Dr. John Ward

CHAMBERLAND: This is Dr. Mary Chamberland, and I’m here with Dr. John Ward at the Centers for Disease Control and Prevention in Atlanta, Georgia. Today is Tuesday, September 26, 2017. I’m interviewing Dr. Ward as part of the Oral History Project, The Early Years of AIDS: CDC’s Response to a Historic Epidemic. John, welcome to the project.

WARD: Thank you.

CHAMBERLAND: Do I have your permission to interview you and to record this interview?

WARD: Yes, you do.

CHAMBERLAND: John, you first arrived at CDC [Centers for Disease Control and Prevention] as an EIS or Epidemic Intelligence Service officer, assigned to the AIDS [acquired immunodeficiency syndrome] program in July of 1984. Much of your early work in the AIDS program focused on the risk of HIV [human immunodeficiency virus] transmission by blood transfusion. You subsequently assumed a series of increasing leadership positions within the AIDS program. Later, you became the editor of the MMWR [Morbidity and Mortality Weekly Report] in 1998, and since 2005, you have served as the director of the Division of Viral Hepatitis. But before we discuss your work on AIDS at CDC, let’s talk a little bit about your background. Could you tell us where you grew up and about your early family life?

WARD: Sure. I was born in Montgomery, Alabama, and spent most of my childhood there. My father was a computer analyst for the U.S. Air Force at the Air Force base there, and my mother was a clerical worker at a local department store. I had one older sister, who went on to become a social worker and head of foster care programs for the State of Alabama. And I think it sort of reflects the family I grew up in. I think it was a very religious-oriented family, one that was very involved, in large degrees, with various social programs, and I think it sort of helped shape some of my attitudes in medicine later on.

I got interested in medicine because of a high school teacher in physiology who was very captivating and suggested that I had the right aptitude, I guess, to go into medicine, and so they got me thinking about that. And I went to the University of Alabama in Tuscaloosa as an undergraduate in biology and with a minor in history. And then I applied and got accepted to the University of Alabama School of Medicine in Birmingham [UAB], which is where I did my medical undergraduate training.

CHAMBERLAND: And then did you stay in Alabama for your clinical years?

WARD: I did. I did my internship and my residency at Alabama, and indeed, when I came over to interview for the EIS program, the interviewers asked me if I had ever left the state. It looked like I had been fairly cloistered all my life. So I’ve always felt like I was on the remedial program here at CDC with that kind of introduction to the agency. But we had a very good infectious disease program there. And actually, Jefferson County, which is where Birmingham is located, was one of the four counties that had a viral hepatitis surveillance program supported by CDC.

And I got very interested in public health as a freshman in medical school because a Methodist minister who ran the Student Union at the University of Alabama had started a program called the Alabama Coalition for Community Health. And he would sponsor, or he would get the communities to sponsor, health fairs around the state. And then medical students would go and staff the health fairs and do screenings of various types, which was beneficial, obviously, for marginalized populations in the state, but it also helped those communities understand how they could work together to solve common problems. And there’s examples of communities continuing on to apply for federal grants for water purification plants, et cetera, et cetera.

And so we went and actually lived with the Creek Indians for weeks at a time. We lived with the Choctaw Indians for a while, because they had to be responsible for putting us up, finding a place for the health fair, finding a place for everybody to live, et cetera. And it really was very energizing to meet these populations. Even though I had grown up in Alabama all my life, I really was not aware of those populations until working in that program. So when I became a resident, I asked to be assigned to the health department.

CHAMBERLAND: As one of your rotations?

WARD: As one of my electives. And I was actually the first internal medicine resident to ever have an elective at the local health department. And so when I went over there I worked in the TB [tuberculosis] clinic, but then I began just to look at the hepatitis surveillance data. And then I became interested in vaccination, because the hep B [hepatitis B] vaccine had just become licensed for use, and I became very interested in how it was being used among the house staff. So that was really sort of my first very—you know, very elementary introduction to epidemiology and public health—was there.

CHAMBERLAND: It struck me—and then you said this in your comments—that you were the first student or resident to go over and do an elective in the public health department, because these were the days when public health was not on any medical student’s top-ten list of internship-residency programs. And it was kind of the bottom of the barrel in terms of—from the medical students’ perspective—of people that ended up in public health. So you really were ahead of your time, so to speak. WARD: Yeah, and even our epidemiology course in medical school was voted the worst course that we had, in fact.

CHAMBERLAND: Yes.

WARD: But despite that, I think in part because of that experience in those summer programs, I became very interested in public health. Also, I began to realize in internal medicine, in particular, how many diseases you’re being asked to be responsible for and take care of are preventable, and much better to be prevented than to be treated. And I think that was the other impetus for me to get interested in public health. When I was working at the health department in Jefferson County, the local county epidemiologist, [Dr. James] Jim Alexander, brought me over—this would be about 1982—brought me over to a meeting of a TB program coordinator meeting. So that was really my first meeting at CDC, with [Dr.] Dixie Snider, who was then head of the tuberculosis program, chairing the meeting. So that was my first introduction to CDC.

I then went back into my residency, and I had gotten interested in international health as well. I had done my last six months of my final year in medical school. I had an elective in Melbourne, Australia, studying pediatric immunology, so I got very interested in more global travel, more global experiences. So I somehow arranged an elective at the London School of Tropical Medicine and Hygiene, and thanks to the good graces of UAB, they allowed me to serve that elective. And I really, really can’t remember how I put that together in the days before Google and, you know, email, et cetera. But, you know, I went over, spent two months doing clinical ward work and attending lectures, et cetera, which only increased my interest in global health. And, to some aspects, public health, I guess.

So I got very interested in visiting the World Health Organization. So I had the head of the program at the London School, the clinical program, write me a letter of introduction. I took—there was no Chunnel at that time, so I took the hovercraft over—got seasick on the way—hovercraft to Calais, rented a car, drove to Geneva, Switzerland, to interview. And so I got an interview set up with the World Health Organization, and Mr. Fontaine interviewed me, I can still remember his name. And he started interviewing me in French. And, of course, I know a little French, but not enough to conduct an interview. So he completes the interview and says, “You’re way too inexperienced to work for WHO [World Health Organization],” and I said, “Well, where can I go get this experience?” And he said, “Go work at CDC.”

CHAMBERLAND: Ah, so that’s how you—

WARD: So that was really my first eureka moment, like, wait, maybe I should go work at CDC.

CHAMBERLAND: Gosh, and it took traveling to London by air and then by boat and then by car to finally hear about CDC.

WARD: Yeah, exactly. I had to go hundreds of miles. Yeah, exactly. It was really funny. And then it’s like learning a new word, you know, so then I come back to my residency, and lo and behold, the head of our residency program, Dr. [William E.] Bill Dismukes was a former EIS officer, infectious disease physician at UAB. And so I began to talk to him, and then I found that a resident a year ahead of me in the program was already applying—that would’ve been [Dr. Edwin M.] Ed Kilbourne—and so I began to talk to him about CDC. And so he got accepted the year ahead of me and went off and did, I think, environmental health or what his area of interest was. And then Dr. Dismukes helped me with my application—I think was very supportive, you know—called CDC to reinforce his recommendation for me, which I greatly appreciated him doing.

CHAMBERLAND: Now when you were—in between all of the travel, you obviously were seeing patients as part of your clinical rotations. Had you seen any AIDS patients, either in Alabama or even in London at that time, because it’s the early ’80s, and they were starting to pop up?

