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A VOICE FOR THE PUBLIC'S HEALTH

Donald P. Francis, M.D., D.Sc.

There was no hesitation in my voice. There was no hesitation in my body language. I was on course, the right course. But what I was saying was not pleasant. I was criticizing the actions of my honored and revered Centers for Disease Control and I was criticizing the President of the United States. I spoke the truth about how the public health of America had been put in jeopardy by the Reagan and Bush Administrations. I describe how political extremism and a loss of understanding of the Federal Government's responsibility for epidemic control has prevented CDC from doing its job. It was June, 1992, the 21st anniversary of my public health career.

As I sat at the witness table with Bud Roper who directed the Roper opinion polls, I looked up at Congressman Ted Weiss who carried the subcommittee. He listened intently to both Mr. Roper's and my testimony. He listened as Mr. Roper described the results of his recent poll which showed that Americans felt personally threatened by the AIDS epidemic and were ready for frank and forthright messages on how to prevent sexual and drug-use associated HIV infection. He listened intently as I, as a career officer of the Centers for disease Control, described how the previous Reagan Administration and the present Bush Administration had successfully prevented the launching of an HIV prevention program worthy of the dangers posed by that virus.

Why me? Why was I destined to sit before a Congressional Committee to berate a powerful administration for public health malpractice?

The reasons can perhaps be tracked back to the 1950's westerns that I watched on our family's first television. The white-hatted cowboys on Bar 7 Theater never backed down from what was right, even if it hurt them. These shows, through a cloud of macho naivete with their good-guys-always-win theatrics, installed an impression that the good guy rather than the brute will be victorious eventually. Today that naivet´┐Ż still exists in me, modified somewhat by realities of life's experience which have taught me that, at least in the short run, brutes often do quite well.

But the Bar 7 Theater cannot take all of the credit. My ability to stand strong and often alone against adversity has its roots with my parents. At dinner one night in our comfortable house in Marin County, California, I made a joke about attempts of Governor Orvil Faubus of Arkansas to maintain segregation of blacks. In 1959 the Federal government was taking on states like Arkansas which wanted to maintain the "separate-but-equal" stance of the segregationist's schools. Governor Faubus had made a national plea to send money to him so he and his white supremacists could withstand the force of the Federal authorities. In cynical jest, I suggested that we all send money - Confederate money. My parents laughed at the joke, but wouldn't let it drop. My father suggested I call Herb Caen, a columnist with the San Francisco Chronicle and tell him about my idea. At lunch break the next day, I went to the telephone booth in front of the gymnasium at Redwood High School and called him with my idea. That Sunday, my plea to send Confederate money to the segregation's was the lead paragraph in his column and soon I was on the front page of papers around the country. Considering the value of the true Confederate dollars, I adjusted my plea to send imitation Confederate bills - and they, arrived by the pound.

My parents were both doctors, my mother a radiologist, my father and internist. My grandfather on my father's side was also a doctor. But, my interest in medicine was not stimulated actively by my parents. In a way, their realization of the consuming training and the chaotic life of a physician seems at times to have discouraged my parents from directing me towards medicine. This was especially true for my mother. She was a beautiful and brilliant woman, in Stanford at the age of 15 and one of the first female radiologists to be trained in their program. She, like most women in medicine, was always torn between her career in medicine and her obligation to her children. She did have a great job of balancing it. She would go to her office in San Rafael in the morning and come home to read her X-rays in the afternoon. In a most subtle way, she was always protective of her boys, wanting the best, yet letting them learn for themselves. Few times can I recall her strongly imposing her will. One time of note had to do with our vocabulary. We were raised in a permissive home with little censoring of our cursing, but Beth wouldn't tolerate one word, nigger. I remember bringing it home from school as a derogatory term which I didn't understand but without hesitation to use it. For the first time, I saw the hair raise on her neck and, in a very clear voice, she asked if I knew what it meant. I didn't and admitted it.

