A Short History of Disease

by Sean Martin

  HIV/AIDS

  On 8 May 1980 the World Health Organization made a momentous announcement: they ‘Declare[d] solemnly that the world and its peoples have won freedom from smallpox’.408 For the first time, one of the major diseases in history had been consigned to laboratory vaults and would no longer be claiming lives. No one involved in the smallpox campaign could have suspected that a new pandemic was already upon the world.

  Later that year, a 30-year-old man went to see Dr Joel Weisman, a Los Angeles doctor who specialised in gay men’s health. Weisman noted his patient ‘had painful eczema, persistent diarrhea, and endless fevers.’409 The man was clearly very unwell, but the symptoms puzzled Weisman. A colleague had reported a similar case just a month or two before, of another young gay man, who had a ‘strikingly similar disarray in his immune system.’410 The man was suffering from a ‘constellation of diseases [that] was startling. White fungi grew around the man’s fingernails, fluffy candidiasis was sprouting all over his palate, and he too was suffering from rashes, prolonged fevers, swollen lymph glands, and low white blood counts.’411 By December, Weisman’s colleague had also diagnosed immune deficiency.

  By the end of 1980, there would be 55 reported cases in the USA, four of them fatal. The one thing that linked them was the fact that all the men were gay. Doctors such as Weisman and his colleague, the Centers for Disease Control and Prevention in Atlanta (the CDC), the National Cancer Institute in Maryland, and elsewhere began to fear that something was going on. ‘If something new gets loose here,’ commented the San Francisco Department of Public Health’s Dr Selma Dritz – a specialist in gay health and STDs – ‘we’re going to have hell to pay.’412

  Something indeed was getting loose. On 5 June 1981, the CDC’s Morbidity and Mortality Weekly Report – a journal sent to hospitals, public health institutions, doctors and anyone working with infectious diseases – ran a report on five young male patients with an unusual immune deficiency, who were all suffering from a rare form of pneumonia called Pneumocystis carinii pneumonia (PCP). All were gay. The author of the paper, Dr Michael Gottlieb, commented, ‘The fact that these patients were all homosexual suggests an association between some aspect of homosexual lifestyle or disease acquired through sexual contact and Pneumocystis pneumonia in this population.’ The San Francisco Chronicle ran a story on the report, ‘A Pneumonia That Strikes Gay Males’, the following day. It was the only mainstream newspaper to carry the story.

  PCP wasn’t the only thing afflicting the men with the mystery illness. Many of them were also suffering from a rare form of skin cancer called Kaposi’s Sarcoma, more commonly seen in old Mediterranean men. One of the first cases had been reported to the CDC on 24 April. Ken Horne, a young San Franciscan former ballet dancer, was suffering from Kaposi’s Sarcoma, and also cryptococcus, a fungal yeast infection. The New York Times ran an article on the Kaposi’s Sarcoma cases on 3 July, ‘Rare Cancer Seen in 41 Homosexuals’. The following day’s issue of the MMWR also reported on the prevalence of Kaposi’s Sarcoma among gay men. Many of them were also suffering from PCP.

  News of the ‘gay plague’ spread fast. As with leprosy, the Black Death and cholera, some commentators were quick to ascribe moral blame for the new mystery illness, dubbed GRID – gay related immune deficiency. Just as lepers had been blamed in the Middle Ages for their condition, on the grounds that it was the result of sin, sexual sin in particular, just as the Black Death was the result of everyone’s sins, and cholera afflicted the poor because they were morally weak and had committed the sin of being poor, so GRID was seen by some rabid conservatives as the fruits of the ‘sin’ of homosexuality. The religious right foamed at the mouth. Newspapers ran headlines such as ‘Exterminate gays’ and called for victims to be placed in quarantine.413

  Doctors such as Joel Weisman and Selma Dritz knew full well that gay men were certainly on the front line of health issues in places like San Francisco in the 1970s. Gay liberation meant sex, lots of it, in bathhouses, private cinemas, the back rooms of bars, men’s rooms, alleyways, etc. Such liberal sexual practices – central to gay identity at the time – had led to gay men suffering from abnormally high cases of hepatitis B, as well as amebiasis – a deadly parasitic disease that causes dysentery and diarrhoea and is often transmitted by faecal-oral route or, as was common in gay bathhouse culture, the anal-oral route (rimming, in other words) – shigellosis, a bacterial disease that causes diarrhoea, cramps, fever and vomiting, and a condition known as ‘gay bowel syndrome’.

