Dr. Kevin De Cock

Kevin De Cock

CHAMBERLAND: This is Dr. Mary Chamberland, and I'm here with Dr. Kevin De Cock at the Centers for Disease Control and Prevention [CDC] in Atlanta, Georgia. Today is Monday, June 13, 2016. I'm interviewing Dr. De Cock as part of a project to document CDC's early response to the AIDS [acquired immune deficiency syndrome] epidemic. Dr. De Cock, do I have your permission to interview you and to record this interview?

DE COCK: Yes, you do.

CHAMBERLAND: Thank you. Kevin, although your work on AIDS for CDC began some five years after the initial report of Pneumocystis carinii pneumonia in homosexual men in June of 1981, it was nonetheless pioneering in its own right. Your work led to the establishment of a field station in Abidjan, Côte d'Ivoire (Ivory Coast) to learn more about the global aspects of the AIDS epidemic. However, before we go there, let's talk a little bit about your background. Could you tell us where you grew up and about your early family life?

DE COCK: Sure. I was born in Belgium. My father was Belgian. He was a general surgeon of the old school, and my mother was American. I grew up in Belgium but was sent to boarding school in England when I was seven and finished the rest of my education in England. So I did all my high school and then university medical school in England as well. That's my early education and early life.

CHAMBERLAND: And then you went on to university. Where was that, and what did you study?

DE COCK: I went to the University of Bristol in the west of England, studying medicine. In the United Kingdom, medicine is an undergraduate degree. I did my five years of medical school and then trained in internal medicine in Bristol and the surrounding area.

CHAMBERLAND: What influenced you to be a physician? Someone in person or--

DE COCK: I think from my earliest memories I thought I would do medicine. I suppose the fact that my father was a doctor must have had an influence. But from very early on, I knew that that's probably what I wanted to do. I did have some doubts when I first arrived at university and was thinking of switching to politics and economics, but fortunately I stuck the course.

CHAMBERLAND: Some of your early career in medicine was focused on liver disease, and you actually came to the States to do some of your training. How did that interest in that specialty come about?

DE COCK: To go back a little bit, when I studied medicine I always knew that I wanted to work in a developing country. I'd gotten very interested in the problems of resource-poor countries. When I finished my internal medicine 00:03:00training, I took a tropical medicine degree and got a job as a lecturer in medicine, an assistant professor type position, at the University of Nairobi in Kenya. This was actually quite useful, because not only was it something I wanted to do, but it counted as my Belgian military service. So, I went for two years but stayed three, from 1979 to 1982.

I was very interested in liver disease. I guess that was probably influenced by my professor of medicine in Bristol, for whom I worked, who was a liver specialist. In Kenya, I did a lot of work on liver disease. I did some applied research and applied for a fellowship to do a fellowship in hepatology at the University of Southern California, which at that time was probably the biggest clinical liver disease unit in the United States. So, from 1983 to 1986, I was working at the University of Southern California on the liver unit, as a fellow 00:04:00and then as a faculty member.

CHAMBERLAND: The kinds of diseases that you were--were you involved in some of the hepatitis work that was going on at the university?

DE COCK: Yes, I was interested in hepatology. I was also interested in infectious diseases, particularly in the overlap. The unit I worked on had a major interest in viral hepatitis, and that's really what I concentrated on in those three years. By the time I arrived in Los Angeles, I was already interested in this phenomenon of AIDS. Having read a lot about it--actually, being particularly interested in the very early reports that were coming out about AIDS in Africa, but also AIDS elsewhere. Of course, working in hepatitis, we saw some of the same patients at risk for both. In Los Angeles, we had a major interest and major experience in hepatitis delta virus and again, probably 00:05:00the biggest experience in the United States.

CHAMBERLAND: So, you've been in California for three years. You're focused on this area, but some early interest in AIDS. What is it that then triggered your move to CDC as an EIS (Epidemic Intelligence Service) officer? What made you shift from clinical medicine and move towards public health?

DE COCK: As always or is often, chance, serendipity, who you bump into makes a big difference. My boss, one of my bosses, [Dr.] Allan Redeker, who was well known in the hepatitis world, was friends and colleagues with [Dr. James] Jim Maynard, who was the head of the hepatitis branch here at CDC. Maynard came out to California to discuss with Redeker--they actually wanted to do a study in Brazil. Maynard wanted to do a study in Brazil on delta and actually asked 00:06:00Redeker if there was anybody available to participate in this as a hepatologist. I was going to do that, so that was my initial contact. After my fellowship, I was an assistant professor for a year. I began to think I needed to do some more training, and I had the opportunity to go to NIH [the National Institutes of Health]. But this contact with CDC sounded very interesting, and Maynard and his deputy, [Dr. Harold] Hal Margolis, encouraged me to apply for the EIS program, which I did.

CHAMBERLAND: When you came to CDC to work on EIS, you were in CDC's Division of Viral Diseases, but not working necessarily in hepatitis.

DE COCK: That's right. I expected to be working on hepatitis. But when I arrived I found out, at the conference before starting, when you do the match, I found 00:07:00that they had no positions. I must say, to my surprise at the time. I thought that was the whole point. I then went to the--by then actually I was more interested in HIV [human immunodeficiency virus] anyway, or AIDS. I went to the Special Pathogens branch in Viral Diseases, which is the branch that deals with hemorrhagic fevers, Lassa, Marburg, Ebola, those kinds of viruses. But that branch also had been involved with looking at HIV in Africa, and that actually was what I really wanted to get into. So, it was a good fit.

CHAMBERLAND: Tell us a little bit about your first foray into AIDS-related work out of the Special Pathogens branch. You said that was--they actually had some studies that intersected with AIDS. Tell us a little bit about that first project.

