No Time to Lose: A Life in Pursuit of Deadly Viruses (17 page)

MEANWHILE, WE KNEW
that there was also AIDS in Nairobi. We had seen cases among the prostitutes we treated at our clinic. But until the HIV antibody test was commercially available, we couldn’t do proper testing on a wide scale; we were receiving batches of prototypes, but we were sending all those tests to the Kenyan blood banks. So we banked sera. Working with Joel Breman and Karl Johnson on Ebola had taught me not just to properly preserve all the blood samples we gathered but also to be very careful to have meticulous administration, so we would know who was behind the sera: gender, age, circumstances. That is the type of bureaucracy that I favor. I now had an incredibly valuable library dating back to the early 1980s.

When the ELISA test for HIV antibodies appeared on the market in 1985, we were astonished that 9 percent of all the patients coming to us in Nairobi with sexually transmitted infections had HIV virus in their blood. (This being a rather specific sample of people, it didn’t necessarily have great bearing on the prevalence in the whole population.) Among prostitutes who came in, the figure was over 60 percent: a stunning figure, at the time unparalleled anywhere in the world. Most of these women came from the Kagera region in Tanzania: this was some of the first evidence that the epidemic radiated out from the Lake Victoria region. What had been a smart survival strategy for these women had become a death strategy when the HIV epidemic emerged.

Using the banked sera, we could actually trace when the epidemic in Nairobi started. In 1980, none of the men we saw with sexually transmitted diseases had the HIV antibody. In 1981 it was already 3 percent of men, and 6 percent of women—a little higher among prostitutes, specifically, but not much: 7.1 percent. You could see it was spreading like bush fire. AIDS was a new thing in Nairobi, and it had hit the ground running. Compelled by these results, we decided to add AIDS research to our project in Nairobi, with a major focus on HIV infection in prostitutes. We set up a clinic in the Pumwani district, which was basically a slum that concentrated a large number of sex workers. We used a couple of rooms in the municipal health office; there were goats and sheep and a permanent market of all kinds of second-hand clothes and shoes just outside. You could buy only a left shoe, or only a right one.

Elizabeth Ngugi, the former head nurse, became a key figure, something between a community leader and a mother for these women who were despised, rejected, and badly treated by everyone, men and women. It was thanks to her that the project later achieved its life-changing work with some of these women, and it was in Pumwani that I perceived the incredibly powerful way that they could organize themselves, despite their lowly status. Even before AIDS, groups of women had banded together to contribute to health care or other emergency needs for their peers, and now Elizabeth helped them to set up more consistent groups for support and care.

I USED TO
drive around Kinshasa myself; negotiating the chaos of the streets was actually kind of fun, and in any case I had no spare funds to pay a driver. But once, driving to the prostitute clinic in Matonge, I was followed by three men from Mobutu’s fearsome secret police, the AND. Then they overtook my car, blocking me; they pulled me out of the car and searched it. When they found the slide projector that I had intended to use for a training session for the nurses, they mistook it for a video camera and accused me of being a Pakistani journalist.

A
Pakistani
journalist? I might have laughed, but with my hands against the car I was too preoccupied with other emotions. I told them I was a scientist, a member of Mobutu’s Order of the Leopard, but they just laughed at me and said they were taking me to AND headquarters—which would mean serious trouble, possibly for days. I pleaded with them to take out my wallet—they could have the cash I was carrying—and check for my Leopard ID. When they found it, they muttered about the photograph, but then the atmosphere switched in the second: they slapped me on the back, and laughed, and wanted to know all about my work in Matonge.

“Why a
Pakistani
journalist?” I asked them, and they said it was my beard, and my tan: I didn’t look
completely
white. The whole episode was surreal, just another weird pothole in a normal day’s work in Zaire.