WARD: Right. Did not see them in London, but when I came back to Birmingham, I was very interested in infectious diseases already. And I was doing my infectious disease rotations as part of my internal medicine residency program, and we would have, of course—we would have rounds most mornings with the attendings, where cases were presented. Now, at UAB, the Infectious Disease Program was one of the most highly regarded departments at UAB. And the physicians there who were the professors in that department were considered some of the best doctors there, so we felt like they were “masters of the universe,” as we used to say. And so they began to describe this man in his thirties or forties from Huntsville, Alabama, about a hundred miles away that had this respiratory infection. He had hemophilia. The head of the department, Dr. Glenn Cobbs, proceeded to go through the differential diagnosis. We anticipated his opinion, waiting for him to tell us what this person had, and he goes, “I don’t know what he has.” And I can still remember the chill going up my spine that—the fact that this really young man—granted, with a chronic blood condition, but previously in good health—would come down with this life-threatening pneumonia shocked me.

Later, we found it was Pneumocystis carinii pneumonia. This would have been about 1983, I think. That case was one included in one of the first case series complied by CDC that included persons with hemophilia. My first introduction to HIV/AIDS was the result of transmission by blood and blood products.

CHAMBERLAND: So was it at the end of your three years of internal medicine residency that you had sent in your application to become an EIS officer at CDC?

WARD: That’s right.

CHAMBERLAND: Okay. And you and your EIS classmate—that, I believe, was [Dr. Thomas] Tom Peterman—you were only the second set of EIS officers that had actually ever been accepted into the AIDS program at headquarters in Atlanta. When you came to interview for EIS during the conference and the matching process, had you set your sights on the AIDS program, or were you—With all of your travels and experience, you certainly had had a lot of interests. What did you come to Atlanta looking for and what did you—You obviously ended up with AIDS, and I’m just curious about how that worked?

WARD: Yes, it was interesting. I intended to work on hepatitis at CDC, as I had become interested in hepatitis, because, as I’ve mentioned, of my exposure to the health department and their data regarding hepatitis and hepatitis B vaccination. However, when I arrived, I found that the hepatitis program was assigned an EIS officer every other year, and I was here in the off-year, so the program didn’t have an EIS position. Now at that time, the interviews were conducted on a Saturday and a Sunday for EIS. And as you know, Mary, it’s very much like fraternity or sorority rush, where you’re trying to find who you think would be good, and they’re going to give you a ranking as to who they want. But on the Friday night beforehand, the people who have positions in the EIS program in their departments, they were given three minutes to describe their positions, to attract you to apply for their positions—

CHAMBERLAND: Give their pitch.

WARD: To give their pitch, exactly. And I can remember [Dr. James W.] Jim Curran getting up, and I’m sure he said a number of things, but the one thing that really stuck with me was how he, with alarming clarity, described how this whole epidemic was unfolding, there’s a lot of unanswered questions, and, “He who knows AIDS will know medicine.” And it was like I had, you know, just like—

CHAMBERLAND: That was his hook.

WARD: That was my hook. And it hooked me big-time. I mean, it was like the V8 moment, the lightbulb going off. I realized this is just the start of the epidemic. It’s just beginning. I really wanted to be a part of this. This was on Friday night. As you know, Mary, during the EIS week, programs are having breakfasts and lunches and gatherings to attract interest. I had not gone to any of those for the AIDS program. I had a lot of catching up to do. On Saturday, I interviewed with Jim and with [Dr.] Harold [W. Jaffe] and with [Dr. Kenneth G.] Ken Castro, who was the EIS officer in the year before me, and then cycled back around on Sunday to let them really know my strong interest in this. I think it might have helped that Jim Curran’s wife was from Alabama. I’m thinking that there might be some—a little connection there, maybe. He gave me a nod. But I felt very appreciative when I got the call that I had matched, so I was really, really excited about that. The call came in April.

CHAMBERLAND: April.

WARD: April. So then you still have several months to go back and finish up your residency program. So I go back to do that, and about a week or so after getting selected to be part of the AIDS program at CDC, [Dr. Robert C.] Bob Gallo and [Dr.] Luc Montagnier published their studies and their discoveries of the virus that causes AIDS. At that time, the virus was identified as HTLV-III [human T-lymphotropic virus type III] by the Americans, and lymphadenopathy associated virus, LAV, by the French. I can remember my colleagues in my residency program going like, “Well, that’s over, John. I don’t know why you joined that program. They’re going to find a vaccine for that.” So it was a little bit of a mis-call there, so that was my—

CHAMBERLAND: Yeah, we’re still looking for that vaccine.

WARD: We are still looking for that vaccine.

CHAMBERLAND: So your arrival in Atlanta, which would have been in July of that year, it’s really at a pivotal time. The cause of AIDS had been discovered, and there are now serological tests to detect the virus that became commercially available in March of ’85. And the availability of testing was obviously a watershed moment, and in particular for blood banks, because at that point in time, national surveillance was showing that about 1-2% of all AIDS cases reported to CDC were associated with receipt of transfusions. And although the Public Health Service, really as early as March of ’83, had recommended that people who were at increased risk for acquiring this new disease—this new infection—should refrain from donating blood and plasma, we all know that that is far from a failsafe prevention measure.

So, all of this is unfolding. You begin in the summer of 1984 in Atlanta, and I’m curious, because much of your EIS work and then after is associated with working on blood transfusion issues, how did that come about? Did you volunteer for this? Were you volunteered? Had you started on another AIDS-related project and then diverted over to this? I’m just kind of curious how they got you slotted in this particular area.

WARD: No, when I arrived they basically said, “John, your job is to protect the nation’s blood supply.”

CHAMBERLAND: Protecting the nation’s blood supply?

WARD: Of course, I was going to have help, but that was pretty much what I was assigned to, right at the moment. And as you alluded to, this was a very contentious aspect of the AIDS epidemic, because it was a risk that potentially anybody could have, receiving blood that was contaminated with HIV. There was this sense of the “innocent bystander” of the AIDS epidemic, of people without anything that they could control becoming infected. As a result, it was a very highly visible and politically charged part of the AIDS epidemic that attracted a lot of interest from different sectors of society. And obviously, you know, it’s—a very major focus of public health continues to be protection of the blood supply. I did a lot of work with the FDA [Food and Drug Administration] in that regard as things moved along.

CHAMBERLAND: Now, I’m curious, because in your comments from the last few minutes when you walked us through your training and your various travels, I didn’t hear any mention of blood banking.

WARD: Right, exactly.

CHAMBERLAND: So this was, I presume, a whole new arena for you, other than maybe ordering blood transfusions as a resident.

WARD: Exactly.

CHAMBERLAND: How did you get up to speed on just what the basics of blood banking are and who the players are?

WARD: I really think this is one of the real beauties of epidemiology and real beauties of working at CDC. At CDC, epidemiology is perceived to be a mobile skill, and you’re to move around and apply it as needed. I think that’s what I have seen time and time again here at CDC. And in my case, I was expected to come up to speed on the—by—through reading about blood banking and begin to develop relationships in the field. I began to work on a regular basis with the American Red Cross, American Association of Blood Banks, and the individual Red Crosses around the country at that time. I would go to their meetings, attend their conferences, and then progressively you become more and more knowledgeable about the field. I think that’s actually one of the real attractions of epidemiology and working at CDC, is that you can move around while still having the basic tenets of public health and epidemiology in mind. You can apply that to a variety of different health issues over the course of your career, which makes it a much more rewarding career as a result.

CHAMBERLAND: Mm-hm. You know, in preparing for this interview I went back to read some of the relevant publications and CDC’s MMWRs. It was interesting. In January of ’85 there was—the Public Health Service came out with recommendations anticipating the availability of now commercially available HIV testing and serological tests. And these recommendations were introduced with some fairly cautionary language. They said while there is considerable experience with using the ELISA [enzyme-linked immunosorbent assay] test, which was the serological test in research laboratories, much additional information will need to be gathered following widespread application through blood and plasma donations. So although the test was obviously welcomed, it was clear that there was a lot to be learned about unleashing it, if you will, on a population of blood donors who would normally be expected not to be having a high prevalence of infection.

