by Piot, Peter
I had my penicillin-resistant gonococci with me in the car, and I told him I wanted to study the plasmid’s molecular mechanism of resistance, learn about sexually transmitted diseases, and also work on vaginitis. I had many women patients with chronic vaginitis (an uncomfortable discharge now called bacterial vaginosis), and although this problem seemed to be extremely common its cause and treatment were not well understood.
King said, “OK, why don’t you start tomorrow.” It was that easy. My jaw dropped.
I loved Seattle, in particular the unspoiled nature surrounding it, and its friendly people, but we were a bit frustrated by the lack of good food and coffee. This was Seattle before Microsoft and Amazon.com and with only one Starbucks on Pike Place Market. We drove 13 miles from our home on Lake Samamish to buy bread at a German bakery. Good bread is important for Belgians! Today the city is as sophisticated as can be for good food and many other essentials in life.
I also loved working with King Holmes—loved the atmosphere of intellectual freedom and confidence in an American laboratory, where young people are encouraged to develop their ideas; I flourished in this outlandish environment. King introduced me to Dr. Stanley Falkow, who was chairman of the Department Microbiology at the University of Washington. We agreed that I would share my time between Falkow’s microbiology lab and the clinical work and epidemiology on STDs I was doing with Holmes. From Stanley I learned a lot about modern microbiology, including how to do some of the analytical techniques that were just being developed, such as genetic sequencing of plasmids, the Western blot (which identifies specific proteins), and molecular cloning. (He also taught me how to swear in English.) He is a superb scientist, whose main interest is pathogenesis, the step-by-step explanation of exactly how bacteria cause disease. He taught me always to put myself inside the bacteria—to try to think things out from a bacterium’s point of view. How would I penetrate an epithelial cell in the gut? Why would I jump from an animal to a human? He was a superb mentor. Stanley is now emeritus at Stanford, and whenever we can we get together for very stimulating discussions around a superb pinot noir.
Holmes and Falkow worked together very easily, though they headed different departments. This is not always the case in science: people tend to guard their turf. But Holmes worked with everybody—psychologists, chemists, microbiologists, clinicians. Within his department he had a real flair for team building, which is another rare and important skill. Holmes was constantly traveling, but somehow was able to guide and manage this very diverse group, and when you saw him you received clear attention and guidance. He had assembled a group of incredibly talented people, all working on some aspect of sexually transmitted diseases. Many are now in leading positions in Seattle and many other places worldwide. When I left Seattle, King agreed to continue to be my mentor, and has been so for over 30 years now. We are also united by our appreciation for good wine, and I have kept many a wine label from our dinners all over the world.
I was following up on vaginitis studies, concentrating on a family of bacteria found in the vagina that we thought probably caused the problem. I had a whole collection of it, which I was analyzing. (Ultimately this work didn’t really pan out; although we know now that this bacterium, Gardnerella vaginalis, does play a role, it has to interact with other bacteria to do so.) Later in Antwerp I also studied how to treat the syndrome best, and I demonstrated that the preferred treatment at the time—a sulfonamide cream—actually didn’t work at all, was in fact no better than a placebo. The treatment that did work was metronizodole, an antibiotic active against some parasites and anaerobic bacteria. These were the days when the current evidence base of sexually transmitted diseases was established. This work was small in a way, but useful, and I liked it. I liked the very free and entrepreneurial style of American science. There was a great deal of private money—something almost completely absent in Europe except for the Wellcome Trust in Britain—but above all there was a wide open mindset. If you had a good idea and you were competent, you were given a chance to make good.
