by Piot, Peter
They also had a stiffness about them, and a sadness that I interpreted as the shadow of apartheid: people, particularly men, seemed to have been somehow broken. Even men over sixty were routinely hailed as “Boy.” It was strange, miserable, ugly. But after a while, I understood that these people were as warm as those in Central Africa, just different. Swaziland was a monarchy with an absolute king. South African police were said to be everywhere, supervising everything, so that the exiled African National Congress liberation movement couldn’t use the country as a base of operations. But many whites whom I met at the hotel seemed to be present for two things only—to have sex and to gamble.
In those days I knew hardly anything about sexually transmitted diseases (STDs). But André and I went to clinics, estimated the numbers and type of sexually transmitted infection, reviewed their treatment guidelines (which were almost uniformly ineffective), and saw—it was clear—that the STD problem in Swaziland was enormous. I noticed when I was going through the mission records in Yambuku, and at the Mama Yemo Hospital in Kinshasa, that there seemed to be a sexually transmitted disease problem in Zaire, too; chancroid and salpingitis and urethritis and gonorrhea seemed to figure far more often than I would have expected in Belgium. But in Swaziland, the scale was off the charts.
We were doing clinical examinations, of course. And the kinds of complications and combinations of STDs that we were reviewing were simply mind-blowing. Every clinic was like a museum of genital disease, a cabinet of sexually transmitted curiosities. The patients were all desperately poor. A man would walk in wearing his skirt and you would see that his penis was dripping on the floor. He would pick his skirt up, show me a truly monstrous chancroid, and I would ask, “So when did you last have sex?” And he would say, “This morning.”
I was astonished, because if it were me I wouldn’t be able to put it in my pants, it would hurt so bad. Speaking as a doctor, I was really taken aback, because under those conditions the disease would clearly spread fast and wide. And finally, as a human being I was shocked, frankly. Because it quite often emerged that the sex partner was a much younger woman, and the man could hardly have ignored the fact that his chancroid was highly contagious. Having sex in these conditions was just abominable. So I was quite judgmental about that, and also, incidentally, about the Swazi King, who at the time was seventy-nine years old, and almost every year married yet another virgin.
Prostitution was everywhere I went in Swaziland. The day I arrived at my hotel, the man at reception gave me my room key and when I went up there was a woman there. So I went back downstairs and said, “I want my own room—there is a woman in that room.”
The receptionist looked at me, sort of taken aback, and said, “Oh? Want a boy?”
That, apparently, was the only other option imaginable. At first I assumed that such activity was limited to this particular hotel. I didn’t grasp yet the scale of prostitution in the city.
André and I had no hope of eliminating STDs from Swaziland, quite clearly, but we could do something to help. We arranged to convene a training session for Swazi nurses a few months later, which I would return to direct alone. In the meantime I designed a simple way to identify STDs without any lab tests, developing something called algorithms for treatment. Basically it was a simple flow chart—a tree structure with questions. Are there red bumps on the genitals? Are there also open sores? Are the sores dripping pus? If so, treat with antibiotic XYZ. I sketched this flow chart out quite literally on the back of an envelope, and oddly enough it turned out to be so useful that it’s still being used all over the world after being endorsed by WHO years later. You can find these charts on the wall in many a clinic in Africa today.
When I got back to Antwerp I found a letter waiting for me from the Zairean ambassador to Belgium, Kengo wa Dondo. “The President and Founder has appointed you an Officer of the Order of the Leopard,” it announced. I had no desire to receive any kind of decoration from Mobutu, but I saw no polite way out. So I phoned the embassy and on the appointed day I went there and was handed a star-shaped medal on a piece of bright green ribbon, with the motto PEACE, WORK, JUSTICE. Sure thing, I thought: Justice.
The ambassador explained that I would soon receive a special card, personally signed by Mobutu (who, by the way, had a signature that was just a stab of ink—one line, no curls or letters—which I guess is how a man of infinite power signifies his status). This bright green fold-over card, which looked a bit like a Belgian driver’s license of the time, would give me total immunity and total respect throughout Zaire. I would be guaranteed safety and protection from every kind of harm.
