No Time to Lose: A Life in Pursuit of Deadly Viruses (21 page)

I said, “No, Michel, he means
technical
reasons,” and continued to work on my presentation for the conference, sorting out my slides (no PowerPoint yet!), as this is what I used flights for: to work and read. But suddenly a voice resonated in Arabic through the plane’s loudspeakers, visibly causing panic among the Moroccan passengers, who all looked to the back of the plane. I turned around and saw a man standing there, shouting. He had a cigarette in one hand and something else in the other. A passenger told me that he was a Palestinian who wanted us to go to Baghdad and had requested the liberation of Palestinian prisoners in Israel.

Now I was scared. What to do? The crew told us to stay in our seats, and were magnificent in their handling of passengers who were praying aloud to Allah or God, passing their small children toward the front of the plane. (The passengers were mostly Moroccan immigrants in France and Switzerland, and many were on holiday with their children.) The crew also sneakily raised the temperature in the plane, to sweat out the terrorist. Then the pilot said that we would fly to Tripoli, Libya, and we circled in the dark above the Mediterranean for what seemed like an eternity. Michel said, “I’m going for the guy! I’m over sixty, I’m Jewish, and he’ll kill me first—I’ve got nothing to lose!” I blocked him from standing up and then returned to my presentation, trying to concentrate—a kind of denial technique, I guess. My other neighbor, a twenty-year-old Swiss woman started getting out of control, not with fear as the rest of the plane, but she became sexually aroused, repeating all the time “Quel beau mec” (What a cool guy!). I told her to shut up, but as Freud taught us, the human psyche has many circumvolutions.

Then we started our descent, and the rumors intensified. Some people recognized Malaga (in South Spain), others were 100 percent sure that we were approaching Tripoli, others saw the Mediterranean coast of Morocco. We landed in complete darkness. My heart was beating at superhigh speed, my mouth was dry, and my bladder was exploding. Someone announced that all Arabs could leave the plane, and the others must stay. Oh no, now what? Then someone took my hand and said, “Viens, mon frère” (Come, my brother). It was Guy-Michel Gershey-Dammet, the head of the National AIDS Program in Côte d’Ivoire. While I pulled Michel, the Jew, with me, I mumbled “Waha, waha” (all right, all right) and “Al hamdelila” (God be pleased)—my adolescent trips to Morocco now a lifesaver.

Trying hard to look Moroccan, we ran out of the plane. We were pushed into large armored cars, still in the dark, still not knowing where we were. I was holding hands with both Michels, wondering what would happen.

We were in Casablanca military airport. Troops stormed the plane and killed the hijacker; nobody else was badly hurt. We were driven away and immediately put on a plane to Marrakesh, where we landed after midnight—and there, no support, no apologies, no nothing from the airline or authorities, just a routine wait for our luggage and a struggle for a taxi. Remarkable. In the hotel, I heard what had happened from my old friend Jean-Baptiste Brunet, the head of AIDS at the French Ministry of Health, who had been seated in the back of the plane. A smoker, he had passed cigarettes to the hijacker, and said the man had boarded in Geneva with his arm in a plaster cast, which he had taken off in the toilet, returning with some kind of real or fake bomb device.

I couldn’t sleep for two nights after that. I gave my talk at the conference like a zombie and went back to the airport, where I was told that my return flight was overbooked. No seat. This was really too much. I exploded. I yelled at the poor check-in person, “First I am hijacked, and now you are bumping me off the plane! What kind of company are you? I want to see the manager!”

Instead of the manager, two tall men with dark glasses lifted me up bodily and hustled me into a small room. I was shoved onto a chair, and they put a strong blinding lamp on my face and started pushing me—this was at least as bad as the shakedown at Njili airport in Kinshasa. They shouted, “What hijacking? What do you mean?” I told them what had happened, but they nearly accused me of being involved in the crime. Because of press censorship those days in Morocco, no media had mentioned the hijacking.

Finally they let me go, and I was put in first-class to Tanger and then to Brussels. So at least there was some compensation. The changes at WHO and the troubles of setting up conferences quickly faded.

