?

DOWDLE: Actually respiratory disease and then influenza.

MILLER: Let's shift our focus to your involvement with what was to become known as AIDS. We've talked to some of the epidemiologists and laboratorians about their initial work following the publication of the June 5th MMWR. At that time you were Director of the Center for Infectious Diseases. Can you talk a little bit about your involvement during those early months in 1981, from the leadership and policy position you were in?

DOWDLE: Actually, I was also serving two roles at the time. I was Assistant Director of CDC Science at the same time. What I remember most vividly about this is that [Dr. James W.] Jim Curran and [Dr.] Paul Weisner came into the office and described what was going on. They felt like this could be a major, major issue and that we needed to get on this right away. This was six months into the [Ronald W.] Reagan administration. We were under very strict rules about travel, and we were actually restricted from spending money, from traveling, and we were slated for a 25% cut in both finances and personnel. That was what we were under at the time. So I reminded them that we were under this strict order not to travel, and Paul Weisner said at that time, well, it's better to ask for forgiveness than permission. That pretty much became the mantra of the operation for the entire time. Just things you had to do, things were just too big to be held down entirely by politics, and that turned out to be really a wonderful decision. I think we owe a lot to Paul for his early thinking on HIV [human immunodeficiency virus].

MILLER: What was your initial thinking as to the cause of the disease and the approach to take to figuring out more about it?

DOWDLE: I think there were open minds, but by and large it didn't take very long to think that infectious disease had to be very high up on the priority list. I mean, there were just too many things that pointed in that direction, and too many contacts that would appear to be more than just a coincidence, and it just made sense pretty quickly.

MILLER: How did you and others organize the people working on the disease? At the time, did CDC have the staff and expertise to deal with it?

DOWDLE: It was initially set up as a model that we had followed for other diseases at the time, and one of course was Legionnaires’ disease. For other diseases where-- we initially were not knowing the etiologyâ€"we immediately formed a Task Force, which would bring in all of the expertise that could possibly be brought to bear on that particular issue. This would mean that you brought in toxicologists, you brought in the infectious disease people, you brought in the appropriate epidemiology people, and so on. So there was a Task Force set up initially within a few weeks. It fell to Jim Curran to head up this Task Force. Then that Task Force included both the infectious disease component as well as the sexually transmitted disease component. Once again, toxicologists I should say always played a very important role in any of these investigations. As to whether we had the resources, the answer was absolutely not, but you have to make room to do what you have to do. You have to actually start setting priorities very quickly if you're going to move on that which appears to be a major public health issue.

MILLER: Can you say more about that? Did you rob Peter to pay Paul?

DOWDLE: Yes, of course, because resources to some extent were important. That was more of an issue with the epidemiology, which needed a lot of travel, for example. In the case of the laboratory, a lot of what was needed to start the investigations was there, but the big problem was personnel. As we've explained to the people in Washington time and time again, you don't convert a parasitologist to a virologist. They are different, and if you don't have that depth, then you're restrained without question.

MILLER: Did you recruit people as time went on?

DOWDLE: Oh, yes, but that was much later, much later. Mostly we had to actually have people from other--who were doing very important work in other areas-- to come into HIV.

MILLER: What was the atmosphere at CDC like at the time? I think there was a reorganization going on.

DOWDLE: It was, but the reorganization wasn't really major. I mean, it was a merger of epidemiology with a lot of the other disciplines within CDC. That may have been a little traumatic, but it wasn't a huge reorganization. It was putting like people together who had different skills, which I think was extremely helpful. Before that time there was an epidemiology section and there was a laboratory section.

MILLER: And Dr. [William H.] Bill Foege was the director. Was he supportive of the AIDS investigations and so on?

DOWDLE: Very supportive. I don't think there's ever been any question that Dr. Foege's loyalty--his first priority--was always CDC without question, regardless of the political winds. I think people don't realize how much he worked in the background and how much effort he spent on trying to get the funds and get the resources to actually attack this problem like it should have been.

MILLER: During the summer and fall of 1981, the Public Health Service had regularly scheduled meetings with all the different agencies to discuss this syndrome. Can you tell us a little bit about CDC's role among the agencies, NIH [National Institutes of Health] in particular, NIAID [National Institute of Allergy and Infectious Diseases] and NCI [National Cancer Institute], but also ADAMHA, the Alcohol, Drug Abuse and Mental Health Administration, and FDA [Food and Drug Administration], in addressing this disease in the early years? How did CDC's role come out in that?

