The Coming Plague (60 page)

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Authors: Laurie Garrett

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He looked at his ghastly ledgers and said, “There is no future. It is the end of the world. Without young people how can there be a world?”
 
Bukoba's plight was little known in the rest of the world. Long after Forthal returned to the CDC, confirming the seemingly odd information that a major rural epidemic was unfolding in Central and East Africa, a preconceived dogma continued to dominate the world's perceptions of AIDS: that it was a disease primarily seen among gay men and injecting drug users, that all the African cases were emerging in major cities, and that the heterosexuality of AIDS in Africa was due to “special cultural factors,” such as ritual circumcisions and clitoridectomies.
Some of the misperceptions were the result of the way news of Africa's epidemic unfolded. And some were due to less excusable factors, such as racism. Before the discovery of HIV and the development of blood test kits, several cases of AIDS among Africans were symptomatically diagnosed in Europe, particularly in Belgium and France.
112
As of November 1983, 22 percent of all European AIDS cases were among people originally from sub-Saharan Africa.
 
Long before the antibody test was commercially available, the Pasteur group isolated LAV from the blood of a married Zairian man and woman living in Paris, and concluded that “there is strong evidence that AIDS is endemic in central and equatorial Africa.”
113
But it was the Belgians, particularly Peter Piot and Nathan Clumeck, who most aggressively pursued the AIDS/Africa link. Both men were seeing Zairois and Rwandan AIDS patients in Belgium, and they earnestly believed that major epidemics were underway in the two countries.
114
Clumeck and his Belgian colleagues conceived of a quick way to learn what might be transpiring in Rwanda. In October 1983 they mailed questionnaires to all the doctors working in the Centre Hospitalier de Kigali, the capital's main medical facility, describing the symptoms of AIDS and asking if such patients had been seen. Responses in hand, they went to Kigali in January 1984 and ran T-cell tests on twenty-six patients whose symptoms most clearly fit the CDC definition of AIDS: any combination of
Pneumocystis
pneumonia, Kaposi's sarcoma, wasting syndrome, dementia, chronic high fevers and secondary disease due to typically nonvirulent agents, such as cryptococcus and cytomegalovirus.
After four weeks in Kigali, Clumeck and his colleagues returned to Brussels, convinced that “AIDS could be endemic in urban areas of central Africa.”
115
In early 1983, Peter Piot attended a meeting on sexually transmitted disease in Seattle and spotted Jim Curran in the audience. Knowing Curran was in charge of the U.S. AIDS effort, Piot dashed over and asked him to step outside for a moment.
“Look, we have Zaire cases of AIDS in Brussels,” Piot told Curran. “And I think they all got the disease in Zaire. I'm looking for money. Nobody in Belgium wants to support such a study.”
Piot proposed to return to Zaire and study the nation's possible AIDS problem. Curran was noncommittal, explaining that his office was overwhelmed by efforts to prove to American skeptics that the new infectious disease even existed.
So Piot turned to Dr. Richard Krause, then director of the National Institute of Allergy and Infectious Diseases in Bethesda, and made the same plea. Krause offered a small scientific grant, provided the Belgian took the NIAID's Dr. Thomas Quinn along to Zaire. Filled with a sense of urgency and already having spent over a year searching for research funds, Piot readily agreed.
Krause strongly believed that GRID was an example of the kinds of newly emerging disease problems which he had previously warned the U.S. Congress about, and he made it a point to fly to Antwerp to meet with Piot in September 1983, shortly before Piot and Quinn were to depart for Zaire.
Also at the September meeting in Antwerp were the CDC's head of special pathogens investigations, Joe McCormick, and CDC laboratory expert Sheila Mitchell. Piot was not pleased. After having been ignored by Curran months earlier, he found the agency's apparently newfound interest in African AIDS distasteful and felt McCormick was trying to “horn in” on his study.
McCormick professed to be surprised by Piot's antipathy, and explained that he had been planning a Zaire investigation for months. His presence at the Antwerp meeting was at the bidding of Krause, who realized that Quinn, who had strong experience with AIDS in the United States but had never been to Africa, couldn't possibly handle such an investigation on his own; and Piot, though a veteran of the 1976 Ebola investigation, had no formal connections with the Mobutu government.
