University of California Irvine The Invisible Cure Book Essay

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Based on class notes and your reading of The Invisible Cure, write an essay on the cultural, political and social structural factors, past and present, that have made the HIV outbreak particularly severe in sub-Saharan Africa and what we have learned about how to deal with such an outbreak. Provide specific evidence from the book to back up your claims.

A good answer will be broad and synthetic. In particular, your essay should address these sets of questions:

  • What does the title of the book means? Is there, in fact, an invisible cure, and if so, what is it? How does it work? How reliable is it?
  • What factors worsened the outbreak? What factors, both current and historic, made Uganda more successful than many richer countries like South Africa or Botswana at curtailing the spread of HIV?
  • What is collective efficacy? How can collective efficacy work for controlling outbreaks of more easily communicable diseases, like Ebola or measles?

While some of you may write more expansively than others, this assignment should run five to six double-spaced pages.

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The Invisible Cure RUBRIC Paper criteria Structure - Organization - Flow - Transitions Length -5ptsExceeds Expectations -3.75 ptsMeets Expectations 2.5 pts Needs Improvement 1.25 pts Inadequate - - - There is some level of organization through hard to follow - Ineffective transitions - Rambling format - 3-4pg - Too many punctuation mistakes -Tone is inappropriate or too casual - Question responses are generally well developed Evidence of critical and careful thought There are good, relevant examples - Most questions are addresses, although vaguely Some evidence of careful thought There are some examples and evidence, though general - Question responses are generally well developed Evidence of critical and careful thought - most questions are addresses, although vaguely Some evidence of careful thought There are some examples and - - Grammar/Language - Sentence structure - Punctuation - Tone/vocab - Part 2. - Invisible cure - How does it work - Is it reliable? - - Part 2. - What factors worsened outbreak? - Why was Uganda more successful? - Paper is logically organized Easily followed Effective, smooth, and logical transitions Professional format 5-6pg Use of complex sentences for impact Tone is clear and concise No punctuation mistakes Responses to all questions are well developed Abundance of evidence of critical, careful thought Evidence and examples are vivid and specific Responses to all questions are well developed Abundance of evidence of critical, careful thought - Paper has clear organization structure with some digression Easily followed Basix transitions Structured format 4-5pgs -Uses complex sentences - Few punctuation mistakes - Tone is appropriate - - - - - - - No organization Cannot follow No or poor transitions No format Does not meet 5 pg. requirement - Simple sentences - Difficult to read - - Central questions are not answered Little to no evidence of critical thought There are too few or no examples to support your argument Central questions are not answered Little to no evidence of critical thought There are too few or no examples to Total points: The Invisible Cure RUBRIC Part 3. - What is collective efficacy? - How can it work for controlling outbreaks of other disease (e.g. Ebola, measles)? Total Score (Out of 25ptts) - Evidence and examples are vivid and specific - There are good, relevant examples - Responses to all questions are well developed Abundance of evidence of critical, careful thought Evidence and examples are vivid and specific - Question responses are generally well developed Evidence of critical and careful thought There are good, relevant examples - - - evidence, though general - most questions are addresses, although vaguely Some evidence of careful thought There are some examples and evidence, though general support your argument - Central questions are not answered Little to no evidence of critical thought There are too few or no examples to support your argument TA: MACKENZIE CHRISTENSEN OFFICE: SST6-3 MACKENAC@UCI.EDU SOCIOL 44: WRITING RESOURCES OBJECTIVES WRITING TIPS RUBRIC WORKSHOP OUTLINES WRITING TIPS! ✓ Organize your paper  Use subheadings to clarify the structure of your paper ✓ Subject → Thesis (example) i. Subject: The invisible cure ii. Topic: What does the title of the book mean? Is there, in fact, an invisible cure? iii. Thesis: Tell the reader what you are going to argue ✓ Practice & read good academic writing! For more detailed information: https://teaching.berkeley.edu/sites/default/files/alltips.pdf IN TEXT CITATIONS Must reference author name and year of publication in the text (DO NOT INSERT URL INTO TEXT, please ☺) Direct quotes example: According to Christensen, “if you are citing an author word-for-word you must put the statement in quotes and cites with the page number in which you found the quote” (2019: 17). Or you can use ….(Christensen 2019: 17). Paraphrasing example: According to Christensen (2019) using direct quotations marks is only necessary when the statement is copied exactly as it is written. Working with quotations: https://poorvucenter.yale.edu/sites/default/files/files/Working%20with%20Quotations%201%20-%20The%20Lead-In.pdf General page: https://poorvucenter.yale.edu/writing/undergraduate-writing/writing-handouts REFERENCES * On the last page of the essay (separate sheet), you must include a reference list ASA Reference for Book Author’s last name, first name. Year. Book Title in Title Caps and Italicized. Publishing City: Publisher. ASA Reference Scholarly Journal Articles Author’s last name, first name. Year. “Article Title in Title Caps and in Quotes.” Journal Title in Title Caps and Italicized Volume Number(Issue Number):page numbers of article. Magazine or Newspaper Article Ziff, Larzer. 1995. "The Other Lost Generation," Saturday Review, February 20, pp. 15-18. For more detailed information on ASA: https://owl.purdue.edu/owl/research_and_citation/using_research/formatting_in_sociology_asa_style/references_page_formatting.html For more info on other citation styles: https://subjectguides.library.american.edu/c.php?g=175008&p=2579707 WRITING WORKSHOP 1. Get into groups of 3-4 2. Exchange your paper/outline with a peer 3. After reviewing the outline using the rubric provide verbal feedback to your partner 4. Report back to the group- Challenges? Strengths? MORE GENERAL WRITING RESOURCES *Yale writing handouts for: intros, body paragraphs, research paragraphs, conclusions, etc.  https://poorvucenter.yale.edu/writing/undergraduate-writing/writing-handouts UCI Library: Social Science Databases  https://guides.lib.uci.edu/databases/socialsciences PDF from Northern Essex Community College helps you identify the parts of a scholarly article.  https://skulitech.files.wordpress.com/2018/03/researcharticle.pdf Write a literature Review (You’re not asked to write a lit. review for this class- but still helpful)  https://guides.library.ucsc.edu/write-a-literature-review Reference page formatting guide  https://owl.purdue.edu/owl/research_and_citation/using_research/formatting_in_sociology_asa_style/references_page_fo rmatting.html To my mother, Barbara In memory Table of Contents Title Page PREFACE AIDS RESEARCH FOR BEGINNERS CHAPTER ONE - The Outsiders CHAPTER TWO - The Mysterious Origins of HIV CHAPTER THREE - Why Are HIV Rates So High in Africa? CHAPTER FOUR - The African Earthquake WHAT HAPPENED IN SOUTHERN AFRICA CHAPTER FIVE - Gold Rush CHAPTER SIX - A President, a Crisis, a Tragedy CHAPTER SEVEN - AIDS, Inc. CHAPTER EIGHT - Why Don’t They Listen? WHAT HAPPENED IN UGANDA AND WASHINGTON AND GENEVA CHAPTER NINE - The Invisible Cure CHAPTER TEN - Forensic Science CHAPTER ELEVEN - God and the Fight Against AIDS CHAPTER TWELVE - When Foreign Aid Is an ATM THE FRONT LINES CHAPTER THIRTEEN - The Lost Children of AIDS CHAPTER FOURTEEN - Wartime CHAPTER FIFTEEN - The Underground Economy of AIDS EPILOGUE - Traditional Medicine AUTHOR’S NOTE A NOTE ON THE STATISTICS CITED IN THIS BOOK ADDITIONAL PRAISE FOR THE INVISIBLE CURE About the Author APPENDIX: A MAGIC BULLET AFTER ALL? NOTES ACKNOWLEDGMENTS INDEX Notes Copyright Page PREFACE One morning in November 2001, two officials from a Kenyan AIDS organization picked me up from my hotel in Nairobi and took me on a drive. We drove and drove all day, over muddy tracks, through endless pineapple and coffee plantations, rural villages and slums, through all of Africa, it seemed, to arrive at a small field, perhaps half an acre, with some weeds growing in it and an old woman standing there with a hoe. I had not expected this. I was reporting on AIDS programs for an American foundation, and most of the other projects I had visited were either medical programs, AIDS awareness campaigns using billboards, radio or television spots, or traveling roadshows designed to promote AIDS awareness or condoms or HIV testing. I was about to say something when one of my guides spoke first. “We are very proud of this project.” So I said nothing. About twenty women had saved up for two years to buy this land. All of them were supporting orphans whose parents had died of AIDS, and they hoped the land would produce enough food for about fifty people in all. On a nearby hill, one of Kenya’s vast corporate-owned coffee plantations loomed like the edge of the sea. The old woman kept glancing at it as though it might sweep her away. I was moved by what I saw, although I didn’t understand at the time how this project was supposed to fight AIDS. This book explains how I came to do so. The worldwide AIDS epidemic is ruining families, villages, businesses, and armies and leaving behind an immense sadness that will linger for generations. The situation in East and southern Africa is uniquely severe. In 2005, roughly 40 percent of all those infected with HIV lived in just eleven countries in this region—home to less than 3 percent of the world’s population1In Botswana, Lesotho, and Swaziland, roughly a quarter of adults were infected, a rate ten times higher than anywhere else in the world outside Africa. In other world regions, the AIDS epidemic is largely confined to gay men, intravenous drug users, commercial sex workers, and their sexual partners. But in East and southern Africa, the virus has spread widely in the general population, even among those who have never engaged in what health experts typically consider high-risk behavior and whose spouses have not done so either. Although there were predictions that HIV would soon spread widely in the general population in Asia and eastern Europe, this has yet to occur, even though the virus has been present in those regions for more than two decades. The UN AIDS Program now predicts it probably never will.2 Why is the epidemic in East and southern Africa so severe? And why has it been so difficult to control? I started thinking about this in 1993, when I quit a postdoctoral job in molecular biology at the University of California and went to Uganda to work on an AIDS vaccine project. My results, like those of many others, were disappointing. For more than twenty years, scientists have been trying to make such a vaccine, and most experts predict it will take at least another decade.3 The editor of Britain’s prestigious medical journal The Lancet has even suggested that a truly effective AIDS vaccine may be a biological impossibility. 