  The more the new illness was studied, however, it became clear that there were other susceptible groups. Along with homosexuals, haemophiliacs, heroin addicts and Haitians were suffering. They were dubbed the ‘4 H Club’. It was clear that, whatever the disease was, it was not just affecting gays, and GRID became AIDS – acquired immune deficiency syndrome. To the chagrin of the anti-gay fearmongers, a fifth ‘H’ group was identified in a 1984 article in The Lancet: heterosexuals.

  Peter Piot, one of the authors of the piece in The Lancet, was a Belgian clinical microbiologist who worked at Antwerp’s Institute of Tropical Medicine, ‘the go-to doctor for people arriving from Africa with embarrassing tropical infections.’414 But the patients were increasingly suffering from diseases that were strange rather than embarrassing. One case, from 1979, stuck in Piot’s mind. A Greek fisherman, who had lived and worked on the shores of Lake Tanganyika in eastern Zaire, was suffering from a number of severe infections that eventually killed him. But the autopsy results proved startling to Piot: the man’s internal organs had virtually been destroyed by an unusual mycobacterial infection. Like American patients suffering from Kaposi’s Sarcoma and PCP, the Greek had had a condition that under normal conditions should not prove fatal, but, in his case, it had.415

  Hearing about the ‘gay plague’ in America, Piot wondered whether this might be the same illness that his African patients were suffering from. Colleagues in Brussels had reported numerous similar cases. If there were 100 sick Africans who could afford to be treated in Belgium, what might the number be back home? Piot and his team began taking blood samples in gay bars and clubs, noting higher incidences of syphilis and hepatitis B than would normally be found.416 In 1983, Piot and a team of European and US doctors visited Zaire. They encountered conditions in Kinshasa’s Mama Yemo Hospital that would not have looked out of place in one of Goya’s paintings of a madhouse: some parts of the building had collapsed, there were piles of rubbish rotting in the courtyard, and the wards were full to overflowing. The sick were two to a bed, with more ailing on soiled mattresses on every available bit of floor space.

  Piot recalled his first impression of the wards in Mama Yemo:

  ‘They were mostly twenty-five- to thirty-five-year-olds, with enormous weight loss, intractable diarrhea, and that ghastly, glassyeyed look. Many of them had dramatic itching, with skin symptoms that had not been described in the literature. They had a lot of sores in their mouths – yeast infections and very ugly herpes sores – and eye infections. A few had Kaposi’s Sarcoma markings, especially on their legs, and many were breathing very superficially; perhaps the respiratory distress stemmed from tuberculosis. There was also quite a bit of cryptococcal meningitis, which we knew was a marker of AIDS… their symptoms were remarkably aggressive: they progressed with startling speed and seemed not to respond to treatment.

  ‘We were all silent and staring at each other… When we got out of there, I took a deep breath, as I was nearly breathless. I remember it well – a physical sensation that was so strong, I wrote it down. It wasn’t the happy tingling energy of scientific discovery… [but] the overwhelming feeling that we were facing a truly momentous catastrophe.’417

  When published in The Lancet the following year,418 Piot et al’s findings from Kinshasa ‘clearly demonstrated that HIV [see below] was well established in central Africa where it affected both men and women and was spread by heterosexual contact.’419 Alarmingly, the prevalence of AIDS was higher in Kinshas
a and Rwanda’s capital, Kigali ‘than in San Francisco or New York,’ clearly ‘dispelling any lingering notions that AIDS was a disease restricted to ethnic or sexual minority groups.’420

  While Piot was at work in Africa, an American team of researchers led by Robert Gallo at the National Cancer Institute, and a French team led by Luc Montagnier at the Pasteur Institute in Paris, both announced that they had discovered the cause of AIDS. The human immunodeficiency virus, or HIV, is a retrovirus that attacks the immune system, making normally routine diseases suddenly fatal. There are two main types, HIV-1 and HIV-2. HIV-1 is the more deadly, and is now thought to derive from SIV – simian immunodeficiency virus – which affects chimpanzees. HIV-2 is related to a virus of the sooty mangabey, a monkey found in West Africa. Within HIV-1, there are various subtypes, and it is only HIV-1 group M that causes the pandemic. The incubation period can be anything up to ten years, but when it develops into AIDS, it is fatal. Drugs were powerless to stop it. HIV is transmitted through sexual intercourse, contaminated needles, infected blood or from mother to baby in the womb. Three of the ‘4 Hs’ were covered – but what about the fourth, Haitians? Why had the virus seemingly attacked Haitians, out of all the ethnicities in the USA?

