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The Origins of AIDS

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The Origins of AIDS

  The Origins of AIDS

  It is now thirty years since the discovery of AIDS but its origins continue to puzzle doctors and scientists. Inspired by his own experiences working as an infectious diseases physician in Africa, Jacques Pepin looks back to the early twentieth-century events in Africa that triggered the emergence of HIV/AIDS (human immunodeficiency virus/acquired immune deficiency syndrome) and traces its subsequent development into the most dramatic and destructive epidemic of modern times. He shows how the disease was first transmitted from chimpanzees to man and then how urbanisation, prostitution and large-scale colonial medical campaigns intended to eradicate tropical diseases combined to disastrous effect to fuel the spread of the virus from its origins in Léopoldville to the rest of Africa, the Caribbean and ultimately worldwide. This is an essential new perspective on HIV/AIDS and on the lessons that must be learned if we are to avoid provoking another pandemic in the future.

  JACQUES PEPIN is a Professor in the Department of Microbiology and Infectious Diseases at the Université de Sherbrooke, Canada, where he is also Director of the Center for International Health. He has conducted research on infectious diseases in sixteen African countries and, during the 1980s, worked for four years as a medical officer in a Zaire bush hospital.

  The Origins of AIDS

  Jacques Pepin


  Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo, Delhi, Tokyo, Mexico City

  Cambridge University Press

  The Edinburgh Building, Cambridge CB2 8RU, UK

  Published in the United States of America by Cambridge University Press, New York


  Information on this title: www.cambridge.org/9780521186377

  © Jacques Pepin 2011

  This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press.

  First published 2011

  Printed in the United Kingdom at the University Press, Cambridge

  A catalogue record for this publication is available from the British Library

  Library of Congress Cataloguing in Publication data

  Pepin, Jacques, 1958–

  The origins of AIDS / Jacques Pepin.

  p. ; cm.

  Includes bibliographical references and index.

  ISBN 978-1-107-00663-8 (hardback) – ISBN 978-0-521-18637-7 (pbk.)

  1. HIV infections – Africa. 2. HIV infections – Etiology. 3. AIDS (Disease) –

  Africa. 4. Emerging infectious diseases – Africa. I. Title.

  [DNLM: 1. HIV Infections – etiology – Africa. 2. HIV Infections – history –

  Africa. 3. Acquired Immunodeficiency Syndrome – history – Africa.

  4. Communicable Diseases, Emerging – history – Africa. 5. Disease Vectors –

  Africa. 6. HIV-1 – pathogenicity – Africa. 7. History, 20th Century – Africa.

  WC 503.3]

  RA643.86.A35P465 2011



  ISBN 978-1-107-00663-8 Hardback

  ISBN 978-0-521-18637-7 Paperback

  Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.


  List of figures, maps and table


  List of abbreviations

  Note on terminology

  Map of Africa


  1 Out of Africa

  2 The source

  3 The timing

  4 The cut hunter

  5 Societies in transition

  6 The oldest trade

  7 Injections and the transmission of viruses

  8 The legacies of colonial medicine I: French Equatorial Africa and Cameroun

  9 The legacies of colonial medicine II: the Belgian Congo

  10 The other human immunodeficiency viruses

  11 From the Congo to the Caribbean

  12 The blood trade

  13 The globalisation

  14 Assembling the puzzle

  15 Epilogue: lessons learned




  Figures, maps and table


  1 Phylogenetic analysis showing the relationship between SIVcpz-US and SIVcpz-gab1 and isolates from humans infected with HIV-1

  2 Phylogenetic analysis showing the relatively distant relationship between SIVcpz isolates obtained in Tanzania from P.t. schweinfurthii chimpanzees and isolates from humans infected with HIV-1

  3 Phylogenetic analysis showing the relationship between SIVcpz from P.t. troglodytes chimpanzees in Cameroon or Gabon and isolates from humans infected with HIV-1

  4 Population of colonies of central Africa, 1922–60

  5 Léopoldville’s population, 1923–59: (a) adult men, adult women and children; (b) ratio of adult men to adult women

  6 Age pyramids of Léopoldville in 1955

  7 Migrations and births in Léopoldville–Kinshasa

  8 Satellite photograph of Kinshasa and Brazzaville, early twenty-first century

  9 Prevalence of HCV infection at various sites in Cameroon by year of birth

  10 Incidence of African trypanosomiasis (sleeping sickness) in Cameroun Français and AEF-3, and use of trypanocidal drugs

  11 Incidence rates (per 1,000 inhabitants per year) of African trypanosomiasis, yaws and syphilis in Cameroun Français, AEF-3 and Tchad

