As a result, microbes found the environment of the body of a heroin user far less hostile than that presented by healthy Homo sapiens.
The drug user’s basic lifestyle also offered unique opportunities for microbial passage from human to human. Most of the addicts shared one another’s injecting equipment. When an addict injected heroin, or any other drug, some of his or her blood might be pulled into the syringe when the equipment was drawn from the vein and the plunger reset. If the injector was infected with, for example, Staphylococcus bacteria, the microbes would be withdrawn into the syringe as well.
All the staph bacteria then required was the genetically acquired ability to withstand whatever environment the syringe rested in when not in use. That might mean a few hours hidden outdoors on a subzero Newark night—conditions too tough for most organisms. On a hot, humid August night lying in a watery “cleaning dish,†however, the microbes found a highly favorable ecology. The least challenging situation was the shooting gallery, where one person immediately passed his contaminated syringe to another.
Needles also helped microbes bypass the multitudinous barriers humans had in their skin, nostrils, and lungs, and go directly to the bloodstream. Even organisms with weak “delivery systems,†as Bernard Fields called them, could thrive in the heroin ecology.
Finally, many heroin addicts lived in acute squalor, ate poorly, worked as prostitutes for drug money, and used a broad range of additional intoxicants, each of which uniquely altered the Homo sapiens ecology in ways the microbes might find advantageous.
In 1929 malaria caused by Plasmodium falciparum broke out in downtown Cairo, Egypt, due to needle sharing by local drug addicts. By the late 1930s a similar heroin-driven malaria epidemic was spreading through New York City, reaching such high levels among drug addicts that it was considered endemic. Six percent of New York City jail inmates at the time had signs of malaria infection—all of them injecting drug users. One hundred and thirty-six New Yorkers died of malaria during the period—none of them had been bitten by mosquitoes.50 The epidemic stopped when the heroin retailers, concerned about losing their customers, started adding quinine to their cut heroin.
Such dealer “benevolence†was more than offset, however, by routine contamination of heroin products, the result of poor chemical processing or the use of microbe-supporting substances to dilute the drug.51
Numerous types of microbes managed to successfully exploit the heroin ecology. For example, between 1969 and 1974 physicians at San Francisco General Hospital noticed an increase in endocarditis—life—threatening infections of the heart. In seventeen of the nineteen cases, the individuals were drug addicts. And the organism responsible was the Serratia marcescens bacterium. Despite vigorous antibiotic treatment, 68 percent died. Searches of hospital records as far back as 1963 revealed no prior case of S. marcescens-induced endocarditis in San Francisco, proving it was a newly emergent microbial threat.52
Endocarditis was increasingly a problem worldwide in heroin-plagued cities. Bacteria and fungi entered the bloodstream on dirty needles and colonized the heart valves and other components of the vital organs. In most cases, antibiotic therapy proved fruitless. Prior to 1976 New York City experienced such endocarditis outbreaks among drug addicts, caused by Staphylococcus, Enterococcus, Candida, and Pseudomonas. Chicago, Helsinki, Seattle, Washington, D.C., San Francisco, and Detroit also witnessed outbreaks driven by those organisms, as well as S. marcescens.
Bacterial and fungal infections of all sorts became so prevalent among drug injectors by the mid-1970s that many began to prophylactically medicate themselves with antibiotics. An antibiotics black market, operating in tandem with the heroin trade, developed in many cities in Europe, Asia, and the United States, servicing heroin users with a variety of antimicrobials. But their use of these medicinal drugs was counterproductive, because the black market’s supplies were sporadic and rarely offered consistent varieties of antibiotics.
Drug addicts, therefore, became ideal breeding grounds for antibiotic-resistant organisms. From a public health perspective the problem was restricted to the drug users themselves, who in increasing numbers throughout the 1970s suffered and died from antibiotic-resistant bacteria.
