The traditional public health response to rising rates of infectious diseases is to conduct awareness campaigns, engage community leaders as partners, and promote public access to screening and treatment to prevent the spread of disease. Amid rising rates of sexually-transmitted diseases (STDs) in Rhode Island, the opposite recently occurred on July 1, 2011, when the Whitmarsh Clinic doors were quietly closed to patients in response to state budget cuts.
Operated by Providence Community Health Centers, the Whitmarsh Clinic was the only public STD clinic of its kind in the state. The timing of the clinic closure announcement in mid-June, 2011, was ironic: a team of experts from the Centers of Disease Control and Prevention had just landed in Providence to conduct an investigation into recent and alarming increases in annual syphilis cases. As a backdrop to the climbing rates of syphilis, other STDs have remained a persistent public health burden in Rhode Island with 3,480 cases of chlamydia reported in 2010.
With over 1,500 patient visits in 2010 the Whitmarsh Clinic provided confidential, affordable, and patient-friendly STD testing, diagnosis, and treatment services through a mix of revenue streams, including: insurance billings, patient out-of-pocket payments, and state funding. An essential component of this mix was the state funding; without it, the clinic could not operate on its own, as many of its patients were from low-income communities and lacked health insurance.
In an era of national health care reform that is intended to expand affordable access to health care, the loss of the Whitmarsh Clinic represents a significant step backwards towards reaching this goal. Health care reform is intended to strengthen, not weaken, the “safety net” for patients who otherwise can’t afford health care and/or health insurance. Yet the “safety net” is being frayed and the unique value of public health specialty testing and treatment sites for STDs (as well as for tuberculosis and HIV) are now commonly coming into question. Even if all individuals have both health insurance and a primary care provider, it would be unwise to blindly assume that this safety net is no longer needed.
In the case of STDs, the long-standing societal stigma of having an STD remains prevalent while the public health benefit of STD clinics has not diminished. Today, the STD clinic patient mix is unique: young people who want care without parent involvement, individuals who have stepped out of their monogamous relationships, gay/bisexual men who are not out to their doctors, asymptomatic individuals who may have had sex with someone infected with an STD, and individuals lacking the resources for private health care. Public STD clinics have served all of these groups because of their guiding principles that focus on providing confidential, affordable, and accessible services in a private and safe setting.
The closure of the Whitmarsh House occurred without any public outcry for two primary reasons. First and foremost, due to societal stigma, affected communities and individuals have never developed a common voice surrounding a STD cause, except in the case of HIV – which has its own unique story. Second, the decision to close the clinic was made without any community discourse or public announcement — community members heard the news from Whitmarsh Clinic staff after the clinic’s fate had been sealed by public health officials.
In a time of state budget cuts and layoffs, it is important to be reminded that STDs are among the most common reportable communicable diseases in Rhode Island. STD’s are linked to serious health problems, such as infertility and some cancers, and the presence of a STD facilitates HIV transmission. This is why Rhode Island invests so much into the state-supplied childhood vaccine program – to make sure that children are protected as adults from vaccine-preventable STDs, such as Hepatitis B and human papillomavirus (HPV).
An important lesson can possibly be learned from neighboring Massachusetts, which closed their public STD clinics in late 2008. Since then, STDs have been a growing public health problem in the Bay State. Given the many societal and individual factors that affect STD rates, a causal link between clinic closure and a rise in STD rates is difficult to prove. However, the Massachusetts experience suggests the need to thoughtfully assess the impact of the Whitmarsh Clinic closure on the health of Rhode Island’s families, as well as on Rhode Island’s health care system, especially when individuals are being referred to emergency rooms and urgent care centers for STD care. Allowing the erosion of Rhode Island’s public health infrastructure is bad public policy – eventually, a steep price is paid, usually by our most vulnerable communities.