DE COCK: My supervisor was [Dr. Joseph] Joe McCormick, and it was really Joe, I think, who got CDC involved in Africa in the first place, as far as HIV was concerned. He told me that in the early '80s, '82, '83, he just heard from other colleagues in Europe that something was going on. They were seeing some new disease that seemed to have features of what was being described in AIDS patients in the United States and Europe. Joe actually was instrumental in establishing Projet SIDA [SIDA, the French acronym for AIDS], which was established in 1984. He was key, the senior investigator actually, for the study that was done in 1983 that led up to the proposal to set up this long-term 00:09:00research site. He was also, I think, instrumental in recruiting [Dr.] Jonathan Mann, who was the first director of Projet SIDA.

CHAMBERLAND: This was the project that was in Zaire [now the Democratic Republic of Congo] that was established.

DE COCK: Right. That started in '84. The fact that my branch, Special Pathogens, was somehow peripherally involved in all of this in '86 was very intriguing to me.

CHAMBERLAND: Joe came up, I think, with a project for you to do that involved tracking back to see maybe just how long AIDS might have been in Africa, as I understand it.

DE COCK: Yes, this was one of those rather extraordinary experiences that you couldn't really make it up. There had been--the first epidemic of Ebola described was in 1976, so ten years before I did EIS. It was in 1976 in a very 00:10:00remote part of northern Zaire, now called the Democratic Republic of Congo. Very remote, in a village called Yambuku, which was about 100 kilometers or so, maybe 200, from the border with the Central African Republic. So, way up in the north, in the Équateur region, had been this very severe epidemic that had been investigated. CDC had been involved in that investigation. [Dr.] Karl Johnson was the expert, the leader of the hemorrhagic fever group. Joe was involved in that investigation.

To cut a long story short, there were studies done in the villages, collecting blood samples that were later tested for evidence of Ebola antibodies. Those specimens came back to Atlanta and went into the freezers here. When AIDS 00:11:00happened, and then it was known that there was AIDS in Zaire and the project got set up in Kinshasa, and a test became available for the causative virus HIV, Joe had the bright idea to pull these specimens from the freezers and test them. If I recall correctly, there were, I think, 659 specimens tested, of which five were positive. So, five out of 659--

CHAMBERLAND: Back in 1976.

DE COCK: 0.8%, back in 1976. Joe, somewhat optimistically, said to his EIS officer, [Dr. Donald] Don Forthal, who was the EIS officer the year before me, so in 1985. Joe said to Don, "I want you to go to Zaire, and I want you to go and find these people." Which sounded like looking for a needle in a haystack. Don duly went, and because this region is so remote and people really didn't 00:12:00travel very much, he actually was able to find two or three of them and find out what had happened to the others. Some had died. I think he found two or three who were still seropositive but still alive. I started in '86, and Joe said to me, "I want you to go back there and find the negative people and test them and see if any have become positive." I did that, and it was just a remarkable experience of logistics and funny stories of folkloric events to do what in fact was, technically speaking, a retrospective cohort study. It was a very interesting experience.

There were still--the Ebola epidemic in '76 was a devastating event. In this 00:13:00mission hospital, which also had a school and so on, about half of the priests and the nuns had actually died. But there were still four Belgian nuns there, some of whom, including the mother superior, had been in the epidemic. Now, because I speak Flemish and these were Flemish nuns, I was treated like the son they never had. I was extremely welcomed, and it was just fascinating sitting and talking to them about the Ebola epidemic, but also then doing this study.

Again, to cut a long story short, I actually did find about 80 people. We tested them and none of them had seroconverted. The very interesting finding was that in 1976, the seroprevalence in this very remote area was 0.8%. Ten years later, it was still 0.8%. Meanwhile, in Kinshasa, a quite severe epidemic had emerged 00:14:00over this period of time. We collaborated for the study with Belgian colleagues from the Institute of Tropical Medicine in Antwerp, who were looking at high-risk groups in the local towns and so on. Rather implausibly, out of this adventure really, whose protocol was written on the back of an envelope, we actually got a paper in the New England Journal of Medicine. It was really a rather remarkable event.

CHAMBERLAND: Gosh, that sounds like classic shoe-leather epidemiology, although with a Flemish twist there. This is a really very interesting early experience. Also during your EIS, however, the whole idea of establishing a second study site in Africa, a second CDC-sponsored study site in Africa, came about in a 00:15:00different country, Ivory Coast, Côte d'Ivoire. Tell us a little bit about the genesis of this project. Why was there felt a need to have a project set up in Côte d'Ivoire? What were the goals of the project?

DE COCK: This was chance again, although to some extent chance favors the prepared mind. I came back from--typical CDC experience--I came back from Zaire, I remember it well. It was late November, I think, when I came back. I arrived back in Atlanta on a Saturday or Sunday. On the Sunday I went into the branch just to see if I had any mail and that kind of stuff, and saw some cables lying around about an unknown disease in Nigeria. On Tuesday, so two or three days 00:16:00after getting back, I was told I had to go to Nigeria. I left one or two days later for what ended up being several months of work, with two trips to Nigeria and work in Fort Collins, Colorado, on yellow fever. It was a very big yellow fever epidemic.