But in 1982 injecting drug users in Boston and Detroit were taking black-market methicillin whenever they could to prevent bacterial infections. Strains of the bacteria emerged that possessed two different types of transferable methicillin-resistance genes.53 When the infected heroin users were hospitalized, a new resistant Staphylococcus, dubbed MRSA, spread to the medical staff and other patients.
Tuberculosis also lurked in the heroin ecology. Health authorities in most industrialized countries thought the TB scourge of the pre-antibiotic era was licked, and in absolute numbers of active cases in humans it certainly had declined dramatically by the 1970s. But in New York City hospitals in 1979, Dr. Lee Reichman spotted a trend that had gone unnoticed: TB cases in the city’s poor, black neighborhood of Harlem were appearing at a rate of 406.6 per 100,000 residents who eschewed injectable drugs. But among the addicted residents of Harlem an astonishing 3,740 per 100,000 had active tuberculosis.54
It seemed reasonable to hypothesize as early as 1979 that TB was spreading among members of the heroin-addicted populations of the wealthy nations, even as the disease was disappearing from their general populations. It might have warranted concern that decades of TB control efforts might be defeated if a subpopulation of actively infected individuals was left alone.
Indeed, Reichman had great difficulty finding a medical journal willing to publish his 1979 findings, and the paper was rejected several times, not because of any inherent flaws in the study, but because the journals simply didn’t consider a high level of active TB among junkies terribly important.
Reichman absolutely believed in 1979 that injecting drug users were passing TB infections to one another. Unfortunately, virtually all societies on the planet held injecting drug users in contempt, viewing them as dangerous criminals, pathetically weak individuals, filthy denizens of ghettos, perilously insane characters, or satanically inspired deviants. Microbial threats to such individuals were generally ignored. Nearly every legal system defined some or all drug-related activities as criminal offenses.
Injecting drug abusers were outcasts, at the bottom of the social totem poles of nearly every culture on earth.
Furthermore, physicians generally detested working with addicted patients because the individuals rarely told the truth about activities that might affect their health, often failed to follow doctors’ orders, sold their prescription drugs on the streets, and, if given the opportunity, stole needles and drugs from the hospitals and clinics they visited. Physicians who chose to specialize in treating and researching the unique health problems of drug abusers often suffered denigration from their colleagues, and wealthy private hospitals wanted nothing to do with either the drug-using patients or the physicians who cared for them.55
As a result, few professionals in the world in 1980 were in a position to notice what was going on in the heroin ecology.
One way drug users legally obtained money with which to buy narcotics was by selling their blood to hospitals and blood banks—a practice that would be outlawed in most industrialized countries by the mid-1980s but would continue in much of the developing world well into the 1990s. Most blood banks worldwide in 1980 didn’t test their products for microbial contamination.
Toward the end of the 1970s a new set of players appeared on the international narcotics scene; South American cocaine cartels surfaced that converted the coca leaves of Bolivia, Colombia, and Peru into a potent white powder. Designed to be inhaled rather than injected, cocaine appealed to a different social class. It seemed “clean,†its high produced a surge of energy rather than opiated enervation. And it was very expensive.
By 1980 cocaine had supplanted vintage wine in some cities
as the drug of choice for the upwardly mobile. Its popularity was so great that icons such as pop stars, society matrons, literary celebrities, and professional athletes were fairly candid about their using it. Stories of pop heroes running quickly through $20,000 to $100,000 to support a cocaine addiction filled the gossip columns.
Few microbes were able to exploit the powder cocaine ecology effectively. The powder was dry and acidic—an environment hostile to most organisms. And few addicts could afford the kinds of long-term habits seen in heroin users that allowed for the slow growth and mutation of microbes over several generations of bacterial, fungal, or viral time. But some people turned to cocaine injections, allowing the microbes to exploit a new ecology that offered most of the benefits of the heroin environment.