I decided not to go and get the card. I didn’t want to profit from Mobutu’s regime. I felt that Zaire had twice been the private property of a single individual—first the Belgian monarch Leopold II and now Mobutu—and I wanted no part of any of this corruption.
A few months later I also met Mobutu, the man whom French humanitarian activist Bernard Kouchner called “a bank vault in a leopard-skin hat,” who had changed his name to mean “the rooster who leaves no chicken unplucked” or “the all-powerful warrior who goes from conquest to conquest, leaving fire in his wake,” depending on the translation. Mobutu was on a state visit to Belgium, and he came to Antwerp to thank us for having saved the country. He was wearing that famous leopard-skin hat of his, and he held his magic walking stick, with the head carved like an eagle, and I shook his bloodstained hand. He was very charming, as were so many other dictators I met later as head of UNAIDS.
By this time I had decided to do my doctoral work in sexually transmitted disease. In a way this was logical. Hemorrhagic fevers, like Ebola? They were simply too dangerous and costly for our lab ever to hope to work with. Diarrheal diseases? Sure, that research would be useful, but there was already a group in Brussels that was doing a lot of work in the field. Malaria? It was such a complex problem; I wasn’t sure I would ever be able to master the immunology. But STDs, such as I had seen in Swaziland, here was an area where I could really help people. Except for herpes in those days, you could always cure these diseases, and that’s very gratifying for a doctor.
If you’re a psychiatrist or a geriatric specialist, you’re looking at chronic, complex problems; the work may be frustrating. Infectious diseases, sexually transmitted diseases—these were not prestigious specialties; in fact, they were at the bottom of the ladder in terms of medical status. But I was drawn to them, because these were problems that had solutions; as a doctor, your impact could be strong and quick. It could also be vital to reproductive health, a crucial issue for many women, whose medical needs in this respect (as in so many others) had clearly been ignored for far too long. Also, chlamydia had just been discovered as a cause of genital infection. This was an intracellular bacteria that was difficult to detect, but highly damaging to fertility. I found the microbiology of chlamydia fascinating. So although opting for sexually transmitted diseases wasn’t the smartest career move, it made sense to me from the point of view of scientific curiosity and human need.
BECAUSE OF THIS new interest in sexually transmitted infections, I began seeing more patients in addition to my job in Pattyn’s lab. The clinic that I worked in was housed in the same nice old art deco building as the lab—the Institute for Tropical Medicine—and its full name (which nobody used) was “Clinic for Colonials and Seafarers.” This clinic was known for its treatment of sexually transmitted diseases because in Antwerp STDs were considered a tropical disease—there’s a big harbor and a lot of sailors, and they tended to catch sexual diseases in outlandish places. I arranged to work there two afternoons a week, to further my research.
I liked the work. I wasn’t only dealing with sexually transmitted diseases: this was a consultation for vaccinations, for leprosy and malaria, and what have you. A lot of people began coming to me specifically because they heard that I didn’t share the half-concealed disapproval of some of the other doctors. Also, STDs were rising in Antwerp in the late 1970s, just
as they were everywhere else—especially in the gay population, which had really only just begun to come out of the closet in Belgium, and openly live out what proved for some to be a dangerous lifestyle.
Obviously I knew that many medical doctors see work with sexually transmitted disease as embarrassing. It’s dirty, it’s low-life. But I never felt like this. When you work with STDs, you need to be able to keep your mouth shut (as in any interaction with patients). Confidentiality, competence, a nonjudgmental approach: these are what count.
