The Origins of AIDS (24 page)

The evolution over time in the distribution of HIV-2 infection is also of interest. Surveys in Guinea-Bissau, Ivory Coast and other West African countries over the last two decades reached the same conclusion: HIV-2 is slowly disappearing while HIV-1 becomes prevalent
. In countries outside West Africa with past colonial links to Portugal, HIV-2 has already vanished, with the exception of
India. In
France, out of
164 cases of HIV-2 infection diagnosed in 2003–6, only twenty occurred among French nationals, showing that the virus has had limited epidemiological success despite having been imported into the country by hundreds of
migrants from West Africa. In Guinea-Bissau, as the elderly cohorts slowly age and die, HIV-2 prevalence among adults is waning. Among women delivering at the
Simao Mendes national hospital, HIV-2 prevalence decreased from 8.3% in 1987 to 2.5% in 2004; over the same period, HIV-1 prevalence rose from 0 to 4.8%. In the
Bandim area of Bissau, HIV-2 prevalence among adults dropped from 8.9% in 1987 to 3.9% in 2006 while HIV-1 prevalence increased from 0 to 4.6%. These trends confirmed that HIV-2 is transmitted less effectively than HIV-1 during sexual intercourse. But then, how did it become so prevalent among the generation of elderly Bissau-Guineans?
^8
,
41
,
54

To address this question, and exploit the fact that HIV-2 is compatible with prolonged survival (which offers an opportunity to document associations with exposures that took place decades earlier), we conducted a survey of 1,608 individuals aged fifty and over living in Bissau. HIV-2 prevalence was 15% in women and 8% in men. HIV-2 was not associated with previous STDs or with having sold (women) or bought (men) sexual services. Among men, HIV-2 infection was not more common in those who had fought for either side during the independence war. Among women, however, HIV-2 infection was associated with ritual
excision of the clitoris.
When both genders were combined,
HIV-2 was associated with having been treated for sleeping sickness and with having received IM streptomycin for the treatment of tuberculosis. These three independent associations pointed to parenteral rather than sexual modes of transmission, all of which could have played a role only in the distant past.
⁵⁵

Sleeping sickness in Guiné Portuguesa peaked in 1952. Most patients were treated with IV
melarsoprol (up to fifteen injections, to be repeated if a relapse was diagnosed) while some early cases received IM
pentamidine (usually ten injections). The disease eventually disappeared completely so that virtually all participants who reported having previously been treated for trypanosomiasis were in fact treated before the country became independent in 1974. Meanwhile, streptomycin was used to treat tuberculosis until 1992, when a regimen using only oral drugs was adopted
. Prior to this change, tuberculosis patients received at least 60 and sometimes more than 100 IM injections of
streptomycin
. Finally, excision of the clitoris used to be practised in Muslim ethnic groups during the
fanado
, an initiation ritual during which dozens of girls were excised on the same day by elderly women using the same ceremonial knife. These ethnic groups still practise
excision, but now during individual procedures rather than collective ceremonies.
^56
–
60

For a long time, the only purpose of the Guiné Portuguesa health system was to protect the health of the Portuguese colonists and their Guinean employees in the cities. What happened to the sick villagers did not matter to the colonial masters. Ultimately, large-scale medical campaigns for the control of tropical diseases were orchestrated, but only three decades after similar activities started in AEF and
Cameroun. For instance, while in 1928
Jamot and his collaborators detected and treated in Cameroun 54,712 cases of sleeping sickness,
in Portuguese Guinea (whose population was half a million, one fifth that of Cameroun) fewer than 30 cases were reported.
In 1936, the Cameroun health system treated
81,965 cases of yaws, 56,749 cases of syphilis, 4,313 of
leprosy and 3,332 of trypanosomiasis
. The very same year, in Portuguese Guinea only 232 cases of leprosy and 42 cases of trypanosomiasis were diagnosed, as well as fewer than 100 cases of yaws and syphilis
.
^{56
–
58
,
61
–
65}