She explained it and, in her simple but straightforward way, stated that with our long family association with Texas and Arizona, it would not be surprising that we had black relatives. "Would you like to be called a nigger?", she asked I never used it again. Recently I had the same discussion with my boys about "homo" and "queer".

Despite her, I'm sure, strong feelings, seldom did she try to influence my brother's or my life-important decisions. I do, however, recall her reaction at my announcement that I was going to become a pediatrician. She strongly objected, fearing that my life at home would be destroyed by my obligations to my parents. Similar maternal protectiveness surfaced later regarding her fear of my work in the tropics. She, being wiser than I, recognized the risks I exposed myself to working with dangerous infectious disease in inherently dangerous parts of the world. Her, "be careful" admonitions when I would announce another more dangerous assignment, were greeted by me similarly to the same words delivered each time I drove as a teenager. Little did I know how much she knew and how important her advice was on both accounts. However, I ignored most of it and she allowed it.

My father was even more reserved and just plain supportive of whatever decision Steve, my brother, or I would make. Indeed, getting advice from him was very difficult. He came from an English family whose emotions were buried far below the surface. Occasionally when major issues surfaced, his reluctantly offered advice was immensely valuable. My father, Cy, although trained in internal medicine, became a high-level administrator in the Veteran's Administration. Drafted from a Beverly Hills medical practice into the Navy during the World War II, he not so accurately predicted that socialized or centralized medicine would immanently come to the United States. Considering this prediction, perhaps 50 years to early, he wanted to be in on the ground floor of its organization. To him the Veteran's Administration would be the cutting edge of this movement and he joined up to be on the ground floor of universal health care. Through the years, he became increasingly frustrated with the bureaucracy of the VA and more and more disillusioned with the ability of our government to function. His advice to me when I began my government career and confronted bureaucratic obstacles was, "Don, as an administrator, you have to constantly walk on the edge of being fired. If you want to accomplish any positive change, you will have to take risks." If he only lived long enough to see his son repeat his administrative style.

As time went on, my parents' support allowed me to successfully negotiate the multiple crosses of the 60's. The major crisis was the war. It was the Vietnam war which really brought forth courage in all of us who confronted the establishment and opposed that disgraceful national action. We were forced to often stand alone, different and often despised. In the 1968, I began medical school at Northwest University in Chicago, Dr. Seifert, a semi-retired physician who directed the University Health Clinic inspired my interest in infectious disease by describing tropical diseases like diphtheria, polio, tetanus and measles. Although fascinated, I found concentrating exclusively on my medical career ignored a far greater injustice inflicted on poor villagers of south east Asia not by tropical disease but by our bombers. I helped found a chapter of activist health science students called the Student Health Organization (SHO). We staffed a free clinic on the western side of Chicago and organized anti-war protests and counseled draft evaders.

Although there were a number of medical students at Northwestern who shared my social concerns, there were many more whose major concern, over and above studying for exams, was memorizing sports trivia or investing in the stock market. It was to them that I addressed a letter as I approached my last days in Chicago. In that letter, I urged them to become involved with the impoverished members of our society and I urged them to resist the draft.

Confronted with a medical student writing such a letter, the dean asked me to come to his office. I had been wanting to talk to him anyway because I had received and international pediatric fellowship in India for my last quarter of medical school and was going to ask if I could be excused from having to return to Chicago for graduation ceremonies. But after our appointment, I never had to ask.

From the moment I entered his office he castigated me for my stance against the war. At the top of his lungs he screamed across his huge hardwood desk, "You are a disgrace to the medical profession.". At first I tried to explain my reasoning, that I wasn't really so disgraceful. But it was clear that he was out of control and beyond any attempt at reason. At the conclusion of his diatribe, he ordered me not to come to graduation. During his shouting I was scared. It was far from pleasant being chastised by the pinnacle of the medical school administration. Strangely, however, I was very uncomfortable with the situation, yet comfortable with my position. And, as time past, I felt damn proud that I withstood such a lonely and brutal attack with honor and poise- far more, indeed, than that shown by the not-so-fine dean.