4 I continued to work on AIDS as a writer and consultant for various development agencies after I left Uganda, and I continued to wonder about what might be done to arrest the epidemic, and whether some other device or program might substitute for a vaccine. In 1996, a combination of three antiretroviral drugs, taken for life, was found to dramatically relieve the symptoms and extend the lives of HIV-positive people. At the time, these drugs were patented and extremely expensive, and for years they were out of reach of the millions of poor African patients who needed them. Before long, a worldwide network of AIDS activists began to pressure pharmaceutical companies to cut the prices of these drugs and urged international donors to raise billions of dollars to fund AIDS treatment programs in developing countries. As a result, millions of Africans with HIV are now receiving treatment. In this book, I do not deal at length with this extraordinary struggle, a story that has been ably covered by other writers, some of whom are activists themselves.5 While the humanitarian urgency of AIDS treatment programs is inarguable, these drugs will not halt the epidemic on their own. They are not a cure, they don’t work for everyone, and they can have severe side effects. In Africa, those most likely to spread the virus to others are often at an early stage of infection and are not in need of treatment. In many cases, their infections may not even be detectable by HIV tests.6 Because Africa’s healthcare infrastructure is in such a dire state, treatment programs are expensive and difficult to administer, even when the drugs themselves are practically free. Those who do receive treatment can expect to gain, on average, only 6.6 years of life because the virus eventually develops resistance, necessitating second- and third-line treatment, presently all but unavailable in Africa.7 It is impossible to put a price on six years of anyone’s life, least of all that of an African mother whose children would otherwise be orphaned, so the international community must endeavor to expand the range of AIDS drugs available in Africa. However, it would be better by far if that mother had never become infected in the first place.8 To date, the closest thing to a vaccine to prevent HIV is male circumcision, which was shown in 2006 to reduce the risk of HIV transmission by roughly 70 percent.9 The widespread practice of male circumcision in the predominantly Muslim countries of West Africa may largely explain why the virus is so much less common there than it is along the eastern and southern rim of the continent. It is urgent that as many men as are willing to undergo the procedure have access to cheap, safe circumcision services. But it may take years to develop such services and in the meantime, millions of people will become infected. In any case, HIV infection rates may be quite high, even in West African cities where nearly all men are circumcised.10 As international concern about the epidemic has grown, along with foreign-aid budgets for programs to fight it, a global archipelago of governmental and nongovernmental agencies has emerged to channel money, consultants, condoms, and other commodities to AIDS programs all over the world. During the past decade, I have visited dozens of these programs and spoken to hundreds of people. I never found a panacea, but I did learn a great deal. I learned, for example, that AIDS is a social problem as much as it is a medical one; that the virus is of recent origin, but that its spread has been worsened by an explosive combination of historically rooted patterns of sexual behavior, the vicissitudes of postcolonial development, and economic globalization that has left millions of African people adrift in an increasingly unequal world. Their poverty and social dislocation have generated an earthquake in gender relations that has created wide-open channels for the spread of HIV. Most important, I came to understand that when it comes to saving lives, intangible things—the solidarity of ordinary people facing up to a shared calamity; the anger of activists, especially women; and new scientific ideas—can be just as important as medicine and technology. Like many newcomers to Africa, I learned early on that the most successful AIDS projects tended to be conceived and run by Africans themselves or by missionaries and aid workers with long experience in Africa —in other words, by people who really knew the culture. The key to their success resided in something for which the public health field currently has no name or program. It is best described as a sense of solidarity, compassion, and mutual aid that brings people together to solve a common problem that individuals can’t solve on their own. The closest thing to it might be Harvard sociologist Felton Earls’s concept of “collective efficacy,” meaning the capacity of people to come together and help others they are not necessarily related to. Where missionaries and aid workers have, intentionally or not, suppressed this spirit, the results have been disappointing. Where they have built on these qualities, their efforts have often succeeded remarkably well. It’s easy to be pessimistic about Africa. Headlines from the continent chronicle apparently endless war, tyranny, corruption, famine, and natural disaster, along with a few isolated nature reserves and other beauty spots. Certainly there are many war-torn countries in Africa and many poor, sick people who need assistance. But sometimes helplessness is in the eye of the beholder. There is also another Africa, characterized by a striking degree of reciprocity, solidarity, and ingenuity. Time and again, African people have relied on these qualities to save themselves—and at one time, the entire human family—from extinction. Now, faced with the scourge of AIDS, some of them, including the farmer I met in Kenya, are trying to do so again. Most of the black Africans who now live in the region covered in this book are descended from Bantu farmers who began migrating from western Africa several thousand years ago, across the continent and then south.11On the way, some of them encountered other African population groups—the San and Khoi of southern Africa and the Nilotes of the Sahel, for example—with whom they exchanged aspects of language and culture and with whom they sometimes intermarried. Subgroups splintered off from each other and adapted to local circumstances. Their story is, with some exceptions, not about the accumulation of great personal fortunes and the founding of cities with palaces, cathedrals, and libraries. It is a story of relatively small groups banding together to survive on a harsh and dangerous frontier, of natural disasters and political and economic crises. Survival was not inevitable. The ancient, infertile soils of Africa could not sustain large permanent farming settlements, and the development of towns was further prevented by infectious diseases that spread rapidly as soon as populations reached a certain threshold. When farmers cleared large tracts of land to grow crops, malaria bloomed in the sunlit mud; as herds expanded, the animals succumbed to tuberculosis and sleeping sickness, which spread to their owners. Faced with such a mutable, dangerous world, the people of East and southern Africa developed a genius for local improvisation, adapting to life in forests, deserts, or lakesides. Cut off by the Sahara from the developing technologies of Europe and Asia, they were forced to innovate and developed their own methods of agriculture, iron smelting, and mining. In a world without the apparent consolations of property and bureaucratic institutions, a powerful sense of spirituality provided moral order and solace to the suffering.12 Few groups developed writing, but they relied on drumming, the patterns woven into cloth and beadwork, and their prodigious memories to transmit information and an ever-changing repertoire of stories and myths. On the harsh African frontier, you were nowhere without other people, and this is still the case, even though the crises facing the continent are very different and constantly changing. It is almost impossible to be truly alone in Africa, and this has a profound effect on how people see the world and act in it. In remote villages, the poorest families will invite strangers into their houses and won’t let them leave until they have eaten an enormous meal. Most Africans I know live in households that swarm with a vast and changing cast of inhabitants, including grown offspring, nieces, nephews, poor relations, aged aunts and uncles, and innumerable children. You would need a spreadsheet to establish who is related to whom and how. These societies, wrote the historian Basil Davidson, “enclosed relations between people within a moral framework of intimately binding force … . an intense and daily interdependence that we in our day seldom recognize, except in moments of postprandial afflatus or national catastrophe. The good of the individual was a function of the good of the community, not the reverse.”13 This sense of solidarity has a downside when it contributes to tribalism and social rigidity, but it can also be a source of power and creativity, and it has been at the heart of the region’s most successful responses to AIDS. What I didn’t know when I was in Uganda in the early 1990s was that something remarkable was happening there. During the 1990s the HIV infection rate fell by some 60 percent in the arc of territory along the northern and western shores of Lake Victoria, an area comprising southern Uganda and the remote Kagera region of Tanzania. This success, unique on the continent at the time, saved perhaps a million lives. It was not attributable to a pill or a vaccine or any particular public health program, but to a social movement in which everyone—politicians, preachers, women’s rights activists, local and international health officials, ordinary farmers, and slum dwellers—was extraordinarily pragmatic and candid about the disaster unfolding in their midst. This response was similar to the spontaneous, compassionate, and angry AIDS activism of gay men in Western countries during the 1980s, when HIV incidence in this group also fell steeply.14 Why has such a response been so slow to emerge elsewhere? The complete answer may never be known, but in this book, I suggest that outside of Uganda and Kagera, health officials misunderstood the nature of the AIDS epidemic in this region, in particular why the virus was spreading so rapidly in the general population. As a result, the programs they introduced were less effective than they might have been and may have inadvertently reinforced the stigma, shame, and prejudice surrounding the disease. Much of the stigma and confusion surrounding AIDS has to do with its common association with perceived “irresponsible” or “immoral” sexual behavior. However, what many people—from policy-makers, to public health experts, to ordinary African people at risk—did not realize is that most HIV transmission in this region results from normative sexual behavior, practiced by large numbers of people. It’s not that African people have more sexual partners, over a lifetime, than people in Western countries do—in fact, they generally have fewer.15 However, in many African communities, both men and women are more likely than people in other world regions to have more than one—perhaps two or three—overlapping or “concurrent” long-term partnerships at a time. A man may have two wives, or a wife and girlfriend, and one of those women may have another regular partner, who may in turn have one or more other partners and so on. This “long-term concurrency” differs from the “serial monogamy” more common in western countries, and the casual and commercial “one-off” sexual encounters that occur everywhere. But long-term overlapping relationships are far more dangerous than serial monogamy, because they link people into a giant network that creates a virtual superhighway for HIV.16 Concurrent sexual partnerships have strong cultural, social and economic roots in East and Southern Africa, and this has made fighting HIV very difficult. Fifteen years of vigorous condom promotion in many African towns and cities has had little effect on the epidemic, probably because most transmission occurs in long term relationships in which condoms are seldom used. As family planning experts have known for decades, people use condoms mainly in casual and commercial relationships, and inconsistent condom use offers poor protection against either pregnancy or STD transmission in long term relationships. Urging African people to abstain or be faithful has its limitations too, because most people are faithful already, if not to one person, then to two or three. Many of those at highest risk of infection are the faithful partners of men or women with only one other trusted long-term partner; others are in mutually faithful relationships, in which one partner had concurrent partners in the past. In this book, I argue that the key to the success of Uganda’s early AIDS campaigns was that Ugandans, like the gay men of San Francisco and New York and like the Thai men of Bangkok, knew where their risks were coming from, and this made it easier for them to respond pragmatically. Although Ugandan public health officials didn’t know the word “concurrency” they did know that the virus was spreading in relatively ordinary families and relatively ordinary relationships and that it wasn’t just a problem for “promiscuous” people alone. This made it possible for everyone to speak more openly about how HIV had devastated their lives and to regard those affected by the disease with greater compassion. This openness in turn led people to take obvious steps to protect themselves. Outside of Uganda, most AIDS prevention campaigns in Africa were for years aimed almost exclusively at so-called “high risk groups”—meaning prostitutes, truckers, soldiers, and