The first attempt to organise country-wide public health services came in 1945 with the creation of a vertical programme for the control of sleeping sickness. Predictably,
case-finding led to more cases being diagnosed and treated: 404 cases in 1946, 1,272 in 1948, 1,970 in 1950, peaking at 2,169 cases in 1952 and decreasing thereafter as these efforts eventually reduced transmission.
Treatment of treponemal infections started on a small scale only after the introduction of
penicillin, with 624 cases of
yaws and 59 cases of syphilis reported in 1953
. Incidence of yaws peaked at 2,644 cases in 1956.
Treatment of leprosy also started in the mid-1950s. As cases had been accumulating for decades without treatment, a substantial effort was consented so that 8,389 patients in all were being treated with either IM or oral
sulphones by 1958. Leprosy patients treated with IM sulphones received their injections by the side of the road as mobile teams visited their villages every fortnight. As the treatment of leprosy continued over several years, especially for the lepromatous patients with a large quantity of bacteria in their skin and nerves, many lepers received between 50 and 100 such injections
.

The most likely scenario is that, until about 1950, occasional cases of HIV-2 infection did occur from occupational exposure to SIV
_smm
but forward transmission was limited, because sexual transmission was relatively ineffective and opportunities for parenteral transmission were scarce. The delay in organising public health services, combined with a lower incidence of yaws and trypanosomiasis in this drier land, resulted in a lower proportion of the population receiving IV injections than in Cameroun. This limited the opportunity for the iatrogenic transmission of blood-borne viruses until the late 1940s. Then, after decades of neglect, health authorities instituted disease control programmes, to demonstrate the benevolent nature of Portuguese colonialism in the context of the emergence of African nationalism after WWII, fostered by the anticolonialist stance of the new global superpower, the United States.

This created conditions conducive to the parenteral amplification of HIV-2. From one case of occupationally acquired
SIV
_smm
in a cut hunter, a few thousand were created iatrogenically. Although we were able to document only the role of trypanosomiasis and tuberculosis treatments, it is likely that other interventions, including the parenteral treatment of thousands of leprosy patients, contributed to the exponential amplification of the virus between 1950 and 1970. At this stage, some young girls who had been iatrogenically infected with HIV-2 could start their own chains of transmission during the
excision rituals. Albeit relatively ineffective, sexual and vertical transmission also contributed modestly to the spread of HIV-2 in the overall population.

Subsequent political, social, epidemiological and technological changes resulted in fewer opportunities for the parenteral transmission of HIV-2. When the country became independent in 1974, there was no reason to maintain the disease control programmes of the preceding decades, especially since they had been very effective in reducing the incidence of the targeted diseases. The focus shifted to the provision of primary health care. Apart from the treatment of severe malaria with
quinine, few drugs were administered IV since orally administered antibiotics and antiparasitic drugs became available. As the iatrogenic transmission of HIV-2 was much reduced, the relatively ineffective sexual and mother-to-child transmission was not sufficient for the virus to persist: on average, each HIV-2-infected person infected less than one other individual. Very slowly but inevitably HIV-2 will vanish.

The bottom line is that if parenteral transmission played a key role in the emergence of HIV-2 in Guinea-Bissau, the same mechanisms must surely have contributed, in another region of the continent, twenty to thirty years earlier, to the early expansion of HIV-1, a virus associated with a higher degree of
viraemia than HIV-2, and thus more transmissible through the sharing of syringes and needles
.

Fifty years later, it is astonishing to read some of the colonial and early post-colonial writings about the Belgian Congo which is described as ‘our Congo’ or its inhabitants as
Nos Noirs
, our blacks. Belgium exploited this huge country, much to the profit of its banks and large corporations, but the Congolese benefited from the development of the infrastructure. Good roads were built, an impressive health system was put in place and primary school education was offered to many. It was cheaper for the colonial government to subsidise
Catholic (and, after WWII, Protestant) missions to take care of the teaching, and its expenditures on education were modest. In contrast with their French and British counterparts, Belgian colonialists elected not to train any Congolese elite, presumably for fear that these educated few would sooner or later challenge the colonial order. Only a tiny proportion would be able to enter secondary schools, and very few apart from Catholic priests would have access to post-secondary education. In 1957–8, out of 494 Congolese students attending post-secondary education, 376 were future priests enrolled in the seminaries
. Throughout Africa, the Belgian Congo had the second highest proportion of its population that had attended primary school but the lowest with regard
to post-secondary education. Among adults aged twenty and over, 1.7% of men and 0.1% of women had received at least one year of post-primary education, and respectively 0.5% and 0.04% had completed secondary school.
^1
–
2

