Dr. William Parra

MILLER: This is Dr. Bess Miller, and I'm here with Mr. William Parra. Today's date is October 11, 2017, and we are in Atlanta, Georgia, at the Centers for Disease Control and Prevention [CDC]. I am interviewing Mr. Parra as part of the oral history project, The Early Years of AIDS: CDC's Response to a Historic Epidemic. We are here to discuss your experience during the early years of CDC's work on what would become known as AIDS [acquired immunodeficiency syndrome]. Mr. Parra, do I have your permission to interview you and to record this interview?

PARRA: Yes, you do.

MILLER: Bill, you provided leadership at the highest levels during your distinguished career at CDC, both at headquarters in Atlanta and internationally. You served as the consultant from CDC to the World Health Organization [WHO] on the establishment of its Global Programme on AIDS, and as 00:01:00Deputy Director for CDC's Office of HIV/AIDS during the critical years between 1988 and 1996, providing leadership and management for a $500 million budget and over 500 employees. In addition, you served as a Public Health Consultant to the U.S. Agency for International Development [USAID], the United Nations Development Programme, and Ministries of Health at the global level, and you have served on public health missions to over 50 countries. For this and much more, you received many awards in recognition of your service, including selection for membership in the Senior Executive Service of the U.S. Government. Let's begin with your background. Would you tell me about where you grew up, your early family life and then where you went to college?

PARRA: I grew up in Southern California. My brother and I were part of a very close-knit family there. I went to University of Santa Clara. At that time that's what it was called. It's now called Santa Clara University, near San Francisco, where I was involved in psychology. That was my major at the time. I was interested in organizational psychology, and that was what I was hoping to pursue as I went on in life. I did my graduate work and hoped that I would be able to continue in that field but never did. I ended up accidentally working for CDC, and that's where I've been my entire life.

MILLER: Did you have an interest in health and public health as a young child? Was there anyone in your family that worked in that area that might have inspired you?

PARRA: We had a number of physicians in our family, so we were always talking 00:03:00about health. That was a very important part of our discussion in our family, but that wasn't what I was seeking in a long-term career. What happened was that I was interested in working for another company, and when I saw that they were coming on campus to interview, I went to sign up for them. It turned out that CDC was also interviewing on the campus on that day, so I decided I would sign up for them. I interviewed with them and I got an offer to join the Centers for Disease Control and Prevention, or the Communicable Disease Center as it was known at that time, in Los Angeles, and that's where I actually started.

MILLER: Did you come in as what's known as a Public Health Advisor [PHA]?

PARRA: Yes. I began as a Public Health Advisor assigned to the county of Los Angeles.

MILLER: This was a cadre that was very important to CDC and continues to be 00:04:00important to CDC. The Public Health Advisor: can you describe a little bit what that role is? What is the Public Health Advisor at CDC?

PARRA: I think we, as Public Health Advisors, provide the management side of a public health effort or the logistics side of working internationally. That's what piqued my interest in public health when I began working in it. I really did want to work in the management of public health programs, and I ended up working in a variety of public health efforts, applying those same principles that I had learned initially.

MILLER: Do you remember a little bit about your early assignment in Los Angeles [LA]? I remember there were sexually transmitted disease [STD] or VD [venereal disease] assignments; there was tuberculosis, immunizations. Were you working in a particular area in LA?

PARRA: I was working in sexually transmitted diseases and contact tracing in Los 00:05:00Angeles County, assigned to the clinic there, one of the county clinics. I worked there for about a year before I was transferred to the Chicago Board of Health, where I worked for another year before I was transferred to CDC in Atlanta.

MILLER: What did that involve? What were you doing on a day-to-day basis in LA or Chicago?

PARRA: In Los Angeles I was actually tracing sexual contacts (of) people with sexually transmitted diseases, trying to bring them in to the clinic to test them to make sure that they were not infected. Chicago was a different situation. CDC had five training centers throughout the country to train people in contact tracing. I was selected to lead the Chicago Training Center, which was at the Chicago Board of Health. What I did was actually train groups of people who would come in from different parts of the country at a given time, and we would run through a two-week orientation period. So that was my 00:06:00assignment there. When I moved to CDC at my third assignment, it was to oversee those training centers.

MILLER: Quickly, you were clearly one of the superstars. How does that, speaking to patients, trying to get the names and addresses of contacts, what kind of skills did you need? Obviously, you had them, but what do you recall about that? That must have been awkward and dangerous in some situations. What was that like?

PARRA: It was not as dangerous as it might be today. It's not as difficult or challenging as it might be in today's society, but one of the things we had to do was build trust in the patient. Obviously, we needed the patient to confide in us and to provide us with the information that we thought was so important in following their disease. That meant sitting down with them, spending some time 00:07:00with them and trying to get that information from them in a way that would provide us sufficient following information to find them (the contacts). That wasn't always easy. People didn't always know. There was still, even then, a lot of anonymous contacts, sexual contacts, so we did a lot of searching around the community to try to find people who were connected to this index case.

MILLER: Then you were training new Public Health Advisors as to management issues or interview issues?