When I got back from the second Nigeria outbreak of yellow fever, I was due to go to the AIDS conference in Washington. This was now the end of my first EIS year, 1987, the Third International Conference on AIDS. The first [was] in Atlanta, the second in Paris, and the third one in Washington. I was presenting some of this work from Zaire. I had a couple of posters. I happened to be in my office preparing to go to the conference. My office was--I think it was building 16, which doesn't exist anymore. It was the end of the catwalk, which some may remember. I was in the sub-subbasement, about two floors underground, in what 00:17:00literally was like a cave. It was a really pretty horrible office. The high-security lab was just down the corridor from us. The phone went, and I picked it up, and it wasn't for me. It was for Joe McCormick, my boss. Somehow, whoever was on the other end of the line said, "Well, we wanted to invite him to a meeting on AIDS in Africa that the NIH is organizing just before the Washington AIDS conference." I said, "Well, can I come?" I don't know what would have happened if that phone call hadn't come through.

So anyway, Joe and I both went. [Dr. James] Jim Curran was there and lots of senior people. There was a brief meeting a day or a day and a half before the major conference. It was on research going on in Africa, [with] different groups presenting. There were presentations from people working in West Africa. There 00:18:00were presentations from Projet SIDA in Zaire and others as well. But there were some presentations from West Africa, where the presence of another virus had been described shortly before. [They] described initially serological evidence of this virus by a group, including the Harvard group led by [Dr.] Max Essex and some French workers. The initial paper in the Lancet said that the people who had this virus, sex workers in Senegal to be specific, were not ill and were well.

CHAMBERLAND: Were the viruses similar? Did they characterize the virus?

DE COCK: It hadn't been characterized yet. This was just serological evidence at that time. There were people at the NIH meeting working in other West African 00:19:00countries, specifically Guinea-Bissau and Cape Verde, who were describing patients with AIDS with a virus that was not human immunodeficiency virus 1 [HIV-1]. The French in fact, again the group of [Dr. Luc] Montagnier actually, the French again had isolated this virus which now was called--again, the nomenclature was confusing, but #2 was associated with this virus. So, lymphadenopathy-associated virus [LAV-2], eventually [known as] HIV-2. This seemed to be a different virus, but we knew nothing about it.

There was controversy because one group was saying, "It doesn't cause disease." Another group was saying, "Yes, it does." Then, "Well, if it does, maybe it's not as severe." We had no evidence of how it was transmitted, although presumably [it was] sexual because it was again found in high-risk groups 00:20:00particularly. So, there was debate at this NIH meeting. This was clearly important, because here you had another virus circulating in West Africa which we knew very little about, which was different from HIV-1. The diagnostics for HIV-1 didn't work or only worked partially, or we didn't really know whether they could detect this other virus. This potentially had public health implications, including for the blood supply. As we were sitting there listening to some of this discussion, I leaned over to Joe McCormick and said, "You know what we need? We need another Projet SIDA in West Africa." Joe said, "Yeah, you're right." It went from there. It went from there.

CHAMBERLAND: How was Côte d'Ivoire selected as the study site in West Africa?

DE COCK: At the main meeting, then, when I went to the major AIDS meeting, this really become my passion. I had to figure out how could we do this. I talked to different people. First, I talked to some very senior people outside of CDC to say, "Does this make sense? Do you think this is possible?" Including, actually, [Dr.] John La Montagne, who was of course very senior at NIH. He was a very kind man. I met him--there was a high-level visit to Zaire when I was doing that field work six months previously, and I'd met a lot of senior folks, [Dr.] King Holmes, [Dr.] Karl Western, John La Montagne. I sort of helped shepherd them around. I asked him, "Does this make sense?" He said, "Yes, I think so." I said--I wanted to make sure I wasn't out of place or completely out of judgment. 00:22:00But he said, "Yes." So I spent a lot of time at the conference trying to meet people from different West African countries, because Joe and I had agreed that what we should probably do is visit, visit different countries.

So I made contact with as many people as I could, including people from Côte d'Ivoire. What then happened is we went back to Atlanta and talked to Jim Curran. By this time also Jim had--there was a small group working on international AIDS that was becoming more structured--and Jim had recruited [Dr. William] Bill Heyward to be the leader of that group. We talked to Jim Curran. We got his approval to actually do a field trip out to West Africa. How did we decide where to go? It's a little bit like one of those European conferences in 00:23:00the late 1800s, standing at the map and saying, "Who's there and who's where?" Because in some countries there was work already ongoing, and we clearly wouldn't be welcome.

So we eventually settled on visiting three countries: Guinea, Burkina Faso, and Côte d'Ivoire. The criteria for deciding whether or not to set up a site were really the amount of disease, the amount of HIV-2 that was there, the infrastructure that would support a research site, and the interest and commitment of the government. We went to the three countries, and Côte d'Ivoire seemed the most logical place to go. It was the right decision.

CHAMBERLAND: You, after finishing EIS, became the founding director of the project in Ivory Coast, Projet RETRO-CI [Retrovirus Côte d'Ivoire project], as it is referred to. I think I'd like to--it's a fascinating story to hear about 00:24:00how it came to be founded, because that's not recorded in any of the journal publications. I'd like to explore with you a little bit more about the project, both from an operational as well as a research perspective. You have this initial field trip, if you will, and selected Côte d'Ivoire. When you were talking with a country and then heath officials and then people back in the States, what was the general plan as to how the project would be organized and managed? It was clearly going to be some kind of joint venture with CDC and the country health officials?

DE COCK: Yes. I mean, we looked at the experience of Projet SIDA and sort of judged what went well, what didn't go so well, and try and do our best in Côte 00:25:00d'Ivoire. One thing that was clear was that Projet SIDA was a collaboration between CDC, NIH, and the Institute of Tropical Medicine in Antwerp. That collaboration was not always easy. In Abidjan, we said CDC will be the partner here with the government of Côte d'Ivoire.

CHAMBERLAND: I see. Were there any other groups involved?

