Adventures of a Female Medical Detective

by Mary Guinan

  MMWR published the report in June 1981 (4). The story was a milestone, not only because it was the first report of the new disease but also because it marked the first time the publication used the word homosexual. I thought the title should include the words homosexual men, but I was overruled. The title of the article was “Pneumocystis carinii Pneumonia, San Francisco.” (In another herpes connection, Kaposi’s sarcoma, which is an AIDS-related condition, was discovered in 1994 to be caused by a herpesvirus [now called HHV-8].)

  As to what happened to the search for a cold sore treatment, others continued the research. Oral acyclovir was found to be an effective treatment for both oral and genital herpes infection, and the Food and Drug Administration approved it in 1982. It is a wonderful drug. At the first symptom of a cold sore, I start taking a daily dose. At minimum, acyclovir will reduce the size and duration of the cold sores. If I start early enough, no sore will appear. I never leave home without it.

  An interesting aside is that Gertrude Elion, an American biochemist and pharmacologist who was one of the few women engaged in herpesvirus research, received the Nobel Prize for Physiology or Medicine in 1988, partly for her work on herpesviruses and the development of acyclovir.*

  Reviewing my interactions with the media in those years—and how inaccurate their reports often were—is a painful experience. It illustrates that both audiences and news reporters were less informed on medical matters back then. To the average reader or viewer, a herpesvirus was a herpesvirus was a herpesvirus; the distinctions of type were meaningless.

  And the medical community was also less sophisticated about messaging and communication skills. In 1984, when CDC held a press conference on AIDS, it was the agency’s first press conference in seven years. CDC even eschewed press releases, preferring to publish its findings in “the staid, tradition-honored MMWR,” where the newsworthy bits were often placed deep in the editorial notes, not in attention-grabbing leads (5).

  And it was not until 1987 that CDC hired an expert—former EIS officer Bruce Dan, MD (known as Dr. Dan to his Chicago audience, where he was medical director for an ABC affiliate station)—to teach medical staff about using SOCOs (single, overriding communications objectives), keeping medical information simple, and learning to “flag” key messages (6).

  So I have come not to blame Dan Rather, but to thank him for pushing me into a detour that became a career. He also gave me an important early warning about the perils of scientists trying to communicate to the media on health issues. Now I can laugh when people call me Dr. Herpes.

  FIVE

  Healthcare Workers and Enemy Information in a War Zone, Pakistan, 1980

  IN DECEMBER 1979, the Soviet Union sent Russian military forces to Afghanistan to prop up a Soviet-friendly government that was in danger of falling to rebels. This invasion was another ploy in the ongoing Cold War between the United States and the Soviet Union and their respective allies.

  The United States responded immediately by suspending nuclear arms negotiations and condemning the invasion at the United Nations (UN). In March 1980, President Jimmy Carter announced that the United States would boycott the summer Olympic Games in Moscow unless the Soviets retreated. There was no retreat.

  Russian forces in Afghanistan would soon number over 100,000. Soviet-led Afghan troops fought multinational insurgent groups called the Mujahideen. The fierce fighting resulted in thousands of Afghans fleeing over the borders to the neighboring countries of Iran and Pakistan. In the months after the invasion, tens of thousands of refugees were in Pakistan, camping in the area of the Khyber Pass close to the Afghan border in North-West Frontier Province (now known as Khyber Pakhtunkhwa Province). The lack of resources in this remote area and the soaring population of women and children in the refugee camps created international concern for their safety. There were reports that the Russian troops had crossed the border into Pakistan in “hot pursuit” of the Mujahideen. Pakistan President Muhammad Zia-ul-Haq was a supporter of the Mujahideen in the fight against the Soviet Union, and Pakistan became an important US ally.

  In April 1980, I was working in CDC’s sexually transmitted disease (STD) unit when I received a call from my supervisor. The US State Department had requested CDC’s assistance in evaluating the condition of Afghan refugees in Pakistani camps, and CDC wanted me to lead a team to accomplish this mission.

  I was dumbfounded. I had no particular expertise in refugees. Moreover, I had just returned from a month’s tour at the American University of Beirut, where I had been particularly unlucky. Lebanon was in the midst of an ongoing civil war between Muslim and Christian factions, and I had been caught in the middle of machine gun fire from a militia group that was invading the university hospital emergency room, where I happened to be. Fortunately, the soldiers were not shooting directly at us but above our heads. As rounds of bullets ricocheted off the high cement walls, I instinctively fell to the floor, where I found myself with a group of women (either patients or visitors), none of whom could speak English. Since I could not speak Arabic, we were unable to exchange information on what was going on. The shooting lasted about five minutes. Then the soldiers left, and everyone got up and continued what they had been doing before the interruption. I never found out which militia it was or why they were shooting, but the experience dampened my enthusiasm for traveling to another war-torn area for any reason.

  And lastly, my boss did not want me to go to Pakistan. I had been out of the country enough. Now it was time to do STD work. I was preparing to attend the world conference of the UN Decade for Women in Copenhagen in July 1980, where I would represent the STD unit.

