James A. Mason



CHAMBERLAND: Today is Thursday, January 17, 2019. I'm interviewing Dr. [James O.] Mason as part of the oral history project The Early Years of AIDS: CDC's Response to a Historic Epidemic. Welcome to the project, Dr. Mason, and thank you for being here today. Do I have your permission to interview you and to record this interview?

MASON: Yes, you do.

CHAMBERLAND: Dr. Mason, typically these conversations begin with questions about one's background and training and the like, but in the interview that you did for the polio chapter of the Global Health Chronicles, you spoke at length about this, including your time as an EIS [Epidemic Intelligence Service] Officer, class of 1959, and your selection as CDC's [Centers for Disease Control and Prevention] eleventh Director. Today I'd like to focus more on your time as CDC Director and Assistant Secretary for Health. As such, you were part of some pivotal events in the early history of the AIDS [acquired immune deficiency syndrome] epidemic.

Let me try and set the scene. You arrived in Atlanta in December 1983 to assume the job of the CDC Directorship. At that point in time, with respect to the AIDS epidemic, a little more than 3,000 cases and nearly 1,300 deaths had been reported in the U.S. Although epidemiologic studies had worked out the modes of transmission, there was still a lot of fear among the public about transmission by casual contact, food, insects and the like. In May 1983, scientists from the Pasteur Institute in Paris had reported the discovery of a retrovirus that they described as being the possible cause of AIDS. I wanted to ask, when you were interviewed for the position of CDC Director by Health and Human Services 00:02:00Secretary Margaret [M.] Heckler and others in Washington [D.C.], do you recall if the topic of AIDS came up during your interviews or discussions?

MASON: I don't really remember, but I'm sure there was some mention. AIDS was too much front and center at that time not to have something said about it.

CHAMBERLAND: Yes, already it was some two and a half years since that initial MMWR [Morbidity and Mortality Weekly Report] had come up. Set AIDS aside for just a moment or two. What were your thoughts, when you arrived at CDC to take the helm, about CDC's overall priorities? What was your vision for where you thought the Agency should go?

MASON: I felt that CDC needed to aggressively pursue AIDS. It was a national and 00:03:00international problem. The epidemic had been a concern of mine while I served as Director of the Utah Department of Health. We were heavily involved with AIDS; there was no question about AIDS being a problem. I had participated on several CDC committees while serving as Director of the Utah Department of Health and had pushed hard for CDC to broaden its base. CDC originally was called the Communicable Disease Center, and then it became the Center for Disease Control. CDC's skills and expertise in communicable disease control should be rapidly expanded to control other killers and cripplers. I had been working closely with 00:04:00[Dr. William H.] Bill Foege to encourage CDC's expansion into chronic disease control. We were also concerned about injury prevention. There were some problems that weren't being adequately addressed by the federal government.

Other federal entities were dealing with lead and mercury toxicity, and nothing was happening. CDC needed to step in. Concerns about dental amalgam containing mercury needed evaluation. A good science base for toxic substances had not been established. The Agency for Toxic Substances and Disease Registry (ATSDR) had just been organized at CDC, but its capacity to protect the public's health needed to be expanded. I saw CDC continuing to pursue communicable disease 00:05:00problems, including AIDS, while moving into additional important responsibilities.

CHAMBERLAND: What was it like trying to balance AIDS with these other responsibilities and priorities that you felt certainly were coming of age and needed to be addressed?

MASON: It was very difficult. The Reagan Administration at that time was realistically concerned about the nation's growing federal budget deficit. They were attempting to balance the budget, and the domestic part of the budget was being cut. I was sympathetic with that lofty goal. However, after beginning the CDC Director's job, I quickly realized we didn't have nearly adequate resources 00:06:00to even pursue the AIDS epidemic. Expanding CDC's responsibilities into other areas in the long run would save federal dollars by decreasing the cost of Medicare and Medicaid and enhancing the quality of life of Americans. It was challenging to arrive at CDC at a time when those who had asked me to come were attempting to downsize government.

CHAMBERLAND: How did you go about tackling this? What tools or approaches does a CDC Director have to try and get funding and FTEs [full-time equivalent] to staff up, not just for AIDS but some of these other important issues of the day?

MASON: I refused to accept that the only way we could handle AIDS was by diverting money from other critical, lifesaving CDC programs, and I expressed 00:07:00that. Margaret Heckler was the Secretary of Health and Human Services. I let those in power in Washington know that there was no way I supported diversion of resources to AIDS from other CDC programs. CDC's other activities were important in their own right; we had to have additional funds for AIDS. I had just come from Utah. We lacked funds to pursue AIDS control activities at the state level. None of the 50 state health departments had the resources to carry out what needed to be done to control the AIDS epidemic. More money was needed at CDC, and federal resources for state and city health departments would be essential to get AIDS under control.

CHAMBERLAND: And CDC was often the conduit to get money out to state and local health departments.

MASON: CDC was the only conduit for money that states could use to control AIDS. We are not only talking about AID prevention and control, but also money for tuberculosis, vaccine-preventable diseases and chronic disease control. Too little money was available at state and municipal levels to enable them to staff up and carry out effective AIDS control programs. Funds needed to come through CDC. None of the other PHS [Public Health Service] agencies had that link and responsibility, nor did they have the expertise.

CHAMBERLAND: You mentioned Secretary Heckler. You also worked with her successor, Secretary Bowen, Otis Bowen. What was their reaction? Were they supportive; were they helpful? How did you try and get through this impasse in 00:09:00terms of the administration, the Reagan White House?

