No Time to Lose: A Life in Pursuit of Deadly Viruses (12 page)

One evening at the end of 1979, I received a phone call from the pathologist of the Institute of Tropical Medicine. He wanted me to help autopsy a cadaver. The patient had died of galloping meningitis. He was Greek, but he had lived for decades as a commercial fisherman on the banks of Lake Tanganyika in eastern Zaire, and when he had arrived at the hospital he was already in terrible shape, with tremendous weight loss and a fever of unknown origin.

When we opened up his body we saw that it was devastated. He was riddled with an atypical mycobacterial infection, a clear sign that his immune system had totally collapsed. We were so taken aback that we kept blood and tissue samples in –70°C freezers. I wasn’t smart enough to see that it was a new syndrome, but I knew I had never seen anything like it before.

CHAPTER 9

Nairobi

B
Y THE SPRING
of 1980, I had finished my thesis “The Aetiology and Epidemiology of Bacterial Vaginosis and
Gardenerella Vaginalis
” and I had another, far more exciting project underway. I was going back to Africa, for a research project that I had dreamed up with Allan Ronald, the Canadian physician I had met while in Seattle.

Allan was an amiable man and we talked a lot about Africa. He had established contact with the University of Nairobi in Kenya, where genital ulcer disease, in particular, chancroid, had become epidemic. He told me that he wanted to start a research project on chancroid and proposed that we work on it together. I had a little experience; he had some contacts. It was an opportunity to develop a research base in a city where basic infrastructure like phones and electricity posed no particular problem, and there was a good university. So we made a planning visit to Nairobi in January 1980.

Inspired by what I had seen in the United States, I incorporated a nonprofit group the Foundation for Infectious Disease Research, upon my return to Antwerp, intending to fund the new research program in Nairobi. From time to time, when I gave workshop training sessions to general practitioners, or lectures on STDs, I had my emolument deposited into the foundation. It was not a lot—$300 here, $3000 there—so it didn’t add up to much. Short of robbing a bank, I didn’t know how on earth we would raise enough money to support the Nairobi project.

Then, at a conference on infectious disease, I ran into a new antibiotic that seemed to me a promising candidate to step in as a new chancroid treatment, a more effective alternative to erythromycin. The drug was produced by Schering, a company I thought I could convince to fund a trial on the treatment of chancroid, even if chancroid treatment did not represent even a minor future market for any pharmaceutical company. Where to set up such a trial? While in Swaziland, I had worked with a highly competent and pragmatic English microbiologist who lived in South Africa, Ron Ballard, who had told me there was a truly massive chancroid problem in the South African gold mines, and had asked for our help. The town he mentioned—Carletonville—was the largest gold-mining complex in the world, close to Johannesburg, and with what he described as ideal medical backup in terms of hospitals and labs. On the one hand I wasn’t keen to work in apartheid South Africa, but Ballard argued that there was no moral high-ground to abandoning the poor and needy.

Ballard, Eddy Van Dyck from my lab, and I went to Leslie Williams Memorial Hospital in Carletonville, which indeed was one of the better hospitals I saw in Africa. Clearly the company needed to keep their workforce healthy and productive, but they definitely had no idea how to handle the chancroid problem. Conditions in the gold mines, often over a mile underground, were not only high-risk but also extremely hot and humid; wounds just couldn’t heal, and appalling chancroid ulcers were incapacitating the miners.

The miners were from all over—Swaziland, Botswana, Lesotho, Mozambique, Malawi, Zambia, Zimbabwe—and they were well paid compared to any worker in their home country. I was never allowed down the mines; I would have liked to see what they were like. But I visited the hostels they lived in, and the places they drank, and saw, lining the red soil paths, the wooden shacks with corrugated iron roofs and simple cloth doors—a prostitute in many of them. Every payday there were lines of men outside these places.

The men worked in shifts, six days a week, around the clock; they all hated and feared the work, but all of them had families back home, and they were doing it for them, trying to bring home enough money to give an education to their children, start a business, maybe set up a shop. I knew, though, that many of them were also taking home some truly infernal diseases, in addition to the high risk of work-related accidents and tuberculosis—the highest rate in the world. These men were at the same time victims of pure exploitation and a source of hope for their community to get out of poverty. I was revolted by their working conditions (and those of the sex workers . . . ), was deeply touched by their loneliness and songs full of nostalgia of home, and to this day cannot see gold without thinking of them and what it takes to produce it.