  The State Department had specific criteria for the team leader. It wanted a woman physician, trained in infectious diseases, who had international experience. Why a woman? Because the refugees were primarily Muslim women; cultural mores would preclude an unrelated man from entering their encampments. Why me? Because I was the only woman physician at CDC with infectious diseases training and international experience. It was all very vague. I said I would think about it.

  Hearing of my reluctance to commit, someone from high up in the CDC hierarchy called to discuss the mission. He told me it would be difficult for CDC to refuse the State Department’s request. The pressure was on, and so I reluctantly agreed to go. Another woman physician from CDC, Mary Serdula, MD, would be going with me. She called to get more information, and I told her I knew next to nothing about it. I never spoke to anyone at the State Department, and the paucity of information on what the two of us were expected to do was disconcerting.

  We heard nothing more for weeks. Then in late May/early June, the process began. CDC briefed Dr. Serdula and me on what we should be doing in the camps to assess the health status of the refugees. We were given various field supplies, including an instrument to measure the height and weight of children. We reviewed and modified a questionnaire that we would administer to the refugees through an interpreter.

  Our first stop was Washington, DC, where we had a two-day briefing by various State Department officials, including the so-called desk officers (foreign service officers who are in-house experts on each country) for Pakistan and Afghanistan. From Washington we boarded a flight to Islamabad, the capital of Pakistan.

  While being driven from the airport to our hotel, we passed by the remains of the American Embassy. Pakistani students had burned it to the ground just seven months before (on November 22, 1979). Four people at the embassy had been killed—two Americans and two Pakistanis. The embassy was relocated temporarily to the Agency for International Development offices in another part of Islamabad. Security at the new location was extremely tight.

  During the next few days, Dr. Serdula and I met with various embassy officials and reviewed the game plan. At lunch and dinner, we heard ghastly details about the burning of the embassy from workers who had escaped the building. Two weeks before the burning of that embassy, a mob had stormed the American Embassy in Iran (on November 4, 1979) and t
aken fifty-two American hostages, who were still being held in captivity. (They would not be released until January 1981.) There was great relief that no hostages had been taken in Islamabad. Because of the danger, we did not leave our hotel except when accompanied by someone from the embassy.

  We outlined what we were supposed to do. We were to go the camps and collect information from the refugees that would identify their greatest health-related needs. Using this information, the State Department would determine what resources would be sent to Pakistan.

  The embassy made all the arrangements for our travel. We would be driving about 90 miles with a caravan to Peshawar, capital of North-West Frontier Province, on a fairly reasonable but crowded road. Why so many embassy personnel were accompanying us was unclear. But given the political turmoil, I assumed it was for security reasons, and I was grateful.

  Peshawar is an ancient city close to the Afghanistan border. It had been part of Afghanistan until 1957, when the British incorporated it into North-West Frontier Province. Because of its strategic location, it has been a center of trade for centuries between central and south Asia. It is the administrative and economic center for the Federally Administered Tribal Areas. Most recently, Peshawar has been in the news because of the brutal Taliban massacre of 132 schoolchildren in 2014. But Peshawar was violent, even then.

  The camps we were to visit required passage through a number of these tribal areas. We stayed in Peshawar for a few days while the necessary documents were obtained for our travel through each tribal area. The leaders of each tribal area would be responsible for our safe passage through their territory, and each of them would have to approve our passage. There was apparently a limit to how many persons could be in our travel party, so several of those who traveled with us to Peshawar did not continue on to the camps.

  After a breathtaking drive on a narrow road in the Hindu Kush mountain range, we arrived at the first tribal area. There we were met by tribal leaders, who welcomed us and assigned us a bodyguard with a rifle and bandoleer to protect us while we were under their jurisdiction. This process was repeated at each successive tribal area. We stayed overnight in two of these tribal areas in government rest houses.

  At the second tribal area, while we were arranging our lodging, the leader of the State Department group (whom I will call Bob) told Dr. Serdula and me that several of the people traveling with us were Central Intelligence Agency (CIA) agents. As the conversation continued, it became clear that we were being used as a cover so that the CIA could gather information on what was going on at the border. We were quite shaken and bewildered by this information and asked why we hadn’t been told previously. Bob said he was telling us now so that we would know. Neither of us would have agreed to go had we known the real mission of the expedition.

  We had no choice but to keep going and do what we had been trained to do. Because the refugees were Pathans, a group of nomadic people who live on both sides of the Afghanistan-Pakistan border, we needed an interpreter who spoke Pushtu, their native language. One was assigned to us in Peshawar, a young man who had a name that we could not pronounce. (When we asked him for an English translation of his name, he told us, “Slave of the Prophet.”) I told Bob while we were in Peshawar that I had specifically requested a female interpreter because a man would not be allowed into the tents of the women. He said that he had difficulty finding a woman and was still working on it, but we would have to use Slave of the Prophet for the time being. So the male interpreter accompanied us to the camp.

