The Age of Aids [home page]

interview: don francis

[photo of Don Francis]

Dr. Don Francis was working as an epidemiologist at the Centers for Disease Control when the first reports of what would become known as AIDS came in. As part of the CDC's team of gumshoe epidemiologists who were tracking down the source of the epidemic, he suspected early on that a virus was the cause. He then led the fight to protect the U.S. blood supply, which he correctly suspected was already contaminated, and later left the CDC for the private sector, where he worked on a vaccine attempt that was ultimately unsuccessful. Francis is angry and highly critical of the Reagan administration; he tells FRONTLINE that the CDC's "mission was undermined by the election of relatively simple-minded authorities in the Reagan administration ... saying lesser government is better government, and one of the lesser [ideas] was to throw public health to the wind, and especially throwing public health to the wind if it dealt with diseases that they didn't want to deal with politically." He describes an incident where soon after HIV was discovered, he drew up a prevention plan that included testing, counseling and HIV/AIDS education, but says the plan was rejected by officials in Washington who told the CDC, in Francis' words, "... we want you to look pretty and do as little as you can." He says the administration's instinct "to protect the politicians in Washington rather than the public's health" was "tragic, dangerous and set a precedent that is still reverberating around the world." This is the edited transcript of an interview conducted on Dec. 2, 2004.

... Tell me, how did you first hear of AIDS? Of course it wasn't called AIDS. How did you first hear of the new disease?

I first heard of AIDS from a call from CDC [Centers for Disease Control and Prevention] to my office from the group that was doing sexually transmitted disease, from Jim Curran, who was a doctor there. He called me in my office and said there was this unusual disease in gay men. And this was about a month or two before the 1981 MMWR [Morbidity and Mortality Weekly Report] that came out at CDC announcing the outbreak.

And the outbreak was in gay men. Did it surprise you that there might be a new disease in gay men?

Realize that we've been working at CDC for years on diseases of gay men. As the gay sexual revolution ignited, along came the fire of sexually transmitted diseases soon thereafter, and that was true of a variety of classic sexually transmitted disease: gonorrhea, syphilis and the like, and then hepatitis B, which I was working extensively with gay men on, hepatitis A, etc., etc., etc.

To see another coming up was not surprising. The difference with AIDS was it was not a disease that [we] knew, and we didn't have a laboratory test. We didn't even have a clinical appreciation of the disease. So there was not a surprise that there was a new outbreak, but of great concern was that there was an outbreak that looked extremely dangerous. That is the first patients that we were told about, [who when] we went and visited were dead or dying.

... What were the theories chasing round at the time? We didn't know what it was. What did people think it might be?

Well, of course in medicine, searching for answers, there's always many hypotheses that are thrown out. From our standpoint at CDC, coming from infectious diseases and a new disease in gay men, the presumption was it was infectious until proven otherwise. …

There were other hypotheses early on, very reasonable. When you have a brand-new disease, you should look at the whole variety of possibilities. One which was very reasonable was that this was chemically induced rather than an infectious transmissible agent, because not only were gay men having [sex with lots of people] and lots of sex, but through that process they're also using a variety of chemicals to stimulate their sexual interest. Therefore, there was a hypothesis [that it] might be something contaminated, be it chemical or infectious.

Now, you and other people felt that fairly early on it must be a virus. What in your background or your own previous experiences led you to think that it was possibly a virus?

The hypotheses that this was a virus evolved quite rapidly in the first year or so in the epidemic. First we thought it was a transmissible agent; that really is primarily a bacterium or a virus. The disease, interestingly, was one that had not been seen in humans caused by any known infectious agent. I had recently finished my doctoral work at Harvard on a disease of cats that looked identical to AIDS, caused by a virus.

We, as humans, survive ... by denial, and if whatever we confront is a slow-moving phenomenon, then we can deny and run right over it and carry on.

Then, key in this relatively early was a disease in hemophiliacs. The anti-hemophiliac material used to treat hemophilia goes through a production process of which the bigger infectious agents of bacteria, etc., larger than that are filtered out, and the only ones that can get through that filter would be viruses. It didn't take too long to figure out that it was likely a virus.

