University of California Berkeley Regional Oral History Office University of California The Bancroft Library Berkeley, California The San Francisco AIDS Oral History Series THE AIDS EPIDEMIC IN SAN FRANCISCO: THE MEDICAL RESPONSE 1981-1984 Volume VII Warren Winkelstein, Jr., M.D., M.P.H. AIDS EPIDEMIOLOGY AT THE SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF CALIFORNIA, BERKELEY With an Introduction by James Chin, M.D., M.P.H. Interviews Conducted by Sally Smith. Hughes, Ph.D. in 1994 and 1995 Copyright 1999 by The Regents of the University of California Since 1954 the Regional Oral History Office has been interviewing leading participants in or well-placed witnesses to major events in the development of Northern California, the West, and the Nation. 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It is recommended that this oral history be cited as follows: Warren Winkelstein, "AIDS Epidemiology at the School of Public Health, University of California, Berkeley" an oral history conducted in 1994 by Sally Smith Hughes in The AIDS Epidemic in San Francisco: The Medical Response, 1981-1984, Volume VII, Regional Oral History Office, The Bancroft Library, University of California, Berkeley, 1999. Copy no. Warren Winkelstein, Jr., M.D., M.P.H. , 1983. Cataloging Information THE AIDS EPIDEMIC IN SAN FRANCISCO: THE MEDICAL RESPONSE, 1981-1984, Volume VII, 1999, xxi, 257 pp. Warren Winkelstein Jr., M.D. , M.P.H. (b. 1922), epidemiologist and professor, School of Public Health, UC Berkeley: childhood, education, public health positions in New York state, Salk polio vaccine field trials, and public health service in North Vietnam; history of tension over medical education at UCSF and UC Berkeley; conflicts with National Institute of Allergy and Infectious Disease [NIAID] over direction, contents, and funding of San Francisco Men's Health Study (part of NIAID Multicenter AIDS Cohort Study [MACS]); epidemiological design, collaborations, accomplishments, and publications of San Francisco Men's Health Study; other epidemiological research on AIDS in San Francisco; AIDS vaccine field trial issues, 1994 NIH committee decision against AIDS vaccine field trials; Peter Duesberg and HIV, Winkelstein/Duesberg controversy over HIV. Introduction by James Chin, M.D., M.P.H., Clinical Professor of Epidemiology, School of Public Health, University of California, Berkeley. Interviewed 1994 by Sally Smith Hughes, Ph.D, for the San Francisco AIDS Oral History Series. The Regional Oral History Office, The Bancroft Library, University of California, Berkeley. ACKNOWLEDGMENTS The Regional Oral History Office, on behalf of future researchers, wishes to thank the following individuals and organizations whose contributions made possible this oral history of Warren Winkelstein. Sally Smith Hughes, in memory of John Liebeskind National Institutes of Health Historical Office University of California, San Francisco, AIDS Clinical Research Center Warren Winkelstein TABLE OF CONTENTS--Warren Winkelstein PREFACE by David A. Lennette and Evelyne T. Lennette i SERIES INTRODUCTION by James Chin iii SERIES HISTORY by Sally Smith Hughes vi INTERVIEW HISTORY by Sally Smith Hughes xviii BIOGRAPHICAL INFORMATION xxi I UPBRINGING AND EDUCATION 1 Family Background 1 The Putney School 2 Undergraduate, University of North Carolina, 1939-1943 3 Marriage, First Child, and a Surveyor's Job 4 Medical School and Internship 7 Syracuse University Medical School, 1943-1947 7 Internship, 1947-1948, and Second Marriage 7 II CAREER IN PUBLIC HEALTH 8 New York State Public Health Department 8 Fellowship, 1948-1950 8 School of Public Health, Columbia, 1949-1950 10 Meeting Dr. Mort Levin 10 District Health Officer, Erie County Health Department, Buffalo, New York, 1950-1951 11 Public Health Division, Special Technical and Economic Mission, North Vietnam, 1950-1951 12 Director, Division of Communicable Disease Control, Erie County Health Department, Buffalo, 1953-1956 13 The Polio Vaccine Field Trial 13 Fellowship, Roswell