other rootless, migrant men. Such an approach made sense in the rest of the world, where HIV remains largely concentrated in “high risk groups.” But in East and Southern Africa, the concurrency “superhighway” puts virtually everyone at risk, from cabinet ministers to the women selling tomatoes on the street, even if they are not typically “promiscuous.” Much has been written about the lessons of Uganda’s early success against AIDS, not all of it in agreement, either with the interpretation advanced here or with other interpretations. This is partly because the evidence for what happened in Uganda, and what it meant for billions of dollars in AIDS prevention funding, soon became the object of a tug-of-war between researchers and policy makers on the left and right of the political spectrum. Health officials on both sides interpreted the data in their own ways, and used their conclusions to support programs they favored. We will never know whether lives could have been saved had these policies been based on the evidence for what actually occurred in Uganda, but it is possible that this partly explains why fighting AIDS in Africa has been so difficult, and it may also suggest a way forward. The AIDS epidemic is finally beginning to subside in many African countries, owing to increasing awareness and commonsense changes in sexual behavior. This is heartening, but it is possible that many lives might have been spared had policymakers better understood the nature of the epidemic early on. Much of this book is concerned with donor-funded AIDS programs that failed in some way, beginning with my own vaccine project. I tell these stories not with a sense of satisfaction. I could not have done better myself at the time. But in science, failures are often as important as successes, because they tell us where the limits are. Only by looking honestly at our mistakes can we hope to overcome them. When it comes to fighting AIDS, our greatest mistake may have been to overlook the fact that, in spite of everything, African people often know best how to solve their own problems. They have been doing so throughout human history. Had they not succeeded, I would not be here to write these words, nor would you be here to read them. AIDS RESEARCH FOR BEGINNERS CHAPTER ONE The Outsiders APRIL 1993 ABOUT TWO WEEKS before I was supposed to leave for Uganda, I packed up the materials I would need for the experiment I planned to do there and called Dr. Arthur Murray, whom I would be working with, to confirm the shipping address. “Maybe you shouldn’t send the stuff just yet,” he said. “There’s a problem?” “There may be a problem.” “Is it a bad problem?” “It could be.” “Is it a political problem?” “Well, not the whole country.” “Just the project?” “Yeah, just the project.” A few days later he called and said that everything was OK; the problem had had to do with a truck. “A truck?” “Yeah, a truck.” I knew there had to be more to it than this. I arrived at Entebbe airport in a small propeller-driven plane from Nairobi and walked across the tarmac to a two-story building that had been almost completely gutted. The only light came through the doorway; fragments of electrical wiring and old plumbing fixtures, black with tar and dirt, dangled from the walls and ceiling. A man lounged on an elevated platform; a sign above his head said HEALTH. This was the man who checked your immunization papers. Before I left, I had been told that to be allowed past him you needed to show that you’d had injections for yellow fever, cholera, and typhoid. Malaria pills and injections for hepatitis A and B and rabies were recommended. Arthur was there to meet me. During the drive to Kampala, we talked about my materials, which still hadn’t arrived. I’d called the shippers before I left, and they’d told me they thought a project called CHIPS was closing and, thinking that my project was part of CHIPS, they hadn’t sent anything out for me. I told the shippers to send my parcels anyway, but what was CHIPS? When I asked Arthur, he became tense. “Just don’t talk about that,” he said. So I didn’t. It was midday. I had been up all night on the airplane, and my first view of Africa out of the car window seemed like part of a waking dream. Soldiers in baggy green uniforms carrying heavy machine guns shambled by on the road. We drove along the shore of Lake Victoria, which sparkled in the sun. A bright yellow bird flew up out of a marsh, and vines cascaded from the crabbed and twisted branches of giant trees. I made myself a promise, which I would soon break, to learn the name of every plant and animal I saw. Within a few miles of the airport, the road gave way to threadbare patches of tarmac and our progress slowed considerably. The air was heavy with diesel fumes, wood smoke, and fine ochre dust. We passed through towns: the road became an open-air market, with kiosks selling furniture, chicken coops, spare parts for cars, machine tools, jerry-built appliances of all kinds. Pale green trucks stood in the middle of the street wheezing black vapors. Their flimsy metal frames were piled high with bananas, foam-rubber mattresses, and chickens crammed in their cages, their feathers raining everywhere. Along the roadside, there were old men in baggy suits; dusty, barefoot workers; children dressed in rags; stray goats; and stout women in colorful wraps selling green bananas and charcoal from lean-tos constructed from stripped tree branches roped together with banana leaves. Everything seemed handmade, makeshift, rough-hewn. Small, colonial-style cement bungalows, their roofs dented and askew, ranged untidily over the hillsides. Without a sterilizing winter, their foundations were riddled with cracks from the intrusions of tree roots, creeping molds, burning sun, and driving rain. Over the coming months and years, I too would have to contend with the forces of nature. There would be power cuts and water shortages and broken toilets and stuck doors and cars that started only when you kicked them. Most of the time, someone would find a way of rigging things to avert disaster. ARTHUR DROPPED ME OFF at the house of his colleague, Dr. Celeste Quinn, on the campus of Makerere University, where I would be staying. Celeste was a gynecologist working with the urban poor in Kampala. She was also the director of CHIPS, the U.S. Agency for International Developmentfunded project that I was not supposed to talk about. Like most expatriate residences in Kampala at the time, Celeste’s house was a space pod of Western comfort. There were guards, servants, a telephone, a television. Celeste was a large, slightly intimidating woman, with a physician’s scrubbed white hands. When we were introduced, she extended an ivory arm and gave me a brief smile. She was seeing off some friends at the door and seemed distracted, so I sat in a wicker chair on the back porch and played with her cat, which emerged from its cardboard box and slunk over to me. I would be working in a lab at the Uganda Cancer Institute, a compound of weathered one-story concrete buildings on the grounds of Mulago Hospital, the only state-run hospital in Kampala at the time. The lab was next to the dental clinic, and the screams of the children being treated there could be heard all day long. The Cancer Institute had two barn-like open wards that were so dark and overcrowded that most of the patients and their families lounged on the verandahs and gravel yards outside. They bathed their children under an outdoor spigot and prepared maize meal and mashed bananas on open wood fires. On the Cancer Institute grounds I saw people with growths on their necks the size of pineapples, and people without arms or legs. I saw a man without a nose. My lab was a short distance uphill from the Cancer Institute. Arthur took me there the day after I arrived. We walked through the main lab, which was crowded with equipment and Ugandan technicians, and entered a much smaller room, which had no light and was full of empty cardboard boxes and rusty machine parts. When he pushed the door open, plumes of red African dust rose and swirled around us. “We were thinking of putting you here,” Arthur said. It was clear that some other place would have to be found for the boxes and machine parts. A plasterer and painter would have to be hired, and we would have to install a refrigerator, a light, and a table. Some time would pass before I could begin my experiment. A few days later, a contractor was hired, but he quarreled with the institute’s accountant over how much the job would cost. The two men negotiated within five dollars of each other before the contractor lost his temper and left. It took two days to get him to come back and accept his own terms. I grew accustomed to such delays. The materials I had shipped from California were still missing in any case. The American shipping company assured me the boxes had been sent and should have arrived. The airline said the boxes were with customs, customs said they were with the clearing agent, and the clearing agent said they were at the Cancer Institute, where, according to Celeste, who kept track of the shipments that came in, they could not be found. I had come to Kampala to carry out an experiment that I hoped would contribute to the development of a vaccine to protect Ugandans against HIV, the virus that causes AIDS. I became interested in the problem when I was doing postdoctoral work in California. I had been studying the sexual organs of a tiny insect the size of the letter in ELIZABETH on an English penny, when I realized I was finding it increasingly difficult to concentrate. I had recently heard a lecture given by a scientist named Kathelyn Steimer about the HIV vaccine that her lab at Chiron, a bio-technology company near San Francisco, was working on. It had been injected into about two hundred volunteers so far, and the results were encouraging. After the lecture, my mind never seriously returned to the insect world. My research had been bothering me for some time. In my university biology department, and others like it, “frontiers” were the thing. It was unfashionable to study anything for a practical reason. We thought of ourselves as the astronauts of the cell, exploring the logic left behind by evolution’s intricate digressions. Our heroes were the men and women who described the structure of the gene, saw the first microtubule, and found out how ribosomes worked. We were not in the business of developing cures or vaccines. My academic outpost near San Francisco was some distance from the frontier. In the 1920s, a German scientist discovered that if you stained the nucleus of certain insect cells and looked at them under a light microscope, you saw a black dot. He wrote a series of long, detailed articles on the subject suggesting that the black dot was a chromosome, and left it to posterity to figure out what it was for. My boss believed that the black dot was extremely important. He theorized that it determined sex, that it contained a genetic memory bank, that it was some sort of death clock. We spent hours discussing it. The aphid-like bug I was studying was tiny and round and had six legs, each consisting of three segments. It had a pair of short antennae with seven segments and a tiny mandible. Its little body was covered with pores from which it secreted a white goo in which it hid. I asked my boss whether we all shouldn’t be out helping the poor and the sick, rather than studying the molecules inside the sex organs of a bug that was almost too small to see. “The poor and the sick will always be with us,” he said, “but we will change the way people think about the world.” Although my boss didn’t say it, I knew that he considered work like Steimer’s pedestrian. He had a point, I suppose, but when I looked around at all the people in the lab muttering recondite gene-speak, it all began to seem very strange. I longed for a biological problem that had meaning outside the world of academic conferences and biochemical journals. I had known several people who had died of AIDS. Most were young; all suffered horribly. Although scientists had spent billions of dollars trying to understand how the virus worked, they had as yet found no way to stop its spread. AIDS had devastated the gay enclaves of New York, San Francisco, and Los Angeles, and the news from the developing world was even worse. Millions of people in East Africa, Thailand, and India were already infected. Steimer’s vaccine consisted of a harmless suspension of molecules called gp120, and doctors had injected it into two hundred HIV-negative volunteers so far. Steimer hoped that the gp120 molecules would train their immune systems to fight off HIV if they were ever exposed to it. Many of