  12 New cases of yaws and syphilis and consumption of antitreponemal drugs in Cameroun Français and AEF-3

  13 Cases of leprosy under treatment, and new cases of tuberculosis diagnosed in Cameroun Français and AEF-3

  14 Number of individuals vaccinated against smallpox and yellow fever in Cameroun Français and AEF-3

  15 Number of new cases of endemic diseases in the Belgian Congo

  16 Annual incidence of endemic diseases in the Belgian Congo

  17 Annual incidence of yaws in various regions of the Belgian Congo

  18 Number of new cases of gonorrhoea and syphilis, injections of various drugs and number of visits for free women at the Dispensaires Antivénériens of Léopoldville


  1 Map of Africa

  2 Genetic diversity of HIV-1 in sub-Saharan Africa

  3 Distribution of the four subspecies of Pan troglodytes and the Pan paniscus bonobo

  4 Itinerary of the Brazzaville–Pointe-Noire and Léopoldville–Matadi railways

  5 Map of Cameroun Français and the four colonies that comprised the Afrique Équatoriale Française federation

  6 Map of the Belgian Congo (current names in brackets)

  7 Historical range of the sooty mangabey (Cercocebus atys atys) in West Africa


  1 HIV-2 prevalence in Guinea-Bissau by age, 1987–2007


  I am grateful to several persons who helped me through the various steps of writing up this book. I will list them in chronological order.

  At a very proximal stage, my career in the tropics (and thus my interest and competence in writing this book) would not have been possible without the support and patience of the late Christian Fisch and Jean-Louis Lamboray. I am also indebted to my former mentors and colleagues at the Université de Sherbrooke (especially Raymond Duperval), the University of Manitoba, where I learned respectively to practise medicine and infectious diseases, the Medical Resea
rch Council Laboratories in The Gambia, where I understood how to do research, and the London School of Hygiene and Tropical Medicine, where I studied epidemiology. For more than fifteen years, the Canadian International Development Agency (CIDA) sponsored public health interventions in Africa during which I discovered a lot about sex workers. CIDA had also funded the primary healthcare project in Zaire where I became fascinated by African trypanosomiasis and other tropical diseases.

  Over the seven years that I ultimately spent collecting the historical documents listed in the references section, I was assisted in an ever friendly way by the librarians of the following institutions (also in chronological order): Widener Library of Harvard University; Canada Institute for Scientific and Technical Information in Ottawa; British Library and School of Oriental and African Studies in London; Institute of Tropical Medicine in Lisboa (when I was mostly interested in HIV-2); Institut de Médecine Tropicale du Service de Santé des Armées in Marseilles (where I discovered that what was true for HIV-2 also applied to HIV-1 and suddenly realised that there was enough material for a book, rather than a few standard 3,000-word scientific papers, which had been my initial goal); Archives Nationales d’Outre-Mer in Aix-en-Provence; Belgian Ministry of Foreign Affairs, the Royal Library and Université Libre de Bruxelles, in Brussels; Louvain University and Université Catholique de Louvain; Institute of Tropical Medicine in Antwerp; United Nations Library and the World Health Organization in Geneva; Bibliothèque Nationale de France in Paris; University of Ottawa, Université Laval in Quebec City, Université de Montréal and Université du Québec à Montréal and my own institution, the Université de Sherbrooke.

  During the lengthy process of writing up the manuscript, I became especially indebted to Bernadette Wilson, who expertly edited the many chapters that I had written in English, and translated a few more written in French, and to Christian Audet, who professionally designed the illustrations.

  When I finally reached the stage of seeking a publisher, Michael Watson of Cambridge University Press was kind enough to look at my manuscript and to find it worthy of publication. He then guided me through the difficult but necessary process of further editing the work. Like most academic authors, I initially saw this last step as a multi-organ amputation, but it turned out to be just a long-overdue haircut. Chloe Howell assisted with the finishing touches.

  This having been said, the most important person who helped me through this whole adventure will be acknowledged in the Introduction.



  Afrique Équatoriale Française


  Acquired immune deficiency syndrome


  Centers for Disease Control and Prevention


  Colonies Françaises d’Afrique/Communauté Financère Africaine


  Chemin de Fer Congo–Océan


  Central Intelligence Agency


  circulating recombinant forms


  desoxyribonucleic acid


  Democratic Republic of the Congo


  État Indépendant du Congo (Congo Free State)


  Global Programme on AIDS


  hepatitis B virus


  hepatitis C virus


  human immunodeficiency virus


  human T-cell lymphotropic virus




  injection drug user or intravenous drug user






  Kaposi’s sarcoma


  Morbidity and Mortality Weekly Report


  National Institute for Biological Standards and Control


  Organisation des Nations-Unies au Congo


  oral polio vaccine




  simian foamy virus


  simian immunodeficiency virus


  sexually transmitted disease


  United Nations Education, Science and Culture Organization


  World Health Organization


  World War I


  World War II

  Note on terminology

  Before we move on, I want to point out that for readers unfamiliar with virology, the Appendix provides a brief overview of the viruses that we will be discussing. In a few chapters where this is necessary, elements of molecular biology will be discussed. I aimed to explain them succinctly to readers who have no training in this field.

