The Origins of AIDS (17 page)

A remarkable peculiarity of French colonial history is the way medicine was organised: as part of the military. Young Frenchmen interested in a medical career in the colonies would usually get their degree at a medical school run by the armed forces in Bordeaux, before moving on to the tropical medicine institute in
Marseilles, known as
Le Pharo, after the name of the park where it is located near the old port. Overseas, they would start as a
médecin-lieutenant
and progressively, for the more talented, patient or motivated, move up the ladder to become perhaps a
médecin-colonel
or
médecin-général
at the end of their careers. Very few of them would be posted to the barracks to provide care for the colonial armed forces. Instead, they were posted to the hospitals and disease control units, working among civilians but remaining military doctors so that a strict hierarchy was maintained.
Disease control interventions and modes of healthcare delivery would be decided at the top of the pyramid, by the
médecin-général
, and implemented in a similar fashion throughout the colony following detailed protocols. There were precise definitions of what had to be reported and in what form, and the reports from each hospital or district would be merged into an annual report for the colony, containing an extraordinary number of tables, maps and graphs about the diseases of interest, their distribution, the treatments administered, the exact number of injections for each drug, and so on. Some of these annual reports contained 800 pages. Their format was the same for all colonies, so that they could be consolidated into an annual summary of the health status of overseas France.
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The other important feature of French colonial medicine was its population-based approach. While elsewhere in Africa colonial doctors were satisfied with providing care to whoever managed to show up at the local hospital or dispensary, the French wanted to provide basic health care to everybody, through the treatment of common and chronic tropical diseases. They kept reliable medical censuses of the population (their target), and their intent was to detect and treat all cases of a few selected diseases among this entire population. To do so, they funded and staffed mobile disease control teams who would roam through the bush, day after day, village after village, to examine everyone, find the cases and treat them in order to reduce the human reservoir of these infections and decrease transmission to the point where the disease would eventually disappear. Attending
case-finding sessions was compulsory, and a medical certificate was issued for each person. This public health approach, with massive numbers of individuals treated in their own villages with injectable drugs against a few diseases, offered a unique opportunity for the transmission of blood-borne viruses, whose existence was unknown at the time, to a degree much higher than could have occurred in British and Portuguese colonies
.

Fixed health care in hospitals and health centres was fairly limited initially, and it was just too bad for patients who developed an acute illness between the biannual visits of the mobile teams. Eventually, tensions arose between the champions of the ‘vertical’ approach (disease-specific mobile teams) and those who wanted to develop multipurpose fixed centres providing basic care available year round (the ‘horizontal’ approach, later renamed primary health care). The latter, of course, was necessary to provide care for acute and treatable conditions
such as malaria, pneumonia, gastroenteritis, women with obstructed labour, and so on
.

Eugène Jamot became the most famous French colonial doctor in Africa, and his biography illustrates the colonial medicine system as well as the development of the disease control interventions. Born in 1879, the first in his family to go to college, he studied natural sciences, taught for a few years in high schools in
Algeria and
Montpellier to accumulate some savings and then obtained his medical degree from Montpellier in 1908. After practising in France for two years, he decided he had other ambitions, partially prompted by an unhappy marriage, a difficult relationship with his mother and some problems with the justice system following a violent argument with his stepfather.
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After the tropical medicine course in
Marseilles, his first posting was to
Tchad, following which he received further training in Paris, and became deputy director of the nascent
Institut Pasteur in
Brazzaville.
Two weeks after his arrival, WWI broke out and he was designated to serve as the medical officer of a column that invaded Kamerun from the AEF. After the successful conclusion of this campaign, he returned to Brazzaville from 1917 to 1921
. By then a
médecin-capitaine
, he developed the overriding interest of his professional life: the control of sleeping sickness, which he conceived around specialised mobile teams. He led the first one which operated in
Oubangui-Chari.
⁶

Sleeping sickness (African trypanosomiasis), caused by a parasite called
Trypanosoma brucei gambiense
, was the first communicable disease for which large-scale control interventions were implemented in central Africa. The disease was first described in a European text in 1803 by
Thomas Winterbottom, a British physician in
Sierra Leone. One of its clinical signs, the presence of enlarged lymph nodes in the neck, was known to
slave traders as an adverse prognostic sign, and the price of such slaves was reduced accordingly. After weeks or months of intermittent fever, patients develop chronic meningo-encephalitis characterised by profound daytime somnolence, hence its name, which would last for several months until the fatal outcome, which was universal if
untreated.

Sleeping sickness did not spread to the Americas with the slaves due to the absence of its tsetse fly vector in the New World. It is thought that
the massive displacements of populations that accompanied the European colonisation of central Africa in the late nineteenth century facilitated the dissemination of the parasite. Trypanosomes were imported into regions where the disease had hitherto been absent or uncommon, and spread rapidly in such immunologically naive populations. The high incidence of sleeping sickness preoccupied French and Belgian colonial authorities who, in some regions because of the morbidity and mortality caused by this disease, were running out of their labour force. Furthermore, a high incidence among Africans implied a high risk of transmission to Europeans, who often developed this
lethal disease.