•
PART FOUR
•

CHAPTER 15

An International Bureaucrat

T
HE EPIDEMIC WAS
getting worse and worse. My friend Joseph—Willy’s partner, who had nursed him through his sickness and death—was also now desperately ill with AIDS, even though I had managed to get him AZT treatment. Everywhere I went there was nothing but AIDS, and nothing but bad news.

By 1991 HIV had infected over 20 million people around the world and killed over 5 million. In Africa AIDS was now the number one killer; every survey result was worse than the previous one. In 10 African countries more than 10 percent of the entire population was infected. Faced with the reality of dying infants, the blank horror of the term “AIDS orphans,” hospitals full of dying men and women with AIDS, and much needed professionals passing away because of AIDS, I felt completely impotent. How long could I continue just studying this unfolding disaster? Asking intellectual questions and jetting about to research their possible answers no longer felt like the most useful thing I could do.

I wanted to change the course of the epidemic, not just study it. I was throwing off a lot of my very Flemish underdog type vision of the world: the modesty that can be so fatal to ambition, the assumption that one individual can’t really have an influence. Up to then I had felt as if I were still a student—asking questions, seeking, and learning. Now I wanted to act, to take what I could of that knowledge and use it for the world.

Mike Merson, just as his predecessor Jonathan Mann, had begun calling me, asking if I would join him at the Global Programme on AIDS at WHO in Geneva. I said no at first: I had never seen myself as an international bureaucrat. But Mike was persistent. He offered me a temporary arrangement, a broad mandate, a self-defining position as a special adviser. He suggested that I could take a one-year sabbatical from the Institute of Tropical Medicine. We were doing excellent work there, and in the projects in Nairobi and Burundi as well as in Kinshasa, but a year’s sabbatical would give me the opportunity to take a step back and think things through.

Meanwhile the political troubles in Zaire, a country nearly as big as Europe, were growing ever more tumultuous as President Mobutu’s kleptomaniac rule was under heavy threat from rebellions. In September 1991, exhausted soldiers who had been left unpaid for months mutinied at the army base near the international airport. The civilian population of Kinshasa joined the riot and generalized looting broke out. Homes, shops, and businesses were attacked and over 200 people were killed. France and Belgium sent paratroopers to evacuate thousands of foreign nationals to Brazzaville, the EU suspended aid again, and the United States withdrew all its programs.

Even at the best of times it was often impossible to phone Kinshasa, and of course in those days e-mail was not available outside CERN, the European nuclear research center near Geneva. But our American colleagues at Projet SIDA had a solid communication channel through the US Embassy, and so it was Tom Quinn, in Baltimore, who kept me informed through the weeks of violent plunder in Zaire. Our American and Belgian colleagues were safely evacuated, but Tom and I were concerned about the Zairean staff of Projet SIDA. We were really a big family; seven years of improbable adventures and shared frustration and jokes and joy had welded some intense bonds. Although both Tom and I were glad, in a sense, that there was an uprising against Mobutu, we knew that it could end in horrible bloodshed. There was also the risk that our labs would be looted and that all the work—the people under our care, the sera that we had banked, the data we had accumulated—would be damaged or lost.

It never occurred to me that Projet SIDA might close forever after our colleagues evacuated. I thought we would suspend our work for a month or so, but I couldn’t imagine that this massive investment, by far the largest international research program in Africa, would simply end. However, Mobutu’s death grip on power seemed unending. The troubles in Zaire continued. In November Tom told me that the US government had decided to pull the plug on the whole project. Our American colleagues would not be going back and all US funding was halted.

Frieda Behets and I tried to argue that we should maintain some kind of presence; in fact Frieda volunteered to
be
that presence. But she was paid by American money, and that meant American government insurance, American legal issues: the answer was no. Projet SIDA’s major sources of income were the NIH and CDC, and there was nothing Tom could do about it; legally, his hands were tied. Projet SIDA, a program that had been producing remarkable work and was barely damaged by the looting, came to an end.

Both Belgium and the EU also withdrew all aid—meaning Jos Perriens, our Antwerp clinician, was no longer paid.