  In trying to answer that, doctors inevitably faced the challenge of trying to discover where HIV/AIDS had originally come from. Given that the incubation period can be anything up to ten years, what were then thought to be the first victims – 1975–78 in Kinshasa, 1978–80 in Europe, 1979/80 in the US – could have picked up the virus at any time from the late 1960s onwards. A report published in July 1982 suggested Haiti as the possible source of the epidemic. Between 1980 and 1982, 20 Haitians had been admitted to hospital in Miami, suffering from AIDS. It transpired that all of them had been working in West and Central Africa before being taken sick, and it was towards Africa that scientists began to look for the origins of HIV.

  Mystifyingly, scientists began to uncover cases even earlier than the ones already noted. The earliest they found both came from the Democratic Republic of Congo. A man had died of HIV in 1959, and a woman the following year. In 1987, tissue samples were tested of a young African American from St Louis, Robert Rayford, who had died from a mystery illness in 1969. Rayford had been suffering from immune system collapse, and had also developed Kaposi’s Sarcoma. The 1987 tests showed he had died from AIDS. It is thought he might have worked as a rent boy, been sexually abused, or both. Given that Rayford had been ill since late 1966, it seems HIV may have first entered the USA around that time, but didn’t start to become epidemic until the late 1970s, possibly due to a reintroduction of the virus into the country.

  Then there was the case of the ‘Norwegian Sailor’, whose identity was initially hidden to protect his family. He was eventually named as Arvid Noe421. When samples of his blood and tissue were tested in 1988, it was found he had died of AIDS in 1976. As a sailor in the Norwegian merchant navy, it was thought Noe had been infected by a prostitute in Cameroon at some point between 1961 and 1965. He returned home in 1966, and found work as a truck driver. It was around this time that Arvid Noe began to fall ill. Doctors didn’t know what was wrong with him. Noe’s wife also began to suffer from the same cluster of illnesses; she died in December 1976, eight months after he did. Tragically, it was their 7-year-old daughter who died first, in January 1975. She was the first European to die of AIDS, and the first known case of mother-baby infection.

  While these early cases were coming to light, the number of cases in the USA continued to rise, going from 55 in 1980 to 7699 in 1984, of which 3665 had died. In the UK, 108 cases had been reported, resulting in 46 deaths.422 The World Health Organization launched its Global Programme on AIDS in 1987, and public health campaigns to stop the disease were launched in Europe and the USA. The first International AIDS conference was held in Atlanta, Georgia (home of the Centers for Disease Prevention and Control), and the first antiretroviral drug for HIV/AIDS, AZT (azidothymidine), was approved by the American FDA. AZT was then rolled out for use in Europe. In the UK, a needle exchange programme was started, and safe sex messages appeared across the media. Organisations such as the Terrence Higgins Trust in the UK and the San Francisco AIDS Foundation became well-known for their work in fundraising, providing palliative care and raising awareness. These were all timely measures: by 1987, there had been 40,051 AIDS cases in the USA, with 23,165 deaths,423 and in 1988, it was announced that AIDS cases worldwide had jumped by 56 per cent.424 The possibility that AIDS could become the worst pandemic ever known was being mooted.

  Film icon Rock Hudson was the first major celebrity to announce that he was suffering from HIV, in July 1985; he died from AIDS that October. His death helped boost funding for AIDS research, as Hudson was seen as a ‘respectable’ actor (his homosexuality was not widely known), and if someone respectable could get AIDS, it was clearly a disease that could affect everyone, and not just minorities (Haitians, haemophiliacs) or ‘deviants’ (gays, intravenous drug users). The same issues resurfaced when tennis champion Arthur Ashe (1943–1993) announced he had HIV in 1992. Ashe was among the first high profile non-gay victims of the disease, who is thought to have contracted HIV as the result of a blood transfusion. Ashe’s admission that he had contracted HIV in hospital became a high-profile case, and Ashe, who was also a vigorous activist, used the glare of publicity to ask the UN for more funding into AIDS research.

