Book Review

I went for a run with a local young man in the beautiful hills of Pietermaritzburg, South Africa while I was visiting for a research meeting. We fell comfortably into discussion about health and diseases prevalent in the country, particularly HIV. He asked me if I knew how HIV began and I explained as best as I understood about the viral transfer between animal (monkey) to human. He hesitated as if to answer, and when I pressed him to continue he commented: “Isn’t HIV really just a virus created by American politicians?” I was quite taken aback, shocked in fact to hear this question from him, an intelligent educated man. I wondered if this was denialism, like former President Mbeki who downplayed the viral source as having caused the pandemic and argued around the facts for political reasons with unhelpful consequences. I was reminded that although this pandemic has had devastating physical consequences, it has had massive social implications as well. The populations with high HIV incidence have been deeply stigmatized and changed. Returning to Canada after this conversation, I was particularly intrigued by the title of the new book ‘The Origin of AIDS’ and hoped to gain a better understanding of how Mbeki's “one little virus” could transform the world scientifically and socially. I was not disappointed. Author Jacques Pepin sets out page by page, to unravel the true story of HIV, something attempted only one other time in Hooper's long disputed book ‘The River’. His writing style is frank and conversational, telling you what he has discovered in a simple straightforward style. But by no means is this a simple work. The bulk of the book is a solid scholarly work that is deeply and thoroughly researched. Despite the dense subject matter, the chapters are punctuated with light biographies of key figures, or perhaps simply those he found interesting. He explores every possible alternate theory to the absolute ‘epidemiological end’ so that when you reach his HIV narrative summarized in the penultimate chapter you find yourself easily in agreement. Pepin starts in central Africa at the home of the only chimpanzee source of SIVcpz, the genetic precursor to human HIV-1. Prior to the 1920's humans long hunted SIV-infected chimps in rural Congo. Molecular dating technique locates the oldest case of HIV-1 in Leopoldville, Congo (today's Kinshasa) around approximately 1921. Pepin endorses the “hunter-cut theory “that suggests the advent of firearms in the colonial era (1920's) increased the proximity of hunted chimps to humans and therefore the likelihood of blood contact between wounded hunters and chimps. He estimates from epidemiologic calculations that likely 2 humans were infected with SIVcpz in this manner. In light of this theory and despite the tempest of social change occurring at this time Pepin argues that statistically there is still a missing amplifying factor that enabled the HIV pandemic. Was colonialism alone the culprit? Was it sex? Pepin discusses how French and Belgian colonialists enforced repugnant and racist policies on the indigenous population in Central Africa resulting in largely gender imbalanced (male > female) work camps. Leopoldville was one of them. It was out of this setting that prostitution prospered. Pepin devotes a fascinating chapter to remind us that prostitutes, ‘femmes libres’ at the time, were predominantly unmarried women choosing financial security and independence over their traditional powerless role in society. But they serviced only about 5 regular partners which is determined to be a low-risk prostitution that does not explain the exponential spread of the disease. The economically challenged post-colonial era ushered in a more desperate and rampant ‘high-risk’ prostitution, but according to Pepin's calculations, sex still wasn’t enough. What about massive inoculation campaigns led by health professionals to eradicate STI's and tropical diseases in a pre-oral antibiotic era? Although some of his hypotheses in the book are logical deductions, for this theory, Pepin provides solid convincing support. HIV is transmitted ten times more effectively by injection than sexual contact. As described from his research, these campaigns were designed to reach as big a population possible, from rural villager to migrant worker. This could be done cheaply, with just a few needles and a couple of nurses who would administer medication again and again to hundreds of people. In many cases people sustained upwards of 300 inoculations per year. One glass reusable needle could plausibly have reached one of two SIVcpz infected hunters with devastating amplification as a result. The role of medical professionals in the spread of HIV as suggested by Pepin presents a new emphasis in our collective understanding of the origin of AIDS. It is an almost poignant part of the book that is otherwise written in a calm and rational manner. As a young physician in Central Africa prior to 1980's Pepin often did not have the capacity to retain consistently sterile needles and he realizes, although entirely unintended, the negative impact of his actions. The story carries on in the 60's as we watch the virus travel with a Haitian technician working in fractured post-colonial Congo to Haiti. There, in impoverished Duvalier-era Haiti, HIV-1 was able to thrive in two particular populations: firstly, a plasma collection center Hemo-Carribean, which gave money to the poor for blood donations that were then pooled and sent around the world; secondly a post-liberation promiscuous gay population engaged in sexual tourism. Fast-forward to 1980's, approximately 15-20 years post-incubation, and the first PCP pneumonia appears in the US. Pepin has created a ‘chef d’oeuvre’, a contribution to our knowledge of HIV. He clearly respects the scientific community and therefore readily accepts their praise and encourages their critique of his work. As a testament to his skills as a curious researcher, he became a historical, epidemiological and molecular sleuth. His honest writing even allows us, I believe, to know him a bit as a person: proud intellectual, patient, humble, with subtle humour. Pepin's deconstruction of HIV spread, from its origins onwards, importantly removes the longstanding blame associated with certain populations and sexual practices that has belied the true complex and multifactorial causes of the pandemic for so long. This is a cautionary tale that reminds scientists and medical professionals that although well-intentioned, their actions may tamper with our decidedly unpredictable natural world leading to potentially disastrous results. So, do proceed, but proceed with careful reflection. I would encourage my fellow global health students to read this book because it is a great representation of how health consequences are informed by underlying social inequalities, the very purpose of our field of study. I would encourage my friend in South Africa to read the book to grasp the true story that led to the pandemic. For myself, I remember Mbeki's argument that ‘one little virus’ could not possibly have caused ‘all this’, the AIDS pandemic. In fact, HIV does cause AIDS the disease, but, maybe he had a point – there was more than just HIV that caused the AIDS epidemic.

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