I learned from my contacts in the faculty that the dean had petitioned the faculty committee that I be officially chastised or possibly expelled. He presented my letter to the faculty and asked for comments from the chair of psychiatry who, after reading the letter, commented, "It's one of the best things I've ever read." With that, the dean's balloon collapsed and months latter, I received a diploma in the mail.

The culmination of our anti-war protests in Chicago was the 1968 democratic convention. Months were spent planning for demonstrations which ultimately resulted in a barbaric attack by police which showed the American public how brutish our government had become. Fortunately for my scalp, I, by the time of the convention was in India, pursuing my professional interest in infectious disease - this time controlling tetanus of the newborn at the foot of the Himalayas.

By the time I returned to the United States in January 1969, the ferment over the war was still rising and returned to the fray. By then I was a doctor. Indeed, I was a third generation California physician, beginning an internship at Los Angeles County/USC Medical Center, the very place where my father was an intern 30 years before.

At that time in American history, young doctors were clearly rocking the boat. Each month we held "Moratorium Days" during which tables with literature and anti-war buttons lined the hallways of the hospital. Speakers were invited to the center of the hospital grounds to address the atrocities of the war and the lies peddled by our government. On special days, marches consisting of thousands of protesters, crossed Los Angeles.

Our definition of medical responsibility was different from the past. Maintenance of the status quo, supported by the more conservative practitioners of medicine, was no longer acceptable. We were confronted by many older physicians about our stands, our clothes and our hair. There was constant pressure to conform. There was no pleasure in these confrontations. Each one made me uncomfortable since many came from doctors who were my mentors whom I respected for their areas of expertise and appreciated for their medical teachings. What helped me the most to withstand this pressure were the few supporters within "the system" who, although they may not have appreciated our tactics, supported our right to speak and appreciate our expressions of social concern.

Like my parents earlier in my life, it was supportive people like these who granted me the strength to carry on, to fight and to follow my chosen path. It has been these few sentinel people, who throughout my training and career, have guided me and given me courage. To them I will be forever indebted. The first of these occurred during my first year of medical school. It was a miserable year and I yearned to do something with more relevance and pleasure. During the summer which followed, I visited the Roger Nichols, a professor of mine at Berkeley in whose laboratory I had worked during my last two years at Cal. I told him I wanted to quit medical school and return to Berkeley to pursue a doctorate in medical physics. He, together with Dr. Lawrence of the Donnor Laboratory, sat me down and explained why it was worthwhile to put up with the misery and complete medical school. In clear terms they showed me how much better it would be for me to get a MD.. and, only later, return for my Ph.D. That hour of their time changed my whole professional and political accomplishments. Later, I did get a doctorate in virology from Harvard, but even my doctoral work was centered around my interest in preventing infectious disease in people.

The next crucial guidance came at the conclusion of my second year of pediatric training in Los Angeles. With over 95% of doctors being drafted, it became increasingly clear to me that my conscientious objector application would be rejected by my draft board and I would be required to enter the military and support the war in Vietnam. Being adamantly against the war, yet not wanting to go to jail, I decided to move to Canada. I made an appointment with Dr. Paul Wehrle, the chief of pediatrics at LAC/USC Medical Center, to get his advice as to a good hospital in Canada at which I could finish my pediatric and infectious disease training. Paul had always been one of those supporters who, regardless of how clumsily I had protested some social inadequacy, always understood my goals and counseled me on better ways to achieve them rather than lecture me on the disturbance I had caused.

At this meeting, Paul asked, "Why don't you apply for the EIS program at CDC in Atlanta, but had never heard of the Epidemic Intelligence Service. He explained that two years chasing epidemics would qualify for military duty and, should I be accepted, I would not have to move to Canada. I enlisted for my 2 years and stayed for over 20.

