The Origins of AIDS (25 page)

Mobutu quickly handed power back to the select few civilians with a post-secondary education, but in November 1965, he staged another coup, this time establishing a corrupt dictatorship that would last thirty-two years, later to be described by political scientists as a kleptocracy (a word coined to mean government by thieves). Mobutu’s main achievement was to fight successfully the various secessions and rebellions and to end the balkanisation process, eventually reunifying the country and bringing some peace at last. The Congolese government financed its deficits by printing money, which led to a devaluation of the currency and high inflation (often 100% per year). Pay raises were slow to follow. During the first twenty years of nationhood, prices increased 324-fold while salaries rose only 19-fold. In other words, the purchasing power of the average Zairean in 1980 was only 6% of what it had been in 1960. There cannot be a better measure of the pauperisation of this people
.
^14
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16

During the chaotic post-independence period, most Belgian district administrators, agronomists, doctors and teachers fled the country, fearing for their lives. Promotions were quick in the Congo’s administration, and those who had served as low-level officials during Belgian rule, not because of incompetence but because the racial segregation of the colonial system meant that they could not be trained for higher functions, immediately climbed the ladder, far beyond their level of competence. It was more difficult to replace the doctors and teachers. Few Congolese could teach in secondary schools (only one man out of 200 had completed his own secondary school education), and not a single one at the university level. Neither was there a single Congolese medical doctor in 1960. The country asked for and received substantial foreign assistance in these vital sectors.
^10
,
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The UN provided the first cohorts of technical assistants in 1960. One year after independence, there were only 240 physicians for the whole country, including 70 sent by the World Health Organization (WHO), compared to 760 before that fateful day. By 1963, the UN had 1,400 civilian technical assistants in the country: 800 teachers and 600 experts in various other fields such as health, communications, agronomy, customs, post office, public works, the judicial system, etc. Some countries also sent technical assistants through bilateral programmes; the
Danish surgeon who died of AIDS in 1977 was one of them. In 1964
nearly 2,000 Belgian technical assistants (mostly teachers) were working in the country, but these numbers quickly decreased following disputes between the Congolese and Belgian governments. Post-secondary education was provided through scholarships for Congolese to study overseas and through the creation of specialised national institutions. The WHO funded an accelerated two-year training programme to turn medical assistants into
bona fide
medical doctors
.
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Many of the UN technicians were hired from the Haitian intellectual elite, struggling under their own ubuesque dictatorship of François
Duvalier. Haitians presented many advantages: they were black, well educated, spoke French and were keen to leave Haiti for much better salaries than those they received at home. Several hundred Haitians departed for the Congo in the early 1960s as teachers hired by the
United Nations Education, Science and Culture Organization (UNESCO), the UN agency for education, and as medical doctors under the umbrella of the WHO. As early as 1960, half of the UNESCO teachers dispatched to the Congo were Haitians. In 1963–4, Haitians were the second largest contingent (after the Belgians) among the UNESCO teachers, with 136 of them working throughout the national school system. They were also the second largest group (after the French) in the other fields covered by the UN intervention, with 60 more experts
.
^17
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By some estimates 1,000 Haitians were employed in the Congo in 1963. Progressively, and until the mid-1970s, a larger number of Haitians came as employees of the Congolese government, which at the time had the resources (from mining royalties) to hire foreign teachers that would at last provide young Congolese with the secondary and higher education denied to their parents. There was a substantial investment in enhancing educational opportunities, which required competent teachers willing to work in a rather difficult environment. Throughout the 1960s, Haitian teachers could be found not only in the major urban centres but also in smaller district cities that housed a secondary school. A book on the topic has been written by
Camille Kuyu, a Congolese jurist, who estimated that during that period approximately 4,500 Haitians worked in the Congo. A census carried out in
Kinshasa in 1967 estimated that about 500 Haitians were living in the city, so the total number quoted by Kuyu is not far-fetched
.
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25

Some were single, some were married and brought their families along, while others, posted into rather unstable regions, preferred to
leave wives and children at home. These efforts eventually paid off, and the most important accomplishment (some would say, the only one) made by the Congo in the two decades after its independence was the dramatic advancement in the education level of the population. In the late 1960s, 20% of the national budget was spent on education. The pedagogical institute of Léopoldville, established in 1961 and initially staffed by UN personnel, produced large enough cohorts of Congolese teachers by the mid-1970s
.
¹⁷

Naturally, a number of Haitians entertained liaisons with Congolese women. In his book about the women of
Kisangani,
Benoit Verhaegen tells the heartbreaking story of a very poor fourteen-year-old girl who, out of necessity, had an affair with a Haitian teacher in 1965. After fathering a child, the teacher claimed that he was going home to show the baby to his mother. They never came back, much as the Europeans had done for a long time. The young woman told the author that her dream was to move to
Kinshasa and become a sex worker.
²⁶

These Haitian technical assistants are the most plausible intermediaries for the next step in the pandemic, the export of HIV-1 out of Africa to the Americas. This process required just one of the 4,500 technical assistants to have acquired HIV-1 sexually or otherwise and for this person to go back to Haiti, either transiently or permanently, to start a chain of sexual transmission in the Caribbean island.

