The Coming Plague

by Laurie Garrett

  “It’s a remarkable situation,” Uwe Brinkmann said, having spent time observing the gem miners. “All day long they sit or squat in the streams and rivers zigzagging through the rain forest. It’s steaming hot and humid—you can’t imagine the heat. They wear no protective clothing, and they stand in mosquito breeding areas all day long sifting the water and mud for gems. At night they sleep in open sheds.”

  It was these fortune seekers who proved to be the best customers for the antimalarial black market. They purchased anything, and used anything, to keep the disease at bay. Most of the time they used drugs improperly, encouraging development of resistant strains.194

  Not surprisingly, it was there that multidrug resistance emerged. In 1983 the combined use of mefloquine and Fansidar cured 96.7 percent of all malaria in the gem-mining area. By 1990 the same drug combination cured less than 21 percent of all cases. In practical terms, malaria acquired in the region was incurable.

  Men who contracted malaria in the area but weren’t too sick to travel did their best to sneak past layers of police, armies, and border guards to get home, clutching whatever riches they had sifted from the Khmer streams. But it was tragedy that they carried with them, for in their bloodstreams lurked resistant parasites that were soon sucked up into the probosci of feeding mosquitoes from Bangladesh to Nepal. And so the epidemic spread.

  Despite expenditures of billions of dollars by governments,195 the UN, and numerous Western agencies, malaria was completely out of control in Asia in 1994.

  In 1977, WHO finally abandoned all hopes of eradicating malaria. In 1978 it outlined a global strategy that linked malaria control to primary health care. But in the absence of adequate primary health systems in most of the affected area, that policy, too, failed.

  By 1992, WHO was forced, reluctantly, to admit that there was no global strategy for malaria control. Rather, every individual ecology in each endemic nation needed to develop its own environmentally and socially tailored plan of action. What might work in an African savanna certainly would not be effective in a swampland or an Asian mahogany forest.

  WHO had discovered ecology.

  Weary of failure and angry about corruption in malaria vaccine development efforts,196 the U.S. government moved in 1993 to slash its financial commitment to malaria control efforts. Federal expenditures declined steadily between 1987 and 1990, and in the winter of 1993 two agencies of the government were at loggerheads over whether or not to completely cease funding overseas malaria programs.197

  When Teklehaimont viewed the crisis in southern Asia he couldn’t help but worry about his home, Ethiopia. In 1992 Ethiopia experienced its worst malaria epidemic in Homo sapiens history, with more than 20,000 people killed by the parasites in less than six months. At least 10 percent of the cases were chloroquine-resistant, and the victims were of all ages. When Teklehaimont personally surveyed households in an area of 13,000 people, he found 759 dead.

  And that terrible epidemic was in the face of only chloroquine resistance.

  What will happen if the Cambodian multiresistant parasite gets to Africa? Teklehaimont wondered.

  14

  Thirdworldization

  THE INTERACTIONS OF POVERTY,

  POOR HOUSING, AND SOCIAL DESPAIR

  WITH DISEASE

  The States Parties to this Constitution declare, in conformity with the charter of the United Nations, that the following principles are basic to the happiness, harmonious relations and security of all peoples:

  —Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity … . —Unequal development in different countries in the promotion of health and control of disease, especially communicable disease, is a common danger.

  —Constitution of the World Health Organization, July 22, 1946

  Heavy, purple-tinged clouds filled the equatorial sky, blotting out the harsh noon sun. It was stifling hot, and the air was so moist that beads of condensation mixed with sweat on the skin. Three men struggled to push a bicycle uphill along a road made of thick clay mud, rutted deeply from the two or three vehicles that had passed from Bukoba, bound for Uganda, since yesterday.

  Wrapped in white cloth and elephant grass, a five-foot bundle lay stretched across the handlebars. The somber trio maneuvered their way past a steady stream of pedestrians, most of whom bore enormous bundles upon their heads or carried a huge Nile perch dangling from their shoulders, the fish so massive that its mud-covered tail trailed along the road.

  Each time the men hit a large rut, one of them carefully steadied the bundle, while the other two gave the bicycle a strong shove. Passersby, recognizing the nature of the bundle, carefully avoided staring and ceased their laughter or chatter. Even the wild young boys who dodged school and helped smugglers get their goods across the Ugandan border grew silent when they spotted the bicycle’s burden.

  The journey eased when the men reached a plateau and turned off the road onto a well-beaten footpath. Winding their way through dense, verdant banana groves, they occasionally passed a mud-and-thatch home. Residents greeted them with nods or a quiet “Jambo,” children scurried to their mothers’ sides, staring wide-eyed at the bicycle and its load. As the trio moved on, clusters of people gathered up specially wrapped bundles, called children to their sides, and fell in line. Soon a procession of a few dozen residents of Kanyigo had formed.

  In the distance could be heard the high-pitched ululating of female voices. The procession drew near to the mournful sound and a child stationed along the path spotted the bicycle and ran ahead to alert others of its approach. The keening suddenly stopped, and for a moment the only sounds were those of squawking Lake Victoria birds and human feet tromping over mud.

