The story of the origins of AIDS

Dr. Pépin. Photo by Roger Lemoyne.

As buried treasures go, the reams of dry reports and technical data that Jacques Pépin unearthed while sifting through dusty medical archives from France’s bygone colonial era wouldn’t make most people’s Top Ten list. But to hear the soft-spoken Quebec epidemiologist tell it, the information he found one day in Marseille in 2006 was the scientific equivalent of discovering Ali Baba’s cave. “I hit the mother lode,” recalls Dr. Pépin, a clinician, professor and head of the department of microbiology and infectious diseases at Université de Sherbrooke. “When I got back to my hotel room, I just sat there thinking, ‘My God, this is incredible.’”

The same is being said about The Origins of AIDS, the acclaimed new book that he wrote as a result of that discovery. Published in October by Cambridge University Press, it pulls together and blends existing and new scientific evidence to chronicle both the emergence of HIV/AIDs in Africa in the early part of the 20th century and its evolution into a global pandemic. In particular, the book sheds new light on the pivotal role French colonialism played in spreading HIV from likely a single bush hunter infected with a simian immunodeficiency virus in central Africa in the early 1920s to large swaths of Africa and beyond.

Notably, its central premise, which has created a buzz in international scientific circles, is that the medical campaigns carried out by the French beginning in the 1930s to treat tropical diseases – using unsterilized or poorly sterilized reusable syringes – inadvertently propagated HIV infection to pandemic proportions.

The book also provides new insights and details on unknown or little-known episodes from the dark underbelly of French colonialism. These include the disastrous construction of a railroad line across difficult jungle landscape which resulted in the deaths of thousands of workers and led to the creation of massive government-run camps. These camps, filled with health-compromised workers and prostitutes from across French colonial Africa, offered the ideal setting for the fast-evolving HIV virus to perfect its ability to live in the human organism and be transmitted through sexual intercourse. That ability enabled the virus, as the book illustrates, to make its way to Haiti in the 1960s, where for-profit blood banks among the poor and sex-seeking gay tourists from North America helped the virus spread worldwide.

“I think Dr. Pépin did an excellent job,” says Beatrice Hahn, a professor of medicine and microbiology at the University of Pennsylvania’s Perelman School of Medicine and one of the world’s leading experts on the origins and evolution of human and simian immunodeficiency viruses. “He describes aspects of the early AIDS epidemic that have not been told before. And knowing history is important to avoid repeating it.”

According to Dr. Hahn, the book is a unique blend of solid research and compelling storytelling from a world-class scientist with a long and intimate working knowledge of African medicine and infectious diseases. “It took a very special person to do this,” she says. “Dr. Pépin has done the public a great service.”

Robert Brunham agrees. A professor in the infectious diseases division at the University of British Columbia and director of the UBC Centre for Disease Control, he calls Dr. Pépin’s book “the definitive report” on the origins of AIDS. “It is a beautifully told and highly useful story that reads like a detective novel,” says Dr. Brunham. “I think it is the kind of book graduate students would love to read. It illustrates the social determinants that allow viruses to spread and become global, and shows how connected  we all are at the local level.”

For Dr. Brunham, who was head of the epidemiology department at the University of Manitoba when Dr. Pépin studied there 25 years ago, The Origins of AIDS also gives its author some overdue recognition. “Jacques is already one of the best epidemiologists in Canada,” says Dr. Brunham. “I think now, with his book, he’ll be justly seen internationally as one of our national treasures.” In late January, Radio-Canada named Dr. Pépin “Scientist of the Year” for 2011 for his work.

Growing up in Sherbrooke, where his father Jean-Marc was a general internist, young Jacques Pépin dreamed of working in Africa. “It seemed so exotic to me [and] I had missionary zeal, though not in a religious way,” recounts Dr. Pépin, 53, in his tiny office at Hôpital Fleurimont, part of the U de Sherbrooke teaching hospital network. “I thought working there would be a useful and challenging way to live my life.”

That desire was the main reason he decided to follow in his father’s foot-steps and study medicine. With the help of a Belgian pediatrician he knew, Dr. Pépin went twice as a medical student to the Republic of Zaire (today the Democratic Republic of Congo) to work as an unpaid volunteer in a 250-bed regional hospital in Kinsantu, a two-hour drive west of the capital, Kinshasa. From the get-go in Africa he was smitten by the people he met and the places he visited. He says he was most impressed by the resourcefulness of the Congolese and their ability to handle adversity with grace and good humour. “The Congolese laugh at frustrating situations that would make most other people cry,” says Dr. Pépin. “If they didn’t, they would cry a lot.”

Dr. Pépin returned to Zaire – for good, he thought – as a newly minted physician in 1980. He spent much of the next four years at another so-called “bush hospital” in Nioki, 500 km northeast of Kinshasa. In addition to meeting a local nurse, Lucie, who is now his wife, Dr. Pépin did clinical work and epidemiological research on African trypanosomiasis, or sleeping sickness, under the auspices of a CIDA-funded program. He would later write a chapter on the disease that still appears in tropical disease reference books, and for three years he chaired a World Health Organization task force on treatment, cementing his reputation as one of the world’s foremost advisers and experts on trypanosomiasis.

