A Matter of Life and Death. Sue Armstrong

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СКАЧАТЬ tell you a good story. On my last day in Kampala, the British Council gave me a Landrover. January/February 1986, Kampala; not a good time to be there. Museveni had only just conquered the capital, and was moving north to try to get rid of the rebels from Gulu and beyond. Getting around Kampala was bloody difficult – pot holes, shell holes and what have you. Nelson Sewankambo and his great buddy David Serwadda – another Ugandan public health physician who’s become very famous in AIDS – said, ‘We should do a quick study. Is the virus (because it was still not HIV, it was just ‘the virus’) transmitted horizontally?’ In other words, if you live in the same household as someone, but don’t sleep with them, do you get it? ‘How can we answer this? What we need is a lot of blood samples very quick. Let’s go down to Rakai District, where this is supposed to have started.’

      Nelson said, ‘I know the district medical officer of health; I’ll ask which are the worst-affected villages and do we have his consent to bleed everyone and bring the samples back for analysis.’ The DMO said, ‘Yes.’ So we drove down there in the Landrover at dawn. The DMO had a map and he said, ‘Go to these villages here.’ So we went with our bundles of syringes and needles; we found the village head man and asked, ‘Do you approve?’ (This is what consent was in those days!) We bled about 100 people in two or three villages. At the end of a long day we came back with lots of little vials of blood, all labelled and coded and so on. My task was to get these to England, and to the public health laboratory in Porton Down – and in particular to Bob Downing or Graham Lloyd, two more famous names in HIV virology, who would do the analysis.

      The next day I left Kampala, having spent two extraordinary weeks that changed my life. I had a Thermos flask packed with ice and containing 100 vials, and in my suitcase I had loads of tissue blocks of AIDS pathology. I kept thinking, as I passed through several airport departure stations, ‘If someone asks me what’s in this flask, what am I going to say?’ But no one ever asked! A different world now, isn’t it?

      When I got home, a courier took them away to Porton Down. It became a paper: ‘The AIDS virus is not transmitted horizontally.’

      As I say, we were also wondering about TB. While I was still in Uganda I thought, ‘HIV makes TB worse in many contexts, but how can we prove this? I wonder if the pathology looks different?’ We obtained tuberculous lymph node biopsies from patients with AIDS, analysed them and published our findings. It was the first description of tuberculosis pathology being very different from standard TB when you’ve got HIV disease. The bacterial loads in these people were just colossal. If you do the stain for tubercle bacilli, which we call a Ziehl–Neelsen test, the bacilli come out red. With these cases you didn’t need to look under the microscope – if you just held them up to the light the whole slide looked red! Phenomenal densities.

      However, the sheer overwhelming importance of tuberculosis didn’t really sink in until the early nineties – another half decade. And that happened in part, I like to think, from work we did in Côte d’Ivoire.

       How did you find yourself working in Côte d’Ivoire?

      Kevin de Cock had started a project in West Africa. He was asked by CDC to investigate HIV-2, which had just become evident. CDC didn’t want to be caught with its pants down a second time, because they had kind of misfired with working out what HIV-1 was. (In fact, no one did very well – Heavens, this was a new disease!) So the CDC said, ‘We need an HIV-2 project; go and find the place to do it.’ It became evident that the only place he could possibly work was Abidjan, because the communications in alternative places didn’t work. And there was a big American Embassy there, so the Retrovirus Project, Côte d’Ivoire – a collaboration between the CDC and the Ministry of Health of Côte d’Ivoire – was set up with American money. A new building went up in the grounds of the huge hospital; Kevin set up his unit and they started doing basic HIV work, with HIV-2 as the added interest.

      Sometime around 1989 he said, ‘Come out to Côte d’Ivoire to see what we’re doing and see if it interests you.’ So I went out for two weeks in early 1990. I was appalled by the climate, and I was staggered by the amount of work going on. They had a wonderful lab. Most of the scientists were Ivorian – basically, they’d employed the best of the medical and paramedical Ivorians to work there, and paid them salaries which were somewhere between Ivorian and American. And they had very good infrastructure, with computers the like of which I’d never seen before. I met a lot of doctors. I met the pathologist, who was very nice. I looked at the mortuary, and thought, ‘God almighty, what a ghastly place.’ They all said, ‘Come and work here,’ and I said, ‘No, no, no!’

      But then Kevin said, ‘Would you like to finish off a project for us?’ He gave me a whole lot of tissue blocks and slides. They turned out to be a set of autopsies, and as I worked through them I found that they were 50/50 HIV-positive and HIV-negative people. The HIV-positive people had TB and a bit of Pneumocyctis, and the HIV-negative people had boring things like lung cancer. And when I looked more closely I saw they were, in fact, consecutive deaths – every person over a period of, say, three months had been autopsied. I thought, ‘You can’t do that in England!’ I asked Kevin, ‘How on earth did you get consecutive deaths autopsied?’ And he said, ‘Ivorian Law, Napoleonic Code, it’s French. Anyone who dies in a teaching hospital can be autopsied without consent required.’ I said, ‘Kevin, I’m coming back!’ And he said, ‘I knew you’d say that. That’s why I got you out here.’

      I still have nightmares just thinking about 1990 and the panic to get things going. We got a project that seemed okay but it would never pass muster now – ethically, no one would even contemplate doing this today. We drew up a project to autopsy as many people with HIV – and some HIV-negative controls, including children – as we could in a year. God, it was hard work! My own kids were doing O and A levels, so I went there by myself, and just worked flat out essentially for a year. But when people accuse me of being bad – which they do, very occasionally – I say, ‘They wanted it. The Côte d’Ivoire Ministry of Health supported this to the hilt, and more! And that’s what was done then.’

      What manifestations of AIDS did you find in Africa that were different from in the West?

      I was doing a lot of HIV work in London by then. UCH and Middlesex Hospital refurbished a mortuary dedicated to HIV for me in 1989, and we did loads of consented autopsy cases, and a few coronial ones. They all seemed to be the same then: all Pneumocystis. All the patients I was looking at were gay, white, middle-class men – that’s what AIDS was in London then. Africa was completely different.

      The first thing that struck us in Côte d’Ivoire was, ‘Actually, it’s all TB.’ More than half of the cadavers I looked at had tuberculosis. I couldn’t believe it. This became evident after about the first two or three months, and Kevin and I said, ‘Well, even if the project comes to a stop now, we’ve proved what it is, it’s TB.’ So you’ll find, in the early nineties, loads of papers written by Kevin and me and others just banging the TB drum, and stressing the importance of diagnosis, prophylaxis, etc., because we knew TB was the major problem.

      I should say that whilst we were doing this project, the clinicians in the hospital in Côte d’Ivoire rapidly got wind of it and every Saturday morning there was a clinico-pathological meeting of the cases we’d seen that week – with the professor of that particular ward, his senior doctors and all the junior doctors as well – and they all loved it. No one said, ‘Ethically you shouldn’t be doing this.’ They all said, ‘This is fantastic. We’ve never had feedback like this; this is hot feedback. The patient died on Monday; we now know why he died. This has never happened with us before.’ They gave me every possible help. This was real clinical pathology going hand-in-hand with management of cases. They gave me a huge party when I left, and said, ‘Please come back! This is what medicine’s meant to be all about.’

      I came back to the UK in 1992. And the СКАЧАТЬ