the volunteers were homosexual men who had watched their friends die of AIDS. Some of these men were sexually active themselves, and thus they were also at risk of HIV infection. Although they had been advised to avoid risky sex and use condoms, not all of them complied with this advice. Soon Steimer would know whether her vaccine protected these men or not. She was hopeful because Chiron had developed a similar vaccine for hepatitis B that had saved many lives and earned the company billions of dollars. So far the results with the HIV vaccine looked promising too. A few weeks after Steimer’s lecture, I asked a doctor I knew who had worked on AIDS in East Africa if he thought a molecular biologist might be useful there. He suggested I write to a professor in San Francisco who was conducting a study of sexually transmitted diseases (STDs) in Uganda. Perhaps he would be able to give me some advice. I had read about the AIDS epidemic in Uganda. One-third of adults in the capital city, Kampala, were HIV positive, and the virus was spreading along trade routes into the countryside. Thousands of children had been orphaned by the disease, their farms left idle because their parents were dead or too sick to work. I wrote to the professor and phoned his secretary some time in August. She said he was very busy but had time to see me at eleven-thirty on October 23, 1992, for about fifteen minutes. Professor Cornelius was about fifty, a small, round man with a tennis-ball fuzz of hair around his cheery face. “So, you want to go to Africa!” he boomed. He talked about the poignant beauty of Kampala—the crowded, dirty city; the skeletal remains of the stone buildings, gutted by war; the surrounding hills and the vast slums in the folds of land between them—and about Makerere University and Mulago Hospital, once the most distinguished in East Africa, destroyed by Idi Amin, Milton Obote, and twenty-five years of murder, corruption, and neglect. In the mid-1980s, when health officials first recognized the magnitude of the AIDS crisis in Africa, they feared that this great plague affecting heterosexual people would spread north, to Europe, the United States, and other developed regions. There were predictions that it was only a matter of time before large numbers of ordinary non-gay, non-drug-using Americans— college students, Wall Street executives, housewives—would find they were HIV positive. So the U.S. government, through the National Institutes of Health and the U.S. Agency for International Development, poured money into research. Professor Cornelius was one of those trying to find out why so many heterosexual people in Africa were infected with HIV. At the time, there were many theories about it, but Professor Cornelius and others believed that it had something to do with the prevalence of STDs there. HIVinfected cells and virus particles do not penetrate unbroken skin, and they don’t survive long outside the body. In order to pass from one person to another, they must encounter mucous membranes, the slimy surfaces of the body’s internal cavities, such as the vagina and rectum, and even then, it is not a certainty that infection will occur. STDs—syphilis, gonorrhea, herpes, and so on—cause genital sores and ulcers that Professor Cornelius and others thought created direct channels to the bloodstream through which HIV could pass very easily. STDs were common in Uganda. Although most cases could be cured with cheap antibiotics, two decades of civil war and economic demise had left half the population without any medical care at all, and the situation wasn’t much better in other impoverished African countries. Professor Cornelius was overseeing several projects related to AIDS in Uganda, one of which, CHIPS, the project I was discouraged from talking about, was being run in Kampala by his young colleagues Celeste Quinn and Arthur Murray. In the course of their work they had collected blood samples from thousands of patients at a public STD clinic in Kampala, which were now stored in a freezer. About half the patients were HIV positive. No one had yet studied these samples. Perhaps this was something I would like to work on? We discussed possible experiments. During the meeting, Professor Cornelius was interrupted by an urgent phone call, and his secretary appeared at the door making frantic gestures that I was not supposed to understand. I HAD BEEN IN KAMPALA for three weeks. The plasterer had fixed up my little lab, which now had a light and a table, but I still needed a refrigerator. The Cancer Institute’s accountant authorized the money to pay for it, and Vicki, the large, beautiful Ugandan woman who ran the institute storeroom, said she would help me buy one. She warned that Ugandan dealers would double the price of anything a white person bought, and recommended we go to an Asian shop. Traders from the Far and Middle East have been coming to East Africa for centuries. Until the 1970s, South Asians ran most of Uganda’s businesses, factories, and sugar and cotton mills; they built many of the towns, taught in the university, and owned a great deal of property. Then, in 1972, Idi Amin threw them all out and gave their property to black Ugandans. Chaos ensued. The new African entrepreneurs were totally inexperienced and the economy fell into ruin. Amin spent what little foreign exchange remained in the country on whiskey and transistor radios to placate the army, and soldiers and other government henchmen looted at will.1 Yoweri Museveni, president since 1986, in a bid to both redress past injustice and restore the economy, offered the Asians the chance to return and reclaim their houses, shops, and factories, and many did. The Asian shop Vicki took me to was small and crowded, but the man behind the counter seemed to know her, so we didn’t have to wait long. He showed us a refrigerator called a Sno-Cap. “How much?” Vicki asked. “Twelve hundred thousand shillings.” “Eight.” “No.” Silence. “OK, eleven hundred and fifty.” “Nine.” “No.” “Come on, nine hundred.” “Eleven hundred and that’s as low as I can go.” Vicki looked at me and I shrugged. “OK,” she said. The refrigerator that arrived at the lab a few days later was half the size of the one we thought we had purchased. My boxes were still missing. I consulted Celeste, but all she could do was sympathize. In the two years she had been working in Africa, she had seen this happen a thousand times. Sometimes things just vanished. Uganda was a developing country after all, and life here was chaotic. Celeste had something to confide in me too. The project she was running was also in trouble. CHIPS—the Community Health Initiative to Prevent Sexually Transmitted Diseases—was a $1.5 million project funded by the U.S. Agency for International Development (USAID). Celeste was the director and had written the original request for funding and had hired the 132-person Ugandan staff. CHIPS had been running for about a year and was located in a Kampala slum called Kisenyi, which means “swamp” in Swahili. It lies between two hills, where two of Kampala’s many cathedrals stand. Catholic and Protestant missionaries brought Christianity to Uganda in the 1870s, but within a decade the converts were at war. Thousands were killed and peace would not return for another twelve years. Religious tensions persist in Uganda to this day; Kampala’s Catholic and Protestant cathedrals now face each other from adjacent hills, and Kisenyi lies in the depression between them. When it rains, garbage and silt run down the hills and collect in Kisenyi. The air smells of rotting banana peels, children gather food from garbage heaps, and rivulets of sludge course through the narrow passageways that serve as streets. Kisenyi is where people displaced by war or poverty end up when they come to Kampala. Everyone is poor and unemployed, and yet everyone appears to be doing something. The men fix bicycles, make things out of wood, or steal. The women sell things: roasted bananas, cigarettes, sweets, themselves. The prevalence of both STDs and HIV infection was very high. CHIPS was established to see what effect a neighborhood STD clinic and HIV testing center would have on the spread of HIV. At the time of my visit, the only treatment available to people with STDs was the clinic at Mulago Hospital, which was overcrowded, far away from where most poor people lived, and frequently out of medicine. Like many AIDS projects in Africa, CHIPS was an uneasy collaboration among three parties with different interests: USAID, which provided the money; Celeste, who was responsible for spending it; and the people of Kisenyi, on whom the money would be spent. USAID’s goal, determined by the US government, was to reduce the spread of HIV and other STDs and to promote family planning in developing countries. Its officials hoped that the CHIPS clinic would serve as a model for programs throughout Africa that would achieve both aims at the same time. USAID had a lot of money to spend—some twenty million dollars in Uganda alone at the time—and therefore it also had considerable power. It gave jobs to scores of American experts in public health, waste management, education, and so on, who in turn hired hundreds of local people. The interests of the people of Kisenyi were different. Free condoms and treatment for STDs were fine, but the CHIPS clinic was the largest, most modern building in the area. When they saw the walls going up, they must have wondered what it was all about. They must have hoped it would provide treatment to save the countless children in Kisenyi who die of malaria, diarrhea, and pneumonia every year, or the scores of women who die in childbirth. Perhaps it would even offer treatment for AIDS. Some people may have hoped to get jobs there. Moreover, Celeste was a scientist. She wanted to know which STDs were most common in Kisenyi, and the best and cheapest ways of treating them. She also wanted to know exactly how many people living in the area contracted HIV each year, and how many cases of infection could be prevented by the services offered at the clinic. Such a project might seem simple, but she must have encountered many frustrations along the way. I can only imagine all the things that could have gone wrong. AT MULAGO HOSPITAL, down the hill from the lab at the Cancer Institute, an American doctor was trying to determine how best to treat cryptococcal meningitis, which often affects people dying of AIDS. The doctor was ordinarily a mild man, but when I asked him if I could accompany him on his rounds, he agreed only reluctantly and seemed irritated. I asked if anything was wrong. “You’ll see,” he said. Cryptococcal meningitis is caused by a fungus that infects the fluid bathing the brain and spinal column. Everyone is exposed to the germ that causes the disease; its spores can be found on the leaves of certain trees or in the air. But the only people who get sick are those whose immune systems are in such disrepair, because of AIDS, cancer, or some other cause, that they can’t fight it off. The symptoms are nausea, vomiting, disorientation, and headaches so severe that when a child dies of AIDS in Uganda, it is often said that he died of headache. At the time, the powerful antiretroviral drug cocktails that can vastly improve the lives of AIDS patients had not been developed and would not become widely available in Uganda for another decade. The only treatment for cryptococcal meningitis available in Uganda at the time was amphotericin, a highly toxic medicine that, even in moderate doses, caused permanent kidney damage. The doctor was being paid to study a relatively new drug called fluconazole, which was not as toxic, but was very expensive. It was provided free to all AIDS patients willing to participate in the doctor’s study, but without antiretroviral drug cocktails, most of these patients would die within a few months anyway. Following the doctor on his rounds, I was not surprised by the chipped paint and grimy windows, the torn, dirty sheets, and the few items of rusty furniture. But I didn’t expect to see someone lying in a pool of blood, or meet a man who had spent the previous night having a seizure. A nurse, had there been one, would have known how to stop it, but the man stopped it himself, by lapsing into a coma. There were so few nurses at Mulago that patient care—feeding, washing, and alerting the doctors in emergencies—was virtually all done by family members. Mulago was a public hospital, and basic drugs and supplies should have been provided free, but they were rarely available. When a patient needed a drip line or an aspirin, a relative went to a market nearby. Some nurses and doctors also sold drugs and equipment—some of it stolen from the hospital stores—and they