Dr Peter Piot, the clinical microbiologist and former executive director of UNAIDS, has written a memoir that is sure to reignite the Aids debate. But despite the controversies, there is now hope: “mortality from Aids has declined dramatically in just about every country”.
Dr Peter Piot has been at the forefront of the global fight against infectious diseases for much of his 62 years on earth. His tenure as UNAIDS executive director ended in December 2008, but he is still involved in the fight against infectious diseases in his current job as director of the renowned London School of Hygiene & Tropical Medicine.
Dr Piot, a Belgian, has a story to tell. And how better to do it than in a memoir. He admits though that “sixty-two may be a bit young for writing a memoir. However, I felt that the distance between events and writing was long enough, but yet not too hazy, to tell my story of two of the most extraordinary adventures of our time: the discovery of Ebola hemorrhagic fever and Aids, and the world’s response to them.”
He quotes one of his greatest admirers, the late Dr Jonathan Mann (the American co-discoverer of the HIV virus), at the beginning of the book, to emphasise the importance of the mission they set themselves:
“Our responsibility is historic,” Mann said, “for when the history of Aids and the global response is written, our most precious contribution may well be that at the time of the plague we did not flee; we did not hide; and we did not separate.”
Dr Piot’s memoir, written with the help of Ruth Marshall, comes with an evocative title, No time to lose – A life in pursuit of deadly viruses. It was published in June this year, and knowing the controversial grounds that he was treading, he covered himself with this caveat: “This is a memoir of discovery, selected moments, people, and developments, seen through one lens – my own experiences – with no ambition to give a complete picture. Scholars not as involved as I are better placed to write those books.”
However, despite the heavy subject of death that fills his book (considering that he deals with two of the world’s most deadly viruses, Ebola and HIV), Piot still manages to pepper the memoir with some hilarious anecdotes. Consider the following:
During a 2005 meeting with the then Brazilian president, Luiz Inácio Lula da Silva, the president embarrassed his minister of health by telling Piot: “My minister of health has said we should stop smoking but the president likes his cigar. He says no sugar, but how can I drink coffee without sugar? No to alcohol, but the president likes his cachaca every evening. Are you now coming to tell me no more sex?”
Lula then burst out in a huge laugh. He had already instructed his ministers and diplomats to support UNAIDS.
Then, on one of Piot’s numerous visits to Cuba as UNAIDS boss, he went to a school in the provincial capital of Mazantas, to hear 10-year-old children make a presentation about HIV and Aids, after which one little girl, unfazed by the presence of the provincial governor and the secretary of Cuba’s legendary Communist Party, stood up and asked Piot:
“You know, Doctor, why we’re having this problem of Aids?” Surprised by the boldness of the little girl, Piot answered “no” and told the girl he would like to hear her opinion. With no shred of coyness, the little girl told him: It was because “all the men here are bisexual!” Everybody roared with laughter. And then there were two Catholic nuns from Europe – one in Côte d’Ivoire and the other in Namibia – who were promoting the use of condoms against the wishes of Rome. Piot met the first one at a health education session for young women in a Catholic mission near Yamoussoukro, the birthplace of the late Ivorian president, Felix Houphoët-Boigny.
“At some point,” Piot recounts, “a drawing of a condom appeared on the flip chart, and I asked the nun who was making the presentation: ‘Sister, are you promoting condoms?’ She blushed, and replied: ‘Doctor, when I show this chart, I think as a woman’.”
A similar defiance awaited Piot in Namibia when visiting a Catholic hospital. “I asked the same question to the nun in charge: ‘Sister, are you promoting condoms?’
“Her answer was short: ‘Doctor Piot, Rome is a long way from Namibia.’ And away she went. It made me understand that even a religion with a hierarchical structure and as apparently rigid as the Roman Catholic Church’s is not in reality monolithic, but guided in its daily work by the variable styles of individual humans.”
Meanwhile, the Holy See and its multitude of priests around the world continued to preach against condoms, to the point where one day in 2003, Cardinal Lopez Trujillo, head of the Vatican’s Pontifical Council of the Family, made it known, in a much publicised statement, that condoms could not prevent HIV as they had little holes in them through which the virus could penetrate. The outrage that Piot felt as head of UNAIDS, led to, first, a protest to the Papal Nuncio in Geneva where UNAIDS is based, and later a meeting with the Vatican in Rome, where a compromise was reached between the Holy See and UNAIDS.