  The villagers of Kanyigo reached a small clearing, surrounded by banana trees. To one side was a round thatched-roof house. On the opposite end of the clearing a group of men took turns shoveling out a large hole in the clay soil. In the center of the clearing stood a thirty-five-year-old man wearing a button-down shirt, dark cotton pants, and a brightly colored print sash. As the bicycle trio approached, the man drew close to him five small children, aged two to seven years, each of whom wore sashes identical to his.

  Without exchanging words, the trio greeted the man and his children, silently untied their elephant grass-wrapped bundle, and carried it into the hut. As they entered the home, the women’s wailing resumed inside. Its volume and pitch were at first painful to hear, and some of the gathered children, unfamiliar with social propriety, cupped their hands over their ears. Mothers quietly clucked disapproval; the children obediently dropped their hands and stared with apparent fear at their sash-adorned counterparts.

  The families took turns approaching the father and children. Whispered greetings, bowed heads, proffered gifts, some tears, an occasional hug.

  Some of the adults stepped into the hut, stopping for a moment until their eyes adjusted to the darkness, and then groped their way through the crowded one-room home to a seat upon the clean floor of packed dirt. They sat in concentric circles surrounding the five-foot bundle that had quietly been set in place by the bicycle trio. An older woman occasionally lost control, wailing loudly and flailing about so wildly that her friends were forced to restrain her.

  AIDS had claimed another life in Kanyigo. The thirty-two-year-old woman, who now lay upon her floor, swaddled in cloth and elephant grass, left behind a husband and five children.

  “She was suddenly attacked by stomach pain four months ago,” the widower said. “So she went to her birth village, the next village over, to stay with her family. She had no appetite. She wasn’t eating anything. We tried to force her to drink tea, eat bread. We really tried to force it on her. But it was no use. At eleven o’clock yesterday morning she collapsed and died.”

  The man spoke in a monotone, too overwhelmed to express emotion. H
e looked down at his children, who stoically stood by his side, stifling their tears. His eyes swept over them and then settled on the visiting Mzungu. He studied the American for an instant before speaking.

  “It is a great deal of work for me to feed them, care for them, and do my work. Why don’t you take the children? I give them to you.”

  I

  Jonathan Mann was tremendously excited. True, there were any number of things that could still go awry; diplomatic noses might start bleeding, political shenanigans could well break out. But he and his highly energetic—and sly—staff of the World Health Organization’s Global Programme on AIDS had for months carefully and strategically planned for this day.

  “We are entering a new era,” Mann had assured an international press corps. “We will make 1988 the year we turn the tide against the AIDS virus.”

  And here he sat, his bow tie straight, hair brushed, as usual, straight back off his forehead, wearing a natty tailored European suit, giving him the air not of a CDC epidemiologist but of a French diplomat. He looked out over the largest gathering of Ministers of Health ever assembled. Of the representatives of 148 nations who now sat before him in the vast Queen Elizabeth II Conference Center in London, 117 were Ministers of Health or their country’s equivalent. Every key nation, save one, was represented by the most politically powerful health official in their land: Mann was ashamed to say that the exception was his own country. Still not wishing to give AIDS a priority status, the Reagan administration sent Dr. Robert Windom, who ranked two notches down the power ladder from the Secretary of Health and Human Services, Otis Bowen.

  Never in history had the majority of the world’s top health officials gathered to discuss an epidemic. No scourge—not malaria, smallpox, yellow fever, or the plague—had ever commanded such diplomatic attention. Some 700 delegates and 400 journalists were also present in the London hall on this ice-cold January morning in 1988 to witness the World Summit of Ministers of Health on Programmes for AIDS Prevention. Mann felt that it was a coup for his program, for WHO, and for millions of powerless people with AIDS.

  Mann urgently hoped to drive home a message to the world’s health leadership: AIDS is spreading; if it hasn’t yet emerged in your country, it will, unless you plan now, follow our recommendations, educate your populations, and embrace condom-based programs as a prevention strategy.

  As of January 26, 1988, some 75,392 cases of AIDS had officially been reported to the World Health Organization. But that figure was a gross understatement of the true dimensions of the pandemic: most nations lacked genuine systems for amassing and recording such health statistics. Mann tactfully didn’t mention from the podium what everyone in the audience knew to be true; namely, that many nations were deliberately covering up their epidemics for political and economic reasons. Such delicate issues would be dealt with later, in private arm-twistings and minister-to-minister preplanned strategic confrontations.

  Mann differentiated the ways in which the AIDS virus was spreading from person to person. In what he called Pattern I countries, such as those of North America and Western Europe, AIDS was spreading primarily via the sharing of needles between intravenous drug users and sexually among gay men. In Pattern II countries, such as those of Africa, AIDS was a heterosexual disease.

  Though he was cautious in his public choice of words, it was Pattern III nations that most concerned Mann as he spoke in London. Asia, the communist bloc, the largely Muslim Middle East, and much of the Pacific region had only very tiny outbreaks of AIDS. Some of these countries were truthfully reporting no cases of the disease, and several more were accurately stating that the handful of cases in their countries all involved foreigners or citizens who had acquired HIV while living overseas. In those Pattern III countries, the relative handfuls of cases were equally likely to have resulted from heterosexual, homosexual, needle, or blood exposure.