Indeed, the aim of many of the disease control initiatives implemented during the early colonial era was to protect the Europeans by decreasing the reservoir of the pathogen in the African population around them. Institutes of tropical medicine were established in
Marseilles,
London,
Liverpool and
Brussels to find technological solutions that would lower the mortality of Europeans in Africa, which was even higher in the centre of the continent than on the coast. A British government publication stated that ‘in the days when the west coast was the white man’s grave, the Congo forest would have been his purgatory’. The annual medical reports of each French colony started with a detailed section on health problems of the Europeans, with a list of all those who had died during the previous year, along with the cause of death: it was just too bad for your reputation if you had died from alcoholic cirrhosis or complications of
syphilis.
⁷

Substantial resources were allocated to the control of sleeping sickness, organised around what became known as the Jamot doctrine. The idea was simple: mobile teams would visit each village, examine everyone, detect as many cases as possible using simple methods (microscopic examination of blood or lymph node aspirate) and treat them on the spot with whatever drugs were available.
Initially, drugs were not very effective for the patients themselves, who often died despite treatments which could not get rid of the parasites in the brain. However, the drugs reduced the patients’ infectiousness by suppressing the presence of trypanosomes in the blood. For a long time trypanosomiasis treatment was geared more towards a collective benefit than improving the individual fate of the patient receiving these
toxic arsenical drugs.

In these early days, members of the case-finding mobile teams did heroic work under harsh conditions. For instance, in the space of
eighteen months in 1917–19, Jamot examined 89,743 individuals in Oubangui-Chari, diagnosing and treating (mostly with SC drugs) 5,347 trypanosomiasis cases, and did all this with only three microscopes and six
syringes. They would spend twenty days per month in villages, sleeping in huts provided by the local population, with no facilities whatsoever. Much of the travelling between villages, many of which were inaccessible by road, was done by foot. They were taking a substantial risk themselves as they spent two-thirds of their lives in locations harbouring a lot of tsetse flies infected with trypanosomes. Several healthcare
workers developed trypanosomiasis and died from the disease or its treatment. As a contribution to medical knowledge, some published their own cases, describing the progression of their symptoms in a type of scientific paper which has fortunately disappeared: the
auto-observation
. By shortening the period during which a patient was infectious, their interventions quickly proved effective, reducing the incidence of and mortality from trypanosomiasis by more than 65%. In 1922, Jamot was transferred to Cameroun Français, recently acquired by the French during WWI, where the authorities were discovering the extent of the trypanosomiasis problem inherited from the Germans
.
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Jamot had a strong personality, was highly motivated and worked hard. He quickly became known for his favourite slogan: ‘I will wake up the black race.’ He obtained very substantial resources, to the point where his specialised and autonomous sleeping sickness organisation, created in 1926 and based in
Ayos, east of Yaoundé, was seen by many in the administration as a state within a state. Jamot answered directly to the governor, and was independent of the chief medical officer of the colony and local administrative authorities. Several egos were bruised in the process. At one point, half of the medical doctors in Cameroun were working under Jamot, who coordinated twenty-eight mobile teams operating throughout the country, with a staff of 17 physicians and 400 healthcare workers.

He was revered by his subordinates, known as the
jamotains
, while his approach became the
jamotique
. In the communities visited, roughly 500 villagers were seen each day. The work was organised like a production line with each member of the team having well-defined roles: bureaucrats took care of the paper work (registries, individual certificates), nurses palpated the necks and marked with a cross the foreheads of those who needed microscopic examinations, a small army
of microscopists would examine the blood and lymph node aspirates, yelling when a trypanosome was detected so it could be corroborated by the doctor, while other nurses performed the lumbar punctures for disease-staging on those found to be infected. Eventually, the doctor would prescribe the treatment to be administered by nurses, who would stay behind after the rest of the team had left for the next village. During Jamot’s tenure in Cameroun, 150,000 cases of sleeping sickness were diagnosed and treated. However, when the incidence decreased, some of his medical colleagues wondered whether it was reasonable to spend so much on trypanosomiasis and so little on the fixed health facilities which would provide basic care all year round
.

Jamot published forty scientific papers during his career, a large number for an African-based non-academic doctor. Some contain extremely detailed descriptions of the distribution of trypanosomiasis in Cameroun and of the treatments used. A free thinker, he repeatedly and publicly said that the dramatic epidemics of trypanosomiasis in Cameroun and AEF had been triggered by European colonisation and the forcible displacement of large populations. This freedom of speech did not sit well with his military status. Other conservatives did not appreciate that while remaining legally married to his French wife, who never went to Africa, Jamot lived for many years with a Fulani from north Cameroon whom he married according to tribal customs and with whom he had three children.

