Daan Mulder Memorial Symposium – Introduction


correspondence Peter Smith, Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK. E-mail: peter.smith@lshtm.ac.uk

This supplement to the Journal is dedicated to the memory of Daan Mulder whose tragically early death in October 1998 deprived us of someone whose work in Uganda made critically important contributions to our knowledge of the epidemic of AIDS which is devastating populations in large areas of Africa. The topics of papers in the supplement were among those covered in a memorial meeting which was held at the London School of Hygiene & Tropical Medicine in December 1999.

Not all of those who presented a paper at that meeting were able to contribute to the supplement and we are grateful to the friends and colleagues of Daan who have joined the original presenters in preparing the review papers in this volume. Authors were given the brief to review the current status of knowledge on the epidemiology, natural history and control of HIV/AIDS. We think they have met this challenge well.

At the invitation of the Uganda Government, and with support from the British Medical Research Council, Daan set up a large population-based study of the epidemiology of HIV/AIDS in a rural area of Uganda. One of the most important initial findings to emerge from the research programme was the first demonstration in a population-based study in Africa of the enormously increased mortality rates among those who were HIV-infected compared to uninfected individuals. In a population in which the adult seroprevalence of HIV-1 was 8.2%, half of all deaths among adults were attributable to HIV infection and over 80% of all deaths among those aged 13–44 years were similarly attributable ( Mulder et al. 1995a ). These results, which have since been repeated in a number of other studies ( Sewankambo et al. 1994 ; Borgdorff et al. 1995 ; Nunn et al. 1997 ; Todd et al. 1997 ), did much to destroy the credibility of the views that were being promoted at the time, by a vociferous few, that the magnitude of the AIDS epidemic was being greatly exaggerated and that HIV was not the cause of AIDS. It is a grim irony that this supplement is being published at a time when the link between HIV and AIDS is being questioned in South Africa at the highest political level, in ways which to the outside observer seem to be highly destructive of AIDS control activities. Daan would be turning in his grave at this latest tragic turn of events.

Daan's lasting interest in, and passion for, the health of those in developing countries, was stimulated when he first went to Tanzania as a medical officer at the Kola Ndoto Hospital in Shinyanga in 1978. After a period with solely clinical duties in Shinyanga, he took responsibility for the planning: first, the regional leprosy and tuberculosis control programme and then, in 1981, for the national programme. He joined the London School of Hygiene and Tropical Medicine as a mature student to study epidemiology in 1983, passing the final examinations with distinction. He was unusually gifted mathematically for a physician and his dissertation was a complex mathematical analysis of national tuberculin surveys he had organized in Tanzania. In 1987 the Medical Research Council (MRC) was invited by the Ugandan government to set up a research programme on AIDS in Uganda. Daan was recruited to lead the programme from the Royal Tropical Institute in Amsterdam, where he had continued his work on tuberculosis and leprosy control after leaving the London School. Uganda was just emerging from a long and bitter civil war. Much of the infrastructure in the country had been destroyed and a devastating epidemic of AIDS was raging. Much of the research on the disease that had been conducted in Africa at that time was around small, rapidly conducted cross-sectional surveys, often by ‘safari’ researchers who rushed in and then out with their serum samples and left little behind but anger and confusion. Thus, visiting ‘northerners’ were regarded with considerable suspicion and distrust. It is an enormous tribute to Daan that under these circumstances he was able to set up a longitudinally based programme of research which was to become one of the pearls of the MRC's overseas field research portfolio. The programme, which continues today (under the leadership of Professor Jimmy Whitworth from the London School), has had many accomplishments. Among the most important were the careful documentation of the enormous magnitude of the burden of morbidity and mortality caused by HIV in the rural study area, as mentioned above, and the first report of a decline in HIV-1 prevalence in a general population in sub-Saharan Africa with high overall HIV-1 prevalence ( Mulder et al. 1995b ). The programme became, under Daan's direction, the major population-based study on HIV in Africa. The MRC has a strong biomedical orientation. Daan was very quick to recognize that understanding of the AIDS epidemic required not only biomedical research but also research on the behavioural and social determinants of the disease. The programme of research that Daan developed had components ranging from molecular biology to anthropology and it is a tribute to his vision and breadth that so much was achieved.

Even after his lung cancer had been diagnosed, and knowing the likely prognosis, he continued to work on the development of research programmes on HIV and tuberculosis and made arduous field visits to South Africa and Uganda. To the end, his mind remained active and stimulating, only his body could not keep up.