In 1984, Dr. Pépin took what he called “the toughest decision I ever made” by returning to Canada for three years of internal medicine training – one year in Sherbrooke and two at the University of Manitoba. “The long-term prospects of a general practitioner in Congo weren’t good because more Congolese were being trained,” he explains. “I needed a specialty to continue working there.”

The move was a good one. Besides learning English, Dr. Pépin was able to expand his knowledge about infectious diseases and hone his considerable research abilities under infectious disease specialist (and Canadian Medical Hall of Fame laureate) Allan Ronald, now professor emeritus at U of Manitoba.

Dr. Pépin returned to Africa in 1988 to work at a British research station that was doing research on HIV-2 in The Gambia in West Africa (HIV has two strains, named 1 and 2). He helped set up a variety of internationally funded research projects that explored, among other things, the interaction of HIV infection and sexually transmitted diseases, and he developed public health strategies and awareness programs that have been credited with saving thousands of lives in several African countries.

When the British research team decided to switch the focus of their work to perinatal transmission in 1990, Dr. Pépin chose to accept a job as an infectious diseases physician in Sherbrooke. “I didn’t want to leave Africa again but I couldn’t see myself studying newborns,” he recalls. “That wasn’t what I was trained to do.”

Once home, Dr. Pépin and his wife relished the stability for raising their two young children. Continuing to work with various infectious disease projects in Africa, Dr. Pépin also made a name for himself in Canada when, after conducting two epidemiological studies on C. difficile colitis, he helped to identify a virulent strain that was causing dozens of deaths in hospitals across Quebec and in other provinces. The second study, published in the Canadian Medical Association Journal, was named the best article of 2005 by the Infectious Diseases Society of America.

It was another epidemic – a massive outbreak of African sleeping sickness in the early 1980s – that led Dr. Pépin to Marseilles in 2006. The trip was part of a painstaking pursuit that he had been carrying on part-time for three years to find evidence to prove his theory – or rather, a gut feeling – that the use of intravenous drugs to treat the disease was at least partly responsible for the transmission of HIV.

The trip came on the heels of an article he had published in AIDS, the official journal of the International AIDS Society. It used the results of a study involving 1,600 people in Guinea-Bissau – together with historical information about medical campaigns in the former Portuguese colony that Dr. Pépin found by poring over old newspapers and records in medical archives in Ottawa, Boston and London – to suggest that both ritual clitoris excision and multiple injections to treat sleeping sickness and tuberculosis were responsible for the spread of HIV-2.

He hoped to find similar proof about another outbreak of sleeping sickness in the former French colony of the Central African Republic by going through medical archives at the Institut de Médecine Tropicale de Santé des Armées, a military-run facility in Marseille. He soon realized, on the first day of his visit, that he had stumbled onto a goldmine of information about widespread intravenous treatment of not only sleeping sickness but also a half-dozen other major diseases including leprosy and yaws. “When I saw all the material there, like one 800-page report with a hundred tables of data on numbers of injections given and the drugs used, I was literally speechless,” recalls Dr. Pépin. “I realized I could expand my research to other countries and other diseases.”

He spent the next two weeks frantically photocopying and scanning reports. “I just grabbed everything I could and took it all home with me.” After digesting that material, he returned to Marseilles a few months later – this time armed with a digital camera – and took photos of thousands more pages of material about medical campaigns in French colonial Africa.

It was during that second trip that Dr. Pépin says he experienced the dizzying eureka moment: the realization that he had very likely discovered the smoking gun – the mechanism that led to the widespread transmission of HIV. That became clearer, he adds, when he began writing up his findings and linking them with the information he had already uncovered, as well as his own first-hand experience. “It was like a massive puzzle,” he says. “But I knew then that I finally had all the pieces I needed to complete the picture. It just took time to put it together.”

The information he found in Marseilles has helped Dr. Pépin to write, in addition to his acclaimed book, two major scientific articles, with more in the pipeline, on the transmission of other major diseases in equatorial Africa.

“Jacques is the recruit I’m most proud of,” says microbiologist Raymond Duperval, who hired Dr. Pépin in 1990 when he was head of the department of infectious diseases at U de Sherbrooke (he retired last year and the position is now held by Dr. Pépin). “He is a tireless worker, a real research machine. But he is also an extremely modest person, very approachable. To meet him you’d never guess he was a scientific superstar.”

True to form, Dr. Pépin smiles sheepishly when asked about the high praise he has received for his book. “It was a labour of love,” he says of the project, which took him four years to complete and cost him thousands of dollars of his own money. “Being able to tell a coherent story of AIDS was my goal. I’m happy that I was able to put all the bits and pieces of the puzzle together.”

Mark Cardwell is a freelance journalist based in Quebec City whose specialties include medicine and health.