DE COCK: Not initially, but in, I think if I remember correctly, in 1991, Projet SIDA essentially stopped operations because of political and civil disturbances. We had been working in some of the same areas, including working with high-risk populations such as sex workers. When that happened, I said to my Belgian colleagues, I said, "Look, can we try and move some of this work, this very good work going on in Kinshasa to Abidjan?" Which actually, they did. [Dr.] Peter 00:26:00Piot visited us in, I think it was 1991, [Dr.] Marie Laga from Antwerp, and then we actually--they seconded an epidemiologist named [Dr.] Peter Ghys. He worked with us in Abidjan for several years.

CHAMBERLAND: I didn't realize that there was such a gap. I knew that the Belgians eventually became involved in the project, but it was because of Projet SIDA coming to an end and folding. Interesting. How difficult was it to get the project started? What were some of the challenges? You said one of your criteria was that there was some sort of infrastructure in place, but I imagine that you were pretty much starting from scratch to build this. So I was just curious how that actually happened. Sort of the mechanics of it all and what number of staff 00:27:00that you were working with. I imagine it would be pretty skeletal.

DE COCK: Again, there's just story after story one could tell. When I started, it was myself, and we had recruited an English laboratory technologist called Anne Porter. Anne had been known to the hemorrhagic fever group because she'd done some work with them. She had come to CDC for a short while to do some familiarization. She and I went out to Abidjan together--or arrived more or less the same time. Yes, I mean, there you are with your suitcase, and that's it. You sort of say to yourself--you had talked earlier about planning. There had not been a great deal of planning, I must say, and no firm instructions. We sort of 00:28:00had to figure it out.

We went about setting up a lab. That was the first thing. We were housed in the Infectious Diseases department at Treichville Hospital, which is the university hospital. Pretty rudimentary conditions, very rudimentary conditions. But we were given an empty room that was a lab, and we set it up. Here actually is where you saw, compared to other countries, the raw power of CDC, logistics, the American Embassy in Abidjan. The flying in of equipment and materials. I have photographs of trucks being unloaded and stuff. We worked very, very hard and very quickly.

Everybody was--there was a great deal of skepticism from some Ivoirian 00:29:00colleagues and from French colleagues, because Abidjan, Côte d'Ivoire, is very, very firmly influenced by the French Colonial links. So this American group coming to set up, this was an interesting experience. There was a fair amount of skepticism about it, but then we did our work, and we showed results very quickly. We were very well accepted. It was a real--there was a lot of diplomacy involved.

CHAMBERLAND: So you and Anne basically wrote up a shopping list and said, "We need X number of whatever test tubes [Crosstalk]"

DE COCK: Yes, Anne did most of that.

CHAMBERLAND: And it arrived and--

DE COCK: And we had done--in our foray the year before, we had done a pilot study. So we'd set up a temporary lab and that pilot study was done in--that 00:30:00trip, that initial trip we made, I had stayed on to do a pilot study in Abidjan and in Burkina Faso. So when we started definitively in 1988 with Anne Porter, we set up a lab. That was the first thing to do. We set up some simple data management and so on, and started recruiting people. The first people I recruited were some medical students who I'd worked with. I'd worked with some medical students in that pilot study, and one or two of them came to work with us long-term. They took a risk actually, because they were stepping out of their own system and they had to--I remember sitting down with some of them and sort of counseling them, saying, "Look, we're serious. We're very serious people. I don't know what the future holds, but we're serious about this."

CHAMBERLAND: Were they actually going to have to take a leave of absence from 00:31:00medical school to do this?

DE COCK: Yes, or certainly alter their future career plans. Like I mean jumping ahead.

CHAMBERLAND: Because you intended this to very much be a full-time job for them, obviously.

DE COCK: Yes.

CHAMBERLAND: And all of this took about--you said it was a relatively short period of time. Like three, four, six months?

DE COCK: I mean it was progressive. We sort of just kept growing and growing. It really was making it up as you went along. In terms of answering the question, sort of, "I'm here to do AIDS research. Well, now what?" I actually, there I think the Holy Ghost came down, because I--

CHAMBERLAND: Those Belgian nuns. They were praying for you.

DE COCK: I thought--where do we start? There's very little known. I thought, "Well, I guess we should do a study to determine how much AIDS is there. And how much of it is due to HIV-1 and how much to HIV-2." As we were doing that, I also 00:32:00thought, "You know, we should do a study trying to figure out how much death is there from AIDS, and how much of that is due to HIV-1 and HIV-2." Both of these studies have a lot of stuff that never gets into the materials and methods of the paper. What we did for the first study--here, it was the right thing to do, but we were also lucky in that I thought, "Well, let's screen consecutive hospital admissions across the city and determine how many of these patients have AIDS. And if we apply those numerators to a denominator of the city [population], at least we would come up with an estimate of the minimum incidence of AIDS." Because obviously the numerator would not capture everybody in the city with AIDS.

I was also very fortunate to, totally haphazardly--a guy walks into my office, 00:33:00this little cramped office where there were now six of us working with no space at all, and a French guy comes in and introduces himself. Says he's a demographer and he's just lost his job, or his job is being abolished, and he's looking for something to do. He heard we were working. We'd hired a Belgian data manager who was quite a good statistician as well. Now we had a demographer, and we just got very good collaboration getting some meaningful denominator data. The study took a few months. We wrote it up, and it got published in the Lancet. Our first paper, within less than year we had a paper in the Lancet that actually attracted a lot of attention.

