by Piot, Peter
I tried to find out where these women came from. Most of them appeared to be Kenyan, but in other neighborhoods, such as the Pumwani district, there were concentrations of young women from Muhaya villages in the Akagera region near Lake Victoria in Tanzania. Their situation was a little like that of the gold miners in Carletonville. They traditionally came to Nairobi for a year or two, accumulated some capital, went back home, got married, and started a business. Just about everyone in their villages knew pretty much what they did to earn a living, but they pretended they didn’t know and that made everything all right.
I spent about a month in Nairobi, to get things going. To staff the project on a permanent basis, I recruited Lieve Fransen, whom I knew from medical school in Ghent; she had worked in Mozambique for the first government after Independence and was tough as nails. She later became the director of the European Union’s AIDS Task Force and is now a director at the European Commission Communication department. Allan had sent in a Canadian fellow, Frank Plummer, who was the real pioneer of the project (with Allan as mentor and driving force). Frank, a tall teddy bear from the Canadian plains, was the eternal optimist, an entrepreneur with more new (and excellent) ideas than any of us could remember, and always ready to support our Kenyan colleagues. He is now director of the Canadian equivalent of the CDC. When Lieve Fransen returned to Belgium in 1984, she was succeeded by Marie Laga, who had worked for Médecins Sans Frontiêres in Burundi, an unflappable woman who had a gift for communicating with people and who became a leading figure in HIV prevention work in Africa. And then there was Elizabeth Ngugi, a tiny, but superenergetic Kenyan nurse and professor of community health, who brought a local public health perspective. She pushed us continuously to work more with communities of women and sex workers, looking beyond the medical and epidemiological issues we were trying to resolve, and also addressing the root causes of prostitution and assisting women in their struggle for a decent life free of coercion. (The project increasingly did so.) All this created the foundation of a long-term partnership between the universities of Nairobi, Manitoba, Washington, and later Ghent, and the Institute of Tropical Medicine, which over 30 years later is still active.
From the onset, we were committed to ensuring that the results of our research benefitted the people of Kenya. This was not so easy, as this kind of translation of science into policy and implementation involves many steps and many institutions (as I later learned the hard way as head of UNAIDS). Our main interlocutor was the Ministry of Health and, fortunately, over the years the Kenyan administration became more open and committed to our work. I wrote grant proposals for the European Union, which had just launched a new program to support research on health in developing countries. At the end of 1982 Herbert Nsanze and I were notified that what seemed like a massive grant was on its way to us—150,000 écus ($200,000, at today’s exchange rate) to fund a study to determine the best way to treat chancroid and resistant gonorrhea in Africa. The penicillin-resistant gonococcus from Cote d’Ivoire that I had discovered in Antwerp was already marching across the continent, spreading far faster than in heterosexual communities in Europe or North America.
By this time I was going to Nairobi three or four times a year, whenever I managed to scrape together the budget. Gradually we began working on other pathologies. We were the first group in Africa to work on chlamydia, which turned out to be a lot less common in Nairobi than it was in New York or Brussels. (We wondered at first whether this was because of a very common eye infection, trachoma, which was also caused by a member of the chlamydia family; perhaps suffering that eye disease as a child provided protection against the genital infection. But following studies in two areas around Nairobi, that theory didn’t hold.)
We also became very involved in sexually transmitted diseases during pregnancy—what they do to the pregnancy and, if it continues to term, to the newborn child. The previous medical literature talked about gonorrhea making African women infertile, but there hadn’t been any proper research on these complications using modern clinical and microbiological techniques since the early 1960s. It seemed to me though that given the number of women that we were seeing at the Casino Clinic—and the kinds of complications that appeared to be common—the problems caused by STDs in pregnancy were probably much bigger than people thought.
So we went to Pumwani Maternity Hospital, the largest maternity hospital in East Africa. It was like a baby factory, with 25,000 births a year, in an atmosphere so filthy and neglected that I wondered how anybody merits to start life this way.
The contrast between the maternity hospital where my children were born (in the meantime blonde Sara was born in 1980) and the conditions these long-suffering Kenyan women had to give birth in were simply intolerable. The doctors at Pumwani were paid a pittance, and so they were often completely unavailable. They concentrated on their private practices and left the whole place to the nurses and midwives, strong women who worked with incredible dedication. And yet many of the health authorities of the country, who quite obviously knew about the situation, didn’t act, usually mentioning budgetary problems whenever I brought it up. Of course they had a point—in those days a major part of the nation’s health budget was absorbed by Kenyatta National Hospital, the university hospital on whose campus we had our office. But better management and incentives would have gone a long way to improve the situation at Pumwani Hospital.
At the university, the professors were smart and committed, maintaining high standards of medical education. But the sobering reality was also that medical services were deteriorating fast. Women routinely bled to death; the level of preventable neonatal deaths and infections was inexcusable; and the appalling conditions I saw in Pumwani really motivated me a lot to work on simple methods of at least preventing the worst kinds of postpartum infections.