According to Piot, they agreed to the following: “UNAIDS had no competency in theological and moral matters, and the Church had no competency regarding ‘the quality of materials’.
“In other words, the Church would refrain from statements about condoms, and UNAIDS would refrain from criticising the Church. This carefully-worded verbal agreement saved, I think, many lives, and isn’t the preservation of life the highest imperative of them all?”, Piot asks in his book.
And that is not all. On his many travels as a soldier against HIV and Aids, Piot did actually meet, in Uganda, Canon Gideon Byamugisha who was openly living with HIV. And as Piot puts it: “He surprisingly became a speaker on Aids across Africa, and did a great deal to take the sting away from HIV in Christian communities and beyond.”
Out of Africa always something new, one old sage once said. But nothing could be more inspiring in Piot’s book than an encounter with Michel Sidibe’s chameleon. Sidibe is a Malian and the man who took over Piot’s job as UNAIDS executive director in January 2009. Piot tells how they had met for the first time in Uganda in 2000 where Sidibe was UNICEF’s country representative. A fine African, Sidibe decided to impart a bit of African philosophy to the Belgian doctor. The story is better told in Piot’s own words:
“Michel was from Mali, had spent time in Zaire (now known as DRCongo), and he enjoyed life: we hit it off immediately. So we went out for dinner to Le Chateau, a steak restaurant in Kampala. And Michel told me a story.
“At puberty, like most boys of his ethnic group, he went through initiation, so that he could learn to be an adult. He had to live alone with other boys his age and he was given a chameleon: for a week, he had to observe and think about this chameleon. After the allotted time, he returned to the elders and they told him about life and about the secrets of the ancestors.
“When they finished, they asked, ‘Tell us about the chameleon’. So Michel said: ‘It changes colour’. ‘What else’, they asked. He listed characteristics.
“This was a long Malian story, but the conclusion was that by observing a chameleon, one can learn life’s great lessons: First, a chameleon’s head is completely still. It always faces the same direction. Stick to your goal. Second, the eyes are always moving, scanning the environment. Always be prepared.
“Third, the colour changes in response to the environment. Be flexible, know how to adapt, but keep the head pointing straight ahead. If it moves, you are an opportunist and you will fail.
“Fourth, a chameleon catches food by shooting its tongue, and if it is too soon or too late, it won’t catch its prey – it will die. Timing is everything.
“Michel and I ate a big steak together, became friends for life, and a few months afterward I asked him to join me in UNAIDS as head of all country operations.
“The chameleon story doesn’t tell you where to go, but it tells you to keep a balance between the need to change colour and the need to stick to your guns. When I’m in a very complex situation, unsure how far to compromise and taking in everything around me, I ask: ‘Does this fit with my strategic plan?’ The image of the chameleon is my guide.”
Out of Africa always something new indeed!
Fighting Ebola and Aids
Piot first arrived in Zaire in 1976 when his mission was to fight the deadly Ebola virus that had erupted in one district of the huge country. This would be his initiation into scientific discovery, “and into the world of what is now called global health”.
Piot saw himself as a man created to do good in Africa, even to save the continent like the Europeans of old. It is a credit to his Flemish instincts for him to think and act so benevolently towards a people and continent far removed from the shores of his little Belgium. Africa will forever be grateful for his great work.
However, stringing his own words together, it is not difficult to see, sadly, the subliminal prejudice about Africa that Piot grew up with, and which he carried on his missions to Africa. Long before he set foot in Africa, Piot saw the continent (deducing from his own words) as the land of diseases and dangerous viruses – the land that needed to be saved!
And his “dream” (his own word) was realised with the outbreak of Ebola, HIV, and Aids. Sadly, the realisation of his dream rendered him impotent to consider other facts and places than Africa. “At the age of 27, I was leaving my home to discover myself, and heading to a place of big, apocalyptic emotions: despair and exuberance and tragedy and fear. A place that was really coming apart from the seams; a slow-moving disaster scene that had just once again hit a new catastrophe. It was my dream [remember this magic word]: I was going to the heart of Africa – Zaire – to explore the outbreak of a new virus.