[What is HIV's latency period and why is it such a problem?]

One of the real menacing issues of HIV is the long incubation period of the long latent period from the time that one is infected to the time that one gets the disease. That has many, many aspects that to this day continue to trouble anyone working with the disease. First, one is working on the initial outbreak, trying to figure out how they got it. It's a lot easier in an epidemic if everyone ate at the same restaurant or everyone had sex with the same person and two weeks later they come down with a disease. It's much easier to trace.

When you have a disease that has a 10-year incubation period, just think about what it takes to check out all those contacts to find out where they possibly got it, etc., etc. So it was a difficult epidemiological challenge. …

I use [the analogy of] what the physiologists explained to me is the boiling frog; that if you take a frog and dump it into a pot of boiling water, the frog fights like crazy to get out of the pot. But they tell me that if you put the frog in cold water, then put it on the stove and slowly heat it, the frog will just sit there and cook. Indeed in a sociologic sense, it's exactly what we see with these long incubation periods, because we, as humans, survive ... by denial, and if whatever we confront is a slow-moving phenomenon, then we can deny and run right over it and carry on. ...

The problem with a long-latency infectious agent is if during that long latency period, where the person is not obviously sick and not bedridden but indeed is out in society and indeed having sexual activity or sharing needles or such, the person is infectious and therefore becomes a silent carrier that can infect lots of other people. Now, early in the epidemic, we did not know that all of the individuals essentially who were infected with HIV continued to excrete the virus and indeed were potentially infectious to others. But as time has gone on, we've gotten to understand the virus. It's become clear that these people [are] ... potentially infectious to lots of people for years. That is a huge challenge to control an epidemic when you have this silent, large number of carriers in the population.

You said in the early days, ... immediately it was a very dangerous disease. It was killing people very quickly. How was it killing them? How bad were the patients?

... Everyone really should see AIDS in the flesh to understand its severity. Late-stage HIV/AIDS patients go through an incredible loss of body weight, suffer from a whole variety of symptoms and miseries, and wither away like a concentration camp internee, [like] a person who's starving. It's a horrible, horrible disease that just slowly chews away at the human body.

[Do you remember meeting your first AIDS patient?]

The first time that I saw AIDS face to face was probably in early to mid-1982, when the head of the AIDS program at CDC and I flew up to New York and went to a hospital in New York and actually saw a variety of patients, from somewhat functional and talking to comatose and in their last stages of the disease. It was impressive even for someone like myself that's been all over the world, seen god-awful diseases. This one got my attention. ...

I had great empathy for the patient and at the same time, for someone who's searching for the agent, [I] had great concern about all the people working for me in the laboratory searching for it, that this was not a bug that one would take lightly. It is one that one would treat like any other highly fatal [infection], and in the laboratory one should be very, very careful. It got your attention in ways that you felt deep in your gut -- both concern, empathy and fear.

With benefit of hindsight, how did the HIV get out of Africa and arrive here?

The origins of AIDS now I think have been relatively well figured out, and we can paint a picture now and draw the map of how it evolved. This is a virus that circulated in animals in Africa, higher primates, especially chimpanzees, probably for eons, and the chimps are relatively well adapted to it. It was the classic interaction of humans with animals that actually spawned the disease in the human population. This is not new; there are many diseases that come from animals, from farms to your chicken eggs and your kitchen if they've been contaminated, etc., etc. Food-borne outbreaks and indeed other types of outbreaks associated from animals to humans are old, old, old.

[In] public health, this one was unique in that it came out of the bush and probably came from the slaughtering of chimpanzees, which is common in Africa, and that the butcher of that would no doubt stick himself with some bones as he cut the chimpanzee up. That individual [and] his wife [in his] hut in Africa share the meat. Everyone would cook it, and only he would come down with [the] disease, maybe then infect his wife and then his child and in that hut would probably die, and nothing more would come up.

