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Transcript - The Global History of HIV

memorial ceremony for those lost to HIV and AIDS


On World AIDS Day 2020, in the midst of another pandemic, Ohio State University History Professor Thomas McDow presented a close look at the historical factors that shaped the global spread of HIV, from equatorial Africa to the world.

Thomas F. McDow is a specialist in African History at Ohio State University. He co-teaches a course with a microbiologist on the global history and science of HIV and is writing a history of HIV in Tanzania.

[Listen to the podcast here.]

Transcription Begins Here:

Dr. Nicholas Breyfogle 
Welcome, everyone, to "The Global History of HIV," brought to you by the history department, the Clio Society and the College of Arts and Sciences at The Ohio State University, as well as by the Bexley Public Library. My name is Nick Breyfogle and I'm an associate professor of history. And I'll be your host and moderator today. Thank you so very much for joining us. Today is, as the screen behind me says World AIDS Day, December 1st. And on this day, and in the midst of another pandemic, we welcome Professor Thomas McDow, who will look closely at the historical factors that shaped the global spread of HIV, from equatorial Africa to the world.

Dr. Nicholas Breyfogle 
Let's get to know our speaker. Professor Thomas McDow is an associate professor of history at Ohio State University, who specializes in the history of Africa and the Indian Ocean. He's the author of "Buying Time: Debt and Mobility in the Western Indian Ocean," and he earned his Ph.D. at Yale University. Professor McDow's current research is on the history of HIV/AIDS in Tanzania, with a focus on African scientists and society. This new project and his lecture today both grew out of his innovative teaching. In cooperation with Jesse Kwiek, a virologist, Professor McDow developed and teaches two popular courses on HIV that are cross-listed between the history and microbiology departments. The first is a large lecture course entitled, "HIV, from Microbiology to Macro History," offered each spring. The second is a month-long study abroad course in East Africa called "HIV in Context, Tanzania."

Dr. Nicholas Breyfogle 
With that introduction, let me mention the plan today. Professor McDow will offer a short overview of the long history of HIV. And then he'll take your questions, and we'll open up things for discussion. If you're interested in asking a question, please write it in the Q&A or the question-and-answer function at the bottom of your screen on Zoom. And we'll do our best to get through all the questions that come our way. Now, without further ado, let me pass you over to Professor Thomas McDow, who will take us on an exploration of "The Global History of HIV." Professor McDow.

Dr. Thomas McDow   
Thank you so much, Nick, for hosting. Thank you to ASC and Clio Society and the Bexley Library for making this event possible. I'm delighted to be here today. And to help us think about what we celebrate and remember on World AIDS Day. So we were together today in the Zoom space, in part because we're living in the midst of a pandemic of COVID-19. Which puts us in mind to think about the AIDS pandemic and the way that has affected the world. So I just, for comparative purposes, I have some things for us to think about. And part and one of them is that we are in celebrating and acknowledging World AIDS Day we are thinking about and recalling the 38, the 32 point 7 million people who have died from HIV and its related illnesses in the near, the last 40 years. This is a huge number. And even last year, in, we live in a world where AIDS, there are medicines which make it possible to treat HIV, but not cure it. But still there are 690,000 people who died of HIV last year. Thinking about COVID and its impact we see a, we see also a devastating, a devastating disease. And there are I'm sure in the Q&A, we can talk about some of the comparisons or lessons learned or those kinds of things. Today I want to focus more narrowly on the history of HIV and help us think about it in a global context. And the level of PSA as a professor who gets to speak in front of people. I want to make sure we all know what we're talking about, that HIV is the Human Immunodeficiency Virus and it causes in the Acquired Immunodeficiency Syndrome or known as, known as AIDS. To be clear about the way that it's spread, and that also a point that was controversial at some time that HIV, the virus, causes AIDS. And the effect of the disease is to take over your immune system and dismantle it turning your immune system into a system that creates, replicates the virus, and decimates your ability to fight off diseases.

Dr. Thomas McDow   
A key aspect of HIV is that it takes five to 10 years after infection for it to begin to affect a person. And that but then once that begins without treatment, people will die of the, of opportunistic infections that your immune system would otherwise fight off. And as I mentioned, there are drugs available today. And we've made incredible progress both in developing these drugs and giving them out broadly. But as I noted before, there's still hundreds of thousands of people die every year from AIDS-related illnesses. I said there's no cure. If you read the newspapers closely or follow the scientific literature, you'll know that there have been two people who have been cured of AIDS. But that has been through a very unusual process of bone marrow replacement and a genetic set of presuppositions which may make it extremely expensive, highly dangerous, and thus not able to be rolled out widely, so an area still of development.

