Patient Zero and the Making of the AIDS Epidemic

by Richard A. McKay

  edgment that someone like him— who has undertaken extensive research, who has seen

  some of his interviewees subsequently retract their recorded testimony, and whose oppo-

  nents have misrepresented and then ignored his points— might have genuine concerns that

  he was witnessing something resembling a cover- up.

  33. For example, Hilary Koprowski, “Hypotheses and Facts,” Philosophical Transac-

  tions of the Royal Society of London B: Biological Sciences 356, no. 1410 (2001): 832; Stan-

  ley A. Plotkin, “Chimpanzees and Journalists,” Vaccine 22 (2004): 1829– 30. Hooper’s re-

  buttal to this allegation can be read on his website: “The Allegation That The River Has

  Damaged Modern Attempts to Eradicate Polio,” AIDS Origins (blog), October 15, 2004,

  http:// www .aidsorigins .com/ allegation - river - has - damaged - modern - attempts - eradicate

  - polio.

  Introduction 13

  panzee to a single human.34 Others have investigated the sociopolitical

  and environmental conditions in early twentieth-

  century Africa that

  may have contributed to the early expansion of HIV.35

  The Origins of AIDS (2011)—a substantial contribution to the dis-

  cussion from Jacques Pepin, a microbiologist and infectious disease spe-

  cialist—offers a detailed contextualization of the colonial environment

  of central Africa in the fi rst half of the twentieth century and argues

  for the plausibility of the “cut hunter” theory. Pepin presents compel-

  ling evidence for a previously little- known outbreak of disease sugges-

  tive of AIDS in a railway camp in French Equatorial Africa in the 1920s

  and early 1930s. Building on computer estimations that have dated the

  crossover event to the fi rst decades of the twentieth century, he takes

  “1921” as a date for argument’s sake. Around this time, he proposes, an

  unknown individual— “the true ‘patient zero,’” he writes— came in con-

  tact with the blood of a chimpanzee infected with a simian immunodefi -

  ciency virus; Pepin suggests that sixty million people in the world today

  can trace their infections from this individual.36 Pepin also provides use-

  ful historical evidence to demonstrate the close trade and employment

  ties linking the colonial territories of French Equatorial Africa and the

  Belgian Congo near the towns of Brazzaville and Léopoldville. Here, an

  34. Michael Worobey et al., “Direct Evidence of Extensive Diversity of HIV- 1 in Kin-

  shasa by 1960,” Nature 455, no. 2 (2008): 661– 64. By holding as a constant the rate at which

  a virus mutates, they argue that this “relaxed molecular clock” method allows researchers

  to estimate backward to the time of the initial crossover event, to a virus from which all

  subsidiary strains began mutating away. Critics of this approach, of which Hooper is again

  one of the most vocal, contend that such a method cannot work with a virus like HIV.

  The virus evolves four to ten times as much through recombination— when an individual

  is infected with two or more strains of HIV and the viruses swap genetic information with

  each other— as it does through mutation. The relaxed molecular clock method, these crit-

  ics contend, cannot control for this recombination. See Hooper, “Michael Worobey’s Wob-

  bly Research into the Early History of HIV,” AIDS Origins (blog), March 19, 2008, http://

  www .aidsorigins .com/ michael - worobey - wobbly - research - early - history - hiv; Simon Wain-

  Hobson et al., “Network Analysis of Human and Simian Immunodefi ciency Virus Se-

  quence Sets Reveals Massive Recombination Resulting in Shorter Pathways,” Journal of

  General Virology 84, no. 4 (2003): 885– 95.

  35. For example, Tamara Giles- Vernick et al., “Social History, Biology, and the Emer-

  gence of HIV in Colonial Africa,” Journal of African History 54 (2013): 11– 30.

  36. Jacques Pepin, The Origins of AIDS (Cambridge: Cambridge University Press,

  2011), 1– 58, “patient zero” quotation at 40.

