The Coming Plague

The Coming Plague Page 53

by Laurie Garrett

  Still, Bukoba’s young men claimed that AIDS was spread by women.

  “People are aware of the girls. Afraid of them,” twenty-eight-year-old Henry shouted over music in the Bukoba disco. A bachelor, Henry declared that he had “no intention of getting married. I am looking for a girl, but I can’t choose which girl has AIDS or doesn’t. I am very afraid, because it is death, you know. No medicine. Perhaps I will wait to marry, wait until there is a cure.”

  And the women, most of whom now boycotted the disco, said with equal certitude that the Juliana disease carriers were all men.

  “I know my boyfriend is seeing other women when he travels to this place or that place,” a young hotel clerk explained. “But what can I do? When he comes home he is so handsome and I reach out and say, ‘Oh, darling, darling,’ and all is forgiven.”

  The Tanzanians of Kagera were adamant that the disease came from Uganda, and with equal certainty the Rakai residents across the border pointed their fingers at the Tanzanians. Most people didn’t know what a virus was—there was no word for it in Swahili, the closest approximation being vinidogodogo, or very little thing. But they did know that evil existed and could be manipulated by witches and sorcerers to inflict harm on their enemies.

  It made sense, then, to assume that the new disease came from old enemies.

  Kidenya, Nyamuryekunge, and Tkimalenka rejected such superstition and searched for hard facts. They counted the sick and the dead, knowing their total represented a mere fraction of the true AIDS tally. Villagers knew the disease was incurable and therefore wouldn’t make arduous journeys on foot to district hospitals. Nevertheless, by the end of 1985 the Kagera District’s hospitals had seen 206 AIDS cases, 35 of whom had died in the facilities. Kidenya guessed that they were seeing 5 to 10 percent of the cases.

  Blood samples collected by Forthal from local residents were analyzed at the CDC, revealing that antibodies to HTLV-III/LAV were present in 41 percent of the first hundred patients diagnosed symptomatically by the doctors.

  Of particular concern to Kidenya and Nyamuryekunge was the discovery that people with AIDS were about five times more likely to have had a series of injections for some reason during the previous two years than were other patients in their hospital.

  It worried Kidenya that in America AIDS was spreading via the dirty needles used by people addicted to narcotics. The local practice, born of economic necessity, was to reuse syringes and needles so often that the tips had to be sharpened on whetstones so they could still puncture human skin. Such was the custom in his own hospital, Kidenya said. “But for the time being we believe the problem is not so bad in our clinics. Our people know they must at least try to be clean. But, you see, there is another type of drug supplier, an injectionist. For us, these people are very hard to find. They hide in the fields or whatnot. But they may happen to get hold of a syringe and perhaps some antibiotics. And without any medical knowledge they sell injections. So, you see, the people may go to them. And surely these injectionists do not worry about sterile needles.”

  The problem had only worsened since the villagers had heard of AIDS. Knowing that the licensed doctors had no cure for the disease, those who suspected they might have Juliana’s disease turned to the injectionists, who, like the snake-oil salesmen of America’s Wild West, claimed their potions could cure anything.

  To show his visitor the true scope of the Kagera District’s AIDS problem, Kidenya negotiated privately with the regional party leader for a petrol ration and organized a trip north toward the Ugandan border. The first stop on the tortuous, muddy drive was the Bunazi Rural Clinic, staffed only by medical assistants and midwives. The chief medical assistant gave a tour, anointing each concrete hole with an illustrious title, such as “pediatric ward” or “maternity ward.” But few rooms had beds, there was no surgical theater, and the pharmacy had little more than chloroquine and aspirin. In a small side room a woman held pieces of paper, each bearing information about patients. A man was bent over a microscope, studying samples of blood, urine, or stools. No other equipment graced the room.

  “This is our pathology laboratory,” declared the medical assistant. As he said this, a gust of wind swept all the samples and papers onto the dirt floor. The medical assistant led his visitors on to a general men’s ward. As was the case in Bukoba, the term AIDS was never used, but two men were pointed out as suspected HTLV cases. Both were war veterans, coughing from tuberculosis and obviously dying. The assistant explained that usually such cases would be transferred to Bukoba, but there was no petrol for the truck. Asked how many AIDS cases had been sent from Bunazi to Bukoba, the medical assistant said only six.

  Asked about syringes, the medical assistant pointed to a small kerosene-fueled autoclave containing several steel syringes and other equipment awaiting sterilization.

  An hour further along the muddy road a small village was perched on the Ugandan border. The area was occupied for nearly a year by invading Ugandan troops in 1978. Then Tanzanian soldiers had bivouacked there while battling the Idi Amin government. The village bore the scars of war: bullet holes along the walls, abandoned, rusted vehicles, the complete absence of any valuable supplies.