Dr. Thomas McDow   
But so, what my questions today are, what can we learn from thinking about the history of AIDS and HIV? And many of the audience maybe already has some idea about this. You might have some associations, especially from the 1980s, about Freddie Mercury or Magic Johnson, acknowledging they've had AIDS, or of Ryan White, the Indiana teenager who captured the world's attention, or Rock Hudson, but also of protest and of anger at the government, at the slow-footed government response to this. And you know, from this history of HIV, when we think about that, in the United States, there are things that we can take from that and that we can understand, certainly the stigmatization of the groups that were most affected and the people who, the groups that had the highest levels of AIDS when it, in the early 1980s. But that also led to greater visibility for these groups, both for good and for ill. The number of people who suffered the discrimination that came up around this, these are part of the American story. Also, this you know, Ronald Reagan didn't mention AIDS in public until 1987. And Bush also and even Clinton's records are uneven on this. So you know, and how this echoed into the culture wars of the time. We saw a slide of protests and the way that protests drove drug discovery, put pressure on scientists and funding agencies to make changes, which did you know, with happening, at the same time, a number of amazing scientific breakthroughs and discoveries, both of understanding the virus and its replication process. But also to develop drugs, develop new drugs, and to adapt old drugs to make it possible to treat HIV and development to the point of developing a multi-drug cocktail, which could efficiently suppress the viral load, the virus that people carried in them, and make that both undetectable and untransmissible. And also the process of memorialization. Many of you may know about the AIDS quilt, that people made squares to commemorate and remember loved ones who had died from AIDS, and also this day like today when we have a chance to think about AIDS in the world, and what has happened from that. So but my question is from an American point of view, but what do we get when we step back and look, take a global view. And so I'm a historian of Africa. And so I'm going to take us to think about African history and HIV, and also the surprising factors that led to its global spread, where we'll have to dive into the cold war and its politics, and will even get Nelson Mandela out of prison.

Dr. Thomas McDow   
In 2017, in Africa, and especially equatorial, eastern and southern Africa, the burden of disease and the prevalence of HIV is much, much higher than other places in the world. So it's important to keep in mind this uneven burden of the disease, and also its spread into all countries of the world and the way that they're, that every place has been to touched by HIV, but that Africa has had the most suffering and the greatest burden of the disease. So in 2018 67.8% of all people who were HIV positive lived in Africa. And the epidemic there. If there is, if we could say a single epidemic or different epidemics, overlapping epidemics of HIV, look quite different than you might then think. The way you might imagine HIV from the US perspective. First of all, more women than men are infected, and that the primary mode of transmission is heterosexual contact. But although there are epidemic or they are spread by injection, injection drug use, mother to child transmission and also by men having sex with men.

Dr. Thomas McDow   
And so if we want to understand this question of why has HIV disproportionately affected Africans, the most important one, again, we're thinking historically, is time. And that the disease first crossed over into humans in Africa. And it turns out, that was a long time ago. And so there's a greater degree of exposure. And so and a longer time that for it to move around before we had a sense of what it was, but then also the structural pieces of the global economy. And that made it difficult or that some parties were unwilling to get ARVs, antiretroviral drugs, to Sub Saharan Africa until quite late, almost 10 years after they were available in other parts of the world. So that's, that's the bigger picture. But I want to, I want to zoom in and think a little bit about when and where the virus emerged in humans, and how we might understand that, and then think about how HIV became a global disease.

Dr. Thomas McDow   
So that's our focus today, is to understand where HIV came from, and how it became a global disease. And it turns out, you know, we're good. I'm a historian, and I tell my students, if you're ever trapped in an elevator with a historian, just ask them, what are their sources, right? What is your archive that you use? And they'll get so excited, and they'll be able to keep talking. And you can, you know, mind your own business at that point. But so when we think about how would we, how do we reconstruct and understand the history of HIV, certainly know that the emergence of the disease, the first cases were recorded in 1981, or noticed in 1981.

Dr. Thomas McDow   
But it turns out, there's a deeper prehistory of the virus that we can think about, and that the way of understanding that comes from the virus itself. We can look at viral replication cycles, and genetic variation and mutation within the virus to put things together. And it turns out that two samples that were taken, one in 1959, and one in 1960, which were called ZR59, and DRC60, those samples that were taken and put in and stored in a lab, for someone with other conditions, scientists were able to go back and recreate the viral RNA in those samples and understand them, and then compare them to each other and put them in a family tree to trace back the most common recent ancestor. And so in doing that, it turns out that HIV is much older than it was initially believed. You know, I've, you know, many, I don't know what your own ideas of when HIV emerged, when it was first humans contracted HIV. But that when we go back and use the set of very complicated equations and work by Michael Worobey, who's at the University of Arizona.