MASON: Neither Secretary Heckler nor Secretary Bowen was able to convince the administration to provide CDC with the resources necessary to get the job done. They did what they could. I explained to both that I would be loyal to the administration's budget when I appeared at House and Senate budget hearings. However, when senators or representatives asked questions, I was unwilling to just tell stories and hold to a party line. I was going to answer honestly when 00:10:00asked about the CDC's resource needs to manage the AIDS epidemic and maintain other essential public health activities.

CHAMBERLAND: That's a radical thing to do, because traditionally within an administration you're supposed to toe the line in terms of what the White House wants vis-à-vis budget and whatever. Did you face any repercussions for being truthful about the resource needs?

MASON: I felt those I reported to supported my position. What choice did I have? I couldn't reassure Congress that our budget request was sufficient when it was not true. My personal integrity was on the line. I didn't have to work for the federal government. There are other things I could do to earn a living.

CHAMBERLAND: Was Congress sympathetic? Did you have some sympathetic supporters? 00:11:00I imagine it was a bit of a mix.

MASON: No one called me on the carpet. I think most people respected what I did. I spent time in meetings in the White House because Margaret Heckler had little health background and needed backup. I spent more time in the White House than most of my predecessors had, because of the situations I found myself in. Later, with Dr. Bowen, I was often asked to attend cabinet meetings because I could answer questions about controversies surrounding the AIDS epidemic. I was asked to answer President [Ronald W.] Reagan's questions about AIDS on several 00:12:00occasions. One time, Vice President George [H. W.] Bush asked me to join him in his office to discuss AIDS matters that came up in a cabinet meeting in greater depth. There were no problems when I was able to get beyond White House and Congressional staff and provide elected leaders in the Executive Branch and Congress with the facts. It was useful to be able to have those opportunities.

CHAMBERLAND: Eventually increased funding was appropriated for CDC and the other PHS agencies.

MASON: Yes. We were not totally successful, but bit by bit we began to receive needed funds for in-house CDC and state and city AIDS activities. Congress usually appropriated more than what was in the White House budget.

CHAMBERLAND: What do you think turned the tide, at least in terms of the increased appropriations? Certainly, it sounds like you were persistent in trying to bring people's attention to the needs.

MASON: I'm not sure the tide ever really turned; it was a continuing battle. It wasn't a one-time win and then everything was fine. We had to win each year's appropriation. As I mentioned, Congress appropriated more than the White House requested.

CHAMBERLAND: That's an exhausting sort of thing. But CDC was not alone in this. I presume NIH [National Institutes of Health] and FDA [Food and Drug Administration] were in the same position?

MASON: Absolutely, with varying degrees of success.

CHAMBERLAND: All of you [were] battling there for your funds. Let me switch a little bit to another topic. I had mentioned a few moments ago, when talking 00:14:00about events that had transpired, that the Pasteur Institute had reported the discovery of this new virus that they called lymphadenopathy virus or LAV. It was about a year later, in April 1984, that Secretary Heckler announced that Dr. Robert [C.] Gallo from the National Institutes of Health and his colleagues had isolated a virus that they named HTLV-III [human T-lymphotropic virus III]. They provided a lot of data to support that HTLV-III was the definitive cause of AIDS. The day before the press conference, the New York Times ran a front-page story in its Sunday, April 22, edition, and it featured your photo and an interview with you. The story read in part, and I quote, "Dr. James O. Mason, Head of the Federal Centers for Disease Control, said today that he believed a 00:15:00virus discovered in France was the cause of acquired immune deficiency syndrome, or AIDS. 'I believe we have the cause of AIDS, and it's an exciting discovery,' Dr. Mason, who is a virologist, said in an interview. 'The public needs to know that this is a breakthrough and that it is significant.'" I was wondering if you could tell us a little bit about the back story about all of this. How is it that your views preempted in some way Secretary Heckler and Bob Gallo's announcement that happened the very next day? Did you know that they were about to announce the findings from the NIH scientists?

MASON: You are describing a very difficult episode in my career.

CHAMBERLAND: I bet.

MASON: Several weeks before the event you mentioned occurred in Washington, the French scientists visited CDC and shared their breakthrough AIDS virus isolation 00:16:00results. They also visited several universities in the United States, where they reported their findings. This occurred about five months after I arrived at CDC. I didn't know Secretary Heckler well and hadn't met Dr. Robert Gallo. CDC had been supplying him with specimens from AIDS patients. The National Cancer Institute (NCI) at NIH depended upon CDC for specimens and epidemiologic data. However, NCI scientists weren't sharing information with us. CDC didn't know about their research findings. We only knew about the French accomplishments. A New York Times medical reporter visited CDC a week before Secretary Heckler's 00:17:00announcement. I knew him personally, and he asked me when I thought the virus causing AIDS would be discovered. I responded that the French had probably already isolated the virus. I mentioned the information the French scientists provided during their visit at CDC and advised him to get in touch with them for more information. A week later the New York Times heard about the planned press conference in Washington about the virus causing AIDS. Initially the press conference had been scheduled for Friday, with Assistant Secretary Ed [Dr. Edward N.] Brandt and Dr. Robert Gallo participating. Secretary Heckler was traveling away from Washington and got wind of the press conference. She postponed it until Monday at a time she could participate. By then everyone knew something big was going on. The New York Times went back to my conversation a 00:18:00week earlier with their reporter. They published an article on Sunday with my picture on the front page, reporting the French had isolated the AIDS virus. This was the day before Margaret Heckler, Ed Brandt, and Bob Gallo's planned press conference.