I knew that ideally, my career and my life were going to be about developing countries. I was still searching, but it seemed now that it would probably involve something literally below the belt. So at the clinic in Antwerp I took samples from patients and tried to work them out in the lab. That’s how I came to isolate a new, penicillin-resistant gonococcus from the urethral pus of a sailor who had sex while on furlough in Ivory Coast. Up to then, penicillin resistance in gonorrhea seemed to occur through mutations in the bacteria’s chromosome. This meant that as resistance built up, you needed a bit more penicillin, but once you attained the correct dose the bacteria would succumb. With the new type of resistance an increased dose wouldn’t help, because the bacterial strain produced enzymes that could actually destroy penicillin. Worse yet, the genetic information for producing these enzymes was transmitted by plasmids—extrachromosomal molecules of DNA—that could be transferred among different bacteria, a potentially serious public health problem.
The first gonococci of this type were discovered in US soldiers and Marines stationed in the Philippines; another was isolated in a man from Ghana. So my strain was the second found in Africa. I published the discovery in 1977. It was just a letter to the editor of The Lancet, but to a young researcher from Belgium that was the big time. The next year, when working in the laboratory of Stanley Falkow at the University of Washington in Seattle, we characterized the plasmid and the mechanisms of resistance.
All this work piqued my interest in gonorrhea; I tried to learn as much as I could. But when I looked into the medical literature, it was like looking into the Dark Ages. And it was the same with chlamydia. There was a whole field here crying out for some serious science, but at that time the only person applying scientific methodology to the study of STDs seemed to be someone named Dr. King Holmes, from the University of Washington in Seattle. He had worked with the navy in Vietnam, to estimate the risk of acquiring gonorrhea; he had worked on resistant strains, finding new etiologies; and he had started working on chlamydia and pelvic inflammatory disease (PID).
That really caught my attention because I saw so much of it in the records at the Yambuku mission. Holmes was doing very basic work on PID—what caused it, what microorganisms are associated with it. Common wisdom said it was bacteria ascending into the vagina from the environment—basically the scenario where you catch something from a toilet seat—but Holmes and his team demonstrated that it was almost always linked to sexually transmitted disease. This may not have been a socially convenient explanation but at least it indicated the correct treatment.
I met King Holmes for the first time at a conference in Rotterdam. I was coorganizing this founding meeting of the International Society of STD research—a group of young “Turks,” who aimed to transform the science of STDs. As I recall the talk was on the various possible causes of nongonococcal urethritis—chlamydia, herpes, or other organisms such as Ureaplasma urealyticum—and I found King to be an inspiring, charismatic, even humorous speaker. He could have made the phone book sing. After his talk, I went up to have a few words with him.
I’m not sure what I expected, but it was certainly not that King Holmes would take the time to ask me questions about my work, and appear to listen to the answers. I didn’t know yet that in the United States there was a totally different kind of relationship in academia, much more open and egalitarian. King is an extraordinary scholar, with an unlimited curiosity for disciplines far beyond his own specialty of infectious diseases, and above all, with a great capacity to mentor young researchers to get the best out of them. Soon after our brief encounter, he became my mentor as well.
A few months later, in early 1978, I obtained two fellowships—from NATO and from the Belgian Science Foundation—to go to the United States. My plan was, first, to attend the CDC’s Epidemic Intelligence Service training course that Joel and I had discussed. In those days, this program was unique in the world. It was created in the 1950s to develop a corps of epidemiologists to investigate epidemic outbreaks, with a structured method for how to investigate disease outbreaks of known or unknown origins and what to do about them.
I also wrote to King Holmes and told him that I had a fellowship, and that I planned to attend the CDC course and work for a few months at the CDC’s Special Pathogens Lab. I asked Holmes if I could then also come and work at his lab in Seattle. Holmes answered Sure. I felt I knew what I was doing. Nothing was really fixed, but I was a grown-up now and that suited me fine.
CHAPTER 8
America and Back
I ARRIVED IN ATLANTA in June 1978. Karl Johnson, our team leader in Yambuku and head of “Special Pathogens” at the Centers for Disease Control, picked me up at the airport in his old Volkswagen station wagon and dropped me at the home of Stan Foster, a CDC epidemiologist and smallpox veteran, where I stayed for a few weeks, before moving to Karl’s house in Snellville, a small town east of Atlanta.