PARRA: Interview issues. As I mentioned before, there were five training centers: [Atlanta], Los Angeles, Chicago, New York [City], Houston and what we did was receive not only federal employees who were new Public Health Advisors, but we also had the opportunity to train state health department employees. We opened the training opportunities to them as well and had as many training 00:08:00classes as we needed to provide training for the people who needed it. There were training individuals assigned to each one of those locations. I had originally been assigned to Chicago, but when I was in Atlanta, what I did was supervise the five individuals who were trained, as well as continue to develop curriculum, not only in contact tracing but in the supervision of people who provided that particular work.

MILLER: Again, this was a federal program. Was it well funded? Was there a strong community health orientation at the federal government? This is in the late '60s.

PARRA: It was the late '60s. There was good bipartisan support for the project, 00:09:00and we really were able to carry out everything we needed to (do), with great support from the Division of, I guess, the Venereal Disease Program, as it was called at that time. Later (it was called) the Division of Sexually Transmitted Diseases. We moved into the development of new training methods, new approaches to training, both in the supervisory capacity as well as in the elicitation of contacts and emphasizing compliance with oral medication requirements that a patient might have.

MILLER: In LA, for example, you were a fed embedded in a local health department, and of course, all over the country that was the case. How was that? How did that work for yourself and later when you supervised others, the 00:10:00relationship between this federal employee and the state and local (employees)?

PARRA: It was fantastic. I think the opportunity to work in a clinic and understand the daily requirements of a clinic, as it might have represented any clinic in the country, was very important. It was part of my training. I needed to understand the contact tracing requirements, the work requirements of individuals, both as Public Health Advisors as well as local health departments. Subsequently as I moved up the line and was more involved in funding, I could understand the specific needs of those communities out there.

MILLER: Was there any resentment among the locals of a federal employee coming in and having--

PARRA: Sometimes people referred to (us as) the feds because we were embedded in the clinic working alongside the state or county employees, or city employees 00:11:00for that matter, and sometimes it was a combination of all of them in one location. Sometimes people would say, we were here before you or we're going be here long after you leave, but it's important that you work closely with us, which we understood. Our job was to embed ourselves and to work in close collaboration with that local area. We didn't identify ourselves as federal employees. We identified ourselves as representing the county of Los Angeles or whatever, because if you went out in the community knocking on doors, you didn't say you were from the CDC.

MILLER: Fast forwarding a bit to 1984 and getting into your role in AIDS, at that time you were seconded from CDC to the World Health Organization to provide special management assistance during WHO's initial global response to the AIDS 00:12:00epidemic and to the establishment of the Global Programme on AIDS. What an amazing time to have been seconded to WHO and to Geneva. Can you tell us a little about how you got selected and what you were asked to do initially?

PARRA: The director of the then-called Center for Infectious Diseases (at CDC), [Dr. Walter R.] Walt Dowdle, asked me if I would be interested in being seconded to WHO. WHO had a Division of Communicable Diseases that had a lot in common with the (CDC) Center for Infectious Diseases, and they really needed a liaison to work across all the programs, not just HIV [human immunodeficiency virus]. WHO wasn't yet committed to a global program on HIV. I went to Geneva at the end of '84. I integrated myself again into a multilateral organization, being part of that organization, working with the Division of Communicable Diseases and 00:13:00interacting with the various components of the Center for Infectious Diseases. When the first International Conference on AIDS occurred in the summer of 1985, WHO then began to establish a global response to AIDS, initially called the Control Programme on AIDS, and then the name was changed to Global Programme on AIDS. As the program was established, a director was going to be recruited. There was an effort to find the right person that would be able to lead this international effort. [Dr.] Jonathan [M.] Mann, a CDC employee who was then doing AIDS research in Zaire was selected, and he was also seconded from CDC to work in this division (at WHO). He worked briefly in this division before the (WHO) Director General moved it to the Office of the Director General to give it more visibility. At that point he was no longer part of the Division of Communicable Diseases.

MILLER: That must have been an incredible time to be at WHO-- again, (with) the reports coming in, the understanding of the international extent of this epidemic. Can you describe a little about your early days and months at WHO?

PARRA: It was very exciting, it was very challenging, and it was clear that so many countries around the world had more questions than they had answers. They were looking to WHO for those answers, what to do with this, how to deal with this. They were asking so many questions, and every day that I would walk into the office, we had a table full of telexes, at the time, of countries asking questions: could WHO provide an answer on this, what about yellow fever vaccinations in HIV-infected patients, what about trial contact lenses, what 00:15:00about a variety of questions that they just didn't know the answers to. WHO couldn't provide those answers without pulling together a group of experts first and compiling those recommendations. I think it was a time when we were trying to move as fast as we could. We didn't have extra budgetary support from countries yet for HIV/AIDS, so it had to come out of the WHO budget. That didn't happen until Jonathan Mann came on board and a meeting was held with a variety of interested countries to determine whether or not WHO should launch a well-funded global effort. The countries came through, funded it, and WHO then proceeded to have a much more robust effort globally.

MILLER: This was an interesting role for CDC. Was there history of a lot of 00:16:00secondees from CDC to WHO? Do you have a sense of why CDC was selected for this important role?

PARRA: First of all, there had been a number of secondees to WHO over the years. That was not unusual at all. What was unusual was for me as a non-M.D. to be assigned to WHO, because WHO had high requirements in terms of training for people who worked there. But the director of the Division of Communicable Diseases was very interested in the Public Health Advisor concept at CDC, and he wanted to try it out in his division as a model for the rest of WHO. So he had talked to Walt Dowdle about the possibility of establishing that effort to see how well it would work in the division.