During my stay in Seattle, I had two encounters that turned out to be defining a few years later. The first one was with Tom Quinn, who had just joined King’s group to study anogenital chlamydial infections. Tom is a very jovial infectious disease specialist, always sparking with new ideas, and with a voice you can recognize at a hundred yards’ distance. (Five years later we joined forces to investigate AIDS in Zaire.) The second one was with Bob Brunham, a fairly shy and very thoughtful Canadian infectious disease physician and immunologist with curly hair, who was working on a vaccine against genital chlamydial infections. A little bit because we were the two foreign fellows in King’s group, but also because of some common interests in Africa, we became quite close friends. Bob told me about an epidemic of chancroid in Native Americans in Winnipeg, where he was at the University of Manitoba in Canada. Following my experience with this supposedly tropical STD, I was immediately fascinated by this outbreak in the Canadian prairies. His mentor in Canada, Dr. Allan Ronald, head of Infectious Diseases at the University of Manitoba, invited me to Winnipeg to exchange experience on chancroid and its cause, Haemophilus ducreyi, as there had hardly been any scientific and therapeutic advances on chancroid for several decades. When I landed on May 1, 1979, it was snowing! (I thought, This must be a tough place to live!) We hit it off, and decided to work together in Kenya, where chancroid was a big problem.
While I enjoyed every minute of work and life in Seattle, I was often disturbed by the absence of a social safety net—such basics as universal health coverage—as well as the easy assumption of some people I met that poverty was basically your own fault. But I also noted that there was far more talk than in Europe about gender inequality and the lack of fairness for women in society. Seattle was a very open-minded place; we were circulating among people who were interesting and diverse.
I became quite a fan of many aspects of American society. I could see that Belgium, and indeed Europe, was becoming ossified, suffocating entrepreneurship in science but also in many other areas of society. I was still deeply Flemish—my genotype so profoundly rooted. But the way those genes were expressed—my phenotype, as it were—was shifting.
However, Greta had no legal right to work in the United States, and as our year there crept by this became a problem. As my fellowship funds began running out we gave more thought to the idea of whether to stay in Seattle. I concluded that if all European scientists who came to America decided to stay, then Europe would really have a problem. I was all charged up with energy and knowledge and I wanted to help change things in Belgium.
WHEN I RETURNED to Antwerp in September 1979, my priority was to finish my doctoral thesis on the etiology of vaginitis. (I finally completed it in the spring of 1980.) I needed clinical material and that meant the STD patients at the Clinic for Colonials and Seafarers. But after a while it became clear that my research—and their treatment—would be enormously facilitated if we could set up a separate clinic exclusively for sexually transmitted disease. Instead of hiding these people, tucking them away alongside people with bilharzia or dengue, we could focus on their specific problems with more professional protocols better adapted to their lifestyles. We would become the first and most important STD clinic in the country. We could associate that work with the kind of outreach that I had seen in Seattle—epidemiological surveys of communities prone to STDs, even community talks.
So at the end of 1979 I marched into the office of the director of the Institute for Tropical Medicine and said so. He was a very conservative man and the idea simply appalled him. He didn’t want to draw any more attention than necessary to this unsavory clientele of mine, with their dirty diseases. Although ultimately he did agree to set up a separate STD operation, he put our clinic at the very back of the building, next door to the animal house—the room where the small rodents were kept. Access was through the back door of the institute; I worked with one nurse; and our opening hours were 5 to 7 P.M.
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br /> However, I was undisturbed. The rest of the day I continued to work in the lab, where I was still just number four in the pecking order. And in that little clinic what I saw was that, particularly in the gay community, very serious epidemics of STDs were developing. And (mostly in heterosexuals) we were also seeing a huge rise in chlamydia.
I began appearing on the radio, in newspapers, and on TV, to talk about it, because the only way to solve this kind of problem is to discuss the risks and the precautions that people need to take. And just as I discussed homosexuality or sex-related drug use with my patients, I also had no special embarrassment about talking about intercourse on TV.
One evening at the end of 1979, I received a phone call from the pathologist of the Institute of Tropical Medicine. He wanted me to help autopsy a cadaver. The patient had died of galloping meningitis. He was Greek, but he had lived for decades as a commercial fisherman on the banks of Lake Tanganyika in eastern Zaire, and when he had arrived at the hospital he was already in terrible shape, with tremendous weight loss and a fever of unknown origin.