We then started the study trying to, again with the same group of people and the demographer, trying to establish mortality rates. We did a study going to the city mortuaries and bleeding cadavers, doing blood tests on dead bodies and getting results on HIV prevalence, how much HIV-1, how much HIV-2, and again applying those figures to denominators. The astounding result from that study was that in this area of West Africa, in this country of West Africa, where AIDS was not recognized to be a problem at all and the world didn't think it was a problem, we showed with these two papers that it was the leading cause of death in men. It was the second leading cause of death in women, because maternal 00:35:00mortality and death from abortion were more frequent than AIDS. The minimum incidence of AIDS was actually higher than that in New York City, and approached that of San Francisco. Putting that out was obviously impactful and put us on the map. All of the sudden, we were a well-recognized, important research site in a very short period of time.

CHAMBERLAND: That is astounding. When you went back and tried to sort this a bit, were people that had died, people that you were looking at in your consecutive hospital admissions, were they demonstrating the characteristic 00:36:00diseases? Opportunistic infections that were associated with AIDS? Were there differences between the HIV-1 and the HIV-2 patients? Maybe just elaborate a little bit more on some of these key findings for these two studies. You're using the terms AIDS, and I think that can apply to both HIV-1 and 2.

DE COCK: Yes.

CHAMBERLAND: So you're originally going in there to study HIV-2, and I think you end up being a little surprised that HIV-1 is actually getting to be the bigger problem.

DE COCK: That's absolutely correct. We saw very quickly that HIV-2 was certainly there. It was associated with disease, but there was much more HIV-1. HIV-1 was increasing or had increased, whereas HIV-2 in terms of prevalence seemed to stay relatively stable and at a low rate.

CHAMBERLAND: Had it been recognized in the community? Had healthcare workers or people that [you] talked to said, "People are getting sick with something we haven't seen yet." I was curious if there were these clues.

DE COCK: There are again some important lessons here. I'll come back to the issue of diagnostics in a minute. There are some very important lessons because, yes, the clinicians knew they were seeing AIDS, and it had the same characteristics as described elsewhere in Africa. There was a room, it was like something out of Dante, actually. There was a room in the Infectious Diseases unit where the most advanced cases of HIV with classic wasting syndrome were housed. This room had--a lot of these patients had chronic diarrhea, and the hospital was using cholera beds, these beds with the holes in the mattresses, for these patients. This was room number 24. I remember it very well. It was 00:38:00just where people died, basically. You had these skeletal people, skeletally thin, barely moving. There was a very strong characteristic smell in that room which would get into your clothes and into your hair. It was where the patients, particularly with chronic diarrhea, were sort of left. Chronic diarrhea and wasting syndrome. Actually, those people, we later learned when we were able to do more studies that these people had very advanced immunodeficiency, very low CD4 counts and so on.

The hospital recognized they had a problem, particularly in infectious diseases, but it hadn't been counted in any way. What was interesting was I--another early study we did--I found somewhat haphazardly that actually, of course they had admission registers. I started looking at these registers, and these registers 00:39:00went back years. I thought, "My goodness, here you've got--" and they had a diagnosis usually listed, at least a provisional one, such as chronic diarrhea and so on. But what I did was to, again with help, to go through all these registers, and we were able to show very clearly that between 1983 and 1988, and particularly from about '85, there were these escalating deaths and rates of death in admissions to the Infectious Disease unit or to the medical wards of the hospital or the hospitals across Abidjan. The rates of death were dramatically increasing, more in men than women. But I'll come back to that.

In surgical patients, this was not the case. It was all documented there, but 00:40:00nobody had actually looked at it. That was another paper that we published on mortality trends.

To go back to HIV-1 and HIV-2, obviously we--there was a sort of dual track to our work, if you will. Studying HIV disease overall, but also trying to learn more about HIV-2. Of course, for this we had to get our diagnostics perfected as much as we could. This was difficult because the tests evolved over time, but when we first started there were no very good tests, actually. There was a lot of cross-reactivity between the reagents that we did have for HIV-1 and 2. So we spent a lot of time perfecting diagnostic algorithms and evaluating different reagents, including synthetic peptide-based tests and Western blots, specific 00:41:00Western blots. We spent a lot of money on buying reagents, and I think we were the biggest consumer in the world, actually.

CHAMBERLAND: So you were doing that all on site. It was not a case of sending specimens to Atlanta.

DE COCK: We were working with Atlanta, and we did send specimens back, but a lot of this was on site.

CHAMBERLAND: Really?

DE COCK: Yeah, yeah, yeah.

CHAMBERLAND: You were doing some fairly advanced laboratory work.

DE COCK: Well, it was serology. It was pretty basic. I do remember--I arrived in Abidjan in 1988, in late June, I think it was. We had our first site visit from headquarters in about February, the following February. This was about eight months later, I remember because there were more people on the site visit than there were working in the project. It was very stressful, very, very stressful having this. Jim Curran was leading the delegation. I think [Dr.] Gary Noble was on the team. It was a big team. [Dr.] Harold Jaffe was on the team as well. We 00:42:00were explaining the difficulties of serology, and I remember Harold shaking his head and looking very sort of depressed and saying, "Well, if we can't figure out this serology, we might as well pack this up." This was both a worrying and a motivating statement. I took it seriously, because I agreed. We did make progress and eventually were able to differentiate the two much more specifically, particularly through the use of synthetic peptide-based tests.

Jim Curran then, I remember another phrase from him, saying after a lot of discussion, "All right, when are you going to start your first cohort study?" We did then establish specific cohort studies looking at mother-to-child transmission of HIV-1 and 2, comparing them. HIV-2 barely transmitted from 00:43:00mother to child at all. Looking at differences in disease, [and] coming to the conclusion that yes, HIV-2 does cause AIDS. It does appear to be slower and associated with better survival, but still causes AIDS and death. And that actually HIV-1 is the dominant problem, as it has become or rapidly became throughout West Africa. In a way actually, HIV-2 is sort of--we talk about emerging infections. Infections can also recede, and in a way HIV-2 is a kind of receding infection, but it still exists.