tended to overcharge. In the early 1990s, doctors at Mulago earned about $150 a month; nurses, fifty dollars. It was not surprising that some of them were so alienated that they made what extra money they could from their patients. Some, having taken other jobs, did not show up for work at all. The doctor went from bed to bed. There was another man in a coma, and another so weak he seemed able to move only his eyes. One patient had a private room. The place was tidy and sunny and clean. He must have been rich. Someone had brought two straw shopping bags full of provisions: cups and saucers, a Thermos flask, books, a soap dish. The patient looked all right to my untrained eye, not thin, with no obvious rashes or sores, breathing quietly—although he was moaning and writhing and holding his head. The doctor said he would give the man codeine, but the only way to make him comfortable would be to knock him out completely. He died the next day anyway. “Sometimes I don’t know what I am doing here,” the American doctor told me. But I did, and so did this doctor’s employers. Conducting this trial in the United States would have been far more expensive because the American patients would have required far better care. But ethical standards required that the pharmaceutical company needed only to ensure that the Ugandan patients received the standard of care in Uganda, which was very low indeed. At least the patients were getting something as a result of the trial, I thought. There was no placebo group, so everyone was treated. Nevertheless, the doctor knew that after the trial ended, he and the company would leave Uganda. No further patients at Mulago would receive free fluconazole until 2002, nine years later, when Pfizer, the company that makes it, under pressure from AIDS activists and manufacturers of generic drugs in Thailand and India, offered the drug free to African hospitals. Pfizer’s donation program, though generous, has been slow to get off the ground, and even today, cryptoccocal meningitis remains a common cause of AIDS-related death throughout Africa. Medical research in Uganda can be profoundly frustrating for the doctors involved. They are caught between the demands of their employers for convincing survival curves and those of their patients for help of any kind. A high proportion give up and leave. But for some, Mulago is a rewarding place, recalling a time when doctors were closer to their patients than they are now. Medicine in the West relies on expensive diagnostic techniques unavailable here, but some doctors I met in Uganda admitted that they had learned a great deal from being forced to rely only on a stethoscope. As one of them told me, “I never realized there was so much you could learn just from listening to someone’s heart.” I withdrew after a while to sit on a bench beside a thin old man who was staring straight ahead and wheezing. Between patients, the doctor came over to me. “Are you all right?” he asked. A funny question, I thought, to ask someone visiting such a place. “I’m not sure I can take this,” I said. “I can understand that.” If only my materials would turn up so I could start my experiment, I might not feel so useless, I thought. I tried to think of ways around it, of what local substitutions I could make, of what I could borrow from other scientists around Kampala. But what I was trying to do—design an HIV vaccine for Uganda—was way out on the high-tech edge. Many of the materials I was expecting came from highly specialized labs in the United States, and existed in small quantities. They were made nowhere else. Some of the materials had been donated to me by scientists who cared about the AIDS epidemic in Africa and wanted to contribute in some way to my project. I had been in Uganda for only a month, and already, I was disappointing them. WHEN HIV was first identified in 1983, many researchers thought it would be easy to develop a vaccine to protect people against it. But by the time I arrived in Uganda a decade later, this optimism was beginning to fade. To understand why it has been so difficult to make an AIDS vaccine, it helps to know what happens when a person first becomes infected with HIV. HIV is a spherical virus whose surface is covered with tiny stalks. There is a ball at the end of each stalk that consists of a clump of molecules called gp120. The gp120 molecules function like a key, enabling HIV to break into particular white blood cells—called CD4 cells—that help protect the body from disease. Once inside the CD4 cells, the virus takes over the DNA copying machinery and forces the cells to churn out millions of new viruses, until the cells eventually burst open and disintegrate or clump together and die. In the bloodstream of HIV-positive people, a billion CD4 cells are hijacked and killed each day, and 100 billion new HIV viruses are produced.2 Right after infection with HIV, people feel nothing, but after a few weeks or months, some people become feverish, and the lymph nodes in their necks and armpits swell as the first immune response against HIV is being made. Lymphocytes and antibodies—Y-shaped molecules with mitten-like protrusions that latch onto and kill infected cells and microbes—clear most of the virus particles, but some viruses escape by mutating: they change slightly, infect new cells, and continue to reproduce. The body must make new lymphocytes and new antibodies to fight the mutants, but the mutants mutate again, necessitating a new immune response. The human immune system is able to fight off most viruses and clear them from the body, but not HIV. By the time the immune system begins making cells and antibodies it is too late. The virus has embedded itself in so many CD4 cells that it is impossible for the immune system to clear it without destroying itself in the process. As the CD4 cells die off, the body loses its ability to respond to a range of other infections. The patient is slowly consumed by diseases that are harmless to other people and dies. When I first heard Dr. Steimer’s lecture, I learned that it might be possible for a vaccine to prevent the virus from taking hold in people who were exposed to it. This is what had encouraged me to abandon the tedious complexities of the insect gonads that I was studying. The vaccines that protect people against infections are usually made from harmless versions or fragments of the microbe that causes the infection itself. When the vaccine is injected into the body, the immune system reacts as though it were the real thing. The bone marrow and lymph nodes generate cells and antibodies that specifically kill that particular microbe. These cells and antibodies constitute what biologists call “immunological memory.” They remain in the blood for years. If the real microbe enters the body, they are able to destroy it in hours rather than weeks or months, and clear it before it seizes control of vast numbers of CD4 cells. Back in California, I had learned that there were about thirty HIV vaccines under development, but many researchers were already losing hope that any of them would work because of the vast number of mutants. By all accounts, the most promising vaccine at the time was the one designed in Steimer’s lab at Chiron Corporation. Shortly after Professor Cornelius suggested that I might work with the bank of serum samples in Uganda, I contacted Dr. Steimer and she invited me to visit her lab. Chiron was founded in 1981 by a group of molecular biologists from the University of California, San Francisco, who had been among the first to isolate a human gene and clone copies of it in a test tube. Cloning provided an entirely new mechanism for making drugs and vaccines, and it soon inspired visions of corporate empires in biology similar to the rapidly growing software empires that had been established a decade before. Biologists who had once scrounged through forests, swamps, and sewers to find natural molecules that might be effective in treating diseases could now engineer them in bright, clean laboratories, or so it was hoped. Chiron occupies a ten-acre lakeside compound near San Francisco, and employs two thousand people, largely paid for by its multibillion-dollar sales of a vaccine for hepatitis B, the first vaccine to be created by cloning. I recognized Dr. Steimer immediately. She was tall, slim, and blond, and had the same efficient but melancholy and distracted manner I had noticed when she was giving her lecture. She showed me around the lab. We passed through the two main rooms, where work with uninfected specimens took place, and the isolation room, where technicians wearing blue bodysuits, booties, shower caps, rubber gloves, and face masks were working with live HIV virus. Was the virus really so dangerous to work with? I wondered. Dr. Steimer explained that although HIV mutates, she and her colleagues had a strategy that might contain it. Her vaccine consisted of gp120 molecules that her technicians had cloned in her lab. Because gp120 was the “key” that allowed the virus to break into cells, part of it was “conserved”— meaning it could not mutate without destroying the function of the key. Steimer hoped her vaccine would stimulate the production of antibodies that would grab onto this special conserved part of gp120. Like a piece of gum on a door key, the antibodies would prevent the virus from unlocking the cells and infecting them. Steimer hoped that her vaccine would give the immune system a head start, so that it could make such antibodies early and kill HIV in hours, before it began flooding the body with mutants. Because the vaccine was made artificially by cloning, it contained none of the virus’s genetic material and posed no risk of infection. At the time, the DNA of the HIV mutants from about five hundred different patients around the world had been analyzed. No two of them were identical, but they seemed to fall into some ten distinct categories known as subtypes, which tended to circulate in different populations around the world. Most people in the United States were infected with the subtype known as B, and Dr. Steimer’s vaccine was made from the gp120 of a subtype B virus that had been isolated from a patient in San Francisco. Dr. Steimer hoped that it would protect people from infection with subtype B, but she knew it would be unlikely to protect people from infection with other subtypes circulating in other parts of the world. Nevertheless, a vaccine for subtype B would be an enormous breakthrough. A test of any vaccine involves three phases. First it is administered to a small number of volunteers to ensure that it does not make them sick. Next it is given to a larger group of volunteers, to see if it induces the production of the right kinds of antibodies and cells. Blood is drawn from these volunteers and added to the virus in a test tube. If the volunteers are making good antibodies, the blood will kill the virus. Phase III is a massive, fantastically expensive venture involving thousands of healthy volunteers, who receive either the vaccine or a placebo. After several years, the rates of infection in the vaccinated group and the placebo group are compared, and the statistics indicate whether the vaccine protects people or not. If the vaccine fails completely, equal numbers of people in the vaccinated group and the placebo group will become infected. If the vaccine is perfect, no one in the vaccinated group will become infected. If the vaccine is only partly effective, some members of the vaccinated group will become infected, but far fewer than in the placebo group. While the volunteers in a Phase III trial are healthy, they are chosen because they have a high risk of becoming infected. In the case of HIV, they might be young gay men or intravenous drug users. They must be told that the vaccine is experimental and might not work and that in any case, they might receive only the placebo. They are warned to take every measure to protect themselves. The success of the trial depends on the fact that a significant number of these people—for whatever reason—will be exposed to the virus anyway, despite these warnings. Dr. Steimer’s vaccine was in the second stage of testing. It had been deemed safe, and the antibodies produced by healthy volunteers killed various laboratory mutants of subtype B. These lab strains contained pure stocks of virus that had been propagated in an incubator for years. Viruses taken from patients were far more diverse and complex, having adapted to survival in the body, in the presence of an active immune system, rather than in a plastic flask. Dr. Steimer and her colleagues were preparing to determine whether the antibodies her volunteers made would kill these “wild-type” HIV strains, taken from real people with