Haitians were not the only foreigners present in substantial numbers in post-independence Congo; there were also thousands of Belgians
. Although many went home during the troubles, some stayed or came back, especially those who owned a business or had lucrative jobs in the private sector. Prior to independence, Belgians made up about 80% of the Europeans living in Léo, followed by the
Portuguese (7%) and the French (4%). A number of Belgians acquired HIV in the Congo in the 1960s (and probably even earlier), from free women whose sexual services they
purchased
. This was documented by
Jean Sonnet, the former head of internal medicine at the university hospital in
Kinshasa, but in these cases forward transmission seems to have been limited to their spouses.
^27
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Just before and after independence, a few hundred Americans were living in the Léopoldville area. Most were Protestant missionaries, usually married, and thus unlikely to have been sexually exposed to HIV.
Fifteen years earlier during WWII, American troops had been stationed in the Congo, including Léopoldville, to beef up the colony’s
defences, and they were known to have assiduously frequented the bars in the capital, but this occurred too early to fit in well with the rest of the story
.
²⁹

Some of the UN troops who fought against the secessionists in Katanga and other parts of the Congo between 1960 and 1964, 250 of whom were killed in action, could also have been infected as HIV-1 may already have been present outside Léopoldville. At its peak in 1961, the Organisation des Nations-Unies au Congo (ONUC) mission was 20,000 strong. Over the course of the four-year operation, a large part of the
Nigerian,
Ghanaian,
Ethiopian and
Malaysian armies cycled through the Congo; 6,200 Irish, 5,600
Indian, 3,250 Moroccan and 3,175 Tunisian soldiers also served, as did smaller numbers of troops from
Guinea,
Mali,
Sudan,
Liberia,
Sierra Leone,
Pakistan,
Indonesia,
Canada,
Norway,
Sweden,
Denmark,
Egypt, etc. The ONUC troops in Katanga have been accused of a number of rapes. Throughout the mission, about 200 Canadian communications officers, mostly francophones from Quebec, were stationed in Léo and they frequented assiduously the city’s bars and brothels.
No early case of AIDS has been documented retrospectively in the countries that provided the troops, but admittedly some might have remained unrecognised or unreported, resulting in epidemiological dead ends
.
That being said, the rest of the story that will unfold in the
next section
strongly suggests that
Haiti was indeed the stepping stone for the export of HIV-1 to the Americas.
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When the first reports describing AIDS appeared in the US in 1981–2, Haitians were quickly identified as a risk group, the fourth ‘H’ after heroin users, homosexuals and haemophiliacs. Case series of AIDS among Haitians living in
Miami,
New York,
Montreal and Haiti were published. Unlike some of the other risk groups, Haitians were easily identifiable: black persons speaking English with a peculiar accent (or no English at all). Furthermore, many of them were illegal
migrants or asylum seekers or, if living legally in the US, not yet American citizens. There had already been some anti-Haitian sentiment building up in
Florida, triggered by the recent arrival of thousands of boat people fleeing their dynastic dictatorship.
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During the first few years of the epidemic, when the modes of transmission of the new disease were not understood, mass hysteria became
the rule rather than the exception. Before the discovery of HIV as the aetiological agent of AIDS, many different hypotheses were proposed, including the emergence of a Haitian virus perhaps related to bizarre voodoo practices. Haitians living in the US became victims of atrocious discrimination, stigmatisation and prejudice. Some were sacked from their jobs, others were kicked out of their flats, people were even afraid to talk to them, in some clinics they would be asked to queue separately from other patients, Haitian children were taunted at school or even beaten up, Haitian businesses went bankrupt as clients were scared, etc. In Haiti itself, the tourism industry vanished overnight, and thousands lost their source of income. From a high of 144,000 in 1979, the number of visitors decreased to as few as 10,000 in 1982–3. According to medical anthropologist Paul Farmer, it generated an epidemic of discrimination and ‘an entire nation of impoverished people had been relegated to the status of a health hazard’.
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The Haitian community in the US reacted strongly and successfully lobbied the CDC so that Haitians were removed from the list of high-risk groups in 1985, something which was politically sound but epidemiologically debatable. Epidemiologists define a risk group as a subpopulation among whom a disease is more common than in the whole population and at whom specific preventive measures can be targeted. Amongst the first 1,000 cases of AIDS reported to the CDC, fifty-four (5.4%) occurred among Haitians, only three of whom admitted being homosexual; at that time about 0.15% of the US population was born in Haiti
. In retrospect, although heterosexual transmission of HIV-1 had already occurred on a similar scale in several African countries, Haitians living in the US represented the first population among whom this was documented and they suffered because other modes of transmission, such as casual contacts, were initially suspected.
⁴²

