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Chapter 10 reviews the history of colonial medicine in the Belgian Congo. In this huge colony, Belgium established arguably the best healthcare system in tropical Africa, with more than 2,500 institutions of all kinds. As in the French colonies, there were large-scale disease control interventions using injectable drugs. A network of public health laboratories, including those in Léopoldville and Stanleyville, are ruled out as being instrumental in the early propagation of HIV. The brilliant career of Lucien Van Hoof, the colony’s chief medical officer for twelve years who also did cutting-edge research on the control of sleeping sickness, is highlighted. The rather debatable medical practices in Léopoldville’s STD clinics are examined; ‘free women’ were forced to undergo a long series of intravenous injections if they were thought, often wrongly, to have had syphilis previously. An outbreak among these women of ‘inoculation hepatitis’ was recognised in the early 1950s. An analysis of changes in the incidence of tuberculosis in various parts of the Belgian Congo in the 1950s suggests that HIV was already driving this increasing incidence in Léopoldville. A recent study identified several routes for the iatrogenic transmission of blood-borne viruses during the colonial and early post-colonial era.
Chapter 9 looks at the history of colonial medicine in French Africa. Eugène Jamot, the most famous French military doctor, spearheaded efforts in the 1920s to control sleeping sickness. These interventions were later extended to other endemic diseases such as yaws, syphilis and leprosy. Case-finding activities in every village, with on-the-spot treatment of infected patients with injectable drugs administered using unsterilised syringes and needles, led to massive infection with the hepatitis C virus of as many as half of some birth cohorts. Obviously, this could have resulted in the concurrent iatrogenic transmission of HIV, in the very parts of central Africa inhabited by the chimpanzee source of the virus.
Chapter 11 looks at human immunodeficiency viruses other than HIV-1 group M. This includes the other three groups of HIV-1 (groups N, O and P) as well as HIV-2. Their geographic points of origin are identified and an attempt is made to understand their very different fates: from two persons infected (HIV-1 group P) to seventy-eight million (HIV-1 group M). It is concluded that chance and geography played a role (i.e. whether or not the viruses had access to the capital of the Belgian Congo), as well as biological factors (HIV-1 group M being more transmissible). Then HIV-2 is examined: its simian source, geographic distribution, and lower pathogenicity and transmissibility. Through a review of the colonial and post-colonial history of Guinea-Bissau, its epicentre, it becomes clear that iatrogenic transmission must have been the driving force in the emergence of HIV-2. The path of this retrovirus is followed all the way to Goa in Portuguese India, and historical factors support the view that this may have been the first successful exportation of a human immunodeficiency virus outside Africa.
The official birth date of the AIDS epidemic is 5 June 1981. In an article of fewer than 500 words published in the Centers for Disease Control’s (CDC) Morbidity and Mortality Weekly Report, American clinicians described a cluster of five cases of Pneumocystis carinii pneumonia, a very rare infection of the lungs hitherto seen only in patients with severely compromised immune systems. These five initial cases were diagnosed between October 1980 and May 1981. All were gay men living in Los Angeles who had previously been healthy and were not receiving drugs that suppressed the body’s immune response. Quite a strange coincidence.
Chapter 13 summarises how the blood trade, and especially the sale of plasma, obtained from ‘donors’ who repeatedly attended specialised ‘plasmapheresis centres’, played a substantial role in the worldwide dissemination of HIV and also in the amplification of HIV shortly after it arrived in Haiti. In Port-au-Prince, a for-profit plasmapheresis centre, owned by a Miami investor and a Haitian minister, attracted several thousand poor men and women who sold their plasma week after week for a few dollars in 1971–2, just a few years after the virus arrived in Haiti. HIV spread extremely quickly in other plasmapheresis centres, especially in China, where quarter of a million people were infected with HIV. Other victims included haemophiliacs from many countries who were contaminated when treated with a coagulation factor concentrate whose preparation required the pooling of plasma from thousands of donors in many countries, procured through ‘plasma brokers’.
