Syphilis Stubbornly Keeps Its Grip on Society’s Fringes

The fugitive disease finds refuge in forsaken places: On street corners where women sell themselves for the price of a crack hit. In neighborhoods with boarded-over homes and shells of businesses long gone. In forlorn mobile home parks off rural highways and seedy truck stops off interstates.

Syphilis, a centuries-old human scourge, sustains itself these days on a noxious brew of poverty, racial inequality and hopelessness.

There is no good medical reason for it to endure. All but eradicated in many developed countries, syphilis is easily prevented with condom use, easily detected with a blood test and easily cured with penicillin when it is caught early. Some Americans are under the impression it died with Al Capone.

Yet, in a smattering of U.S. communities that are remarkably unmoored from basic health and social services, syphilis has stubbornly settled in.

Its persistence is difficult to fathom. Nationwide, the tide of the disease is rapidly receding, leaving fewer cases in fewer places than at any other time on record. Half the nearly 6,700 cases are confined to 25 counties, putting public health officials tantalizingly close to their goal of wiping syphilis out.

The trouble is that the hot spots are manifestations of some of the nation’s most miserable public health and social failures. They are reminders of how difficult it is to rid marginalized communities of even an easily cured affliction.

“If we can’t defeat syphilis, it doesn’t bode well” for more elusive enemies like HIV, said Dr. Peter A. Leone, director of sexually transmitted disease clinics in Wake County, N.C.

High concentrations of syphilis often signal a range of other intractable community ills: other sexually transmitted diseases, diabetes, tuberculosis and infant mortality--not to mention drug infestation, prostitution, unemployment, blight and homicide.

Syphilis sores make it easier for the AIDS virus to spread. In addition, syphilis kills and cripples children, causing permanent neurological damage to the fetuses of infected women.

The syphilis problem is all the more urgent to many health officials because it represents one of the most glaring examples of racial disparity in U.S. health care. African Americans accounted for 75% of cases in 1999, with rates 30 times higher than those for whites. The disparity has nothing to do with biology. It has far more to do with the fact that a disproportionate number of blacks live in poor, isolated communities.

“It is immoral” that such disparities should endure, said the Rev. Edwin C. Sanders II, a prominent African American pastor in Nashville. “Perhaps civilization hasn’t advanced as far as we think it has.”

Syphilis does crop up in other social contexts. Los Angeles County recently reported more than 100 cases, mostly among homosexual and bisexual men who are thought to have shrugged off safe-sex messages. But those cases are considered “outbreaks,” not long-standing problems.

The U.S. Centers for Disease Control and Prevention wants to attack the 25 most afflicted counties, clustered mostly in the Southeast and Midwest. Congress, long loath to fund battles against sexually transmitted infections, nearly doubled the federal syphilis elimination campaign this month, to $33 million a year.

Health experts say timing is key: For largely mysterious reasons, syphilis rates rise and fall in seven- to 10-year cycles. The last national syphilis epidemic peaked a decade ago.

Defeating syphilis would mean eliminating a communicable disease without a vaccine for the first time in U.S. history. It would require the health care system to connect with communities long cut off by neglect and mistrust. To forge those connections, health officials must rely on the locals: barbers and beauticians, preachers and shopkeepers, even former drug addicts and dealers, to promote prevention and treatment.

That is why a group of elderly women in the Rev. Sanders’ congregation gather regularly to assemble safe-sex kits for Nashville neighborhoods ravaged by syphilis and HIV.

“You would never think of these grandmothers doing this. . . . You’d think of them baking their perfect cakes,” Sanders said. But “we pray that whoever’s hands these [kits] fall into . . . they will accept the help, and the hope, that we have to offer.”

Syphilis Thrives Alongside Crack Trade

A tour of syphilis strongholds begins in a cluster of decaying neighborhoods in northern Indianapolis, where crack-addicted women saunter along the sidewalks to lure johns who are driving by. They might get as little as $5 a customer around here, but many are between highs, counting on quick cash and heavy volume.

In this underground economy, the goods and services are crack and sex. Young women sell sex to get the drug. Men, young and not so young, sell the drug and maybe spend a little on sex.

“It’s out of control,” said Lena Tibbs, who owns a convenience store with her husband, French, and lives nearby. “At 2 or 3 in the morning, people are fighting and cussing outside. . . . They roam the street like zombies all through the night. . . . They have no respect for anything--just that rock.”