CHAMBERLAND: Let's go back to a couple of the points that you raised when you were describing some of your early findings. You said that the review of the hospital admission records indicated something changed about 1983-'85. That period of time is when you really began to see an escalation in admissions of 00:44:00this uncharacterized but clearly different syndrome. And also you talked about rates in men as opposed to rates in women. Were you able to go back and figure out, epidemiologically, what was going on in '83-'85, or actually before that? What were the factors that led to this escalation and some of the differences that you saw in men versus women?

DE COCK: Yes, it was very interesting. When we did that hospital study, the first one looking at the minimum incidence of AIDS, for every woman with AIDS there were three or four men. Initially we found this perplexing, because one of the striking findings in Kinshasa back in 1983 had been a one-to-one ratio of 00:45:00male to female, which was taken as evidence of heterosexual transmission. Here we were in an epidemic that we assumed was heterosexual, yet we had this discrepancy. The explanation was that AIDS probably began with a group of sex workers, female sex workers, who had many clients. Abidjan is--and Côte d'Ivoire as a whole, but particularly Abidjan--is an unusual city in that many people come there, particularly men, to find work. Or they used to at that time. They come from many surrounding countries.

So, in that hospital study, we asked people where they were born. Rather than asking them what nationality they are, we asked them where you were born. And there were something like 20 countries of origin. You'd never find that in--you 00:46:00wouldn't have found that in Kinshasa. So, men come to work, taxi drivers, gardeners, security guards, laborers, et cetera, from all surrounding countries, and they come on their own. So there was a very strong sex industry, and that initially had been largely populated, or disproportionately populated, by women from Ghana. There was a tradition actually, that women from Ghana went to Côte d'Ivoire to work as sex workers and eventually would go home. So I think what you had was a restricted group of sex workers supplying a large group of men. With time, what happened is that ratio slowly equalized out, but it took years to do it.

CHAMBERLAND: I see.

DE COCK: There's a lot of literature on this and evidence. This is true. In fact, again what doesn't get into the materials and methods. We started, we set 00:47:00up a sex worker clinic, again, trying to look for HIV-2 and working on the whole subject of other STIs (sexually transmitted infections) and HIV with our colleagues from Antwerp. We copied what they had done in the Matongé area of Kinshasa.

We set up a clinic. It was called the Clinique de Confiance. There's a story there because it's a play on words, because there was a type of condom that was being promoted: Prudence. And the advertising slogan for Prudence condoms was "Confiance d'accord, mais prudence d'abord." So confidence, trust, okay, but Prudence, which is the name of the condom, first of all. So we called it the 00:48:00Clinique de Confiance because of this play on words with the condoms. But of course, the acronym for Clinique de Confiance is CDC. It was kind of clever.

We had set up that clinic because there was also a demand for services and for testing. In fact, I had accompanied the head of the AIDS program, Dr. Odehouri [Koudou], who was one of our first contacts who facilitated our entry there and was a main collaborator. He invited me to go with him to see the ambassador from Ghana, who was a military man. The reason that Odehouri wanted me to go with him is because the ambassador didn't speak any French and Odehouri didn't speak any English, so as was often the case in my career actually, I ended up translating 00:49:00between Africans.

So we go into the ambassador's office and sit down and how are you and so on. He says, "I need your help. There are several hundred thousand Ghanaian women in Côte d'Ivoire, and they're all prostitutes." I said [to myself] the Ghanaian ambassador has just said to me that all the Ghanaian women in Côte d'Ivoire are prostitutes. I thought to myself, "I couldn't imagine sitting in the American ambassador's office or the Belgian ambassador's and hearing this." But in fact there were a lot of sex workers. Less today I think. There's a particular area of Ghana where they came from, and there's historical reasons for all of this, and a whole literature to it actually, and sociology and so on. It's a very interesting--it was rather sad--fast forward, we did set up a clinic. We worked 00:50:00with a lot of Ghanaian women. We worked with the chiefs and so on. It was a well-known phenomenon. Of course, when these women got sick, they had very little help and would have to try and get home. It was--initially, when we first started out, was a very, very high prevalence: 70, 80% prevalence in this group of women.

CHAMBERLAND: And so they became infected because their clients are coming from other countries in Africa where there were higher prevalence's and obviously HIV.

DE COCK: Because of so many contacts, they obviously are a risk group. So I think there's lots of evidence that in Abidjan, it started as an infection in sex workers and their clients, and then spread from there.

CHAMBERLAND: Very interesting. You said the epidemic eventually, the ratios 00:51:00between male and female genders, evened out, became more or less one-to-one. The time that this is going on, that you're observing and describing this in Africa, the epidemic in the [United States] US and in other more developed countries, although certainly heterosexual transmission has been well recognized by this time, [was] documented in these countries being tied more to IV drug use. But clearly still during this period of time, cases among homosexual men were the predominant risk category. I was just curious: in your studies, were you trying to probe for evidence of other risk factors, such as homosexuality in men, intravenous drug use, or use of needles, or other methods for percutaneous 00:52:00exposure. My sense is that, at least at that time, certainly cases in homosexual men, that as a risk factor was just not surfacing.