real infections. If that worked, they would proceed to Phase III. Chiron could not finance a Phase III trial of the vaccine itself, but the U.S. Congress, on the advice of the National Institutes of Health, was considering pitching in with $20 million. Their decision would depend on additional lab data, and was expected sometime the following year. My thoughts were these: The World Health Organization (WHO), sensitive to the fact that the poorest nations might be overlooked in the high-tech scramble for an AIDS vaccine, had designated four developing countries as potential sites for AIDS vaccine trials—Thailand, Brazil, Uganda, and Rwanda. Dr. Steimer’s vaccine was designed only to work against subtype B infections, prevalent in the United States. Nevertheless, if it worked, and if information could be obtained about the subtypes circulating in Uganda, the company might consider making a vaccine that could be tested there in the future. Although Ugandans would never be able to afford to buy such a vaccine, perhaps the United Nations or some other institution would pay for it. My contribution would be to determine which subtypes of HIV were prevalent in Uganda. Some information about this was already available, but Chiron scientists had developed a new test that could identify HIV subtypes from blood samples very rapidly. Once the experiment was up and running, it would be possible to test hundreds of samples in a few weeks. This would enable me to find out just how common the different subtypes in Uganda were, and what kind of gp120 vaccine might work there. I could begin by testing some of the thousands of samples from the STD clinic that had been stored in the freezer at the Cancer Institute in Kampala. Routine HIV tests, such as those offered in hospitals and clinics around the world, are designed to detect not the virus itself, but antibodies that react with HIV. Such tests, known as enzyme-linked immunosorbent assays, or ELISAs, were first developed in the 1970s. The ELISA forms the basis for home pregnancy tests, as well as tests carried out in doctors’ offices for hormone deficiencies, infections, and other medical conditions. One of Dr. Steimer’s colleagues had designed an ELISA that could distinguish antibodies against different HIV subtypes. It could tell if someone was infected with A, B, C, or some other subtype. Dr. Steimer suggested I use this technique to investigate the antibodies in the Kampala serum samples. I worked in Dr. Steimer’s lab on the vaccine project for a couple of months to earn money and learn the new ELISA technique. Meanwhile, I planned the trip to Uganda carefully. Not knowing what to expect, I packed as though I were setting up an ELISA on the moon. I packed scissors, pencils, tape, pipettes, chemicals, plastic ELISA dishes. These were among the materials that were lost on the way to Kampala. Dr. Steimer was prepared to pay for the materials I would need to do the experiment, but not for me. In Uganda, I would have to support myself. The doctors in Kampala were prepared to let me use the stored blood samples in their freezers and give me space in a lab, but they would not pay me either. Nevertheless, I was happy about the arrangement. The project was very small, and although it would turn out that others were thinking along the same lines and would also publish surveys of HIV subtypes in Uganda, I felt like a pioneer.3 Such feelings are rare in biology these days. The hour of the lone scientist following his or her imagination into the unlit corners of nature is passing. These were the days of the Human Genome Project, the biotech revolution, and the five-million-dollar grant. Whatever you might have wanted to do, others had thought of it already, and they had more money, more technicians, more pipettes, more frogs, more of whatever it takes than you did. So you joined their lab and you did what they said, or forget it. But here in Kampala, I was on my own. I WAS STILL WAITING for my materials to arrive when Arthur offered to show me the blood samples stored in the freezer at the Cancer Institute. They had been collected over the preceding four years, subjected to a routine HIV test, and labeled with numbers but no names. Arthur carefully opened the upright freezer where they were stored. There must have been a hundred plastic sandwich bags filled with vials in there. He put out his hand to make sure they didn’t fall on the floor. “They’re kind of a mess,” he said. The vials were stored randomly, without regard to the age of the patients, or where they came from, or any detail of their medical history. Arthur left me to sort through the bags. It took an hour to go through the first one, from which I retrieved four samples that I thought I could use. The next bag went more quickly, but it contained only three usable samples. By the end of the week, exhausted from boredom, I had 193. I decided to test these first and if my results were ambiguous, I would somehow find the strength to return to the freezer for more. But in order to proceed, I needed my materials from California, which still could not be found. One day, while I was still waiting for my boxes to arrive, I took a taxi across town to visit a friend. The driver asked me what I was doing in Uganda. When I told him, he bristled. “How can you make a vaccine when the virus mutates so much? As soon as you make your vaccine, the virus turns into something else, and your old vaccine is useless.” I explained that we hoped to get around that problem and told him about the neutralization experiments, the T-cell binding sites that we thought might make good targets for vaccine-generated antibodies, and so on. He seemed to accept this, but then he asked, “Why bother looking at this V3 loop?” “Well, we think that’s important too,” I said. I had similar conversations with a construction worker, a group of high school students, a hairdresser, and the man who mopped the floor of the lab. I had to confront questions about mutation rates, opportunistic infections, and why some people didn’t get infected even though they seemed to be having a great many sexual relationships. Nowhere else had I found people so inquisitive and well informed about AIDS. In Kampala, everyone talked about AIDS. There were AIDS clubs, meetings, conferences, marches, candlelight vigils, benefit breakfasts, lunches, and dinners; there were AIDS T-shirts, hats, banners, books, and cartoons; there were movies, plays, songs, poems, and dances about AIDS. When I told the cab driver that I was impressed with how much people in Uganda seemed to know about HIV, he said, “Everyone is affected by it. Everyone has a friend, a sister, someone who is sick or dead because of AIDS.” During the following two years, I would hear over and over again that someone I knew had died or was burying a relative. Some of my colleagues in the lab seemed unusually thin, with shiny, feverish skin and eyes that seemed to grow larger every day. Twenty years of war and deepening poverty meant that Ugandans were used to seeing children die. For some, the death of a child was even considered natural. But fatal illness had always been rare among people in their twenties and thirties, even in Uganda. Now in some parts of the country, AIDS had increased the death rate among young adults fivefold. In 1993, some two million Ugandans were living with HIV, and hundreds of thousands of people had already died. Around 18 percent of adults were HIV positive, the highest national HIV infection rate ever recorded at the time. Why was AIDS sweeping through Africa with such speed, and why had a similar epidemic in the West so far failed to emerge? Some people attributed the African epidemic to extreme promiscuity, or to exotic rituals involving blood. But such explanations seemed unlikely. Surveys carried out in African cities suggested that Africans do not have more sexual partners, on average, than people in the West do. While bloody rituals involving the repeated use of sharp instruments—female genital mutilation and scarification, for example—are practiced by isolated groups in Uganda, these are not the groups with the highest levels of HIV infection. Anal sex and other forms of sodomy are rare here—or at least they are not admitted to. At the time, most researchers pointed to the prevalence of STDs in Africa, as Professor Cornelius had explained to me back in San Francisco. Gonorrhea and syphilis were unknown in Africa before European contact, but once introduced, these diseases spread rapidly. During the first decades of the twentieth century, 20 percent of all patients at Mengo, Kampala’s first missionary hospital, had STDs. The VD epidemic caused alarm among the colonial authorities, who blamed themselves for modernizing Uganda’s tribes too quickly, causing moral breakdown. For some officials, Africa seemed like the Garden of Eden, and the Fall was taking place right before their eyes. “Among the … unclothed Nilotic tribes, a notable degree of sexual morality is found to exist,” wrote the British governor of Uganda in 1909. “Unfortunately, more clothes means less morals.” The Baganda, “who have always been greatly addicted to wearing apparel, are of notoriously lax habits.”4 Ugandans themselves also blamed the syphilis epidemic on the immoral influence of missionaries and colonial authorities. Tribal patriarchs claimed whites undermined their power to enforce traditional codes of behavior. To address this, “social purity” campaigns were launched, which promoted moral conduct with lectures and pamphlets; as in nineteenth-century England, single women suspected of prostitution were forced to submit to random pelvic examinations and sent back to their families. Well into the 1950s, all pregnant women attending mission hospitals were dosed with mercury solutions. Whether this harmed the unborn children of these women is unknown.5 When antibiotics became widely available in the 1960s, the VD hysteria subsided. Then during the 1970s, rates of syphilis and gonorrhea began to rise again.6 At the time, President Amin was overseeing a campaign of terror that is legendary, even by African standards. Hundreds of thousands of people died and many of the country’s institutions, including its health-care system, all but collapsed. Doctors were murdered or fled into exile, hospitals were looted of every movable item, the economy shrank by half, and imported medicines became a rare luxury. Amin was overthrown in 1979, and a series of civil wars followed, during which four successive leaders were toppled one after the other. When Yoweri Museveni took over in 1986, he brought peace and stability to the southern regions of the country, but reconstruction proceeded slowly and by the time I arrived in 1993 few Ugandan clinics were equipped to treat anything, let alone STDs. Most people had to walk for hours to reach a clinic of any kind. When they got there, they often found that antibiotics were out of stock, and few health workers knew the correct doses anyway. When Ugandans noticed genital lesions, they often ignored them and hoped they would go away, or they went to a traditional healer. Many continued to have sex until it became too painful. CHIPS was a pilot project, a single clinic for STDs in a single urban slum. Similar clinics were planned for the rest of the country, but this was the first of its kind. We were on our way into town one day when Celeste told me she intended to close CHIPS. She said that she was preparing a flyer to distribute to everyone working on the project sometime in the next week. It would say that work had not been proceeding on schedule, and that USAID had decided to withdraw its grant. This meant that 132 Ugandans would lose their jobs, Kisenyi would lose its clinic, and people would continue to go without treatment for STDs. She explained that it had taken nine months to set up the CHIPS clinic, to hire and train the doctors, nurses, counselors, drivers, accountants, statisticians, and data-entry clerks. During that time the building had been renovated in Kisenyi, and large amounts of equipment and supplies had been purchased from the United States, shipped to Uganda, and stored under lock and key at the Cancer Institute. Then Celeste left the country. She went to the Seychelles on a holiday, then to an AIDS conference, and then on a speaking tour of the United States. She applied for and was offered a prestigious job on the medical faculty of a midwestern university. She returned to Uganda three months later. Back in Kampala, she found that the odometer on one of the CHIPS vehicles had advanced by hundreds of miles, that money had disappeared from CHIPS bank accounts, and that a Ugandan colleague had placed three of his sons on the payroll. Only thirty