But what happened in Africa in the '70s, '80s and ongoing now is the urbanization of Africa, so where instead of living in the bush, ... especially males migrated to their urban centers for work. Then you had the unique situation of a bunch of urban males in Africa who had sexual gratification needs, and that would be supplied by women moving to Africa to really commercially benefit from sexual needs through prostitution.

Now, the infected chimpanzee butcher comes into a larger city in Africa, now has sex with a woman who has sex with a lot of other people, and this chimpanzee butcher is a very different result from what happened in his home village. Now the woman gets infected, and thousands of other people get infected, and then it goes on and on and on and on. Then the map goes from rural Africa to urban Africa. It's not hard then to see with modern transportation, which, again, didn't exist a century ago, of airplanes taking infected Americans and infected Europeans to urban centers in that part of the world.

Then you need the amplification system. Again, the amplification system in Africa is the prostitute, and this virus just searches out, and when there is a amplification system it takes off -- be it a shooting gallery and a bunch of junkies sharing needles or a gay bathhouse with gay men having sex with lots of others. So any amplification system -- prostitutes, needle sharing, commercial establishments for needle sharing and the commercial establishments for sex -- and you get this explosion in each of these different settings, and you have this large gay outbreak in Europe and the United States. You have the drug users spinning off in different parts of those countries and others, and the prostitutes everywhere.

So this disease has crossed the Atlantic. If you like the benefit of hindsight or if you'd been running CDC or whatever, what should the correct strategy have been? How could this have been contained straightaway?

The problem we had in the early days of AIDS, in my opinion, was essentially discarding of the role of government and public health by the higher authorities in the United States. Indeed, the United States public health often led the scene for what it would be elsewhere, with CDC being a bit of a model for the rest of the world to watch. … We were an organization that would fly all around the world and find bad outbreaks and try to work with local authorities to try and control those outbreaks so they wouldn't go anywhere else. That was classic public health.

This mission was undermined by the election of relatively simple-minded authorities in the Reagan administration in the United States saying lesser government is better government, and one of the lesser [ideas] was to throw public health to the wind, and especially throwing public health to the wind if it dealt with diseases that they didn't want to deal with politically.

The combination of this anti-government approach that we have -- cut, cut, cut -- ... and [an attitude, which] I'm not sure whether it was malicious intent or just simple-mindedness, that if gay men get their disease and other people have sex and get their disease and junkies get their disease, Godspeed, this combination set a stage that was really horrific, that we feel the ramifications of today; that public health was undermined [from] doing its required effort to stop an epidemic, and that the leaders at the highest levels of government would not stand up and say, "Look, guys, I know that sex is unpleasant, needle injection is unpleasant, but we as a society have to take care of ourselves, and I will speak to you about that right now and go on talking about ways to interrupt the outbreak." The highest authorities in the United States really inhibited us at CDC and set the stage to really help the outbreak spread.

You said earlier on, in a situation like this, that the first stumble can be fatal. What was the first stumble?

The important part about dealing with epidemics is to deal with them early. Just like the fire department would really rather come into a building when there was smoke coming out of one window instead of when there are flames coming out of every window, because it's a lot easier to control the fire early on, it's much easier to control an epidemic early on. The first sight of AIDS, with the incredible dangers that it obviously posed in terms of mortality, should have said, "We have to take this fire on very early." The reality was that's what we at CDC recommended, and that was actually told to us not to happen by the higher authorities and the United States government.

In what way told? What did they say?

As an example of what the higher authorities said, after we figured out the cause and I was running the laboratory at CDC there, was working with the Institute and others to determine the cause, then we had a lot of information. We had laboratory tests. We saw how far the virus had gone, how it was transmitted. It was all very clear by that time.

Then I shifted at the direction of the higher levels of CDC to make a plan of prevention. I think we called it Operation AIDS Control, and that plan was terribly expensive -- it was $30 [million], $40 million per year at the federal level and more at local levels, state and local. We would launch programs for testing and counseling and education for HIV/AIDS. That program was outlined in several pages by me, and several pages [of the] document went to the director of CDC. ... It went to Washington, and the word that we got back from Washington, as best as I can recall, was something like, "No, we're not going to fund it, and we want you to look pretty and do as little as you can."