Dr. Thomas McDow   
We see that the dates are, you know, between in the first decade of the 20th century, or this or the early 1920s, that the moment when HIV emerged in humans. And again, this is a phylogenetic analysis that just moves backwards from the genetic similarities to figure out what was the most common recent ancestor of these two samples. So those samples from 1959 and 1960, taken in Leopoldville or then Kinshasa in the, what's now the Democratic Republic of Congo, have helped us unlock this history. So now we knew when it happened, but how do we know where and how that transfer occurred. And essentially, that chimpanzees, the chimpanzees who live in the region of the Sangha River, carry a Simian Immunodeficiency Virus, which is closely, is the closest relative we could find to the Human Immunodeficiency Virus. And chimpanzees, it turns out, don't cross rivers and so actually, Beatrice Hahn and her graduate students collected over, across Equatorial Africa, collected monkey scat and used that to recreate the virus, the Simian Immunodeficiency Virus, and then determine where the most likely place that happens. So this is in the southeast corner of Cameroon along the Sangha River, and the hypothesis is that blood to blood contact between a hunter who was hunting chimpanzees then cut him or herself and then that their bloods mixed and in the human blood, the Simian Immunodeficiency Virus or SIV, transformed into HIV. But one incident and there are other forms of HIV that are out there other that come from other primates that we've, that we can track. And they've been named, but from one instance of Zoonotic transfer, how then can we get the global pandemic? How can we have a disease that would reach out across the globe and kill more than 32 million people and have 38 million people living with the disease today? So that's part of what I want to talk about. Because this happened. If we look at, think about the first decade of the 20th century, we're talking about a period that some of you might know from your studies of literature and the heart of darkness of colonial exploitation of the Congo River watershed and movements in that area. A time when steamboats and paddle boats took, came on the Congo River to make it easier to move around to move out the hard timbers, the ivory and the rubber that were being taken from the Congo River watershed, but also meant greater mobility for African people. So perhaps our hunter moved down the river or moved through this rivering system. But what we know is that by 1959, or 1960, in Kinshasa, which was called, known as Leopoldville in the colonial Belgian Congo, that we have someone who had the virus in their blood and remained in a tissue sample. So this process of amplifying the virus we think happens through migration, through the growth of cities, and the demand for labor and colonial cities, but also through colonial medicine and interventions to try to stop things like sleeping sickness, or YAZ, and other things where, and also immunization campaigns, which resulted in, you know, the reuse of needles, and also in clinics for sexually transmitted infections, where people were required to come in for treatment. But then also in giving treatments, the colonial medical officers reuse the same needles with various people. So there's a way that this amplification happens in this colonial period in Kinshasa or Leopoldville in the late 1950s, again, with a five to 10 year delay between infection of the onset of symptoms, it would be hard for someone to understand what had happened or to make that connection.

Dr. Thomas McDow   
But if we want to move then from Leopoldville in the colonial Congo, how can HIV become a global disease? And to do it, to understand that we need to think about the context of African decolonization and the Cold War. Because the first sample that we talked about, ZR59, was taken in the Belgian Congo. By 1960, the Belgian Congo became the Democratic Republic of Congo. It was an independent nation, but Belgian decolonization set into motion a set of contingencies which resulted in HIV spreading around the world. The end of June 1930, when the Belgian King arrives to hand over power, and to complete the decolonization of the Congo with Patrice Lumumba, who was the Prime Minister elect and Joseph Kasavubu, who was the president elect. The Belgian decolonization had been quite hasty. In 1955, someone who's a political scientist in Belgium, who had suggested that the decolonization of the Congo could happen in the next 30 years was laughed out of the room for being far too liberal. It would take much longer than that. But the global winds of change that were happening and the push for decolonization, Belgium decolonizing and granted independence in the Congo very quickly. So that happened in 1960. But also with very few preparations. Few civil servants, there were not developed governmental structures, or people to man those situations. But also it happened within the context of a global Cold War and the Congo was rich in minerals included and other mining wealth and also as a source of uranium. Some of the uranium, in fact, that had been used in the Second World War for the atomic bomb that was dropped in Japan. And so quickly after the independence of the Congo, the Cold War context came, caused great difficulty in the Congo. Lumumba was seen as not sufficiently loyal or interested in Western allies and was potentially open to the Soviet Union. And also the wealth, the mining wealth in Congolese provinces was considered too valuable to be left to an African Government. And so after independence on June 30, a cascade of events set Congo into crisis, which, over the next five years and legacy of that continues to this day, which involves a succession of one region and another part of another region. UN peacekeepers coming in, the Prime Minister being assassinated, the UN Secretary General dying in the Congo or near the, on the way to the Congo in mysterious circumstances, and ended in a coup in 1965, in which Joseph Mobutu overthrows the government and puts himself into power, where he stayed until 1997, as the kind of archetype of the Cold War kleptocrat. The Katanga province and a succession and then the region of Katai that left, this is where the mining wealth and the uranium was. Patrice Lumumba was assassinated in 1960, with the complicity of the US CIA. They're still, people are still trying to get to the bottom of what happened when Dag Hammarskjold went down in a mysterious plane, when his plane flying in Zambia on the way to Katanga went down. And there's, you can have great, there's great films and conspiracy theories all around this but mysterious circumstances indeed for the UN Secretary General to be to be killed. The Congo crisis took up you know, dominated the news, The New York Times, the paper of record, in the US from March 1, 1961, three different articles and a picture above the fold about what was happening in the Congo and what was going on there. So this was a global story. And as we'll see with the story, HIV has global implications. But so how, what are these global implications? How did this happen? Well, in fact, it's connected to, part of our story, we have to go to the Caribbean and think about the island nation of Haiti.