The colony’s first university, Lovanium, a Catholic institution on the outskirts of Léopoldville, closely associated with Université Catholique de
Louvain in the motherland, welcomed its first students in 1954, more than thirty years after universities were established in
Dakar and
Kampala. By 1960, Lovanium took in only 420 students
. It was soon followed by a secular university in
Elisabethville, where most students were . . . Belgians. In 1958, to provide care for a population of 14 million, the Belgian Congo had 700 medical doctors and not a single one of them was Congolese. Despite six years of post-secondary education, the highest level a Congolese could reach under the Belgian regime was a medical assistant. The Congolese were considered too primitive to become doctors, unable to understand the rules of professional conduct and ethics and the infinite value of human life. Strangely enough, at the same time there were already 600 Congolese priests, who had been through six years of university-level philosophy and theology. When the country became independent, only thirty or so Congolese held university degrees earned at home or abroad.
^3
–
6

In 1955,
Antwerp university professor ‘Jef’
Van Bilsen proposed a thirty-year programme for leading the country to independence. Unrealistic, overoptimistic, naive, was the response of many in the Belgian establishment. Yet only four years later in February 1960, following a conference in Brussels, the colonial power announced that it would grant independence to the Congo at the end of June. What had happened? The Belgian government belatedly understood that it was fighting a backward and ill-fated opposition to a profound wind of change blowing across most of the world. After India and other Asian countries, African colonies started becoming independent with
Ghana in 1957, followed in 1960 by the whole of French Africa, including
Congo-Brazzaville across the river. Only the fascist dictatorship of Portugal and the racist regimes of South Africa and Rhodesia did not understand in which direction history was heading.

The prosperity of the early 1950s had brought to the Congo Belgian settlers, mostly Flemish farmers and stockbreeders, whose blatant racism and the large pieces of land they were granted had exacerbated the ever-increasing nationalist fervour of the Congolese. Out of nowhere,
dozens of political parties were created, competing for small factions of the future electorate, outdoing each other week after week in their demands for ever-quicker accession to independence. In Léopoldville, the riots of January 1959 had shown that the natives would not tolerate colonial oppression much longer.
For the first time a few months earlier, a large number of Congolese had travelled to Belgium during the 1958 Brussels universal exposition. To their amazement, they discovered that there were plenty of poor whites performing menial tasks in the public and private sectors. Oppression is a state of mind in which the oppressed accepts its fate as normal and unavoidable and its inferiority as congenital rather than imposed by past events, and in 1959, the Congolese began to reject this colonial paradigm. A civil disobedience movement emerged, mostly around Léopoldville. Taxes were left unpaid, administrative censuses were boycotted and workers in private and public enterprises went on strike.
Other anticolonial riots broke out in Stanleyville and
Matadi. After their French neighbours’ disastrous colonial wars in Indochina and Algeria, there was no appetite in Belgium for a conflict in which young conscripts might die. Furthermore, the public thought their colonial kin were privileged (better salaries, free housing, cheap domestic staff) and did not want to pay the costs of large-scale interventions aimed at protecting this
status quo
. Opinion polls showed that more than 70% opposed any form of military occupation of the Congo.
^7
–
8

The Belgian government decided to replace colonialism with neo-colonialism. Let us have a few Congolese as nominal heads of government and ministers and keep them happy with limousines and posh houses while retaining control over what really mattered, the economy, especially the lucrative mining industry in Katanga. Within a few months, a constitution was drafted and adopted by the parliament in Brussels, and legislative elections were held. The first draft of this constitution had proposed that King
Baudouin would remain the Congo’s head of state but the ungrateful Congolese refused. A power vacuum developed, and at some point Belgium had no fewer than six ministers managing various aspects of the decolonisation process.