Where crack flourishes, syphilis often does as well. The last national epidemic of syphilis largely coincided with the crack wave a decade ago. The wave struck later in impoverished neighborhoods of the Midwest and Southeast, creating a sex-for-drugs exchange that still fuels the spread of syphilis. The single hardest hit area last year was Marion County, Ind.--home to Indianapolis--with 407 new cases.

“It’s pitiful,” said one gaunt, fast-talking woman, hustling on Clifton Street. Syphilis has hit “half the girls over here.”

She’s had it herself. It appeared as “a little thing on my private parts,” she said. She figured, mistakenly, it was AIDS. She was diagnosed only because she happened to be hospitalized for pneumonia.

She’d always assumed syphilis showed up as a rash. In fact, that’s a symptom of second-stage syphilis. The first, most infectious stage is a sore, which is often hidden inside women’s bodies and disappears on its own.

Partly because of syphilis’ stealth and largely because of the general chaos in these women’s lives, the disease is scarcely on their radar.

Jackie stops to chat after a night of drinking and drugging so intense that she doesn’t remember whom she had sex with, how many there were or if any of them used condoms. All she recalls is waking up to see a well-known drug dealer, someone she suspects is not “clean,” zipping up his pants.

Jackie--who speaks on condition that she be identified only by her street name--hasn’t had syphilis or HIV, but she’s had six other infections, including gonorrhea. Nate Rush, an assistant director at the nonprofit Indiana Minority Health Coalition, gently tells her she really ought to go get checked again.

“I’m cool for now,” Jackie says, cutting Rush off.

She has other things on her mind. Five days ago, she blew her sobriety--22 days of hard work. Now she’s got to find another program and start all over again. She is tired. “I done walked this block so many times, even the kids say, ‘There she goes again.’ ”

“If you could take this [drug] habit, snatch it out of me, I could be a good person,” she tells Rush.

Rush nods knowingly.

Jackie is like a lot of other female crack addicts in Indianapolis, south Chicago, Nashville, southeast Raleigh, Va., and other syphilis centers. In their worlds, crack takes top priority. Not getting beaten, shot or arrested ranks high. So does not losing their children to foster care. But HIV often is a distant fear. Acceptable risks include gonorrhea, chlamydia, hepatitis, and bladder infections. Syphilis may not even make the list.

Women get tested for syphilis sporadically--at free clinics, in hospitals where they are admitted for other problems or in jail. By then, they might have infected many others.

The crack-syphilis connection also exists in some rural areas, where the drug has led to mobile prostitution. Drug-hungry women summon truckers via CB radio, rendezvous with their dates at truck stops and may even ride the route. Even in the remote river delta community of Greenville, Miss., one of the engines of the epidemic in the mid-1990s was a combination brothel and crack house, dubbed, by some dark humorist, “the university.”

Trying to link crack addicts with health care tests the skills of outreach workers such as Justyna Santora-Hassan in south Chicago, who on this day is trying to get a safe-sex message to Tooty, a 32-year-old crack addict. Tooty got syphilis in 1992 but didn’t get fully treated until years later.

Within minutes of climbing into Hassan’s van, Tooty begins dramatically rocking back and forth, tossing the popcorn she was eating everywhere. Her eyes roll, she moans and her high-speed speech becomes nearly incomprehensible.

“I’m getting out,” she says suddenly. “Pull over.”

She gets out at a vacant lot, dropping the condoms Hassan has given her all over the sidewalk. As the van pulls away, a police cruiser pulls up beside her.

“She’s really not that tough,” Hassan says, eyeing her client and the cop in the side-view mirror. “Her addiction just consumed her.”

Cut in Public Health Spending Blamed

It’s easy to point the finger at crack. But there are other, subtler explanations for why syphilis ebbs and flows.

Take Baltimore’s ordeal in the mid-1990s. The city’s syphilis cases quintupled; by 1998, it topped the national list of syphilis hot spots.

The CDC was inclined to blame crack, but crack had been in Baltimore for years. Dr. Jonathan M. Zenilman, an expert in sexually transmitted diseases at Johns Hopkins University, has a more mundane theory: a dip in public health resources.

In the early 1990s, he says, there were 36,000 patient visits a year to clinics serving Baltimore’s poor.

