Review of The River: A Journey Back to the Source of HIV and Aids by Edward Hooper.
London Review of Books, Vol 22, No 5, 2 March 2000
More than a thousand pages long and the fruit of a decade's work, The River amounts to something more than the attempt to track down the source of Aids. It is, in fact, three books rolled into one. The investigation advertised by the title is, of course, of the highest significance. It was in 1981 that attention was first drawn to the condition, as evidence mounted that gays in New York and California were falling victim to illnesses like pneumocystis carinii pneumonia (PCP) and Kaposi's sarcoma, rarely seen in otherwise healthy young people. A number of theories were proposed as to its origins, some unscientific ('the wrath of God'), and others (homosexuality or Haitians) generally discredited once the human immunodeficiency virus had been isolated.
The race to identify the ultimate source of the condition gradually lost its appeal, for understandable reasons. The historical epidemiology poses daunting difficulties, as do the political ramifications: identifying an origin automatically means pointing an accusing finger, and who would accept being stigmatised as the group or nation which gave Aids to the world? And once it became clear that Africa was the continent not just worst, but first ravaged, the problem became all the more sensitive. In any case, treatment and prevention were the top priorities. The consequence is that, as the American medical historian Allan Brandt wrote a few years ago, 'the biological and geographic origins of the organism remain obscure.'
Some things were agreed, however. It became accepted that HIV is a zoonosis - that is, rather like new-variant CJD, a human disease acquired from animals. The virus had evidently evolved from a simian immunodeficiency virus (SIV): a type of slow virus found naturally in monkeys and apes which, while not harming its hosts, produces diseases in other primates. How the species barrier had been crossed was not established. Amid the usual wild allegations - kinky tribal sexual practices with monkeys (the suggestion of a Cambridge virologist), or some magical practice involving bloodshed - most investigators settled for the 'natural transfer' hypothesis: humans had presumably picked up an SIV through a monkey bite, or in preparing and eating primate food.
How it happened raised the question of when. This is the problem posed by all 'new' diseases: should the first ascertained incidence be taken as truly Case Number Zero, or as merely an artifact of imperfect recording? Was syphilis born in Naples in 1493, or had it simply arrived from some unknown elsewhere, perhaps with Columbus from America? Advocates of the 'natural transfer' hypothesis, including Luc Montagnier and Robert Gallo, credited as the discoverers of HIV, have assumed that Aids was an old disorder which became subject to the medical gaze only when Westerners were affected. And how had that come about? A disease long contained within certain isolated Central African populations had supposedly 'escaped' as a result of the globalising tendencies of modern life: economic development, deforestation, trucking, warfare and its refugees, tourism, prostitution and so forth. Obviously, if Aids were an ancient disease, hopes of tracing its 'source' faded.
Such views have been challenged. It had always been the opinion of some that the amplification (though not the origin) of Aids resulted from slipshod medical practice in the Third World, notably the repeated use of unsterilised needles in the administration of antibiotics or in vaccination (the 1960s and 1970s saw the massive World Health Organisation smallpox eradication campaign). A more dramatic claim was that Aids was a consequence of the use of contaminated supplies of oral polio vaccine (OPV), principally in Central Africa but perhaps also elsewhere.
Oral polio vaccine, though initially thought less safe than Jonas Salk's 'inactivated' vaccine (IPV), had been preferred for Third World use because one dose gave lifetime immunity and it could be administered more simply. In 1992, the American journalist Tom Curtis and other lay writers advanced the OPV/Aids hypothesis: defective polio vaccine, cultured on infected primate tissue, had introduced primate immunodeficiency virus (PIV) into humans, triggering the evolutionary chain reactions that led to HIV. Though supported by a few prominent professional sympathisers, like Sir William Hamilton, advocates of this theory have experienced great difficulty in getting their work published in respectable medical and scientific journals (Curtis's piece finally appeared in Rolling Stone).
This is the theory Hooper takes up and elaborates in minute detail in The River. He begins with the accidents attending the early introduction of polio vaccine in the US in 1955 (when defective batches, manufactured using monkey tissue, caused polio outbreaks) before moving onto Aids, via a thorough trawl of the published medical literature and, above all, on the basis of many years of interviews with those active in research since the 1950s.