Can you talk—I want to talk, obviously, a lot about studies that you and others went about in evaluating this new test in the real-world setting of the blood bank. But maybe before we get to the mechanics of it, can you tell us a little bit about what were some of the concerns or pressing questions that, screening millions of donors of blood and plasma, were being raised? What were some of the concerns and questions that your studies really needed to address?

WARD: Well, that’s right. I mean, just the—how well would the test work when screening millions of people every year, rather than being out of the research environment? And what kind of quality control issues within individual laboratories, the sort of variations just by the different staff working on the tests in laboratories? Who was being found positive? Were they really infected? Blood banks were always worried about throwing out blood unnecessarily. And so, are you over-calling an infection and therefore having a valuable product discarded unnecessarily? So those were those big issues too. And then, you know, then actually how well does it really work in protecting the blood supply? So there was sort of a mix of concern about quality, concern about documenting that the test was indeed good, so you could protect the blood supply, but also reassure the public that the blood supply was being protected by the blood screening. And then minimizing the discard of blood unnecessarily.

CHAMBERLAND: Right. And that discard of blood, obviously, if a unit tested positive—no matter how good a test is, if you’re using it in a presumably low-prevalence population, you’re going to pop up with some false positives.

WARD: Oh, yeah.

CHAMBERLAND: And, obviously, even if subsequent testing went on to show that it was likely that the donor was not infected, the blood bank would be nonetheless obliged to discard the unit. Were people concerned, again, about the impact this might have on the donors themselves? Because I know the blood banks are very—back then, and still today—are very protective of their donors in the sense that they’re very appreciative, obviously, to these people who have given a lot of their time, and many of them do it repeatedly to donate a unit of blood or plasma. But were there also real concerns about the potential social or psychological impact that it might have on donors to sort of be calling them up and say, “Well, got the results of your test, and it’s positive”? I was curious if that was also part of the mix of discussions that you had before undertaking the studies.

WARD: Not before undertaking the studies. There was some concern about how you convey the information to donors as they were found to be infected. I would have to say, the largest issue around donors was that by having the testing available in blood banks, the major concern was that you would be attracting people who were at risk, had no other way of being tested, and then they would go and donate blood just to see if they were infected. And even if the test was good, you’re going to miss some people because no test is perfect, and you would actually be causing some harm unnecessarily. The other complementary activity underway was to provide alternative test sites around the country so that those people who did want to know their status would have an outlet, rather than only a blood bank. It’s a secondary way of protecting the blood supply.

CHAMBERLAND: Yeah, that’s a really good point. And I’m assuming that you really weren’t particularly involved in the setting up of the, quote, “alternative test sites,” but that was fairly novel, I think, in and of itself—that this new test is available, there is a sense that people will want to know what their status is and there was really no place to go. I mean, you couldn’t go to your doctor’s office, for the most part, and ask for a test. So people were going to show up at blood banks, which I could see would be worrisome.

WARD: Right. And for some, they may even feel like it’s more confidential than going to a local clinic—

CHAMBERLAND: Ah, yeah, good point.

WARD: —a small-town physician or something like that. A big concern how the donor population might change because of the attraction of the test being available.

CHAMBERLAND: Okay. So I imagine, these were all—

WARD: It was all swirling about.

CHAMBERLAND: It was swirling. Who were some of the players that were engaged in all of these discussions and—do you remember?

WARD: Well, there was a lot of—

CHAMBERLAND: Obviously, people within CDC—

WARD: Obviously, well, within CDC, I would brief Jim Curran, obviously, Harold Jaffe, [Dr. James R.] Jim Allen was my immediate supervisor and responsible for these and other epidemiologic studies, [Dr. Walter R.] Walt Dowdle who was deputy director of the CDC at that point in time, and [Dr. James O.] Jim Mason, the CDC director. This was a high-visibility issue within CDC. We would meet with people with FDA on a regular basis. The heads of blood banks, [Dr.] Roger Dodd comes to mind at the American Red Cross. [Dr.] Paul Holland, who used to work at NIH [National Institutes of Health] in the transfusion service, who ran the blood bank in Sacramento, was still very influential. [Dr.] Harvey Alter at NIH was very involved in those early days. There was a number of others. I can’t really recall all the various community advocates at that point that was having a say around testing. But just access to testing—

CHAMBERLAND: Was a big issue—

WARD: —because it was getting licensed now, how do you make this test available was gathering steam as a major point of discussion between community advocates and the government, which, as you know, continues to this day.

CHAMBERLAND: So let’s talk a little bit about your first big study to protect the nation’s blood supply, as Jim Curran had charged you when you walked in the door as an EIS Officer. How was it decided that CDC would join forces with the American Red Cross and their regional office here in Atlanta to do a collaborative study on the test, how good it performed? How did that all come about?

WARD: I wasn’t privy to all those conversations as an EIS—

CHAMBERLAND: Oh, so some of them may have antedated your arrival?

WARD: Well, I think the test came out, as I recall, in February, after I joined the program as an EIS officer the previous July. It was licensed in February of ’85. Right around that time, or maybe within one or two weeks, Jim Curran and Harold Jaffe come to me and said, We’re going to do an Epi-Aid to investigate how well this test works. An Epi-Aid is the term for a CDC investigation of a new outbreak or other health problem. I think it reflects the ongoing collaboration CDC had with FDA already. You know, you’ve mentioned the 1983 meeting—CDC was already very involved in this whole area of HIV and the blood supply. We can do this type of study much better than the FDA can, I believe. So we took it on. They said, We’re going to do it here in Atlanta with the Atlanta Red Cross. We went over and met with [Dr. Alfred J.] Al Grindon, who was the chief medical officer of the Atlanta Red Cross. I’m not really sure how all the funding worked at that time.

CHAMBERLAND: It’s probably better not to know.

WARD: Exactly. But it was an emergency situation, and things get done. We fashioned the study: we developed a sample size calculation; we developed, from the package insert, the estimated sensitivity and specificity of the test; we estimated prevalence, and then estimated how large the study needed to be to be meaningful. As a young EIS officer, I think it really taught me how to evaluate a test, predictive value positive, predictive value negative. And a lot of people talk about sensitivity and specificity when they talk about tests, but what they’re really talking about is predictive value positive and predictive value negative. As this varies, your test interpretation varies, depending on the prevalence of the infection in the population that you’re testing. In the case of blood donors, you’re testing a fairly low-risk population.

My job, after writing up, with help, the protocol—basically I went out and interviewed people who were positive on the test. I did that at the Atlanta Red Cross headquarters on Monroe Drive. I did it at CDC. CDC had a little clinic at that time right between Building 1 and Building 6, which are no longer existing. Persons would come in. I would see them there and talk to them—I had a standard interview, of course—draw blood on them myself, and then have that blood sample tested at CDC for confirmation of the antibody result and to do the Western blot to confirm the presence of HIV.

CHAMBERLAND: Were people cooperative? Did you get—because obviously, the test—the Red Cross would be running the serologic screening test and then identifying who the people were that it deemed to be positive. I believe CDC’s labs were doing confirmatory testing for that.

WARD: That’s right.

CHAMBERLAND: And then would offer, I guess, to these positive donors the opportunity to enroll in the study to be interviewed by you.

WARD: That’s right.

CHAMBERLAND: Were these positive donors cooperative?

WARD: They struck me as very cooperative.