  But in the early 90s, HIV/AIDS was still seen mainly as a disease affecting gay men; the escalating numbers of heterosexual casualties in Africa made the news less often. As with the Spanish Flu, it was a classic case of third world (i.e. black) lives mattering less to first world media corporations. (Asked if getting AIDS was the hardest thing he had ever had to face, Arthur Ashe replied, ‘No, the hardest thing I’ve ever had to deal with is being a black man in this society’.425) When British writer and journalist Ed Hooper visited East Africa to research the effect of AIDS, he was met with some frightening facts. The disease was known as ‘Slim’ because of the weight loss and wasting it caused. No one knew exactly what caused it, or where it had come from. Its prevalence among the general population in Uganda was alarming. One doctor remarked that there were no high-risk groups for the disease except ‘being Ugandan’.426 Hysterical patients received minimal treatment in overcrowded hospital wards, where the nurses were too terrified to touch the patients (the conditions Peter Piot and his team encountered at Mama Yemo Hospital in Kinshasa in 1983 were clearly not unique). People resorted to witchcraft remedies, such as eating dog’s liver soup, in an attempt to get well. Others killed themselves. Whole villages lay abandoned. The situation that confronted Hooper was ‘one of very high levels of infection, increasing numbers of people with full-blown AIDS, and of a quite inadequate government response.’427

  Heading back to Kampala, we picked up a hitch-hiker who was eager to talk about the epidemic. He himself knew of two cases of Slim, one a woman who now had skin ‘like a frog’s’. He told us that Slim was not caused by ‘free sex’, but by sharing needles for injections, or the straws that were commonly used for drinking malwa, the local beer. The prostitutes in Kyotera, he added, were telling people that Slim disease was not AIDS, but a special type of poisoning caused by certain Tanzanian tribes who were expert in witchcraft. When we questioned him further, he told us that a local priest had said at the funeral of a ‘Slim victim’ that the disease was like one of the plagues of Egypt, striking down the immoral.428

  Drugs were initially too expensive to be widely distributed in the West, let alone Africa. HAART (Highly Active Antiretroviral Therapy) was developed in the mid-1990s, and proved effective in subduing the effects of the disease. Over the next decade, the cost of these drugs came down and did eventually reach Africa. The problem with developing vaccines has been that HIV doesn’t behave like any other known infection: it mutates rapidly, resulting in a genetically diverse group of subtypes and forms. If a drug works for HIV-1, for instance, it may do nothing for HIV-2,
and within those two strains, there are the M, N, O and P groups, and further distinctions within some of those (such as HIV-1 group M subtype C), and so on.429

  Vaccines have also played an intermittent role in the search for the origins of HIV. One theory proposed that HIV had been accidentally created by scientists when they were developing anti-polio treatments for the developing world in the 1950s. These early vaccines had used monkey kidney cells which, when administered in the Congo in the late 50s and early 60s, had accidentally kick-started the AIDS pandemic. This theory, known as the Oral Polio Vaccine theory, has been largely discredited, although the earliest known cases of HIV do seem to have come from the Democratic Republic of Congo, as we’ve seen.430 What remains a possibility is that the re-use of hypodermic needles in the campaigns against polio and smallpox helped spread HIV, but this remains conjectural. If true, it would be one of the more horrible ironies in the story of humanity’s battle with pandemics.

  Current medical thinking on the origins of HIV suggests that it first appeared in southeast Cameroon at some point between 1884 and 1924.431 Both main types of HIV are now known to be related to Simian Immunodeficiency Virus (SIV), which affects chimpanzees and sooty mangabeys respectively. At some point, the virus made the species jump between monkeys and humans, possibly when hunters became infected from either eating bushmeat, or from cuts sustained while butchering the meat.

  The date of 1884 is significant because that was the year in which the Germans took over Cameroon and began developing the country’s infrastructure, building road and rail networks, ‘with a view to exploiting the country’s potential wealth – ivory, rubber, timber, coffee and cocoa – to the full.’432 The result of this was twofold: new roads and railways disrupted traditional Bantu hunting grounds, and cities began developing. The crucial species jump may therefore have happened when the Bantu were seeking new areas in which to hunt, territories not being disrupted by German expansion; or conversely, it could have been the monkeys who were displaced. Either scenario is conjecture, and we must also remember that the species jump could have happened on more than one occasion before the virus was established as a human disease. But this is where the railways, roads and expanding cities came in: as a way for the new disease to travel and multiply.