By mid-decade, those visits had dipped to 23,000. The public health budget had suffered some slashing in the interim and the city’s health outreach staff was nearly halved.

That meant the infection was “floating around and communicable longer,” Zenilman said. It spread, he said, because sufficient money and manpower were not there in time to stop it.

Potterat offers yet another explanation. He says syphilis spread outward from Baltimore’s core areas of infection because the city, in an attempt to improve public housing, blew up two major housing projects and cleared out deteriorating row houses. Residents were scattered widely and syphilis “shot-gunned all over Baltimore.”

The racial disparity among syphilis victims has defied an easy theory. Merely asking why it spills into African American neighborhoods more than anywhere else is touchy.

“How do you raise the specter of disease without stigmatizing a group of people?” asked Leone, the North Carolina physician.

A cloud hangs over any discussion of syphilis and blacks. That’s because of the notorious Tuskegee, Ala., study in which 399 black men were led to believe, beginning in the 1930s, that they were being treated for syphilis--or “bad blood,” as it was known. In fact, they were intentionally left untreated for more than four decades by federal researchers curious about syphilis’ long-term effects. The study lives in the memories of many older African Americans, engendering mistrust or even aversion to the public health system.

Many African Americans resent any implication that syphilis is a “black disease.” Indeed, as late as the 1940s, syphilis was epidemic in the United States: It infected a wide range of communities and races. Since 1997, the disparity in syphilis rates between blacks and whites has been substantially reduced, but blacks still are afflicted far more often. Some skeptics argue that the disease is more likely to be counted among blacks because they rely more on public clinics that carefully report the disease.

Many epidemiologists concede that syphilis probably is underreported among whites--but they insist that doesn’t account for the wide ethnic disparity. Instead, they cite a combination of socioeconomic, historical and cultural factors.

One consideration is patterns of sexual partnership. In a study last year that grabbed attention among disease experts, E.O. Laumann of the University of Chicago found that African Americans are more inclined than others to choose partners of the same race. That would account, in part, for why a disease might remain concentrated.

Laumann also found that African Americans tend to have more complex sexual networks. Monogamous whites (defined as having one partner a year) tend to choose partners like themselves, leaving highly sexually active whites to pair up with one another. But among African Americans, a monogamous person is more likely to choose a highly sexually active partner. That would make the risk of disease more widespread.

Another issue, according to disease experts, is the shortage of eligible men in some impoverished black communities, because of premature death or imprisonment. Disease risk goes up if men take more partners and women have fewer choices.

Also, blacks are more likely to live in poor neighborhoods such as those in Baltimore, where the fabric of public health care is frayed. They are more likely to live in parts of the country--such as pockets of the rural South--where syphilis historically has been under-treated because of racism, remoteness or a dearth of resources. Some people there still lack cars, telephones or even indoor plumbing, let alone regular health care.

Even in cities with better public transportation and more free clinics, patients may be deterred by fear of stigmas, long waits, competing priorities, apathy or even a lack of awareness about symptoms and services.

Although the deception of Tuskegee is over, black leaders such as Fred Gray, the attorney who won an apology to Tuskegee victims from President Clinton in 1997, contend that the medical double standard it so egregiously exemplified is not.

African Americans, they note, suffer markedly worse consequences than whites from diabetes, hypertension and heart disease. They also have far higher rates of HIV and infant mortality. Studies have suggested that blacks are less likely to receive certain higher-end care and even basic treatment for pain.

“I am not sure there has been a concerted effort [or] a meaningful desire to improve health care for minorities” in this country, Gray said. “If [the government] really wants to atone, there needs to be a health care agenda . . . to do away with the disparities between the minority and the majority. And that’s a much broader question” than syphilis.

Reaching Out to Those at Risk

As outsiders, federal officials are mindful that they can do only so much: increase screening, respond rapidly to signs of an outbreak and expand medical services.

Insiders, on the other hand, can tap into a community’s trust and its hopes for something better. That’s why the government needs people like Sam Williams.

Williams, 49, has lived in southeast Raleigh most of his life, in an old neighborhood where crack houses and churches vie for dominance. He knows “practically everybody,” and if not, he says, he knows their parents.