CHAMBERLAND: Yeah, because you were trying to find out if they had risk information.

WARD: Yeah. I had very few refusals. And again, we have to remind ourselves that this study was being done in 1985 in Atlanta, Georgia. The AIDS epidemic is only about four years old, and the test is new. Most people don’t know they’re infected. And there were remarkable personal stories uncovered by the testing. Now, obviously, I met people who were false positive—you know, they were not infected with HIV, and they had histories that were fully consistent with that test result. But then you also were telling people for the very first time if they were infected with the virus that causes AIDS.

CHAMBERLAND: Oh, gosh.

WARD: I really was the first one to tell a fair number of people that they had the AIDS virus in 1985, at a time when it was a very, very scary disease. And AIDS still should be so considered currently. Fortunately we have interventions that make it less scary than it was at that point in time. And the stories really vary. A few come to mind. One, a minister in a small Southern town, married, with three to four children, would come up to Atlanta to see his parishioners in the hospital, and then stay over and have a separate lifestyle than [what] he was associated with in his small town. I had to tell him he was positive. He had to share that information with his family. Difficult. However, he became fully open about his sexuality and began to live his sexuality. He moved to Atlanta, and fortunately, he was a long-term survivor. I saw him about—at least twelve years after my study, and he was still doing fine and heavily involved in various AIDS causes. This is one example.

On a more tragic note, I interviewed a woman who was found to be positive who had only had—after years of celibacy, had just decided to become more sexually active. She had had only two sex partners. Unfortunately, one of them was HIV-infected. She had become infected just recently. And another one: I interviewed a man who was living in Atlanta from the New York City area, and he reported that he had fifty or more female partners a year and had no other risk for HIV. As a result, I attributed his risk to heterosexual transmission. Years later, when I was working at the VA [Veterans Affairs] Hospital here in Atlanta, doing my clinical rotation in the HIV clinic as part of my commission core activities, that individual came through the clinic and laughingly told me he had been an injection drug user at that time. This was almost certainly the true cause of his HIV infection.

CHAMBERLAND: Oh, my goodness.

WARD: Yes, he admitted that he had made the whole thing up and that he was actually an injection drug user.

CHAMBERLAND: So did you two immediately recognize each other?

WARD: Oh, yeah—well, he recognized me and then introduced himself and then we began talking. So we had to correct that on the form, because heterosexual transmission, you know, is a little bit less common, particularly female-to-male. So it was a little bit more consistent for him being a drug user. And I met gay men who were already more open than the one I just described. I had to return for some follow-up confirmatory testing, et cetera. We developed doctor-patient relationships at a time when there were few physicians who actually knew anything about HIV.

CHAMBERLAND: Yeah, and I’m really also struck how difficult this was, because at this time, as you say, there’s not a lot of physicians that know much about AIDS, there wasn’t—we were still learning about the natural history of AIDS. You couldn’t really give them a lot of detailed information about the likely course of their disease. There was no treatment that you could really offer them. There were certain preventive messages that you could deliver, which, as you illustrated, in some instances would involve them in having to share their status with sexual partners or others. So I can see where this just must have been a really wrenching part of the study for you.

WARD: No, it really—it really made it real, very real, what was happening, having it done at the personal level. And so we did that study from late February through, I guess, May. I presented it at the EIS conference.

CHAMBERLAND: And what did you find, in terms of the performance of the test? I’m sure everybody was interested in how that was turning out.

WARD: We were really trying to keep the study a bit under wraps, so, again, not to influence who was coming in to get tested, et cetera. In addition to testing people here at CDC and at the headquarters of the American Red Cross in Atlanta, I would go out into rural areas and interview donors in small offices of the American Red Cross. I remember going down to LaGrange, Georgia, which is about sixty miles south of Atlanta. I was supposed to meet a donor there who was positive. The Red Cross office was on the second floor of the courthouse. I sat on the steps of the courthouse waiting for the donor to come by. Now, Coca-Cola had just changed their formula from sugar to corn syrup. This media truck from the local radio station pulls up. These people get out with all these microphones and everything. I’m going, “Oh no, someone’s found out about this study—I’m going to get interviewed. I’m going to get interviewed here.” And sure enough, they walk right up to me and they go like, “Can we talk to you?” And I say “I guess.” And they bend over with a mic and ask, “What do you like better, new Coke or old Coke?” I replied, “I think I like the old Coke better.” So the concern over media leaks was a little over-call on my part.

I brought the data together. My first study at CDC, a very simple study, which was perfect for me as an EIS officer—I began to analyze who was positive, and then who was positive on the Western blot, to show they were truly infected with HIV, and their characteristics.

CHAMBERLAND: The confirmatory test is the—

WARD: And I found that the persons who had a small number, indicating less reactivity on the antibody test, were least likely to be positive on Western blot, and those that had a very high value were most likely. And so I came up with, anything over 6.0, you had about an 88% chance of being positive, whereas if you were less than 2, it was 6% or 10% chance of being truly infected with HIV. And I have to say, you know, being my first introduction into doing studies, I marveled at the fact that for that little space of time, I was the only person in the universe that knew how well that test worked, you know, in the blood bank setting. And so then I went in to show the results to Jim Curran, and I laid it all out for him. And of course I’m not fully certain how to interpret these findings, and I said, “People that were positive with a value of 6.0 or higher—”

CHAMBERLAND: So, strongly reactive to the serological test.

WARD: “If they are strongly reactive on the antibody [test], they had an 88% likelihood of being infected with HIV.” And I said, “It’s not 100%, but it’s 88%,” and so Jim goes, “It’s okay, it makes it more believable if it’s not 100%.” So that was a good joke. We had a good laugh about that. But then we presented it. We rushed it into publication. It was published in JAMA [Journal of the American Medical Association], and that 6.0 was really used as a real—you know, those kinds of values, for a short time, as people began to get familiar with the test—it was really used to help interpretation in laboratories around the country.

CHAMBERLAND: So your findings did lead to—I don’t know if modifications is the right word, but it helped people interpreting, if you will, the EIAs [enzyme immunoassays] and setting maybe some cut-off values and whatever?

WARD: Yeah, absolutely. And then also just the likelihood—helping with the interpretation with the EIA, and helping, as a result—like, you know, if you got a negative Western blot but you had a high value on the antibody test, it was indicative that you probably should redo the Western blot, that maybe the Western blot wasn’t done well. So it really helped in the laboratory to interpret the test as people began to get more and more experience with it.

CHAMBERLAND: Okay. Okay. Yeah, so this real-world, real-time evaluation of a test that is still with us today, obviously much-improved over time. Was the CDC/Atlanta region Red Cross study the only study that was happening to evaluate the test? Were other entities involved? I was just curious if everybody was zeroing in on this very detailed study here in Atlanta, or were there others, and if you were communicating or collaborating or sharing results. Just curious.

WARD: No, it was really the only one.

CHAMBERLAND: Really?

WARD: Really, at that time. We were still a fairly small operation then. And AIDS had not really caught on as a large national health issue. Even though there was a lot of concern about the blood supply and the case counts were up to around five thousand, we still did not have large budgets to study AIDS or to prevent AIDS. I think that really began to change when Rock Hudson was diagnosed with AIDS, and people began to take it more seriously. You know, when I first got there, to the AIDS program, the Georgia Public Health Association invited us to give a talk on Jekyll Island about AIDS. And I was asked to go and of course I said yes, but we did not have enough money in our travel budget to travel—

CHAMBERLAND: For you to drive down to Jekyll Island—

WARD: —from Atlanta, Georgia, to Jekyll Island on the Atlantic coast. It was really amazing. And you know, over several weeks we were able to muster the money and I did end up going, but that just sort of shows you how thin the margins were as far as budgets were concerned.

