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In Zambia, a no-nonsense cancer surgeon named Anne Bayley had also seen this new type of KS13 patients in 1983, eight of whom were dead by the end of that year. She was virtually certain it was related to the new disease that was killing American gay men, many of whom had aggressive KS, so she started alerting colleagues. Serwadda, too, had read about the new disease among homosexuals, and he wrote Bayley about the KS patients he was seeing. But Serwadda wasn't convinced they had AIDS: "I was thinking, 'The disease is here already? Even in black heterosexual women?' "
The chance to find out came in 1984, when the antibody test was developed for HIV, then called HTLV-III. For best results, blood samples had to be fresh, so Serwadda got up before dawn, drew blood and biopsies, and sent them off to London with a passenger who took them as carry-on. But because of a postal error, Serwadda wouldn't learn the results for several months.
In the meantime, he was transferred to the medical ward, where he encountered patients wasting away with intractable diarrhea. Many of these patients had a distinctive skin rash or oral thrush, a rare fungal infection that signals immune suppression. "You would ask these patients where they were from," he recalls, "and it was always Rakai, Rakai, Rakai District. That was very strange."
What ultimately distinguished the new cases is that they wouldn't heal. Desperate, the doctors tried treating their patients for TB, or typhoid, or malaria, but patients with Slim would not get better, or would only improve for a short time before succumbing to relentless new infections.
In their letter to Mbeki, Rasnick and Geshekter wrote, "It is nearly impossible to distinguish the common symptoms attributable to HIV disease or AIDS from those of malaria, tuberculosis, or malnutrition." The speck of truth in this statement is that HIV does not itself cause the illnesses that ultimately kill AIDS patients. Instead, HIV slowly destroys the immune system, leaving the patient vulnerable to whatever microbes circulate in the environment. In the early stages of AIDS, when the immune system is only partly weakened, it can be hard to differentiate an ordinary patient from one infected with HIV. The rare diseases, such as aggressive KS, don't usually attack until later in the illness. That's why Roy Mugerwa, who began practicing medicine long before AIDS, never had a eureka moment. Instead, he recalls, "You observed over time patients coming in with symptoms you can't explain. You are stuck, and that strikes you as queer."
TB, for example, is almost always confined to the upper lungs. But in HIV patients, it frequently spreads elsewhere in the body. Who got TB also changed. Mary Mbaziira, a veteran nurse at Masaka Hospital just north of Rakai, remembers that before the advent of AIDS, TB was largely confined to "very poor people or those herding cattle," who contract the germ from raw milk. As AIDS spread, who came down with TB? "People around," she says, gesturing expansively.
Geshekter concedes that there may have been an increase in the illnesses associated with AIDS, but claims that any such rise was caused not by HIV but by the economic damage wreaked on Uganda by the dictatorships of Idi Amin and Milton Obote, the wars for liberation, and the imposition of financial "reform" by Western organizations such as the International Monetary Fund. He points to the work of Cambridge University history professor John Iliffe, who documents how public-health spending in Uganda plummeted during the 1970s and early '80s by as much as 85 percent as per capita GDP shriveled.
Apart from the fact that Iliffe is "appalled" by Geshekter's interpretation of his work, the poverty theory doesn't fit the facts. In interviews with doctors, Slim patients almost never mentioned food shortages, and Rakai, where the disease originated in Uganda, is very fertile. What's more, war refugees suffered symptoms that were markedly different, recalls Nelson Sewankambo, now dean of Uganda's Makerere University Medical School: "I had never seen the constellation of symptoms and signs that we began to see with Slim."
So when Serwadda finally received the test results from those four KS patients, he rushed to show them to Sewankambo. Every one of them had tested positive for HIV. All but one of the control patients with ordinary KS had tested negative. "That's when it dawned on us," says Serwadda. AIDS was in Uganda.
Almost immediately, Serwadda started spending his weekends at the medical library, leafing through case notes made by Sir Albert Cook, a missionary doctor who established Uganda's first hospital more than 100 years ago. Cook's renowned case notes, containing his hand-drawn anatomical sketches, "are very detailed and meticulous," says Serwadda.
As a doctor treating Slim patients, Serwadda knew what he was looking fornot just the words diarrhea or wasting, but clinical descriptions that matched what he was seeing. He kept going back for months, carefully turning the yellowed, brittle pages. But, he says, "I didn't see it."
In the wards, however, he and other doctors were seeing more and more of it. In Zambia, Anne Bayley plotted her aggressive KS cases on a graph and realized that while the total numbers were still small, the increase was exponentialan exploding epidemic. In Uganda, the newspapers started reporting on the strange new Slim epidemic in Rakai, prompting a team from the Ministry of Health to investigate. They didn't test the blood for HIV, but they did allow a brash surgeon named Wilson Carswell to send it, at his own expense, for testing.