Only McCormick had been invited by the government of Zaire—a formal request for an AIDS investigation having been arranged by McCormick's old friend Kalisa Ruti, chief counselor to the Minister of Health. Furthermore, McCormick's African research experiences were extensive, and since his 1979 brush with Ebola in Sudan, Joe had continued investigating hemorrhagic diseases on the continent and in the laboratory. He had, for example, established that people living in the Haut-Ogooué region of Gabon, a rain forest area, were routinely exposed to Ebola, and 6 percent of
that population had antibodies to the virus.
116
He and Karl Johnson had completed RNA maps of the Zaire and Sudan 1976 strains of Ebola, proving that McCormick's initial hunches were correct: the microbes represented two different viruses that, in an apparently amazing coincidence, appeared simultaneously in two locales.
117
On their flight to Kinshasa the American and European scientists argued over who would be in charge of the Zaire investigation. Piot felt that the entire mission had begun in his Antwerp laboratory, and insisted that the effort should therefore be under his leadership. And he noted that Quinn was similarly less than pleased about McCormick's presence. In years to come such tensions between non-Zairian scientists conducting research in that African country would recur with nearly every investigative effort, contributing to difficulties in understanding the depth and nature of the Central African epidemic.
When the scientists reached Kinshasa, they found that the Ministry of Health and physicians from the University of Kinshasa and Mama Yemo Hospital were quite keen to learn whether some of the strange ailments they were seeing in their patient population were due to AIDS. The team, officially headed by Piot, set to work immediately, identifying possible AIDS cases in the hospital, confirming their infections in the laboratory, and determining how the disease was spreading in Kinshasa. The most difficult task—counting T cells one by one on microscope slides—fell to Sheila Mitchell, whose ability to set up a makeshift lab and excel under extremely difficult conditions drew praise from all the Zairian, Belgian, and American men involved in the investigation.
Key among the Zairian physicians was Dr. Kapita Bila Minlangu, who had already recognized the country's AIDS problem. During the first few days of their investigation, Quinn, McCormick, and Piot identified possible AIDS cases on the Mama Yemo wards, most of which had already been pinpointed by Kapita. In addition to the patients present on the wards, Kapita had for several months been saving medical information on odd cases that came through the facility.
Two things were immediately obvious: AIDS was claiming many of the patients in Mama Yemo, Ngaliema, and Kinoise hospitals; and women and men were equally likely to have the disease. Both findings stunned the foreign scientists, whose view of the disease had been shaped by the American and European AIDS model.
Even though the cause of the disease and appropriate blood test kits weren't yet available, Mitchell had little difficulty confirming most of the suspected AIDS cases because many of the patients had
no
T-helper cells.
A total of thirty-eight AIDS cases were identified and confirmed based on T-helper cell counts; 53 percent were men, 47 percent women. An astonishing 26 percent of the patients died during the three-week period of the study, and the foreign scientists observed the same eerie phenomenon Forthal would witness in Bukoba: patients grew sicker almost by the hour,
and died before their eyes. The average patient had been symptomatic for only ten months, and all of them had lost more than 10 percent of their total body weight during that brief time.
Comparing their histories with those of controls (patients hospitalized for ailments that clearly could not be AIDS), McCormick found the AIDS patients were more likely to have traveled outside the Kinshasa area, to be either divorced or unmarried, and to have had more than one sex partner during the previous year—the twelve-month median among AIDS cases was seven sex partners.
They found no evidence that any of the cases involved intravenous drug use or homosexuality.
