A Bit More Detail

Assorted Personal Notations, Essays, and Other Jottings

[BLOG-LIKE POSTING] Notes on Jacques Pepin’s description of the history of HIV/AIDS

When I saw the new book by doctor and Université de Sherbrooke professor Jacques Pepin, The Origins of AIDS, I’d high hopes that he’d satisfy my curiosity about the ultimate origins of the HIV/AIDS epidemic. We know that HIV has its origins in the retroviruses of chimpanzees in central Africa, we know in pretty good detail the routes and mechanisms the virus took in the human world from about 1980 on, but we’ve only informed speculation about what happened to take HIV from being an exclusive property of chimpanzees to a human pandemic. Pépin has managed to fill in the gaps.

Briefly, building on equally on the latest medical researches–things like the study of early samples of HIV which place the disease’s communication to the human population in central Africa in early 20th century–and actual documentation from colonial-era French and Belgian central Africa about epidemiological trends and medical practices, Pepin confirms and refines Jim Moore et al’s scenario for HIV’s emergence in the context of a colonial central Africa, presented by me in my 2007 World AIDS Day post. In central Africa, the theory goes, hunters of chimpanzees occasionally got injured by them and more rarely got infected with HIV. Somehow, likely through the mass forced population movements associated with colonies, someone infected with HIV didn’t die after infecting a handful of people–sexual partners, children–who died within the space of a few years without transmitting it further but instead transmitted the virus to a wider population, where it spread thanks in large part to an already disease-ridden environment. How do you detect a disease most notable for enabling other diseases? (Millions of dead, it turns out.)

Pépin expands on this not only by identifying early possible signs of AIDS predating –describes the “cachexie du Mayombe”, marked by wasting, swollen lumph glands, and cerebral atrophy without obvious causes like cancer or tuberculosis, that hit forced labourers on the Congo-Océan railway in the early 1930s. He reinforces how population movements are key, with the Kinshasa/Brazzaville conurbation standing out as a destination for migrants. The twinned capitals of the Democratic Republic of Congo and the Republic of Congo formed a pole of attraction for migrants across central Africa from their late 19th century founding, giving the virus a chance at rapid regional dispersion once it got there.

His particular innovations stand out in his emphasis on the importance of colonial medical campaigns in spreading the virus across populations, and in his detailed description of the sex trade in Kinshasa/Brazzaville. From a relatively early date, in its central African colonies France mounted multiple energetic campaigns against infectious diseases like sleeping sickness in its central African colonies, doing broadly commendable work in fighting a disease that–partly because of the dislocations of conquest–threatened to depopulate large regions. Most unfortunately, these medical campaigns made use of needles which were badly sterilized, if sterilized at all. This helped the HIV that infected a single hunter in a single community to infect many more people–in his community, even in other communities–than would otherwise be possible. Too, the policies of the Belgians, particularly, in preventing the migration of women and the formation of families on the Congo Free State’s capital led to the creation of enduring prostitution that, once independence and economic dislocations hit, mutated into a system of prostitution characterized by mass numbers of partners that allowed for the rapid spread of the virus. (The use of unsterilized needles to administer antibiotics at a STD clinic didn’t help, either.)

How did it get from central Africa to the rest of the world? Pepin highlights the migration of professionals from Francophone Haiti to Francophone Zaire in the 1960s, people fleeing Papa Duvalier’s terror for an environment where they could earn. The diversity of HIV in the world beyond, the author suggests, is such that the epidemic outside of central Africa can be traced to a single unlucky Haitian. On arriving in Haiti in the late 1960s, the virus then spread, Pépin suggesting that unsterile blood donation facilities helped the Haitian epidemic become as huge as it did.

The above is a brief summary. The book’s release led to extensive coverage in Think Africa Press and The Globe and Mail and in The New York Times and in an interview on CBC Radio’s show The Current, all of which are recommended.