Now, that was about as contrary to the philosophy of CDC, and in my 10 years with CDC was abhorrent. At that point I asked to be sent out to the field, actually to California, where some authorities wanted to do something, but it was clear that the federal government was not going to be behind the state and local authorities to do that, and that set an incredible precedent. One, it set a precedent for other conservative, high-level governors and the like to say: "Well, the highest levels of the White House don't necessarily think we should put money into HIV/AIDS; then why should we? And it's also embarrassing to talk about sex and needle exchange and needles and school education about abstinence and sex and choices, etc., and I don't like that anyway. And since Ronald Reagan didn't like it, then I'm not going to do anything either." …

… How soon did people like you see that this was not confined to the gay community? How quickly could you see that it was actually going to affect potentially the whole of society?

Organizations charged with protecting the public's health should protect the public's health wherever the public is, whomever the public may interact with, what kind of sexual activity, what kind of activity they have. That is really immaterial to the public health controller. Why is that? Just like the fireman -- a fire in the impoverished parts of the city is really no different than a fire starting in the higher-end of parts of the city, because the fire will spread.

The thought that a disease that is sexually transmitted will limit itself to certain segments of society is naive. We've known that for years, all the way back to 1200s, 1300s in world history. The importation of syphilis around the world spread very nicely, thank you, from sailors to royalty, so the thought that HIV would stay in a given area was either denial or malicious wishes by those who inhibited control programs.

People talk about gumshoe epidemiologists. What does that mean?

The lapel pin -- I should have worn it today -- for the Epidemic Intelligence Service of CDC is [an] outline of a shoe with a hole in the sole. This is really the essence of public health epidemiology, that when there is an outbreak of any kind, there's really only one way to figure it out, and that's to get out and go talk to the patients, talk to the people, talk to their contacts. Gumshoe or shoe-leather epidemiology, that is the essence of understanding an epidemic.

With AIDS, that's exactly what we did. When there were cases that were reported, there would be a CDC person usually along with the state or local person. They'd go and investigate each person, talk to them with initially, [give them] maybe a 20-page questionnaire -- everything from their pets to their sexual activity -- trying to figure out exactly how it all fit together. Now, that's quite easy with short-incubation-period phenomenon; it's a little tougher with a 10-year incubation period because of the amount of time. You have to find out what they did over these period of times. [It] was a greater challenge, but the ability of people like Bill Darrow at CDC [who] went out, and really the sociologists that really put the society piece together and interviewed these folks found out that the early cases really did link together in years past. That was critical, to have that kind of worn-out shoe leather, to actually get out there and talk to the people with the disease to figure it out.

As the focus became more clearly sexual, what kind of questions would investigators have to ask patients or victims?

The evolution of an epidemic investigation always is based on yesterday's information: What did you find out yesterday? And the question you ask today ... -- we really interviewed the first cases [and found] out that these were gay men who had lots of sex. These were what was called the fast-lane gays; at that time, they had visited gay bathhouses, had literally sometimes hundreds of sexual contacts.

The type of questions evolved then of not only how many contacts you had -- we'd really established this is probably sexually transmitted -- but then what kind of contact did you have compared to a group of individuals who didn't have AIDS. So you have what's called a case control. You take cases, interview them, and take a group of controls and interview them. It found that one of the number of sexual contacts and receptive anal intercourse were the key pieces.

Then you take that next question. You ask the same thing in the evolutionary sense to IV drug users, find out it's people who share lots of needles, etc. Then the sexual contacts, heterosexual contacts would come out. Who did you have heterosexual sex with? How did you have sex? …

Now, also in this evolutionary sense, a group from CDC went off to Africa and started interviewing people there. The hospitals were already starting to get filled with AIDS cases at the time, and it was clear that these people were not IV drug users; they were not gay men. These were heterosexual individuals who also had, as studies went on, had lots of sexual activity, too -- heterosexual activity. It all fit a really very reasonable pattern from sexually transmitted, blood-borne transmitted disease, which we had seen before with other viral infections.

Do you think that the fact that it broke out in the gay community in this country almost blindsided the medical establishment, so people were looking to link the disease to gay activity rather than more general sexual social activity? In other words, was it a false path?

