Jan. 6th, 2018

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I decided to continue with my self-education project on the AIDS epidemic by reading The Origins of AIDS by Jacques Pepin. Pepin is an expert in the study and treatment of infectious diseases. Early in his career, he spent four years working as a medical officer in Zaire, and later, conducted research on HIV in The Gambia and other nations in central and west Africa. He is now 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.

Pepin begins by offering the readers a brief summary of his explorations of the origins of HIV, noting areas where his narrative is based on solid evidence and others, where scientific evidence is unavailable and he has made use of the most reasonable hypotheses to fill in the lacunae in the scientific record.

"This book will summarise and assemble various pieces of the puzzle that have gradually been delineated over the last decade by a small group of investigators, to which I have added historical research of my own. Some elements are irrefutable, such as the notion that the Pan troglodytes troglodytes chimpanzee is the source of HIV-1. Other elements are less clear, for example the exact moment of the cross-species transmission (sometime in the first three decades of the twentieth century). My own contribution focused around the idea that medical interventions requiring the massive use of reusable syringes and needles jumpstarted the epidemic by rapidly expanding the number of infected individuals from a handful to a few hundred or a few thousand. This set the stage for the sexual transmission of the virus, starting in core groups of sex workers and their male clients and later spreading to the rest of the adult population. Some parts of the story rely on circumstantial evidence, such as the links between the Congo and Haiti and the potential contribution of the blood trade in triggering the epidemic in Port-au-Prince, from where it moved into the US."

In his Introduction, Pepin acknowledges that, as a medical doctor, working in Zaire during the early 1980s, with limited resources, he probably engaged in procedures that, while considered best practices at the time and under those circumstances, contributed to the spread of HIV infection. He treated many patients for tuberculosis with a protocol that involved multiple injections of streptomycin, and many more for sleeping sickness with injections of a drug called melarsoprol; glass syringes were reused and sterilisation with an autoclave was not always possible - indeed, many of the medical outposts he worked in had no autoclave. Given the time period and the conditions of his work, it is almost certain that at least some patients were infected under his care. It was in part his realisation of this, which grew from later research into the links between treatment for sleeping sickness and HIV-2 infections in what had once been Portuguese Guinea, that led to his decision to research the origins of AIDS. He adds:

"Some may say that understanding the past is irrelevant, what really matters is the future. I disagree. There are at least two good reasons for attempting to elucidate the factors behind the emergence of the HIV pandemic. First, we have a moral obligation to the millions of human beings who have died, or will die, from this infection. Second, this tragedy was facilitated (or even caused) by human interventions: colonisation, urbanisation and probably well-intentioned public health campaigns. Hopefully, we can gain collective wisdom and humility that might help avoid provoking another such disaster in the coming decades."

As this suggests, in his narrative, Pepin looks not only at the scientific story of the transformation of the simian infection agent SIV to the human agent HIV, but also at the historical conditions that enabled the disease - which many scientists believe may have crossed the species barrier on multiple occasions during the history of human-ape interactions in Africa - to reach epidemic proportions on this occasion. In doing so, he takes aim squarely at the social choices that made these conditions possible - from the catastrophic effects of European colonialism on African societies, to the devastating role that the profit motive played in the spread of the virus through collection and distribution of blood and blood products.

Pepin's narrative is detailed and strongly argued; he provides a great deal of technical information, but not so much that the informed layman cannot follow the argument and see how its conclusions have been reached. Beginning with basic epidemiological information - the distribution and prevalence of the many types and sub-types of the virus found in Africa, and what this implies to the scientist searching for the origins of the disease - Pepin follows each link in the chain of evidence like a forensic puzzle.

I found it fascinating reading, and was impressed by the breadth and depth of Pepin’s research into every aspect of the scientific and sociological elements that led to the breakout, at this place and time, of a disease that had started to develop, then sputtered out on a number of earlier occasions. From the gender ratios of the residents of Brazzaville in the 1930s to post-colonial Zaireian policies on regulating prostitution to the history of large-scale public health programs involving injection treatments for disease such as sleeping sickness, trypanosomiasis, yaws and syphilis in the different colonies of French Equatorial Africa and the Belgian Congo, the degree of detailed documentation of the conditions that led to the HIV epidemic is exhaustive.

Pepin’s style is an interesting blend of the dry academic, and the wry wit. His occasional asides, which often point out issues of colonialism and racism, are personal and in a way, endearing. Case in point: when discussing the work of Louise Pearce, an early medical researcher, he begins “Louise Pearce, a visiting American scientist (always referred to as Miss Pearce rather than Dr Pearce, her unmarried status apparently being more important than her degrees!)...” I came to look forward to these trenchant observations as moments of connection to the author amidst the sometimes daunting mass of data.

Overall, an excellent epidemiological study that should answer all but the most technical questions anyone might have about the origins of the AIDS epidemic.

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