Under apartheid the men were away from home for 11 months to work in the mines, and whereas some established a stable relationship in South Africa, sexual expression was often limited to occasional commercial sex. From the perspective of sexually transmitted agents, many sex partners (the miners) for few women (the sex workers) is ideal and gives rise to explosive epidemics, as we saw then for chancroid. (This perverse organization of labor in the mining industry in South Africa undoubtedly paved the way of what became the world’s most severe AIDS epidemic 10 years later, with some of the world’s highest HIV prevalence rates occurring in sex workers around Carletonville, of whom 78 percent were HIV-positive in 2001.) In spite of the huge STD problem, the apartheid government of the time did not support STD prevention programs, not even condom distribution.

Within five weeks we studied enough patients in the clinical trial to demonstrate that the antibiotic indeed worked remarkably well, as compared to the then recommended treatment of erythromycin. (Despite its success the new antibiotic was never marketed.) Because the study concluded much faster than anticipated and we were very economical on our expenses, I made enough money to seed our Nairobi project. Meanwhile, Allan, in Canada, had put together enough money to start working, so I joined him in Nairobi at the end of 1980.

Nairobi was a lively city, full of small and bigger business, an infrastructure to host both business clientele and tourists. The people were mostly much better off than those in Zaire. But what struck me most of all were the huge slum areas, particularly the Kibera and Mathari Valley shanty towns, the largest slums on the continent outside South Africa—one mass of undulating corrugated roofs where everyone lived on top of each other, in garbage and sewage, while the Kenyan élite and expatriates flourished in spacious villas in the hills. Conditions in Kibera were far worse, in those days, than anything I saw in Zaire.

We worked very closely with the chairman of the university’s Department of Medical Microbiology, a refugee from Rwanda and Uganda named Herbert Nsanze, a handsome sophisticated man who was very personable and very smart. We occupied a little office at the medical school at Kenyatta National Hospital, with a clunky Commodore computer that we used for statistical analysis. There was no phone. It was a smart group of people, and we became a very well integrated little project—not so little, after a while. Several years later we were joined by King Holmes’s group at the University of Washington, and Marleen Temmerman’s team at the University of Ghent, and the project grew to become one of the most productive and long-standing research collaborations in Africa, forging a very large number of groundbreaking studies.

Allan arranged for us to work in the municipal STD clinic, popularly known as Casino Clinic, because it was next door to the Casino Cinema on River Road. This was a very lively but also quite rough area, kind of a skid row, as described in “Going Down River Road” by Meja Mwangi, one of Kenya’s most popular writers. There were countless bars that had tiny rooms where the prostitutes and bar girls went with their clients. They were dirty, really depressing places visited by mostly poor people. I’ve seen so many rooms like these, in Bombay and Bangkok and Kathmandu, and I still honestly don’t know how anyone can have sex in a place like that. The smell alone would make me impotent, besides other considerations of love and disease.

Unlike in Kinshasa, there was hardly any music in this kind of bar, just a lot of straightforward drinking. When the alcohol level was high enough the clients headed upstairs with the women who worked there. And then the next day, or next week, quite a few of the men and women queued up at the Casino Clinic. Literally every morning hundreds of people were waiting when the doors opened at 7
A.M.

It was worst for the women. Dr. Da Costa, who was a Kenyan-born Indian Catholic, railed against them—“You whore, you slut”—and told them they only got what they deserved. As a doctor he was actually pretty competent, which was fortunate, because he was the only doctor in the Casino Clinic and it was basically the only sexually transmitted disease clinic in the city, as well as being at the time the largest STD clinic in Africa. As an empathetic doctor, however, he was a nightmare. I remember the young women crying at his pronouncements that now they would never be able to have children, which is indeed one of the major complications from untreated gonorrhea and chlamydial infection. I noted, too, that many of them were probably not involved in commercial sex; many were actually the regular partners and wives of male clients. Whereas I admired him because basically no other physician wanted to do this unglamorous and stressful job, I had to wonder why he was working there, since he hated his clients so deeply.

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.