diarrhoea that became the most common symptoms of Aids in African patients.4 In the late 1970s doctors across the river in Brazzaville observed similar cases. Physicians in Kinshasa initially attributed these symptoms to tuberculosis, which spread epidemically in the region during the 1970s and 1980s, perhaps in synergy with HIV. By 1985, one-third of tuberculosis patients in Kinshasa’s hospitals also had HIV.5 A more distinctive indicator of Kinshasa’s emerging HIV epidemic was cryptococcal meningitis, an agonising and commonly fatal infection of the brain. Hitherto generally confined to children, it spread in a distinctively urban form to adults with damaged immune systems and became increasingly common at Mama Yemo from the late 1970s.6
When blood taken in 1980–1 from antenatal clinic attenders in Kinshasa was later tested, it showed that HIV prevalence among them had grown during the 1970s from 0.2 per cent to 3 per cent.7 The world’s first HIV epidemic among a heterosexual population had begun before the existence of the virus was even suspected. That, more than anything else, was why Africa was to suffer so terribly during the following decades. Yet enlightenment now came quickly. In June 1981 American doctors published the first account of an epidemic of pneumocystis carinii pneumonia among American homosexuals. On reading it, physicians in Brussels and Paris realised that they had treated similar conditions since the mid 1970s, chiefly in Africans from the equatorial region or Europeans who had visited it. Of the first 96 recorded Aids patients seen in Europe, 54 were Africans, 40 of them from the DR Congo.8 In contrast to infected Americans, however, they were heterosexuals in roughly equal numbers of men and women, they did not take drugs, and they had no obvious risk factor in common except their geographical origin. In October 1983 joint American and Belgian teams left for Kinshasa and Kigali.
At Mama Yemo, Kapita Bila showed the visitors the patients he suspected to be suffering from Aids. ‘The moment I walked into the hospital in Kinshasa I realised something terrible was happening,’ recalled Peter Piot, later the first head of UNAIDS.9 ‘Meningitis was only one manifestation of the disease,’ wrote his colleague Joseph McCormick:
Some developed such exquisitely sore mouths and tongues that they were unable to eat. Those who could manage a few bites of food were suddenly stricken by cramps and disgorged a copious amount of diarrhea. Their skin would break out in massive, generalised eruptions. Infected fungating masses would appear inside and outside their bodies. When the infection didn’t consist of voracious yeast cells [as in cryptococcal meningitis], there were many other parasites ready to eat the brain alive. None of the victims could comprehend in any way what was happening to them or why. And we? All we could do was watch in horror, our roles as physicians reduced to scrupulous observers and accurate recorders of documentation. Our one hope was that if we could understand the processes we were observing, someone, somewhere, might find some solution.10
Diagnosing by symptoms, the team identified 38 Aids cases in Kinshasa’s hospitals, 20 men and 18 women. Of these, 29 were from Kinshasa itself, but others came from all parts of the country, indicating how far the virus had spread. On 3 November the team presented its findings at a medical meeting at Mama Yemo, warning that the disease appeared to be sexually transmitted, incurable, and fatal. ‘If there is a misfortune spreading terror in Kinshasa in the last few days, it is assuredly AIDS,’ a local editor wrote five days later. ‘It is spoken of in the most varied ways . . . at the office, at the market, in bars, in families . . . Never in my memory as a journalist have I seen such concentration on a subject as disagreeable as strongly feared.’11 It was his last such comment, for President Mobutu’s increasingly unpopular and insecure government banned the subject for the next four years. ‘For the four million Kinois,’ a foreign journalist wrote in 1986, ‘the disease, for lack of any official information, still has no name. Signs, therefore, suspicions, often infantile beliefs. Aids all the same.’12
Reactions abroad to evidence that the disease was widespread in a heterosexual population were equally hostile. American medical journals rejected Piot’s report and it took over a year to convince the American government. In the meantime the World Health Organisation cautiously endorsed the discovery by French scientists that Aids was caused by a retrovirus. McCormick persuaded the Centers for Disease Control in Atlanta to fund a research project in Kinshasa.13