MILLER: Who was your boss at that time? Was it Walt Dowdle back in Atlanta, (or) 00:17:00was it this director of the Division of Communicable Diseases?

PARRA: Almost my entire career has been spent working for two bosses: the boss at a local level, whatever that level might be, whether it's the state health department or a county health department and, of course, my CDC boss. When I worked for WHO, I was assigned to Dr. Fakhry Assaad, who was the Director of the Division of Communicable Diseases, and on a day-to-day basis I worked for him. But obviously I reported to Atlanta because CDC was in fact my employer, and Dr. Dowdle knew very well that I needed to meet the requirements of both the WHO and the CDC. That's what I had been trying to do, so that was not a difficult adjustment for me to make.

MILLER: You moved your family to Geneva [Switzerland], is that right?

PARRA: That's correct.

MILLER: How was that? Was that your first international assignment?

PARRA: That was my first international-- well, I don't think you'd call Puerto 00:18:00Rico an international assignment, so that was my first international assignment abroad. I moved my entire family, my two daughters and my wife. We loved it. All of us adjusted very well to life in Geneva and had a difficult time coming back four years later.

MILLER: It was that good.

PARRA: It was that great. Both the work and the living conditions were wonderful. It was a great time to be there.

MILLER: You were there as Jonathan Mann came to lead the Global Programme on AIDS. Dr. Mann was a larger-than-life figure in the early years of international AIDS particularly, and his work initially in Zaire and then establishing the 00:19:00Global Programme on AIDS. Of course, he perished in 1998 in a plane crash. Can you tell us a little about your experience with him and what was he like?

PARRA: I worked with him only about a year before he was moved over to the Office of the Director General, but we got to know each other personally very well. Our families spent a lot of time together. Jonathan was very charismatic. He spoke French fluently, which allowed him to move into circles or countries where French was a primary language and communicate with them as easily as he would with English-speaking countries. He immediately provided very compelling evidence of why WHO should have a global response to AIDS, and he was very well funded. There was a point where he had a hundred employees at WHO, and that was 00:20:00unheard of at the time. WHO doesn't always have very many employees dedicated to a particular public health effort, but that one was a very large one.

MILLER: What did he emphasize? What were some of the things he felt should be emphasized? He's just been in Zaire, so he recognizes that there's something very big going on in Africa, and he is a CDC colleague in background, so he knows, of course, about the U.S. epidemic. What was some of the initial thinking that he and you decided, as far as moving this project forward at WHO?

PARRA: I think one of the things that we realized early on is that people with HIV/AIDS faced a certain amount of discrimination in countries through-out the 00:21:00world, and I think that somewhat became his platform of human rights. He felt very strongly that this was an issue that had to be dealt with, that we had to be able to develop a system of accepting people with HIV/AIDS without any potential loss of employment or housing or whatever, and he was very strong in that point. I think he may have been the first person who really put great emphasis globally on that issue.

MILLER: Your role then is to take the vision and the problem as it was understood at that time and move it into implementing a strategy and programs and so on. Can you talk a little about that? Who did you collaborate with? How did it move from vision to actual work?

PARRA: I worked with Jonathan for about a year only. The rest of the time he was working out of the Office of the Director General, so I didn't work with him on a day-to-day basis. Initially we were working on developing a strategy paper that would provide compelling evidence for funding from other countries. We were spending time trying to get an orderly response, a timely response to countries who really had very specific questions about what to do. There were so many different issues that remained unanswered, both there and in the U.S., but very specifically in developing countries. People just didn't understand how best to deal with this issue.

MILLER: Do you remember some of those issues?

PARRA: Anything from morticians to optometrists and ophthalmologists to people 00:23:00that dealt with water and possible contamination of water. They realized that people were immunocompromised, and they just didn't know what put people at risk and what didn't. They also needed to have some guidelines so they could recommend those guidelines to their own ministries of health, and they in turn to the regional health centers that might have existed in their country. Just an incredible--I think we had maybe 30 telexes a day, and there was no way to get the answers because some of the answers we didn't have yet. Some of them CDC had, but whether they applied to a developing country or not was an issue that needed to be explored, so we needed to gather at least on the phone some experts who would provide us with some guidance on how best to deal with that issue. This was a time when conference calls were very complicated; faxes were just 00:24:00beginning. It wasn't easy. Everything had to be done by phone or letters, and it was just a very difficult time, very time consuming.

MILLER: Did you have any others working with you and Dr. Mann? It sounds like a very high-pressure situation. Was it?

PARRA: We had the Office of Communication of WHO working with us, because obviously they were putting out some of the facts and figures as well as answers to questions and trying to make a broad distribution of those questions. So we worked closely with them. Jonathan worked alone for a great deal of that time until he was able to secure funding. That's the way WHO works. You have to secure extrabudgetary funding from countries if you want to develop a program. The extent to which you can develop that program is dependent on how much you can raise in terms of commitments from countries.

MILLER: Was that part of your mandate? Is that part of what you were working on?

PARRA: No, Jonathan worked on that on his own. I helped him, but he was working on that on his own, and, as I mentioned before, the moment he was able to secure that funding he was moved to the Office of the Director General. I continued my secondment to WHO working primarily on the other public health problems in the Division of Communicable Diseases, but I was no longer working on a day-to-day basis with him on HIV/AIDS.