“Often when I left for Africa, I felt I could be more useful: I could make a difference… Meanwhile in Antwerp, I became the go-to-doctor for people arriving from Africa with embarrassing tropical infections…”
‘It must be Africa’
The above paragraphs are from different parts of Piot’s new memoir, but the thread is unbroken, to the point where, when the first cases of HIV and Aids were being reported from the US in 1980, his antennae immediately switched to Africa. “It must be Africa, the land of diseases!”
Piot tells it himself: “5 June 1981, the Morbidity and Mortality Weekly Report (MMWR) ran an item on 5 gay men in Los Angeles who had contracted Pneumocystis carinii pneumonia, which until then almost exclusively appeared in severely immuno-suppresed patients…
“Soon after the first publication, cases were reported 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.
“There were a number of talks [in Antwerp’s gay bars] 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 why Africa, Dr Piot?
A famous “Greek fisherman” that Piot mentioned “had lived for decades as a commercial fisherman on the banks of Lake Tanganyika in eastern Zaire”. He had sought medical treatment in Belgium in 1978 (elsewhere in the book, it is said to have been in 1979, it may be a typographical error), and when he died, Piot had been called upon by a pathologist of the Institute of Tropical Medicine to help perform an autopsy on the body.
“When we opened up his body,” Piot says, “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 centigrade 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.”
But when the first Aids cases erupted in America in 1980, Piot’s antennae jangled: “It must be Africa!” He immediately remembered the Greek fisherman of Lake Tanganyika! Even though Piot does not directly use the words “Africa, origin of Aids” at this juncture (he knows how sensitive that epithet is to Africans), he does so indirectly.
But intellectually, Piot must have known that the Greek fisherman’s geographical location on Lake Tanganyika in eastern Zaire was a mere red herring. He was a commercial fisherman, he had money, he could travel to any part of the world, he could pick up a new virus anywhere, he could come back “home” to eastern Zaire and pass on the virus or develop a disease.
As Piot himself admits: “In June 1985, the first International Aids Conference was staged in Atlanta, Georgia. By this time 17,000 cases of Aids had been reported, but more than 80% of them were in the United States.” So the origin of Aids could have been anywhere.
But this rational calculation appeared not to pass across Dr Piot’s radar. “It must be Africa.”
As it happened, Piot was saved from this agony by his friend Henri Taelman, who was the head clinician at the Institute of Tropical Medicine in Brussels. “Not much older than I,” Piot recounts, “he had vast clinical experience in Africa, and his work was his life. Henri and I began going through the hospital files, trying to check whether there was anything new – any kind of syndrome we missed earlier. This was where the Greek fisherman’s case suddenly became obvious: an inexplicable death, his body eaten away by an unusual infection, obvious signs of a powerfully degraded human immune system.
“Slowly, one after another, other patients started walking in to the institute, nearly all of them with an African connection. They had chronic diarrhoea, with startling weight loss, and infections that were unusual, highly aggressive, and suggestive of an extraordinary and mysterious immune collapse …”
Piot tells how wealthy African women had been coming to the hospital in Brussels. “They were desperate, very thin, very worried, very sick … Their medical situation deteriorated with spectacular speed. We had no idea how to treat them…
“With most of our patients coming out of Central Africa, I felt it was urgent to go there and take a look at the situation on the ground. If we were seeing 100 people from Central Africa coming to Belgium with this new illness, there might be thousands who couldn’t afford the flight or obtain a visa. By this time, in September 1983, we had firmly identified 40 patients with the new syndrome in Belgium, 37 of them from Central Africa.”
And so off Piot went, to Africa, sorry Zaire.In the largest hospital in the capital Kinshasa, Piot says they saw “50 or more cases of what we thought to be Aids, though we still needed laboratory confirmation to be sure of our clinical impressions.”
Was it the moment of fulfilment he was looking for? Piot says: “There was curiosity of course, and an urge to find some kind of solution, but also the overwhelming feeling that we were facing a truly momentous catastrophe. And I suddenly realised that this epidemic would take over my life. It was my aha moment.”