DOWDLE: CDC of course, had in a sense the lead on the investigation, so there wasn't a great deal of attention paid by the other agencies because they didn't necessarily see what their role would be at that point, although it did seem to be also in the very early days a big enough problem for NCI, NIH to get involved. FDA was actually drawn into it fairly quickly because of the pentamidine and so on, which was needed for Pneumocystis [carinii pneumonia]. So they were brought in, but it was still pretty much a minor role. The actual meetings that occurred so often turned out to be informational type of meetings rather than actual sort of planning actions.

MILLER: Was there competition at that time?

DOWDLE: In the early days there was virtually no competition between the agencies, but there was not any unwillingness so much as just the roles weren't clear because the disease was emerging. So these things [competition] sort of came along as the disease became, and the pattern became, more clearly seen.

MILLER: Can you talk about the political and social climate at the time, and how did that affect the early work? This was 1981. As you mentioned, Ronald Reagan was President. What were the reactions to a disease affecting homosexual people and bath houses and all that?

DOWDLE: Let me back up a little bit, because I think one of the things that we saw in Legionnaires’ disease was that once the etiologic agent was pretty much confirmed, and that came out of CDC, it was actually presented for the first time at the meeting of the American Society of Microbiology. We thought, here it's all wrapped up, and here was the evidence, and so on. But many in the audience just simply did not believe it. Many people, many physicians, the news media thought that this had to be something to do with a toxin. They just couldn't believe it. Here everyone said it could be anything else but not a bacteria, and it turned out to be a bacteria. So there was disbelief everywhere, and it was a long learning curve.

The same thing happened with HIV [human immunodeficiency virus]. The same thing happened with the blood banking industry. It just took a long time for this to sink in, that this is real, this is something big. Once that occurred, things began to change. But up until that time, you just couldn't get a lot of attention, and that was the biggest problem. Of course, it was also the minority groups in which this [HIV] was occurring, which didn't help matters in terms of getting the help that was needed.

MILLER: Can you say more about that, that it didn't help matters. How big was that? Many people, Randy Shilts who wrote his book And The Band Played On, and others thought that that was a huge aspect of what held back progress in identifying the--

DOWDLE: Well, in a sense it was, but in another sense I think it's far more complex than to just blame it entirely on the fact that it occurred in certain high-risk groups. It was much more complex than that. I mean, there was culture involved, there were political attitudes involved, religion involved, it was everything in this that was involved. It's very complex, and it's hard to really point out that there was a particular bad guy in all of this, or bad group in all of this. That's hard to do. I think you have to think about these things for a while, and it just doesn't happen overnight. It also didn't help--it was about a year there that pretty much in the early days, and because it continued to occur in the gay community, that the newspapers simply didn't pick it up. It was a long time there before you practically got nothing in the press.

MILLER: Why was that?

DOWDLE: That was in, I'd say, about '83, until the virus was discovered. Then you got a lot more press.

MILLER: Why do you think that was?

DOWDLE: Because at that point, it still seemed to be a problem in the gay community, and it still seemed to be a problem in smaller groups and certainly with drug-abusing individuals, and then with also the Haitians. If you remember at that time that got to be a part of the description of the epidemic, and it was not in the general public. It was not in what they saw as the big supporters or the majority of the people. It didn't occur in people that you would be running across every day, so there was just not that connection. Two things happened, I think. One is that when it got into the blood community and was finally acknowledged to be in the blood community, once they finally realized this, then that, of course, got people's attention. But the one that really got people's attention was of course Rock Hudson, which changed everything at that time.

MILLER: So Rock Hudson, the movie star, in 1985 dies of AIDS.

DOWDLE: Right.

MILLER: So it's in America's favorite son.

DOWDLE: Rock Hudson had been a friend of a number of people who were Hollywood friends of people who were friends with the Reagans, and so forth. So here was finally somebody they knew, so that then brought a lot of attention. Don Berreth, who used to be the [press] officer here at CDC, the press officer, actually had a chart. You remember this chart I'm sure, where it showed the number of news articles that came out depending on what was being said and what was being picked up, what was being done. It was amazing how some things got a lot of attention and other things got none whatsoever.

