The Coming Plague

by Laurie Garrett

  “We can’t behave like gods-in-the-sky when we work in developing countries,” Mann would say. “And we can’t publish without fear of impunity, without a sense of responsibility to the people we study.”

  These and other grievances were aired at the Bangui meeting, and McCormick’s goals for the gathering were met. Western scientists had an opportunity to see abstract concepts like “infrastructural development” or “economics-driven prostitution” come to life when their hotel-room taps produced no water or prostitutes pawed them in elevators in the Central African Republic’s best accommodations.

  “The most crucial obstacle to comprehending the African AIDS epidemic and bringing it under control is the lack of [local] training and tools of communication and analysis,” McCormick said. And the Western scientists, most of whom were on the African continent for the first time in their lives, had a chance to experience firsthand the significance of McCormick’s remarks when they tried to telephone their American or European offices or buy batteries for their shortwave radios.

  Assad, too, wanted the African government representatives at the conference to get past their resentments and face the reality of AIDS. At one point he demanded that each country representative tell the assembly exactly how many AIDS cases had been diagnosed and what were the suspected infection rates in their nations. On a first pass around the room most African country representatives hedged—some denied any knowledge of AIDS in their nations. Assad then told the group, “You’re not being honest. I know, I’ve been there, I’ve seen AIDS in your countries.”

  Assad threatened to cut off WHO shipments of cholera vaccines and other vital supplies to countries that didn’t speak up candidly. The following day, most African representatives provided numbers, though everyone knew that no country had epidemiology surveillance systems that could keep track of all its citizenry, and the data greatly underestimated the region’s AIDS epidemic.

  Rwanda reported that they’d seen 319 AIDS cases since 1983, 86 in small children. Kenya reported ten cases; four were foreigners. Zaire cited the Project SIDA data, which found antenatal clinic infection rates in Kinshasa of about 6 percent. Zambia reported that of 143 women who gave birth at University Teaching Hospital in Lusaka in the days prior to the Bangui meeting, seventeen were infected with HIV, as were fifteen of their babies.

  Assad became a convert to the AIDS cause, and readily agreed with McCormick’s opinion that a special epidemic effort had to be coordinated out of WHO. McCormick made his private pitch to Assad. He wanted an office established in Geneva that would serve as an international clearinghouse for AIDS information and technical expertise. He wanted it to have enough WHO clout to be able to intervene in multinational scientific disputes.

  Assad readily agreed, and asked Joe to do the job, but McCormick had other ideas.

  “There’s somebody I want you to meet,” he said.

  Later, McCormick introduced Assad to Mann, and before the Bangui gathering ended, Mann had agreed to become director of a new global AIDS program. For the next six months he would commute between Geneva and Kinshasa, trying to ensure the survival of Project SIDA while giving birth to a new global AIDS effort. There was just enough money in Assad’s budget to pay for Mann’s plane tickets and a part-time secretary. His salary would still be paid by the CDC.

  The Project SIDA group soon found explanations for more of the misleading information that had surfaced in Atlanta and via Western medical journals. The apparent cases of household transmission in Africa turned out to be the results of mother-to-child transmission during pregnancy, the birth process, blood transfusions, and breast feeding.136 The extraordinarily rapid AIDS deaths that had been observed in the Lake Victoria region did not seem to hold true in Kinshasa, where a years-long asymptomatic infection stage appeared to precede AIDS in Zairian men and women, just as it did in gay American men.137

  Older children (aged two to fourteen years) were getting infected through nonsterile needles used both in hospitals and by illegal injectionists, and by blood transfusions given to treat anemia episodes brought on by malaria.138

  Similarly, the 6 percent seropositivity level they discovered among Mama Yemo Hospital personnel was not the result of spread within the facility, but of receipt of contaminated blood transfusions, multiple sex partner heterosexual activity, and nonsterile medical injections.139

  Biggar, Njelesani, and other American and Zambian scientists coauthored a study reassessing rates of HIV infection in Lusaka’s hospital, using the new British-made HTLV-III (HIV) test. They found that rates of infection—far from Biggar’s prior estimate of 55 percent for the general Zambian population—actually peaked in 1985 at 29 percent seropositivity, seen among patients in Hira’s STD clinic. In the antenatal ward 8.7 percent of the women were infected; hospital employees had a 19 percent infection rate.140 But even the new, lower figures ranked among the highest infection rates in the world. Furthermore, with no cure or vaccine in sight, Njelesani could foresee a horrendous growth curve for the future of Zambia’s epidemic.