  Pattern III, in other words, represented the potential future of the worldwide AIDS epidemic. There was still a window of opportunity for public health action that might successfully prevent HIV from emerging in the majority of the world’s populations.

  Many of the Pattern III political leaders had already recognized the threat of HIV importation, of course, and taken their own steps to curb such events. However, Mann and his staff, which included smallpox hero Daniel Tarantola, were appalled by many of the anti-emergence measures some countries had taken. Privately, Tarantola had already spent months flying all over the world in attempts to convince many of the same ministers who now sat in the London conference hall that AIDS wasn’t anything like smallpox. There was no vaccine that one could require that immigrants and visitors receive. The virus didn’t manifest itself symptomatically for years—perhaps over a decade—in ways that indicated its presence even to the infected individual. And the AIDS blood test wasn’t foolproof.

  “What are you going to do, test every immigrant five or six times a year, every visiting student once a week? If you think you can keep the virus out of your country with legislation and testing, you are wrong,” Tarantola told public health officials.

  Mann was worried that the world would become a patchwork of repressive public health regimes with laws aimed at keeping a virus, as well as its potential carriers—gays, Africans, prostitutes, drug users, poor immigrants—out. He feared that it would push populations that already existed at the margins of global society further away from the mainstream, medicine, and all hopes of disease control. Indeed, restrictions intended to control populations at greatest danger for HIV infection might actually have the reverse effect, exacerbating the social and economic conditions in their lives that drove them to adopt risky behaviors. Simply put, he felt certain that this moment in London was pivotal to deciding whether HIV’s emergence in most countries would be prevented through education of local populaces or temporarily stalled by repressive laws.

  “Our opportunity—brought so clearly into focus by this Summit—is truly historic,” Mann told his distinguished audience. “We live in a world threatened by unlimited destructive force, yet we share a vision of creative potential—personal, national, and international. The dream is not new—but the circumstances and the opportunity are of our time alone. The global AIDS problem speaks eloquently of the need for communication, for sharing of information and experience, and for mutual support; AIDS shows us once again that silence, exclusion, and isolation—of individuals, groups, or nations—creates a danger for us all.”

  Though his words were received with thunderous applause and a standing ovation, Mann knew that many of those before him who were loudly slapping their hands together and politely nodding approval were, back home, promoting policies of mandatory quarantine of HIV-positive individuals, escalated repression against homosexuals, even public execution of AIDS sufferers.

  As a scientist, Mann knew that the men and women now looking up at him on the dais, studying his smile and careful public modesty, were People of Politics. They might wear the titles of health officials, but their modi operandi were less those of the laboratory or hospital than those of the maneuvering, backstabbing, and power plays seen in parliaments and presidential inner circles. What the ministers said publicly here in London would be at least as much for domestic consumption as for the sake of any global effort to stop the pandemic.

  Anticipating such limitations, Mann and his Global Programme on AIDS (GPA) staff had toiled for months in preparation for this moment. Lifelong WHO veterans, and occasional renegades, Tarantola and Manuel Carballo showed Mann how to maneuver around the labyrinthine and often byzantine United Nations bureaucracy. Swiss-American Tom Netter, having spent years covering the rise of Solidarity and the fall of communism in Poland for the Associated Press, plotted every step of the GPA’s interactions with the international media. Spanish-born Carballo, who knew every no
ok and cranny of the World Health Organization even better than WHO Director-General Halfdan Mahler, helped spot the few potentially influential individuals within the bureaucracy who understood the urgency of the AIDS epidemic.

  “This is a place where people put URGENT! on requests for pencil supplies,” Mann said in wonder. “The concept of genuinely dire emergency has almost no meaning here.”

  Carballo couldn’t have agreed more. One of the happiest days of his life was when he joined the GPA staff. He felt charged up, at the top of his performance and truly impassioned about his work, possibly for the first time in his life.

  They all did: American epidemiologists Jim Chin and David Heymann, Venezuelan biologist José Esparza, British public health expert Roy Widdus, Tarantola, Mann, and the dozens of scientists and public education experts who came to Geneva under special contracts to advise the GPA. They shared a mission: stopping the further spread of AIDS. And as Heymann and Tarantola had done before in their efforts to stop smallpox, these men were willing to bend every UN and WHO rule as far as possible to stop the pandemic. They were believers. Between them they shared the ability to write and converse in at least fifteen languages. And they had a camaraderie that was quite uncharacteristic of the usually opportunistic careerist atmosphere pervading most United Nations programs.

  When Mann had originally left Kinshasa to take the reins of power in Geneva in November 1986, he had a total working budget of $5 million, a part-time secretary, and three epidemiologists who were borrowed from other programs. Mann’s own salary was still paid by the U.S. Centers for Disease Control.

  By the time he reached London for the January 1988 Summit, less than two years later, forty-year-old Mann commanded a far-flung AIDS program, a considerable staff, and a budget of over $50 million, with $92 million promised for 1989. It was, by WHO bureaucratic standards, a meteoric rise.