I think the fact that the disease was sexually transmitted at all was a factor against the ability of society to respond appropriately. The fact in North America and Europe [that it] was primarily a gay sexually transmitted disease added an order of magnitude, more impediments to a society dealing with it. Then you throw in junkies on top of it, and the discomfort that even a well-meaning elected official has to deal [with] was tough. The fact that it was sexually transmitted and gay sex-transmitted just meant ... there's an initial inertia that a political, elected individual would like to avoid that and not look at the overall responsibility that he or she may have.

All of this together -- the fact that it was sexually transmitted, the fact that in the more wealthy parts of the world it was introduced into the gay population first -- made it an icky disease that no one wanted to work with. ... You couldn't design a virus to be better in today's modern world, with a long incubation period where people were infectious throughout the whole thing, and spread by sex. In much of the world there's this privacy or religious avoidance that makes politicians not want to deal with it, and with an outbreak of this size, politicians had to be involved.

And they failed to be.

Politicians had to be involved, and politicians failed to be involved, except for a few that really took the bull by the horns. It turns out that they helped, but they couldn't turn the tide against this massive inertia that existed, especially in the United States government level.

... Briefly sum up how the connection between Zaire and Haiti could have happened.

There are really a couple of possibilities of how HIV got out of Congo, or Zaire. Did it come directly by airplanes and tourists who had sex there and brought that to Europe or North America? Another possibility is with the interaction between the Haitian educational people -- teachers who were contracted to work in Congo/Zaire. [They] came back to Haiti, and we knew at the time there was a great gay commercial activity and popularity to visit Haiti. Did the virus come from West Africa to Haiti from there to essentially the gay population New York, then back to Europe, or did it go individually? I don't think we'll ever know that, but that certainly is a possibility, that Haiti was an intermediate stop.

... How did HIV get into the [clotting] factor?

The terrible outbreak of HIV in the hemophiliac community, which essentially eliminated an entire generation of hemophiliacs in several parts of the world, but certainly in the United States, was really a very simple situation. That is that clotting factor is obtained from blood or plasma that is donated blood or sold. In the old days, one had to take the liquid part of the blood plasma and extract the Factor VIII from it.

Now, to do that most efficiently and properly, you need a large amount so that it can treat thousands of people. So how do you do that? You take plasma from thousands of people and put it together and then extract the clotting factor, put it in a bottle, and it goes to the homes of hemophiliacs to be injected in them. Well, a better way to transmit an infectious agent than that would be difficult -- that is, you take thousands of people, put them into a bottle, and then send that out and inject it into other people with a needle.

What happened was that people really at risk of HIV/AIDS -- drug users who wanted to sell even though they were not allowed to sell their plasma, they got in prison populations and were selling their plasma; and the blood industry did not exclude gay men from blood donation -- ended up contaminating essentially all [or] lots of Factor VIII material that was used to treat hemophiliacs and infected essentially all of the hemophiliac population with a 100 percent fatal virus that eliminated an entire generation of hemophiliacs. …

… When did it become [clear], certainly to you and your colleagues, that this had happened, and how did the blood banks react?

The first cases of AIDS in the hemophiliac population surfaced in the summer of 1982, and then in the subsequent months there were about five cases that came in transfusion recipients that were announced in January of 1983. This was a time when IV drug users were already transmitting the disease. It was well known that it was in blood on the end of needles shared by IV drug users; it would be logical, therefore, that it would be transmitted through therapeutic blood product used with hemophiliacs or blood transfusions. For us as epidemiologists, this was not a great leap, and we waited until we had a couple of cases, at least or three or four or five cases, before we held big meetings. But then we held big meetings and turned to those responsible for protecting the recipients of those materials to do something about it, and that was another public health disaster.

What happened?

There were several intersecting forces that ultimately killed tens of thousands of hemophiliacs and transfusion recipients in the United States and around the world. Those really were a combination of I would say laziness, profit motive and this incredible inertia that some groups have to not change.