In 1980 Don Francis found himself in the midst of an outbreak of a new strain of hepatitis B, spread among injecting cocaine users in New Bern, North Carolina. It seemed to have begun among the teenage sons and daughters of the city’s upper-crust families, who had started shooting cocaine as an adolescent fad. Soon their poorer peers were following suit, having discovered that the expensive drug went a lot further when injected, rather than snorted.
When Francis got called to New Bern to head up a CDC investigation, ten of the teenagers had died of fulminant hepatitis B infections of their livers, and many more were sick. The virus was spread, of course, through shared needles. What alarmed Francis was how rapidly these kids got sick and died. These otherwise healthy adolescents were “dropping like flies,†Francis told colleagues at the CDC. He suspected that it was what he called “a two-hit phenomenonâ€; some other bug was in the kids—possibly also passed by the needles—that acted in concert with the hepatitis virus to produce a disease more lethal than either could create on its own.
Francis injected hepatitis extracted from the blood of the infected New Bern teens into chimpanzees, but no disease occurred in the animals. For weeks he tried to make other test animals sick, with no result. In the end Francis was forced to give up. The New Bern teenagers stopped dying as soon as they ceased injecting cocaine, and there was no evidence that the mysterious microbes had found their way beyond the tight-knit cocaine ecology of the North Carolina city.
Not knowing what lurked out there, waiting for an ideal ecological opportunity to pounce, galled Francis no end.
Even as he closed the books on the New Bern case, another microbe was exploiting to its advantage the unique ecologies of cities on three continents.
11
Hatari: Vinidogodogo (Danger: A Very Little Thing)
THE ORIGINS OF AIDS
Everybody knows that pestilences have a way of recurring in the world; yet somehow we find it hard to believe in ones that crash down on our heads from a blue sky.
—Albert Camus, The Plague, 1948
And that was the day that we knew, oh! In the world there is a new disease called AIDS. I thought surely this will be the greatest war we have ever fought. Surely many will die. And surely we will be frustrated, unable to help. But I also thought the Americans will find a treatment soon. This will not be forever.
—Dr. Jayo Kidenya, Bukoba., Tanzania, 1985
PRELUDE
Greggory Howard stood across the street from the ugly brick building and watched as junkies went in and reformed addicts came out.
Howard had tried methadone before—who hadn’t? It was easy enough to buy on the streets during tough times when the police were busting local dealers or the supply from wherever hadn’t made its way to Newark.
But today he was going to walk in that door and sign up for the methadone maintenance program. Last night’s hit was the last.
He’d said that before, of course, but this time Howard was fed up with beatings, arrests, and looking up at the stars from a filthy alley. He was sick and tired of being sick. He wanted to “feel good about Greggory again.â€
Inside the Essex Substance Abuse Center, fluorescent light and iron bars greeted him, and Howard almost fled. But then he spotted the Dixie Cups. Methadone didn’t come in Dixie Cups on the streets, but he had heard about this. It was almost impossible to steal a paper cup of neon-pink liquid and sell it on the streets. You had to drink it down right here, under glaring lights with the authorities watching.
Howard’s body was trembling with the anticipation of that pink substitute high.
He stepped up to the iron-barred window and announced that he would like to quit his heroin habit.
Three thousand miles away in San Francisco, Bobbi Campbell stood adjusting his nun’s habit. Campbell and friends from Fruit Punch, a gay men’s radio talk show, had formed the Sisters of Perpetual Indulgence. The dozen or so Sisters would don their habits and carouse, given any good public forum. Handsome, black-haired Andy would shed his usual reserve and twirl a rosary while loudly declaring the beauty of gay love. Tall, thin Charlie would dance in circles singing “I Enjoy Being a Girl.†Fred, with scraggly beard and wire-rims poking out of his face-framing habit, created endless clever chants, plays on Catholic homilies.