This was my first time in the United States, and it was as great a culture shock as going to Zaire—more, in some ways, because I had expected it to be essentially the same as Europe. People in Snellville left their air-conditioners on all the time, even when their doors and windows were open. Everywhere I went I needed a credit card but I didn’t own one—this was 1978, remember, and in Belgium credit cards were rare. There were guns. Huge cars. The stereotypes piled up. In Georgia people call you by your first name after seconds. All around me in Atlanta were black people who were very different from Africans, while the CDC was all white, barely a single dark face in the crowd.
As part of the CDC course, I had to do a survey on contraceptive practices in inner-city Atlanta. I went with a veterinarian who was a black American from Harvard, and he was a bit nervous to do it. But I said, “No problem, I’ve been to Zaire”—I was the explorer. We drove around neighborhoods of burned-out buildings that looked like Beirut, knocking on doors. We asked questions to people who could barely understand my English; I certainly could not understand theirs. This was daytime work, so most of the people who answered the door were single women and perfectly friendly. Then a guy opened the door to his apartment and he had a Colt in his belt.
I have no recollection at all of the results of the survey, but I met some very interesting people at the CDC, chief among them the director, Bill Foege, the forty-two-year-old father of smallpox containment. He insisted on meeting personally with each foreigner who attended the course; he questioned me at length about my experience in Africa, and I found that remarkable. Foege was a very impressive figure, and not only because of height. Working as a medical missionary in eastern Nigeria in the 1960s, just as the people of Biafra began to fight for independence, he had had the job of performing smallpox vaccinations, but he didn’t have enough vaccine to cover everyone. When a three-year-old boy came down with smallpox, he devised a system for mapping its likely spread and vaccinated only people in market villages and places where the child’s family habitually traveled. His surveillance and containment scheme stopped the outbreak in its tracks and inaugurated a new tactic in the fight against the disease. (Thirty years later our paths crossed again as senior fellows at the Bill & Melinda Gates Foundation in Seattle, and he was as inspiring as ever.)
The plan was for me to work for a while with Karl at the high-security Special Pathogens Lab. I had to suit up in a space suit that had its own air supply and obey an incredibly disciplined, very highly organized regime. Really I just couldn’t handle the discipline. I forgot things, and the
n had to undress and shower before leaving the lab to go get them, and go through the whole ritual again on return. It was too cumbersome for me—
After a couple of weeks I decided to cut short my now two months’ CDC experience and head to Seattle to work with King Holmes, because my scientific interest had really moved from hemorrhagic fevers to sexually transmitted diseases. Greta had joined me in Atlanta, with Bram; we had bought a Toyota station wagon, in anticipation of exploring the New World, so the most logical idea seemed to be to pile everything into the car and drive across the country. We took our time, and stayed at campsites.
I was surprised by the number of churches on our way, though even a small European town like Antwerp has plenty of old Catholic churches. I could feel the unexpected agricultural power as we drove past miles and miles of fields planted with corn and wheat. The natural beauty of America was stunning, but although people were friendly, they seemed suspicious of us—with our accented English, we were clearly foreigners—and I remained startled and frightened of the pickup trucks with gun racks.
Bram, who was fifteen months old, took to running around the campsites without pants or a diaper. He liked it, plus it cut down on heat rash, and to us it seemed like a perfectly normal thing for a small child to do. But people couldn’t seem to deal with this infant nudity. The more polite ones would come up to us with a concerned look and say, “Your son has lost his pants.” The less inhibited would berate us—“Why is your kid going around naked?”
When we got to Seattle—beautiful, the Olympic mountains capped by snow, the coastline jagged with clear blue fjords—I telephoned King Holmes, who had perhaps forgotten all about me. He said, “Well, you’d better come for lunch at my place.” This astonished me, though actually it turned out to be a peanut butter sandwich in his kitchen. When we finished, Holmes asked me, “So, what would you like to do?” and again I was startled: in Europe, the professor tells you what you’re going to do.