CHAMBERLAND: So this new test had been—it was being deployed in other, certainly blood centers around the country—

WARD: Oh, absolutely.

CHAMBERLAND: But I’m really fascinated to learn there was just this one very detailed look going on, at the Atlanta region’s collaboration between CDC and the Atlanta region of the Red Cross. That’s fascinating.

WARD: Yeah.

CHAMBERLAND: For a test that was going to have that much of an impact.

WARD: Yeah, really, I have to say, I’ve often thought that CDC in the early days of the AIDS epidemic was very much like the Washington Post in the early days of Watergate. We were pretty much the only game in town for investigation. And then over time, more and more people got interested in it, got involved in—and information began coming from different sources. But at that time, CDC was in the lead. And I think all the people you interview for this history will agree that one of the accomplishments that CDC can be the most proud of is the steps we took to protect the nation’s blood supply.

CHAMBERLAND: Mm-hm. Do you remember, as the results of the study became public —you alluded to the MMWR, your JAMA publication—but I believe results probably became public earlier than the JAMA publication. Do you remember what the reaction was among public health officials, the blood banking community, the general public? Because we talked earlier about the concern, the deep concerns going into the study about, how well would the test perform? Were we going to be in a position of having to discard a large number of units? Do you remember what people’s reactions were, or how that played out?

WARD: Well, it was very well received, because it was very good news that the people that were positive, for the most part, were truly infected—that the number of persons found to be positive was relatively small, and so the test was functioning very, very well. So it was very welcome news. If anything, we had to sort of harness the enthusiasm of the blood banking community, because they wanted to really be very robust in their estimations of how many infections were being prevented here and the number of infections that were being missed. And we didn’t feel like we had enough information yet to say that, so it was a little bit of a—I guess what we would call now irrational exuberance among the blood banking, because the test was performing so well.

CHAMBERLAND: Well, on that note, as the saying goes, no test is perfect. And sure enough, it wasn’t long before cases of AIDS started to be picked up in persons who had reportedly received blood that had been screened by this new test and found negative for HIV antibodies—and you and others published a detailed analysis of thirteen HIV-infected persons who had received blood from seven donors in February of 1988, in the New England Journal of Medicine. So let’s talk a little bit about this. First of all, you start hearing about these cases—I’m curious how these cases started to come to light—and were you shocked? Was this unexpected?

WARD: It was surprising. You are really there dealing with the unknown, so you really don’t know quite what to expect. Again, it’s a real testament to how clinicians have a vital role in public health surveillance, because they’re the ones who begin to call attention to these cases of people having HIV antibody detected that had no risk other than recently receiving blood transfusions that had been screened by blood banks. And we had just shown that the testing was good.

So what we did was we went in, I interviewed the clinicians, got the risk information of their patients, and then we got the information about the donors to those cases. And they were happening around the country. These weren’t—to your point, they weren’t large numbers of cases at that time, but they could be indicative of a larger problem, because then everyone, obviously, is getting tested after they get a unit of blood. What we found was that the donors had evidence of recent exposures that could have infected them with HIV, and that they were in what was called the “window period,” between the point of infection and the point of developing detectable antibody. And so that really helped to identify an area for quality improvement of the test—how do you shorten the window period so that more and more of those infected donors can be picked up? It also reinforced the value of screening out people who were at risk for HIV.

CHAMBERLAND: Yeah, most of these donors had risk factors?

WARD: Yeah, almost all of the donors had risk factors, and so they could have been excluded, but they had donated, and they had donated during this window period, and therefore the blood was used for transfusion. It was interesting. I did that study from my desk at the CDC. I did all of the interviews from my telephone. I wrote it up with the help of [Dr.] Scott [D.] Holmberg and Jim Allen and Harold Jaffe and others at CDC. And because of the national interest in this issue, the New England Journal quickly accepted it for publication, and the results really helped define what else needed to be done to protect the blood supply.

I have to say, the results spawned this “zero risk” guiding principle of the FDA—that our goal is to make the U.S. blood supply HIV-free. And over the next decades, really, they have progressively sought to improve the antibody testing, sought to improve detection of the virus within that window period, first with an antigen test for HIV and then by PCR, polymerase chain reaction, which is used today. And so that window period has become very, very narrow. And so it is very, very rare for HIV to be missed, certainly in blood banking.

CHAMBERLAND: Yeah, because back then, I think the ELISA test took something like, you know, maybe about eight weeks at least after infection—

WARD: That’s right.

CHAMBERLAND: —to develop a level of antibodies that was able to be detected by the ELISA test. And as you say now, the tests are such that they can detect evidence of infection within days of someone having been exposed. Did your interviews with these positive donors shed any light on why it was that high-risk donors continued to donate at blood drives? And did it help identify any additional measures that blood banks could take to try and dissuade donors from donating, or, if they felt pressured to donate, other ways that it would be possible for them to alert the blood center that you really shouldn’t use my blood here?

WARD: Yeah. I think it was a combination of donors not assessing their risk fully, so they sort of under—

CHAMBERLAND: Didn’t really think it could happen to me.

WARD: Yeah, there may be a little bit of self-denial going on, that I could really be at risk for HIV/AIDS, at that point in time. I think that was part of it. The other part of it was how blood drives are conducted, where people did not feel like they could opt out without people feeling like, “Ah-ha, he must have a—”

CHAMBERLAND: Because these are done in the workplace or in a church setting?

WARD: Yeah, in the workplace, and it’s a very promotional expectation that you should be donating. And so people felt like, Well, if I say no to the blood bank, people will think I’m gay.

CHAMBERLAND: I have a risk factor.

WARD: I have a risk factor. And so it helped people reevaluate how those blood drives were conducted, so that people had a better opportunity to opt out in a way that would be less stigmatizing for them.

CHAMBERLAND: I remember in those days, while we were working at CDC, there used to be—and there probably still are, I guess—the Red Cross would do collection drives here at CDC in one of the big auditoriums. And there would be emails that would go around, and my recall is that there was particularly a lot of pressure on people who had been previous donors to step up to the plate again. And so, as you say, in these kinds of settings it would be potentially very uncomfortable for someone to suddenly say, “Oh no, I’m not going to do it this time.”

My recall is that I think some of the blood banks came up with novel ways to try and address this, to allow people to donate in a setting—but then there was, I think, another step where they had this “confidential exclusion questionnaire” where everybody was asked to indicate, “Should my blood be used for transfusion? Yes or no.” People could say “no,” and it allowed them to donate, but then given this information that they provided in another question, if you will, to the blood collection agency.

WARD: Mm-hm. The other thing that really changed because of the AIDS epidemic and the blood supply was how blood was used in clinical medicine.

CHAMBERLAND: Good point.

WARD: Blood was heavily used in clinical medicine. You know, I can recall, during residency, the notion was, “Let’s pink them up before they leave.” You know, “Let’s top off the tank,” and people would be given a couple of units of blood just as a final measure. And all that got reevaluated because of the AIDS epidemic, and clinicians began to be more judicious in the use of blood, and even recapturing blood during surgery and having that used. So really, the AIDS epidemic totally transformed the blood banking industry in this country.

The other element of this is the plasma industry, and that’s where the clotting factor products were developed from plasma donations, and I’m sure [Dr.] Bruce Evatt and others you’ve interviewed have talked at length about that. But that’s quite a different donor pool that you’re pulling from, much more frequent donations, paid donations, et cetera. And the products from those are manufactured from a large number of donations, and so your exposures through plasma products is much larger than through transfusion. And, regrettably, as you go around the world, HIV was introduced in a number of countries by the plasma products that were manufactured here in the United States.