  Little news of the African debate of 1983–86 or of the spread of AIDS around the continent reached the remote Government Hospital in Bukoba. Drs. Kidenya and Nyamuryekunge were still fighting credibility battles with their Tanzanian colleagues when the continent’s health leadership gathered in Bangui. And their hospital administrator continued to enter the names of the dead in his supplies ledger.

  As the first January snow of 1986 fell outside his Geneva office, Fakhry Assad reflected on the Bangui meeting.

  “The nine [African] countries141 that officially attended the meeting all said, ‘What can we do about it? We are paralyzed. We have no infrastructure, no treatment, no education. We have nothing to give.’ This had been completely overlooked by people from the outside,” Assad said. “Frankly, just to say, ‘Educate your people in regards to sex,’ how many would really believe in it? You have to have serious sero-surveys, interviews to assess the problem locally. And even if you find clear evidence of an epidemic, what means will you use to educate? Are you going to do it over the radio: who has transistors? Any country, if he has the means to control a disease, he will. But here [with AIDS] he can only say, ‘I have a problem, and I don’t know how to solve it.’”

  Those most deeply involved in the AIDS fight now realized the microbe had won the first round, successfully emerging in outbreaks on at least three continents in Homo sapiens populations ranging from heroin addicts in U.S. ghettos to heterosexual neurosurgeons in Kinshasa; from Michael Callen and Bobbi Campbell to Noticia.

  The virus had gone from epidemic to endemic status in key population groups around the world. It had defeated the powers of science that just a decade earlier had led public health planners to confidently agree to cut their sexually transmitted disease budgets.

  By the time Assad reflected pensively in his Geneva office, Campbell was dead, Callen was battling yet another round of opportunistic infections, Noticia’s body was buried in a banana grove in her home village, and Greggory Howard was walking the streets of Newark preaching the AIDS gospel to junkies huddled around trash fires, telling them, “I have the HIV as a result of my drug abuse.”

  “I’m listening to him, man, cuz he’s one of us,” said a tall, thin African-American self-described “junkie homosexual.” Stabbing the air to drive his points emphatically home, Howard’s fan said, “He speaks the truth, man. We all know this AIDS thing is a killer. Especially for us black people. I’m telling you, man. I’m telling you.”

  IV

  Because of the legacy of blame, accusation, and exaggeration concerning AIDS in Africa it was impossible to have an apolitical, “pure science” discussion of the origins of the human immunodeficiency vi
rus during the 1980s. Not until the Sorbonne’s Mirko Grmek published his book on the subject in France in 1989142 would discussion begin to free itself from the fetters of prior blame. Still, there would remain in the 1990s a decided timidity in AIDS academic and policy circles about broaching the subject of the origins of the global pandemic. The official line of the World Health Organization, first enunciated by Assad in 1985, would remain the agency’s position in 1994: AIDS emerged simultaneously on at least three continents.

  Few scientists accepted that position, recognizing it for what it was—a political compromise. But publicly they went along with WHO’s stance because it was too politically dangerous to do otherwise. Far too much finger pointing went on during the 1980s to allow anybody by 1990 to feel that an environment of complete intellectual freedom could surround the question of the origin of AIDS.

  “So the origins debate will go on,” wrote Canadian analyst Renée Sabatier in 1988.143 “It is probably optimistic to hope that it will be conducted without continuing imputations of blame, and without a continuing belief by others that blame is being imputed. But scientists, media, and politicians alike would do well to exercise great restraint in this discussion, since feelings of being blamed are already seriously hampering efforts to control AIDS.”144

  Shunning the subject, some scientists would simply say, “Well, it doesn’t matter, really. AIDS is here, the pandemic is spreading all over the planet. Let’s deal with the here and now. What’s past is past.”