  14

  chapter 0

  unknowingly infected individual could have brought HIV from one co-

  lonial region to another relatively easily on a one- hour boat ride. He also

  contends that iatrogenic infections— unintentional HIV transmission by

  doctors re using unsterilized needles— are likely to have played a signifi -

  cant role in the rise of HIV in Africa in the early to mid- twentieth cen-

  tury (though not in the present day).37

  Pepin draws on recent studies to conclude that the virus traveled from

  central Africa to Haiti during the 1960s, in the body of one among sev-

  eral thousand Haitian workers who were recruited to work in Zaire dur-

  ing that decade and who later returned to their home country.38 He sug-

  gests the possibility that high- volume blood plasma collection in Haiti

  provided an effi cient means of transmitting the newly introduced virus

  to many Haitians. From there, through the transnational blood indus-

  try and sexual liaisons between American homosexual travelers and in-

  fected Haitian men, the same subtype of HIV made its way from Haiti

  into North America by the early 1970s. There it spread silently through

  populations of injecting drug users, men who had sex with other men,

  and the recipients of blood products, before coming to the attention of

  investigators when these infected individuals fell sick up to ten years

  later.39 From the vantage point of 2011, Pepin is able to place “the case

  of the Air Canada fl ight attendant, the so- called ‘patient zero,’” at the

  very end of his account. He serves as a highly visible fi gure, emblem-

  atic of the disease’s amplifi cation and rapid spread in the 1970s through

  North America’s gay communities, but not a unique player in this over-

  all global diffusion.40 North American readers did not share the benefi t

  of this synthesis in 1987, when newspapers reported the identifi cation of

  a Canadian fl ight attendant as “Patient Zero” for an epidemic thought

  then to have begun in the late 1970s. “Patient Zero” would therefore, by

  virtue of his transatlantic travels, offer the simple solution to Americans

  asking the question, “How did AIDS arrive here?”41

  37. Ibid., 3– 4.

  38. Ibid., 187– 90.

  39. Ibid., 231– 33.

  40. Ibid., 234.

  41. Embellishing Randy Shilts’s account, media accounts hypothesized that the fl ight

  attendant had been infected with the virus during sexual encounters with “Africans” in

  Europe; see, for example, “Canadian Said to Have Had Key Role in Spread of AIDS,”

  New York Times, October 7, 1987, B7.

  Introduction 15

  HIV/AIDS Histories

  Following a few questions and an announcement apologizing for the

  need to reschedule a talk by the NCI scientist Robert Gallo, Curran

  took the microphone. He began his presentation with the ominous note

  that “we are in the fi rst couple years of the recognition of a disease that’s

  going to probably be with us forever. You will hear a lot about this over

  the next decade or so I think.”42

  * * *

  The bulk of this book is concerned with the early North American

  AIDS epidemic, roughly between 1981 and 1996
.43 The beginning of this

  period is marked by the fi rst organized recognition of the emergence of

  a possibly new disease and the growing awareness of the problem’s scale

  and severity. The numbers of dying patients intensifi ed year by year dur-

  ing this time— dozens, hundreds, and eventually thousands— against an

  initial backdrop of governmental silence, widespread homophobia, and

  apparent apathy. To fi ll this void, a remarkable patchwork of community-

  based voluntary service organizations sprang up in lesbian and gay com-

  munities across North America to respond to the needs of the sick and

  dying.44 Mounting anger among these communities gave rise, from 1987

  onward, to direct action groups such as the AIDS Coalition to Unleash

  Power (ACT UP). These activists succeeded in challenging the view

  that AIDS was universally fatal and in changing the contours of treat-

  ment access.45 The health circumstances of most people with AIDS did

  42. “NCAB Meeting,” 15– 16.

