It was supposed to be on its way out. Just four years ago, syphilis--the "great pox" of the 15th century--had declined to rates so low in this country that the Centers for Disease Control and Prevention announced a bold new plan to eliminate the disease by 2005. But the stubborn scourge has come bounding back, with outbreaks from Miami to Seattle. Last week New York City health officials announced a 50 percent increase in syphilis diagnoses between 2001 and 2002. San Francisco's numbers more than doubled in the same period. And health officials who'd hoped to herald the disease's demise are putting the public on high alert.
The concern isn't just about the spike in the disease, but what it could foreshadow for a deadlier epidemic. The sores that mark syphilis increase the risk of HIV transmission two- to fivefold. That people are even contracting syphilis suggests the erosion of safe-sex practices. "Every case of syphilis might mean one more transmission of HIV," says Dr. Thomas Frieden, New York City's health commissioner.
After a steep decline in the 1990s, syphilis rates rose by 2 percent between 2000 and 2001, from a total of 5,979 cases to 6,103. While the actual numbers are small, the increase is almost exclusively among men--a 15 percent jump. At the same time, rates among women and African-Americans, and in the hard-hit South, dropped. The rise is being attributed to urban outbreaks among gay and bisexual men, known in the health world as "MSM," or men who have sex with men. In Chicago, for example, MSM accounted for 63 percent of syphilis cases last year, up from only 14 percent in 1998.
Syphilis can be diagnosed with a blood test and cured with antibiotics. But since the initial lesions are painless, the disease can go undetected. Condoms protect against transmission. Yet safe sex can be difficult to practice 100 percent of the time. And the impact of powerful AIDS drugs has tempted many men to let their guard down. For younger men, especially, "the old prevention messages of the '80s don't resonate," says Ronald Johnson of Gay Men's Health Crisis. Even older men, scared into strict condom use in the 1980s and '90s, "have done some backsliding with respect to their behavior," says Dr. H. Hunter Handsfield, of Seattle and King County's public health department.
Anonymous sex plays a big role. Bathhouses and sex clubs are part of the problem, but health officials are also concerned about the Internet; in San Francisco, half of all men diagnosed with syphilis last month reported meeting sexual partners online. Then there are "circuit" dance parties, where drugs and sex abound. Some men mix stimulants like crystal methamphetamine or ecstasy with Viagra, leading to more sex with more people and, thus, "more friction and more breakage in the skin," says Charlie Rabins, of Illinois's public health department.
"Syphilis is just the tip of the iceberg," says Dr. Gail Bolan, of California's health department. Already about 70 percent of MSM syphilis patients are also infected with HIV. New York data show that two thirds of men infected with both syphilis and HIV engage in unsafe sex. And some of these men may also be having sex with women. Says Dr. Peter Kerndt, of Los Angeles County health department: "A bridge into the heterosexual community could wipe out the gains we've made."
Containing the outbreaks is an enormous challenge. Cities like L.A. are launching provocative awareness campaigns, with Web sites and billboards. But big hurdles accompany every small step. Health activists are butting heads with a federal government that questions the effectiveness of condoms and promotes abstinence, to the exclusion of other forms of prevention. There's never enough funding. And debate over the efficacy of safe-sex initiatives rages on. Still there's no getting around the urgency: an old enemy is back--and vigilance remains the most powerful weapon we have.