CHAMBERLAND: I imagine they read the New York Times in Washington, D.C.

MASON: Oh, yes, they did, and immediately phoned me. They were upset and wanted me to fly to Washington immediately to participate in Monday's press conference.

CHAMBERLAND: Did you think you might be fired over this?

MASON: I thought I might and didn't care. My motives were honorable, and the information I provided to the New York Times was correct and appropriate. NIH also knew about the French discovery.

CHAMBERLAND: It's interesting that in your comments you note that there clearly wasn't a lot of information-sharing that was going on between NIH, at least in this regard.

MASON: That was the problem. I might have been able to protect both the Secretary and NIH had I been in the loop. As it turned out, the virus Bob Gallo isolated was the same virus the French isolated. When I arrived in Washington that Sunday, I was informed they were going to announce that NIH had isolated the AIDS virus, and NIH would have developed an AIDS vaccine within a year or two. I advised them that making either statement would be a mistake. I suggested they announce that both NIH and French scientists had isolated the virus responsible for AIDS and warned them not to promise an AIDS vaccine in a year or two. What Gallo had accomplished was noteworthy, but credit should have been 00:20:00shared with French scientists. I knew AIDS vaccine development and licensure would take many years.

CHAMBERLAND: It didn't turn out that way.

MASON: No, it didn't quite turn out that way. They went ahead and disregarded my suggestions.

CHAMBERLAND: We're still looking for the vaccine.

MASON: We still are looking for an effective vaccine.

CHAMBERLAND: Did this have any long-lasting effects on your relationship with the Secretary or others?

MASON: It had a long-lasting positive effect. The secretary's advisors counseled 00:21:00her to go ahead with the intended announcement as planned, and she did and got hammered. As a result, the relationship between Secretary Heckler and me became much closer. She recognized my advice was sound. Following this experience, she asked for my advice before making health-related statements and took me to the White House when health-related matters were on meeting agendas.

CHAMBERLAND: As testimony to that, in February 1985, some 15 months after you 00:22:00started as CDC Director, you were asked to take on the role of Acting Assistant Secretary of Health, as Dr. Ed Brandt was stepping down from the position. I guess that is a good indication that you were held in high esteem.

MASON: I enjoyed working with Secretary Heckler. She was a fine person. I think it would be very difficult to be Secretary of Health and Human Services without having some health-related experience. She was surrounded by political people. She had little science experience and needed someone she could rely on with a medical background. I think she felt I could help her stay out of trouble.

CHAMBERLAND: When you went up to Washington to take on the Acting Assistant Secretary for Health position, there were a myriad of agencies that were working on AIDS. There's CDC, there's FDA, there's NIH, [the] Alcohol, Drug Abuse and Mental Health Administration. Can you talk a little bit about the relationships among the agencies with respect to the early response to AIDS? When you got up there, what did you find that was working well and not so well?

MASON: All the Public Health Service agencies reported directly to the Assistant Secretary for Health [ASH]. Today they report to the Secretary. There was a 00:24:00close relationship between the ASH and each agency head. I had become acquainted with them because there were weekly agency heads meetings in Washington. We knew each other, and now I was, so to speak, their chairman. We soon established another meeting. I established a weekly AIDS Coordinating Council meeting that followed the agency heads meeting, with the agency heads and their key people working on AIDS. The agency heads were wonderful men and women. I was fortunate to be working with very capable individuals. We were able to improve 00:25:00coordination and communication between the agencies on AIDS and other matters. When [Dr. Robert E.] Bob Windom became ASH, he continued the weekly meetings. Although not perfect, I think there was pretty good coordination between the agencies during the period I was there.

CHAMBERLAND: Did you have to deal with any turf battles between the agencies about overlapping or perceived overlapping responsibilities? Was that something that was a problem?

MASON: Not really. Most potential duplication was between NIH and CDC. CDC was primarily responsible for nationwide disease control, disease prevention and 00:26:00epidemic investigation. NIH funded research and carried out --

CHAMBERLAND: NIH is basic research.

MASON: NIH. Thank you for that correction. The potential overlap was with CDC's referral, epidemic support and applied research laboratories. NIH emphasized basic research. The important thing was close communication between the two agencies. There was great strength in the different laboratory roles when NIH and CDC communicated and collaborated. HRSA (the Health Resources & Services Administration) and FDA had laboratories with very different roles. In other areas, there was very little overlap between the agencies.

CHAMBERLAND: While you were Acting ASH, the first Public Health Service Plan for 00:27:00the Prevention and Control of AIDS was developed, in 1985. Can you talk about that? How did that come about? What did it take to make that happen?

MASON: CDC had an AIDS prevention and control plan with goals and objectives. The plan defined what needed to be accomplished. It served as the foundation for CDC budgeting. There had never been a PHS AIDS plan involving all the agencies and their different responsibilities. The weekly AIDS Coordinating Council was the place where the PHS Plan was assembled. It encompassed all the Public Health Service agencies and defined the measurable results each agency was responsible 00:28:00for achieving. It was incorporated into each agency's budget.

CHAMBERLAND: It's interesting that when I was preparing for this interview, I came across a New York Times editorial from August 1985, about the time that this Plan came out. It read in part, "James Mason, Acting Assistant Secretary for Health, developed a plan of action and persuaded the administration to raise its AIDS budget by 40% instead of reducing it by 10% as was proposed." It sounds like the plan had an impact.