  43. Drawing upon UNAIDS categorizations, this book defi nes North America as Can-

  ada and the United States. Within this offi cial categorization system, Mexico is grouped

  with Latin America, a separation which is obviously arbitrary. As will be demonstrated in

  chapter 2, there is a long history of cross border fl ow of sexually transmitted diseases be-

  tween Mexico and the United States. Indeed, political borders have never halted the move-

  ment of populations and diseases.

  44. When compared with later decades, individuals who identifi ed as bisexual and

  as transgender or transsexual were less frequently highlighted as distinctive community

  members during this period. In a bid to strike a balance between historically sensitive ter-

  minology and recognition of these often more marginalized individuals, in this book I will

  refer to both “lesbian and gay communities” and “LGBT individuals.”

  45. Deborah B. Gould, Moving Politics: Emotion and ACT UP’s Fight against AIDS

  16

  chapter 0

  not substantially improve, however, until the development of treatment

  regimens that made use of several antiretroviral drugs simultaneously.

  This advance, known as combination therapy or highly active antiretro-

  viral therapy (HAART), was publicly heralded at the 1996 International

  AIDS Conference in Vancouver. From this point on, the character of

  the epidemic, in resource- rich countries at least, changed irrevocably.

  With HAART, many patients who had previously been near death expe-

  rienced the “Lazarus effect,” restored to nearly full health like the bibli-

  cal character said to have been resurrected through a miracle of Jesus.46

  This is not to suggest that this breakthrough, brought about through the

  work of patient activism and scientifi c research, was a panacea. Side ef-

  fects from antiretrovirals, divisions in the highly affected gay commu-

  nities between HIV- positive and - negative individuals, and shifts in ac-

  tivism toward gay marriage and away from community involvement in

  health have all left many survivors doubting the “miracle” of their ex-

  tended lives.47 The point to be made, rather, is that the pre- HAART era

  of the epidemic was substantially different from the period that followed

  in the United States and Canada, and this book’s chronological focus re-

  fl ects this difference.48

  Within this early period of the epidemic, the three years from the

  spring of 1981 to the spring of 1984 are of particular historical interest.

  (Chicago: University of Chicago Press, 2009), 55– 175; United in Anger: A History of ACT

  UP (New York: United in Anger, 2012), documentary fi lm directed by Jim Hubbard and

  produced by Jim Hubbard and Sarah Schulman; the director kindly provided me with a

  review copy of this ninety- three- minute fi lm via online streaming prior to its release on

  DVD in 2014.

  46. Jason Szabo, “Re- Birthing Pains: Protease Inhibitors, The ‘Lazarus Syndrome,’

  and the Transformation of the Acquired Immunodefi ciency Syndrome” (paper presented

  at the 82nd annual meeting of the American Association for the History of Medicine,

  Cleveland, OH, April 26, 2009); John 11:1.

  47. See, for example, George Chauncey, Why Marriage? The History Shaping To-

  day’s Debate over Gay Equality (New York: Basic Books, 2004); Rupert Whitaker,

  “Thirty Years of AIDS: Triumphs, Failures, and the Unlearned Lessons,” lecture at

  King’s College, London, November 3, 2011, podcast, MP3 fi le, 49:10, http:// podcast .ulcc

  .ac .uk/ accounts/ kings/ Humanities _and _Health/ 3 _11 _2011 _Rupert _Whitaker _Triumphs

  _failures _and _unlearned _lessons .mp3.

  48. This periodization is borne out in Ronald Bayer and Gerald M. Oppenheimer,

  AIDS Doctors: Voices from the Epidemic: An Oral History (Oxford: Oxford University

  Press, 2000), 226– 33. More recently, one of the physicians interviewed by Bayer and Op-

  penheimer referred to the pre- 1996 years as “the hysterical old days of AIDS”: Abigail

  Zuger, “With AIDS, Time to Get beyond Blame,” New York Times, April 19, 2010, D6.

