Last June a little plane bumped medown in Blantyre, Malawi. A ragged4-WD took me into town. I got theluggage off my back, shook handswith the guys (I have been part of agroup investigating susceptibility tobacterial lung infections for severalyears now) and e-mailedhome — “Africa is still the only placefor a scientist!”. What?

Sub-saharan Africa — even thename is evocative — appeals at manylevels. It is a vast continent of starkphysical contrasts. Scorching heat inthe Namib and breathless chill onKilimanjaro. Everywhere awesome attimes and yet the awful never faraway, but part of the draw.

That awfulness most often turnsout to be a face of the HIV globalpandemic. This disease, for cliniciansand scientists poses the greatestchallenge of our generation.Highlighted as never before by therecent Durban conference, the HIVvirus has infected 22.5 million peoplein sub-saharan Africa in onlytwo decades. Mean life expectancyamong Malawians is now back below40 for the first time in 50 years. Moredeaths are expected in the sub-saharan region in the next few yearsthan in the whole 14th centuryplague epidemic in Europe, andthese deaths will be in the young andupwardly mobile. 1300 teachers diedin Zambia in the first 10 months of1998. 200 000 AIDS orphans werefound in one small area of Tanzania,and the worst is yet to come. On andon it goes — all just numbers butdeep down we know that this is thebig one.

For the clinician, HIV is thebackdrop to all of hospital practice in

Africa. It means new symptoms,signs, diagnoses, and (sometimes)treatments. As I write, the ‘Principlesof Medicine in Africa’ are quiteliterally being re-written as three-quarters of inpatients are HIVpositive. Today in Africa, doctorsmust learn this new book, embracethe challenge of a new ‘extrememedicine’ and live with a newexpectation of failure.

Everywhere awesome at times,but the awful never far away

For the scientists standing intheir thousands world-wide to facethis pandemic, Africa is the crucible.Here in the mass of tragicallyinfected people are also found theselected few who by naturallyresisting the infection provide a leadin the search for an end to all of it.Africa is the epicentre of AIDS andalso the furnace from which willsurely emerge the solution.

The scientific and otherimperatives exerted by this epidemichave been recognised. Multiplesources of funding are accessible toinvestigators in Africa and theircollaborators in the USA and Europe.A particularly good source is theWellcome Trust Tropical MedicineProgramme. On good days, like theone with which I began, I cannotimagine working anywhere else butthere are problems.

First, the land of physicalcontrast can break anything. ‘A.W.A.’we say (‘Africa wins again’) as thefreezer melt spreads a year of

collected isolates over the floor. Oragain, ‘the Malawi rule of two’ whichstates that in order to have anythingworking all the time, two must bekept ready — be it fluorescentmicroscope or flat iron, PCR block orplumbing wrench. People break too,and some very quickly — like thesurgeon I remember years ago inUganda who spent his first Africannight operating on an injured youngwoman. She later died in the wardfor lack of a blood transfusion and hewent home on the nextplane…A.W.A.

Second, the awful is often moreimmediate than the awesome. Thereare days when we spend and spendand spend in the laboratory while thepatients die and die and die onlyyards away for lack of medicalsupport. The awesome and elusivescientific answer seems somehowshabby and unworthy beside theimmediate suffering. Never was thismore stark than when my tissueincubator and microscope occupiedan isolation ward while patients layon the floor outside.

Thirdly, Africa is remote. Not inthe physical sense that the nameevokes either — more like when youfind the library shut when you needthat journal today. The library is shutin Africa every day. Work hard hereand get fewer results for more effort.Come home ill-informed, de-skilledand underconfident.

In return, though, Africa willgive you more physical andintellectual space, more freedom,more life. I’m going to drive downfrom England to spend four moreyears with alveolar macrophages,AIDS and Africa. Maybe we won’tmeet there — but I will be in theright place.

Address: Division of Genomic Medicine,University of Sheffield, Sheffield, S10 4FA, UK.

R4 Current Biology Vol 11 No 1

Feature

Africa wins again

Clinician and immunologist, Stephen Gordon, can’t imagine workinganywhere else but the African infrastructure and HIV pandemicpresent a massive challenge for researchers, he says.