MASON: That's what good planning accomplishes. A comprehensive plan with powerful justification became the budgeting foundation. Spelling out what are you going to accomplish, why the task is important and what happens if it doesn't get done gets people's attention. You put a price tag on results and 00:29:00spell out cost benefits. Then it is up to the Secretary, the White House and Congress to assist in obtaining necessary resources.

CHAMBERLAND: You were Acting Assistant Secretary for less than a year and came back to Atlanta December 1985, I think coincident with Secretary Heckler leaving as Secretary of Health and moving on to another position.

MASON: When I saw an opportunity to get back to CDC full time, I took it. I hadn't spent much time with my family that year.

CHAMBERLAND: You were commuting.

MASON: I put my excellent Deputy [Dr. Donald R. Hopkins] largely in charge of CDC. I would spend time at CDC on Mondays, get on a plane and fly to Washington and return Friday or Saturday. It was not a good time for family life. The change of Secretaries allowed me to disappear. They had begun recruiting a 00:30:00full-time Assistant Secretary for Health. Bob Windom was waiting in the wings.

CHAMBERLAND: It felt good to be back in Atlanta.

MASON: I told them I didn't want the job of ASH. I could have remained in Washington, but my life has been wrapped around five-year periods in a position. Not necessarily --

CHAMBERLAND: Because you had barely started getting things going as CDC Director when you were uprooted.

MASON: That's right. I wanted to return to CDC, because I had only been there a year. I still had three years left to accomplish something. Continuing the fight against AIDS, and developments like bringing the National Center for Health Statistics to CDC, organizing chronic disease and injury prevention and building up the Agency for Toxic Substances and Disease Registry weren't done. I still 00:31:00had a job back in Atlanta.

CHAMBERLAND: As much as I would like to talk to you about some of those other topics, we're going to have to stay on track a little bit with AIDS. I want to move to this area of AIDS information and education, because this was an area that I know you had a lot of involvement in. So, 1987 saw the launch of two important activities in this arena. Firstly, CDC established the National AIDS Clearinghouse to distribute printed materials on AIDS. Secondly, the America Responds to AIDS campaign began. The campaign, among other things, included the development and distribution of public service announcements for television and 00:32:00radio networks across the country. Just to get us started, why were these initiatives needed? It's 1987, so we're almost six years out from the first MMWR publication about these cases of AIDS. What sort of information-- or information gaps-- was CDC trying to address?

MASON: We were tracking the AIDS epidemic quite well by then, and it became clear we knew far more than the public did about preventing its spread. The prevention message was not getting out to either the general public or those participating in risky behaviors. It's difficult to get health messages out. 00:33:00Look how long it took for smoking. People are still obese. People don't understand, even though public health has been working for 20, 30 years to get messages out. We couldn't wait that long for the AIDS message to register. I was convinced CDC needed to involve some of the very best in the private sector in advertising and communications. It was imperative to reach out to the best in the private sector, even though there were federal organizations that had health communication responsibilities.

We budgeted and convinced Congress to provide funds permitting CDC to work with and purchase the very best communications services. We were able to interact with top-notch communications people in the fields of television, radio and print. This was something government had never done in the health area. We also 00:34:00desired to more effectively endorse diversity. AIDS was a diversity disease. Planning, involving and consulting with people at risk for AIDS, including gays, lesbians, drug abusers, prostitutes, Haitians and other minorities, was essential. We needed to know how to effectively involve groups who were being infected with HIV [human immunodeficiency virus] and to communicate with the American public.

Everyone needed to understand how AIDS is and isn't spread. Too many people in the United States believed that AIDS was spread through casual contact. They heard AIDS could be mosquito-borne. CDC had published guidelines for managing children with hemophilia and HIV infection in schools. The guidelines stated it 00:35:00was safe for AIDS-infected children to attend school. CDC was lambasted by op-ed writers and the general public because of unfounded fears. People were scared. They wouldn't let their kids attend school with someone who was HIV positive, even though AIDS didn't communicate casually between children. Studies showed there was no transmission of AIDS in homes where there were children positive for AIDS. Children in Africa who played with each other and slept in the same bed didn't spread AIDS. CDC needed to get the truth out across the nation. Using the very best advertising and communication experts in the nation was an opportunity to get the message out to a national and worldwide population.

CHAMBERLAND: A couple of key things: it sounds like the bringing onboard of a professional advertising public relations firm, I think it was Ogilvy and 00:36:00Mather, was it?

MASON: That's correct.

CHAMBERLAND: Then it also sounds like there was a concerted effort to include in the development process the affected communities, as you said. Were they part of assisting you in the development or testing of these advertisements?

MASON: Absolutely. In fact, CDC allowed and funded gay and lesbian organizations to produce their own video and written material to prevent HIV transmission. I didn't feel comfortable putting my name on everything they produced, and the government didn't either. However, CDC allowed organizations to produce materials to communicate to their high-risk populations in a way we couldn't duplicate. A lesson I learned during the AIDS epidemic was to love and 00:37:00appreciate people who had behaviors differing from mine. They were ill, or at risk of becoming infected, and CDC wanted to succeed.

CHAMBERLAND: You had some real interactions then with the various advocacy groups that were springing up at that time.

MASON: We had to have those contacts if we were going to succeed.