  The site of the camp was a large barren area, where tents had been set up for the refugees. The tents were not close to one another. It was extremely hot—well over 100 degrees Fahrenheit all day. Dr. Serdula and I wore light cotton clothes that we had had made for us in a local shop in Islamabad. They were wide pants and long shirts that reached below our knees, much like the clothing that many Muslim women wear. We also bought headscarves.

  The sun made it almost unbearable to work in the heat of the day, so we worked mainly in the early morning and in the evening. We selected an area for the interviews and then numbered the tents. We decided on visiting every fifth tent to interview the occupants, most of whom were women and children. Finally, the female interpreter arrived. The women welcomed us and were very cooperative in answering our questions. After the interviews, we also measured the height and weight of each child with the instrument provided to us by CDC. The measuring process was conducted outside the tent and usually attracted a crowd of people.

  After the first few days, we had questions from many women about why we did not come to their tents. It was difficult to explain, and we never really knew what the interpreter told them. The interpreter was linked to a political family that was no longer in a position of power. She wore a beautiful white dress and showed little empathy for the refugees, and we were sometimes concerned whether she was accurately representing their or our words.

  Dr. Serdula and I worked for almost a week, and then we were told it was time to leave. A few days before we left, a group of men in the camp asked to speak with me. The leader thanked us for coming and for being concerned about their health, but he said that they needed more help. He asked me to tell the president when I returned to the United States that they needed “guns to fight the Haj.” (Haj means “holy war.”) I told him that I would deliver his message.

  We returned through the tribal areas to Peshawar, where we stayed a few days to write our report. Bob and his group went back to Islamabad. We reviewed all the data that we had collected and prepared a draft report with recommendations. Then we flew to Islamabad. Dr. Serdula went home, but I stayed a few days, working at the embassy to complete the report.

  I refused to believe that the only purpose of our trip was to give the CIA access to the war zone. After all, we had accumulated reasonable information on the status of the refugees, which might be useful in making decisions on resources. I gave the full report with all the collected data to a top embassy aide and asked that he put in on the ambassador’s desk. I then left for Copenhagen and the UN Decade for Women conference. I never found out whether anyone read the report. Maybe it is better not to know.

  A few years ago, I ran into Dr. Serdula at a CDC meeting, and the first thing we discussed was how we had been used by the CIA. We both still felt terrible about it, almost like they had stolen part of our souls. We were supposed to be the “good guys.”

  The CIA again used public health workers in Pakistan in 2011. According to an editorial in Scientific American, titled “How the CIA’s Fake Vaccination Campaign Endangers Us All,” the CIA, hoping to identify Osama bin Laden’s family, used a sham hepatitis B vaccination project to collect DNA from residents in Abbottabad who were living close to bin Laden’s suspected hideout (1). After bin Laden’s capture and death on May 2, 2011, the fake scheme came to light, and villagers along the Afghanistan-Pakistan border chased off vaccination workers, accusing them of being spies.

  The misuse of public health workers had repercussions. In December 2012, nine female Pakistani workers were gunned down while administering polio vaccinations, prompting the UN to withdraw vaccination teams. A similar attack occurred in Nigeria in February 2013, when nine female vaccination workers were massacred. These attacks are presumed to be retaliation for the vaccinator ruse in the capture of bin Laden.

  In January 2013, several deans of US schools of public health signed a letter to President Barack Obama stating their belief that public health programs should not be used as cover for covert operations and urging the president to assure the public that this type of practice would not be repeated (2). The president did not respond.

  While working on AIDS in Africa, I encountered widespread belief that the CIA had deliberately put the AIDS virus into vaccines in order to kill Africans. In India during the smallpox eradication program, women in some villages would run away when they saw us coming because they believed vaccination was a family planning plot to sterilize them. I was certain then
, and still am, that these suspicions were totally unfounded. I mention these events only because they illustrate how suspicions about the West and its medicine are rife in many countries, especially underdeveloped ones. We only lend credence to such fears when public health workers are used for political purposes.

  SIX

  An AIDS Needlestick at a Rundown Hotel in San Francisco, 1982

  THE HOTEL was close to Skid Row, in the Tenderloin District of San Francisco, and it reflected the seediness of the area. The fact that the clothes washer and dryer for hotel guests were located in the lobby, one on either side of the registration desk, gives you some idea.

  I had chosen the hotel because I could get a room with a refrigerator within the federal government rate (about $45 per day in 1982), and because it was directly across the street from the post office. One pleasant feature was a back courtyard with tables and chairs, where one could enjoy the beautiful autumn weather. My room was on the second floor, with a deck overlooking the courtyard, and I could walk around it between interviews.

  Several months after CDC reported the first cases of what eventually would be called AIDS (1), I conducted my part of the first case-control study of the new disease in this hotel. I was one of the thirty people in CDC’s Kaposi’s Sarcoma and Opportunistic Infections (KSOI) Task Force, which led the study. Four cities were included in the study: Atlanta, Los Angeles, New York, and San Francisco.