  Or, as Zambian President Kenneth Kaunda put it in 1987: “What is more important than knowing where the disease came from is where it is going.”

  But few researchers honestly held such a belief. For if AIDS could emerge so successfully worldwide in the age of genetic engineering, antibiotics, sophisticated biochemistry, and global telecommunications, what other microbes might in the future exploit similar conditions? If humanity hoped to prevent its next great plague, it was vital to understand the origins of this one.

  Once the HIV antibody tests for screening blood samples had been perfected, the “sticky sera” problems solved, and the Bangui symptomatic definition of AIDS drawn up, it became possible to look backward and ask when and where AIDS had occurred prior to its recognition in California in 1981.

  Given the numbers of sexual partners many gay men had prior to becoming infected with HIV, it was considered nearly impossible to trace the epidemic back in time through that population. Researchers could never know who gave the virus to whom, and when.145

  The clearest tracings could be accomplished by following the AIDS/ hemophilia population, because blood-bank records and stored plasma allowed researchers to match some infections to the HIV-positive donors and to put dates on the times of infection.

  Unfortunately, to protect themselves from potential lawsuits brought by people who acquired HIV as a result of transfusions or use of plasma products, many European and American hospitals deliberately destroyed old records and blood samples. Under U.S. law they were required to maintain such records and samples only for five years, and by 1986 hospitals and blood banks all over the country began actively shredding their pre-1982 paper trails and purging computer files. By allowing such wholesale destruction, the U.S. government condoned elimination of a crucial set of clues in the AIDS mystery.

  CDC studies of HIV/blood connections in Los Angeles, however, revealed that the earliest date of HIV infection of a person receiving contaminated blood-clotting products was 1978. It was an isolated case, however; the bulk of all blood product infections in the United States occurred in 1983–84.146

  It would be tempting to conclude that, given the extraordinary numbers of donors’ microbes to which people with hemophilia were annually exposed, HIV either didn’t exist in North America prior to 1978 or was so rare as to escape chance exposure even for individuals who injected products derived from the pooling of the blood of over 300,000 people a year. Widespread home use of Factors VIII and IX wasn’t possible, however, until 1975, so it is conceivable that HIV was present in the U.S. blood donor population for decades prior to 1975, but at such a rare level—say in one out of every million Americans—that the chance passage of blood products wasn’t of sufficient likelihood to produce disease that would be noticeable at the population level until 26,000 people with hemophilia started to routinely inject themselves with clotting factors derived from the plasma of tens of thousands of donors per year.

  A study by the U.S. National Institute of Drug Abuse found that serum drawn from injecting drug users in 1971–72 tested positive for antibodies to HTLV-III (HIV). Some 1,129 samples obtained from 238 individuals who were surveyed for other reasons at that time were reexamined using the Abbott ELISA test for HTLV-III (the standard test): about 10 percent were positive. The possibly infected samples, which came from all over the United States, were retested using a more precise method—the Western Blot—and fourteen were positive, for an infection rate of 1.2 percent.147

  Virologist William Haseltine of the Dana Farber Cancer Institute at Harvard ran tests on 1979 blood samples from New York City injecting drug users; 30 percent, he said, were positive for antibodies to HTLV-III (HIV). “It was the druggies, not the gays, who started it,” Haseltine declared. 148 The Boston scientist never published his New York City drug users data, which was sharply criticized by researchers who worked closely at the time with the city’s heroin- and cocaine-using populations.

