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
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
3:00training, 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
4:00and 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
5:00the 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
6:00Redeker 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
7:00that 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
9:00research 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
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
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
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
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
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
There were still--the Ebola epidemic in '76 was a devastating event. In this
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
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
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
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
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
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
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
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
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.
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
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
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
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
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
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
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
Everybody was--there was a great deal of skepticism from some Ivoirian
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
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
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
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,
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
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
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
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
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
40:00nobody had actually looked at it. That was another paper that we published on
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
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.
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
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
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
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
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
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
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
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
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
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
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
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
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
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.
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
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
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
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
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
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
61:00cases 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
62:00involved 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
63:00population. 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
64:00there 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
65:00struck 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
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
66:00worked 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.]
67:00Stefan 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
68:00there, 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
69:00back 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,
70:00because 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
71:00didn'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.