Still in graduate school at U.C. Berkeley, Bobbi, already a nurse, was the baby-faced member of the group. He wanted being gay in 1981 to be playful and joyous. Never mind those serious-politico-homosexual-rights-types who were embarrassed by flamboyant queens. Nurse Campbell, “Soeur en Drag,†called himself Sister Florence Nightmare.
Everything about the full-time party that was San Francisco seemed fabulous to Campbell. True, everybody he knew seemed to have more than their share of one bizarre illness after another, but if it was all so joyous, who cared?
In Manhattan, Michael Callen was making music: disco dance tunes, gay love ballads, anthems. He, too, was thoroughly enjoying these days of liberation.
“Promiscuous†was a special word for twenty-six-year-old Callen. By the logic of the day, if it was liberating to openly declare one’s right to have sex with a man, “it seemed to follow that more sex was more liberating,†Callen said.
Like many, if not most, of the members of Manhattan’s exploding gay community, Callen had left small-town America to escape the claustrophobia of his native Ohio. Raised a strict Methodist, the slender, nonathletic youth sang in the church choir and tried to belong. But he clandestinely devoured literature on homosexuality, most of it written by straight male psychologists. And he reached two conclusions: if homosexuality was a sickness, then he had it; and the best place to be “sick†was New York.
At age seventeen he had arrived in Manhattan, and soon discovered the gay bathhouses and sex palaces. With the exception of a several-months-long affair with a gay police officer, Callen’s life from 1972 to 1981 was an endless string of sexual trysts and anonymous encounters—well over a hundred per year.
Thousands of miles and as many cultural leaps away, along the shores of Lake Victoria, Noticia finally had a dignified job as secretary to a Bukoba businessman. True, his tiny business wasn’t much and her pay, even by Tanzanian standards, was rather modest, but the job was honest and covered her bills.
After a year in Mombasa and Nairobi working as a prostitute, secretarial work wasn’t at all bad. She had left her village of Nganga in late 1979 when it became obvious that her family would never recover from the shame of her rape by occupying Ugandan soldiers. Now, no man would marry her.
Noticia could not have risen above outcast status unless she left Nganga. So she had followed the example of many other Mhaya women of Kagera province and made the long, difficult journey across Lake Victoria by steamship, then overland hundreds of miles to the turquoise Indian Ocean.
In the Kenyan seaside city of Mombasa, Noticia serviced the sexual needs of three or four men a day for very little money. Later, in the Sofia Town slums of Nairobi, she fared a bit better, making more money than she had in Mombasa. She saved enough money to return to Bukoba and start a new
, independent life.
Noticia was a shy young woman, and her voice was as soft as silk. Her high cheekbones and dignified carriage attracted the men of Bukoba like bees to honey. They would beg her to go to the disco to dance, drink Safari beer, and listen to flattery.
Noticia felt hopeful about her future.
A thousand miles to the south, Dr. Subhash Hira and his staff at Lusaka University Teaching Hospital went over their medical records in a routine meeting. It was the usual daunting list of sexually transmitted diseases: syphilis, gonorrhea, chlamydia, chancroid, and the like. One of Hira’s assistants pointed out that there was a woman on the ward suffering from an unusual case of herpes zoster: tough, perhaps a special kind of herpes.
Hira suggested that everybody keep an eye out for such things, and the meeting moved on.
I
In the fall of 1980, Dr. Michael Gottlieb was in his office at the University of California at Los Angeles Medical Center when a colleague asked if he would look at a particularly unusual respiratory case. A short while later, a frail man of thirty-three waited in one of the outpatient clinic’s private rooms.
Gottlieb was startled by the obvious severity of the man’s ailment. He appraised the patient carefully: pale, almost ashen; extremely thin, bordering on classic anorexia; a mouth full of the white “cottage cheese†indicative of a fungal infection; coughing uncontrollably, and evincing severe lung pain. It looked like pneumonia, but it was exceedingly rare that Caucasians of this age developed such brutal illness in Los Angeles.
The Coming Plague Page 43