MILLER: Did you feel prepared for this? It sounds like it could have been pretty overwhelming. How did you react to all of that?

PARRA: Another public health challenge, you know? I loved it. I think in public health you always want to be able to work on something that's so exciting that 00:26:00you are eager to work on it every single day, and you can work as long as you can, as far as you can and go as far as you can in trying to address the issue. I found it a very exciting time, and I missed it when the office was moved to the Office of the Director General.

MILLER: Did folks from Atlanta come out and work with you, whether it was Dr. Curran or Dr. Dowdle or any assistants in a big way come from Atlanta?

PARRA: In 1988 at the International Conference on AIDS in Stockholm [Sweden], I sat down with Dr. [Gary R.] Noble, who was then deputy directory for HIV at CDC. He was talking about a new office of HIV/AIDS that was going to be established at CDC, and would I be interested in this position. At that point in time I really missed working in HIV/AIDS, and I thought this was an exciting way to 00:27:00come back to CDC, because you never know what you're going to go back to once your term is finished. I accepted the position, and at the end of 1988 I came to work for Dr. Noble in the Office of HIV/AIDS.

MILLER: You were actually helping develop the office when you came back. Can you describe that a little bit? What was the mandate of this office? There were so many different people at CDC working on different aspects of AIDS by 1988. What was the goal there?

PARRA: The goal there was to function in a matrix-managed fashion. That is, we functioned like a small CDC. We essentially funded all the different Centers for their HIV work and provided the FTEs [full-time equivalent employees] to get 00:28:00that work done. So it was a CDC within a CDC. In fiscal year 1989, HIV constituted about 40% of the CDC budget, so it really required us to work very closely with almost every center on issues that were related to HIV/AIDS.

MILLER: What was your role there? There were a number of different divisions working on aspects of HIV/AIDS. How did you go about helping in terms of structuring and managing money that came to CDC for AIDS and getting it to all these different competing, probably, groups of people?

PARRA: They were competing, of course. Everyone felt that what they were doing 00:29:00was very important, and it was. We had to sort out the priorities, and we had to make decisions on the distribution of the FTEs. My role as the deputy director of the Office of HIV/AIDS was to work closely with the director and help make decisions about the distribution of funds. My recommendations were ultimately considered, and we made decisions each year on whether or not the goals of that particular program within CDC had been achieved, whether or not they needed more, whether or not they needed less, and we functioned that way for a number of years.

MILLER: How did you make those decisions? What were some of the competing--there were programs, epidemiology and surveillance, there were lab issues.

PARRA: There was even NIOSH [National Institute for Occupational Safety and Health-- part of CDC located in Cincinnati, Ohio] on safety issues. NCHS [National Center for Health Statistics, part of CDC located in Washington, D.C.] 00:30:00was involved in national surveys. Chronic diseases was involved, and the Divisions of Adolescent and School Health and Reproductive Health. There were a lot of different centers involved, and we met with them on a weekly basis. We actually met with all of them on a weekly basis and on an individual basis every week.

MILLER: The center leadership?

PARRA: The Office of HIV/AIDS met with them. Every Friday we met with everyone together, and during the week we met with each of the different centers so that we became familiar with what they were doing. We were also very aware of what our appropriation language was directing us to do. We had to make sure that those were being carried out in a way that was acceptable to Congress, and that was part of what I had to do. I had to deal with reviewing and finalizing responses to Congress on various questions that were posed, and in the early years there were lots of questions posed by congressional staff members. We had 00:31:00to respond to those as priorities, and we had to--Friday was always our busiest day, because that was the day that we had to respond to congressional inquiries.

MILLER: What was, in those years, again looking at the late '80s, early '90s, what were some of the highest priorities from the congressional point of view for CDC's role?

PARRA: There were some unusual ones. I wouldn't say they were the most important ones, but if you look back at the fiscal year of 1989 appropriation language, (that) was the first year that I came there, and we developed the Office of HIV/AIDS. Congress directed us to establish a 24/7 information hotline that would answer questions from the public about what the signs and symptoms were 00:32:00and where to go to be tested and how much would it cost. So we had to establish that hotline that was part of the requirement. Secondly, Congress wanted us to fund community-based organizations [CBOs] directly. That did not sit well with state health departments, because we were not used to bypassing them, so we had to figure out ways to work with state health departments when we funded their community-based organizations directly. We also were directed to work with national minority organizations, which was not something that CDC had done in the past. Finally, we had to work on public service announcements. We were directed to develop those, even paid advertising if necessary to get the message out. This drove us into a very new world I think at CDC, working with the National Association of Broadcasters and working with a number of organizations we had never worked with before, not directly anyway. That was very exciting. 00:33:00Part of my job was to facilitate that interaction between ourselves and the different centers on the requirements of the appropriations language.

MILLER: It's a good thing you like challenges. It sounds like you had plenty. Let's talk a little more about the community-based organizations. I remember those years and that debate very well. Where was it coming from to move from the state and local health departments into the community? Who were these community-based organizations, and what would they be able to do in terms of AIDS prevention?