CDC was just the spot for me. I was very interested in pediatric infectious disease, but, unknown to me, I had become increasingly interested in preventive medicine and public health. In infectious disease the first case of an unusual disease is always a wonderful experience. I will never forget my first cases of tetanus, meningitis, whooping cough, diphtheria, malaria, botulism, tuberculosis or typhoid fever.

But treating some of these diseases can be extremely difficult. I remember most notably baby boy Stills, a young poor child from central Los Angeles with whooping cough. Every night just after dinner he would have such severe coughing that he would have a cardiac arrest. We would all rush to his bed side and spend hours reviving him. My interest in this fascinating disease subsided as the grueling need to care for him became routine. Baby boy Stills lived, but not without extensive costs and misery to him, his family and the hospital staff who cared for him. And it was all preventable. Baby boy Stills had not received his baby shots. One of these, the "P" of DPT would have completely prevented the entire 6 week episode. I pledge to myself that all babies under my care would be immunized. Never should a preventable disease be allowed to torture such young and innocent victims. Unknown to me, that was one of the principle roles of CDC.

My first assignment was to the State Health Department in Portland, Oregon. Before I even found a house, I found myself out in eastern Oregon battling an outbreak of bubonic plague. In the year and a half I stayed in Oregon, I fought outbreaks of measles, diphtheria, hepatitis, and leptospirosis. But the final was the outbreak of smallpox that was imported into Yugoslavia. With only two hours notice I was asked to pack my bags and join a team of about 10 CDC people in Washington, D.C. for immediate departure to Yugoslavia where a pilgrim to Mecca had traveled through Iraq on his return and imported smallpox to the southern, largely Muslim area of Yugoslavia. Within weeks, with aggressive vaccination combined US and Yugoslavian teams stopped the outbreak. Without that effort, it would have spread throughout the country and beyond.

Following the Yugoslavian smallpox outbreak, I met perhaps my most influential guide-person, Bill Foege. After defeating smallpox in Yugoslavia in 1972, I met Bill at a smallpox division picnic in Atlanta enroute back to Portland. Unfortunately for me, I met him first on the opposite side of a volleyball net. Bill, being 6 foot 7 inches, is not the person to face in volleyball. He had no mercy and pummeled me with spikes and lobs.

Still dripping from sweat caused by the combination of volleyball and the intense tropical air of Atlanta, I told him, I enjoyed beating back smallpox in Yugoslavia and that, if he ever planned a larger effort and needed help, I would join. It was only a few months later, that CDC, the World Health Organization and several other countries began "Target Zero" the worldwide campaign which 5 years later eliminated smallpox from the world. I first went to Sudan, where I headed the national program. Sudan, the largest country in Africa, had only 250 miles of paved roads. I spent the better part of a year in a Landrover covering all corners of the country searching for any case of smallpox. Sudan, extending from the southern edge of the Sahara to the northern edge of tropical central Africa, is a wonderful country. In it I found excellent people working in the most difficult conditions. They eradicated smallpox in the absence of roads, hotels, cafes or telephones. They did it well and they did it with honor. I watched them work with northern Arabs with swords hanging at their waists and with southern blacks with stretched ear-lobes and ivory bracelets.

The Sudan should be a prosperous country. It has a well-educated elite, it has great natural resources and it has a cultural quality of honesty and integrity seldom seen elsewhere. After smallpox, I returned to Sudan twice, once for an outbreak of Ebola virus 1976 and once 9 years later to help them with AIDS. On both return visits the quality of life had noticeably decreased - and it started low. The Arabs have been fighting against the southern blacks, the Muslims were fighting against the non-Muslims. And the economy, the pride and the honor of the country declined, all because of a few brutes whose selfish desire for power drives an already impoverished and abused people to a worse state.