CHAMBERLAND: And if it was going to be considered credible in terms of its messaging. Challenges to come up with, in these various information campaign approaches, factually correct information that can be understood by the general public. But the material, this information, touched on subjects-- sex, drugs and the like-- that were certainly fairly controversial. I'm assuming that you had 00:38:00to get clearances from levels within the Public Health Service, from the White House. Can you describe some of the challenges that you encountered in getting approvals for some of these campaigns or materials?

MASON: We did have problems getting clearance, and I understood where those who opposed some of the material were coming from. It isn't until you got down in the trenches and became acquainted with those who were at risk of AIDS that you began to understand how to effectively communicate with those at risk, to halt the epidemic. This was a little bold for the federal government, but we felt we 00:39:00had to go there. I don't know how we could have quickly accomplished what was necessary without going there. It was controversial, and, in some instances, we didn't get approval. CDC never received approval from the White House after we recommended that a brochure be mailed out to every household in the United States. We just did it. Congress, however, aided and abetted by appropriating $25 million for the brochure. Twenty-five million dollars isn't much money today, but back then it represented a lot of money. Congressional intent language with that appropriation spelled out that the content of the mailed-out 00:40:00brochure would be the responsibility of the CDC Director. That requirement probably was unconstitutional, but it was never challenged.

CHAMBERLAND: This is the Understanding AIDS brochure --

MASON: Yes.

CHAMBERLAND: -- the brochure that was mailed to every household in America. The original plan, if I have this straight, was for CDC to develop and distribute this brochure in October 1987. I think you wanted it to come out coincident with National AIDS month. When you say it was never approved, it was that initial timeframe that you were never able to meet because of the pushback that you were getting.

MASON: CDC didn't have an appropriation for developing, printing and mailing the 00:41:00brochure, or White House approval. But we wouldn't give up.

CHAMBERLAND: What were people in the administration -- I know the Domestic Policy Council was an entity that you interacted with pretty regularly -- what were their issues? What were their fears or concerns? What was so upsetting to them about putting out science-based information?

MASON: I never heard concerns about the brochure or its content from President Reagan or Vice President Bush. I'm sure they weren't that close to it. We had all sorts of problems, however, with White House staff who were politically inclined. CDC's brochure contained well-documented facts about preventing HIV transmission. It explained that the disease wasn't spread casually from person to person. I still received concerned calls from White House staff, even after 00:42:00the brochure was printed and ready to mail out. The brochure stated, for example, "You won't get AIDS from a kiss," and the staffers argued we were wrong. They expressed fear that the brochure would mislead. They were still concerned about casual spread and AIDS transmission by mosquitoes. I was confident the brochure wouldn't offend or mislead my children or the American public. It was frank, science-based and critically needed. We couldn't allow politics to contaminate its content.

CHAMBERLAND: It was actually appropriation language, which also gave you the 00:43:00money to have CDC develop and distribute this brochure, that was really what allowed this to go forward .

MASON: That's right. I felt that the appropriations language could have been challenged by the White House, but it wasn't. The threat of a challenge finally occurred a week or two before the brochure was put in the mail. By then the brochure was already printed, and it was too late to stop it.

CHAMBERLAND: Can you tell us a little bit about the involvement of Surgeon General Koop in the brochure? I think it was the front page of the brochure that featured a message and his photograph. How was it that he came to be involved in the Understanding AIDS mail-out?

MASON: I worked very closely with [Dr.] C. Everett Koop. He was a marvelous leader. When I reflect on the Surgeon Generals I've known, he is the most 00:44:00impressive and well known by the public. His effective campaigns for personal responsibility and against smoking made him a favorite of the public. People recognized his picture and name almost as well as the President of the United States. We planned to feature the picture of a prominent and trusted person on the front page when CDC designed the brochure with Ogilvy and Mather. We wanted the brochure to get the attention and earn the confidence of Americans. Dr. Koop was identified as the person who could best fill that role. He was chosen 00:45:00because of what he represented. We invited him to read the final draft of the brochure. He was quite willing to allow his name and picture to be used on the front page.

CHAMBERLAND: Previously there was a -- was it called the Surgeon General's Report on AIDS? There had been a report that had come out under his name prior to the brochure that I think was a little bit more technical. You're right, and certainly wearing the uniform of the Public Health Service he had a very -- not authoritative, but as you said, people believed in their Surgeon General. If he said it, it must be true.

MASON: That's why he was chosen. You may have noticed the names of Secretary 00:46:00Bowen and Bob Windom at the bottom of the brochure. It was a bit sensitive, telling them we felt the picture of Surgeon General Koop would be the strongest way to get the message out. They took it well.

CHAMBERLAND: This was a big undertaking. I don't think it had been done prior to this time, to contemplate sending out a brochure through the U.S. Postal Service to every household in America. Can you give us a little bit of insight into the level of detail in terms of planning to make this happen, because you were really leading and coordinating this, correct, from CDC?

MASON: That's right.

CHAMBERLAND: How did you go about making sure that this happened and happened on 00:47:00time, because you had a deadline to do this?

MASON: First, a lot of excellent people were involved. At CDC I enjoyed the privilege of working with Dr. Don Hopkins, CDC Deputy Director; Dr. Walter Dowdle; Dr. [James W.] Jim Curran, who was heading AIDS at CDC at that time; [Dr.] Gary [R.] Noble, Deputy for Science; to name but a few. I can't begin to describe the ability and dedication of so many who were involved. They were good scientists and managers, just good people. The brochure couldn't have been completed without their backing and help. Their participation at CDC allowed me to go outside and make sure we were dealing with the best in the private sector. I couldn't expect others to manage what was happening in Washington to slow down 00:48:00CDC's efforts. We had confidence in Ogilvy and Mather. I had Dr. Bowen's and his deputy Don M. Newman's support. Others also got behind the brochure. CDC had a lot of help; the main resistance came from White House staff.