The European population, which made up less than 1% of the total, fetched around 50% of all revenues in the Congo; apparently, this was an improvement from ten years earlier. Due to a recession and increasing difficulties in collecting taxes, the Belgian Congo’s budget was deeply in the red during the late 1950s, while hundreds of millions of
dollars in cash or gold had left the Congo, a process which continued after 1960 and was facilitated by the new country’s central bank being conveniently located in Brussels. The Congo was already broke on the day it was born. It would not take long before the nascent government was unable to pay its civil servants and soldiers regularly, a factor which contributed to the impending chaos
.
^7
,
9
–
11

The future Patrice Lumumba was born Elias Okit’Asombo in the Sankuru region in 1925. Educated in missionary institutions, already a rebel and expelled from four successive schools, he managed to complete his middle school education. Aged eighteen, he moved to Stanleyville where he adopted a new name from his mother’s side to mark a break with his turbulent past. Lumumba was mainly self-taught, a workaholic and prolific reader of everything he could lay his hands on. He worked as a post office clerk, a part-time journalist and later a salesman for a brewery in Stanleyville and Léo.
¹²

Lumumba was first imprisoned for one year in 1955–6 on charges of misappropriating post office funds. It was during this jail term that he became critical of Belgian rule.
After his release, he participated in the creation of the Mouvement National des Congolais (MNC), of which he became president. While most other emerging political parties were regional and ethnicity-based, the MNC aimed to be a national non-tribal organisation. Lumumba developed his oratorical skills promoting Polar beer in the many bars of Léopoldville, which enabled him to widen his network of sympathisers. Sent back to jail in October 1959, charged with inciting an anticolonial riot in Stanleyville, his anticolonialism grew more radical. He was released a few days after sentencing to attend the Brussels conference
. The MNC rejected Belgium’s plans for neo-colonialism and supported a unitary vision for the future country
.

Lumumba’s party won the most seats in the May 1960 legislative elections, the only free and fair elections to be held in this country during the entire twentieth century. After forming a fragile coalition with smaller parties, Lumumba became prime minister.
The members of parliament then voted to elect Joseph Kasavubu as president of the country. The new Congo constitution mirrored that of Belgium, where the prime minister held most of the power. However, unlike Belgium at that time, the Congolese constitution created a federal
state divided into six provinces, with substantial powers given to elected provincial governments. The leaders of various secessionist movements soon emerged from these provincial assemblies.

During the ceremony marking the Congo’s accession to sovereignty on 30 June,
King Baudouin’s paternalistic speech started by saying that this day represented the ultimate outcome of the grand undertaking conceived by the genius of Leopold II, not a conqueror but a civiliser. President Kasavubu responded in a polite and appreciative manner. Lumumba, who was not even scheduled to speak, rose and went to the microphone, addressing his words to the ‘independence fighters, today victorious’. The tone was set. On his first day as head of government, Lumumba gave a fiercely nationalistic speech, denouncing the colonial oppression of the previous eighty years, the racism, exploitation, humiliations and torture. Even if the second part of his address spoke of reconciliation, human rights and shared prosperity, the Belgian government decided that this man was too dangerous and had to be eliminated as soon as possible.

The day after independence was proclaimed, all territorial district officers, all senior civil servants, all army officers, all private sector management and practically all secondary school teachers remained Belgian. Of the 87,000 Belgian nationals living in the Congo, 10,000 were civil servants of the new government, 17,000 worked in the private sector and 3,000 were missionaries (the rest were their dependants). The high (and naive) expectations of many Congolese towards independence were utterly disappointed. This did not go down well in the army, especially after its commander, general Émile
Janssens, famously stated that ‘after independence = before independence’. Five days later, a mutiny inside the barracks of Léopoldville and
Thysville spread to most of the country.
Lumumba sacked Janssens, replaced him with Congolese officers headed by Joseph Mobutu and raised soldiers’ wages by giving everybody a promotion, but he could not regain control over the 25,000-strong army, which split along tribal lines.

Rioting crowds killed Belgian nationals here and there, those who happened to be at the wrong place at the wrong time. In some areas, Belgian women were systematically raped. Belgian paratroopers were rushed in to evacuate foreigners. Those living in Léopoldville quickly crossed the river to the safety of Brazzaville. In the strategic port of
Matadi, Belgian aeroplanes gunned the city, apparently unaware that almost all expatriates had been safely evacuated, killing scores of
innocent Congolese civilians. This mistake further fuelled the rebellion of additional units of the army, now joined by civilians as well.