His story centres on the setting-up and operation of animal laboratories in tropical Africa, notably at Lindi, near Stanleyville, in what was then the Belgian Congo. From 1957, three years before independence, thousands of chimpanzees and monkeys were captured and caged there, to be used in a variety of scientific investigations, before in some cases being flown on to the US. At the same time, Hooper documents mass polio vaccination trials in Central Africa in 1957 and 1958 using the so-called CHAT live attenuated vaccine, developed by the Polish-born American virologist Hilary Koprowski, who in 1950 had been the first person to feed oral polio vaccine to humans. Thanks to meticulous tracking, Hooper establishes impressively precise correlations between the geography of the CHAT trials - almost a million vaccinees in the Congo, Rwanda and Burundi alone - and those areas in which Aids first became epidemic. These, he maintains, provide strong circumstantial support for the OPV/Aids hypothesis.
For the 'contaminated vaccine' inference to hold water a further point must be established. The zoonotic jump from SIV to HIV is feasible only in respect of transmission from chimpanzees, not monkeys. According to the official line, which is staunchly upheld by Koprowski, successively a researcher at Lederle Laboratories and the Wistar Institute of Philadelphia, only safe monkey tissue (usually minced kidney) had been used to culture the polio vaccine, never risky chimpanzee tissue. Hooper's investigations point, however, to the strong likelihood that chimpanzee tissues were used: some of his interviewees were prepared to admit as much, though conclusive documentation is lacking. He and others surmise that CHAT was an acronym for 'chimpanzee attenuated'.
Much of The River is devoted to reconstructing a grim roll of Aids fatalities from the mid-to-late 1960s - before, that is, the syndrome was identified and named. It is crucial to the OPV/Aids hypothesis that there should have been no cases before that time. Hooper lavishes attention on a handful of instances, highlighted in recent years, of people (mainly Westerners) alleged to have died of Aids-like conditions before then: one in Montreal in 1945, one in Toronto in 1958 etc. In particular, he tells the story of David Carr, a Manchester sailor who died in 1959, and was widely reported some years ago as having been the 'first' Aids victim. Over the course of some fifty pages, threaded in and out of the book, Hooper elucidates Carr's tours of duty with the Navy, speculates on how, why and where he might have been stricken (was his ship involved in nuclear testing in the Pacific? did he frequent African brothels?) and finally establishes, on the basis of clinical evidence, that whatever he died of, it wasn't Aids. Some otherwise oddly early German cases might, he suggests, have been the result of transmission from Congolese football supporters who travelled to Germany in 1974, when Zaire got to the final stages of the World Cup. On the whole, he is persuasive in his claims that the outcropping of Aids in the 1970s is best seen not as a data artefact but as a genuinely new disease.
Since The River was published, scientists at the Los Alamos National Laboratory in San Francisco have statistically traced the probable origin of HIV-1 to 1930, using calculations based on the family tree of the virus and the rate at which it mutates. Bette Korber, the head of the research team, said she thought Hooper's thesis was unlikely, but would not rule it out. Hooper does not pretend the OPV/Aids hypothesis is watertight; it is offered soberly, if insistently, as the theory which best fits the salient epidemiological facts: above all, the geo-chronology of the African epidemic - why so recent, and why there? Further investigation is required, but while there is no clincher - no smoking gun - OPV/Aids has all the requisites of a legitimate hypothesis. It even appears falsifiable by Popperian standards - for example, were it conclusively proved that people were dying of Aids before the CHAT vaccine.
In fact, it seems that key evidence is to be had: samples of the relevant polio vaccines survive in commercial and government laboratories - in the Wistar Institute, the Swedish Institute for Disease Control in Stockholm, and perhaps elsewhere. Till now those institutions have refused to allow the vaccines to be independently tested for the presence of HIV-1 precursor viruses, demonstrating at the very least the tendency among scientists to close ranks against outsiders. Hooper makes much of what he regards as tell-tale memory lapses and self-contradiction among those he interviewed, and of the mysterious disappearance of vital documents: most of Koprowski's papers from this time had been 'lost in a move'. He describes how he and fellow whistle-blowers were threatened with defamation writs by Koprowski and others, and how interviewees who had initially been forthcoming later clammed up, sometimes after phone calls from Koprowski or his attorney. A cover-up is not implausible. After all, the consequences - legal, political and financial - for individuals, governments, pharmaceutical companies and international agencies like the WHO if the OPV/Aids hypothesis were to be substantiated would be unimaginable.
Considerations like this are central to Hooper's second book-within-the-book. Whether or not he has nailed the source of Aids, his investigations give a remarkably clear picture of the way science and medicine were conducted a generation ago, of the protagonists' subsequent rationalisations of their conduct, and of the politics of science today.