When we opened up his body 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°C 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.
CHAPTER 9
Nairobi
BY THE SPRING of 1980, I had finished my thesis “The Aetiology and Epidemiology of Bacterial Vaginosis and Gardenerella Vaginalis” and I had another, far more exciting project underway. I was going back to Africa, for a research project that I had dreamed up with Allan Ronald, the Canadian physician I had met while in Seattle.
Allan was an amiable man and we talked a lot about Africa. He had established contact with the University of Nairobi in Kenya, where genital ulcer disease, in particular, chancroid, had become epidemic. He told me that he wanted to start a research project on chancroid and proposed that we work on it together. I had a little experience; he had some contacts. It was an opportunity to develop a research base in a city where basic infrastructure like phones and electricity posed no particular problem, and there was a good university. So we made a planning visit to Nairobi in January 1980.
Inspired by what I had seen in the United States, I incorporated a nonprofit group the Foundation for Infectious Disease Research, upon my return to Antwerp, intending to fund the new research program in Nairobi. From time to time, when I gave workshop training sessions to general practitioners, or lectures on STDs, I had my emolument deposited into the foundation. It was not a lot—$300 here, $3000 there—so it didn’t add up to much. Short of robbing a bank, I didn’t know how on earth we would raise enough money to support the Nairobi project.
Then, at a conference on infectious disease, I ran into a new antibiotic that seemed to me a promising candidate to step in as a new chancroid treatment, a more effective alternative to erythromycin. The drug was produced by Schering, a company I thought I could convince to fund a trial on the treatment of chancroid, even if chancroid treatment did not represent even a minor future market for any pharmaceutical company. Where to set up such a trial? While in Swaziland, I had worked with a highly competent and pragmatic English microbiologist who lived in South Africa, Ron Ballard, who had told me there was a truly massive chancroid problem in the South African gold mines, and had asked for our help. The town he mentioned—Carletonville—was the largest gold-mining complex in the world, close to Johannesburg, and with what he described as ideal medical backup in terms of hospitals and labs. On the one hand I wasn’t keen to work in apartheid South Africa, but Ballard argued that there was no moral high-ground to abandoning the poor and needy.
Ballard, Eddy Van Dyck from my lab, and I went to Leslie Williams Memorial Hospital in Carletonville, which indeed was one of the better hospitals I saw in Africa. Clearly the company needed to keep their workforce healthy and productive, but they definitely had no idea how to handle the chancroid problem. Conditions in the gold mines, often over a mile underground, were not only high-risk but also extremely hot and humid; wounds just couldn’t heal, and appalling chancroid ulcers were incapacitating the miners.
The miners were from all over—Swaziland, Botswana, Lesotho, Mozambique, Malawi, Zambia, Zimbabwe—and they were well paid compared to any worker in their home country. I was never allowed down the mines; I would have liked to see what they were like. But I visited the hostels they lived in, and the places they drank, and saw, lining the red soil paths, the wooden shacks with corrugated iron roofs and simple cloth doors—a prostitute in many of them. Every payday there were lines of men outside these places.
The men worked in shifts, six days a week, around the clock; they all hated and feared the work, but all of them had families back home, and they were doing it for them, trying to bring home enough money to give an education to their children, start a business, maybe set up a shop. I knew, though, that many of them were also taking home some truly infernal diseases, in addition to the high risk of work-related accidents and tuberculosis—the highest rate in the world. These men were at the same time victims of pure exploitation and a source of hope for their community to get out of poverty. I was revolted by their working conditions (and those of the sex workers . . . ), was deeply touched by their loneliness and songs full of nostalgia of home, and to this day cannot see gold without thinking of them and what it takes to produce it.