MILLER: Did you have a lot of interactions with the media in the early period?

DOWDLE: Yes, but I tried to make this as little as possible, because almost everything I said, you know, sometimes it was taken out of context, and I never found it too productive in that sense. I never thought what I was trying to say really was actually reported in exactly the spirit in which it was reported, so I found it a little frustrating. I think others did, too, but they were much more-- perhaps a little more-- accommodating than I was.

MILLER: You mentioned the labs, and, of course, you had a big role in the laboratories at CDC overall. So by mid 1982 there was agreement that this syndrome was caused by an infectious agent, and there was a search that began to identify the agent There was a big demand in the clinical immunology sense of how to describe the status of patients, and once the virus was identified, [to develop] serologic tests. Can you tell us a little bit about the role of the labs at CDC and the definition and diagnosis of the disease, and how that played out?

DOWDLE: It really is quite interesting. The lab, of course, in the early days you didn't know exactly what you were looking for, so it was pretty well a shotgun approach to what it might be. But then it didn't take too long before it was very clear it was a retrovirus. [Dr.] Don [P.] Francis played a very large role in this, because he had actually worked with retroviruses in Harvard. So then there was sort of a shift in the operations to look for a retrovirus. But like all other, again, I can give you many examples where we were looking for the right group but not with the characteristics that we thought it should have. So therefore I would have to say that probably all of us wasted some time in looking for a retrovirus, but not the retrovirus with the characteristics that AIDS had. Therefore it could have been isolated much more quickly had we actually--in retrospect, why did we do that, you know, because it became very simple to isolate HIV and became very simple to do serologic tests for HIV. But at the time, when you start out with an unknown, you'll also have preconceived ideas, and you have to get over those before you actually go into the mode of total open-mindedness.

MILLER: Can you say more about the preconceived ideas? What were people thinking and doing?

DOWDLE: The retrovirus that most people had worked with actually took a long time to isolate the viruses. This one [HIV] actually infected the cells very early and demonstrated the infection quite early. But in many cases it was just missed. It really was. Once again, it's not an unusual thing. That's what happens most of the time. You work with what you know, and the problems are the things you don't know. That's what took so long with Legionnaires’ disease, because you were looking for something that had other characteristics.

MILLER: Did the CDC have a virology lab that was active? Did you feel like you had the people that you needed in that sense? Was CDC actually heavily involved in trying to identify the virus, or more towards the immunology that was needed or the serology?

DOWDLE: CDC was involved in looking for the virus very early on, but we had no Atlanta in-house retrovirologist, and this was a very special technique. Retrovirologists were almost all academic, because these did not seem to be major disease producers in human beings. It took very long for them to show up at all, and often some of these were cancers, so this was not exactly the type of thing that CDC would do. So we didn't have any retrovirologists. The only retrovirologist we had in CDC was actually working in hepatitis in Phoenix, and that was Don Francis. Don came to Atlanta and was actually actively involved in the lab work and starting it in earnest.

Of course, interestingly, when the French reported the discovery of LAV [lymphadenopathy-associated virus] at the time, and about that time--well, that was much before NIH. Finally when it was announced that NIH had discovered HTLV-III [human T-lymphotropic virus III],which was the same thing as LAV, then there were two other labs. CDC already had six isolates or more, and then another lab had also some isolates. So there were four labs essentially right at the same time that could have announced it. It was all published, but [Dr. Robert C.] Bob Gallo had actually more data at the time.

MILLER: This could be a murky road, but how was the interaction between CDC and NIH at that time? CDC and Bob Gallo.

DOWDLE: Let me go back to the time I was trying to set up an [AIDS] office in the Public Health Service in Washington. It was '86, and at that time there were a number of things going on. One of the things that was going on was this actual debate that was going back and forth in not only the field of virology but at the international level, where the French and the Americans, in this case Gallo, were both claiming that they had discovered the virus. I mean, it was just like a soap opera. Just one thing after another. It was never quite clear to me why the U.S. went to such pains to try to establish ownership of the discovery and cut out the French entirely. I never have understood why that happened. I could understand it at an individual level, but this was happening at a governmental level. In fact, one of my jobs when I first got up there was to actually participate in this movement, if you will, to get it established as a U.S. virus. The U.S. had all the patent rights, and all the patent rights weren't really a major deal because others would have to use it. Anyway it certainly was a concern to individuals that this be done.