CHAMBERLAND: Was there any attempt to get a sense of what the impact of the 00:49:00brochure was? Were you able to get a sense of the proportion of people that actually read it, or if there were upticks in requests for information and the like?

MASON: Part of our funding was for evaluation of the brochure's impact. More important than whether it was read was whether it changed behavior. Reviews were favorable. More important than the evaluation was what happened to the AIDS epidemic in the United States after the brochure was mailed. The brochure went out in 1988, and the number of new infections began to decline subsequently, as did public fear. Of course, this can't all be ascribed to the brochure, but I'm confident it was well worth the effort and expense.

CHAMBERLAND: I want to talk about another event that occurred around this time. It was 1987, and it was in May of that year that the Public Health Service added HIV to its list of "dangerous contagious diseases." As a result of this, immigrants, either tourists or people seeking to live in the United States, were going to be required to be HIV tested. If found to be positive, [they] would be prohibited from coming to the United States. Firstly, can you tell us a little bit about what is the dangerous contagious disease list, and then secondly, what was the thinking about adding HIV to the list?

MASON: The list included infectious syphilis, gonorrhea, and I've forgotten the other diseases.

CHAMBERLAND: TB [tuberculosis], active TB, I think.

MASON: Yes, active tuberculosis and infectious leprosy. The White House and many in Congress felt that AIDS/HIV infection should be added to the Migrant and Refugee Health list of Communicable Diseases of Public Health Significance. I took an unpopular position at CDC, that since the list already included infectious syphilis and gonorrhea that are not spread casually, one had to either add HIV on the list or remove syphilis and gonorrhea. I understood some of the problems that would be created by adding HIV to the list. I detested the discrimination that might occur to HIV-positive individuals coming to the United States. CDC left syphilis and gonorrhea on the list, and that came back to haunt us. With the public's fears and concerns centered on the AID's epidemic, CDC was 00:52:00not going to get syphilis and gonorrhea off the list or keep HIV from going on the list. It was a battle I felt CDC couldn't win at that time. The administration and most members of both parties in Congress wanted HIV on the list of Communicable Diseases of Public Health Significance. There were people who didn't agree with me. Putting HIV on the list resulted in no international AIDS conferences being held in the United States until after HIV was removed from the contagious disease list in 2009.

CHAMBERLAND: There was no appetite to consider your other option of removing syphilis and gonorrhea.

MASON: They were on the list with Congress's approval, and there was no way 00:53:00Congress would remove them in 1988. I was trying to put science ahead of politics, but the inconsistency of leaving syphilis and gonorrhea on the list while fighting to keep HIV from being added crossed the credibility line and left us vulnerable.

CHAMBERLAND: It came back, this inclusion of HIV/AIDS and then HIV on the list, cycled back a couple of times in subsequent presidencies, the George H.W. Bush and the Clinton presidencies. There were various -- Congress deliberated about this again. Some of this I think occurred when you were the Assistant Secretary for Health. Were you ever drawn back into this discussion again, when Congress 00:54:00was revisiting these issues in later years?

MASON: I have no memory on this specifically. There may have been discussion in the White House while I was around; I don't remember. It was over 30 years ago.

CHAMBERLAND: You found yourself in disagreement with, I'm presuming, some of CDC's HIV scientists, epidemiologists, about this decision to add it on to the list. You alluded to that. You said it was unpopular.

MASON: It was very difficult for people with a science background. HIV is not transmitted casually, and it introduced a significant potential for discrimination when HIV was placed on the list.

CHAMBERLAND: It sounds like you felt like you were boxed into a corner almost, because of the construct of aligning it with syphilis and gonorrhea.

MASON: How can you leave syphilis and gonorrhea on a list of communicable diseases of public health significance and not put HIV on?

CHAMBERLAND: Eventually it did get taken off the list. I guess we should add for the record that in 2010, I think it was during the Obama Administration, it was removed from the list. Let's move on to recommendations and guidelines. You 00:56:00talked a little bit about this as well. This is another one of CDC's key responsibilities, either alone or as part of the Public Health Service, to develop HIV-related guidelines and recommendations, and a lot of these were 00:57:00controversial. Oftentimes CDC was being tasked with developing a guideline when there was extremely limited data to try and support recommendations. You mentioned the development of the CDC guidance related to HIV-infected schoolchildren, daycare centers -- very unpopular. You said CDC came out in its guidance and said for children that had no overt medical problems or whatever, there was no reason that they should be excluded from school. Another one that I think was controversial in its day was when HIV testing became available in 1985, 1986. It was now possible, initially for blood banks but then individuals, 00:58:00to be able to be tested for HIV. The question arose, who should be tested, and how should they be tested? CDC and the Public Health Service put out guidelines in August of 1987. Can you talk a little bit about the issues that were debated around the development of testing guidelines? There were differing views about the volunteer nature of the testing, who should be tested, what would be the repercussions for individuals that were found to be positive. Can you talk a little bit about the development of those guidelines and some of the --

MASON: I'll respond to the best of my memory. First, there was no treatment for 00:59:00AIDS when the HIV test became available. Many who had engaged in activities that transmitted HIV wondered whether they were infected. Initially, the only way for them to obtain an HIV test was to visit a blood donation center. We wanted to discourage people at risk of infection from donating blood, as this would adversely affect the safety of the blood supply. When a person donated blood, the HIV antibody test was done on the donation. Individuals who had been recently infected wouldn't test positive, and their blood would be used in transfusions.

