My Pre-story 

Syphilis is called The Great Imitator. It can look like any number of diseases. In its first stage, the only evidence of infection is a painless sore at the bacteria’s entry point: Syphilis test. Weeks later, as the bacteria multiplies, skin rashes bloom on the palms of the hands and bottoms of the feet. Other traits of this stage include fever, headaches, muscle aches, sore throat and fatigue. These symptoms eventually disappear, and the patient progresses into the latent phase, which shows no external signs. But if left untreated, after a decade or more, syphilis will reemerge in up to 30% of patients, capable of wreaking horror on a wide range of organ systems. Dr. Marion Sims, president of the American Medical Association in 1876, called it a “terrible scourge, which begins with lamb-like mildness and ends with lion-like rage that ruthlessly destroys everything in its way.

The history

Italian physicians described French soldiers covered with boils from Syphilis tests dying from a sexually transmitted disease. As the affliction spread, Italians called Syphilis the French Disease. The French blamed the Neopolitans. It was also called the German, Polish or Spanish disease, depending on which neighbour one wanted to blame. Even its name bears the shame of divine judgement. It comes from a 16th-century poem about a shepherd, Syphilus, who offended the god Apollo and was punished with a hideous disease.

Around the same time, the Public Health Service launched an effort to record the natural history of syphilis. Situated in Tuskegee, Alabama, the infamous study recruited 600 black men. By the early 1940s, penicillin became widely available and was found to be a reliable cure, but the treatment was withheld from the study participants. Outrage over the ethical violations would cast a stain across syphilis research for decades to come and fuel generations of mistrust in the medical system among Black Americans that continues to this day.

With the introduction of penicillin, cases began to plummet. Twice, the CDC has announced efforts to wipe out the disease — once in the 1960s and again in 1999.

It can be cured with injectable penicillin.

In the latest effort, the CDC announced that the United States had “a unique opportunity to eliminate syphilis within its borders,” thanks to historically low rates, with 80% of counties reporting zero cases. The concentration of cases in the South “identifies communities in which there is a fundamental failure of public health capacity,” the agency noted, adding that elimination — which it defined as fewer than 1,000 cases a year — would “decrease one of our most glaring racial disparities in health.”

Two years after the campaign began, Syphilis testing cases started climbing, first among gay men and later among heterosexuals. Cases in women started accelerating in 2013. Followed shortly by rising numbers of babies born with syphilis. The reasons for failure are complex. People relaxed safer sex practices after the advent of potent HIV combination therapies, increased methamphetamine use drove riskier behaviour, and an explosion of online dating made it hard to track and test sexual partners, according to Dr Ina Park, medical director of the California Prevention Training Center at the University of California San Francisco.

However, federal and state public health efforts were hamstrung from the get-go. In 1999, the CDC said it would need about $35 million to $39 million in new federal funds annually for at least five years to eliminate syphilis. The agency got less than half of what it asked for, according to Jo Valentine, former program coordinator of the CDC’s Syphilis Elimination Effort. As cases rose, the CDC modified its goals in 2006 from 0.4 primary and secondary syphilis cases per 100,000 population to 2.2 cases per 100,000. By 2013, as elimination seemed less and less viable, the CDC changed its focus to ending congenital syphilis only.

Yang prepares a letter asking Angelica to get in touch

Yang waited until the end of the day. Then, she called the clinic to see if Angelica had gone for her shot. She had not. Yang would have to block off another half day to visit Huron again. But she had three dozen other cases to deal with.

States in the South and West have seen the highest syphilis rates in recent years. In 2017, 64 babies in Fresno County were born with syphilis test at a rate of 440 babies per 100,000 live births. About 19 times the national rate. While the county had managed to lower case counts in the two years that followed, the pandemic threatened to unravel that progress, forcing STD staffers to do COVID-19 contact tracing, pausing field visits to find infected people and scaring patients from seeking care. Yang’s colleague handled three stillbirth cases in 2020. In each, the woman was never diagnosed with syphilis because she feared catching the coronavirus and skipped prenatal care.

The job of prevention

Yang, whose caseload peaked at 70 during a COVID-19 surge, knew she could not handle them all as thoroughly as she’d like. “When another investigator mentored me, he said: ‘You’re not a superhero. You can’t save everybody,’” she said. She prioritises men who have sex with men because there’s a higher prevalence of syphilis in that population and pregnant people because of the horrific consequences for babies.

The job of a disease intervention specialist isn’t for everyone. It means meeting patients whenever and wherever they are available. And in the mop closet of a bus station, in a quiet parking lot to inform them about the disease. Then, extract the names of sex partners and encourage treatment. Patients are often reluctant to talk. They can get belligerent, upset that “the government” has their personal information or shattered at the thought that a partner is likely cheating on them. Salaries typically start in the low $40,000s.

A solution to the problem

Jena Adams, Yang’s supervisor, has eight investigators working on HIV and syphilis. In the middle of 2020, she lost two and replaced them only recently. “It’s been exhausting,” Adams said. She has only one specialist trained to take blood samples in the field. Crucial to guarantee that the partners of those who test positive for syphilis also get tested. Adams wants to get phlebotomy training for the rest of her staff, but it’s $2,000 per person. The department also has no one in the field who can administer penicillin injections. That would have been key when Yang met Angelica. For a while, a nurse who worked in the tuberculosis program would ride along to give penicillin shots on a volunteer basis. Then he, too, left the health department.