Rarely in history has a country disintegrated so rapidly. The Lumumba government collapsed as 80% of its expatriate servants departed within a few weeks, unlike their compatriots in the private sector who preferred to stay rather than become unemployed in their homeland.
Provinces seceded from the central state, most notably mineral-rich Katanga on 11 July and southern Kasaï a month later, encouraged and supported by Belgium, its army and its large corporations. Katanga had been providing half of the central government income but received only 25% of expenditures. Its secession had been planned for months: neo-colonialism might be more likely to succeed if it focused on the resource-rich regions.
Lumumba and Kasavubu wrote to UN secretary-general Dag
Hammarskjold asking for immediate help.

The Security Council decided to intervene in the middle of July. UN troops arrived in Léo the following day and 8,400 were in the country within ten days. Relations between Lumumba and the UN quickly deteriorated, the former being convinced that the UN supported Belgium and the secessionist government of Katanga rather than the legitimate government of the Congo. By this stage, the impetuous and uncompromising Lumumba had become paranoid. He travelled to New York with little success, demanding the UN troops to be under the control of his government, which the secretary-general could not accept. President Eisenhower refused to meet him, and State Department officials thought that Lumumba was mentally unstable. Although certainly not a communist and only one month after having made a similar request to the US government, the desperate Lumumba asked the
Soviet Union for help. The Soviets sent planes, along with their pilots and technical advisers. Most of these were part of the UN effort, but some were assigned directly to the Lumumba government. In the midst of the cold war, this was the worst of all of Lumumba’s blunders
. The CIA started actively helping the Belgians in their various plots to get rid of the prime minister. The chief artisan of his own failure, Lumumba never understood that he did not have the political, military and economic power needed to sustain his own policies.

In September 1960, Lumumba was dismissed by Kasavubu, and in turn Lumumba dismissed Kasavubu
. The constitution did not allow for either of these moves. After a few days of confusion, Lumumba was definitively overthrown in a bloodless military coup led by the very
person he had just appointed head of the army, colonel Mobutu. Lumumba’s appeal to
Moscow had provided the perfect justification, if one was needed. Mobutu quickly expelled all Soviet advisers. Placed under house arrest, Lumumba tried to escape to
Stanleyville where his support remained strong, but he was captured after a few days on the run, imprisoned and then transferred to his arch-enemies in Katanga. One might wonder how the central government in Léo could transfer a prisoner to the Katanga secessionists, against whom they were fighting a low-grade civil war. The explanation is simple: Belgium controlled both ends of the equation, and thought it would be easier to eliminate this dangerous man in Katanga, where he had no political or tribal support. There, in January 1961, five hours after his arrival, he was executed by a firing squad supervised by Belgian policemen. Days later, his body was cut up and dissolved in acid. A state crime had been committed, ordered by the Belgian minister of African affairs, who had cleared this decision with his prime minister. It remains unclear whether the king, a devout Catholic, also approved of this murder. Much to its credit, Belgium formally apologised forty years later for its role in the assassination of Lumumba
.
¹³

The elimination of Lumumba did not prevent the situation from degenerating into a complex civil war, in which UN troops actively participated in combat in Katanga. The UN secretary-general’s plane crashed in northern
Rhodesia on its way to a meeting with Katanga’s leader, and it remained unclear whether this was the result of foul play or just an accident. Eventually, the Katangese secession was defeated, but other regions tried to fight the central government, especially the Province Orientale where a Lumumbist government was set up, and a large region east of Léopoldville where a left-wing guerrilla attempted to overthrow the regime
.

Hundreds of thousands of refugees took shelter in Léopoldville, the economy plummeted, unemployment became the rule rather than the exception, and we have seen in
Chapter 6
how this chaos and the ensuing poverty radically changed the face of
prostitution in the capital, allowing for the successful sexual amplification of HIV-1, one or two decades after the virus had been given a boost in the same city through parenteral mechanisms. At some point, the number of infected individuals reached a critical stage beyond which the dissemination of HIV-1 into the rest of the Congo, and beyond, became unavoidable.