Fund Cuts Cited in Outbreak of Syphilis Cases

The worst outbreak of syphilis in Los Angeles County in 40 years has been exacerbated by a series of local and federal economy measures and policy decisions, according to officials outside as well as inside the county venereal disease control system.

Supervisors and field investigators say they believe that the outbreak was made worse by county and federal cost cutting, lack of coordination within the county health department and the failure to bolster dwindling field staff at a time when the disease is spreading rapidly.

‘Benign Neglect’

“There’s been a lot of benign neglect in the Los Angeles County program,” observed one high-level official close to the system who asked not to be identified. “When you’ve emasculated the program and not paid attention to it the way they have, this is the result.”

In response, county and federal officials blame years of budget tightening. They cite rising public health costs that have not been accompanied by funds increases. If some decisions ran counter to principles of public health, they insist that they had no choice.

Several officials said low pay and high stress have made it difficult to fill vacancies created by employees who have left the program. Program administrators admit that they cannot even hope to meet accepted national standards of effective venereal disease control.

‘From Fire to Fire’

“It’s got to be a flaming crisis before we can get someone’s attention to put resources in” to the county health department, county Health Director Robert C. Gates said in an interview. “What will be next? We go from fire to fire. It’s no way to run a railroad.”

Syphilis is an infectious, chronic venereal disease transmitted through contact with infectious areas of the skin. Because its initial symptoms are painless and appear fleetingly weeks after infection, the disease can go undetected or ignored.

If untreated with antibiotics, the bacteria that cause syphilis infect the bloodstream and can cause damage to the nervous system or heart disease years later. Infected mothers may give birth to deformed or blind babies. Some are born dead.

The current rise in syphilis, which is a nationwide trend, is especially ominous because syphilis may heighten a person’s risk of infection with the AIDS virus. Experts say the genital lesions created by the disease can serve as an entry point for the virus.

“The really sad part is this is an eminently preventable disease,” said Dr. Michael Rosenberg, executive director of the American Social Health Assn. ‘It’s an old disease which was well under control. And we’re losing control of it.”

Signs of trouble surfaced early in Los Angeles County. They showed up in the 1985 statistics on congenital syphilis--a tragic bellwether for epidemiological change. The number of babies born with syphilis in 1984 and 1985 jumped from five to 10.

It could have been merely a statistical blip, recalled Dr. Shirley Fannin, the 50-year-old pediatrician in charge of the county’s communicable disease control program. But as months passed, it became clear it was not. That number abruptly tripled in 1986, rose to 39 in 1987 and is expected to go as high as 68 in 1988.

Case Climbing

The overall number of cases of infectious syphilis in the county were also climbing--from 1,558 in 1984 to 2,770 in 1986 to 4,198 in 1987. Moreover, the syphilis incidence per 100,000 population has now reached 55.6, nearly four times the national average.

Fannin and others also noticed a striking epidemiological shift: The disease was moving away from its traditional base of white, gay males. It was spreading almost exclusively among the urban poor: blacks and Latinos, heterosexuals, often users of drugs.

There appeared to be a number of reasons for the rise in syphilis:

- One reason appeared to be the spread of crack, a powerfully addictive form of processed cocaine. Young women had begun exchanging sex for the drug, field investigators noticed. Crack use seemed to be linked to a lot of sexual activity in general.

- There had been a steady decline in the manpower essential for, among other things, “partner notification”--the crucial process of finding and alerting the sexual contacts of infected people and persuading them to be screened and treated.

The number of federal venereal disease control workers assigned to Los Angeles County has dropped from about 50 to less than 20 in a decade. The number of state assignees during the last few years has dropped from 11 to three. County manpower has also shrunk slightly.

- A serious outbreak of penicillin-resistant gonorrhea in Los Angeles County in the early and mid-1980s had distracted and rerouted workers from syphilis.

- Experienced workers nationwide have left VD programs to work in new programs aimed at controlling AIDS.

“If you turn your attention to one thing, you turn it away from something else,” Fannin said in a recent interview. “You cannot run twice as fast, OK? If you have a certain number of people to do a job and that job expands, you cannot keep up.”

The county has had other financial problems.

Faced with an acute shortage of prenatal services for the indigent, health department administrators in 1985 began looking for new sources of revenue. In August, 1986, they began charging people $20 a visit to the county-run health clinics, which in the past had offered free diagnosis and treatment for tuberculosis and sexually transmitted diseases.

People in the sexually transmitted disease program voiced reservations about the new policy. They said they feared that the fees would keep people out of the clinics. But they were overruled by top health department administrators.

Number Dropped

In the first month alone after the policy was instituted, the number of sexually transmitted disease cases handled dropped from 8,685 to 7,186. Month after month, it continued to drop.

By January, 1988, the number of clinic visits had fallen to 4,941.

Meanwhile, the Sheriff’s Department was wrestling with the cost of its own blood testing for syphilis. For 25 years, all people entering the jail system had been screened--a practice that even department officials say is in the best interests of public health.

But the screening was not “cost-efficient,” said Dr. John H. Clark, the department’s chief physician. Of as many as 20,000 specimens screened monthly, about 500 were positive. But a third of those people had left the jail system before their results even came back.

Analyzing the samples was consuming 60% of the personnel time in the department’s medical laboratory at a time when the condition of entering inmates was deteriorating. So, after lengthy deliberations, the department dropped routine screening in 1986.

