In his book, The Origin of AIDS, Dr. Jacques Pepin looks back at the events that triggered the emergence of HIV/AIDS in Africa and its subsequent development into a modern pandemic. He shows how the disease was first transmitted from chimpanzees to man, and then how colonization, urbanization, prostitution, and public health campaigns combined to fuel the spread of the HIV.
After finishing medical school, Pepin worked for several years as a medical officer in Zaire in the 1980s. He returned to Canada in 1990 and worked as an infectious disease physician in Quebec, while also managing HIV control projects in central and west Africa. Pepin is currently a professor in the Department of Microbiology and Infectious Diseases at the University of Sherbrooke, Quebec, where he is also Director of the Center for International Health.
He spoke to a packed house at the Harvard School of Public Health on May 7th. Before his talk, he sat down with Martha Henry, HAI’s Director of Communications, to answer a few questions.
SPOTLIGHT: You started your career in the early 1980s as a medical officer in a bush hospital in Zaire [now the Democratic Republic of the Congo]. What was it like working there?
PEPIN: Challenging, because of the conditions in Zaire at that time. I’m not sure it’s any better now. The country was already in very bad condition. Everything that normally a government organizes was already, to a large extent, vanished. The roads were in an abysmal condition. The phone system didn’t work. The postal system didn’t work. The nurses’ salaries were pitiful and were stolen every other month. The banks didn’t work, so the overall environment was a bit difficult. In the small rural Nioki hospital, for most of the time, we didn’t have an x-ray machine that was functioning. I had to do work for which I had little preparation, such as C-sections, appendectomies, etc. It was very challenging, but at the same time, I was very happy there, because I felt that my work had an impact on the lives of very poor but brave people. And it was a constant adventure!
SPOTLIGHT: Your book seems like the perfect illustration of how completely interconnected the world is—what’s known as the butterfly effect. One flap of a butterfly’s wings sets off a series of actions that causes a hurricane halfway around the globe. In the case of HIV, in the 1920s one hunter in Africa butchers a chimp and gets blood in an open cut; 90 years later, 30 million people have died of AIDS. What role does chance or luck play in an epidemic?
PEPIN: It’s certain that if you look at the spread of HIV, chance played a substantial role in several steps in that process. Certainly the virus had been present among chimpanzees for hundreds, if not thousands, of years. And probably a hunter once in a while got infected, the hunter infected his wife, both died of AIDS in their village ten years later and that was the end of it.
In the first few decades of the 20th century, there were basically two factors that allowed the successful spread of HIV. One was the social changes associated with the colonization, so basically the urban prostitution. The other was the medical interventions.
It will never be proven, but I think what probably happened is that out of the few hunters who were infected with the simian virus, one of them was diagnosed with some tropical disease and was treated with intravenous injections in his own village, because that’s how it worked. The French doctors had mobile teams that would go to the villages, screen the whole population twice a year, and those that had a given disease would be treated right there.
So eventually from this first hunter, a second patient was iatrogenically infected, and then a third patient, and so on. Eventually it reached a threshold, probably a few hundred, or maybe even a thousand persons infected through injections, and at this point it was unavoidable that some of these people would travel out of their rural area and eventually migrate to a city and start other chains of transmission. But without that initial hunter who happened to be treated for that specific tropical disease, that wouldn’t have happened.
There were other facilitating factors. The completely botched decolonization of the Congo in 1960 created chaos. That chaos changed the face of prostitution in the city of Leopoldville, so there was then room for the sexual amplification of the virus. The chaos was such that the Belgian teachers and doctors and agronomists all left in a hurry and they were replaced by thousands of Haitians. One of them got infected with HIV and brought it back to Haiti and so on. So there were several cases of “What would have happened without this or without that?”
I think that basically chance played a major role at the very beginning, without that hunter being treated for a tropical disease with intravenous drugs, well that hunter would have died and that might have been the end of it. Once the virus was present in Leopoldville in the Congo, it traveled to North America through Haiti, but even without Haiti, maybe the route may have been different, but I think the conditions were already pretty good for its relentless dissemination. And one of these conditions, of course, was the tremendous increase in international travel. So once it had reached a critical mass of infected persons in Leopoldville, it was bound to disseminate, one way or another.
SPOTLIGHT: A lot of your book was based on your original research, but you also draw on the work of many other people. Who was influential in your thinking about the origin of AIDS?
PEPIN: I’m very grateful for the work of two researchers. One is Beatrice Hahn at the University of Pennsylvania. She was the principal investigator of a group that showed that the chimpanzee of central Africa was the source of HIV-1. The other person whose work was very useful to me was Michael Worobey, who is at the University of Arizona. He’s an evolutionary biologist. He worked a lot on the timing, trying to calculate when the first infected person existed and how rapidly HIV spread in Leopoldville.
SPOTLIGHT: In talking about how AIDS has spread, there’s a long history of blaming others. How did you take that into account as you were telling the story?
PEPIN: I tried not to blame anybody. I just tried to describe what I think most likely happened. When I have been interviewed, journalists focused a lot on the role of medical interventions. They have to find someone who is guilty. It makes for a better story—the good person and the evil person.
I’ve repeatedly said that if I had been a doctor working in Cameroon in the 1920s and 1930s, I certainly would have done the same thing that these doctors did. They did their best with the tools they had at the time and with very little knowledge. So I’m not blaming them at all.
If you look at a deeper level, the colonization of Africa played a major role in the successful emergence of HIV/AIDS, so you could blame the colonizers. But could colonization have been avoided? I doubt it. If it hadn’t been in the late 19th century, probably some European powers would have gone there in the early 20th century. If you look at the world situation at that time, it was bound to happen.
So, no, I wouldn’t blame anybody specifically. I think it’s a combination of many factors that created the pandemic.
SPOTLIGHT: Are you continuing your research on the origin of AIDS?
PEPIN: I hope to carry out two more epidemiological studies. I was quite close to doing a study of elderly people in Guinea-Bissau, which is the epicenter of HIV-2, but unfortunately, about a month ago they had a coup and it’s been really chaotic. For now, this will have to be postponed.
I’m also hoping to conduct a study of elderly people in Kinshasa, because this is really the place where HIV, from its crucible somewhere in the rural areas of Central Africa, eventually reached a critical mass arrived and managed to spread. The idea would be to get elderly people and test them, not for HIV, but for the hepatitis C virus and the HTLV-1 virus and try to identify modes of transmission of these viruses among the population in the colonial era or just after decolonization. So I am still quite interested in the topic.