MILLER: At the highest levels.

DOWDLE: So when I went into the first meeting, I said, I didn't know why we were doing this. This was a very high-level meeting. I said I didn't know why we were doing this, the French had established claims for this well in advance of the Americans, and I said, why are we doing this? I never got invited back to that meeting ever again. And that went on. Lawyers were involved, and finally I guess it was about that time, or later on in that year, that they finally had a--I think the people who signed the agreement were at a very high level of the government. I think it was [Jacque] Chirac, and it was extremely high that said, okay, they're co-discoverers. But it took years to finally sort that out totally, and, as you know, the French won the Nobel Prize for discovering the virus later on. I never understood it. Never understood it.

But to answer your question, at my level when I was at CDC working with influenza and other respiratory viruses, I had a very good relation with FDA, had a very good relation with NIH, particularly NIAID. I mean, it was just fun working together, really a lot of fun. But then as I got into Washington, it didn't work out quite so well at the top level as it did at the working level. I used to say that even when I was there, I had to go out to NIH just to get a fix on reality, because here were people I could really feel comfortable with and talk with. I'd say I have the greatest respect for our fellow agencies at the time, but also there were personalities in some of the agencies, which didn't make life so interesting or so much fun.

MILLER: Let's go to '86, when you were asked to be coordinator for AIDS activities for the U.S. Public Health Service and were assigned to Washington, D.C. At that time, just to set the stage, the actor Rock Hudson had died of AIDS, and in a New York Times article, [Dr. Anthony S.] Tony Fauci, the director of NIAID, estimated that one million Americans were infected with the AIDS virus. That year at President Reagan's request, Surgeon General [C. Everett] Koop issued the Surgeon General's Report on AIDS. Dr. Margaret [M.] Heckler was Secretary of Health [and Human Services]. And then the next year in 1987, Randy Shilts, a journalist, published And The Band Played On, emphasizing the U.S. government’s indifference and lack of funding for a disease that affected homosexuals. So what an amazing time to have been in Washington, and you were there. Can you tell us a little more about that experience, what you did and who you interacted with?

DOWDLE: When I first arrived, I had an office which was two doors down from Dr. Koop, and he used to complain that as Surgeon General the only thing the administration would let him do is talk to third graders. I mean, I am quoting him directly. This is exactly what he said: that he was not allowed to do anything else. He virtually wasn't. He was not called on to be a spokesperson or take the leadership that the Surgeon General should really deserve. Then when Congress requested that the Surgeon General come out with a report, being a respectable resource, then everything changed. I mean, it was absolutely amazing. I had the pleasure of working with--at the time I was not the chief author, but I was reviewing and working with him at the time up there and with his staff. Once the report got out, once it was published, all of a sudden he became a spokesperson for HIV that couldn't be stopped. It just took a life of its own. I think he was a remarkable man, did a remarkable job, and I think did much to push the HIV agenda forward. Even though he personally had very deep problems with the origin of the epidemic and the continued transmission, for which he didn't see that there was a very good reason.

Having said that, I think that also applies to our (CDC) Director at the time, [Dr. James O.] Jim Mason. Once again, I think this agency has a real debt to Dr. Mason because of Dr. Mason's dedication to making sure that we were talking about people, not classes of people, that our dedication and our whole mission was to actually work with people and not classes. I think it's really amazing, considering where he came from in his religious background, to actually make that type of distinction.

MILLER: So Dr. Mason was a Mormon and heavily involved with the Mormon church, a deacon. Can you say more about that? I think Dr. Mason maybe doesn't always get the reputation that you think he deserves. Do you want to say a little bit more about that?

DOWDLE: When he left here, he left CDC to become Acting Assistant Director of HHS [Health and Human Services] for health.

MILLER: I think that was 1990 or something like that.

DOWDLE: We'll check on the dates. Yes, okay, correct, sorry, '89. It's about '89 he became Acting Assistant Director, that's what it was. But the whole point was that this actual image of the administration and image of the medical community were so different. The gulf was so wide, and I think Jim really did a yeoman's job in just focusing on that constantly. I would say it was very discouraging at times, but nevertheless he really did defend CDC in the whole project.