CHAMBERLAND: Such as the clotting factor concentrates—the hemophiliac—your very first patient that you saw.

WARD: Absolutely.

CHAMBERLAND: These clotting factor concentrates were comprised of hundreds, if not thousands, of donors.

WARD: Exactly.

CHAMBERLAND: So a huge exposure over time, if you will. Your work in this area—you were able to spin off, if you will, some additional studies in this area – of trying to get a better handle on the risk related to transfusion-associated AIDS, because now that you had a reliable test that could identify donors, you could—with, obviously, external collaborators and blood collection agencies and health departments and the like—get a better handle on just what the risk of transmission might be from an individual donor. And I’m thinking if—once a donor becomes infected, was it pretty much a given that he or she would continue—if they continue to donate—would be transmitting HIV?

WARD: Yes, we did studies looking at the whole donor history for repeat donors, and after a certain point in time, because of the way HIV persists in the body, that the donor remains infectious, certainly through blood transfusion—blood donations leading to blood transfusions—as long as they donate. So you really need to get them out of the donor circulation.

You mentioned the natural history and how little was known in 1985. People knew, obviously, that AIDS could kill people, but you didn’t really know, does it kill everyone? I mean, who survives this, who doesn’t, and why? And so the natural history questions were really, really big. So my second project as an EIS officer was to develop the first natural history study of HIV at CDC, actually, and we did it by identifying these persons who had become infected through receiving contaminated blood. Now, the beauty of that type of cohort study is that you have a date of infection.

CHAMBERLAND: You knew exactly when they got infected.

WARD: Yeah, you knew exactly when they got infected. The downside is that they tend to be older, they tend to have other diseases, they tend to die for the reason that they were given the transfusion to begin with. So you have some selection issues that you have to be mindful of. And so, someone getting infected at age fifty may not be representative of someone who is getting infected sexually much earlier. But at a time when almost nothing was known about the longitudinal risk over time, it was a very important study. And we did that in New York, Los Angeles and San Francisco. This is when you were given orders without a lot of direction—that sometimes works out.

So the San Francisco part of the study was not going well. So Harold Jaffe said to me, “John, I want you to go to San Francisco. Get the study straightened out. Don’t come back until it’s straightened out.” So I spent about two weeks in San Francisco, which is not a bad place to spend two weeks, by the way. But also, it was the heartland of the AIDS epidemic in America. It’s probably one of the highest prevalences in the world.

I can remember Jim Curran going there and coming back and saying, “AIDS is palpable in the streets of San Francisco.” And at that time, it really was. I mean, you could really see people who were getting gradually decimated by their virus. You became a lot more in tune with what was going on around the country. We got the study going. San Francisco became a very productive part of the study. And those researchers, [Dr. Michael] Mike Busch and [Dr. Herbert] Herb Perkins and others, did a great job. Mike continues to be one of the world’s experts on blood safety when it comes to HIV. We followed the HIV-infected persons over time, with periodic bleedings, periodic physical exams, history. We brought the data together. We found that about 50% of persons would die of AIDS within eight years of their transfusion. So that was one of the first estimates of the natural history, what’s your risk of AIDS and death after infection. And so that was also published in the New England Journal, about 1989, I guess. It was very important information, you know, at that time.

CHAMBERLAND: Were there any differences among the recipients in terms of their progression to AIDS?

WARD: Yeah, that was really interesting. So I found that if the donor developed AIDS soon after giving that unit, that the recipient progressed more quickly than recipients who got blood from donors who did not progress to AIDS as quickly themselves.

CHAMBERLAND: So from donors who were still early in their own disease, so to speak?

WARD: Apparently earlier in their own disease. So that was also part of our findings. Now, while we were doing those studies, and right around 1986-’87, as more resources, money, became available, NIH became much more involved in HIV/AIDS. And so they funded a very large blood safety study—its TSS, Transfusion Safety Study—that was a few years behind us, but was larger. And so that particular finding was not confirmed by their study. And so, for whatever reason—there may be other factors to explain that, sample size being one, perhaps—that study finding was not confirmed. We were reporting the data that we found. Not everything in science gets confirmed. It doesn’t mean that you get bad science, necessarily, it just means you have differences in methodology or the population and other factors. I believe that was apparently the case for that particular finding.

CHAMBERLAND: Because I know in your paper you hypothesized that one of the possible explanations for this might have been related to what we now call viral load. If the donors who were donating close—sort of at the end stage of their disease, so they weren’t symptomatic, because they obviously would have been excluded as a donor—but that you were hypothesizing that maybe they had a higher viral load as their disease churned on. And that maybe these recipients were getting larger inoculums of virus. It sounded like a good hypothesis.

WARD: Right. At that point in time, we were just putting out some ideas for further exploration. You have more pathogenic strains of HIV that were circulating, and so we were just putting those out for areas for additional research.

CHAMBERLAND: Now, you talked earlier about your opportunities to be interviewing donors back with the study that you did with the Atlanta region of the Red Cross. What about opportunities for contact with recipients? Were you interviewing those, or did you have contacts with recipients or their families?

WARD: I did on occasion. In particular, I did a study at Cedars-Sinai Medical Center, which had given a lot of blood through their pediatric programs, particularly their pediatric intensive care units. This study provided an opportunity, again, to look at the natural history of HIV among children, which was even less studied at that point in time than adults. It was the first time I met Dr. David [D] Ho, who was a young researcher at Cedars-Sinai at that time. He later went on to become a science expert in HIV. We would follow these children. Of course, this was a very particularly tragic set of circumstances, when you have children who apparently have survived whatever disease resulted in them going into the intensive care unit, now coming out and then several years later becoming ill and succumbing to HIV/AIDS. I had a fair amount of contact with some of those families through the Cedar-Sinai transfusion service.

And to show you how profound an impact this has, you know, even fourteen, fifteen years later, I would still get letters from the family members, the parents of those children, as they had taken on AIDS as a cause, I’m sure of—sort of in memory of their children that they had lost. You know, taking it on as a cause, ensuring that no one had to go through this again. Ensuring that blood banking was very safe and looking for any kind of—any weaknesses in the system. And so they would write me when they would see something in the media or something that they were working on, knowing that I had worked on this at that point in time. Even though I had moved on, they had not moved on. And so, you know, all around you at that point in time, or at least all around for me, you had those personal connections with the HIV/AIDS epidemic. And I’m sure that’s still true for CDC, many of the large epidemics that we respond to. But I mean, you’re involved at a government policy level, you’re involved at a science level, you’re involved in a clinical level, you’re involved with it at a personal level.

And then, I think the other telling part of the AIDS epidemic in the ’80s was the community response. Just being in the room with organizations that were developed just really out of pure desperation—a mixture of desperation and love. I mean desperation because loved ones were being lost, and people who weren’t activists by training, certainly, were becoming activists out of necessity. The Lavender Hill Mob, you know, ACT UP—you know, we would have meetings like that at CDC with those organizations, being chaired by the deputy director of CDC. I’m sure it was a very new area for CDC to be involved in, and I think it was a real testament to CDC that—to the flexibility of being responsive to a health crisis, and then moving along in trying to engage the public in what you’re doing so that you become—to develop a team that works together rather than works across purposes.

And I really learned, whenever you can, seek to identify the community members who are very interested in what you’re trying to prevent, and engage with them, bring them into what you’re doing. And maybe what you’re doing isn’t the best way. More often than not, working with those community-based organizations, I believe we learned something and benefited from it. Then in turn, they feel like they’re listened to, they feel like their government is a participatory government and not a top-down management government. And it really—it taught me a form of public health that I tried to continue to follow, and to be respectful of the community-based organizations, be respectful of the public who’s concerned about this, recognize that they are either living with it [or] have been impacted by it, and you can benefit from their point of view. And then, by engaging them, they have a better opinion of what you’re trying to do, and then, more often than not, will join forces with you rather than not. And having that energy is better than having people pulling in opposite directions.