I HAD BEEN
helping Jonathan Mann set up his program at WHO in Geneva: I helped him identify people who could work in his new Control Program on AIDS, and set up advisory committees with the few scientists working on AIDS in those days. His right hand was Dr. Daniel Tarantola, a French veteran of many public health programs, including smallpox eradication, and unsurpassed for his organizational capacity (and humor). We had met in Nairobi and hit it off immediately. Daniel’s brainchild was the short-term national AIDS plan that Jonathan wanted every country to adopt. The main idea was that by establishing a plan, AIDS would be discussed in the Ministries of Health, a budget would be allocated, money raised from donors, and as many countries as possible would finally start HIV prevention programs (treatment was not yet an option in the 1980s). They would take a clear look at the epidemiological situation and develop a program for “social marketing” of condoms, which meant that rather than go for boring public health–type messages, they would use the techniques of consumer marketing to promote a social good. Additionally, it involved developing distribution networks that meant you didn’t have to go into a pharmacy to buy a condom, but could buy one in small kiosks and at ambulant vendors together with soap and matches and lightbulbs.

With few exceptions, such as Uganda, the majority of African governments still either denied the reality of the epidemic or showed a cynical skepticism, accepting international aid without making much of an effort to fight the virus. In rich countries AIDS was associated with homosexual behavior, prostitution, or intravenous drug use and it was difficult for them to acknowledge these realities in their own countries. When confronted with studies showing very high levels of infection they denounced them as biased samples or said that their country was struggling with far more important health issues, which for most African countries at the time was absolutely true. However they did not see the epidemic that was spreading silently: in most countries outside Central Africa, people had been infected with HIV too recently to be ill or die; it takes on the average eight years after infection before one develops AIDS.

Zaire was, I believe, the first country to adopt a national AIDS plan; Ngali left Projet SIDA to become director of the plan. He began distributing condoms to the women who sold drinks and cigarettes and cola nuts at stands set up outside bars and nightclubs, or those just walking around with trays on their head. They were called the
marchés ambulantes
, “the walking markets.” They made a little profit on their condom sales and it was a much more effective way to reach people. Mobutu’s party had developed a very effective way of reaching people through traditional groups—theater, dance, and other entertainment—and Ngali worked the AIDS message into that process. With Population Services International (PSI) we developed a cool brand of condoms, “Prudence,” “pour l’homme sur de lui-meme” (for the self-assured man), with the slogan “Confiance d’accord, mais prudence d’abord” (Trust is fine, but prudence comes first). It worked. Prudence condoms became very popular in Kinshasa. HIV prevalence in the city in 2010 is hardly higher than 25 years before, and it may be that these early prevention programs had a real impact and saved many lives.

Music was key. Franco Luambo, from the TP-OK—Tout Puissant Orchestre Kinshasa—Jazz Band, was one of the most popular singers in Kinshasa. He wrote a song, “Attention Na Sida,” and people danced to it in every nightclub. “
Use radio, TV, newspapers / To tell the people about AIDS / We have to tell them how to protect themselves / We must all fight AIDS . . . ”
Then he died of AIDS, in 1989, and a copper plaque with his name on it was fixed to the tall stone pyramid, “Le Monument aux Artistes,” on the Place de la Victoire. By the early 1990s almost every name on that pyramid belonged to a young and talented musician, and almost every one of them had died of AIDS. All the plaques have been stolen now, but the bare, stubby pyramid remains: a slightly surreal reminder of yet another terrible loss suffered by Central Africa.

Ngali confided in us the kind of pressure he was under to kick back part of his budget to officials from the Ministry of Health and other cronies of the regime. He was a principled man, and he worried a great deal. It is a high-risk project, to be an honest man in Zaire; a few years later, he died in a mysterious car accident.

When Mann laid out his scheme for every country to issue a short-term plan for fighting AIDS, his idea was to short-circuit the resistance he was encountering from the WHO regional directors by sending consultants to each country who were directly responsible to WHO headquarters. Each consultant would take a look at the current AIDS situation and how it was being dealt with, and specifically epidemiology, clinical management, lab services, blood banks, and condom availability and promotion.