MILLER: When you talk about the administration, is it] the Reagan administration, or the political leadership that he had to deal with?

DOWDLE: When I was in Washington, one of my jobs was to periodically go up to the Office of Science and Technology Policy in the White House. I would go over there every several weeks and report to the director of the office and to the staff on HIV progress. So there would be discussion on things I might report. Some things I thought were very important were just totally overlooked. We talked about things that might relate to policy, but, of course, there were no comments on this, but--

MILLER: Why was that? Was there just a desire not to deal with this?

DOWDLE: No. The person, the director at the time, was Bill [William R.] Graham. These are nice enough folks, but when it came to discussions of policy and what might be done about this and what actions might be taken and what they might want to discuss, it was made very clear to me, not only there but in other places, that I was not a member of the team. It was very clear that the members of the team did not include a civil servant. I mean, the team was strictly a political team, part of the administration. That separation, that divide I met on I don't know how many occasions. Being part of the team meant that you could be trusted. Not being part of the team, you weren't trusted; not because of an individual but, you know, you could have other motives for doing what you were doing. You didn't have a base to report to, if you want to put it that way. So they were extremely careful about what they did and where this [information] went, whether any of this information went to Reagan or even to his staff, I don't know. That's what it was supposed to have done, but I don't know.

MILLER: Can you give an example of that? Were you looking for support for prevention activities or what might come up that just fell on deaf ears, is what I'm hearing. DOWDLE: Well, you never know. You've got a few layers to go through. Once again, so many different things here, but let me just go ahead a little bit. That very tightly held team and highly controlled environment in which these discussions were made were typical of that administration. The reason why I'm saying this is because it's not necessarily a particular party. George [H. W.] Bush Senior became President in 1989, and when he became President everything changed. Immediately everything changed. He was very open. He wanted the civil servants to be part of the team. It was a much different environment, and in fact later when I was Acting Director of CDC, it was actually within a few months after Bush had come into office that he wanted to meet with the gay activists. It was the Act Up primarily, which you will remember very much. So I went with him to the Marriott at Crystal City, and I was within--close from the two of us--and we walked down this hall. This hall was lined with the Act Up members going into this--and as we turned the corner to go into this hall, then all the cymbals and the whistles--and I don't know if you've experienced this or not--but in this very narrow hall it was absolutely frightening. It was a frightening experience. Not for me, but I mean, it was frightening seeing the President of the U.S. walk down this hall with all of this. Anyone could've reached out. Anyone. Then finally meeting with the group in the auditorium. So I'll always remember that and what a contrast between what Bush did, as opposed to Reagan, ignoring it essentially through most of his entire time. It was a different--once again, personalities but also cultures that get involved. So it was different.

MILLER: So what an experience. Here you're a technical person having a leadership role and then being put in a very political arena. What else did you do that year when you were there?

DOWDLE: During the year I was in Washington, I also had a number of meetings, at least pulling together a number of meetings from the agencies that were there, in addition to CDC. So we met on a number of different topics and, of course, one of the topics that came up just constantly was the need to get education out there, other than the Surgeon General's. The Surgeon General's report was a very generalized thing aimed to the general population, but it was very clear you needed to have more specific information to the affected groups. So I did quite a bit of that. In fact, when I came back to CDC, I came back as the Deputy Director for AIDS, and the first thing I did--I came back late in the year--and the first thing I did was to sit down with Jim Bloom and myself. We actually worked over the Christmas holidays every day and actually drawing up a plan that would specifically target the individual groups.

MILLER: Jim Bloom being?

DOWDLE: Jim Bloom at one time was the Executive Officer here at CDC. At that time he actually had been replaced, but had been working with me on this as well. He was a very savvy guy when it came to resources, and that was extremely helpful. So [we] actually had this thing planned, all laid out, and had brought in some CDC people to look at this and so forth, to see if we could get this funded in some way and get people in the administration interested in doing this. So we presented this to Dr. Mason in early January, and where it went, I have no idea, but I do know that it went to Washington. What happened after that I don't have any idea. Absolutely no feedback. The old saying is never write a letter to your boss until your boss asks for it. This wasn't the case with Jim Mason, but I mean up the line. So when it became clear that it wasn't going to work at all, it absolutely got no traction, and considering the effort we put on it, no acknowledgment or anything. So then it became clear that, okay, we've got to do something more general. Then I happened to be talking to Paula Van Ness, who was a coordinator of one of the AIDS education service group in Los Angeles. I was so impressed with what they were doing that I said, come join us. So she came to CDC, and we were going to do a more general approach to this whole thing.