Dr. Thomas McDow   
Because in the 1960s, Haiti had its own Cold War dictator, François Duvalier, known as Papa Doc, who ruled Haiti with an iron fist and had a secret police that were, that made it very difficult for intellectuals and others to do well. I couldn't help but point out that Duvalier, as known as Papa Doc, did study Public Health at the University of Michigan. The educated elite and civil servants and others were eager to find things to do outside of Haiti. It turns out in the very same New York Times of March 1, 1961, but back on page 10, there's a little article about 28 Haitian secondary school teachers who were leaving to go work in the Congo. These Haitians were well-educated, they were French speaking, they had a variety of skills that were useful to the Congo in the midst of this crisis, and the failure of Belgian decolonization, of having trained Africans to take over the functioning of government. By 1962, they were the second most representative nation there. And by 1967, there were 4,500 Haitians working in the Congo. So it seems one of these people contracted HIV and carried the virus back with them across the Atlantic to Haiti. So again, using phylogenetic trees and mapping from known viral samples in the US, we understood, we see that sometime between 1963 and 1971 HIV came to Haiti. And then through, whether it's through sex tourism, through blood banking, and plasma collection that was happening among poor Haitians for it to be used in the United States, or other means, or the movement of one individual, that HIV entered in New York sometime between 1969 and 1974 and then also made its way to California from these networks. And so, you know, the first cases that capture the world's attention were in Los Angeles in 1981, and San Francisco was imagined as or seen as a place where HIV proliferated, but the phylogenetic began using the virus itself, and to understand it's then using its replication process and mutation process, we can trace back and understand how the disease spread in this way. So Haiti and Haitians' rush to fill in the void of Belgian decolonization in the Congo was one of the ways that HIV came to the Western Hemisphere, and it came to the United States. But also in the broader Cold War context, it's useful to think about what else made HIV a global disease and in this case we should think about Cuba and its role in the Angolan  Civil War, an Angolan fight for independence, because this was another vector by which HIV came to the Western Hemisphere.

Dr. Thomas McDow   
So, Fidel Castro backed Agostinho Neto and his Marxist movement for the popular liberation of Angola, and they had begun fighting for independence in 1960. Che Guevara arrived in Angola in 1965 to begin to organize, how to support the MPLA and what could happen there. The Cold War stakes were high in Angola. A quote from the US Secretary of Defense in 1975 speaking to the National Security Council, he said, "We might wish to encourage the disintegration of Angola (Cabinda to have that in the clutches of Mobutu, right, and as a year the next country up or the Democratic Republic of Congo, the next country up who was a staunch U.S. ally) "would mean far greater security of the petroleum resources," right. And so the Cold War stakes there are high, the United States and South Africa backed the UNITA against the MPLA with a goal of destabilizing and controlling Angola. And this is in the '70s and into the '80s. During this time, a large number of Cubans went to Angola, something like 5% of the overall Cuban population served in Angola, many of them in the military, but also civilians who are teachers and then filled in, other, teachers and doctors and other roles. So there's a tremendous presence of Cubans to help bring about liberation in Angola and support the MPLA. And it turns out that this, the fight in Angola, this hot war within the Cold War, set off, set into motion, a set of dominoes and changes which ended white supremacy and minority rule in south, in southern Africa. South Africa in the, during this time, was ruled by the apartheid government. They also controlled Namibia which was, had been a Trust Territory, after the second, after the First World War and Rhodesia, and only in 1980 had become Zimbabwe and become independent. But when the MPLA, the Angolan forces, and the Cubans defeated the U.S. backed Nita, and the South African allies who were also fighting in Angola in 1988, this forced the peace treaty. The Cubans agreed to leave Angola, but South Africa agreed to pull out of Angola and to pull out of Nambia. This was, this connected to a broader set of protests in South Africa and townships and efforts by Africans to make townships ungovernable under the white supremacist apartheid regime. People refused to serve in the military to go fight in it, even white South Africans refused to serve in the military, to go fight in the Namidia or fight in Angola. And so these things, all of these processes and pressures on South Africa, led to the freeing of Nelson Mandela, after 27 years in prison, and the beginning of multi-racial elections in South Africa in 1994 and kind of a miraculous story. And South Africa has its own, South Africa is the country with the most people living with HIV. And there's a whole story there. I, if you take my class, if you want to hear more, I don't have time to tell it all today. But certainly Nelson Mandela considered Castro an ally and a friend because of his efforts to help liberate Southern Africa. You know, whereas the US government under Ronald Reagan called Nelson Mandela, referred to Nelson Mandela, as a terrorist at the time in the 1980s. So again, these cold war rivalries and divisions are part of what is motivating this world and the spread of HIV. Because it was Cuban soldiers and Cuban volunteers who, when they returned to Cuba, discovered that they had HIV. And so it's this connection with Angola and their attempts or their efforts in liberating and standing with Marxist allies to bring that about, also brought HIV to Cuba, a distinct epidemic or linkages that are in addition to the Haitian connection through the Congo, which brought HIV to the U.S. And so, again, a takeaway I want you to have from this is the global spread of HIV came about because of the decolonization of Africa, and also was very much tied to the context of the Cold War and the international rivalries that were taking place at the time.