As part of their reaction and defence against discrimination, an argument was developed that HIV had actually been exported from the US to Haiti through the
sexual tourism of American gay men who bought sex from male prostitutes. This hypothesis was put forward before epidemiological studies were conducted in Haiti but it was plausible. Indeed, thousands of American gay men travelled to Haiti in the 1970s and early 1980s.
Homosexual tours were organised out of
San Francisco and
New York, and some specific hotels (Habitation Leclerc, for example, a walled enclave for those with deep pockets, or Pension Tropicale for the others) catered to this clientele which had a lot
of money to spend. The French Canadian airline steward who was linked to many of the early cases of AIDS in the US, and dubbed by some ‘patient zero’, was one of these visitors. An international gay convention was held in Port-au-Prince in 1979, attended largely by Americans.
Herbert Gold, a San Francisco writer, described the gay scene in Port-au-Prince in the late 1970s: the parties were fabulous and apparently some attractive boys were trained for export to the US. This had been going on for quite a while because already in the late 1940s Suzanne
Comhaire-Sylvain had described in
Kenscoff, near the capital, the existence of homosexuality between some of the café workers and foreign clients, a harbinger of what would later happen on a wider scale.
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As late as 1982, the Spartacus international travel guide for gay men provided tips such as ‘your partners will expect to be paid for their services but charges are nominal’. The going rate seemed to have been $10 to $15. Haitian men were described as ‘handsome, very well endowed, highly sexed, uninhibited and affectionate’. In retrospect, however, most people would agree that the statement that ‘much of the population is bisexual’ may have been somewhat exaggerated. It was noted that the local authorities became less tolerant after 1980 when several youths had been hospitalised following sodomy injuries caused by sadistic Caucasian tourists. At the other end of the island, the
Dominican Republic, formerly a ‘paradise for gay tourists, particularly paedophiles’, had turned into a nightmare due to the bad behaviour of these tourists. Throughout this travel guide, there was certainly a casual attitude towards sex being purchased in Third World countries and a refusal to call it by its true name, prostitution.
⁴⁸

In its 1985 edition, a few years into the AIDS epidemic, the Spartacus guide reported that the reaction of the
Duvalier government had been to expel from the country foreigners who owned gay bars and hotels, that visitors were now screened at the airport and those who looked gay or whose names were on a list of unwanted aliens were sent back on the same plane. Two years earlier, the Port-au-Prince authorities had announced that all Haitian gay men would be jailed for six months followed by another six months of rehabilitation. A fairly large number were arrested, but they either paid bribes or threatened to name names and most were quickly released
.
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Homosexual prostitution was part of a bigger picture in which, as an unavoidable consequence of an island of deep poverty being located so
close to the US, other types of visitors came to Haiti for vacations that included sexual adventures. After the fall of Batista,
Cuba was no longer available for such holidays of sun, sand and ‘duty-free sex’ and another nearby destination was found. Middle-aged American or Canadian women could enjoy a week or two with a Haitian gigolo, and white heterosexual men also had a good time, sometimes with girls in their early teens. Of course, there was a substantial amount of commercial sex for the internal market as well
.
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It was postulated for some time that all cases of AIDS among Haitians must have been acquired homosexually, and the fact that many Haitian AIDS patients denied having had sex with another man reflected cultural barriers against acknowledging homosexuality. It is interesting to note that, as a reaction against stigmatisation, the response was to lay the blame on a risk group that had itself been highly stigmatised in the US, long before AIDS.
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What is the evidence in support of Haiti having been infected from the US or vice versa?