The Zairean staff of Projet SIDA tried to keep the program going to some extent, using leftover funds from the Belgian Cooperation Agency and from our department at the Institute of Tropical Medicine. Although our budget couldn’t hope to match the shortfall from US funding, I was legally less hamstrung than Tom was and I kept some funds going for a while: Médecins Sans Frontières took over the prostitute clinic in Matonge, and we channeled some money to them. I also tried to organize fellowships overseas for the staff members who had university degrees: laboratory technicians and physicians. Several of them obtained PhDs, and are now in important positions in public health and development agencies and in pharmaceutical companies in the Democratic Republic of Congo, as the country is now known, and throughout the world. They were a remarkable group of very smart and energetic young scientists, who would probably not have had an opportunity to grow scientifically and professionally without Projet SIDA. As for the thousands of blood samples, when the situation in Kinshasa stabilized, Skip Francis picked them up and brought them back to Bethesda.

But the program to screen blood collapsed. All our studies were cut short. The cohorts we had carefully assembled for long-term follow-up fell apart. As for clinical investigation—the bronchoscopes, the diagnostic tools, the care we gave to patients—all we could do was hope for the best and leave the equipment to Dr. Bila Kapita and his colleagues at Mama Yemo Hospital. Kapita was stoic—he is not the kind of man to express reproach—but I knew how bitter he felt at this abandonment, and I admired his dignity. As of today he is still in charge of Internal Medicine at the hospital; he is by any standard a hero, and people with his integrity, commitment, and work ethic are Africa’s future.

The end of Projet SIDA broke my heart in so many ways. It was a very sobering experience. I think it changed me as a person. I felt the temporary nature of things.

The next time Mike Merson approached me was in December 1991, at a conference on AIDS in Africa in Dakar, Senegal. This was by far the best organized conference on AIDS in Africa, thanks to a dynamic team led by one of Africa’s leading scientists, Professor Souleymane Mboup, a brilliant and humble military microbiologist, a very sophisticated man who trained numerous West Africans. Mboup was working with Max Essex at Harvard on HIV-2. He was the primus inter pares of a remarkable group of Senegalese AIDS experts, who were among the first on the continent to mount an open and effective response against AIDS, with the full support of then President Diouf. It was a first step toward “ownership” of the epidemic by Africa’s scientific elite and proved highly successful. HIV prevalence has been kept as low as 1 percent up to today.

The time was ripe, and Mike convinced me: I agreed to take a sabbatical from my work in Antwerp. I moved the whole family to Geneva for a year and began work at WHO’s Global Programme on AIDS in August 1992.

WHEREVER I GO,
I integrate quite rapidly into the new environment, but at the same time I never feel that I am fully part of the system, one of many contradictions. It goes all the way back to how I felt growing up in my family, my village, my school. That semi outsider feeling keeps me sane, I think.

I didn’t see the move to WHO as a radical change in paradigm for my work. I had been going to Geneva so often—every couple of months—that it no longer seemed like foreign territory. And I certainly did not feel that I had suddenly transformed into an international civil servant. I hadn’t “sold out.” I was an adviser, on a one-year contract.

In a senior position at WHO, I felt I could have more influence on the course of the AIDS epidemic than if I remained in Antwerp. In these days WHO seemed like a very rich organization, though its annual budget of $2 billion was less than that of many hospitals in Europe or the United States; but the AIDS program alone controlled $150 million, and it could reach almost anywhere in the world. In Antwerp I administered perhaps $1 million a year, and the number of lives I could hope to impact was infinitely smaller. I also wanted to learn how an international organization functions.

From the very first week in Geneva I was confronted with the dark side of WHO: because of a “preexisting condition,” Greta was not eligible for full health insurance. That the World
Health
Organization would deny its employees something so crucial shocked me. Fortunately we could continue to benefit from Belgium’s excellent health care system, but I was bitter about the failure of the employees’ union to support my position. A few years later I would stage another battle with WHO’s leadership, its health insurance, and the then head of the UN Joint Medical Service in Geneva to ensure that people living with HIV could be recruited as full employees with the same medical benefits as other staff; this took years of trench warfare.