Clark expressed reservations about the decision, however unavoidable.

“It is a major public health problem,” he said of the rise in syphilis. “Strictly from a public health perspective, all things being ideal, I would certainly agree that everybody who comes into the . . . jail ought to be screened.”

Raises Concerns

Jim Dobbins, a communicable disease specialist with the California Department of Health Services, said the decline in routine syphilis screening statewide raises concerns about the possibility of a curious ripple effect referred to as “importation.”

For example, in rural Tuolumne County, syphilis cases increased from two to 22 between 1986 and 1987, state figures show. That rise is traced almost entirely to inmates transferred from Los Angeles County to the Sierra Conservation Center, a medium-security state prison.

In late 1986, the Los Angeles County health bureaucracy began consolidating troops.

Most of the approximately 20 federal workers who had handled syphilis countywide were moved into seven “core districts,” those areas in South Los Angeles that seemed to be responsible for 75% of all the disease.

But the vast majority of county public health workers, responsible for other venereal diseases, as well as such things as rabies and TB, remained where they were. Apart from the small federal force, there was no funneling of resources to the districts hit hardest.

Core Districts

Even now, none of the clinics, even in the core districts, offers weekend or evening hours. People coming for screening and treatment often face long lines and quotas on the number of patients who can be examined each day. Health officials in those areas say they have repeatedly been denied requests for additional staff.

“It’s very demoralizing to know that you need staff and have applied for staff over the years and to be told it’s not in the budget,” said Dr. H. P. DesLonde, district health officer for the county’s hard-hit southwest district. “That is definitely bad for morale.”

Out in the field, workers and supervisors say morale has scraped bottom.

The shift in disease has drawn field workers into some of the county’s roughest areas. There have been muggings, car thefts, intimidation and threats of violence. One worker, held up at knifepoint in a county clinic, has been out on “stress leave” for months.

In late February, officials in the sexually transmitted disease program drew up a table of organization. Only 21 of the 34 field staff positions were filled. One month later, they had to amend the chart because the number of unfilled positions had climbed to 17.

Caseloads Climbing

At times, caseloads have climbed as high as five times the optimum level. Case investigations have grown increasingly superficial, supervisors admit. Cases considered likely to be less infectious are ignored, not because they pose no risk but because there is no time.

Only about 40% of those cases investigated result in documented instances of getting a sexual contact to treatment, compared to a federal standard of 60% to 100%. Robert Bartholomew, director of the county’s sexually transmitted disease program, calls the national standard “almost meaningless in relation to L.A.”

Why there has not been more aggressive marshaling of resources remains in dispute.

Mark Schrader, an official with the federal Centers for Disease Control in Atlanta who supervises field operations for controlling venereal disease, said federal manpower in Los Angeles and nationwide has dwindled, largely as a result of federal budget cutting.

But he said it is also increasingly difficult to find workers willing to work in Los Angeles because of the high cost of living.

Asked whether the manpower crunch has contributed to the national syphilis rate, he said, “To be honest, it probably has to some extent.”

Propose and Recommend

On the county level, Bartholomew and Fannin point out that they have no control over the forces of the 21 health districts in the county. All they can do is propose and recommend. They say they made it clear to administrators that they need more manpower.

“What we’re talking about is that countywide (public health workers) are clustered in areas where the problem isn’t,” Bartholomew said in an interview. “One might think maybe they would want to shuffle things around.”

But top health department officials counter that the need was never made clear.

Lawrence D. Roberts, the deputy director who supervises the district health offices, suggested that Fannin failed to effectively make her case. If she had submitted a detailed analysis and recommendations, he contended, top department administrators would have tried to oblige.

But the bottom line, Roberts and Gates argue, is the absence of additional money.

“I don’t think the department is adequately funded in total,” Gates said, citing the pressing problems of trauma care, AIDS, prenatal care and others. “If you had unlimited money, you could do a lot. You could solve many, many problems.”

“Whose ox is going to be gored? Do you cut out prenatal services?” Roberts asked. “The people of the state of California have to determine if they are willing to pay for these services. Are folks willing to have their taxes increased?”

THE RISE IN SYPHILIS CASES

Infectious syphilis cases have increased substantially in Los Angeles County since 1984, according to figures from the U.S. Centers for Disease Control. State officials attribute the disproportionate rise in syphilis among women to what they believe is the increasingly widespread practice of exchanging sex for highly addictive crack cocaine.

Reported Cases of Primary and Secondary Syphilis

1984 1985 1986 1987 Men 1,333 1,419 1,918 2,649 Women 225 435 852 1,549 Total 1,558 1,854 2,770 4,198

Rates of Infections Syphilis Per 100,000 Population

1985 1986 1987 Nation 10.5 11.2 14.7 California 16.6 22.3 28.5 Los Angeles County 24.3 35.2 55.6 South Health District* 82.0 264.7 402.4 Orange County 24.5 37.7 26.1 San Diego County 16.4 17.8 33.9

*South Health District in Los Angeles is roughly bounded by Florence Avenue to the north, Alameda Street to the east, Figueroa Street to the west and 120th Street to the south.

Rates of Congenital Syphilis Per 100,000 Live Births (1987)

White Black Latino Asian 1.7 121.0 17.0 0.0