In retrospect, the first probable cases of AIDS in Haiti were recognised in 1978–9. This retrospective chronology is based essentially on diagnoses of Kaposi’s sarcoma (KS), a cancer which had rarely been diagnosed in Haiti prior to 1979. This is the form of skin cancer developed in the character played by Tom Hanks in
Philadelphia
, for which he received an Oscar. AIDS-associated Kaposi’s sarcoma involves internal organs but patients also display multiple skin lesions which can be easily biopsied, provided the patient has access to a hospital equipped to do
histopathological examinations. AIDS-associated KS has to be distinguished from ‘endemic Kaposi’s sarcoma’. While the former is associated with a profound immunosuppression and a high mortality, the latter is an indolent cancer, compatible with prolonged survival, which has long been recognised as endemic in parts of Africa, including the Belgian Congo,
AEF and
Uganda. Among eighteen cases of KS diagnosed in Haiti or among Haitians in the US in 1979–81, most died within six months of diagnosis: clearly, this was not the ‘endemic’ form of the disease. There was a male preponderance.
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Similarly, cases of probable AIDS with KS among gay men were identified retrospectively in the US in 1978–9. Such temporal coincidence suggests that whichever country got HIV first, the other one got it not long after. The median incubation period from acquiring HIV until developing AIDS is about ten years, but can be shorter in some patients.
These observations suggest that HIV was introduced into both Haiti and the United States at the end of the 1960s or in the early 1970s.
^62
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However, it does not imply that HIV was introduced into both countries at exactly the same time, for several reasons. KS is not the best marker for retrospectively recognising the emergence of AIDS in a population. Kaposi’s sarcoma is a cancer caused by another sexually transmitted virus, human herpesvirus 8. During the early years of the American epidemic, Kaposi’s sarcoma as an AIDS-defining illness was much more common in homosexuals than in other risk groups, presumably because human herpesvirus 8 is transmitted better during homosexual than heterosexual intercourse. KS was seen in 21% of homosexuals with AIDS, but in only 6% of male heterosexuals and 1% of
haemophiliac men who developed AIDS. Once infected, for some reason males in general are intrinsically more susceptible to the cancer-causing effect of the virus than females (fifty years ago, in central and East Africa, endemic KS was five to thirty-three times more common in men than women). By analogy, changes in the incidence of KS in Haiti probably reflected the introduction of HIV into its homosexual/bisexual community rather than among individuals who acquired HIV through other modes
.
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,
66}

Access to a diagnosis of Kaposi’s sarcoma was infinitely better in the US than in Haiti. In the US, it would have been very unlikely for somebody with KS not to have a skin biopsy with
histopathological interpretation and registration of the case in a cancer registry. In Haiti, it is plausible that some of the early cases of KS were missed. It is interesting to note that a case of AIDS (without KS) was diagnosed in
Montreal in 1978, in a Haitian who went to
Canada for medical treatment. Since only a tiny proportion of Haitian patients would have had the contacts and resources to travel abroad to seek medical treatment, there must have been earlier cases of AIDS who died quietly in Haiti without a diagnosis
. The most frequent HIV-associated opportunistic infection in Haiti would have been
tuberculosis, a disease that was already so common in the impoverished island, long before HIV emerged, that any change in its incidence or clinical pattern would have taken years before it was noticed.
⁶⁷

As in Africa, scientists tried to locate archival samples of serum. Out of 191 Haitian adults from a rural area tested for
dengue fever in 1977–9, none was HIV-positive. Molecular biologists came to the rescue of historians and provided estimates of the respective chronology of the
two apparently concomitant epidemics in Haiti and the US.
A first study using a molecular clock estimated that the founder of the B subtype in the US originated in 1967 (confidence interval: 1960–71). In the
phylogenetic tree, the seven B subtype sequences from Haiti ‘branched off’ earlier than the other B subtype sequences, which suggested that HIV in Haiti antedated its introduction into the US.
^68
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More precise measures were generated when researchers recovered HIV-1 sequences from archival specimens collected at a
Miami hospital in 1982–3 from Haitian AIDS patients who had recently emigrated to the US and had presumably been infected with HIV-1 while in Haiti. These sequences were compared to isolates from the US and other countries, all of which were HIV-1 group M subtype B. If HIV-1 had arrived in Haiti first, non-Haitian subtype B strains would be expected to be phylogenetically nested within an older and more extensive range of Haitian genetic variations, with Haitian lineages branching off closest to the ancestor. This is exactly what the analysis showed. The probability that subtype B emerged in the US prior to Haiti was estimated at less than one in a thousand
.
⁷⁰

Analyses supported the hypothesis of a single epidemiologically successful introduction of subtype B from central Africa to Haiti, from where it was re-exported to the US. The time of the most recent common ancestor of subtype B in Haiti was estimated to be 1966 (confidence interval: 1962–70) while the most recent common ancestor for the US epidemic was estimated at 1969 (confidence interval: 1966–72). In other words, HIV was introduced into Haiti around 1966, and from there it moved to the US around 1969, give or take a few years. This was consistent with another study which dated the founder of the US type B epidemic at 1968.
^70
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