1
Intentions
This book has a modest purpose. Many history students interested in Africa wish to study the HIV/Aids epidemic but are hampered by the lack of an introduction to the detailed literature. This book is intended as an introduction, for students and other readers.
The book is not a work of research. A thorough history of the epidemic during its first thirty years would demand fieldwork in affected communities, interviews with those involved, and study of unpublished records of international organisations, national governments, and private individuals. I have not attempted any of these, nor have I the necessary medical and anthropological skills. Instead, the book is a synthesis of the more important and accessible published material, put into a historical form.
A historical account offers four advantages. First, it suggests an answer to the question posed most provocatively by President Mbeki of South Africa: why has Africa had a uniquely terrible HIV/Aids epidemic?1 Mbeki attributed this to poverty and exploitation. Some earlier analysts suggested that Africa had a distinctive sexual system.2 This book, by contrast, stresses historical sequence: that Africa had the worst epidemic because it had the first epidemic established in the general population before anyone knew the disease existed. Other factors contributed, including poverty and gender relationships, but the fundamental answer to Mbeki’s question was time. Like industrial revolutions or nationalist movements, Aids epidemics make sense only as a sequence.
Second, a historical approach highlights the evolution and role of the virus. Because HIV evolves with extraordinary speed and complexity, and because that evolution has taken place under the eyes of modern medical science, it is possible to write a history of the virus itself in a way that is probably unique among human epidemic diseases. At the same time, the distinctive character of the virus – mildly infectious, slow-acting, ineradicable, fatal – has shaped both the disease and human responses to it.
Third, many aspects of the epidemic come into focus only when seen in the longer context of African history. Although HIV/Aids was profoundly different from earlier African epidemics, it arose from the human penetration of the natural ecosystem that is the most continuous theme of the African past. That the virus created a continental epidemic, however, was a consequence of Africa’s massive demographic growth, urbanisation, and social change during the later twentieth century. Everywhere the epidemic took its shape from the structure of the commercial economy that had grown up during the colonial period. Human responses, in turn, became part of an ongoing interaction between inherited moral understandings of disease and the medical explanations propounded by international authorities and modern African doctors. Like all great epidemics, HIV/Aids became a catalyst of change, but in directions already set by longer historical processes.
Finally, the African epidemic has itself changed over time. It is still at an early stage: ‘the end of the beginning’, as the head of the UNAIDS organisation described it in 2001.3 Yet in much of Africa the epidemic has already evolved from explosive expansion to maturity, while human responses have graduated from unwitting vulnerability to planned containment. In the process, many Africans have displayed the endurance common throughout their history. Their experience has taught the world much of what it knows about HIV/Aids. It is time to give that experience a historical shape.
2
Origins
The earliest convincing evidence of the human immunodeficiency virus (HIV) that causes the acquired immune deficiency syndrome (Aids) was gathered in 1959 amidst the collapse of European colonial rule in Africa. In January 1959 rioters briefly seized control of the African townships of Leopoldville, the capital of the Belgian Congo, shocking its rulers into frantic decolonisation. In the same year an American researcher studying malaria took blood specimens from patients in the city. When testing procedures for HIV became available during the mid 1980s, 672 of his frozen specimens from different parts of equatorial Africa were tested. Only one proved positive. It came from an unnamed African man in Leopoldville, now renamed Kinshasa. The test was confirmed by the Western Blot technique – generally considered the most reliable method – and by different procedures in three other laboratories.1 Although nothing of this kind can be absolutely certain, there are strong grounds to believe that HIV existed at Kinshasa in 1959 and that it was rare.
One importance of the Kinshasa case is to establish a date by which HIV existed, but in itself the case does not imply that the Aids epidemic began in western equatorial Africa. If that unnamed African had been the first person ever infected with HIV, it would have been an incredible coincidence. Once Aids was recognised as a medical condition early in the 1980s, researchers found several early accounts of patients whose recorded symptoms had resembled it.2 Luc Montagnier, whose laboratory first identified HIV, thought that the earliest case had been an American man who died in 1952 after suffering fever, malaise, and especially the pneumocystis carinii pneumonia that afflicted later American Aids patients,3 but no blood had been stored for later testing and the symptoms demonstrated only suppression of the immune system, for which there could have been reasons other than HIV. The same was true of a Japanese Canadian who died in 1958 and a Haitian American in 1959. More convincing was the case of a fifteen-year-old, sexually active American youth who died in 1969 with multiple symptoms including an aggressive form of Kaposi’s sarcoma, a tumour common in later Aids patients. His stored blood tested positive for HIV by Western Blot, but the finding was later questioned. Other possible early cases were found in western equatorial Africa. There was no stored blood by which to confirm a specialist’s retrospective diagnosis of Aids in an African woman who was hospitalised at Lisala on the middle Congo in 1958 and died in Kinshasa four years later after suffering wasting and Kaposi’s sarcoma. But a Norwegian seaman contracted HIV some time before 1966, possibly while visiting Douala on the coast of Cameroun in 1961–2, and later infected his wife and child; all three retrospectively tested HIV-positive, although with a form of the virus different from that found in Kinshasa in 1959.
These cases are intriguing and were the bases for early controversy about the origins of HIV, but they reveal little except that it existed but was rare in the 1950s. The real grounds for believing that the dominant form of the virus originated in western equatorial Africa, probably in the broad area of Cameroun and the Democratic Republic of Congo (DR Congo), lie in three other directions. One is that HIV clearly results from the transmission to human beings of the ancient and related simian immunodeficiency virus (SIV), an infection of African monkeys that had also spread to chimpanzees.4 That such an animal disease should pass to humans is not surprising, because several major human infectious diseases are contracted from animals, notably plague, sleeping sickness, yellow fever, some forms of influenza, and, most recently, Creutzfeldt-Jakob’s Disease.5 How such a transmission took place with HIV will never be known, but one possibility may have been infection by blood in the course of hunting as men penetrated the equatorial forest. One study of 1,099 people engaged in hunting and butchering in Cameroun, published in 2004, found ten who had contracted simian viruses, although in this case not HIV.6 Aids is a by-product of the human mastering of the natural environment that has been the core of African history.
SIV has been transmitted from animals to humans at least eleven times and probably many more. There are two forms of the human disease: HIV-1, which is responsible for the global Aids epidemic, and HIV-2, which is less virulent and infectious and is virtually confined to the West African coast between Senegal and Côte d’Ivoire. HIV-2, discussed in Chapter 6, is closely related to the SIV common in the sooty mangabey monkeys of that region. By 2005, HIV-2 infections had been divided into eight groups, each believed to have resulted from a separate transmission. Only two of these groups, lettered A and B, had established themselves as human epidemics, suggesting that many unsuccessful transmissions may also have taken place in the past.7 By contrast, the animal virus most similar to (although still quite distant from) HIV-1 and probably ancestral to it is the SIV occasionally harboured by a species of chimpanzee (Pan troglodytes troglodytes) whose natural territory is the forest of Gabon, Equatorial Guinea, Central African Republic, Cameroun, and Congo-Brazzaville, somewhat