An “aha moment!” Slowly Piot was building to a crescendo: “In most countries outside Central Africa, people had been infected with HIV too recently to be ill or die,” he says matter-of-factly. “It takes on the average 8 years after infection before one develops Aids.”
And now he drops all the pretence: “In terms of the origin of Aids,” he says, “this meant it might have been around for decades or perhaps even a century, because if there is no amplification of risk, there can be a very slow rate of transmission, like a barely flickering candle.
“Today we know HIV hasn’t been around for centuries; based on genetic diversity analysis, we know it could have originated in the 1930s or perhaps even 1900s, probably in west Central Africa north of Congo, but it can’t be much older.
“But since that time, I have felt it is wrong to speak about Aids in Africa unless I also make it clear that there are many Africas, with different Aids epidemics, with very different social factors at work,” Piot adds.
But notice his language: “We know it could have originated … probably in west Central Africa…” In Queen’s English, “could have” and “probably” mean that these big scientists are still not 100% certain about the origins of Aids, except that it is convenient to pin it on an indolent and gullible Africa.
Piot actually makes an effort to expand the “African origin” by telling how in 1989 two members of his team, Bob De Leys and Martine Peeters, had isolated two “very unusual HIV-1 strains from a couple from Cameroon… the genetic variation of HIV appeared to be even wider than we thought… The virus that we found was aberrant. We called it ANT70, though it is now known as Group O.
“Per molecular clock calculations, Group O seemed to be the oldest virus strain yet identified. It may be even older than SIVcpz, a virus closely related to HIV-1. That discovery came more or less by chance, when Martine and her French husband, Eric Delaporte, were screening monkeys and apes for HTLV human T-lymphotropic virus…
“They were working in Franceville [Gabon] at a medical research centre funded by the French petroleum company Elf-Aquitaine. All of us were stunned when an apparent healthy chimpanzee was found to have a virus almost identical to human HIV…”
And Dr Piot goes on: “Many viruses have species-jumped at some point, and these are viruses that overwhelm their new target group with epidemics because no immunity has yet developed against them. So this research contributed to exploring the complexity of HIV, and to showing that its greatest diversity is in west Central Africa, specifically Cameroon and Gabon.”
Dr Piot admits that “there was uneasiness” in Africa about the origin of Aids “because of the Western discourse about Aids: this was often perceived as very offensive, redolent of the common European fallacy of Africans’ hyper-sexuality”.
But Piot’s own simple explanation of how HIV is transmitted perpetuates the “African’s hyper-sexuality fallacy”. Says he: “From the perspective of a virus, what is sex between human beings but contact between mucosal surfaces? It may not sound very romantic, but that’s the contact that makes the virus jump from one cell to another to perpetuate its own life.
“I don’t think the virus cares whether the sex is good, or about the colour or gender of the person who inhabits that mucosal surface. Granted, some types of intercourse may be more efficient than others, but none was exclusive. So I was always puzzled by this dogmatic insistence on Aids as a homosexual disease.”
Having said that, Piot cites data showing that on the average Americans, not Africans, have more sexual partners in a lifetime than any people in the world.
But by insisting that Aids is passed on principally via sex, Piot is effectively saying Africa had more Aids cases than anywhere else because Africans had, or have, more sex. It makes perfect common sense, except that Piot claims he does not believe in “the common European fallacy of African hyper-sexuality”. So how then did the millions and millions of Africans get infected by Aids if Africans were not hyper-sexual?
Encounter with Nujoma
Enter Sam Nujoma, Namibia’s former president. Piot tells how President Nujoma had once deviated from a keynote speech at the annual conference of the International Labour Organisation, and gone on to tell nearly all the labour ministers of the world, that “Aids is a man-made disease”, and that “states that produced chemical weapons to kill other nations are known – they are probably here, and they have
the responsibility to clean up the Aids mess”.
Piot says: “I was sitting next to the rostrum, and nearly fell off my chair… In my speech, which followed his, I set the record straight, and over lunch I tried to convince him that besides the absurdity of the conspiracy, the technology was not there yet to create a new virus. He clearly did not believe me.”