DE COCK: We did ask the relevant question in our studies and found no evidence of it. On the other hand, across the continent, male-to-male sex is not easily talked about and certainly wasn't back then. If you knew gay men and asked them--everywhere there's groups and societies. So, there definitely was a gay network, a network of men who have sex with men. We didn't--and later the project has gone on to work with such groups--we didn't have evidence of them or 00:53:00find them. And drug use at that time was not an issue either. Today we know from different studies in different countries that, yes, of course there are men that have sex with men, as there are everywhere. When you look, there are high rates of HIV, and the issue of drug use has increased as well, certainly in East Africa.

CHAMBERLAND: In terms of some of the other work that you did, I also understand that you did a bit of work in looking at the impact of tuberculosis on mortality in HIV-infected patients. That was an area that really brought some fruitful findings. Can you tell us a little bit about that?

DE COCK: Yes. We did a lot of work on tuberculosis. Again, I think it was fortuitous and fortunate that at the beginning we did make some good decisions. 00:54:00The pilot study that we had done back in 1987 was really to look at HIV-1 and HIV-2 prevalence in some sentinel groups. The groups were hospitalized patients, STI patients, tuberculosis patients, pregnant women, and blood donors. There were the five groups. Tuberculosis patients had, as one would expect, a higher [prevalence rate of HIV infection]--we can say now, as we would expect. In those days, it hadn't been very long that it had been recognized that tuberculosis itself was increased in frequency in people with HIV. The first firm description of that out of Africa, I think it was only in about 1986–actually, it came from Kinshasa--but led very quickly to lots of people interested.

So we'd set up good relations with the tuberculosis program. When we started our 00:55:00definitive work, the director, who's a French colleague, Dr. [Raymond] Bretton, he was only too pleased to work with us because we were providing him with what nobody had, which was HIV serology. So his patients were being universally tested from a very early, early time. Again, one of our early papers was to show, looking at this question, does HIV-2 cause disease or not--one of our early papers was to show that there was an increased prevalence of HIV-2 in tuberculosis patients, and of course HIV-1, very much so. But also HIV-2 compared with control populations.

Later, we did a very important study with a colleague of mine from England, [Professor] Sebastian Lucas, who's a pathologist. I had gotten Sebastian 00:56:00involved in a smaller study looking at lung disease, where patients had been autopsied and the histology slides needed to be read. This was a study that showed people dying with HIV with lung disease had very high rates of tuberculosis but no Pneumocystis was found. Sebastian very kindly was visiting, and he kindly read these slides and that paper was published. But he asked, "How come all these autopsies were done?" It turns out within the French system in that hospital, if patients were dying of an infectious disease then autopsies could be done routinely. Again, a large logistic exercise was to invite 00:57:00Sebastian and a technician from [the United Kingdom] UK to come and set up a sort of almost industrial level-histology section to our project. He did hundreds of autopsies in the course of a year--a very important study showing that tuberculosis just dominates HIV pathology. He did several hundred autopsies, prioritizing also the smaller number of HIV-2 cases and really nailing down very firmly the disease associations and causes of death in people with HIV-1 and HIV-2.

It actually was very important, it wasn't just descriptive, because that led to the question, "Well, what can we do about this?" before antiretroviral therapy, and actually led to the proposal and then a clinical trial of co-trimoxazole 00:58:00therapy, which was very, very important.

CHAMBERLAND: Fascinating. Fascinating. I was going to ask you--there's obviously a real richness to the studies that you're doing. You're coming up with important observations and findings. Were you early on able to translate some of these findings into prevention and control type messages and measures? How good, effective were they? Were they hard for the population to take on board?

DE COCK: The country had a National AIDS Control Program, and we worked closely with them and provided data. Yes, we participated in crafting advice and trying to help in whatever way we could, looking after patients. We were very aware of the need to do everything possible. How effective was prevention work? For 00:59:00example, working with the sex workers, we had impact because over the course of a few years, HIV incidence clearly declined, prevalence dropped, condom use went up, and so on. But it still remained at very high levels. We did what we could. And of course, this led to the co-trimoxazole work, which was actually done after I had left. But I think it did have an impact.

We also engaged in and invested in training. We set up local courses, a sort of simple two-week course on epidemiology, which then attracted people from the sub region. We sent quite a few of our people to do Master's degrees in the United States or in Belgium. There were a lot of spin-offs that happened.

CHAMBERLAND: Were you involved in setting up a systematic program of surveillance for cases of AIDS or HIV infection in Abidjan? If so, how did it differ from systems of surveillance that perhaps were done in more developed countries? You mentioned your classifying cases. I was curious about some of the challenges of a case definition in a country with limited resources. Talk a little bit about surveillance.

DE COCK: Yes, perhaps the case definitions [came] first. In 1985, Joe McCormick, again, had been involved in a meeting, that [the World Health Organization] WHO organized in Bangui in the Central African Republic, to discuss case definitions for AIDS. Because at that time it seemed unlikely that serology would ever be available on a large scale and that to recognize, document, and report AIDS 01:01:00cases would require some sort of clinical case definition. One was put together with major and minor criteria. It focused on signs like fever and wasting and chronic diarrhea, lymphadenopathy, such things. Of course, evaluating such a case definition was difficult, because studies were done and we did some. Evaluating it against HIV positivity was an imperfect way of evaluating a case definition. That was what was done.

What we found was that, actually, the case definition was quite specific, in that most people who met the case definition, about 90% of them, were HIV positive. But it was not sensitive. It was only about 50% sensitive. So we got 01:02:00involved in discussions about case definitions, and these discussions quickly became quite high level. We interacted a lot with WHO in Geneva, and we wrote about this and so on. Actually, HIV testing did become much more available than anybody had thought. Of course, tuberculosis had to be accommodated into some kind of case definition. It was never perfect, but we ended up influencing that whole international debate.