CHAMBERLAND: Yeah, that’s a really very good observation. And I was going to say that AIDS, I think, on a national level, international level, AIDS was probably the first disease that really brought about that kind of engagement. But I say that—but I’m also, now, having listened to your stories of your early years in Alabama, that you actually—these electives that you did, that you went out into the community and lived with these Native American tribes in Alabama, you were actually doing that—

WARD: Yes.

CHAMBERLAND: —way back when. Obviously on a smaller scale, but now, I mean it’s more or less become—I hate to say commonplace—but this idea of activism on a national level—breast cancer awareness, AIDS awareness—all of that, it really got, I think, a big push from the AIDS epidemic. Not all of it was harmonious, because certainly in the early days—and we talked about—at the time when the serologic testing of the blood supply was about to begin, I’m not sure all of the activist groups were particularly happy about that. I’m thinking of gay men in particular.

WARD: Right.

CHAMBERLAND: That for them, it was very—there were real concerns about confidentiality, concerns about the impact of a positive test on their livelihood and things of that nature. So I don’t know whether you were directly involved or observing any of those discussions—

WARD: Oh, yeah.

CHAMBERLAND: There was not, at least in the beginning of testing of the blood supply, complete agreement that this was going to be a good thing.

WARD: No, absolutely. I’m not saying it was all sweetness and light, but at the same time, we didn’t shy away from the engagement. You know, you had to sort of stick with it, and I think even—as you stick with it, even if there are differences of opinion, you have a higher likelihood of resolving them over time because you’re working with them. And then as the AIDS community-based organizations became more established, some of their techniques were pretty astounding. So it wasn’t all sweetness and light. But I think to say, as a young epidemiologist at CDC, learning that that should be an expected part of public health—is to engage the community—was not lost on me.

CHAMBERLAND: Well, I’m guessing that this was one of those lessons learned that you’ve carried on to your job in the Division of Viral Hepatitis.

WARD: Absolutely.

CHAMBERLAND: Because your time in the division as its director has been absolutely transformational in terms of some of the advances in therapy and vaccine and et cetera. And I assume that this is also a rubric that you’re following in hepatitis, in terms of getting community involvement.

WARD: Right, I think AIDS trained me well. I think my first supervisors, Jim Curran, Harold Jaffe, and Scott Holmberg and Jim Allen, were part of that training where you really were—where teamwork was valued, where people’s opinions were valued, where you were expected to do a good job and you were given assignments with that expectation. There was a real sense of expectation for innovation and new ideas and not being stuck in the status quo, but that you were part of large epidemic with a lot of unknowns, and you needed to try to step up and fill out that void so that we would have a better sense of how to move forward. And in the community work and engaging partners, I’ve already mentioned.

So I think that really, that training has served me very well in my hepatitis work, where we now have a curative treatment for hepatitis C— a lot of issues regarding access and cost of treatment, stigma of people, marginalized populations having inequitable access to care. I have to say, what’s missing in the hepatitis are those large vocal community-based organizations.

CHAMBERLAND: Really?

WARD: So I really miss them. You know I—

CHAMBERLAND: How interesting.

WARD: Yeah, and just because of the nature of the differences in the disease and the populations affected. But I really believe that my early years in AIDS has really shaped my whole career in public health.

CHAMBERLAND: I wanted to ask you specifically about that in relationship to your tenure as the MMWR editor. Certainly, when you were a young recruit and a junior epidemiologist, you certainly had your chance, I’m sure, to write many an MMWR article. And I was curious if your experiences working on AIDS influenced your thinking about the role of the MMWR during the public health emergency that unfolded during your time as editor. I’m thinking specifically of the SARS [severe acute respiratory syndrome]—the worldwide SARS outbreak, [and] monkey pox, which is an outbreak we experienced here in the United States. And I’m just curious, again, about how your early days on AIDS might have influenced your editorship at the MMWR.

WARD: Well, I became interested in the MMWR because of my work in AIDS. We would put out reports quite frequently to update the country and public health departments, of course, all around the country, about what was changing in HIV/AIDS. So I became very accustomed to writing for the MMWR, and really began to value the role of policy development for CDC, how CDC can develop policies and put them out and really change the standards of health care—health care delivery or public health delivery around the country. So I really began to be very appreciative of the role of the MMWR for CDC. And, you know, there would be some days, because of the high visibility of HIV and AIDS, where I would sit with Walt Dowdle and Jim Curran sweating over one or two sentences in the discussion. And so, again, that was not lost on me, the power of precise messaging. You know, making sure that what you want to say is being said and it’s not being misunderstood. And that’s very much what the MMWR really tries to do.

So the editor did not turn over very quickly then. It turned over in 1998. And so I was ready for a change after fourteen years of HIV/AIDS, and so I took that on. That sense of innovation, or the expectation for innovation, that I picked up during my years at AIDS was not lost on me at the MMWR, even though it was a fairly—it’s a publication that prided itself on not changing. But I felt like we changed it.

So I invented the Epidemic—I invented Epi-X, which is Epidemic Information Exchange, a secure channel for people to share information about outbreaks. It’s still going on. We made it move out of just a weekly publication to one that could be published as needed, et cetera. Within a month after getting there, I wanted to start a continuing education program as part of the MMWR, thinking it would help drive interest in readership. That part of CDC had no money for that, so I called the AIDS program. And it was the end of the year. They had some end-of-the-year money, and so I was able to buy the three computer servers to help me set up the—and it was the first online continuing education program at CDC—was in the MMWR, but, again, that was in part because of my relationships at AIDS.

Then we began to have some major public health emergencies. Over my tenure, we had the anthrax cases right after 9/11 that we were heavily involved in. We would stay up many a night, working all night to get the report out by 9:00 a.m. the next day, as it was expected to be released at that point in time. I take it as a point in pride that at some point the FBI [Federal Bureau of Investigation] called the CDC saying that the MMWR was releasing too much information. I thought that was like—I thought I was doing my job, information sharing for the public. So I don’t put that on my résumé, but I’m proud about that. And then we had a large outbreak, and Mary, you were involved in SARS, coming out of China and Hong Kong. And, Mary, you did a great job of writing for the MMWR, as did a few others, and we really chronicled that whole outbreak. If you go back and look at the MMWR for SARS, every week you can see it unfolding, and then see it sort of—

CHAMBERLAND: Yes. That’s a great word, chronicle, because for all the innovations that you and others initiated. And the technological innovations that allowed the MMWR to do things like turn things around on a dime, not be restricted to a weekly format, be able to do it electronically instead of through the post, et cetera, I think it created a whole lot more pressure and the expectations were a lot higher. Be that as it may, again, in preparing to chat with you today, I had a look back at the first five years of the AIDS epidemic. And in those days—I don’t know, I was told it was Jim Curran’s idea—but all of the AIDS-related MMWRs were bound together in a series of volumes until, I think, the early to mid-’90s. And I was actually astounded that in the first five years, beginning with that first June 1981 report of Pneumocystis carinii pneumonia and Kaposi’s sarcoma among homosexual men in New York and California, CDC put out eighty-eight MMWRs, and it absolutely chronicled the unfolding of the epidemic in real time. And I think you’re right, it did the same for anthrax, for SARS, and for all the many public health emergencies that certainly came after that. So it really—it does serve as a timeless resource.