Mid-20th-century science, as recalled by Hooper's interviewees, was a world of swashbuckling optimism: antibiotics were conquering infectious diseases, DDT was promising to eradicate malaria, the WHO and other agencies were waging war against tropical disease. Everything was up for grabs; science and medicine were patently 'good things', and it seemed that there was no limit to what could be done in the name of progress and the relief of suffering humanity (even if it might involve some pretty dodgy contracts with the military). British and Belgian, American and African scientists reminisce about the time when a young researcher could anticipate being saluted as the conqueror of this or that lethal disease and becoming a Nobel laureate. Funding and experimental animals were readily available; and, as the interviewees candidly admit, few obstacles were put in the way of those who wanted to do trials on such 'volunteer' populations as prisoners, children in orphanages, the mentally handicapped - and black Africans. 'Those were . . . the good old days,' Stanley Plotkin, Koprowski's former colleague confided, 'when people were deciding themselves what was ethical . . . rather than referring it to a committee.'
Hooper's interviewees proudly fished out their trophies and photograph albums and told of practices which would leave their successors envious - or squirming embarrassedly in their seats. Hooper generally avoids being too judgmental, recognising that it would be unfair to apply to an earlier generation our present more rigorous standards regarding clinical trials or informed consent. He equally avoids being grossly wise after the event with regard to the risks of cross-species viral transmission: these were not self-evident back in the 1950s. His interviews show how scientific standards have changed - and how in the process science has created smokescreens around its past ('it's all just history,' one ageing researcher told him by way of self-exoneration). But has so much changed? Will son-of-Hooper look back at our valve implants from pigs and baboon liver transplants and ask whether science will ever learn?
Which brings us to the third and final 'book': the book of Hooper himself. It would be mean not to admire the man. An indefatigable investigator, he flies to Africa to check a fact, he gives up his job as a teacher to devote himself full-time to his quest, and at one point has to beg a loan from a sympathetic scientist so that he can continue. He is well boned-up: an interviewee has only to equivocate or suffer a tiny memory lapse, and out of Hooper's bag comes the relevant dog-eared offprint, to set the record straight. Finally, despite its immense size and the inevitable longueurs ('down on the lakeshore, the water fell in tiny waves on the beach'), The River makes compelling reading: there is something awesome about Hooper's unswerving devotion to the pursuit.
Yet there is more to his self-presentation than meets the eye. He complains about the difficulties of piecing together protagonists' lives and motives, but, despite the omnipresent first person, himself remains a shadowy figure - the jacket blurb is less than informative. He relates the weird epistolary encounters he had with his US counterpart, Louis Pascal, a reclusive New York OPV/Aids hypothesis champion. Initially affable, Pascal turned sour, withheld information, started manipulating Hooper, and relations ceased with Hooper calling him 'paranoid'. Might the boot be on the other foot? After all, Hooper confesses to long delays in supplying information promised to others, not least tapes of their interviews, and he happily prints material obtained 'off the record'. He sees many of his scientists as insanely driven, involved in an ugly race to solve the mystery: a description which sometimes seems to fit him, too. At one point the rector of a Swedish institute accuses him of blackmail.
All this comes out most clearly in Hooper's pursuit of Koprowski. All good Aids stories have a villain: sometimes it's homosexuals, sometimes homophobes, often it has been Robert Gallo, who carried out shoddy work on the virus and then claimed all the credit for identifying it. This time it's Gallo's old chum, Koprowski, to whom all trails inevitably lead. Variously described by Hooper's informants as a Renaissance genius, or 'a man of extreme ambition' and 'very limited conscience', Koprowski is evidently blessed with bluster, charm and an overweening ego, a man who would cut corners and stop at nothing to realise his scientific dreams.
As the plot thickens, Hooper eventually manages to get to interview Koprowski (the stage-managed scene is amusingly written up). Cut and thrust follows, threats of writs fly, and Hooper ends up concluding that honours were even. At one point Koprowski alludes to the deadly encounter between Holmes and Moriarty, casting himself as Holmes. One can easily imagine Hooper reversing the roles, and much of the book's fascination lies in his love/hate relation with his adversary. Koprowski sought glory, by eradicating polio: like him, Hooper seems to have sought to crack the biggest problem he could find - and in a blockbusting book. The River might equally well have been called The Obsession. Something drove the virus-hunters to their triumphs and the ghastly nemesis. Was it the same demon that drove Hooper on his quest for the source of Aids, that modern caput Nili. He may, or may not, have found that source; he has certainly written a gripping mystery story.
Roy Porter teaches at the Wellcome Institute for the History of Medicine. His many books include The Greatest Benefit to Mankind: A Medical History of Humanity (1997). He is working on a general history of the Enlightenment.