  Introduction 17

  They span the time separating the earliest concerted efforts by physi-

  cians and epidemiologists to identify and investigate the problem, and

  they include the widely reported discovery of a virus by a team of NIH

  scientists led by Gallo.49 While discussions and debates over the cause

  of AIDS would smolder on after this time, these disputes were gradu-

  ally exiled to the edges of orthodoxy. Before the spring of 1984, there

  had been a multitude of theories about how AIDS was caused and much

  debate about the consequences for the gay community. After May 1984,

  the scientifi c consensus that AIDS was caused by a virus legitimated the

  greater involvement of the scientifi c and medical establishment, and it

  downplayed the importance of the epidemiological research that had

  played an important part in the earliest phase of the epidemic.50 It also

  paved the way for a more generalized acceptance— or “blackboxing”— of

  the idea that the condition was caused by a single virus, though there

  would be continued, limited resistance to this dominant view from a

  small minority of dissenters.51

  Historians and other observers examined the period from 1981 to

  1996 in evolving waves of coverage. Some initially attempted to draw les-

  sons from the past— for example, past responses to plague or syphilis in

  North America or Western Europe— to interpret the unexpected arrival

  of a deadly new epidemic in resource- rich countries in the late twentieth

  49. At the time, Gallo’s discovery of the virus drew the most media attention in North

  America, notwithstanding the isolation of a virus by a team of French scientists at the Pas-

  teur Institute in Paris in 1983. Later, after many years of dispute, the French team would

  be widely acknowledged as having priority for the discovery, a view which was bolstered

  in 2008 when Françoise Barré- Sinoussi and Luc Montagnier were awarded a Nobel Prize

  for their work. In her recent book on three decades of AIDS, Victoria Harden traces to

  Shilts’s book what she describes as the “character assassination” of Gallo; see Harden,
/>
  AIDS at 30: A History (Dulles, VA: Potomac Books, 2012), 170.

  50. Gerald M. Oppenheimer, “In the Eye of the Storm: The Epidemiological Construc-

  tion of AIDS,” in Fee and Fox, AIDS: The Burdens of History, 284– 86.

  51. Epstein, Impure Science, 26– 31. One thread of dissent, HIV denialism, downplayed

  the role of HIV, emphasizing instead the importance of cofactors in individuals who de-

  veloped AIDS. From 1987 onward, Peter Duesberg, a biochemist and vocal minority pro-

  tester in studies about the etiology of AIDS, would repeatedly challenge the dominant

  view that HIV caused AIDS; Epstein, Impure Science, 105– 78. Denialism took a more

  political, anti- Western, and ultimately tragic shape when South African president Thabo

  Mbeki drew on Duesberg’s ideas to resist the considerable evidence that AIDS was caused

  by a virus that could be treated with antiretroviral therapy; Nattrass, AIDS Conspiracy,

  77– 104.

  18

  chapter 0

  century.52 Gradually, this “apocalyptic” coverage yielded to a more nor-

  malized approach, mirroring a more routinized medical response to

  AIDS, which by the early 1990s began to assume the characteristics of a

  more chronic condition.53 Some academic historians struggled with the

  challenge of writing dispassionately about contemporary events, particu-

  larly when their interpretations faced angry resistance from more activ-

  ist observers, for whom these events were frequently confl icts with mor-

  tal consequences.54

  The earliest of the AIDS histories, And the Band Played On, a pow-

  erful chronicle written by the San Francisco– based journalist Randy

  Shilts, remains one of the most cited accounts of the American expe-

  rience and continues to shape historical interpretations of the fi rst

  fi ve years of the epidemic. In 2007, a USA Today editors’ choice arti-

  cle listed the bestseller, alongside Stephen Hawking’s A Brief History of

  Time and Salman Rushdie’s The Satanic Verses, as one of the most in-

  fl uential books of the past quarter century.55 The Library of Congress

  included the book in its 2012 exhibition entitled “Books that Shaped

  America,” seeing it as having “a profound effect on American life.”56 By

  the time Shilts died of AIDS in 1994, his book had been translated into