Nujoma might have been speaking with the US “appropriations for 1970 hearings” at the back of his mind. On 1 July 1969, the Congressional sub-committee of the Committee of Appropriations had heard presentations by the US military and biological weapons establishment, asking for funding to research and develop a “synthetic biological agent that did not naturally exist and for which no natural immunity could have been acquired”, as part of America’s biological warfare weapons.
The documentation on those hearings still exists in the Library of Congress. Part Five shows how the military men had told the Congressional committee that the Soviets were probably working on the “agents that we have considered”. The Americans feared “the possibility of technological surprise”. So the committee wanted more information, which was immediately given by Dr Macarthur who made the presentation:
“Molecular biology,” he told the committee, “is a field that is advancing very rapidly and eminent biologists believe that within a period of 5 to 10 years, it would be possible to produce a synthetic biological agent that does not naturally exist and for which no natural immunity could have been acquired.
“The dramatic progress being made in the field of molecular biology led us to investigate the relevance of this field of science to biological warfare. A small group of experts considered this matter and provided the following observations:
“1. All biological agents up to the present time are representatives of naturally occurring disease, and are thus known by scientists throughout the world. They are easily available to qualified scientists for research, either for offensive or defensive purposes.
“2. Within the next 5 to 10 years, it would probably be possible to make a new infective microorganism which could differ in certain important aspects from any known disease-causing organisms. Most important of these is that it might be refractory to the immunological and therapeutic processes upon which we depend to maintain our relative freedom from infectious disease.
“3. A research program to explore the feasibility of this could be completed in approximately 5 years at a total cost of $10 million.
“4. … The matter was discussed with the NAS-NRC [National Academy of Science-National Research Council], and tentative plans were made to initiate the program. However decreasing funds in CB [chemical-biowarfare], growing criticism of the CB program, and our reluctance to involve the NAS-NRC in such a controversial endeavor have led us to postpone it for the past 2 years.
“It is a highly controversial issue and there are many who believe such research should not be undertaken lest it lead to yet another method of massive killing of large populations. On the other hand, without the sure scientific knowledge that such a weapon is possible, and an understanding of the ways it could be done, there is little that can be done to devise defensive measures.
“Should an enemy develop it, there is little doubt that this is an important area of potential military technological inferiority in which there is no adequate research program.” So President Nujoma was not spewing “absurd conspiracy” after all. These things were being considered as far back as the 1960s. And with America’s record of using its black people as guinea pigs in medical experiments, Nujoma’s views were not exactly “conspiracy”.
During the Cold War years, germ warfare research was a reality, and anybody could sneak any number of viruses into “west Central Africa” and clandestinely insert them into the population as part of their research. If Piot does not believe in “African hyper-sexuality”, then it is not “absurd conspiracy” at all for Nujoma to consider other modes of transmission of HIV and Aids on the continent.
In the face of such details, it is not surprising that governments in Africa suspected that the Aids orthodoxy had something to hide.
Nujoma was not the only African president who nearly made Piot fall off his chair. The other was Thabo Mbeki of South Africa, who he met on 31 March 2000. Piot says Mbeki’s “arguments were technical and detailed, but they were partial. At every point, Mbeki came up with arguments that were not insane, indeed all were based on some truth; but they were spurious.”
AIDS on the retreat
A “spurious truth” actually takes the cake. However, the world can take solace that Aids is now on the retreat, and as Piot says at the end of his book, mortality from Aids has declined dramatically in just about every country.
“Today the cost of antiretroviral treatment has fallen from $14,000 to less than $100 per person per year. In 2000, fewer than 200,000 people in the developing world were on antiretroviral treatment – most of them in Brazil. In 2011, there were about 7 million. In 2000, barely 0.1% of African people with Aids received treatment; today it is about 40%. By any measure, this is a spectacular progress, unparalled in international development,” Piot concludes.
His book is sure to reignite the Aids debate.
(No Time to Lose – A Life in pursuit of Deadly Viruses. By Dr Peter Piot (with Ruth Marshall). Published by W.W. Norton & Company. ISBN 978-0-393-06316-5. Price £31 (UK), $28.95 (USA) hardback)