Dr. Thomas McDow   
Thank goodness, we are at a different place with the disease and the thing and that we can think about in a different way. AIDS is no longer a death sentence, right. And so the UN AIDS, the UN agency that focuses on HIV had a goal for 2020, was they called 909090. And this depends on Antiretrovirals being available and widespread testing. And the goal was for 90% of those people who had HIV to know their status, 90% of those people who know their status to be on Antiretroviral treatment, and 90% of those people to be on antiretroviral treatment long enough, and consistently enough to suppress their viral load. If you're taking Antiretroviral drugs, and you suppress your viral load, it is impossible to transmit the virus any further. And so these goals, the world will not make them exactly, or many nations have fallen short of their individual goals to meet the 909090 goals. But this makes a tremendous, we've moved a tremendous way from the 1980s when AIDS was a death sentence, that everyone who contracted the disease would die from it. So I want to stop there and move to questions. Because you know, this is a small part of the story of the history of AIDS and HIV and that we can stop to acknowledge on this day on World AIDS Day. Because when we stop to acknowledge World AIDS Day, we pause to reflect on millions of lives cut short. We pause to think about the immense suffering that people have gone through, as they've been affected by this disease. And we also must, what I'm hoping to help you do today is to acknowledge the global history of HIV and the complex, interconnected world that we inhabit, a world that makes it possible for zoonotic transfer to occur as we push against environments and change the way that we do things, the human-centered world. But also a world that in its connections that we might underestimate, shows how connected the world is, and also the possibility in the world to address disease, both as through medical interventions, but also human interventions to decrease stigma, and find acceptance for those who are infected. So thank you so much for tuning in to this talk and to understand one part of the global history of HIV. I'm very much happy to take your questions. Thank you so much.

Dr. Nicholas Breyfogle 
Thank you so much, Dodie, this is so, I really, really appreciate it. This was an incredible, I mean, it was a lot in 30 minutes. It was a great explanation to take us through all of these different kinds of connections. And it's a great reminder of the ways in which the stories of the history of disease and the human experience of disease is often tremendously complex and has very, very deep roots. I would be, I'd be curious if you'd taken a quiz, how many people would have known the fact that, you know, that HIV goes back, this goes, you know, over a century. It's quite remarkable that way. We, yeah, let's take some questions now. We had some questions submitted in advance. We also have some that are up here at the moment. I may take a couple that have just come in kind of in real time. One of the people in the audience wants to know what accounts for more women than men having AIDS in Africa. And if you can explain that, I think particularly coming from the American perspective, where the associations rightly or wrongly are the opposite. Can you tell us the story there?

Dr. Thomas McDow   
And this I mean, yes, again, so one of the challenges is our own perception of, from an American point of view, of who is, who has HIV and is likely to get AIDS. Again. In the African context, you know, there are more women than men, and that the predominant form of transmission has been heterosexual contact. It turns out that there are a few things that are protective of HIV, and one of them is medical circumcision. And so, and this was, people thought about this, from what they saw result of in areas of Central or Eastern and Southern Africa where people traditionally circumcised tended to have lower rates of HIV among men. But then in the 1990s, a set of randomized control trials done in Kenya and South Africa showed that, in fact, this was the case and that male circumcision is something like 65% protective against men contracting HIV. Of course, if you don't contract HIV, you can't spread HIV. And so in the early 2000s, there was a great rollout of voluntary, what they called voluntary, male medical circumcision to increase the number of men who were circumcised, and thus, to reduce the transmission of HIV. So that's part of the, that's one of the reasons that men have less HIV. But also the vaginal secretions and tissue are a place that HIV is more, more easily enters the system. And so that, yeah, that the fact that women are more susceptible to HIV is something that we often lose again, from the American point of view, we lose sight of.

Dr. Nicholas Breyfogle 
Wonderful. We have someone else who's interested in if you can speak to the impact of the work being done by the Gates Foundation or the Clinton Foundation in terms of their work with HIV and AIDS?