A forceful advocate of disease control in the African colonies, Jamot became well known in France, especially during the Paris colonial exposition of 1931, as the man who conquered sleeping sickness. He was honoured by scientific bodies, received the
Légion d’Honneur
, and was even nominated for the Nobel. He took advantage of his notoriety to obtain ever-increasing resources for trypanosomiasis control in Cameroun. Even though the incidence was now 90% lower than when he arrived, Jamot had a more ambitious goal: its eradication, which seemed possible given that there was no significant animal reservoir of the parasite.

His high profile would eventually cost him his job. His many enemies found a good pretext to get rid of him when one of his subordinates decided, apparently on his own, to double or triple the dose of a new
arsenical drug,
tryparsamide. This went on for more than a year with the result that hundreds of unfortunate patients in the
Bafia area became blind, as the drug was toxic to the optic nerve. Jamot’s implication in
this disaster remained unclear. The young Bafia doctor was sacked but he protested and an inquiry was held. Jamot, who was then in France, did not show up at the ministry of colonies as requested. This was not appreciated. While on a stopover in
Dakar on his way back, colonel Jamot received a telegram. He too had been fired from his post in Cameroun.
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He was sent to organise sleeping sickness control in French
West Africa, from a base in
Ouagadougou. Jamot spent the next three years crisscrossing this vast territory, finding 70,000 new cases. However, he was caught up in similar disputes with the medical and administrative authorities concerning the importance and degree of autonomy given to the sleeping sickness control organisation. Discouraged by what he viewed as a lack of understanding of the seriousness of the problem, in 1935 Jamot retired from the military and went back to his village in France to work as a general practitioner. A broken man, he died of a stroke a year later.

There is no doubt that Jamot and his teams saved entire communities from extinction. In some villages in the upper
Nyong region east of Yaoundé, up to 97% of the inhabitants were found to have trypanosomiasis during successive surveys, and sleeping sickness was causing more fatalities than all other diseases combined. Other villages, which could not be visited in time by the mobile teams, had been entirely wiped out by the disease: a large part of the population had died, and others had left the area looking for a more secure location. After Jamot’s departure from Cameroon, the concept of disease-specific mobile teams roaming the countryside was adapted for the fight against other tropical diseases, especially yaws and
syphilis. But this very dedication and efficacy created tremendous opportunities for the iatrogenic transmission of blood-borne viruses
.

To evaluate the potential contribution of tropical disease control interventions in the spread of viruses, a detailed review was necessary. Fortunately, good archives have survived to this day. Most of these reports were kept at the tropical medicine institute of
Marseilles (located, quite appropriately, on the Allée du Médecin-Colonel Jamot): annual reports of the health services for Cameroun Français, Moyen-Congo, Oubangui-Chari, Gabon and AEF. The AEF included Oubangui-Chari, Moyen-Congo, Gabon and Tchad. As the latter is not inhabited by
P.t. troglodytes
, I collected data for the first three territories (from now on called AEF-3). For Cameroun, the annual reports sent
to the League of Nations and United Nations were available at the UN library in Geneva. Additional information was found in annual reviews of communicable diseases in French overseas territories. For each disease of interest except malaria, it was possible to calculate the annual incidence (number of cases per 1,000 inhabitants), which is important for inferring which ones were the most likely factors behind the high prevalence of
HCV described in the
previous chapter
and potentially the emergence of SIV
_cpz
/HIV-1. Denominators used to calculate incidence rates took into account the changes in boundaries between AEF territories and natural growth of these populations (
Figure 4
). At the time, few diseases were treated with orally administered drugs, so in practice an annual incidence of, say, 10 per 1,000 meant that during this year 1% of the population received a series of injections for the treatment of this specific disease.
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For a long time, treatment of sleeping sickness was based on drugs that contained arsenic, hence their general designation as arsenicals. The same arsenical drugs, or similar compounds, were also used to treat yaws and syphilis, among other infectious diseases. For most of the 1920s, SC
atoxyl was widely prescribed, often combined with a second drug given IV, for instance tartar
emetic (the drug used in Egypt to treat schistosomiasis). In the 1920s, the introduction of
tryparsamide, a drug developed at the
Rockefeller Institute, resulted in a dramatic improvement: patients with involvement of the brain could now be cured
. Just for 1927–8, 900 kg of atoxyl (about one million injections) and 600 kg of tryparsamide (135,186 SC and 71,903 IV injections) were used in Cameroun by Jamot’s teams. The number of injections declined thereafter (
Figure 10
), as the control efforts proved effective. After 1928, tryparsamide was usually administered IV while another arsenical drug,
orsanine, given SC or IV, was used for early stage cases. In AEF, treatments were standardised through instructions of the
médecin-général
: twelve weekly SC or IV injections of orsanine if the cerebrospinal fluid was normal, or twelve weekly IV injections of
tryparsamide if cerebrospinal fluid was abnormal, to be repeated annually for two more years to ‘consolidate’ the initial treatment. On average,
tryparsamide-treated patients received thirty-six IV injections
.
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