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.â€
Joe McCormick had no difficulty convincing health authorities in Zaire and Belgium to take AIDS seriously. And the authorities in Kinshasa were enthusiastic about McCormick’s suggestion that a joint Belgian/Zairian/ American AIDS research center be established in the country. McCormick’s headaches didn’t start until he returned to Atlanta, where Curran supported a long-term Zaire AIDS study, and outgoing CDC director Bill Foege was eager to be helpful; but Reagan’s newly appointed CDC director, James Mason, seemed lukewarm toward the idea. At Foege’s urging, McCormick spoke directly with Assistant Secretary of Health and Human Services Brandt.
“There’s a one-to-one sex ratio of AIDS cases in Zaire,†McCormick told Brandt, “proving that AIDS can be, and is, a heterosexual disease.†Brandt absolutely refused to believe McCormick, maintaining that some overlooked factors had to be involved in Zaire. AIDS, Brandt insisted, simply was not a heterosexual disease.
It would be more than a year before the Reagan administration’s health leadership would accept the idea that AIDS in Africa was primarily heterosexual. The administration would never fully acknowledge that the virus might also be heterosexually transmitted in the United States. Indeed, disputes over heterosexual transmissibility of the virus and the applicability of the African (read: black) experience to the Euro-American (read: white) context would rage within the upper echelons of the U.S. government throughout the eight-year-long Reagan administration and well into the term of his successor, George Bush.
The Euro-American scientific community would be similarly divided over interpretations of African AIDS and heterosexual transmission of HIV, and that tension would persist well into the 1990s. Because AIDS had first been noted among gay American men, many scientists and politicians insisted that the modes of transmission of the virus were rigidly limited to those first observed in the United States—anal intercourse, injecting drug use, blood product contamination, and “Haitians.â€
But, of course, th
ere was heterosexual transmission of AIDS in America, in Europe, in Haiti—in every geographic location on the planet into which HIV had infiltrated. Among the very first cases of AIDS reported in New York City were heterosexually acquired infections.
Some public health officials critical of the Reagan administration quietly argued that there was a racist subtext to the debate: nearly all heterosexual cases reported worldwide by mid-1984 involved people either living in Africa or of African heritage. In Europe and the United States nearly all clearly identified heterosexual transmissions reported to authorities by mid-1984 involved blacks or Hispanics; most were immigrants or visitors from African countries, the Dominican Republic, Haiti, and Puerto Rico.
A well-intentioned effort to gather evidence for heterosexual transmission of the virus began, its focus consciously directed at Africa. In essence, European and North American researchers had domestic agendas that underlay much of their African research.
But Jacques Liebowitch reflected a sentiment more popular among AIDS researchers at the time, saying, “We built a focus on Zaire … [to look at] people who didn’t fit into any of the other known risk groups, such as being homosexual.â€119
Joe McCormick had no such initial intent for Project SIDA,120 as the joint Zairian/American/Belgian research effort would be called, nor were the physicians of Kinshasa particularly interested in seeing precious resources wasted on proving what their medical charts already made clear: namely, that AIDS in their country was a heterosexual disease. Curran and McCormick decided that Project SIDA would be a serious African AIDS research center, designed to answer questions important to Africans. Curran immediately began scrambling for funds, carefully avoiding Brandt’s office, while McCormick tried to find the right CDC scientist for the job.
The creation of Project SIDA went on quietly in Atlanta and Kinshasa while most of the Euro-American research effort in Africa continued to focus on two issues: heterosexual transmission and the scope of Africa’s epidemic. As soon as the Pasteur group had a crude LAV test available, they collaborated with McCormick, Piot, and Quinn on analysis of the blood samples collected in Kinshasa hospitals. They confirmed that 97 percent of the patients Kapita had diagnosed as AIDS cases had antibodies against LAV (HIV). Most troubling: so did many of the controls, which indicated that there was an asymptomatic stage of the disease and that infection was far more prevalent in Zaire than it had initially seemed. Seven percent of the apparently non-AIDS patients hospitalized for noninfectious reasons came up antibody-positive, as did 5 percent of the new mothers who were on the obstetrics ward of Mama Yemo Hospital in 1980. In addition, serum collected from a mysteriously ill woman on the Mama Yemo obstetrics ward in 1977, who died of apparent immune deficiency in 1978, proved positive for antibodies to LAV.
Both the rate of adult infection in Kinshasa and the apparent age of the Zairian epidemic merited serious concern. By contrast, the French overall rate of apparent LAV infection in 1983 seemed to be less than 0.3 percent. 121 The Pasteur group was at the time receiving blood samples from other African countries, and had evidence for similarly alarming rates of LAV (HIV) infection in the general populations of Rwanda and the Central African Republic.
During the 1983 winter holidays Jonathan Mann answered his phone in Albuquerque. Joe McCormick—a scientist Mann admired immensely but had never met—introduced himself and got down to business.
“How would you like to work in Africa?â€
Mann was stunned. But the CDC’s New Mexico-based epidemiologist and bubonic plague expert listened intently as McCormick described what he had seen in Kinshasa.
Though Jon and Marie-Paule Mann had three young children, and none of them had lived in a developing country, it didn’t take much to convince the family to move to Kinshasa. For Parisienne Marie-Paule it meant speaking her native tongue; the kids relished the adventure. And Mann recognized with considerable excitement the scientific importance of such work.
