POSTING 49: BATTLE-SCARRED VETERAN 


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Frerichs, R.R. Battle-Scarred Veteran is General in Global War on AIDS.

SEA-AIDS Network, August 5, 1998.

Posted in response to:

New York Times, July 21, 1998

"Battle-Scarred Veteran is General in Global War on AIDS"

By LAWRENCE K. ALTMAN, M.D.

GENEVA -- It was November 1983, and Dr. Peter Piot, who had done pioneering work on the Ebola virus in Africa the previous decade, was returning to Zaire to get his first look at an emerging disease, AIDS. The scene of his return to Mama Yemo Hospital in Kinshasa "is branded in my brain," Dr. Piot recalled last week. "I walked into the hospital and saw all these emaciated men and women."

Dr. Piot's team quickly showed that the Zairian patients had developed AIDS through heterosexual sex -- a finding that was initially met with disbelief by medical experts. But Dr. Piot (pronouced PEA-ott) knew his work was important. "I realized AIDS would take on immense dimensions in Africa and would change my life because here was something so complex -- sex, Africa and the politics of AIDS," he said. "But I did not realize in what sense it would change it."

Today, Dr. Piot, a 49-year-old Belgian, is executive director of the United Nations AIDS Program, the chief coordinator of the global war on AIDS. It is a position to which he brings scientific expertise, an avid interest in history and a political will that once led him to march against NATO headquarters to protest Belgium's possible entry into the Vietnam War.

In his frequent meetings with heads of state, the bearded, Flemish doctor tackles diplomacy with the directness of a scientist, particularly when leaders scoff at the monstrous public health threat they face in H.I.V., the virus that causes AIDS.

An African leader, for example, asserted that his country was well prepared to handle AIDS and took pride in reporting recent tests showing he was not H.I.V. infected. Dr. Piot then asked what the leader would do if, injured in an accident, he needed a blood transfusion. The leader, whom Dr. Piot declined to name, contended that his country's blood supply was safe. But Dr. Piot, fresh from a visit to a blood bank, knew better because the bank had no laboratory kits to screen blood before transfusions.

The skeptical leader called the blood bank and learned that the blood was in fact dangerous. The leader then summoned his health minister and ordered him to adopt the United Nations AIDS Program's recommendations. That country's program now works well, Dr. Piot said.

The doctor who can sway a head of state's views about AIDS was a member of an unusually diverse class at the University of Ghent Medical School in Belgium. More than a dozen of his classmates are now diplomats, government officials and drug company executives. As for Dr. Piot, he nearly dropped out of medical school because, he said, he was so appalled by the curriculum's disregard for public health. He stayed principally because of the fun he derived from lampooning the faculty in a newsletter.

In 1976, when he had been out of medical school two years and was researching tropical diseases in Antwerp, Belgium, Dr. Piot and his colleagues discovered a mysterious virus that was causing a deadly epidemic of hemorrhagic fever in Zaire. It was later named Ebola, the horrifyingly quick virus that in 1995 caused a widely publicized outbreak in Kikwit, Zaire.

Last week, this reporter shared a Flemish dish, "water zooi," that Dr. Piot's wife, Greta, a psychologist, made from chicken and vegetables that Dr. Piot grew in the garden of their French countryside home near Geneva. The Piots recalled how their lives unexpectedly changed directions when, at a scientific meeting in Paris in 1976, a notice was flashed on a screen asking Dr. Piot to make an emergency call to Belgian officials.

"Go to Zaire tonight," Dr. Piot was told. Earlier, the same Belgian officials had opposed sending a team to investigate the epidemic in Yambuku, Zaire, from which Dr. Piot's team in Antwerp had isolated the new virus. Suddenly, Dr. Piot's presence in Zaire was needed because American, French and South African scientists were there and the Belgians did not want to be embarrassed by not being represented. Dr. Piot's wife was two months pregnant, and the trip was supposed to last no longer than 10 days. So Dr. Piot asked "Tomorrow?" The Belgian officials agreed.

Rushing to Antwerp, Dr. Piot found that his passport had expired and his picture was missing because he had used it for an application.

Even so, Dr. Piot, wearing his wedding suit (his only one), boarded the flight. A cooperative Belgian diplomat told Dr. Piot to cling to his coattails when they arrived in Kinshasa, and Dr. Piot entered Zaire through a V.I.P. lounge.

The rest of the trip had little diplomatic glamour. Dr. Piot proceeded to a missionary hospital in Yambuku, a village in a jungle where the Ebola virus was killing more than 300 people.

Although Dr. Piot's team escaped Ebola infection, one member became so seriously ill that he had to be taken to South Africa. His illness could not be diagnosed.

At one point, Dr. Piot was ordered to fly to a meeting to report on the investigation. A helicopter landed in Yambuku to whisk him away. In chatting with the pilots, he found their breath reeked of alcohol, and Dr. Piot refused to board. An hour or so later, the helicopter crashed, killing the two pilots and a passenger who had taken Dr. Piot's place.

A few days later, Zairian officials ordered Dr. Piot to retrieve the rotting bodies from the jungle, saying it was his moral duty to do so because by refusing to board the helicopter he indicated he "knew" it would crash.

By the time Dr. Piot returned to Belgium, his wife was six months pregnant, and he had a new professional focus. Excited by the field epidemiology he had just completed, he went to the Centers for Disease Control and Prevention in Atlanta, which had a maximum security laboratory that was better equipped for work on the Ebola virus than the Institute of Tropical Medicine in Antwerp.