Chapter 5 sets the stage for the rest of the story. While several infectious agents were exported from Africa to the Americas and the Caribbean during the slave trade, this was not the case with HIV, which indirectly confirms its relatively recent emergence in central African populations. This chapter briefly tells the story of the European colonisation of central Africa by France and Belgium. It explains how the Franco-Belgian incursion in south-east Cameroon during World War I (1914–16) created much greater intermingling of populations and may have provided a route for HIV to reach the Stanley Pool.
Chapter 8 explains how blood-borne viruses are transmitted through contaminated injections. Throughout the world, intravenous drug users are a high-risk population for HIV and the hepatitis C virus. Medical interventions that re-used unsterilised syringes and needles were also implicated in the transmission of blood-borne viruses. In Egypt, millions were infected with the hepatitis C virus through the mass treatment of schistosomiasis, a parasitic disease. Hundreds of thousands of American soldiers were infected with the hepatitis B virus during World War II through a contaminated yellow fever vaccine. In Romania, Libya, the former Soviet Union, and more recently in Cambodia and Pakistan, large outbreaks of iatrogenic HIV infection have been reported and continue to occur.
Chapter 3 explores exactly when HIV’s odyssey began – that is, when it made the leap from chimpanzee to human. It reviews the saga of the building of the railway between Brazzaville and the Atlantic Ocean, and the staggering mortality among the thousands of men forced to work on the construction sites. This part of the story features Léon Pales, a clever French surgeon posted in Brazzaville who performed autopsies and identified a new disease eerily similar to AIDS among some of the railway workers. The last few pages of this chapter describe how evolutionary biologists estimated the time when the common ancestor of all HIV-1 strains, the one that infected the very first patient, existed, which was probably in the first two decades of the twentieth century.
Chapter 16 explores the fate of two individuals who left their mark on the history of AIDS, but for very different reasons. Gaétan Dugas, a French Canadian airline steward, was falsely accused of being the man who brought the virus to the USA and of having deliberately infected dozens of other gay men in some kind of morbid vengeance. This ‘false villain’ was eventually exonerated by evolutionary biologists who succeeded in characterising Dugas’ own virus. The life of Jonathan Mann, a visionary humanist who founded the World Health Organization’s special programme on AIDS, illustrates the beginning of the international battle against HIV/AIDS in the late 1980s. A parallel is drawn between Mann and Rieux, the main character in Albert Camus’ novel The Plague.
Thirty-nine million deaths later, are there any useful lessons that can be drawn from the tragedy of AIDS? Or was it just an extraordinary confluence of chance events, unlikely to ever be repeated? In retrospect, two factors probably drove the transformation of SIVcpz into pandemic HIV-1. Even if their respective contributions will never be fully sorted out, there is little doubt that without both of them the pandemic would not have developed.
Chapter 1 starts by describing how, shortly after HIV was identified as the cause of AIDS, it became increasingly clear that the virus originated in Africa. Tests of archival blood samples, retrospective confirmation of early cases of AIDS and comparison of the genetic diversity of HIV in different parts of the world all pointed to central Africa, and especially the two Congos, as the probable location for the beginning of HIV’s journey. Studies of HIV subtypes provide the foundation for reconstructing the complex routes followed by the virus across the world. The example of Cuba illustrates how geopolitical events influenced the spread of HIV. The first epidemic of Ebola fever in a bush hospital in the Congo, as well as recent epidemics in the same country and in West Africa, are used to explain the peculiar characteristics of HIV that enabled it to cause a pandemic.
Chapter 14 assembles the pieces of the puzzle described in the preceding twelve chapters into a coherent narrative of HIV’s journey, from when the first patient was infected somewhere in south-east Cameroon at the turn of the twentieth century until this ‘new’ disease was recognised in the USA in June 1981. The virus first travelled from its Cameroonian crucible to Léopoldville (Kinshasa), where it arrived around 1920, brought either by the crew of the steamships that transported various commodities for export or by troops from the two Congos that had been dispatched to invade south-east Cameroon during the Great War. Léopoldville was the turning point in HIV’s fateful journey, the place where it slowly progressed over some thirty years before expanding more rapidly in the 1950s.