Beginning in about 1900, it was established medical practice to administer silver nitrate eyedrops to all babies at birth to prevent them from acquiring gonococcal infection from the mother and possibly going blind. It was a triumph of public health in Europe. But Nairobi hospitals abandoned this practice after caustic concentrations of silver nitrate—a consequence of evaporation—caused severe eye damage. Damned if you do, damned if you don’t.
So Marie Laga and her colleagues Pratibha Datta and Warren Namaara did a number of classic studies to look at new ways to prevent the transmission of gonococcal and chlamydial infection by using safer tetracycline ointment. At the same time, we began working on ways to treat babies who had already been infected. As it turned out, instead of the recommended penicillin treatment, which was longer term and required hospitalization, all it took was one shot of ceftriaxone, a fairly expensive cephalosporin. Follow up of the babies in the slums was a real challenge, because “regular” addresses often did not exist. Therefore mapping was essential, with information such as “Go to toilet number 7, then three streets to the left, and she lives on the first house on the right with a red roof.” This work remains the basis for current international guidance for the prevention and treatment of neonatal conjunctivitis.
I thought perhaps this was my niche in science: figuring out the connections between sexually transmitted disease in pregnancy and complications in newborns, and then figuring out ways to solve those problems before they happened. It was the kind of work that made my heart lift: applying solid science to a complex problem in poor countries, and developing better ways to prevent and treat disease—in a sense, producing the goods that other clinicians use.
When we started the project we had no business plan, no specific goals, and hardly any money beyond one year of functioning. We were young, optimistic, and committed to solving the formidable problems of ill health Kenya was facing. The challenges were enormous, and none of us had firsthand experience in solving them—logistics, finances, publication rights, and day-to-day management.
Nowadays there are dozens of similar projects in Africa, but at the time we began, none focused on sexually transmitted disease
s and on women’s health. The few existing research programs were nearly all linked with the former colonial powers, whereas it was always important to us to strengthen the capabilities and infrastructure of our African partners. I am particularly proud of the large numbers of Africans, North Americans, and Europeans we trained in Nairobi. Many are now established clinicians, epidemiologists, and researchers in their own right.
Of the researchers whom I recruited for our Nairobi project, almost all were women. This was far from the traditional approach: men dominated research in Africa. But I knew it would make a difference, in terms of the degree of attention that they paid to the African women on whose behalf we were working. Many a time I examined a woman or talked about a case with a colleague and felt overwhelmed with anger. These infections were not just painful, they caused a great deal of permanent damage. Infertility is a drama for women anywhere in the world, but in Africa it can destroy you—your marriage, your value in society, your self-worth. I wanted to dispel the unspoken and cruel assumption that if African women had a fertility problem perhaps that was not a terrible thing.
IN MANY WAYS I loved living in Belgium. I felt the country was changing for the better—becoming more international, particularly thanks to Brussels’ being the headquarters of the European Community, NATO, and a growing number of corporations, with a thriving economy and growing skills in biotechnology and microchips. I loved the food, the artistic life, and the social culture, centered on neighborhood cafés. But there was a strange atmosphere in the country in the early 1980s. There were a number of scandals involving kickbacks to individuals and to political parties, and ultra-right-wing activism by secret groups. A gang of killers went around the country, shooting up stores and supermarkets. A parliamentary commission investigated these crimes, but they were never solved. The extremist Vlaams Blok party emerged; it was mixed up with Flemish nationalism, and xenophobia, and campaigning for the independence of Flanders.
One evening a week I volunteered at a free youth clinic in a battered old terraced house near the Antwerp central station, which mostly involved prescribing contraceptives. Many doctors in those days wouldn’t prescribe the pill to unmarried girls and women, let alone help women find abortions if that was what they desperately wanted. I also saw many drug users, an extraordinarily difficult group to work with as a doctor and emotionally charged for me—I had lost a friend from medical school to an overdose. He was one of our most brilliant students, and I never came to grips with his addiction and death, which occurred when I was in Zaire during the Ebola outbreak.
Often when I left for Africa I felt I could be more useful: I could make a difference. I welcomed the sheer physical space; Belgium is one of the most densely populated countries in the world. There was also the joy that I perceived in so many African cultures. People were poor, but in their poverty they were creative and energetic. In Belgium, by contrast, people complained so much, from the weather to their aches and pains to the state of hospitals and schools, and this seemed to me a gigantic waste of time and energy: Belgium has some of the best education and health care in the world. As our Nairobi research program grew, I began to travel much more widely around Central and West Africa. I went several times to Burundi, where the Institute of Tropical Medicine had a program to train doctors who had received substandard medical education in the former Soviet Union. I also helped out with one of Pattyn’s research projects, monitoring some of his research on the treatment of leprosy, in Burundi and Senegal.