Once on these streets as a heroin and cocaine addict, Williams now patrols them as an outreach worker for the Wake County Health Department. Wake--with Marion County, Ind. and Nashville--won special federal funding two years ago for an aggressive syphilis elimination campaign.

Williams knows just how to draw a crowd. On a busy street corner one evening, he pulls out close-range photos of weepy, watery lesions and rashes. Young men gather around him, their faces masks of disgust.

“Oh, man,” says one, who just minutes before was boasting of his sexual prowess.

“They got a cure for that?” another asks Williams hopefully.

“Make sure you look before you leap,” Williams advises. Then he explains how syphilis plays hide and seek. You can’t always see it on a woman, so it’s best to be safe.

The pictures Williams displays show the repellent effects of later-stage, runaway disease, but he makes no apologies.

“If it comes from Sam, [people] listen,” said Wake County clinic Director Leone, who credits this sort of community mobilization for a 30% drop in new syphilis cases since 1998. “If I say it, it’s coming from some bald-headed white guy.”

The idea is for health departments to form partnerships with established community groups, outreach workers such as Williams and a cadre of volunteers. Among them are French Tibbs and his wife, Lena, the convenience store owners in Indianapolis, who opened up the back of the shop one day for syphilis testing. They include Pierre McCombs, an Indianapolis barber, who posts syphilis alerts on his windows and keeps condoms by his clippers.

“I’m not going to reach a whole lot of people, but hopefully, if I tell someone [about syphilis], they’ll tell someone else,” McCombs said.

The more engaged community leaders become in the fight against syphilis, the more they question the larger inequities they believe the disease represents.

Sanders, the Nashville pastor, wonders aloud why nearly six in 10 cases of the disease in his city are diagnosed in jail. The high yield is largely the result of a new, quick-turnaround testing effort--a technique that has produced remarkable results in a number of cities.

But, “If you have to go to jail to get treated for syphilis, it ought to tell you something about what’s wrong” on the outside, Sanders said.

Judy Wasserheit, the CDC’s chief of prevention for sexually transmitted diseases, says that in the absence of curing poverty or racism, she hopes programs like Raleigh’s can create a “behavioral vaccine” against syphilis and a range of other ills.

Syphilis is “just a starting point” in this effort, not an end point, she said.

Sam Williams added: “We’re just trying to plant a seed.”

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Rates of New Syphilis Cases

Syphilis is on the wane in the United States, with half of the nation’s nearly 6,700 new cases in 1999 clustered in 25 counties. Yet the remaining cases occur in communities unmoored from basic health and social services and point up glaring disparities between blacks and other groups.

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Source: Centers for Disease Control and Prevention, 1999 data

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About Syphilis

What is it: An infection caused by a spiral-shaped bacterium, Treponema pallidum. *

Origins: There are three competing theories: Christopher Columbus’ crew acquired the disease from Native Americans and brought it back to Europe; the Columbian crew was infected in Europe and spread syphilis to the New World; or the disease developed independently in the Old and New worlds. *

Famous victims: Al Capone, Sir Randolph Churchill, Franz Schubert, Charles Baudelaire. *

Transmission: Through direct contact with a syphilis sore during sex. Pregnant women can pass the disease to a fetus, causing stillbirth or infant death. *

Symptoms: Primary stage, 10-90 days after infection, marked by appearance of a tiny sore, usually firm, small and painless and on the genitals or anus. It can be hidden. After one to five weeks, it disappears on its own. Second stage often starts with a rash. It typically lasts two to six weeks and clears up on its own. Other symptoms: fever, swollen glands, hair loss, headaches, weight loss, aches and fatigue. First two stages are the most infectious. Afterward, if untreated, the bacterium can begin to damage internal organs. Years later, syphilis can cause blindness, dementia and death. *

HIV Link: Syphilis makes getting HIV two to five times more likely.

Diagnosis: By blood test, recommended for every pregnant woman.

Treatment: One dose of penicillin can cure someone who has been infected less than a year. More doses are needed for someone infected longer. A baby born with the disease must have 10 days of penicillin treatment. *

Prevention: Avoidance of sex with infected partners; use of latex condoms. *

*

Source: Lovett-Miller-Blanco laboratories, UCLA School of Medicine

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Infection Rates, 1999

The highest rates of syphilis in the nation are concentrated in the Southeastern states.

Source: Centers for Disease Control and Prevention