April is National STD Awareness Month and sexual and reproductive health organizations throughout the country urge you to Get Yourself Tested. RH Reality Check has partnered with The National Coalition of STD Directors (NCSD) to produce a series of articles on the importance of STD prevention and treatment among populations throughout the United States. Other articles in this series include one by Sandra Serna-Smith and Dana Cropper Williams.
Tantalus, a son of Zeus and the king of Sipylos, was cursed by the Greek gods by having to stand to his neck in a pool of water. He was thirsty, but when he bent his head to drink, the level of water quickly receded. He was also hungry, but the fruit that hung above his head was always just beyond his reach. Fulfillment was always so close, but could never be reached.
Tantalus’ curse in many ways epitomizes the multiple efforts for syphilis elimination in the United States. The CDC, in conjunction with state and local health departments, undertook syphilis elimination efforts (SEE) in the early 1960’s and again in 1999. The later effort occurred during a period of historically low syphilis rates and when cases were highly concentrated in specific geographic areas. Efforts were targeted in the southern United States where disease rates were the highest and racial health inequalities were the greatest. In 1998, just 25 counties accounted for half of all early syphilis cases in the United States. North Carolina had five of these “high morbidity” counties and was selected for one of three national demonstration sites for syphilis elimination. The task seemed credible since syphilis was and still is easily diagnosed with cheap, widely available tests and can be treated, in most cases, with a single dose of penicillin.
The national plan was built around five complementary strategies including the following components:
- enhanced surveillance;
- promoting community involvement and organizational partnerships;
- rapid outbreak response;
- expanded clinical and laboratory services; and
- enhanced health promotion.
The idea was to invert the “triangle” by putting community involvement at the top and having local health departments follow the lead of the community.
It worked–well sort of–for awhile. In North Carolina, the rates of syphilis dropped to an all-time historic low in 2003. Forsyth County, one of the five designated elimination counties in North Carolina, reported 54 cases of Primary and Secondary (P&S) syphilis with a case rate of 18.6 per 100,000 in 1998. SEE funding peaked in 2003 at $1.8 million for the sate of North Carolina and $167,000 for Forsyth County. Starting in 2004, SEE funding was cut and reached a nadir in 2009 of $57,000 (a 66 percent reduction in funding for Forsyth County and a 80 percent reduction in state funding). In 2003, at the highest point of federal funding support, Forsyth County reported 1 case of P&S syphilis with an overall rate of infection well below 1 per 100,000. Numbers remained low in Forsyth County over the following several years but, after the money all but dried up, came roaring back in 2009 with 195 cases and a case rate of 34.3 per 100,000. These numbers are even higher than at the start of the syphilis elimination effort.
The failure of syphilis elimination was, in hindsight, predetermined. Although the national program was steeped in community involvement it still followed a basic medical model. The concept was primarily one of “test-and-treat.” Prevention was a necessary and essential part of the program but was not coupled with plans to address the many social contextual factors that set the stage for the racial and ethnic inequities seen for syphilis as well other sexually transmitted infections and chronic health conditions. Since syphilis was not eradicated (i.e. did not go to zero cases) the embers for reinfecting vulnerable sexual networks remained intact. The plan was also not coupled with systematic, acroos-the-board efforts to address the racism, sexism, homophobia, high rates of incarceration for minority males, poverty and segregation that led to distortive mixing of low- and high-risk populations and to concurrency. Both of these factors are bound to other contextual factors that persisted even while rates hit historic lows.
Further complicating elimination efforts were the predictable federal loss of will–and money. When syphilis elimination seemed on the verge of success, case rates dropped which unfortunately meant money got shifted away to other priorities or jurisdictions. The latter is what occurred in North Carolina and Forsyth County. The reduction of funding created a permissive environment for the re-emergence of syphilis, but it alone is not to blame. The loss of money was but a symptom of a flawed approach.
Syphilis warrants the attention given to it by past elimination efforts. But prevention programs should be viewed in the boarder framework of contextual factors. Efforts to “eliminate” disease can only be rightfully–and sustainably–addressed in conjunction with strategies to eliminate social and economic disparities, address the racial, ethnic and sexual minority status conferred on specific groups of people at risk, and reduce poverty throughout our society. A “test-and-treat” model will bring epidemic levels of syphilis under control, but won’t eliminate endemic disease thus setting the stage for reemergence of this most historic infection. If we recast SEE into the models of sexual health and social justice, maybe elimination of health disparities in general will finally be in our grasp.