There was something of a revolution underway in leprosy treatment. Up to then, one form of leprosy (“paucibacillary” or “tuberculoid”) was fairly easily treatable, although the treatment was long. But in lepromatous leprosy—where leprosy bacilli appear all over the body—the patient’s immune system was so damaged there was no real treatment. Pattyn’s group helped show that if you used several drugs in combination, you could actually cure the disease. It was the basis of the near-elimination of leprosy today. The work brought me full circle, to Father Damien, my childhood local “saint,” who tried to care for and treat lepers in Hawaii. While I was still searching my way through the fascinating worlds of academia, research, clinical care, and international development, I was accumulating highly diverse experience and getting ready for the next chapter.
• PART THREE •
CHAPTER 10
A New Epidemic
MEANWHILE, IN ANTWERP, I became the go-to doctor for people arriving from Africa with embarrassing tropical infections and gay men seeking discreet medical advice. Some of the time, men and women who consult a doctor regarding matters below the belt are actually expressing psychological difficulties—pain in relationships. So many of the patients I saw at my clinic in Antwerp were actually the worried well. But the gay men that I saw displayed a truly baroque variety of illnesses, and there appeared to be a real explosion in the homosexual community of syphilis and hepatitis B. If some kind of epidemic wave was underway, we definitely needed to do something about it; but first, it needed to be documented. So, just as I did in Nairobi, I took a few of my students and went out to do a survey at what was clearly the local ground zero: Antwerp’s gay bars.
There were a lot of them. I had gathered, from conversations with gay friends and patients, that the homosexual community in Antwerp—like everywhere else in Europe—was pretty hypersexed. But I wasn’t prepared for what that really meant. I remember the first leather bar we went to, where I faced the startling sight of a man with leather chaps strapped across his bare bottom. And I was particularly surprised by the anonymity of the sex.
In Belgium, the early 1980s were a time when gay men at last felt they could burst into the open. (It wasn’t like Belgium today, when a man easily mentions that he went somewhere with his husband, now that same-sex marriage is legally and socially accepted.) There was still quite a lot of discrimination; it was difficult, for example, to be an openly gay schoolteacher. But Antwerp was then funkier than Brussels, more connected to havens of tolerance like Amsterdam, and far more relaxed about homosexuality than the rest of the country. It had a lively fashion and art scene, a port and a sense of openness to the world, which may have explained the kind of sexual acting-out that I was seeing.
We took blood in the bars, and estimated the prevalence of various STDs. Seven percent had syphilis, and 34 percent had had hepatitis B, figures that were indeed far higher than for other populations in Belgium. We organized a vaccination campaign for hepatitis B, with flyers and feedback sessions in the gay community. And of course this brought more gay patients to our clinic; indeed, that was the intention: to seek people out and treat them. They received state-of-the-art treatment and advice. I’ve also always, instinctively, felt it’s important to touch patients—take a hand, hold a shoulder—to help establish a real connection. My first experience, long ago, was with a leprosy patient, when I first began working with Pattyn. It was a Belgian priest, and he recoiled and said, “No—don’t touch me.” He was convinced I would catch his disease, and when I told him I really would not catch it, he almost broke down. But I was never frightened of touching. I wouldn’t obviously go with bare hands somewhere where there’s blood, or into someone’s mouth, but touching the skin? There’s always soap.
IT HAD BEEN almost five years since Ebola, and I was still fascinated by the sudden epidemic, not the chronic problems of medicine, but the rush of adrenaline that comes with a mystery outbreak. Anyway, it meant that I paged through every issue of the CDC’s Morbidity and Mortality Weekly Report (“MMWR” for the initiated), which would report on outbreaks in the United States and often also in other countries. And on June 5, 1981, the MMWR ran an item on five young, white gay men in Los Angeles who’d contracted Pneumocystis carinii pneumonia, which up to then almost exclusively appeared in severely immunosuppressed patients and rarely so since being identified in orphanages in Europe after World War II. All five men also had aggressive infection with cytomegalovirus. Soon after that first publication, cases were r
eported from other parts of the United States, with some men having aggressive Kaposi’s sarcoma, a rare skin disease usually seen in Central Africa, and occasionally in older white men of Mediterranean and Jewish descent.
Because this seemed to be a new syndrome—and it was occurring in gay men—I read the item with more attention than usual. It rang a little bell, though not necessarily the correct bell. This was something new, something exciting and also intellectually interesting—a mystery. Gay men. Symptoms of unknown origin. I didn’t immediately think of Africa, or about the Greek fisherman whose body I helped autopsy in 1978, but I wondered whether this was also happening in our gay community in Antwerp, in particular after the subsequent reports of what still did not have a name.
Then in October 1981 I went to Chicago to attend the annual meeting of ICAAC (the Interscience Conference on Antibiotics and Antimicrobial Chemotherapy) and the Infectious Disease Society of America, of which I was a member. There were a number of talks there about this new “gay syndrome” (a syndrome is a group of symptoms and signs that collectively are characteristic of one or more diseases). The hallmarks were Kaposi’s sarcoma and Pneumocystis carinii pneumonia, so again, I didn’t make any links with African patients we started to see in Antwerp. But when I returned from Chicago, I talked about it over a beer with my friend Henri Taelman, who was the head clinician at the Institute of Tropical Medicine.