people had been treated at the CHIPS clinic. Clearly the project had gotten off to a bad start. And yet, from what Celeste told me, it should have been possible to make it work. None of the crimes Celeste described seemed so terrible. Perhaps someone had used the vehicle to drive a sick person back to his home village or returned a dead body to its relatives for burial. Perhaps people in Kisenyi were not aware of the services at the clinic, or perhaps they were disappointed that the doctors there would treat only STDs, when they suffered from so many other afflictions. I wondered whether Celeste had not simply lost interest in the project, but it seemed unwise to ask, given her determination to shut CHIPS down. The day CHIPS closed, I was out of town, visiting medical projects in western Uganda. At the time, AIDS was considered less of a problem there, because there were fewer cases and because other diseases overwhelmed it. I had gone with a doctor friend to the district of Kabarole, about two hundred miles west of Kampala, in the foothills of the Rwenzori Mountains, where tea is grown on large plantations. We stopped in a village where tea workers lived in a row of huts made of reeds and mud. About twenty patients had assembled there. We met the children first. They wore ragged American Tshirts and peered at us from around trees. When I smiled back and tried to take a picture, the older ones scattered, laughing, and hid behind the huts; the little ones burst into tears. A Ugandan doctor led us to a small building site that was under construction, “our new clinic,” he joked, and the patients were asked to come in one by one. The first ones all had onchocerciasis, a parasitic disease affecting the skin and eyes, endemic in the tropics. Outside in the tea fields all day, the patients had been bitten by the blackfly that transmits the disease. They had lumps under their skin that contained coiled worms a foot long. Inside, the worms mated and reproduced, and their tiny off spring swam through the flesh, making it wrinkle and itch. I touched one of the lumps and could feel it move. When the villagers learn that doctors are coming to town, they turn up with all kinds of complaints. There was a woman with an abscess, another with arthritis, and a child with a fever. A teenager came in, shy and giggling, and said something softly to the doctor. He turned her by her shoulders so that her back was facing us, and undid her dress from the front. Her back was covered with tiny sores, some of them bleeding. “This is not onchocerciasis,” the doctor said. “I think she suspects what it is.” This rash, I would learn, was an early symptom of AIDS. Later, the American doctor and I drove farther north to visit the main hospital in the region. There was one doctor there—a German—and some nurses who seldom turned up. Water was supplied in jerry cans. The X-ray machine was powered by a generator for an hour a day, if there was enough fuel. The bathrooms had been completely gutted and did not function except as aviaries for the finches that made their nests in the porcelain scraps on the floor. Patients shared beds or slept on the floor. The doctor showed us a bed frame with half the springs missing. “We found a way to get this wire,” he said, pointing to one of the remaining springs. “The people can bend it into springs themselves.” There are clinics and hospitals like this all over rural Uganda. Many have no buildings or drugs at all, and a nurse or doctor who rarely turns up. Some time later, a planner from the Ministry of Health would tell me that the problem was not that the buildings were falling apart: it is not impossible to work in a clinic with no beds or only one wall. What were needed most urgently were decent salaries for health workers and a system for ensuring drugs weren’t stolen on the way to the patients. “With committed staff, you can set up a clinic under a mango tree,” he said. I thought of USAID and its grand aim to control AIDS with brand-new STD clinics and condoms. I thought of CHIPS: $1.5 million, a sizable fraction of Uganda’s entire health budget at the time, spent on refurbishing just one such clinic. I wondered whether a more modest program to raise health workers’ salaries throughout the country and improve the supply of cheap drugs for malaria and other infections, including STDs, might not have been a better strategy. When I returned to Kampala, the CHIPS offices were desolate. A few people were hanging around the administration buildings. Some were told they could work until the end of the month, others a little longer. Perhaps because it was an AIDS project, CHIPS had been infused with enthusiasm. Its employees seemed to believe in what they were doing. Now the spirit had drained out of them. Because I was white, a few people asked me if I could help them find jobs, but what could I do? That evening, Celeste was remote. She said she had detected veiled personal threats. She had been warned, menacingly, she thought, that it was dangerous to go out in Kampala at night. The following week, she went away on safari to Kenya. While she was away, her cat and dog were mysteriously poisoned. Before Celeste left Kampala for good, her boss, Professor Cornelius, flew out to Uganda. He was overseeing various research projects in Kampala, in addition to CHIPS. He met with the Ugandan doctors at the Cancer Institute and learned how his work was going there. In addition to being in charge of a university department, he was the editor of a prestigious medical journal and he had recently been appointed the private physician of an Arab sheik. He lamented the closing of CHIPS but said very little about it. One evening, he accompanied some of us to a local expatriate hangout in Kampala, where a prostitute swanned up to him and put her hands in his pockets. The professor was a little surprised to see me in Uganda. In fact, most of the doctors wondered what I was doing there. Unlike them, I was not employed by the University of California; nor was I currently employed by Chiron. I was in Uganda because I had managed to interest Dr. Steimer in the blood samples stored at the Cancer Institute and had managed to obtain approval from the doctors in Kampala to let me test them. So here I was, living in their rented houses, riding in their vehicles, working in their lab. They let me do this because of their hope that, if my project worked, and if Dr. Steimer’s vaccine also worked, the World Health Organization might sponsor a vaccine trial in Uganda in the near future. In that case, there would be plenty of work for everyone, including me. But for the time being, I was just a hitchhiker, and as hitchhikers sometimes do, I became a little arrogant. Hitchhikers live cynical, parasitic existences, but sometimes they see the landscape more clearly than the drivers. The professor threw a party during his visit and many people came, including a German doctor who had spent twelve years at an up-country hospital. He told us that during the civil wars in the 1980s, parties would last all night because it was too dangerous to go home. The shooting started at about four in the afternoon, and wherever you were then, there you would stay until morning. He and his Ugandan colleagues were on their own in those days. They had very few drugs and supplies; sometimes it was even impossible to find clean water to wash out gunshot wounds. As difficult as things were now, they were far worse then. Our group of Americans looked up to this man, but I don’t know how he felt about us. He told us, perhaps only partly in jest, that they talk about two kinds of AIDS in Uganda: slim AIDS and fat AIDS. People with slim AIDS get slimmer and slimmer and slimmer until they finally disappear. Fat AIDS afflicts doctors, bureaucrats, and foreign-aid consultants with enormous grants and salaries; they fly around the world to exotic places and get fatter and fatter and fatter. Fat AIDS had become so common in Uganda, he said, that if you said you were working on HIV, people thought you were a thief. A CURIOUS THING happened a few days after CHIPS was canceled. My boxes turned up. They had been locked in a storeroom and had been there for more than a month. Celeste was the only one with the keys, but after the project closed, she handed them over to an official at USAID. All the equipment and supplies there were due to be returned to their U.S. suppliers. I knew my boxes would be there. It was the only place I hadn’t looked. Celeste should have known the boxes were in there, since she was the only one with the key. But she had been distracted and upset and perhaps she overlooked or ignored them. The day I found the boxes, I told Celeste about it and she said, “Great!” and gave me a big smile. Some of the Ugandans should have known about the boxes as well, because they would have put them there. The chief accountant kept track, or was supposed to, of everything that came and went from the institute. I remember describing the boxes to him in great detail, and presenting him with a list of their contents. He promised to search. I checked back with him every day. Every day he told me the boxes had not turned up, but he was sure they would do so soon. And yet there they were. Whomever I chose to complain to would blame it on someone else, or just smile. By now, I was beginning to detect, in the way people phrased things, that there was a vague but consistent confusion between accident and responsibility. If something fell or broke, Ugandans said, “Sorry!” At first, I would reply, “Don’t worry, it’s not your fault,” but I soon realized that they knew this already. When someone crashed his car, he said, “The car got an accident,” as if it had caught a cold. Found stealing a cassette tape, the gardener said, “It just got in my pocket.” It reminded me of what physicists called Brownian motion, the random movement of particles, on a grand scale. The natural world obeys statistical laws. When you turn on the tap, the most likely outcome is that water will flow from the tank on the roof into the sink. But there is a very small probability, immeasurable, or nearly so, that all the molecules will drift the other way. In Uganda, the margins of probability were considerably wider. Water still flowed downhill most of the time, but sometimes the wily gardener turned off the supply. He blamed the old pipes the stingy landlord put in and requested “money to pay the plumber” to fix them. Disorder was driven by a tide so strong it pulled everything with it, and the careless, dishonest, and greedy coasted along in the current with ease. I built and dismantled various paranoid scenarios. Maybe the Ugandans had something against vaccine projects. This would not be a trivial matter. In the early 1980s, a medical relief worker was vaccinating people against polio on the Ssese Islands in Lake Victoria when a rumor broke out that whites were using injections to sterilize or kill black children. The islanders rowed him out to a place where the water was deep, tied a rock to his neck, and threw him overboard. Maybe the accountant didn’t like me. Maybe the accountant didn’t like Celeste, and didn’t like me because I lived with Celeste. Maybe Celeste, angry about the outcome of her own project, didn’t want my project to work either. Soon I became too busy to worry about it. When I opened the boxes, everything was there: plastic jars containing powdered chemicals, three expensive micropipettes that were capable of measuring one millionth of a liter of fluid, aluminum foil, waterproof pens, a roll of pink tape. But in order to begin the experiment, I needed to find clean water. The water from the taps in the lab, when they worked, came from Lake Victoria and was sometimes a faint green color and had things floating in it. The experiment called for distilled water, but there was none at the Cancer Institute. The tests conducted there didn’t need it because they came in prepackaged kits, shipped at great expense from the United States. There was a medical research lab across town run by the government, which shrewdly recognized that Uganda’s diseases might constitute a nontraditional export. The lab was associated with a military clinic, and it functioned on a for-hire basis. For a price, scientists from anywhere in the world could study sick volunteers who were being treated at the clinic. Many of these volunteers were Ugandan soldiers who were either HIV positive or, because they were young and sexually active, were at risk of becoming HIV positive. Arthur and Professor Cornelius were on friendly terms with the directors of this lab and often met them to discuss future research projects and other matters. There was a still at this lab, and I went there one afternoon to ask