  With regard to toponymy, in English-language publications West Africa generally encompasses all countries on the Atlantic coast of Africa, plus some in the corresponding hinterland. I will rather use French terminology whereby West Africa starts in Mauritania, ends with Nigeria and also includes the corresponding hinterland. Central Africa (in colonial times, Equatorial Africa) starts with Cameroon and Chad, goes all the way to Rwanda and Burundi and also encompasses the two Congos, Gabon, the Central African Republic and Equatorial Guinea. Most of the story told in this book occurred in central Africa.

  In former French colonies, city names did not change much after independence. Gabon’s major port is still called Port-Gentil, despite the latter character’s dubious human rights record. However, in the former Belgian Congo, these traces of the colonisers were enthusiastically erased so that Léopoldville became Kinshasa, Stanleyville became Kisangani, Elisabethville was renamed Lubumbashi, and so on. The country itself was successively known as the Congo Free State, the Belgian Congo, the Democratic Republic of Congo (DRC) after 1960 (or Congo-Léopoldville, and then Congo-Kinshasa), Zaire under Mobutu’s dictatorship and then DRC again after Mobutu was overthrown.

  The federation of Afrique Équatoriale Française (AEF) included four distinct colonies: Moyen-Congo (present day Republic of Congo, or Congo-Brazzaville), Oubangui-Chari (Central African Republic), Gabon and Tchad. AEF disappeared as a geographic entity shortly before 1960 when independence was granted to the four countries. To avoid confusion between the two Congos, I will use the term Congo-Brazzaville (it also changed names a few times) to designate the independent country that succeeded Moyen-Congo. Cameroun Français, or just Cameroun with the French spelling, refers to the part of current day Cameroon that was administered by France under a mandate from the League of Nations after World War I (WWI) and the United Nations after World War II (WWII), until the country became independent in 1960. The maps in this book use the names of countries and cities as they were known at the time of the events in question, and in principle the location of each city, district, region, river or park mentioned anywhere in the book should be shown on at least one of the maps.

  Map 1 Map of Africa.


  June 1981 is the official birth date of the AIDS epidemic. In a short article published in the Centers for Disease Control’s Morbidity and Mortality Weekly Report (MMWR), American clinicians described a cluster of five cases of Pneumocystis carinii pneumonia, an infection of the lungs hitherto seen only in patients with severe impairment of their immune system. These five initial cases had been diagnosed in 1980–1 among gay men, all living in Los Angeles, who had been previously healthy and were not receiving drugs that suppressed the body’s immune response. At the time, the standard treatment for Pneumocystis pneumonia was an old drug called pentamidine, developed during WWII for the treatment of sleeping sickness, which happened to be highly active against Pneumocystis. Pentamidine was not commercially available and had to be distributed centrally from the CDC in Atlanta. An astute CDC technician found it strange to hav
e received several requests for pentamidine within a short period of time from hospitals in California and, a bit later, from New York as well. This became the first step in the identification of the new syndrome by this federal agency.1–2

  Nobody could have imagined that, within three decades, more than twenty-nine million individuals would have died of AIDS, leaving in the process sixteen million orphans. By 2009, another thirty-three million were living with its HIV aetiological agent, making it by far the most dramatic epidemic since the Black Plague devastated Europe 500 years ago. Since that fateful day in 1981, more than 300,000 scientific articles and thousands of books have been published on HIV/AIDS. Most are biomedical but others analyse the psychosocial, historical, economic, geographic and even photographic features of AIDS. Thus the history of HIV/AIDS from 1981 to 2011 has been described in great detail. Randy Shilts’ And the band played on and Laurie Garrett’s The coming plague contain captivating descriptions of the early years of the pandemic in the US and Europe. Some books have chronicled the AIDS epidemic in Africa after the initial description of the disease, its devastating impact on the lives of so many, a few success stories and unfortunately many more failures in the response to HIV/AIDS, most tragically in South Africa. For a summary of the dissemination of the virus between 1981 and 2006, I recommend John Illiffe’s The African AIDS epidemic. A history.2–10

  However, what happened before 1981 – how did the human race reach that point? – has, to my knowledge, only been addressed in Edward Hooper’s The river. A journey back to the source of HIV and AIDS. This book was written in support of the hypothesis that the emergence of HIV/AIDS was triggered by the contamination of an oral polio vaccine with a simian immunodeficiency virus through the use of chimpanzee cells during vaccine production. There is now overwhelming evidence that this did not happen, as we will see later.11

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