  Nevertheless, the assumption that the AIDS epidemic of North America began among gay men had to be viewed cautiously; even in Michael Gottlieb’s original group of five gay men suffering Pneumocystis pneumonia—the study that first alerted the world to the presence of a new disease—one of the men had a history of injecting narcotics. Henry Masur’s first report in 1981 of AIDS in New York City described eleven cases, five of whom were injecting drug users; one was both gay and an injecting drug user. And among the original four cases in San Francisco were Mrs. Profit and her husband, both drug injectors. Gay American men in the 1970s were no less likely than other population groups to indulge in such drug use—indeed, some studies found gay men two or three times more likely to have injected narcotics, and Harold Jaffe’s earliest representations of the epidemic’s demographics drew sharp attention to the numbers of men in 1981–83 who had histories of both activities.

  Darrow’s research showed that the social conditions for emergence and spread of HIV were ideal in the gay communities of the late 1970s in the United States and Europe, particularly because the population was highly mobile and extraordinarily sexually active.

  “We found that the earliest cases included gay men involved in international travel,” Darrow and his colleagues wrote.149 “It is impossible to conclude that any of these men is responsible for introducing the virus to the United States. In fact, the virus may have evolved or arrived in some other way. Our purpose is not to pinpoint the source or cast blame, but to show that social conditions in the mid-1970s provided a unique opportunity for the introduction and transmission of an insidious and highly fatal viral disease.”

  Before the HIV blood test was available, doctors in St. Louis concluded that the bizarre illness and death of a fifteen-year-old under their care in 1968 had been due to AIDS.150 The teenager was born and raised in St. Louis, had never traveled outside the immediate area, was black, and admitted to “several years” of heterosexual activity. The doctors were unable to cure his medical problems, including galloping Candida infections, devastation of his lymphatic system, Kaposi’s sarcoma, and fulminant infections of Epstein-Barr virus and cytomegalovirus.

  “Although some claim that AIDS is newly imported to the continental United States, the typical features exemplified by our native-born American patient suggest that the syndrome is, at least in part, endemic and appeared
more than ten years before the current epidemic,” the researchers concluded.

  In 1987 scientists presented evidence that the blood of “Robert R.,” as the St. Louis case was designated, contained antibodies to HIV, concluding that the virus had been present in the United States in 1968.

  “If a virus related to HIV has been present in the United States, Africa, or elsewhere for several decades, its failure to spread in an epidemic fashion earlier may reflect either a recent genetic change in the virus and/or sociocultural factors involving sexual practices or numbers of sexual partners,” they wrote.151

  In 1959 a forty-eight-year-old sailor died of Pneumocystis pneumonia and apparent immune deficiency in New York City. The man had traveled widely around the world and was Haitian-born. Though samples of his blood were not available for analysis thirty years later, researchers concluded retrospectively that the sailor died of AIDS.152

  In Europe several previously unexplained deaths would in the mid-1980s be ascribed to AIDS, among them: Danish surgeon Margrethe Rask, who had long worked in rural Zaire, died in 1977 of acute immune deficiency and Pneumocystis pneumonia,153 and a widely traveled Norwegian sailor, who died in 1966. Over the next decade his wife and one of his three children—born in 1967—also died of immune deficiencies. Later blood tests showed that the three had antibodies to HIV.154

  Prior to that there were numerous unsolved cases of apparent immunodeficiencies reported in Europe; the most clearly AIDS-associated involved another well-traveled sailor who died in Manchester, England, in September 1959; in 1983 his doctors retrospectively diagnosed the case as AIDS.155

  All available evidence indicated that the visible AIDS epidemics began simultaneously around 1979 in the United States and Haiti. A review of 1,328 cancer biopsies performed in Port-au-Prince during 1968–77 showed no Kaposi’s sarcoma diagnoses. Yet between June 1979 and November 1981 a dozen cases of the rare cancer were diagnosed in the Haitian capital.156 A French research team tested 211 blood samples collected from adult Haitian immigrants living in Cayenne, French Guiana, in 1983. Using both the standard ELISA HTLV-III (HIV) antibody test and confirmatory Western Blot assays, they discovered that 2.7 percent of the men and 4.9 percent of the women had antibodies to the virus. All of the HIV-positive Haitians had been in Guiana for at least two years, and some since 1974.157 No Guiana-born individuals tested positive.