PARRA: Congress felt, and we agreed, that community-based organizations were situated right in an area of a city that could be at risk or was at risk for HIV. As a result, those communities were very strongly tied to the people they 00:34:00represented, and the feeling was that we should work directly with them rather than the state health department 400 miles away or 300 miles away. The difficulty that we faced at that time was that these community-based organizations were used to dealing very frankly and very openly with their populations about safe sex practices. Congress directed us to make sure that our information systems included information about abstinence as the best way to prevent HIV. We had to figure out ways in which we could meet both the congressional requirements and the community-based organizations as they felt they needed to move forward. We ultimately developed community standards working with the legal office at CDC, and these community standards required CBOs, before they published informational material, to meet with members of their community to ensure that those met the standards of that community. The 00:35:00information in San Francisco might be more frank than it would be in Omaha but just simply reflect the standards of that community, and that's the way we got around that issue.

MILLER: Can you give me an example of what these community-based organizations were, what were they mandated to do, and what could they do with regard to AIDS?

PARRA: Sometimes they held conferences, sometimes they published material and distributed it to their constituents, sometimes they actually had testing program that they ran, if they were large enough to have them. We had to encourage them to introduce counseling and testing in those sites as well, as obviously we were doing with the state health departments. They did a variety of things. Some organizations were very large, and some community-based organizations were very small in what they could do. It was minimal, but they 00:36:00did have access to a community that we wanted to reach.

MILLER: CDC is far away in Atlanta. The community-based organizations are very decentralized and peripheral. Did you work with state and local health departments to provide technical oversight of these community-based organizations, or did you do that from Atlanta?

PARRA: Yes. We worked with the state health departments to collaborate (in) the oversight of these CBOs. In the first place, we didn't know an awful lot about them. Maybe their proposal was great, but we needed to run it by the state health department to make sure the state health department was aware of our intention to fund them. If they knew something we didn't know about that CBO, they would actually let us know.

MILLER: This was an enormous management challenge. Can you talk a little bit 00:37:00about that? Did you have people working for you? What was set up at CDC to help implement all of this?

PARRA: The Office of HIV/AIDS had a number of staff members. I don't remember the exact amount, but it may have been about 30. We had the National AIDS Information and Education program, which is part of the Office of HIV/AIDS. They were doing the PSAs, they were running the hotline or they were subcontracting for the hotline, and they were running a clearinghouse, which was also required in the appropriation language. We had to have a clearinghouse, which was located in Rockville, Maryland, that would respond to inquiries about people who wanted a copy of X,Y, or Z. We also were mandated to provide a pamphlet by the Surgeon General to every household in America, so that was another huge challenge, working with the Post Office about how best to achieve that. These were all 00:38:00demands, I guess you could say, or directives that were provided to us during that very initial period of time, so we had to gear up, we had to develop an ability to respond to them. It wasn't always easy, but we managed it.

MILLER: Looking at the country as a whole, I know some aspects of CDC would divide the country up and assign people to be responsible for certain states. Did you do that, or how did you get various states to provide oversight? Were they funded to provide oversight?

PARRA: We had an office of policy, which essentially had representatives who would function as liaisons to each of the different centers. Our work with the state health departments was actually conducted through the Center for 00:39:00Prevention Services, as it was called at that time. We didn't go out and do that. We actually worked with them, and they were the ones who provided that interaction because they were used to working with the states. They provided the grants to the CBOs, and they ran the counseling and testing programs. We just funded them to do it.

MILLER: There was a division of STDs, a division of tuberculosis and so on in this National Center for Health Promotion. Was there a division of AIDS, or did the STD division take this on?

PARRA: There was a division of HIV/AIDS in the Center for Infectious Diseases, and they were doing the research. It was headed by Dr. [James W.] Jim Curran. The Center for Prevention Services was actually interacting with state health departments on the implementation of prevention programs. That's why we worked with different centers. Each had a different role. We worked with NIOSH 00:40:00[National Institute for Occupational Safety and Health], and they would work with others on equipment safety issues, and we worked with each center on whatever they were strongest in. We didn't try to reinvent the wheel.

MILLER: But for implementing AIDS programs, I don't think there was yet an AIDS division. Was it the STD division that implemented these AIDS CBOs, or by then did they include AIDS in it, possibly?

PARRA: That's a good point. I don't completely remember how that was done. They did have an HIV office, which was our liaison office, whether or not they were integrated. I don't believe they were in the Division of Sexually Transmitted Diseases. They ran the interaction with the states, and they were staffed by people who had a history of working with state health departments and understood the importance of dealing directly with them and funding them.

MILLER: It sounds like CDC had a great role in not only the research and looking at the epidemiology but also in the program implementation during those years, and that you had a big role in making that happen. Can you mention some of the challenges you must have come into in terms of matrix management, which always sounds better than it feels when it's happening. My bias. What was it like trying to implement these critical programs?

PARRA: It was difficult because each center had what they felt were priorities related to the groups they worked with. They had specific requests, they had specific FTE needs, and we had a limited number of dollars. I mean it was a huge budget, but nevertheless when you work across CDC, the budget is relatively 00:42:00limited in terms of whether it meets everybody's needs, and the FTEs were limited as well. I think there was a little bit of competition between the centers to make sure they provided compelling evidence for their requests. Every year we went through the process, and every year we decided how the dollars were going to be distributed and how the FTEs were going to be expanded. It wasn't something that wasn't always evolving. It was an evolving issue and an evolving problem and an evolving challenge.