In terms of practice, really what ended up being most important in that particular historical era was sentinel surveillance in pregnant women. Looking [for], testing for HIV in pregnant women, who back then were considered proxies for the general population. By definition, they were sexually active, they were young. We now know actually that they're not good proxies for the general 01:03:00population. That approach actually overestimates the levels of HIV in the general population. The whole practice of surveillance has evolved and actually continues to evolve. Large population-based surveys today are much more important, done every few years. There are beginnings of case reporting, but they're still beginnings. Our estimates for the global AIDS epidemic are somewhat imperfect, and some of it is based on modeling more than anything else. But compared to other diseases, I think we've done reasonably well.

CHAMBERLAND: You were there for five years as project director. How well did the collaboration, the partnership with the government of Côte d'Ivoire work? Were 01:04:00there any significant social or political issues that arose? Sometimes I know tensions can crop up when a Western country is funding research in a foreign country and perhaps the two countries' priorities don't align. Just curious about the relationship between the government health authorities and CDC's project.

DE COCK: I must say, I think Côte d'Ivoire was remarkably generous to us, because the working relations never really were very difficult. There were odd things that would crop up every now and then, but nothing, absolutely nothing major. They were just remarkably welcoming. For myself, it was another life-changing experience and a very, very deep experience. A truly warm experience. I've gone back a few times, and I always feel so welcome there. I'm 01:05:00struck by the generosity of the country, and we didn't really have any difficulties. But it requires work. It's diplomacy, it's tact. Obviously, you have to convince that you were not simply there to extract. I think we tried to show that we were serious and that we cared about the country, we cared about the epidemic, and we weren't just doing parachute-type research. We were interested in system strengthening.

CHAMBERLAND: I'd imagine over time the vast majority of your staff ended up being recruited from within Côte d'Ivoire. I imagine the staff must have grown [in size].

DE COCK: That's one of the, again, very sort of rewarding things is that many or some of the staff have gone on to senior positions around the world--[The United Nations Children's Fund] UNICEF, WHO, CDC. Actually, there are several folks who 01:06:00worked with RETRO-CI who have positions here in Atlanta now. Some did EIS. One could say, "Well, they're not in Côte d'Ivoire anymore." But some are. But on the other hand, the world is global, and they're working on what we worked on way back then.

CHAMBERLAND: RETRO-CI is still in existence?

DE COCK: It is, but it changed. Unfortunately, and to my surprise, anything can happen anywhere. It's more likely in some places than in others. I never expected political and civil disturbance in Côte d'Ivoire, but they did have it, and it went on for many years. I left in 1993. I was succeeded by [Dr.] Alan Greenberg, another CDC colleague and good friend. Alan had done some good work in Kinshasa also. He stayed for four years, then he was succeeded by [Dr.] 01:07:00Stefan Wiktor. What they really did, Alan and Stefan particularly, was to focus on interventions. A number of important studies were done, including two very important clinical trials: the co-trimoxazole study that really changed global practice, and a study on short-course [azidothymidine] AZT for the prevention of mother-to-child transmission. Now, all of that was based on the early work and the infrastructure and so on.

In the 2000s, political disturbances happened. There was an evacuation. Research--the early 2000s was also when the big AIDS money started coming, initially with the Clinton administration, the so-called Life Initiative, and then [the President's Emergency Plan for AIDS Relief] PEPFAR. RETRO-CI is still 01:08:00there, but it really has become a PEPFAR site. I was there just last December when we celebrated the 25th anniversary–actually a few years late--but we still called it the 25th anniversary. Two years late, yeah. The structure is still there. The staff, some of the old staff are still there, or a few of them. Some of the lab techs, for example, or a driver, a couple of the drivers.

CHAMBERLAND: Amazing. Just a final couple of closing questions. You continue to be, Kevin, a real leader in global HIV/AIDS work. How has that affected you personally and professionally? It certainly sounded like you were barely at home, that you were constantly on the move. Just curious about when you reflect 01:09:00back on a career, what are your thoughts?

DE COCK: I feel very privileged really to have seen the things I've seen. You asked me earlier on at the beginning, going from clinical medicine to public health. I never took a conscious decision to do that. Obviously, it happened. In some ways, I regret that I haven't stayed in clinical medicine. The last time I did clinical medicine was in the '90s. After RETRO-CI, I went to London for four years and there I--it was just before [antiretroviral drugs] ARVs, the modern approach to antiretroviral drugs came in--and three months of the year I was the attending or the director of a large AIDS unit in London. It was extraordinary, night and day, seeing Western medicine applied to late-stage HIV disease, 01:10:00because I looked after the inpatients. Very sick people with very aggressive interventions, until it was clearly of no value anymore. It was a remarkable difference between what I'd just come from. At heart, I still feel a clinician, and I think actually the approach we use in public health and the way you analyze problems is not so dissimilar from the approach used in investigating an individual patient. The identity of a physician remains very, very important to me, it's very core. CDC has been a good place to work. I'm grateful for that, and of course I've been involved in Ebola. What was very odd is that in the two years I was an EIS Officer, when I did lots of very interesting stuff, there were no outbreaks of hemorrhagic fever. I wrote some guidelines and so on, but I 01:11:00didn't do any field work on any of these viruses. And so to have been involved in the last couple of years, quite deeply actually with several--with a total of four--deployments to West Africa for Ebola, has been a remarkable sort of full circle.

CHAMBERLAND: I was going to say, you've come full circle. Well, gosh. This has been very interesting. Thank you so much for sharing with us the early days of Projet RETRO-CI and its evolvement over time. Thank you again.

DE COCK: Thank you, Mary. Nice to talk with you. Thanks.

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