After Sudan, who transferred me to India for "the big one". The major concentration of smallpox left in the world was on the Indian subcontinent. Bill Foege and his family had come to India and he was my boss and my inspiration. It was a hard, often uncomfortable and frustrating battle. We were naive thinking that a few of us with a few extra vehicles and a little extra money to buy fuel and spare parts for the Indian government vehicles could wipe out a scourge which had been consuming parts of a whole continent for a century. We started by capturing all health workers for one week to search all villages for any evidence of smallpox. Bill Foege had discovered when he was working on smallpox eradication in Nigeria that by searching out every single outbreak and vaccinating everyone in contact with each case, smallpox could be controlled and, since there was no animal host of the virus, eliminated.

After months of frustration in India, we regrouped, got additional resources from the Swedish government and launched a major attack in the wet and muddy monsoon season when the virus transmission was lower. Soon cases began to drop. And a few months latter there was no case to be found.

I had to cut short my assignment in India when my mother was diagnosed with nasopharangeal carcinoma. I went home to comfort her and get her stabilized, but I returned to the subcontinent for a few months to help out a troubled program in Bangladesh. Again, I was fortunate to see smallpox go from a pan-country epidemic, killing, blinding and scarring people by the thousands, to a disease of the history books. The exhilaration of beating back such a horrible disease rests with each of us who took part in the eradication program. Few other experiences in life could be as fulfilling as being part of history's first successful eradication program.

The ideas and the execution of such an effort are the result of a few people who care enough to take it on. Bill Foege was the catalyst. He, later to become the director of CDC and, now, the Executive Director of the Carter Presidential Center, continues to be a great inspiration to everyone who is trying to make the world a better place.

Having been "in the bush" for so long, I felt scientifically behind and desired re-education on my return. Fortunately, CDC granted my request of support for additional training. I had initially planned to undertake a fellowship in infectious disease and study for a Masters in Public Health, but felt that the MPH was too general and somewhat duplicative of what I had already learned in the field with CDC. After discussing my plans with several people at CDC, I decide to combine my infectious disease fellowship with laboratory research in virology. With the help of Alex Langmuir, the former head of epidemiology at CDC and the professor at Harvard, I found Max Essex, a virologist studying feline leukemia virus. As I had become increasingly interested in the late manifestations of viral infections, feline leukemia was an ideal bug to study. Unlike acute infections like chickenpox, the common cold or influenza which induce disease within days of infection, viruses like FeLV don't show up until after months to years after infection.

Ultimately, I spent 3 years at Harvard studying the transmission and natural history of FeLV. During that time, I gained immense respect for that virus which, without outward signs of infection, would slowly destroy the immune system of cats leading to cancer or opportunistic infections. Without knowing it, I was being incredibly well prepared for my work on AIDS which, still hidden, had been introduced into the United States simultaneous with the awarding of a doctorate in virology to me by Harvard.

But, at the time, there were no virus infections of humans that fit the model of FeLV and I needed to find a good assignment with CDC to continue my career. The closet match was with the Hepatitis Division in Phoenix, Arizona. Hepatitis B virus, although not producing immunologic disease did produce chronic hepatitis, cirrhosis and cancer of the liver - sometimes decades after initial infection. The match was excellent not only with my interest in vaccines. Merck and Company was developing a new vaccine for hepatitis B virus and my challenge was to test it to see if it worked.

Testing the hepatitis B vaccine filled in the final piece of experience necessary to prepare me for the AIDS epidemic, working with gay men. Being the highest risk group for hepatitis B infection in the United States, gay men were an ideal group in which to study the effects of a preventive vaccine. Towards the end of my study of the vaccine's efficacy in 1981, Jim Curran, an epidemiologist in Atlanta working in sexually transmitted diseases, called to tell me about a new disease in gay men that caused immunosuppression and cancer.

