… and still counting. With an error range of plus or minus five million. That is the current rough estimate of the number of people who have died from the AIDS epidemic. Jacques Pepin’s estimate is 29 million, but that was made a half decade ago, when this impressive work was published. It is a pandemic. Though the overall numbers have yet to reach the numbers who died during the Black Death plague of the 14th century or the Influenza of 1918-19, they are in the same league. The AIDS epidemic / pandemic distinguishes itself from the other two in a number of ways: it impacts certain “marginalized” groups of the population the most, and the prime preventive measure is “falling off a log” simple – it is getting people to actually do it.
Jacques Pepin – not to be confused with a more famous chef with the same name – is currently a Professor of Microbiology and Infectious Diseases at the Universite de Sherbrooke in Canada. He spent four years working at a “bush hospital,” 500 km northeast of the capital, Kinshasa, (once called Leopoldville) in the Democratic Republic of the Congo. Where did AIDS come from? And how did it spread? These are the essential epidemiological questions. Pepin provides a lucid, solid, well-reasoned account. It is written at a technical level that is suitable for physicians and other specialists in the field of AIDS, but he also takes care to provide explanations of technical terms, as well as his reasoning, so that his account is accessible to educated and concerned non-medical readers. It is a work in the field of public health, and therefore Pepin’s account also provides an outstanding analysis of the historical and social conditions which caused AIDS, which could have existed in humans for hundreds of years, to suddenly explode into a global pandemic, aided, in part, by substantial dollops of human folly.
It started with chimpanzees. In Africa. Not any chimpanzees, but a particular subset, with the rather odd scientific name of “pan troglodyte troglodyte.” Chimps cannot swim rivers, so the geographic area of central Africa was rather well-defined. For hundreds of years certain members of this subset had the simian immunodeficiency virus (SIV) which is identical to the HIV-1 virus. How they got it is “beyond the scope of this course” as they used to say in college, and probably still do. It may have crossed over to humans during that course of time, but met an “epidemiological dead end,” meaning it did not spread, and died out with the host. Pepin calculates that the one “crossover” event for the modern pandemic occurred in 1921, with an error factor of more than a decade. Such estimates are possible by knowing the rate of change in the mutations of the genetic sequence of the virus, and applying some back calculations.
What made it take off? First, there were guns! Chimps are clever, and hard to hunt without guns, and thus the availability made that one crossover event, around the year 1921, much more likely. Then there were two other major factors that made it spread. One involved the unintended consequences of French and Belgian colonial health care policies (the two main areas where the “ptt” chimps lived – the Belgian Congo, and three of the four countries of French Equatorial Africa.) The focus of this policy was the elimination of trypanosomiasis (sleeping sickness) and yaws. In the French areas, they used mobile teams, a concept promoted by one of the “giants” in the field, Eugene Jamot. But both with the French and Belgian approaches was the use and re-use of syringes and needles, without proper sterilization (because its importance was not realized, and even if it was, autoclaves don’t work without electric power). Thus, the source for many a new case was iatrogenic – the word that denotes that a disease was contracted through the health care procedures.
The other major factor was the rise of prostitution. Colonial policy required the “labor” of the natives, for building railroads, and fighting wars, etc. Men concentrated in the cities, creating a huge imbalance vis-à-vis the women, and the former’s sexual needs would be met via a class of women who sold their services, sometimes at the rate of a thousand “clients” a year.
“Globalization” forces presented the opportunities for HIV-1 to spread from central Africa to China and Thailand. One of the unusual modes of transmission was another by-product of Belgian colonial policy: there was no native educated class to take over, after the sudden independence of the Congo in 1960. Thus, the new government had to import many teachers from Haiti, and they brought HIV-1 back to the Western hemisphere. Two other sharply disparate factors: gay sex tourism to Haiti, and the company, “Hemo-Caribbean” which prepared much of the plasma for western countries, and was drawn from poor (infected) Haitians, and was operated by Luckner Cambronne, the head of the Tonton Macoutes (Papa Doc’s secret police), were two enormous vectors that spread the disease beyond this one impoverished country.
There is much else, including the different course of HIV-2, which spread from the epi-center of Guinea-Bissau, former Portuguese Guinea. Pepin’s account is overwhelmingly “dry” and scientific, with numerous graphs, yet he leavens it with wry commentary on social conditions. Concerning Dr. Jonathan Mann, another “giant” in the AIDS field, and who died in the crash of SwissAir 111 in 1998, he says of Mann’s outlook: “Since AIDS was linked to poverty, injustice, exploitation, vulnerability and all kinds of inequities, all these determinants of the epidemic needed to be addressed simultaneously. This was dreaming in technicolour.”
The only statement of Pepin’s that I would take issue with is on page 174: “While soldiers stationed in peaceful countries certainly tend to frequent sex workers and acquire STDs, there is little evidence that such prostitution occurs close to combat areas.” (!) Au contraire, as evidenced by French military mobile bordellos… among much else.
Overall, Jacques Pepin has written an excellent scientific account of the origins of AIDS. He is a mix of scientist, historian, sociologist and detective. For that slender sub-group, the wise, it would be an excellent text to prepare for the next pandemic. 6-stars.
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