Jacques Pepin, a Canadian professor of microbiology who, during the 1980s, worked for four years at a bush hospital in Zaire. Pepin coauthored several journal papers on the subject and, in 2011, published a book titled The Origins of AIDS. Having added some deep historical research to his own field experience and microbiological expertise, he proposed that the crucial factor intermediating between the Cut Hunter and the global pandemic was the hypodermic syringe.
Pepin wasn’t referring to recreational drugs and the works shared by addicts at shooting galleries. In a paper titled “Noble Goals, Unforeseen Consequences,” and then at greater length in his book, he pointed instead to a series of well-intended campaigns by colonial health authorities, between 1921 and 1959, aimed at treating certain tropical diseases with injectable medicines. There was a massive effort, for instance, against trypanosomiasis (sleeping sickness) in Cameroon. Trypanosomiasis is caused by a persistent little protist (Trypanosoma brucei), transmitted in the bite of tsetse flies. The treatment in those years entailed injections of arsenical drugs such as tryparsamide—and a patient didn’t get just one shot but a series. In Gabon and Moyen-Congo (the French colonial name for what’s now the Republic of the Congo), the regimen for trypanosomiasis sometimes entailed thirty-six injections over three years. And there were similar efforts to control syphilis and yaws. Malaria was treated with injectable forms of quinine. Leprosy patients, in that era before oral antibiotics, underwent a course of injections with extract of chaulmoogra (an Indian medicinal plant), two or three shots per week for a year. In the Belgian Congo, mobile teams of injecteurs, people with no formal education but a small bit of technical training, visited trypanosomiasis patients in their villages to give weekly shots. It was a period of mania for the latest medical wonder: needle-delivered cures. Everyone was getting jabbed.
Of course, this was long before the era of the disposable syringe. Hypodermic syringes, for injecting medicines into muscles or veins, were invented in 1848 and, until after World War I, were handmade of glass and metal by skilled craftsmen. They were expensive, delicate, and meant to be reused like any other precision medical instrument. During the 1920s their manufacture became mechanized, to the point where 2 million syringes were produced globally in 1930, making them more available but not more expendable. To the medical officers working in Central Africa at that time, they seemed invaluable but were in short supply. A famous French colonial doctor named Eugène Jamot, working just east of the upper Sangha River (in a portion of French Equatorial Africa then known as Oubangui-Chari) during 1917–1919, treated 5,347 trypanosomiasis cases using only six syringes. This sort of production-line delivery of injectable medicines didn’t allow time for boiling a syringe and needle between uses. It’s difficult now, based on skimpy sources and laconic testimony, to know exactly what sort of sanitary precautions were taken. But according to one Belgian doctor, writing in 1953: “The Congo contains various health institutions (maternity centres, hospitals, dispensaries, etc.) where every day local nurses give dozens, even hundreds, of injections in conditions such that sterilisation of the needle or the syringe is impossible.” This man was writing about the risk of accidental transmission of hepatitis B during treatment for venereal diseases, but Pepin quoted his report at length, for its potential relevance to AIDS:
The large number of patients and the small quantity of syringes available to the nursing staff preclude sterilisation by autoclave after each use. Used syringes are simply rinsed, first with water, then with alcohol and ether, and are ready for a new patient. The same type of procedure exists in all health institutions where a small number of nurses have to provide care to a large number of patients, with very scarce supplies. The syringe is used from one patient to the next, occasionally retaining small quantities of infectious blood, which are large enough to transmit the disease.
How much of this went on? Very much. Pepin’s diligent search through old colonial archives turned up some big numbers. In the period 1927–1928, Eugène Jamot’s team in Cameroon performed 207,089 injections of tryparsamide, plus about 1 million injections of something called atoxyl, another arsenical drug for treating trypanosomiasis. During just the year 1937, throughout French Equatorial Africa, the army of doctors and nurses and semipro jabbers delivered 588,086 injections aimed at trypanosomiasis, not to mention countless more for other diseases. Pepin’s arithmetic totaled up 3.9 million injections just against trypanosomiasis, of which 74 percent were intravenous (right into