Under apartheid the men were away from home for 11 months to work in the mines, and whereas some established a stable relationship in South Africa, sexual expression was often limited to occasional commercial sex. From the perspective of sexually transmitted agents, many sex partners (the miners) for few women (the sex workers) is ideal and gives rise to explosive epidemics, as we saw then for chancroid. (This perverse organization of labor in the mining industry in South Africa undoubtedly paved the way of what became the world’s most severe AIDS epidemic 10 years later, with some of the world’s highest HIV prevalence rates occurring in sex workers around Carletonville, of whom 78 percent were HIV-positive in 2001.) In spite of the huge STD problem, the apartheid government of the time did not support STD prevention programs, not even condom distribution.
Within five weeks we studied enough patients in the clinical trial to demonstrate that the antibiotic indeed worked remarkably well, as compared to the then recommended treatment of erythromycin. (Despite its success the new antibiotic was never marketed.) Because the study concluded much faster than anticipated and we were very economical on our expenses, I made enough money to seed our Nairobi project. Meanwhile, Allan, in Canada, had put together enough money to start working, so I joined him in Nairobi at the end of 1980.
Nairobi was a lively city, full of small and bigger business, an infrastructure to host both business clientele and tourists. The people were mostly much better off than those in Zaire. But what struck me most of all were the huge slum areas, particularly the Kibera and Mathari Valley shanty towns, the largest slums on the continent outside South Africa—one mass of undulating corrugated roofs where everyone lived on top of each other, in garbage and sewage, while the Kenyan élite and expatriates flourished in spacious villas in the hills. Conditions in Kibera were far worse, in those days, than anything I saw in Zaire.
We worked very closely with the chairman of the university’s Department of Medical Microbiology, a refugee from Rwanda and Uganda named Herbert Nsanze, a handsome sophisticated man who was very personable and very smart. We occupied a little office at the medical school at Kenyatta National Hospital, with a clunky Commodore computer that we used for statistical analysis. There was no phone. It was a smart group of people, and we became a very well integrated little project—not so little, after a while. Several years later we were joined by King Holmes’s group at the University of Washington, and Marleen Temmerman’s team at the University of Ghent, and the project grew
to become one of the most productive and long-standing research collaborations in Africa, forging a very large number of groundbreaking studies.
Allan arranged for us to work in the municipal STD clinic, popularly known as Casino Clinic, because it was next door to the Casino Cinema on River Road. This was a very lively but also quite rough area, kind of a skid row, as described in “Going Down River Road” by Meja Mwangi, one of Kenya’s most popular writers. There were countless bars that had tiny rooms where the prostitutes and bar girls went with their clients. They were dirty, really depressing places visited by mostly poor people. I’ve seen so many rooms like these, in Bombay and Bangkok and Kathmandu, and I still honestly don’t know how anyone can have sex in a place like that. The smell alone would make me impotent, besides other considerations of love and disease.
Unlike in Kinshasa, there was hardly any music in this kind of bar, just a lot of straightforward drinking. When the alcohol level was high enough the clients headed upstairs with the women who worked there. And then the next day, or next week, quite a few of the men and women queued up at the Casino Clinic. Literally every morning hundreds of people were waiting when the doors opened at 7 A.M.
It was worst for the women. Dr. Da Costa, who was a Kenyan-born Indian Catholic, railed against them—“You whore, you slut”—and told them they only got what they deserved. As a doctor he was actually pretty competent, which was fortunate, because he was the only doctor in the Casino Clinic and it was basically the only sexually transmitted disease clinic in the city, as well as being at the time the largest STD clinic in Africa. As an empathetic doctor, however, he was a nightmare. I remember the young women crying at his pronouncements that now they would never be able to have children, which is indeed one of the major complications from untreated gonorrhea and chlamydial infection. I noted, too, that many of them were probably not involved in commercial sex; many were actually the regular partners and wives of male clients. Whereas I admired him because basically no other physician wanted to do this unglamorous and stressful job, I had to wonder why he was working there, since he hated his clients so deeply.