whether I could use it. The lab was in a long white building with a well-kept lawn that was being meticulously cut with machetes by young men in green uniforms. Soldiers in camouflage stood at the entrance. The director was not in, bu his deputy advised me that if I wanted to use water from the still, I should write a letter to the director, stating who I was, what my project was, and what I needed the water for. I returned to the Cancer Institute and drafted a two-paragraph letter. There were no computers at the Cancer Institute, so I asked the secretary to type it. She did so, and I gave a copy to the Ugandan doctor who was the head of the Cancer Institute. He decided that it would be better if the letter came from him, since he was senior to me and in a better position to negotiate. Eventually, my letter, typed by the secretary and signed by the director, was delivered to the government lab. After a week, no answer arrived, so I went back to the lab to make inquiries. This time, the director was in. He had lost the letter. I explained everything again and he agreed to let me use the water in his lab. The government lab was immaculate and vast. There were seven technicians working there, all wearing lab coats, ties, and clean white sneakers. Some were setting up cultures to diagnose tuberculosis; others were measuring out samples of an herbal mixture, which, it was claimed, relieved the nausea and diarrhea associated with AIDS. It had the color and consistency of alfalfa and was delivered weekly by a traditional healer, an enormous man with one front tooth and a puff of bushy gray hair. I met one lab assistant whose only assignment seemed to be to watch water drip out of the still. He sat for hours on a white countertop and stared at the still with a cheerful, lazy smile. At lunchtime, he removed his lab coat and turned off the machine. As he headed out the door, I asked him to turn it back on. “Don’t worry,” I said. “I’ll watch it.” I then went back to calculating how much sodium hydroxide I would need to adjust the pH of borate to nine. When I looked up again, a gust of steam was pouring out of the still. Apparently the water supply had been cut off, and the machine’s bare coil was about to ignite. A two-thousand-dollar piece of equipment, unavailable elsewhere in Uganda, had almost been ruined. The technicians were forgiving. They said it had happened before. The still could be fixed. The demons of accident are a feature of scientific work, and the thoughts of most scientists, when they are not taken up with novel theories about nature, are mainly concerned with preventing things from screwing up. But I was used to problems on a smaller scale: a bad batch of some chemical, dirty pipettes, mislabeled test tubes, stray bits of fluff in the air falling in petri dishes, careless little mistakes. In Uganda, accidents were of an entirely different order. At the end of the week, I was able to return to my own lab with a dozen bottles of freshly prepared solutions and begin the ELISA tests. After the refrigerator had been installed, there was no room for me, so I had to work in the main lab after all. The place was crowded; there were six of us in a very small room. Nurses came and went, delivering specimens from the hospital, vials of urine and blood and other things to be tested for pregnancy, diabetes, syphilis, HIV. Sometimes the nurses hung around, chatting. Once a person I didn’t know sat down on the floor near my corner, blocking my only way out, and spread thousands of tiny pieces of paper everywhere. The other technicians were very big and we all tried to avoid sudden movements. I ran through the experiment as I had learned it at Chiron, adapting it slightly for this African lab. It was a pleasure and a relief to see the readout of the first experiment. An array of green dots appeared on a plastic dish, each one corresponding to a single patient and a single HIV subtype. The greener the dot, the more antibodies the person had made to that particular subtype, and the more likely he was to have been infected with it. On the first day, I processed four patients’ samples. All were infected with HIV-1, but they carried different subtypes. One had antibodies against subtype A, and another had antibodies against subtype C. Two had antibodies against both subtypes A and D. The next day I processed four more samples. These patients had antibodies against C only, D only, both A and D, and nothing. I was so relieved that the experiment was working that I didn’t realize what I was seeing at first. I was intrigued by how different the patterns of these green dots looked from those generated by the blood samples from California. Almost everyone there had antibodies against subtype B, and only subtype B. But it was hard to identify any pattern in these Ugandan samples. After three weeks, I had tested about fifty samples. I sent a page of data to Chiron to let them know the work was under way. I said I thought the results were interesting and wondered if they did too. I spoke by telephone to a postdoc in Steimer’s lab, and he said he was pleased that the experiment was working. He told me to keep going. One morning I arrived to find the lab dark. The chief technician sat by a window, reading a newspaper. Two other technicians, one a skeptic, the other a Catholic, were arguing about the Ten Commandments. The Cancer Institute had a backup generator, but it had burned out from overuse. The hospital engineer had stopped by, looked at the generator, and shaken his head. The administrator went to call the electricity company, but the phone was out of order. We drove to the electricity company, found the manager, and told him that we were doing AIDS research at Mulago, that our work was being ruined, that lives were at stake, that he had to do something. The problem was with the transformer, he said. There was nothing he could do. He wouldn’t even accept a bribe. Was anyone working on it? No. The engineers were busy elsewhere. We went back to the lab and the lights were, miraculously, on, but it was too late to start an experiment. That night the transformer at the hospital exploded in a flash that lit up the sky over half the city. A friend watched it burn from a balcony café in town. Then the hill where the hospital was went dark. My friend called me. “Don’t bother coming to work,” she said, “for a week at least.” She was being pessimistic. After a few days, the lights were on again. As the weeks wore on, more problems occurred; although always unpredicted, the novelty soon faded. Sometimes I wondered if I should have stayed in the United States, where boxes don’t disappear, refrigerators don’t shrink, water flows on demand, and labs rarely blow up. But AIDS research in the United States would have meant a contract and a salary and a boss. The boss would have told me that what I was trying to do wasn’t worth it. The vaccine would fail, and condoms and STD treatment services would control the epidemic on their own. But mine was a romantic, naïve, ill-conceived mission that just might work, and for that reason the struggles and disasters were never too hard to endure. Perhaps, I thought, CHIPS collapsed because it belonged to no one. When it got into trouble, USAID didn’t care because it was only one of many projects—including STD projects—they were supporting throughout Africa. Taxpayers were unlikely to find out about the failure of one of them, and if they did, they were unlikely to be up in arms about it. The Africans didn’t care because they wanted doctors and medicine more than they wanted buildings and condoms. And Celeste had other plans. While I was working on the ELISAs, the phlebotomist at the Cancer Institute died. Toward the end, I was told, he was so sick that he frightened the patients. He wore a scarf to hide his swollen neck. I asked the American technologist in charge of the lab if she thought many people who worked at the institute were HIV positive. “You know that cute little pregnant nurse who hangs around the ward?” she asked. I did. She was beautiful—small, with perfect features like a child’s—and enormously pregnant. She was married to the phlebotomist. After I had been in the lab for some time, I began helping a technician who was growing cells from HIV-infected patients in dishes in the incubator. There were indications that something was wrong. Some of the cells were dying some of the time, but we couldn’t predict when or figure out why. Most of the cells were fine and producing lots of virus particles, perhaps as many as a hundred per second. I suggested to the technician that he test his cultures to see if they were too acidic or too alkaline. He put a drop of one culture on a piece of litmus paper. Impatient to know the answer, I grabbed the wet piece of paper with a bare hand. The pH was within acceptable limits. Then I realized what I had done: the solution was far more infectious than any bodily fluid, including blood. I washed my hands four times. I did some research and discovered that quite a few lab workers around the world had been infected on the job. Most cases involved an accident with a needle or scalpel. But one technician had been infected when blood splashed on his chapped hand. Another technician was infected when plasma splashed in her eye. Since 1978, there had been thirty-two cases of infection among lab workers where no other risk factor was present. In four cases the technician could recall no incident but percutaneous exposure. That is, HIV got through the skin somehow, through a small cut or rash or maybe the edge of a fingernail. I thought of all the careless mistakes I had made over the years. Once I found I had spilled acid in a wastepaper basket, and another time I contaminated a test tube with radioactivity. On both occasions I was the only one who could have done it, but I had no memory of it; I must have done it unconsciously. How many times had I done this kind of thing? And how many times had it involved the AIDS virus? Over the next couple of weeks, a mild headache came and went. I felt tired, I had a fever, diarrhea, an ear infection. I became aware of my neck and armpits. Everyone in the health field worries about accidental HIV transmission. The American technologist told me that she tests herself every six months or so by ELISA—a test similar to the one I was using for the subtyping experiments. The readout from the test is also an array of dots, each corresponding to a different person. The dots tell you who is infected. If the dot i...
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Running Head: THE INVISIBLE CURE

The Invisible Cure
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Institution

THE INVISIBLE CURE

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The Invisible Cure is a book by Helen Epstein in which she thoroughly explains why the
infections of HIV/AIDS in Africa are on the rise. Epstein explains that if Africa does not watch
out, it may slowly lose its fight against HIV/AIDS. Sub-Saharan Africa has proven to be the first
when it comes to the number of infections since the number of infection in that region keep
increasing with each rising day. Several factors have accelerated the increase in infections in the
area.
The title `The Invisible Cure` means that HIV/AIDS cases can be reduced, but only if some
measures are put into consideration. According to Epstein, Africa has a challenge, and especially
when it comes to healthcare services. Most countries in Africa are developing countries (Epstein,
2008). Therefore, the quality of healthcare that they can provide to unwell individuals may not be
first-class care. There are many other diseases that the countries and some are universal. Epstein
explains that if the first-class countries are struggling with these diseases, such as cancer, yet they
have the required expertise, what about African countries? Therefore, Africa needs to do
something and especially in reducing the rate of infections in the states.
Epstein explains that antiretroviral drugs do help. But at some point, the body becomes
resistant to these drugs. At this point, the person has developed numerous complications. At this
point, most patients die due to multiple complications. Epstein`s position in this is that the drugs
alone cannot help Africa. HIV mutates, and after a while, it rejects the drugs. Africa generally
needs to change its lifestyle. The number of infections in Africa is too high, and something needs
to be done about it and by the Africans.
According to Epstein, Africa`s hope is in `a still-distant vaccine` and in `the invisible cure`
(Epstein 2008). The invisible cure is about changing their lifestyle, and this is in ...


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