ON OCTOBER 7, 1999, the United States officially launched its National Plan to Eliminate Syphilis by 2005.1,2 The basic biologic characteristics that have made it possible for other industrialized countries to eliminate this disease were complemented in 1998 by an historically low primary and secondary syphilis rate of 2.6 cases per 100,000 population, and an extreme concentration of half of all new infections in less than 1% of the 3115 US counties.3–5 Together, these factors supported the feasibility of such a momentous and intimidating undertaking. However, the decision to push for elimination came from the recognition that today, the consequences of syphilis go far beyond congenital infections and stillbirths. The fact that syphilis continues to be one of this nation's most glaring examples of racial disparity in health (with reported primary and secondary syphilis rates 34‐fold higher among blacks than among whites), and the evidence that syphilis facilitates HIV transmission and probably fueled the heterosexual HIV epidemic of the 1990s across the South, created an imperative to translate feasibility into action.5–7
Yet this country has tried to rid itself of syphilis before, and failed.8 What is different this time? The current national plan focuses on five key strategies to achieve elimination: (1) enhanced surveillance; (2) strengthened community involvement and partnerships; (3) rapid outbreak response; (4) expanded clinical and laboratory services; and (5) enhanced health promotion.1 The critical importance of surveillance, case finding and treatment, and education was not lost on our predecessors.8 The roles of private providers and cluster interviewing (now reborn as social network analysis) were clearly recognized,9,10 and the mainstay of our bio‐medical arsenal has changed little from that in the 1960s. What is different is our growing understanding that as we enter the 21st century the persistence of syphilis in the United States is a sentinel event or a community diagnostic indicating risk environments that envelop entire neighborhoods. This is the fundamental concept highlighted by Farley and colleagues11 in this issue of Sexually Transmitted Diseases.
As part of a multicenter study to elucidate factors responsible for the focal persistence of high syphilis rates in the context of precipitous declines nationally, Farley et al. surveyed patients with early syphilis, their uninfected sexual contacts, and age‐matched neighborhood controls around Baton Rouge, Louisiana about their sexual behaviors, healthcare access and use, and exposure to HIV‐prevention interventions.11 The striking results point to differentials in population‐level factors related to access to or use of preventive and curative health services, rather than to differentials in individual‐level sexual behaviors, as key determinants in this high‐incidence area. Cases, contacts, and controls were similar in the frequency with which they reported high‐risk sexual behaviors, such as five or more sex partners in the last 12 months, unprotected sex with “casual” partners, and, for men, exchange of money for sex. The groups differed in the proportions reporting moderate‐risk sexual behaviors (two or more sex partners in the last 12 months) and measures of healthcare access and use, such as having health insurance, seeking care from public providers, and exposure to HIV‐prevention messages or condom‐distribution sites.
We cannot exclude the possibility that these results underestimate differences in individual‐level sexual behaviors. Lower participation among uninfected contacts and neighborhood controls than among patients with syphilis may reflect a tendency among these comparison groups to be interviewed only if they perceived themselves to have engaged in high‐risk behaviors. Regardless, the findings are consistent with a growing body of conceptual work and empirical data that is expanding the focus of our sexually transmitted disease (STD) prevention strategy to place greater emphasis on social and structural interventions that require linkages between the health sector and other community resources. For example, data from the National Survey of Family Growth suggest that in some subpopulations, the social networks and context that are the fabric of risk environments may be more salient than the sexual behaviors of individuals and their sex partners. Black and white women with similar, moderate numbers (two to three) of sex partners face markedly different risks of acquiring pelvic inflammatory disease, presumably because of contact with different sexual and social networks with different prevalences of STDs.12 Recent analyses of the National Health and Social Life Survey echo the primacy of population‐level patterns of sexual mixing in explaining observed racial and ethnic differentials in STD rates in the United States.13,14
Equally important is the concept that STDs are sustained in populations by “core groups” defined not only by high‐risk sexual behaviors, but also by inadequate contact with the healthcare system.15 As with sexual risk behaviors, data on gaps in healthcare‐related behaviors point to many factors beyond the control of at‐risk persons, such as provider or system behaviors. For example, in the mid 1990s, the median ratio of public‐sector STD clinicians to patients with infectious syphilis in southern states with persistently high syphilis rates was less than one sixth of that in comparison states, and limited access to quality STD care has repeatedly been documented in high‐morbidity areas.16–18
The relative importance of population‐level or system‐level factors and interventions differs with different phases of STD epidemics.15 For an elimination effort, in the limited pockets of persistently high morbidity, these factors are likely to be particularly critical. Farley et al have demonstrated again that in these “recidivist” communities, changing individual behaviors may have much less of an impact on eliminating disease than working with an array of community partners to catalyze more systemic social and structural change. However, “strengthened community involvement and partnership,” the centerpiece strategy of the national plan, is easier said than done. To achieve syphilis elimination this time around, STD staff and resources must mobilize community leaders both in health and in other sectors, and must marshal the “social capital” that is present even in some of the most disadvantaged neighborhoods. This demands different knowledge, skills, and approaches from those needed to diagnose diseases, treat patients, or find sex partners. It requires great patience, comfort with radically different perspectives, and willingness to share control to establish a more powerful, far‐reaching foundation for our prevention programs. But it can be done. Community coalitions that have been forged in places such as Nashville, Indianapolis, and several North Carolina counties are excellent examples of such efforts.
To eliminate syphilis, we must remember that in the wealthiest country in the world, as we enter the new millennium, syphilis is a barometer of community health. Syphilis, per se, and its elimination must be entry points, not end points, to work with communities to ensure health.
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