WARD: Absolutely. Absolutely. And so I really—and that’s why I wanted to be part of it, because I really saw it as a real gem, for MMWR and for CDC and, you know, people really. In fact, just to that point, during [President] George Bush’s administration, around 2003-2004, we had some type of entourage come from the White House, maybe the Domestic Policy Council. So I was invited to the meeting. This was when [Dr.] Julie [L.] Gerberding was the director. And after the meeting, one of the people who was visiting pulled me aside and said, “The MMWR is the one publication that we all read every week in the White House.”

CHAMBERLAND: How interesting.

WARD: So that was—I know we’re a little off topic here, talking about the MMWR, but just to your point—and I don’t know if the AIDS epidemic helped make the MMWR, the MMWR helped CDC, but I think the whole stature of the MMWR probably changed a little bit, too, because of that frequency of publication regarding HIV/AIDS in the ’80s and then in the ’90s, I believe.

CHAMBERLAND: Well, I think with the AIDS epidemic, and then, as you say, with anthrax and with SARS, people and even—and you’ve shed light on who some of the readership was and is, the FBI and the White House—people come to rely on it as a solid publication that, you know, it’s the facts. It’s the facts and some interpretation and discussion, and it’s reliable.

WARD: Maybe, if I have time—one other point quickly—and hopefully you’ll be interviewing some of the people I worked with in surveillance, because obviously job one for public health and CDC is public health surveillance. And for AIDS, that’s determined by what’s called the case definition, which were the criteria that you can call someone to be AIDS. Now, originally, the first AIDS case definition was developed around 1982, early 1982. And it was a constellation of diseases, because you didn’t know what was causing these diseases. And we had an AIDS-related complex of people that maybe was an earlier form of AIDS, but the point is, these diseases which are rarely seen in people with normal immunity would not develop, and it was a reflective of their immunosuppressed status. Then, when the HIV test became available, a few more diseases were added, because the HIV test helped to identify other diseases that were associated with the infection. And so that was all very helpful. And then over time, in the ’80s, as CDC got more resources, we were able to give money to states to actually case count. And so the surveillance improved, which greatly helped our monitoring. So that was all good.

So after my time in epidemiology and working on blood safety and a few other things, I got interested in surveillance. And so I went over and joined the surveillance program and eventually became the chief of the HIV/AIDS Surveillance Branch, and, as a result, wrote a lot for the MMWR and a lot of other publications, and developed surveillance systems to look at various diseases associated with AIDS.

You know, rightly or wrongly, some federal agencies began to use the AIDS surveillance case definition as qualifiers for various social services. So as a result, community-based organizations began to be very interested in the AIDS surveillance case definition, because it would have an impact on whether somebody was getting housing or getting food or Meals on Wheels, et cetera. So they began to lobby us to add certain diseases to the case definition. So we had to go through a very, you know, a very tough series of meetings to decide how we were going to change the case definition around 1993. And so we decided to add tuberculosis to the case definition. And then there was a lot of interest in having cervical cancer, because of the immunosuppression increased the likelihood of a woman having cervical cancer, even though that was a very small number of cases relative to other diseases caused by HIV infection. But, you know, speaking of very contentious community meeting, we had a very contentious one in 1993 that brought together a lot of groups in the CDC auditorium. But we went through the process and got that case definition approved, and got it written up and published in 1993, and it’s still the surveillance case definition used today. So it’s served the test for time.

The other issue for community-based organizations at that time was HIV reporting.

CHAMBERLAND: Ah, yes, yes.

WARD: Community-based organizations were a little more accepting of AIDS reporting, because people often did not live long after that AIDS diagnosis. Their point of view, though, was that if you required reporting of an HIV test result, you may discourage people from getting tested, because they didn’t want their name reported to the government. And people were uncertain how the government would use that information, and particularly now that that person may live for a lot longer after that report. So it became a very contentious issue. Again, it taught me a lot about engaging the community to get their point of view, to begin to develop working relationships with them.

It also taught me a little bit about messaging what you’re trying to do. I remember being on the phone with [Dr. Jeffrey] Jeff Levi, who was a major AIDS advocate at that time and helped develop the Ryan White legislation, and has gone on to a public health career of his own. But at that time, he was an AIDS activist, and I was the surveillance program representative. I remember being on the phone with him one day and him saying, you know, “Why does the government need my name? Why does the government need my name?” And I said, Well—

CHAMBERLAND: And it’s not the federal government we’re talking about, because the federal—

WARD: It’s the state government, right. CDC—

CHAMBERLAND: The state government. The federal government long ago had not been taking names, so we are talking about state and local.

WARD: Right. CDC does not get it, but they tend not to make that distinction.

CHAMBERLAND: That’s true.

WARD: But “Why does the government need my name?” And then I started saying, “Well, it’s because we want to ensure the quality of the data,” and this kind of stuff. And he goes, “Stop right there. My soundbite is better than your soundbite, so I win.” Now you can be cynical about that or you could take that as a lesson. And that lesson was, he was right. You know, it wasn’t a compelling messaging. Like, if you can’t adequately explain your point of view succinctly and in plain English, then, yeah, you need to go back to work until you can. Or maybe your position’s not that strong to begin with. I mean the point was, you know, maybe they did have some legitimate discrimination issues, maybe they did have some stigma issues, and maybe our pursuit of data quality doesn’t really match to that risk. So the risk-benefit calculation was not good.

Now, since that time, more and more states adopted HIV reporting. Of course, I think all states now require reporting. But we have new treatments now. It’s a whole different environment. Also, more of that information now is used to actually help people—“Data to Care”, it’s called. So rather than just using that information for pristine epi information, it’s actually being used to benefit individuals. And so that changes that risk-benefit calculation. So, again, I think that experience in surveillance was just very instructive on how to get things done in public health.

CHAMBERLAND: Well, I absolutely agree. We have, in this oral history, been fortunate enough to capture detailed interviews from people that have been very involved in surveillance, like [Dr.] Richard Selik and [Dr.] Martha Rogers, who was involved early on in pediatric surveillance, and [Dr. Timothy] Tim Dondero. And absolutely, I agree with you, it’s the bedrock of everything that we do. I mean, going back to your early days in transfusion AIDS, there had to be a starting point, and it had to be the ability to access information about cases. There had to be a mechanism to get cases identified and then reported in a systematic, cohesive way, to serve then as the basis for learning much more through detailed epidemiologic studies that you and others did. This has just been very interesting, talking about your work on AIDS from very early days, and certainly the hepatitis epidemic, which is another whole interview—

WARD: Right.

CHAMBERLAND: We’ll have to do an oral history on hepatitis.

WARD: I hope so.

CHAMBERLAND: Before we close, is there anything about your work related to AIDS that we haven’t discussed that you’d like to specifically note or comment on?

WARD: Well, I felt just very fortunate and privileged to be part of CDC at that point in time. It was my introduction to public health. You know, at that point in time the attitude around being an EIS officer was that they wanted people that didn’t know much about epidemiology or public health. They wanted a clean slate so that you could be taught the CDC way of public health. So I was a very novice coming in. And people were very good mentors, but they gave you responsibility at the same time. And as I mentioned before, they really appreciated CDC at that point in time in that program, really encouraging you to speak up and really valuing opinions around the table. And I think if you really create that atmosphere you can, more often than not, get the best out of people, because people feel valued and respected. And I think that, together with a sense of innovation and seeking to do the right thing, keeping your eye on the health outcomes you’re trying to achieve and really developing warm collegial relationships all along the way. I think it’s really been, you know, like I say, a great privilege to be part of that. So I was glad I got a chance to talk about it today.

CHAMBERLAND: Well, John, thank you so much for your time. And it seems like a good place to close, on this note. And thank you again.

WARD: Thank you very much. I appreciate it.