Before long, I was asked by CDC to move to Atlanta to head up CDC's laboratory efforts to find the cause of AIDS, which we presumed was infectious. I naively accepted the challenge without knowing the impossibility of the assignment. From what the newly elected Reagan administration had done to my plans to eliminate hepatitis B infection in the United States, I knew that the financial commitment to disease prevention was limited, but I thought that a new epidemic like AIDS could not be ignored, even by the most conservative ideologue. Little did I know what was in store. I was asked to establish a laboratory to discover the cause of AIDS without enough money to buy equipment, to travel to get patient specimens or to hire staff. Collaboration with others was the only way to accomplish my goal and I started with Max Essex, my mentor at Harvard. Max worked closely with Bob Gallo at Harvard and I, ultimately, with the Institut Pasteur in Paris. I supplied specimens from a variety of CDC studies to all of them to help them in their work and followed all leads in our limited lab at CDC. Eventually the Institut Pasteur identified the virus and we worked with them to prove that it caused the disease. But, working in parallel and the National Cancer Institute, Bob Gallo tried, with considerable success, to overshadow the French work and take credit for the discovery. I was caught in the middle as an American government scientist trying to defend French scientists from illegitimate claims by another American government scientist.

With the combination of absent commitment by the Reagan Administration to do anything about AIDS and the unpleasant relationship between CDC and NCI, I decided to direct my efforts at prevention of AIDS. I was asked by CDC to design a national prevention program. Plans for that program were sent to Washington for funding. They were returned without support. At that point, I was caught between a well trained responsibility to prevent disease and a higher administrative authority telling me to do nothing. I then asked CDC to send me to California. California was not only my home, but was also a place where action on HIV prevention was already gaining steam. I spent the next 7 years helping designing prevention programs which serve as models for much of the rest of the world.

But my troubles with Washington followed me to California and I had to ask for help from the good people who had already done so much for me. It was Bill Foege and Jonas Salk (with whom I began working on an AIDS vaccine after arriving in California) who joined together to help me through perhaps my greatest crisis, the attempt by the U.S. Government to fire me from CDC. The crisis centered around the publication of Randy Shilts's book And the Band Played On. I served as one of many sources of information for that book which I reviewed the inadequacies of the early days of AIDS. It was appropriately critical of the Reagan Administration for their lack of leadership, of the blood banks for their ostrich approach to preventing transfusion-associated HIV. When the book was published, my critical comments were clearly reported, especially through my official memos which I had provided to Shilts. A few weeks later, I was asked to come to Atlanta to meet "regarding my future career plans."

In California we had organized a coalition of physicians, public health workers and other AIDS-concerned groups. This coalition was making progress towards designing and delivering an effective AIDS prevention program. With such progress, I was happy with the job and had asked CDC to extend the assignment for four years at which time I could retire from the Public Health Service.

Washington had different ideas. On the days prior to my visit it Atlanta, they had ordered CDC to fire me. I learned the specifics of this order much later. What confronted me at the time was the smiling face of Dr. Jim Mason, then the Director of CDC, as he reached over his wide table in his office and said, "Don, I'm glad you will be coming back to Atlanta to work on tuberculosis." Being rather stunned at being transferred outside my post in California to Atlanta to work on a bacterial disease, I said little to Dr. Mason. Later, talking to Walt Dowdle, Mason's deputy, I learned that the transfer had nothing to do with my performance or CDC's desires. "It's all ordered by Washington." he explained.

Angered by the repression and tempted to respond with force. I wisely sought guidance from Bill Foege and Jonas Salk. They both advised me against any aggressive retort. Instead, they both assured me that they would work with CDC to assign me either to the Carter Presidential Center of the Salk Institute to continue my work in California. They helped me write a diplomatic letter to Jim Mason which explained why what I was doing in California was important and why it was well suited to me and valuable to CDC and the nation. Among other things, the letter pointed out that CDC had sent me to Harvard for a Doctorate in retovirology rather than tuberculosis and that working with AIDS was, therefore, far better suited to my area of expertise. The letter was proper and respectful, yet, with the help of Bill and Jonas, it carried a strong punch. It made CDC look inappropriate if they sent me back to Atlanta for tuberculosis.