Now let's put that in perspective. Clearly the clotting factor material for hemophiliacs was a commercial enterprise, and they had their collection facilities in impoverished parts of the world, collecting material they shouldn't have, and wanted to deny there was any risk, and carried on through that really profit motive, which was a shame more. But that's understandable in a way, a nasty, evil profit motive.

The more difficult one with the blood banks were these were supposedly nonprofit organizations for the public good who were, from CDC's standpoint, killing people just because they didn't want to change their procedures to eliminate people at risk of transmitting HIV/AIDS, which is really primarily gay men at that time in United States and Europe. We were shocked by this.

In retrospect, you think about what a blood banker is. A blood banker is a person who has rules: We do this -- step A, step B. Then we join the blood from person A to person A prime. We do all these tests just to make sure they are not change agents. These are people who are trained to do things by [procedure], and we at CDC turned to them and said, "Change your policies and exclude gay men," and they had to ask about sex and all this kind of stuff in their screening, and they just were resistant to do it -- resistant for literally another year and a half before a blood test came in. In the meantime, tens of thousands of people died.

It was a true tragedy in retrospect by people who just couldn't deal with this sort of new phenomenon in their long-set, established, rote way, and [it was] a tragedy that afflicted many, many people for no reason whatsoever, because gay men were perfectly happy not to donate blood. ... There was no resistance from the gay community; there was a resistance from blood bankers to ask the question. Tragic.

There was a meeting, I believe, where you pounded the table. I mean, this is a foreseeable disaster.

In January of '83, we had the meeting with the blood banks that we thought, frankly, was going to be a straightforward meeting. We presented data. We showed them ways they could avoid this. They could use laboratory tests; they could use histories of volunteers like they always had used, laboratory tests fitting into their system. And they obstructed it from the get-go. It was as frustrating a [meeting] as I've ever been in.

And yes, I pounded the table and yelled at them, asking them how many people they wanted to kill. If it's five now, instead of having another meeting of this kind, I just said: "Just tell us the number. You want 10 dead? You want 20 dead? You want 100 dead? Then we'll make these [recommendations]. We can make the recommendations today, and then you can just count the cases." That didn't go down very well.

I'd like to ask you specifically about Reagan. … Why did it take him so long to even mention the word "AIDS," and what was going on in his head so far as you can tell?

I despise Ronald Reagan and the people around him for what they did to public health in the United States and the rest of the world. He's seen as a benign individual by most, as a nice man trying his best, but this man did not have the appropriate understanding of the responsibility of government protecting citizens. Regardless of what a nice man he was, I don't give the benefit [of the doubt] to nice people who do bad things, and either he or the people he surrounded himself with did bad things. I don't know their reasons behind this, but they could not be convinced, despite our great attempts to go to high levels and convince them, that there was something going on that needed major government involvement to intervene.

They set the stage, the early Reagan people who were anti-government, no doubt certainly not a caring group for homosexuals or IV drug users, and I think were perfectly happy to see them leave the world, but did not have the logic of a government, elected or appointed official, to do their job to protect the public's health. I don't know what was going on in their mind to obstruct our efforts to protect the public's health, but they did, and have been hardly held accountable for that.

How many lives did that cost, would you say?

In the end, their more than impassive inaction, their active obstruction of actions that were necessary, allowed HIV to get a firmer hold around the world and had to be the result of millions of deaths in the long run.

Millions?

Millions. …

… Reagan's administration was keen to reduce the government to cut back on spending. Tell me how cuts in spending affected the fight against AIDS. …

If one looks back at the early days of AIDS and what we required to get as early a jump as possible on the epidemic, to understand it and ultimately control it, there were relatively simple things that you can see that were just not available. For example, my area of responsibility at the time was to establish a laboratory to investigate the cause, ultimately develop a blood test and do all of these things. We really had nothing for the first two years, essentially nothing -- that is, we had to steal equipment from the other laboratories; we had to dig out space. This was not an appropriate response to a disease that had a mortality that looked greater than most other infections that we had to deal with. The initial lack of appropriate response, the initial lack of understanding what government's role in this [was], set the stage for a much worse epidemic than it would have been if we had responded early.