MILLER: Meaning what by more general? I didn't know about this.

DOWDLE: The plan was to get PSAs [public service announcements], TV ads and brochures all aimed at whatever we could get out. She brought in a couple of very--in fact extremely brilliant, very intelligent, very imaginative people from the Hollywood scene, and it was one of the most incredible experiences I've ever had. These people had no concept of government regulations, of how to purchase anything, how to do a contract or anything, and they didn't care. And it drove people around CDC crazy. They kept telling me, fire those people. I refused to fire those people, and we then connected with a public relations firm, it's really an advertising agency, Ogilvie and Mather, who were also very, very good, and they appointed the right people to do this. The whole idea was to get out these PSAs, and the PSAs would then be aired using free public time.

MILLER: Was this America Responds to AIDS?

DOWDLE: And this turned out to be, very shortly, America Responds to AIDS [ARTA]. I mean, from this start with these people who were just total misfits, total misfits, and from the start--what is it, 150-something PSAs? I forget the exact number, but the numbers were huge. Of course, they came out with the Understanding AIDS, which was mailed out to every person in the country; all came out of that. Now, that was later. I was in another job when that finally came out.

MILLER: Was there an education unit at CDC then that worked on it?

DOWDLE: Yes, but this was the group. Oh yes, we drew from everywhere. There were a lot of people who came from the education [unit], but the education group we had here was a little different. It was health education, but we actually stole from these people and from other people.

MILLER: That's very exciting.

DOWDLE: Oh, really very exciting. Really a lot of fun. But I don't know how many PSAs ended up on the cutting room floor. I mean, the actual number that got passed by the administration, it had to be done here. It had to get past me and several others, it had to get past--at that time it was Jim Mason, it had to get past the assistant secretary, then it had to get past the secretary before--

MILLER: Who was Margaret Heckler still.

DOWDLE: Who had to pass final word as to whether it got done. As you recall, trying to actually sell the use of condoms by describing how to put on socks is--

MILLER: I don't remember that.

DOWDLE: When you couldn't use the word, and there was no way to do it except for that [putting on socks]. That was the cleverest thing that I remember of the whole thing. So it was extremely successful. All of the people who were doing this by about I think one or two were left here at CDC. All the others, after getting that done, after getting out the brochure, they gradually went to more imaginative jobs. But it was really important and really very exciting.

MILLER: And a big role that CDC played that I don't know that we take pride in or credit for, that was a very big deal.

DOWDLE: Yes. By the way, I have a copy here of the ARTA reunion, which was 15 years later, and you might want that for the archives or something.

MILLER: Yes, they would, I'm sure.

DOWDLE: I can do that. But to make a long story short, we got in trouble constantly for the ads. Most never got out, but even some that did--most that did, it was so innocuous. But everybody knew about AIDS. Then, of course, in 1997 I think it was, the Wall Street Journal published a big article that said that we had deliberately aimed this towards the general public instead of the groups that needed this information. I mean, it was the only thing we could do. We kept saying, okay, we'll use this general information to actually serve as a platform, and then we can go and provide the educational programs to those who really could benefit most. I mean, that was the whole justification for doing it. But I think it was extremely successful.

MILLER: And a clever way to get something out.

DOWDLE: So that, I remember with a great deal of respect for the people who actually were smart enough to do this type of work.

MILLER: This goes back a little bit, but in terms of decisions made and prevention recommendations made, I wonder if we could discuss briefly the transfusion-related AIDS cases and the famous blood bank meeting taking place in January of '83, when CDC hosted a national conference to determine blood bank policy regarding screening out individuals at high risk for AIDS from blood donors. There were recommendations, but perhaps not as strong as many felt, and then of course there were many cases of AIDS among transfusion and blood plasma products. It would be two years before definitive action was taken, when in January of '85 the provisional PHS [Public Health Service] recommendations were to screen for antibodies, since they were now available. So with the luxury of 35 years of hindsight, could we have responded differently? What was your thinking at the time, and what is it now?