MILLER: Who did you go to for discussion of these? Did you go to Dr. Noble?

PARRA: Obviously I worked with Dr. Noble first and Dr. Curran second, and I worked very closely with him, with both of them, on every decision we made. We 00:43:00ultimately worked with the Director of CDC as well. We met with him once a week, and we reviewed our plans to do whatever was the challenge at the moment. We reviewed that, and we reviewed what our proposed solution was, and we came out with a green light to move forward on it. I think we carefully orchestrated this because it involved so much of CDC. We had to be mindful of that and mindful of the fact that we were representing the needs of the entire organization, not just one division. Even though divisions or centers might have felt that we weren't funding them as well as they would have liked, we needed to respond to the needs of all of CDC.

MILLER: Was the Office of HIV/AIDS in the Center for Infectious Diseases or out of the Office of the Director?

PARRA: It was out of the Office of the Director.

MILLER: That helped you tremendously in terms of your authority over some of the other centers.

PARRA: We were given the authority to distribute the funds and the FTEs. There 00:44:00was never any question about that. The issue was whether or not the center felt that they were being funded at the level they needed. Was Reproductive Health getting the money they needed, was School Health getting the money they needed, was HIV/AIDS Research getting the money they needed? Everybody needed more money because everybody wanted to do more. I think maybe they didn't always agree with some of the investments. I'm sure people in research wondered why we were funding PSAs [public service announcements], which wasn't a reasonable effort. It cost a lot of money to develop those PSAs and move them nationally. But that was part of the appropriations language. We had to move forward with that. The investment of a 24/7 hotline that functioned 365 days a year, never closed, 00:45:00worked out of North Carolina and had about 2,500 calls a day, was a huge effort. It was not cheap but, again, it was an important response to the directives that would set the appropriation language.

MILLER: Who testified in Congress? Did you ever have to go up to Washington, or was that primarily--

PARRA: I did.

MILLER: What was that like?

PARRA: Sometimes CDC had to go up to defend a particular part of the budget and asked us to come along to defend the HIV portion in case we got questions. It was not terribly unusual for me to go with them, because even the finance people at CDC were not totally clear; they were confused about the distribution of funds for HIV. They knew that we controlled that, and as a result it was harder for them to answer the question directly, and they needed us along to respond to congressional inquiries on it.

MILLER: How did you find that experience?

PARRA: I loved working across CDC. That was probably one of my most rewarding experiences: to work with every side of CDC, whether it was procurement, finance, centers, whether it was the Office of Communication at CDC that we had to work very closely with also, because they were dealing with public inquiries coming into the CDC on HIV. It was a great experience to work with all of those. We worked very closely with the legal office [Office of the General Counsel] as well, because there were legal issues that we needed to consider in funding or in considering certain requirements as we moved forward. Every part of CDC was somehow involved in dealing with a particular challenge of HIV/AIDS and worked with us to solve it.

MILLER: You mentioned issues regarding Washington and Congress and so on. This was a particularly difficult time in the life of the AIDS epidemic in the United States. By August of '89, 100,000 cases of AIDS had been reported, but then two years later 200,000 cases and (by) October '95 half a million cases. You were there right at a time of rapid increase in numbers of cases, (with) a big impact on communities of color, as the AIDS case definition was modified and that added patients of color. But testing for HIV, even though it was available, was not 00:48:00scaled up yet, at least initially, and in '88 there wasn't much to offer patients in terms of treatment. There was AZT [azidothymidine], but that was not scaled up. Can you talk a little bit about the political (issues), and then we'll talk about the social climate? This was [U.S. President Ronald W.] Reagan finishing (his term), followed by [U.S. President] George H. W. Bush. What was it like then? What were some of those issues?

PARRA: I believe we had tremendous bipartisan support for HIV/AIDS, even in the initial years. They may have been restricted in their appropriation language, but they nonetheless recognized the incredible public health challenge that we faced. We had a climate of great expectation. I think Congress felt that they would give us what we needed, but we needed to move quickly. The issue was speed 00:49:00and the need to meet expectations on the part of Congress when we weren't ready to move that quickly. There were things that had to be thought through. They were not simple. There weren't any simple answers to those questions, but bipartisan support was there. I don't ever remember Congress questioning or having difficulties with appropriations for HIV/AIDS on an annual basis. I think they were very aware of the support that we needed and that we ultimately got.

MILLER: There were some controversial issues at that time. I think you've referred to a little bit of that: supporting condoms, not emphasizing only abstinence, issues about needle exchange programs, even supporting international 00:50:00conferences that people could attend. Can you discuss some of those? How did those impact CDC's ability to do what it considered its job?

PARRA: Condom distribution programs were questioned initially, because obviously it appeared as if we were encouraging sex and weren't promoting what the appropriations language had specified (which was) that refraining from sexual intercourse was the best way to prevent HIV/AIDS. That was difficult, and I will say that local community-based organizations felt very strongly that that's what we should be doing. They felt very strongly that we should have needle exchange programs as well, and that was a very thorny issue with Congress, because Congress felt that we would be promoting drug addiction by doing that. That was 00:51:00really never approved. There was a tension about how best to go about it, and so I think it became much easier when the condom effectiveness MMWR [Morbidity and Mortality Weekly Report] came out. I think that paved the way a little bit for promoting the use of condoms, but it was a difficult issue for a lot of states as well as for the federal government. So you had to maneuver your way around very carefully because--

MILLER: What did that mean? How would that work? How would you maneuver around carefully?