In terms of my job, I had two immediate deliverables: I was to reorganize the research component of GPA and I was to oversee its newly created division for sexually transmitted disease—boost it, shift its management structure, and set its priorities. Suddenly the sexually transmitted disease section had far more money to work with than WHO had ever conceded to it before, and what I intended to do was set up some studies to look at how to integrate efforts to control sexually transmitted disease and HIV, because these were essentially the same populations and the synergistic relationships among the various infections were gradually becoming more clear.

I had heard of an interesting project that worked with prostitutes in a district called Sonagachi in Calcutta, one of the biggest red-light districts in Asia. At first blush, their approach seemed similar to the one used in Nairobi and Kinshasa, only on a much larger scale. So after I arrived at GPA, one of the first trips I made was to India. This was a shock and an inspiration. In those days there was hardly any HIV in India, but in discrete pockets of the population there was a high number of other sexually transmitted diseases, particularly among sex workers and their clients. (There was also an awful lot of denial: the then minister of health told me, “We don’t do
those things
here.”)

What struck me was the environment that they worked in. Prostitution was on a far larger scale, far more organized and also much more brutal, I think, than anything I had ever seen in Africa. Thousands of prostitutes were tightly packed in huge brothels, many under lock and key; some, in Mumbai, I later saw living in actual cages. Down dark alleys and up dark staircases were small rooms in which two women would receive clients simultaneously, with simple cloths hanging between their beds and children running around. They were often forced, initially, into prostitution by violence, and they were rejected by society as a whole. The misery was palpable. And the smell—I can smell it just writing about it—a stink of sewers and humidity and sweat and genital secretions.

This is the sexual misery of some of the world’s poor. As in the Carletonville mines in South Africa, I felt bad both for the men and for the women, but mostly for the women. There was a lot of violence, because men drank before going to a prostitute and then they beat them up. The police raped them in exchange for letting the brothels operate. Their lives were appalling.

The project’s organizer, Dr. Smarajit Jana, was an entrepreneurial Bengali public health specialist who had just started working with these women, providing medical care for them and their children. He also helped them organize themselves into a union, driven and organized by the women themselves, to try to deal with sexual violence, set up groups for information and support, and impose both the use of condoms on clients and a degree of pressure on the brothel owners. The project also worked with the police to change their roles and end a culture of impunity for sexual abuse of prostitutes. It was impressive, and it worked in terms of disease prevention. At the time, this was a very innovative approach, particularly in a region where women had little power in society in general. This and later experiences elsewhere convinced me that we should not only offer good AIDS and STD care and condoms for sex workers and others at high risk but also general social support and protection from violence. AIDS is just one of their many problems, and often not seen as part of their struggle for daily survival, although it was literally about their survival.

Now I had money to provide that kind of support. I had transformed from someone constantly scrabbling for grants and donations to someone who had a budget to distribute. Actually it’s not so easy to distribute funds for research: we needed to come up with a rigorous scientific protocol, one that would teach us something that could be applied to other projects in the world.

These days, a remarkable HIV prevention program called Avahan is taking this comprehensive approach a step further. It is run by Ashok Alexander and other former staffers from the McKinsey consultancy firm, with funding from the Bill & Melinda Gates Foundation. They added social marketing techniques to induce sexual behavior change and use of condoms, just as if they were selling soap—looking at their customers, their tastes, the package design, the promotion campaigns; they use feedback just as if they were salesmen, looking at where sales go up or down, taking regular surveys on peoples’ beliefs and actions; they use microplanning and mathematical modeling techniques, mapping out in detail where the sex workers operate. Most public health programs lay down a five-year plan and don’t deviate, but Avahan’s approach has been extremely successful in bringing down new HIV infections across the most at-risk populations in India, working with India’s successful national AIDS program. Sex in India, like most societies, doesn’t have what’s called a “normal distribution”: most people have not much sex and a small group has a lot of sex, but every so often there’s a link between them. So by focusing efforts on the peak populations—so-called core groups—there’s basically a very cost-effective impact on the overall level of infection in the general public too.