CHAMBERLAND: Good point.

MASON: Unfortunately, there were people who felt that HIV testing should be mandatory, and those who tested positive should be quarantined.

CHAMBERLAND: That's a pretty hot topic right there, yes.

MASON: I don't believe mandatory testing could or should be implemented in a free country. That takes away a basic constitutional freedom. Were mandatory HIV 01:00:00testing attempted, those who felt they might be positive would turn out to be the least likely to get tested. They would find a way to avoid being tested.

CHAMBERLAND: You had some battles, I presume, with the White House and some members of Congress.

MASON: Indeed, this was an area of controversy.

CHAMBERLAND: As you said, the ultimate outcome, the guidelines that were 01:02:00published in August of '87, by and large recommended offering but not mandating counseling and testing in a variety of settings, typically where high-risk populations might encounter providers: IV drug clinics, sexually transmitted disease clinics. [The guidelines] emphasized also, as you said, the importance of confidentiality and the prevention of discrimination. These came out in August. In May, about three months before the guidelines, President Reagan made his first public speech about AIDS, and it was at Elizabeth Taylor's amfAR [Foundation for AIDS Research] Foundation. There was some sort of a benefit or whatever. In going back again and doing research for our discussion today, I 01:03:00looked at some of the media around that and his actual speech. He pretty much put out there that principle of voluntary, not mandated [testing]; there were still some unresolved issues about testing in the context of people applying for marriage licenses. But I thought it was remarkable that he came out with largely what would appear in the guidance, and I wondered, did you have any role in working with the White House to develop his speech, his remarks?

MASON: I don't think CDC did. I don't know about the Secretary's office, but I'm sure that's what they would have recommended had they been asked.

CHAMBERLAND: OK, OK, because it struck me that it was rather curious--it was a 01:04:00good thing.

MASON: President Reagan attended cabinet meetings where these concepts were discussed.

CHAMBERLAND: Aha, OK. He had heard from you and others about this principle of "offer but don't mandate" testing, for the most part. Another spinoff from this whole idea of HIV testing was where should people be tested. There was a lot of concern that people were going to utilize blood banks, because the blood banks were obviously testing the blood supply. There was a real need to come up with a plan to direct people to where they could find testing.

MASON: We had to have an alternative to discourage persons worried about being AIDS infected from using a blood bank to learn if they were HIV positive.

CHAMBERLAND: Exactly. That also fell to CDC to come up with -- working with state and local health departments this whole set-up of -- I think they were 01:05:00called alternate testing and counseling sites.

MASON: Mm-hmm, that's right. Blood banks initially were the only place where HIV testing was done. CDC held a meeting in 1987 to talk about whether the HIV antibody test that had recently been licensed should be used more extensively with counseling to assist in preventing AIDS. We felt that selective counseling and testing to reduce sexual- and drug abuse-related transmission of the AIDS virus deserved further exploration. The meeting put me and CDC at the vortex of what became a raging controversy. Those on the political right wanted to mandate testing for everyone. They would use testing as a basis for identifying and quarantining persons who tested HIV positive. Those on the left, focusing on individual rights and freedom, were on the opposite end of the spectrum. Not mandating, but offering voluntary HIV testing and counseling to identify those who might benefit from treatment represented a middle ground. The weakness in the middle was absence of any effective treatment modality. But treatment was coming! There could only be justification for mandatory testing before marriage, at sexually transmitted disease and drug abuse clinics and when patients were admitted to the hospital in cities where AIDS infections were common. I was asked at this time why CDC was stepping into this controversy. I responded that we wouldn't be doing our job as public health leaders had we not led out on this critical issue for full discussion.

CHAMBERLAND: That was another sort of revolutionary idea that took hold and was implemented during your time as CDC Director. Are there any other guidelines or recommendations that stick out in your mind or any other prominent battles that you recall?

MASON: Not a battle, but a guideline that in retrospect was obvious. Only surgeons routinely used gloves in a medical care setting when the AIDS epidemic broke out. They used gloves to protect the patient from infection, not to 01:06:00protect themselves. Phlebotomists, nurses giving injections and even dentists didn't glove when they provided care. It was during the AIDS epidemic that CDC introduced universal blood precautions to protect health workers. I think it's interesting that it took AIDS to get that principle implemented. Hepatitis B virus is probably about a hundred times more infectious than HIV, yet healthcare workers weren't using universal precautions, even though hepatitis B infections were common. It took AIDS to introduce what is now standard medical practice. I'm sure this helped the glove industry tremendously. Think of the number of 01:07:00hepatitis B and C as well as AIDS infections that universal precautions have prevented. Blood borne infections still occur when one has a needle prick injury penetrating the glove, but that's rare compared to the blood exposure medical personnel were having.

CHAMBERLAND: Absolutely. There was a whole series of healthcare setting recommendations that CDC developed over a long period of time, as you say, leading to this concept of universal precautions: that every patient should be viewed as being potentially infectious for HIV and hepatitis B. Hence the bad old days, when it was considered a badge of honor if you got a little blood splashed on you--

MASON: Today, even the police carry gloves. If there's an open wound or blood, they put gloves on. CDC guidelines stood the test of time. I don't know of one 01:08:00guideline that had to be significantly altered. Not one guideline was shown to be inappropriate. They were cutting edge when they came out. Science prevailed, not politics.