But they did find heterosexual clusters, linked in much the same way as Bill Darrow's Los Angeles gays. They even established that some of the people in Mama Yemo Hospital had had sex with individuals who were on the list of Belgian AIDS cases, demonstrating that the Africa/Europe sexual net could be as complex and far-flung as the gay American one detected by Darrow. Some of the Zairian females were prostitutes; others were the monogamous wives of men who had sex with prostitutes.
When the foreign scientists left Zaire they had no doubt whatsoever that they had witnessed a heterosexual epidemic, and Piot and McCormick, both of whom had studied sexually transmitted diseases in Africa, were deeply concerned. They knew that syphilis, gonorrhea, chancroid,
Chlamydia,
and
Candida
were rampant in most non-Arab African countries, even though none of those microbes was known to exist on the continent prior to Euro-Arab colonialism and the slave trade eras. The two scientists feared that AIDS might follow that pattern of rapid emergence, quickly overrunning the continent.
The Zairian/European/American group wrote up their study and submitted the paper to the
New England Journal of Medicine.
It was rejected because the peer review panel could not believe the disease was heterosexual and insisted that the team had overlooked some other mode of transmission or an unusual African custom that might be spreading the disease. They received similar rejections from a dozen other medical and scientific journals. The Zaire results went unpublished for nearly a year—a year during which Kidenya's group struggled to understand what was killing people in Bukoba, and a year in which AIDS surfaced, unrecognized, all over East, Central, and Southern Africa. Finally, after much revision, the study appeared in the British journal
The Lancet
in July 1984.
118
Knowing that the existence of AIDS in neighboring Zaire had been proven in October 1983 would certainly have been helpful to Dr. Subhash Hira, whose STD clinic in Lusaka was then filled with mysterious ailments. He had counted a steady increase in particularly aggressive herpes zoster cases since the first had been observed nearly two years earlier.
By late 1983, Hira was seeing patients who were dying of bizarre pneumonias, tuberculosis, and herpes. It rang a bell, and Hira leafed through
French and American AIDS reports in the university library. Though the symptoms he'd seen mirrored those described in San Francisco, New York, and Paris, Hira knew that nobody in Zambia injected narcotics and homosexuality was so rare as to be considered nonexistent among the Bemba, Ndebele, and thirty-five other ethnic groups of the country.
Still, Hira pursued the hypothesis that AIDS was in Zambia. He had his staff tally the numbers of herpes zoster cases seen in the STD clinic since 1980, and the results prompted him to speak to Zambian Minister of Health Dr. Evaristo Njelesani.
What Hira told Njelesani in the Zambian spring of 1983 was that between 1980 and 1982 herpes zoster cases in Lusaka had increased tenfold.
“This all looks like AIDS,” Hira told Njelesani, who was both impressed and concerned.
“How can we be sure?” the minister asked. Hira suggested that the Americans might have a way to test his patients, and Njelesani ordered Hira to find the proper groups in the United States with which to collaborate.
But it would be nearly a year before Hira had answers. Only toward the end of 1984 did researchers at the U.S. Army's Walter Reed Hospital in Washington, D.C., complete an HTLV-III search on blood samples from twenty suspected Lusaka AIDS cases: the virus was found in eighteen.
As soon as Hira got the results in the post, he rushed to Njelesani's office. Minister Njelesani studied the Walter Reed paper, refolded it, placed it in his suit pocket, and ordered Hira to immediately set up a national AIDS effort, coordinating all activities directly with his office. Njelesani imposed one strict rule from the outset: tell the press nothing. The Health Minister feared that Zambian AIDS would be exaggerated, affecting tourism and the national economy. And he was upset by rampant speculation in American and European medical journals (though not yet commonly seen in the popular press) that suggested that Africa was the origin of the AIDS virus.
“We have brought to Africa many viruses that were serious for them, and now we get back from them some retroviruses,” Luc Montagnier had recently told a visiting journalist in Paris. “It's nothing wrong, just a fact. Also the origin of man is Africa, so it is not surprising to find old viruses in this part of the world. Countries should not hide from it. They cannot escape it. These are facts.”

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