PARRA: You maneuvered around by essentially ensuring that you provided the restrictions or by establishing community standards that would allow you to go forward with the funding--of something. Not needle exchange programs, those were never funded. But condom distribution programs, I think if that was a common community standard, it became easier for us to work with local areas on 00:52:00that issue and I think international conferences. I should say, international and national conferences were a problem as well, because we had the ability to fund conferences through a conference support program, and we would frequently fund organizations that wanted to include an HIV/AIDS prevention component in them. Sometimes they were gay organizations, and that didn't sit very well with people in Congress or with the public who heard about that. We did have some repercussions once when we funded an organization to include an HIV component and had to figure out ways to create walls around that component of the conference, so that it wouldn't create the problems that it did in that conference that led to an incredible backlash from the public.

MILLER: This was a time of intense community activism in the U.S.; groups such as Act Up [AIDS Coalition to Unleash Power] and so on. They were often critical of CDC's efforts. Can you describe that aspect? You probably have been referring to that to some extent.

PARRA: Yes, we certainly had our challenges with Act Up, who felt we weren't moving fast enough. They at one time stormed our offices in Atlanta, and they had to be carried off body-by-body by the police department. Another time I took a trip to San Francisco for something else to visit the health department, and Act Up visited me in the lobby and called me down and wanted to talk to me. How they knew that I was in San Francisco and how they knew that I was at that hotel, I'm not sure, but they were all sitting there waiting for me. We were used to that. We were used to dealing with them, and we tried to visit them as 00:54:00often as possible to have constructive dialog about how we could best work together. You couldn't ignore them, you didn't want to ignore them, but you recognized your limitations, and you needed them to understand that as well.

MILLER: In retrospect, now we've got one of the few joys of getting older: you can look back on all of these things and think things through. Do you feel we got it right then? Did we get it right between the congressional and executive leadership of the country and the community activists? What's your thinking about that now?

PARRA: I don't think we could have done it any differently. We were treading new ground. In many situations the legal office was saying to us, we've never dealt with this before and we're going to have to work it out before you can do it. We were often met with challenges that didn't allow us to move as quickly as we'd 00:55:00like, but we understood the reasons why it needed to be thought through carefully. We didn't want to put CDC in a difficult position, and we wanted to make sure that we were moving carefully and deliberately in whatever we did.

MILLER: Can you give an example? What issues might this be, whether it's condoms or trying to get drugs?

PARRA: Informational material that was produced by community-based organizations is one of the issues that was raised at the legal level when we started to get complaints from the public about pamphlets they had seen and the kind of direct information that was included. It might have said it was funded by CDC, so they were complaining--

MILLER: Explicit sexual material? Descriptions of how to use condoms?

PARRA: Exactly. I think we had to develop some guidelines legally that would make the legal office feel more comfortable and would put CDC in a more secure 00:56:00position. That was when community standards issues came up and how we decided that we would fund community organizations to fund at the level and at the scope of whatever the community standards were. If they were more restrictive, then they themselves had to be more restricted. If they were more open and direct, then they could be more open and direct. They had to have community members review the materials before they were publicized or before they were printed and distributed. This was an important component but an issue that required very careful coordination at CDC, because it was creating a backlash on the part of the public.

MILLER: What does that mean? What type of backlash?

PARRA: Letters.

MILLER: Letters complaining about?

PARRA: Maybe letters to the congressmen, then congressional inquiries on the issue. We got a lot of letters complaining about whether or not the case 00:57:00definition was being expanded fast enough or whether or not or why we were funding an organization to publish this, as they called it at that time, smut. .We jokingly referred to those as the smut guidelines but essentially they were given a better name. I wish I could remember the name of the guideline.

MILLER: It sounds like the question is, who is the community? If it's the community norms, is it the small IV drug-using community or small commercial sex worker community that needs certain information, versus a wider community in that state that resents that? Is that part of what--

PARRA: Yes. I think we had to be very locally focused, because we recognized that the United States represents a lot of different people with a lot of 00:58:00different thinking, and that some areas may think differently than others in terms of how frank they can be and how progressive they are. What you could say in Seattle [Washington] and what you could say in Des Moines [Iowa] were very, very different, and the communities expected something very different. So I think we needed to be guided by those community standards and influenced by them in how we dealt with the community-based organizations and their work.

MILLER: It sounds like it was a sea change in the way of working of CDC out to the community instead of just the state health department and local.

PARRA: I think that's where working with the national minority organizations and working with community-based organizations was very helpful to us, because that required us to travel as well to those community-based organizations and 00:59:00understand the issues at the local level better. We had people traveling to see those CBOs in action and to better understand what they were doing and to better articulate their contributions to HIV prevention.

MILLER: It's still needed today, isn't it?

PARRA: Yes.

MILLER: It's been said that responding to the AIDS epidemic was a watershed event in the life of CDC, in terms of moving much more towards efforts of prevention and scaling up prevention. Can you talk a little more about that? We've discussed it to some extent, but getting more counseling and testing and other health activities in the community and out of the state and local health departments.