Now, that's the money side, and there's also a way the independence of institutions like CDC began to be eroded. Explain in your own words what you think was happening there.

In addition to the lack of resources, and indeed not totally independent from it, was the lack of political support to do what was necessary to deal with the epidemic. This now, instead of being an administration that supported its staff and its funding and its statements and research that needed to be done to understand the epidemic and to ultimately control the epidemic, was the opposite. To this day you can read in the paper about what statements are appropriate for governments to make as far as the control of the epidemic, what kind of treatment or needle exchange was appropriate for dealing with drug use. There is still literally in papers on into 2004 and onwards are statements of "We need still to only have abstinence programs in Africa and not talk about abstinence and safe-sex programs." Shocking, absolutely shocking.

[It was] public health malpractice that not only did they limit the funds that would be necessary to accomplish it, but they inhibited the programs, reviewed the programs' publicity and the programs' messages, and were reviewing posters from CDC in the White House. It was just every statement that came out, instead of being a statement of protecting the public's health, became statements to protect the politicians in Washington rather than the public's health. It was tragic, dangerous and set a precedent that is still reverberating around the world. …

... So would it be true to say the failure to get a grip on the epidemic here in the USA in the early days has had an impact on the rest of the world?

The rest of the world often turns to the United States, and specifically CDC, for guidance in dealing with epidemics. No doubt CDC's slowness to respond -- really, forced slowness to respond -- to the AIDS epidemic set a pattern for the rest of the world, saying, "Well, the United States is not doing this; therefore we shouldn't have to do so." I think it's very true that as a trendsetter, CDC's lack of urgency dealing with HIV, recognizing that HIV with its incubation period was already well established, the fire was well burning, and so indeed, that put a greater urgency to respond to it. The lack of American response was a guidepost for the rest of the world, and so the ramifications to the lack of U.S. response really echoed around the world. …

... What was your early vaccine research?

I started my vaccine research at Genentech, which was the lead company making a recombinant technology that outercoated the virus to be used as a vaccine. Unfortunately, in the private sector, even though you have all the power in the laboratory to make an AIDS vaccine, the competition within the company is to maximize the profits of the company. This powerful recombinant technology can be used for lots of things -- medicines, vaccines, etc. -- and I learned very quickly that vaccines don't compete. Why? The ideal vaccine is a single dose or two- or three-dose product, gives you large number of people but [at] a very low price. The ideal drug is one that doesn't work very well, that you take every day for the rest of your life at a high price. And people demand therapies and don't demand prevention.

When I was in the vaccine business, I came in naively thinking vaccines are the greatest tools in the world; they would eradicate these diseases. I helped eradicate smallpox and hepatitis and all these other things. I thought, gee, this is the thing for an industry to get involved in. When you get into the industry, you find out that industry reflects the same priority as the society does. Society sets the values for therapies. Aha. Just like when I was at CDC [and I learned] that they don't value prevention, and then suddenly I'm trying to raise money to make vaccines, and they'd rather invest in drugs. …

[What's needed to develop an effective vaccine?]

The situation with vaccines reflects the situation and social values of the society. If the society valued vaccines, there would probably be a dozen vaccines in the final stages of development to see if they work. Right now, there's really one product that's in a final test, and people are not optimistic with that. We went through the final stages and had interesting results, but required tens of millions of dollars in order to get the answer. The reality is that industry follows social value, and if the society does not value prevention vaccines, industry will not make vaccines. We have to go back to the political system, back to the social system, and say, "There must be a way that you can do that."

Now, interestingly, there are now new public-private partnerships that indeed I'm in the middle of now developing, that is really stimulated by one married couple up in Seattle that have changed the whole enterprise of developing vaccines for the developing world. They see HIV as their major priority, and so it's back to the drawing board how to understand our previous trials, how to redesign the vaccines to actually develop a vaccine, which is not developed by NIH [National Institutes of Health] or universities; it's developed by an industry-type skill, and you have to capture that with money. The [Bill & Melinda] Gates Foundation is trying to do that. …

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posted may 30, 2006

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