Dr. Thomas McDow   
Right. And so the philanthropic aspect of global HIV is a fascinating one. At one level, if we step back and think about it in global trends, we have to see the erosion of trust in multilateral organizations, like the World Health Organization, and distrust of the UN bureaucracy and  its ways of addressing things and the ways that at the end of the Cold War, and the rise of a kind of neoliberal governance or the American Washington Consensus on how the world should be run, that the faith in the UN systems and WHO were going down at the same time, we saw a rise of private philanthropic foundations like the Clinton Foundation and the Gates Foundation, which saw it as that they could step in and make a big difference and make a big difference here. So those organizations have been, the Clinton Foundation was key in rolling out or negotiating prices to make Antiretrovirals more readily available in Africa and in other places by using generics. Again, disrupting a pattern by which the pharmaceutical companies using intellectual property were blocking the spread of, or blocking the spread of generic drugs more easily affordable, generic drugs. And so the Clinton Foundation was huge in that. The Gates Foundation has been tremendous in its fostering research and understanding and helping to set a global agenda in 2001, when the Global Fund for AIDS, Tuberculosis and Malaria was started with, you know, the idea was we needed a much greater emphasis. The globe needed a much greater emphasis, if we were going to be able to do anything about these diseases. The US initially agreed to kick in $200 million. Bill Gates agreed to kick in $100 million. So we see that the role of foundations and philanthropic, the philanthropic role has empowered and strengthened this approach. But critics would also say it's also made the process less democratic and less, involved governments less and less. And so in terms of who gets to make these decisions and where these are made, it's not always deliberative bodies in Geneva, or UN connected things, but sometimes around conference tables in Redmond, Washington, right, to boil it down. And so you know, that we can, as scholars, we can approach this role of philanthropy and see, one, the incredible contributions they've made and the way that it has made possible for the era of great successes against HIV. We can also see shortcomings and the way that they could be more democratic or the way the agenda setting process comes into being.

Dr. Nicholas Breyfogle 
You were mentioning kind of the role of governments and sort of different types of political forces, which I have two questions that I think are kind of connected with that. One, so I'll read them both, because I think they'll come in together in some respects. One is, can you talk about how global political forces have supported and threatened the achievement of the kind of 909090 goals? And I think connected to that, what do you see as the role of PEPFAR in the history of HIV in Africa, these kinds of different kind of agendas.

Dr. Thomas McDow   
PEPFAR came out of George W. Bush's State of the Union address in in January of 2008, when he saw tremendous opportunity to address AIDS in Africa. And so he proposed this Emergency Plan for AIDS Relief, which has now become known known as PEPFAR. And, you know, this, in some ways is probably his most enduring legacy or positive legacy, and most important, in terms of the amount of resources that he committed to HIV. And part of this has to do with the historical context, after September 11, 2001, reevaluating what global partnerships and instability in the world might mean on American shores. People began to see the question of HIV and its effects on society, especially in African nations, where it kills people who are adults in the prime of their life, because they're, they're the ones who are sexually active. And it kills, it cuts them down in the process of social reproduction, I mean and reproducing society and family and family life. And so, you know, PEPFAR stepped in and imagined aids to also be a security issue, and was able to bring together a lot of forces and tremendous amount of resources to fight HIV, and to treat and to roll out treatment, broad treatment for HIV all around the world, but particularly in Sub Saharan Africa. So we see just, this is just showing how much you know, just exactly how much money was put into this. And so, you know, when we line up the efforts of the Global Fund, of PEPFAR, of UN AIDS, we see a sort of multipolar world where the Some are, as I said, in the interest of philanthropy, some are individual nation's interest. And also then these international bodies, we can see the politics playing out there. I was in Tanzania in 2017, after Donald Trump had been elected president of the United States, and there was some talk that he would cut PEPFAR funding. And, you know, many countries in Tanzania and Malawi, places I've been, depend extremely, I mean, they depend on PEPFAR money to make Antiretroviral drugs possible, and the success that they made. And then the way to the 909090 goals Malawi is ahead of the United States on those goals is due in part to the funding of Antiretroviral drugs. So talking to a doctor in rural Tanzania, we asked him well, what would happen if this funding if PEPFAR funding was cut, and he just shook his head wistfully, and said, "Many people will die. Many people will die." And so you know, I think we can't underestimate the way to which the US commitment to PEPFAR has saved millions of lives around the world. And so that's been, it's been an incredible part of the story and one that we shouldn't lose sight of in terms of US efforts in that direction.

Dr. Nicholas Breyfogle 
It's really a remarkable accomplishment. Not to kind of take us necessarily in a negative direction but one of the questions that sort of is interested in hearing too a little bit about, are there political forces that are getting in the way? I mean, if PEPFAR, for example, is a great example of a success story, in a lot of ways, are there political forces in the world that are preventing or impeding the opportunity to reach these 909090 goals?