CHAMBERLAND: Yes, and I wanted to ask you about that. As the CDC Director or the Assistant Secretary for Health, in the context of guideline development, you seemed to be constantly navigating a fine line between the science and the 01:09:00politics of it. You seemed to find yourself in that position over and over again, walking this fine line of wanting the science to be correct, absolutely, but then [dealing with] the realities of the political context of the day. That must have been very challenging.

MASON: It was challenging, and it takes us back to the word trust. If everyone knows it's going to be science based, not politics or custom, understanding exists even in the absence of agreement. Science helps people reach agreement when they communicate person to person. That was true, at least in the 1980s. Unfortunately, today society has arrived at a place where even science is debatable. Look at climate change. However, in the relationship of trust that 01:10:00existed during the early AIDS period, even a Republican administration and a Democratic Congress could generally work things out, because science trumped politics. We were able to negotiate differences using a science base, and both political parties knew where CDC was coming from.

CHAMBERLAND: Before we close, I wanted to ask you a few questions reflecting back a bit. What are your insights, now that we look back 35-40 years ago, about how CDC approached the AIDS epidemic? What do you think CDC did best? What are things we could have done better?

MASON: I'm the wrong person to address that question because I was so involved. 01:11:00Bill Foege, who preceded me as CDC Director, was there when AIDS was identified. He put the initial AIDS studies on a solid science-based foundation. CDC's abilities with shoe-leather epidemiology, reporting, surveillance and in-depth, critical analysis alerted the world to the fact it faced a major epidemic of a new infectious disease. Without CDC's expertise and capabilities, the AIDS epidemic may have grown significantly before it was recognized. During my period at CDC, we were involved in building the resources for epidemic control and prevention. Of course, we could have done a better job. We lacked resources for investigation, research, control and prevention activities. The states and cities impacted by the epidemic were resource poor, and needed services were not established as early as they might. Communication between different parts of the Public Health Service during the early phases of the epidemic was not ideal. CDC communicated well with the public about what was going on. You raise a good question. It is difficult to identify a lot of defects other than the serious lack of funding to fight the epidemic at all levels of government. Someone more objective then me should answer that question.

CHAMBERLAND: What impact do you think AIDS had on CDC? Sometimes it's remarked 01:12:00that AIDS was a turning point for the Agency, that the Agency became more politicized with the AIDS epidemic. Do you think it did have an impact on the Agency?

MASON: AIDS had a major impact on CDC. People may have known about CDC before AIDS, but they didn't know much. The agency was hidden away in Georgia. CDC was not well recognized by the general public. I never heard about CDC while attending the University of Utah School of Medicine. The same is true of the Surgeon General. After AIDS, everyone knew about CDC and had heard of Surgeon 01:13:00General C. Everett Koop. What do we hear about the Surgeon General today? Today, most people couldn't tell you who the Surgeon General is. The Surgeon General is lost to public view, and we need to make sure CDC doesn't follow the same path. AIDS allowed CDC to become scientifically and politically visible. CDC's budget grew rapidly. The public felt comfortable with CDC; it responded well. The public had confidence in CDC's recommendations and guidelines. Congress became a major supporter of CDC with both appropriations and an enlarged scope of responsibility. Congress felt that CDC's AIDS accomplishments could be replicated in pursuing the nationwide epidemics of chronic diseases and injury. AIDS opened the door and gave CDC an opportunity to show what it was capable of 01:14:00accomplishing. Sometimes I wonder whether CDC should consider getting involved in the important health issues relating to climate change in a way that would help the public credibly separate science from politics.

CHAMBERLAND: Let me ask you: what about the impact on you personally, in your job as CDC Director and Assistant Secretary for Health? Your work was conducted under a lot of public scrutiny, political scrutiny, glare of the media. How did you handle that? How did you decompress from these kinds of -- from a high-pressure job like that?

MASON: I wasn't totally successful in handling stresses. If you were to ask my wife, she might tell you about the late evening when I punched a hole in the wall of our bedroom during a phone call from a White House staff member just before the AIDS brochure was mailed out.

CHAMBERLAND: Literally?

MASON: Really. That's how I worked out my anger on that occasion. That was the only time it really got to me. It was a telephone call about the AIDS mail-out.

My CDC job was really a very interesting adventure. I enjoyed it. I enjoyed the 01:15:00people I worked with at CDC and in Washington. I don't know of a person at CDC who wasn't a friend. I respected and highly regarded my coworkers. If I learned anything during that period, it was how important other people are and how much fun it is to work together with others to accomplish something worthwhile. I also learned to appreciate people who suffer from health problems. I knew and talked with people with AIDS and appreciated how discrimination can hurt. I left that job with a better understanding of people who are ill or disadvantaged. It 01:16:00was a great experience.

CHAMBERLAND: Are there any closing thoughts? Anything you want to add that we haven't covered?

MASON: No. I just thank you for giving me the opportunity to rattle on and express myself.

CHAMBERLAND: We are delighted that you could be included in the oral history. As I said, at the start of our discussion you were in the hot seat. It was a very exciting time. Lots of things were happening, good and not so good, with the AIDS epidemic at the time. I thank you very much for sharing your memories with us.

MASON: You're welcome.