Curran, who had long been impressed with Mann’s work, was quite pleased with the choice. Mann had displayed a talent for handling dicey political and press issues during his tenure in New Mexico. This skill, demonstrated from the first day Boston-born Mann had arrived in the state and faced public concern about a case of bubonic plague, would be crucial. The often tense status of relations between the U.S. and Zaire governments and the competing interests of AIDS researchers from all over the world who were eager to investigate the African epidemic would test Mann’s mettle.
By March 1984, McCormick and Mann were in Kinshasa, working with Kapita, Drs. Nzila Nzilambi, Ngaly Bosenge, Kalisa Ruti, and other Zairian scientists to establish Project SIDA. McCormick acted as Mann’s mentor, passing on in the course of a month as much as he could about Zairian languages, customs, and politics, as well as how to properly play the role of an outside American expert when working in a postcolonial, impoverished country lacking in basic infrastructural support.
Mann learned his lessons well—perhaps too well from the perspective of other foreign scientists and members of the press. He never spoke to outsiders without first clearing his comments with the Zairian Ministry of Health; he fought off foreign researchers who failed to collaborate with Project SIDA on its terms; and primary among those terms was a willingness to collaborate as equals with Zairian scientists and abide by the press and publication limitations set by the Zaire government.
“I’ll tell you anything you want,†Mann would say to all non-Zairian callers, “if you come here with a letter from the Zaire government. But without that letter, I won’t talk to you at all.â€
Ten years later some rival scientists would still speak bitterly of Mann’s policies at Project SIDA, claiming that he froze them out of Zaire and treated the country’s AIDS epidemic as his personal “turf.†But Zairian scientists would have nothing but praise for Mann, as well as for Piot. Project SIDA would prove to be the most prolific AIDS research effort on the continent from 1984 until its closure, due to civil war in Zaire, in 1991.
While most other African governments either were confused about the extent of their epidemics and still in the rudimentary stages of local research or were deliberately maintaining public silence out of a sense of national pride and economic concern, Zaire was quite open. An unfortunate side effect of the government’s candor was a series of false international assumptions that would persist for over a decade: that Zaire had the worst of Africa’s epidemics; that AIDS definitely started in Zaire; that all other AIDS outbreaks could be traced back to a Zairian origin.
Though Mann was in charge, Project SIDA included Drs. Henry Francis and Tom Quinn of the National Institute of Allergy and Infectious Diseases. Together with their Zairian colleagues, the team did HIV prevalence studies showing that by 1985 the general population infection rate in Kinshasa was about one-third that seen among gay men in San Francisco, and that multiple heterosexual partners, medical injections with nonsterile needles, and foreign travel were the key risk factors.122
As the dimensions of the global AIDS epidemic grew, the CDC organized the first International Conference on AIDS, which convened in April 1985 in Atlanta. About 2,000 scientists and reporters from thirty nations attended the grim gathering, during which the scale of what was by then considered a pandemic became apparent.
Though the Atlanta meeting would, correctly, draw attention to Africa’s plight, it would later be established that nearly all the assumptions, and the data upon which they were based, were false. As the scientists assembled in Atlanta, AIDS was indeed emerging in Central Africa. But it was not doing so via some of the means described or on the terrifying scales presented.
At the meeting, Luc Montagnier said blood tests on samples drawn in Kinshasa in 1970 showed that one out of every 220 men and women then had antibodies to LAV (HIV); in 1980, he claimed, one out of ten Kinshasa adults was antibody-positive. And, he t
old the gathered scientists, AIDS was spreading within African households by a variety of nonsexual means. Robert Gallo disputed the household transmission claim, but agreed that AIDS was rampant in Africa, noting that 65 percent of children in Uganda tested positive for antibodies to HTLV-III (HIV).
Nathan Clumeck reported that 88 percent of the female prostitutes tested in Kigali, Rwanda, had antibodies to HIV—up from 70 percent levels of infection in 1982 blood samples drawn from local prostitutes. The general population, Clumeck said, had an infection rate by the end of 1984 of 9 percent. 123
Dr. Robert Biggar, of the U.S. National Cancer Institute, reported that infection with both the HTLV-I and HTLV-III (HIV) viruses was extremely common all over Kenya, even in remote pastoral areas. On the basis of HTLV-III antibody tests run on blood samples collected by the CDC in Kenya in 1982–84 during various disease studies (not AIDS), Biggar claimed that over half of the Kenyan population had at some time been infected with the AIDS virus and nearly a third had antibodies to HTLV-I. The strongest responses, he said, were among the nomadic Turkana people of northern Kenya, nearly 80 percent of whom were infected with the AIDS virus. 124 Biggar also claimed that up to 15 percent of the children, 25 percent of the elderly, and 20 percent of young adults in the remote Kivu District were infected with HTLV-III. 125 And he told reporters that over half the young women tested on the antenatal ward of Lusaka’s University Teaching Hospital—55 percent, to be precise—carried antibodies to HTLV-III (HIV) in 1984.
Similarly terrifying levels of infection in Africa were reported by a team working with Robert Gallo. On the basis of HTLV antibody tests of stored blood samples that had been collected by the National Cancer Institute in 1972 and 1973 from schoolchildren in Uganda as part of a Burkitt’s lymphoma study, the team concluded that 66 percent of the children were infected with HTLV-III (HIV) nearly a decade before anybody realized that AIDS existed. The blood samples had been collected in the remote West Nile region of Uganda, an area of tiny villages located amid swamps and heavy rainfall.126
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