Dr. Thomas McDow   
Well, I mean, I think that we've all had a crash course in the politics of pandemics. And we've seen the way that people have different interests in what is playing out. I think, in part, we see that the tremendous amount of money attached to PEPFAR has meant that governments have, in some cases, made great efforts to try to comply with those kind of goals. There are questions we can raise about sovereignty and who gets, you know, again, who's making these decisions and those kinds of things. You know, that the, I think it's an older example, but you know, that in South Africa, in the early 2000s, Nelson Mandela's successor, Thabo Mbeki, was someone who denied that HIV causes AIDS. And so his own, which was a sort of scientific stance, but also a political stance, and in part a response to the tremendous challenge of confronting AIDS in South Africa, and the impossibility at that time of being able to, or what he imagines the impossibility to be able to plot to supply Antiretroviral drugs. He backed down on that and Antiretroviral drugs came to South Africa and have had a tremendous success. So you know, there is that, there was that piece. The next frontier is going to be pre-exposure prophylaxis, right, which has already been, people might have heard of Truvada, which is a pill that people who are in a high risk of exposure to HIV can take every day prophylactically to keep them from getting it. And this is available in the United States. It's being tested elsewhere. But the question is, again, with intellectual property and the price of drugs, you know, is it feasible to have that, to people who are in high-risk groups or vulnerable parts in relation to HIV exposure, to be able to do that. And so again, the politics of drug pricing and drug availability, how do we weigh the benefits to shareholders and the benefits to people who are potentially infected with HIV? These are economic questions, and also political questions that have to be, that are being worked out and that people are debating.

Dr. Nicholas Breyfogle 
Yeah, and moral questions as well, I would think, and very difficult ones, for humans to make decisions about. You just mentioned kind of South Africa, one of the people in the audience writes to us that she has been in Lesotho, Africa and in believes, here I'll quote, "I believe that I heard that for how small this country is they have one of the highest AIDS rates per capita in the world. Do you know what contributes to this and what has been done to hopefully reduce AIDS in Southern Africa? Is a big part of the story in terms of the reduction, the antiretrovirals? Are there other aspects of the story there and what causes such a high rate in such small places?

Dr. Thomas McDow   
Right. This a part of that and so the question is exactly right. That among the highest rates in the world are Lesotho, which is a country that is surrounded on all sides by South Africa. And what used to be called Swaziland is now called Eswati, or Eswatini , which is also tucked in between South Africa and Mozambique. You know, the geeky 19th century historian of Africa would tell you, that's me, would tell you that these are, these were independent kingdoms, which were which managed to negotiate with the British to keep their independence rather than be folded into agglomerations of South Africa, that became Union of South Africa, eventually independent South Africa. Yet they also were places that relied heavily on or that the people from Lesotho and from Swaziland, or the Swazi Kingdom were migrant laborers in Southern Africa, into South Africa for the mining sector in South Africa. So in part, you know, these vectors that made the mines of South Africa, producing gold and platinum, were some of the, and diamonds, right, the De Beers company that found diamonds in South Africa, market diamonds in South Africa, are the ones who helped you understand that "Diamonds Are Forever" and the launch, the brilliant marketing campaign to make the diamond, the stone for the engagement ring. But the way, that side of the story obscures the tremendous labor costs of mining and the exploitative practices of recruiting mine labor, so as far away as all throughout Southern Africa, but these same chains of recruitment of bringing people to live on compounds in southern Africa, were also means of transmission of disease, tuberculosis in the 1920s, when ill workers were sent home sent home to die. Those also became HIV in the 1980s and 1990s. So these economies of Southern Africa which relied on migrant labor were also particularly susceptible to HIV. So that's part of the story, along with other aspects of, you know, medical systems and availability, the availability of drugs.

Dr. Nicholas Breyfogle 
Excuse me. We have a couple of questions about some of the basics of the disease, and also the kind of transmission into the United States. Let me give you kind of together. So the first is, if you're diagnosed with HIV, do you, will you always get AIDS? And the second asks, what are your thoughts on Robert Rayford and how and when HIV entered the United States? So what about disease?