Park Memorial Institute, Buffalo, 1956- 1957 14 State University of New York at Buffalo 14 Establishing an Epidemiology Program at the Chronic Disease Research Institute 14 First Deputy Commissioner, Erie County Health Department, Buffalo, 1959-1962 15 III PROFESSOR OF EPIDEMIOLOGY, SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF CALIFORNIA, BERKELEY, 1968-PRESENT 16 Appointment 16 Acting Dean and Dean, 1971-1981 17 Introduction to the AIDS Epidemic, 1983 18 Girish Vyas 18 A Request for Proposals from the National Institute of Allergy and Infectious Disease, 1983 18 Tensions Within the UCSF AIDS Group 19 Decision to Initiate a Proposal to NIAID 20 Continuing Tension with UCSF over Medical Education at Berkeley 22 Efforts to Establish a Medical School at Berkeley 22 The Health and Medical Science Program at Berkeley 23 IV THE SAN FRANCISCO MEN'S HEALTH STUDY 25 More on Tensions Within the UCSF AIDS Group 25 The NIH Request for Proposals 26 Government Contracts vs. Grants 26 Crisis #2: Freedom to Publish 27 Proposing the Study 28 Design 28 Institutions Involved 29 Other AIDS Epidemiologists 31 The Contract Review System 32 The Budget 32 A Multicenter Study 33 Opposition 33 The Questionnaires 35 Possible Reasons for Choosing the Five Participating Groups 35 Data Analysis 36 Including a Heterosexual Population 38 Proposed Etiology 40 Taking a Conciliatory Approach with NIAID 40 More on Crisis #2: Freedom to Publish 41 Sensitivity to Gay Community Concerns 42 The Stop Work Order, April 20, 1984 42 Funding Problems 42 Delays in Launching the Field Study 44 Consulting the Research Team 45 The Four Other Research Centers and Population Recruitment Policies 45 More on Crisis #2: Freedom to Publish 47 A Paper on AIDS Prevalence, 1984 47 Criticism of Publication by the Other Centers 48 Changes in the Contract's Publication Policy 48 The Contract Modification Regarding Virology 49 Anthony S. Fauci, M.D. Takes Action: The Studies Are Separated 50 The Contract Renewal, 1987 53 Request for Neuropsychiatric Examinations 54 Other Concerns 56 Enemies 57 Compromise 57 A Site Visit 58 Crisis 14 58 Improved Relations with NIAID 58 Proposing a Survey of Young Homosexual Men 59 Delayed Approval 60 Phasing Down the Men's Health Study 61 Various AIDS Epidemiological Studies 63 The San Francisco City Clinic Study 63 Andrew Moss and the Merger 63 Accomplishments of the Men's Health Study 64 AIDS Epidemiology 66 Recognizing Immune Deficiency in AIDS 67 Recognizing AIDS as an Infectious Disease 67 Designing the Study 68 Using a Population-based Sample 69 Using San Francisco Census Tracts 69 Collaborating Institutions 71 The UCB Survey Research Center 71 The California State Department of Health and Human Services 73 Jay Levy at the UCSF Cancer Research Institute 74 Irwin Memorial Blood Bank 74 The UCSF AIDS Specimen Bank 74 Biohazard Precautions 77 The California Public Health Foundation 77 The UCB School of Public Health 77 Resolving Tensions and Turf Battles 78 The Questionnaire 80 Poliomyelitis: The Wrong Model 82 Specimen and Data Collection 83 AIDS Epidemiology in San Francisco 85 Early Studies 85 The Northern California AIDS Epidemiology Consortium 85 Andrew Moss Joins the Study 86 The Three San Francisco Cohorts 86 AIDS Vaccine Studies 86 Publications Stemming from the San Francisco Men's Health Study 87 The Two Papers in JAMA 87 The Paper on Declining Rates of HIV Transmission 89 The 1987 Paper on Infectivity 89 The Gay Community 90 The Promiscuity Issue 90 The Participant Advisory Committee 91 Organizing Conferences for the Media 92 Handling Community Inquiries 92 Targeted Prevention 93 Letters to the Editor 94 Pros and Cons 94 The Effect of the New AIDS Definition 96 Papers Stemming From the San Francisco Men's Health Study 98 The Flap Over Infected Seronegative People 98 Epidemiological Contributions to the Epidemic 100 Decline in Epidemiological Findings 101 Focus on the Gay Population 103 Epidemic Modeling 104 Stigma 105 Multidisciplinary Collaborations 106 More on the