Jonathan asked me a couple of times to join his team at WHO Headquarters, but I was not ready yet to make the leap from fieldwork, research, and seeing patients, to the more distant policy level—as much as I had become convinced that policy was key to stopping this unfolding epidemic. I did, however, go to Ghana for WHO as a consultant, to help set up the Ghanaian AIDS Plan, in a team led by Lev Kodhakievich, a Russian who had worked in smallpox eradication. The Ghanaian government initially was suspicious and we had to wait for a week to receive permission to work, which we received thanks to the intervention of Ghana-born Peter Lamptey, who established the AIDS program of Family Health International, to which I became an adviser. In the meantime we visited some of the old castles along the coast, where dozens or hundreds of slaves were once crammed like produce into the basement, sometimes directly under the chapel or the airy dining room of the dwellings of their English, Dutch, or Danish masters.

Ghana didn’t have a huge AIDS problem, except in one northeastern region. Just like the Tanzanian women in Nairobi, women there traditionally went to the capital or to a neighboring country, Côte d’Ivoire, for two or three years, where they would work in commercial sex and then come home with enough money to start a business.

We visited Kumasi, the seat of the Ashanti King, who once ruled major parts of West Africa, and you could see how poor the people were in 1986 in Ghana: in the market people were buying
half
an onion, because they couldn’t afford a whole one, and no hotel rooms were complete—they either had no windows, no running water, or their restaurant menus were virtual, with most items not available. We ended up combining the whole trip with a training program for lab technicians on how to do HIV antibody tests, because although fewer than 3 percent of prostitutes who had never been out of the country were seropositive, 51 percent of prostitutes who had recently been working in Abidjan, the capital of Côte d’Ivoire, had the virus.

IN JUNE 1986,
the International AIDS Conference took place in Paris, and the whole event was dominated by the standoff between Gallo and Montagnier. America versus France; which man had isolated and identified the HIV virus.

There was no real doubt in my mind that the French were the first to discover the cause of AIDS, even if Gallo had greatly contributed to the development of the HIV antibody test. But this very chauvinistic conflict discredited the whole field for several years: people thought AIDS research was not really about science, but loaded with ego and personal ambition. It was not until 1987 that the two teams came to a compromise, and even then it had to be negotiated by officials close to presidents Reagan and Mitterrand: political figures who belonged nowhere in a dispute about science. In 2008 Françoise Barré-Sinoussi and Luc Montagnier received the Nobel Prize in Physiology or Medicine for the discovery of HIV—Bob Gallo should have shared the honor.

Nzila and Ngali flew with Mann to Paris, but what they really wanted to see was Zaire’s old colonial overlord, tiny Belgium. So I invited them to stay at my place in Antwerp. It was magical to see Belgium through their eyes; and we staged a truly memorable evening at a wonderful café—The Sweet Name of Jesus—run by a Zairean near the cathedral.

I WAS INCREASINGLY
becoming a manager, and I enjoyed it. It was not only about budgets and administration, writing up reports so we could get funding, but also to bring on ideas, lead people, translate science into policy, and negotiate collaborative efforts. In Nairobi I helped someone structure a hypothesis, laid out a research project, and then I met them again three or six months later to check how it was going. That may have been the most efficient way to work, but it was less and less hands-on. In Antwerp the lab had grown from 20 to well over 100 people, and I became part of the senior management team at the institute. I was putting together a group on AIDS and STD so there would be much more interaction among clinicians, epidemiologists, and the key people in the microbiology lab. I was also still running the STD clinic, which had morphed from a part-time office beside the rodent housing in the Institute of Tropical Medicine to a much bigger, full-time affair, with three physicians and a nurse. We also moved to a higher floor, with access through the front entrance rather than a back door, and signage that announced where we were and what we did—sexually transmitted diseases—in letters big enough so you could read them.

I helped start the Flemish Center for AIDS prevention and various self-help and support groups for people with HIV. I was involved in numerous consultancies involving clinical, epidemiological and lab work, not just on AIDS but also on tuberculosis, reproductive tract infections in women, and low birth weight. I was doing studies with new antibiotics as well as studies of the new vaccines for hepatitis A and hepatitis B; of sexual behavior; of programs to
change
sexual behavior. I also had master’s and PhD students: the institute already had a master’s program in Public Health that focused on the organization of health services, but in the mid-1980s I devised a second master’s program called Disease Control that taught techniques of outbreak investigation, epidemiology, and program management.