Using colonial census data, surveys of how modern bush-meat hunters butcher kills, and infection rates among nurses stuck by dirty needles, Dr. Pépin calculates that, in the early 1920s, a maximum of 1,350 hunters might have had blood-to-blood contact with troglodytes chimps. Only 6 percent of the chimps — about 80 — would have been infected, and fewer than 4 percent of the scratched hunters probably could have caught it. That would suggest only three infected hunters at most.

Given how inefficient most sexual spread is — in some cases, a husband and wife can have sex for months without passing H.I.V. — sex alone would not have let three hunters, or even a dozen, pass on their virus to today’s millions, he argues. There must have been an amplifier.

Studies among heroin addicts — he cites examples from Italy, New York, Edinburgh and Bangkok — show that blood transmission is 10 times as efficient.

In the 1920s, machine-made glass syringes replaced expensive hand-blown ones, and the Belgians and French attacked many diseases in their colonies, both out of paternalism and to create herd immunity to protect whites. Patients might get up to 300 shots in a lifetime. Other diseases have spread this way; an Egyptian campaign against schistosomiasis ended in 1980 after giving more than half its “beneficiaries” hepatitis C.

Thus, one hunter’s group M infection could have become dozens. Then Dr. Pépin’s focus shifts to the twin cities facing each other across the Congo: Leopoldville (now Kinshasa) on the Belgian side, Brazzaville on the French.

They are the epidemic’s cradle; viral diversity is highest there, and the earliest positive blood sample, from 1959, was found there.

From 1900, both grew from tiny river outposts into cities, but only black men with colonial work permits were allowed to live in them legally. Naturally, women followed. But until 1960, brothels were rare. Most of the women were “femmes libres” — escapees from rural polygamy who typically had only three or four clients for whom they also cooked and did laundry.

Colonial authorities tolerated and taxed this. At one point, the “unmarried woman tax” was 20 percent of the budget of Stanleyville.

Since femmes libres had few partners, viral spread was probably sluggish, although occasional hepatitis outbreaks were noted at clinics where prostitutes got penicillin shots for syphilis — suggesting amplification by needle there, too.

In the 1960s, everything changed. World War II had swollen the twin cities, which supplied raw materials the Allies lost when Japan conquered Asian colonies. Then, when whites fled the chaos of independence, economies collapsed. Poverty was rampant.

Dozens of bar-brothels called “flamingoes” sprang up, competition forced desperate women to have sex with up to 1,000 clients a year, and venereal disease treatment dried up. There must have been a viral explosion like the one that happened 20 years later in a closely studied band of prostitutes in Nairobi: In 1981, 5 percent of them had the virus; three years later, 82 percent did.

The next link was Haiti. Because white Belgians never trained an African elite, only about 30 Congolese outside the priesthood had university degrees at independence.

To fill the gap, the United Nations hired bureaucrats and teachers from abroad. About 4,500 Haitians answered the call; they were black, well educated, French-speaking and eager to earn more than they could at home.

Now Dr. Pépin’s calculations get slightly more speculative.

Group M of H.I.V.-1 is, in turn, broken into subgroups A through K.

Haiti’s epidemic, like that of North America and Western Europe, is nearly all subgroup B. But subgroup B is so rare in central Africa that it causes less than 1 percent of cases.

That suggests AIDS crossed the Atlantic in just one Haitian. Molecular clock dating indicates it reached Haiti roughly in 1966.

Once again, Dr. Pépin argues that rapid expansion through sex alone is mathematically impossible and that there must have been an amplifier. He believes the culprit was a Port-au-Prince plasma center called Hemo-Caribbean that operated only from 1971 to 1972 and was known to have low hygiene standards.

Plasma centers take blood, spin it and return the red cells. If new tubing isn’t used for each patient, infections spread. Sloppy plasma operations caused later H.I.V. outbreaks in Mexico, Spain and India and, most famously, in rural China, where 250,000 sellers were infected.

Hemo-Caribbean’s co-owner was Luckner Cambronne, leader of the feared Tontons Macoutes secret police. Nicknamed the “Vampire of the Caribbean,” Mr. Cambronne, who died in 2006, bled 6,000 sellers who were paid as little as $3 a day and exported 1,600 gallons of plasma to the United States each month, according to an article in The New York Times.