Dr. Thomas McDow   
Those are two great questions, and they and they're the kind of things that historians love, because they bring up the wrinkles and make us think about the contradictions and the way that the big story may or may not be the whole story, right. And so part of it is, you know, if you get diagnosed with HIV, will it progress to AIDS? You know, the short answer would be yes. The more complicated answer is not always. And it turns out that there are, they discovered a small subset of people, for instance, there are a group of sex workers in Nairobi, who were having several, you know, who have over the course of a year hundreds, if not 1000s of exposure, potential exposures to HIV, who never developed, who never contracted HIV or who never progressed AIDS. And so, these people are called long-term elite controllers. And people are trying to understand what are the genetic variations and other things that make it make it possible that there are some people who do not seem to be able to, who do not seem to get AIDS, even if they have lots of exposures to HIV. And that's, again, a kind of wrinkle and that the scientists can tell you a lot more about it, but it's interesting to keep in mind to think about the broad variation of the human genome and experience and how that might play out in various settings. So that is part of it. And then the question of Robert Rayford, who was a teenager, in a teenager in Missouri, and they and died of mysteriously in the, in the late 1960s, of a disease that wasn't understood was happening, but it was a complete collapse of his immune system. Again, it seems and so, you know, 1981 is the date that people think about as understanding of HIV, or what was then, it was AIDS. But in fact, you know, there are these cases of, there's a Norwegian sailor who had been on the coast of West Africa, who died in an early period. There's a Belgian doctor who'd been in the Congo and, like potentially, been exposed to and died of an immune suppression disease. And so Robert Rayford is one of those cases with, you know, would suggest that HIV, it seems like what he had was HIV. But if you read, even reading, the Wikipedia article will let you know that the kind of understanding at the time was quite limited. And then what's happened since with the tissue samples and others have made it very difficult to confirm. Although I think there's a consensus that he did have HIV or something like HIV, but that was in 1969, in the American Midwest, and not, you know, not a coastal city. And so understanding his story, and this and the stories of people like him, who were, you know, potentially among the first people in the world, and you could do this in different countries, help us understand the complexity of disease, and also highlight some of the mysteries that we still don't understand in thinking about this global history.

Dr. Nicholas Breyfogle 
I'm hoping we can sneak in time for one more question. We've talked today a lot, which makes sense, as an African history specialist, about Africa and the United States. We do have a question here about whether you can speak at all to kind of what's going on with HIV/AIDS in the Soviet Union and Eastern Bloc? And did they suppress the incidence of the disease? Did that lead to more infections?

Dr. Thomas McDow   
That's a great question. And, you know, one of the two of us in this conversation is a specialist on Russia and the Soviet Union. So that's not me, but you might have some, you might have some things to add. My sense would be, there's a few interesting stories and that we can think about that as AIDS played out in the 1980s and in what we now see as the end of the Cold War that people didn't know that at the time. It became, you know, that the Soviet Union seized on it as a tool for propaganda, and, in fact, planted stories about AIDS and the way that it had spread and potentially being a CIA plot and other kinds of things to destabilize or to challenge American influence around the world. But the Soviet Union, and then Russia, the governments have been in my understanding have been quite reticent in addressing AIDS. We saw in Russian prisons the explosion of extreme multi-drug resistant tuberculosis and tuberculosis and HIV often go hand in hand. So the same conditions that made the proliferation of tuberculosis across the former Soviet Union, especially in prison settings have also made it possible to have also spread HIV. The societal stigma about men having sex with men, and the ability to talk about that, or address that publicly, and the same way of dealing with addiction, especially those addicted to injectable drugs, and the criminalization of that and the fact that people who are convicted of things are thrown into prison, and not treated are contributing to those factors. So some of them are the very biological and medical factors that have helped spread HIV everywhere. And some of them are particular factors that deal with the both the culture that you know, the political culture and social culture of these countries and the political choices that they've made. But you know, as we live in a world where HIV is, well, or we have the tools to address HIV and reduce the numbers, but the places of growth, of increasing HIV infections, are in our in Eastern Europe and Russia. And so, you know, we have to think about tools and techniques, approaches that have been developed and have been quite successful in other parts of the world that have really, you know, suppressed HIV, in individuals virally suppressed people in Southern Africa. How might we roll out those kinds of campaigns or how might we adapt campaigns like that to make antiretrovirals widely acceptable and accepted in places like Eastern Europe, where there is an epidemic that continues to foment.

Dr. Nicholas Breyfogle 
Thank you. Yeah, I just actually put into the question-and-answer box for anybody's interested a link to an article on the immediate response of the Soviet Union to HIV/AIDS and the way in which they simply tried to deny its existence and to pretend it didn't. It couldn't possibly exist in their particular country. And the devastating consequences of that. We'll send you know, after the webinar we'll send an email, a follow-up email, which will have some extra kind of readings and other things that you can explore if you would like. The time always goes by so fast. But thank you all so very, very much for joining us today and for your marvelous questions. I am grateful to Professor Thomas McDow, for sharing his expertise here today. And I hope you will all join me in giving him a virtual round of applause. Thank you. Thank you. Thank you.

Dr. Thomas McDow   
Thank you so much. And I would just say that I think one of the enduring legacies of HIV has to be the way that we approach people who are ill, and that have infectious diseases and the degree to which we stigmatize those populations. When we make it harder to talk about those diseases and people's infections, we make it hard to treat them, we make it hard for societies to move past pandemics. So I think they're important legacies that we keep in mind, even as we look back on World AIDS Day to remember those who have died and those who have suffered from this devastating disease.

Dr. Nicholas Breyfogle 
What a perfect way to end. Thank you so much. Thank you all for joining us. Again, stay safe and stay healthy, and we'll see you all next time.