Projet Sida, as it became known, began work in June 1984 and defined the epidemiology of the urban disease in a form that still dominated medical thought two decades later. A collaboration between American, Congolese, and Belgian specialists, initially led by an idealistic public health expert named Jonathan Mann, the Project had nearly 300 staff at its peak and the advantage of newly devised equipment to test blood for HIV. Its most important finding was that between 6 and 7 per cent of pregnant women at Kinshasa’s antenatal clinics were already infected with HIV, whereas earlier estimates of the epidemic had observed only the much smaller numbers with advanced Aids. Mann warned in 1986 that ‘one to several million Africans may already be infected’. He reckoned the annual incidence of new infections at between 0.5 and 1.5 per cent of hitherto uninfected people.14 The Project also identified the means of transmission as sexual intercourse, exchange of blood by injection or transfusion, and infection from mother to child, excluding aerial transmission, insect vectors, and casual contact.15 Sexual transmission was bidirectional, whereas the possibility of women infecting men had hitherto been uncertain. Among new infections, eleven were women to every ten men, although women in their twenties outnumbered men by three to one.16 In other respects those infected did not have a strong social profile. The earliest observed cases had often been prosperous people who could afford multiple partners and medical treatment, but antenatal prevalence at Mama Yemo was somewhat higher than at a fee-paying hospital. The age profile, however, was distinctively bimodal, peaking in infants and young adults.17 Perinatal transmission and pediatric Aids were among the Project’s most novel findings. Mothers with HIV lost 24 per cent more of their babies in the first year of life than did those without it, the risk varying with the stage of the mother’s disease.18 Adult HIV was associated with tuberculosis and sexually transmitted diseases, the latter being one of several indications linking HIV to risky sexual behaviour. Some 27 per cent of Kinshasa’s commercial sex workers had HIV.19
The Project also revealed an alarming connection between HIV transmission and blood transfusion, which had become common in large African hospitals since the Second World War. Mama Yemo gave about 80 transfusions a day, chiefly in childbirth or to severely anaemic children. The blood came from relatives or was bought from unemployed people recruited at the hospital gates. At least 5 per cent was infected with HIV. Since transfusion almost invariably transmitted the virus, the hospital was creating four new HIV cases each day. Of its patients aged 2–14 and too old to have been clearly infected perinatally, 11 per cent were HIV-positive and 60 per cent of these had received transfusions.20 Injections with re-used and unhygienic needles were another alarming danger, for injections had been immensely popular among African patients since the 1920s. The Project found that one group of HIV-infected children under 24 months old with HIV-negative mothers had received an average of 44 injections (excluding vaccinations) during their lives. Among adults, HIV prevalence increased with the number of injections received. It was impossible to demonstrate causation, for patients may have needed injections because they were already ill, but Mann concluded that infected blood was a significant factor in HIV transmission, although, as the age profile suggested, sexual intercourse was more important.21
Projet Sida effectively ended in 1991 when rioting soldiers looted its premises and the expatriate staff withdrew, although Congolese doctors tried to continue the work. Meanwhile research had also revealed the extent of HIV elsewhere in the western equatorial region. Kinshasa’s epidemic had spread up the river and into the neighbouring Lower Congo area, where estimated adult prevalence reached 4 per cent in semi-urban and 2.8 per cent in rural areas in 1989–90.22 The distant mining towns of Katanga and their surrounding rural areas had similar prevalences at that time,23 but little was known about the countryside outside the Lower Congo. Kinshasa’s epidemic seems to have made only a limited impact on the immensity of the country at this period. Brazzaville, across the river, appears to have shared Kinshasa’s epidemic pattern at a slower tempo. In the late 1970s it saw symptoms later characteristic of Aids and in 1983 it sent patients to France