DOWDLE: In regard to the blood banking problem, particularly with the hemophilia patients, once again it's that learning curve that you experience in every new event like this. It's not simple. It's very complex. There are people who are absolutely convinced that it's not happening. This is something that's, as they used to say at the time, you're the same people who brought us swine flu, and that was not taken very lightly.

MILLER: Referring to the swine flu, where there were vaccines given and then there was no big epidemic.

DOWDLE: Correct. Thank you for bringing that up. It was that type of disbelief, and it was also that they just didn't see the problem yet. This was very early, the first meeting that we had, and we couldn't get anyone to really agree on this. In frequent meetings with the blood banking industry, it was a very bad scene. They just were absolutely against what we were saying. There was no real discussion, no real sense of trying to understand what the problem was.

MILLER: What was their thinking? They were obviously concerned about destroying their supply of blood.

DOWDLE: It was so infrequent, they said that it was notâ€"that you could not justify the expense or justify all of the fear that it would bring. So they just couldn't buy it.

MILLER: Were there medical people here, or are we talking with administrators?

DOWDLE: Oh, no. No, these were medical people. These were the physicians who were chief physicians of the groups that were represented. [Dr. Joseph] Bove is the name that comes out. Joe Bove, by the way, apologized in print later, I think, in one of the symposia that were held. He actually apologized to CDC. But the interesting thing was that, again, from their position and CDC's position, CDC was seeing this unfold. I mean, you're living it. You're with it every day. It's unfolding. As you see it unfolding, it becomes very clear long before you have all the data that you necessarily need. What they wanted was all the data: you know, tell me that I've got this two miles away from me, then I might act. That gulf becomes clear all the time. For an agency like CDC to get their message across is often extremely difficult, because you're living with it and they aren't. The audience has just got other things on their mind, and it's not something they think about all the time. It takes a while. It takes that learning curve.

MILLER: Were you patient? Are you a patient person? How did you deal with those kinds of controversies?

DOWDLE: Well, it does take--and these were not political issues. I mean, they were internal medical issues. You just have to convince people, and the only way you're really going to convince people is data. The data. And you just keep getting more data and you get more data and you present it to them, and if you have few cases, they can tear them down. If you have many more cases, it's impossible to tear them down. So that's what it takes to change minds and change set opinions.

MILLER: And that's kind of CDC's strength.

DOWDLE: That's CDC responsibility to do that, yes. It doesn't work just to say believe me, trust me. You've got to provide the data to back it up.

MILLER: In closing, I'd like to ask a few questions about the personal aspects or impact of your work on AIDS. Did you worry about becoming infected yourself? Certainly in a laboratory setting or elsewhere, were you worried about your staff? What was your thinking about that?

DOWDLE: Again, I don't think that was a major problem within CDC. As I recall, there were a few instances of staff who were really not connected or didn't have the background. These were people who were not directly involved in this and who had concerns. But I think by and large the medical staff, the laboratory staff, I didn't see any really major concerns among this group.

MILLER: You were a big part of something that changed the history and course of public health. How has that affected you personally?

DOWDLE: There's no doubt that you certainly learn a lot about human nature. There's no question about that, and there's also no question that you really have to try to look at these things from different sides. There are not many instances where you're dealing with bad people per se or evil people. Most of the time you're dealing with people who are actually sincere in saying what they're saying and doing what they're doing. So how do you work with people, and how do you bring them to what you see is the consensus as it ought to be. I think that's one of the more important things: that you just can't go in saying these people have ulterior motives or something like this. Rather you've got to say, okay, these are sincere people. I'd say very few I've ever worked with weren't, and the question is how do you get them to recognize that this is a problem that deserves support and deserves help.

MILLER: With the advantages of 35 years of hindsight, any additional closing thoughts on the AIDS epidemic and the work that CDC did on it?

DOWDLE: I would just say that in respect to HIV and respect to AIDS and respect to essentially all the very exciting things that I had at least the privilege to be part of or even to view in CDC, that I'm extremely proud of this organization and always will be. I would say that in the days since then CDC has still held up its extremely important reputation. It's a fantastic agency, and I hope people always remember that: what it's not only done in the past but what they're going to be able to do in the future.

MILLER: Thank you very much.

DOWDLE: Thank you.