But Dr. Piot found that he was not cut out for the discipline required in a high security laboratory. He forgot things, and had to undress and shower before leaving the lab to retrieve them. Then he had to go through the time consuming ritual needed to reenter. In addition, the man who relished the freedom of working in the African jungle was extremely uncomfortable in the confining environment of the C.D.C.'s headquarters.

After two months, Dr. Piot and his family left for the University of Washington in Seattle, where he specialized in sexually transmitted diseases. In Zaire, Dr. Piot had been struck by the large number of women who had suffered pain and had become infertile because of pelvic inflammatory disease, a condition resulting from infections transmitted in sexual intercourse.

In one of life's strange twists, a fellowship from NATO, the very organization that Dr. Piot had protested, paid for his stay in Seattle, where he worked with Dr. King Holmes, widely considered the leading expert in sexually transmitted diseases, and Dr. Stanley Falkow, an internationally recognized expert in microbiology, who now works at Stanford University. Of his decision to pursue a fellowship from an organization he once marched against, he said "I loved the irony of it, and I highly appreciated it. That's democracy."

Dr. Piot was astonished at differences between the European and American educational systems. In Belgium, he said, students were taught to regurgitate what the faculty members said without challenging their views. In the United States, faculty members asked students their opinions and expected answers. When so challenged, "my first reaction was they must have mistaken me for someone else," Dr. Piot recalled after sipping wine from a bottle provided by his brother-in-law, Yves Catulle, a sommelier and wine merchant in Brussels. "If I had not trained in the United States, I probably would have left medicine,"

Dr. Piot said. He returned to Belgium and earned a doctorate in microbiology at the University of Antwerp in 1981. On learning about AIDS later that year, Dr. Piot recalled the case of a Greek fisherman who lived in Zaire and who died in 1978 of what Dr. Piot realized in hindsight was AIDS.

Itching to return to Africa to study the new disease, Dr. Piot gained support from the National Institutes of Health in Bethesda, Md., and went in November 1983. After research at the Kinshasha hospital, Dr. Piot's team submitted a paper on the transmission of AIDS through heterosexual sex to the editors of The New England Journal of Medicine. The editors rejected the paper, citing one expert who said "it is a well known fact that AIDS cannot be transmitted from women to men." In 1984, The Lancet published the paper.

Now, just weeks after speaking at the 12th International AIDS conference in Geneva, Dr. Piot said he never dreamed that AIDS would become "the runaway epidemic" that it is today in much of the world. Overshadowing the conference were new statistics showing that one of every four adults in two African countries, Zimbabwe and Botswana, were infected with HIV.

"I am angry that the international community and all countries have not done their jobs," he said. "I am angry that we heavily underestimated what was possible and how the epidemic would evolve."

Until 1996, the World Health Organization ran the global AIDS program. But then Dr. Hiroshi Nakajima, WHO's director-general, was harshly criticized as being ineffective. (Dr. Nakajima left WHO on Monday after 10 years in the position.) In 1996, the United Nations created its AIDS Program, a coordinated effort among five United Nations agencies and the World Bank.

Dr. Piot, who is also assistant secretary-general of the United Nations, was chosen because "he and his group have contributed as much or more than any to a rigorous scientific base for sound

AIDS prevention and care policy in developing countries, always linked to humanitarian concerns for affected populations," Dr. Holmes, the Seattle expert, said. "His political abilities are bonuses."

A budget of $60 million a year and a staff of 150 limit the options of the United Nations for defeating a virus that has infected 34 million people. Dr. Piot's main weapons are influence, moral suasion and the leverage of expertise. He has negotiated with industry to develop vaginal microbicides as new preventions and helped arrange a $300 million World Bank loan to India to combat AIDS.

Dr. Piot said he left the AIDS meeting in Vancouver two years ago determined to find ways to get the new, expensive combination drug therapies to underdeveloped nations. Staff members thought of something the United Nations had never done -- negotiating with industry to lower the price of certain drugs in those areas. Dr. Piot said he was skeptical but let them proceed. Now some AIDS drugs are available in some countries at one-half to one-third of their cost in the United States.

Dr. Piot also has urged government, industry, researchers and developing countries to expedite testing of experimental H.I.V. vaccines, particularly in areas where they are needed most.

In 1995, Dr. Piot was made a baron, one of Belgium's highest honors, and had to create a coat of arms. It centers on the disease that has become his life's work. Birds, representing freedom, surround hands clasped for solidarity and the red ribbon that is the symbol for the fight against AIDS.

R.R. Frerichs Posting

The need in South and Southeast Asia for open discussion, fresh ideas and active leadership in the struggle against HIV/AIDS is clearly evident, as the epidemic continues to grow in many of the region's countries. 

Enclosed (sent to SEA-AIDS by RRF) is an interesting profile of leadership, describing the often dissenting path Dr. Peter Piot took before heading UNAIDS. While much has been learned in Dr. Piot's professional lifetime about how to slow down the epidemic, much still remains to be done, including developing more effective ways of detecting persons infected with HIV and using this knowledge to prevent further transmission of the virus.

Perhaps with the dissenting spirit of their leader, UNAIDS will question the dogma that surrounds HIV testing and look for other paths to promote widespread detection. While premarital and antenatal testing offer hope to many, fear of testing and disclosure are major hurdles that need to be overcome, The NY Times article suggests that UNAIDS can transcend multiple barriers when the organization is willing.

Showing such strength or will would be very helpful in encouraging the development of innovative HIV testing strategies, complementing the many prevention and intervention efforts that already exist.

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