Jim Mason immediately recognized the power of the letter. I was told he was furious upon reading it and said that I had written the letter for the press. At that point the press knew nothing about the letter. However, they were on the trail. By the time I returned to California from Atlanta, the television show "60 Minutes" called to ask if I was being punished for expressing my opinions. I told them that my assignment was being reviewed "as a routine" and I didn't think that there would be any problems. But I knew and Jim Mason knew that if they tried to punish me, the press would come down unmercifully on CDC. The book had cast me as somewhat of a hero within the bureaucracy and the press would have loved to confront CDC on my behalf. In addition, Art Agnos, the Mayor of San Francisco, in whose office I worked one day a week, had assured me that he would join with Foege and Salk to defend against my adversity. He was the chair of the AIDS Committee of the U.S. Conference of Mayors and carried substantial weight. Fortunately, CDC recognized their situation and repulsed the attack from Washington. Mason left me in California and I quietly retired to in February, 1992.

Now I've merged my past experience of vaccines and AIDS to try to develop an HIV vaccine. I have joined Genentech, a biotech company in South San Francisco, where much of the most advanced AIDS vaccine work has taken place. In my spare time I am working with an international group of concerned persons to establish a large fund to ensure that advances in AIDS vaccine development can be made available to the developing countries of the world.

It has been people who have helped me through my life, I don't want to give the impression that such help was always associated with some cataclysmic career decisions or that it always came from big name leaders. In the most disparate and distant lands in which I have worked, I have had the fortune of being helped by people constituted of gold. In Nigeria, it was Patrick Gbarara, in Sudan, Abdel Gadir and Dr. Omer el Haj, in the India Rejinder Signh and Dr. M.I.D. Sharma, and in China, Dr. Xu Zhi-yi. I miss them all and, if I could, would keep them around me no matter what I was doing. It is with them that the credit belongs for such great accomplishments as the eradication of small pox from the world. It is with them that the future of the world rests.

One of the hardest life-lessons for me to learn was that some people are truly bad. Or at least they do bad things. That realization has been more difficult for me to comprehend than almost anything else. After all, in Bar 7 Theater the bad guy ALWAYS lost. In real life many bad guys win. If you are opposite them in the game of life you lose also. Working for a decade on AIDS allowed me a unique view of the bad side of science, medicine and politics. The evil that emerged from self-serving scientist, them-versus-us politicians and homophobic religious leaders was at the same time enlightening and frightening to me. Waiting for the guy in the white horse to arrive can be deadly in the midst of a vicious epidemic like AIDS. Perhaps I should have been educated by my experience with Dean Young at Northwestern, but I wasn't. Hard lessons come hard. Only after years of trying to placate and sidestep obstructionist or negative people, have I learned to join forces with allies and confront the adversity directly. If good is going to be victorious over evil, the evil must be reckoned with directly, actively and swiftly.

Finally, not even the briefest review of critical junctures in my life would be complete without mention of my family. My parents died in the middle of my career I still miss them immensely. I still need to talk to them, to hear their subtle advice, to tell them what I have been doing. But they are gone. My brother, Steve, remains as a vestige of the original family and his support in tough times has been of immense importance.

And then there is my family at home, my wife Karen Starko, a well known doctor and epidemiologist in her own right having gained fame for discovering that aspirin caused Reyes syndrome, and my sons Oliver and Stephen. They are the real substance of my life. With all my work and accomplishment, little will be remembered and all can be replaced. But these boys will be a legacy of which I will always be proud.

In reading over this chapter, I fear that I may have misled the reader of this story by giving the impression that my life and my career have been planned out, well directed and well organized. Nothing if further from the truth. There was no plan. My parents never put high expectations in front of me. In grammar school I wanted to be a garbage man (I like their boots) or a mechanic (I like their tools). I went to Berkeley because my girlfriend went there. I went to Harvard because another girlfriend went there. I went to CDC for two years to avoid participating in the Vietnam war. And it all worked out.

***

From the book The Doctor-Activist: Physicians Fighting for Social Change, published by Plenum Publishing Corporation.

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