The conclusion of Think Africa Press is quite worth noting.

Aside from turning an astonishing mass of research into a highly readable book, one of Pepin’s great accomplishments is the way he methodically addresses everyone’s – usually unknowing – culpability in spreading HIV. No one, not the bushmeat hunters in Central Africa, not the doctors distributing vaccines, not the sexual tourists who carried HIV from Haiti to the US, and not Pepin himself, realised the role they were playing in launching the worst pandemic in modern history. One of the key subtexts he proffers is that no one is to blame for the origin of AIDS, but that everyone must take responsibility.

The responsibility, as I’d written back in 2007, lies in that of the relatively privileged towards the relatively underprivileged. If the disease hadn’t emerged among radically disenfranchised populations in colonial central Africa and later spread preferentially to other disenfranchised and discriminated-against populations, it would have been noticed earlier. But it wasn’t, largely because no one cared enough to notice.

HIV seems to have made the leap to the United States towards the end of the 1970s and silently spreading. There, the first people known to be infected with HIV appear to have been users of IV drugs, the sexual partners, and their children. The first child suffering from AIDS that pediatric AIDS specialist James Oleske met was born in 1974 in New Jersey to a teenage girl with multiple sexual partners who used intravenous drugs. Later on, the first children born in New York City were children born in 1977, suggesting that HIV was present among users of IV drugs and their sexual partners as early as 1976. Shortly thereafter, the disease began spreading into gay/bisexual populations–in 1978, as many as 4.5% of a San Francisco cohort were infected with HIV. The connection of HIV with the socially marginal is reinforced by Michelle Cochrane’s analysis of some of the earliest cases of AIDS in San Francisco in When AIDS Began: San Francisco and the Making of the Epidemic makes the point that, far from being the well-off middle- and upper-class gays depicted by Randy Shilts in And the Band Played On, many of the first recorded victims in San Francisco were actually badly off, including several homeless people and more people employed at menial wages.

Why did no one see the big picture before the early 1980s? In badly-afflicted central Africa, as John Iliffe argues, the long latency period of HIV and the fact that AIDS manifested itself in terms of other well-known diseases helped hide the epidemic, even as civil tumult and economic collapse gutted local medical systems. César Nkuku Khonde’s “An Oral History of HIV/AIDS in the Congo” does suggest that many Congolese in the mid- to late-1970s were worried by a growing number of unusual deaths, but the paradigm of a new disease processes wasn’t picked up until the early 1980s. Many puzzling cases were diagnosed among people with central African connections by Western medical systems: a Belgian-Congolese married couple who left Congo in 1968 and died of AIDS in the late 1980s, a Belgian in Shaba state in the early 1970s who had multiple sexual partners, a Congolese child born in 1974 who a Belgian soldier who served in Zaire between 1976 and 1978 with multiple sexual partners, a Danish surgeon who was exposed to HIV-infected fluids while a surgeon in a hospital in the north of the country, a Canadian survivor of a plane crash outside of Kisangani in 1976 who received a blood transfusion there and died four years later in Edmonton … Again, no one picked up the AIDS paradigm. By the time that it was, HIV was too entrenched to contain. The lack of the AIDS paradigm played a major role n the United States and elsewhere in the developed world, perhaps aggravated by the concentration of HIV/AIDS in some of these countries’ most socially isolated and ignorable populations. Even in contemporary Canada, after all, 60-odd prostitutes could disappear in Vancouver between 1978 and 2002 before local police began a serious investigation.

The net result of this mixture of apathy and incapacity was that by the time that AIDS was first noticed in the United States, perhaps a quarter-million people had been infected with HIV around the world. Gaëtan Dugas, the famous supposed Patient Zero, had nothing to do with the emergence of HIV; he was just one more victim.

We owe Pepin thanks. Not only has he identified what seem to be the likely origins and developments of HIV before AIDS was noticed, but his arguments about the importance of responsibility point the way to stopping future epidemics. The details matter so much.

Written by Randy McDonald

December 1, 2011 at 11:57 pm

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