PARRA: I think when the opportunity to test people for HIV/AIDS came out, we 01:00:00recognized that there needed to be some guidelines and people needed to be counseled about the implications of their tests and the implications of their results. We moved ahead to work on counseling and testing programs and to fund those at state levels through the Center for Prevention Services. They were responsible for implementing counseling and testing programs throughout the nation. We also had to work with the private sector and with labor unions, essentially because we were trying to deal with discrimination as another issue. We had a project called Business Response to AIDS, and we had a project called Labor Response to AIDS. Basically both of these were working with the private sector to provide us guidelines on how to deal with workforce accommodations for people with HIV and how to make sure that they in turn worked with their respective companies to reduce discrimination that was likely to come when people find out that employees were HIV infected. This was a very difficult 01:01:00time, because we were all being pulled in different directions. We wanted to deal with this discrimination issue, and it was part of our National AIDS Information Education program. We had a lot of private companies that were very willing to work with us that had experienced these issues and had developed policies within their companies on how to deal with people with HIV, how to accommodate them within the workforce. They were important in providing us guidelines that ultimately were distributed to any company that wanted them in the United States on how best to deal with this issue, because they also had questions about how to deal with someone with HIV/AIDS. Should we fire them? What do we do with them? Can they drink out of the water fountain? Can they-- whatever. They had questions, too, and concerns, and if they didn't have concerns, their employees did. We needed to make sure that they received some guidelines and some assurances that they could reasonably accommodate these 01:02:00individuals in the workforce.

MILLER: You then moved on to assist in the formation at CDC of a National Center for HIV, STD and TB Prevention, and you had a pretty significant role in developing this. Can you move us into that sphere? What was the motivation for developing this center and combining the diseases?

PARRA: I think in 1995 or so Dr. David Satcher, then Director of CDC, made a decision that it was time to consolidate HIV work into one center and subsequently include STD and TB [tuberculosis] in it. My task was to work with 01:03:00Dr. Helene [D.] Gayle during those six months that it took us to pull the center together. We had to essentially work with everyone to determine the amount of funding and the amount of FTEs that would come out of those centers and come into the new center. That was a challenge, because it was a big budget, a lot of FTEs, and we had to decide what was staying and what was coming into the new center. That was completed at the end of--I think it was early 1996.

MILLER: At the time, did you think it was a good idea? What were the pros and cons from your point of view of doing this?

PARRA: I loved the matrix-managed system, simply because it allowed us to work with so much of CDC, but I recognized that there needed to be an organizational focus on these issues, that perhaps we were not working as closely with STDs or TB as we should, and that maybe the consolidation of these efforts made a lot of 01:04:00good sense. When we started working on the consolidation, I was fine with that. I thought it was an important opportunity to move forward into the next phase of HIV prevention at CDC, and so we moved on.

MILLER: What was the thinking in terms of STDs and TB, let's say, not school health or not reproductive health with perinatal transmission or not NIOSH [National Institute for Occupational Safety and Health]? How were some of those decisions made? Was it a time where the focus was changing more towards implementation, so move it to that world?

PARRA: Certainly moving more toward implementation, although research continued to be a very significant part of the effort. I can't really answer why 01:05:00reproductive health and school health were not moved over. The feeling was that school health had a very strong tie to states and to superintendents of schools, and as a result trying to recreate it in the HIV world didn't make sense. Reproductive health also felt they needed to work in a more integrated way and shouldn't have two different competing components to it. So those two remained in the chronic disease center, while all the rest of them were integrated into the new center, and then hepatitis was subsequently incorporated as well.

MILLER: How do you think it worked out?

PARRA: As far as I know it worked out well. I mean, obviously I was there only a few months into the consolidation and the early implementation of the center. Then I moved on to the National Center for Environmental Health shortly after that, but I think it worked better than the matrix-managed system at CDC, simply 01:06:00because it was time. It was time to move it to the next phase of organizational development.

MILLER: In closing, you played a very significant role in some very critical times of this epidemic, and it spanned a big portion of your career and had a huge impact on public health in this country. Can you say a little bit about how that has affected you? Did you continue to work on AIDS later in your career?

PARRA: I didn't. I moved to other public health challenges, but I think it prepared me to see so many different facets of public health I had not seen before HIV/AIDS. It really allowed me to appreciate the challenges we have in chronic disease, where lifestyle changes are something that go on forever, and I recognize that as something that we had to deal with. You couldn't vaccinate someone; you had to really change their lifestyle in order to reduce the infection of the community. I think that brought me to another world of public health, which I appreciate, and also I felt it was time to move on to a different set of challenges. I think when '96 came about, the end of '96, I decided to make a move and to move to the National Center for Environmental Health. I always have appreciated the highlight of my public health career having worked in HIV/AIDS.

MILLER: Were you ever worried that you or your family would become infected with AIDS?

PARRA: No.

MILLER: In concluding, are there things that you think CDC could have done better, as you look back at all of it?

PARRA: As fast as we had to move and with as many people at CDC as we had to work with, everyone was always incredibly cooperative and incredibly willing to just lay down whatever they were doing to try to deal with this pressing problem. I don't have one single concern or complaint about how we moved forward. I think it was a great period where people were very eager to lend a hand, and we were able to move successfully with whatever challenges we had at the time.

MILLER: Thank you.

PARRA: Thank you.

END.