  Tkimalenka parked in front of the only building in the tiny hamlet that didn’t sport bullet holes. A bright-faced, energetic young woman stepped out of the modest tin-roofed structure and, recognizing Tkimalenka, grinned and shouted, “Karibou, Bwana! Jambo!”

  She urged the group inside, where, as eyes adjusted to the dark, three large, barren concrete rooms came into focus. In one there were three beds without mattresses. “They took the mattresses in the war,” the village paramedic explained. In another there was no furniture, but a strong cord hung from the ceiling. “This is where we used to weigh the babies to see if they were well. But that was before somebody stole the scale, which hung from the cord.” The third room was her office, containing a wooden chair, a small steel desk, and a bare wooden shelf.

  “This is my office,” she said proudly. “Where I keep track of the health of everybody in the village.”

  Atop her desk rested a foot-long shiny steel box. She opened the box to reveal two glass syringes, ten needles, and a dead fly resting in fetid water.

  “Do you use these syringes?” the visitors asked.

  “Yes, when we have something to give. Right now we have nothing. But sometimes we have vaccines for the children, or antibiotics. So then, yes, I use these,” the young woman answered.

  She described how she sterilized the equipment. Without electricity or kerosene, she couldn’t use an autoclave. She had no alcohol with which to swab the needles. Before any round of injections she would hang a steel pot full of water on a tripod over a wood fire outside, boil the equipment, let it cool, and inject whoever needed vaccines or medicines. In such a situation it wasn’t usually possible to sterilize the needles between each patient, she explained, but she was able to make sure that the needles were clean from one period of use to another. Proud of her work, and of the polite smile on Kidenya’s face, the young woman graciously thanked the group for their visit. Later, when the young woman was out of earshot, Kidenya admitted that the sterilization procedure concerned him.

  Back in Bukoba the group discussed the implications of such severe shortages of syringes. If one child in the village became infected with the AIDS virus, all the preschoolers might be infected in a single day’s measles immunization campaign.

  “Yes, yes, that is very bad. But what about the blood supply?”

  Nyamuryekunge shifted his bulk in his chair and reminded the group that he was a surgeon. “It is most difficult for me because we do not have the AIDS blood test.” No one could find the prospect of transfusing contaminated blood more alarming than a surgeon, given that virtually all surgical pr
ocedures entailed loss of blood that must be replaced to ensure patient recovery. Yet a single blood test cost more than Tanzania’s annual per capita medical spending of less than three dollars.

  “You see, when I have an elective operation, not an emergency, but the operation itself requires a transfusion, then I’m not very keen to perform that operation,” Nyamuryekunge said. “But when the patient must have emergency surgery, then either the patient dies of AIDS in five years or he dies now. So in that case I give the blood now. Save the life now and let’s pray the blood is not infected with the virus.”

  Kidenya sighed and said he hoped that the steps they were taking to educate the people of Kagera about the disease would soon stop the epidemic. Or that the Americans would shortly find a cure.

  “It pains me to care for an AIDS patient. It really pains me. Because whatever I give I know it is not helping the patient,” Kidenya said. “I don’t fear contracting the disease, but it pains me to know that whatever I do, whatever book I turn to, it’s useless. Your heart is not settled at all. At times I feel the disease is torturing our patients too much. I would like a disease which kills quicker. This one is too slow in killing. The patient wants to see you, demands your help. The help you cannot give.”

  Mr. Rutayuge, the hospital’s wiry, older administrator, listened. It was his task to order supplies from Dar es Salaam and then fight like hell to see that they reached Bukoba intact. Now the doctors couldn’t tell him what to order. Nothing, they said, would help. And so many were dying in his district that Rutayuge began to enter their names in the ledgers where he once itemized supplies and revenues.

  “For so long the young people have been running around, not listening to their elders. Even before the war with Uganda some of them were running around. Crazy. They don’t listen to the old ways. After the war it was worse. Discos, prostitutes, babies, so many babies!” Rutayuge’s frail body shuddered; he seemed to be fighting back tears. “Now some of the elders say to them, ‘Look here, we told you! Now you are sick. You are paying for all your running around.’”

  Rutayuge appeared to be a practical man, not the sort who normally waxed philosophical or grim. He was a hospital administrator who, day to day, devised ways to replenish medical supplies for a rural clinic that hadn’t “officially” received anything in weeks, perhaps months. With no budget, but plenty of ailing patients, Rutayuge negotiated deals with Ugandans, Rwandans, Burundians, even distant Kenyans, exchanging local goods for fuel, bandages, streptomycin, sheets, bedpans, painkillers for the dying, vaccines for the young, and aspirin for the rest.

  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 di
fferent 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.

 

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