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National Syphilis Elimination Launch: Nashville, Tennessee, October 7, 1999

2000; Lippincott Williams & Wilkins; Volume: 27; Issue: 2 Linguagem: Inglês

10.1097/00007435-200002000-00001

1537-4521

Jeffrey P. Koplan,

Syphilis Diagnosis and Treatment

I HAVE BEEN Director of the Centers for Disease Control and Prevention (CDC) for the past year, and people are constantly asking me: “Are you enjoying the job?” It is events like this one that make my job enjoyable. This, to me, is what public health is all about; it is the most gratifying aspect of public health. We are at a unique moment in history. That is said often, but I will give you some reasons why I believe it is true. At the end of this evening, I hope that you will walk out of this room believing that it is the case as well. There are many different people in this room from different backgrounds: healthcare workers, clergy members, students, teachers, community workers, social workers, and legislators. A common thread among us is that we want to make a difference. We have chosen different ways to do it-different emphases, in different parts of our society-but we all want to make a difference. There are many ways to make difference. There are many issues: social issues, health issues, societal injustices. There are many causes of ill health. So why have we chosen this particular illness, one that you do not hear much about and that people do not like to talk about? Why have we chosen syphilis, this day, here in Nashville? I would like to make the case for how we can make a difference-how we can fulfill our professional goals and get personal satisfaction from this moment. We are at a unique moment in time with this illness. Syphilis is an illness that has existed for centuries. In some ways, that is why we want to target it today. The mention of syphilis should evoke images of Spanish galleons and pirates-another century, another place. It is not a disease of 1999; it is not something that people should suffer in 1999. If you look around and ask, “Who is at risk for this disease? Is it people who are wealthy, who have access to health care, who live in rich communities? Is it widespread across this whole country?” The answer is: no, that is not the case. Syphilis has become focused in communities of need, among people who do not have access to health care and who suffer many other injustices in our society. This is all the more reason to target these groups and improve their health, to eliminate a disease of the 18th and 19th centuries. Syphilis is not a 21st century disease; it should not even have been a 20th century disease. Syphilis is easily treatable with one of the cheapest of our medications. It does not require fancy antibiotics or biomedical research. You do not need genetic therapy to treat it. You do not need an operating suite. All that you need is penicillin. All that you need is to identify the case-easily done with existing technology-and treat that person with penicillin. When you do that, you stop the spread of the disease. You find out who else has been exposed, and you stop it cold-right there. It is so simple. It is such a small investment for us to make. It can make a huge difference, but we have not been doing it; however, we are going to do it. We are going to stop this illness as we enter the 21st century. We have eliminated a number of diseases in this country-or at least made them unimportant-largely through vaccines. For example, most of us grew up with polio around us. I had a neighbor who lived across the street and went away for a couple of weeks, and then came home in a wheelchair. That was the first time that I learned about polio. Some of us had measles, or our parents did. These are diseases that you have heard about or know about or experienced that simply are not around anymore-they are history. And that is why we are here today. Throughout the 20th century, a number of people have had the privilege, honor, and satisfaction of saying, “I was part of history. I worked on the elimination or eradication of a disease.” Take smallpox, for example. There is no longer any smallpox disease anywhere in the world; hundreds of millions of lives have been saved. Or, for example, take polio elimination. Today, wild polio virus is no longer circulating and causing new cases of paralysis in the United States. Here in Nashville, 50 years ago, both Meharry and Vanderbilt hospitals would have had wards full of patients in iron lungs; today, there are none. Now we have a chance to do something very similar-a unique opportunity. That is why you are here, and why there is so much enthusiasm to eliminate syphilis. Now we have the lowest number of cases we have ever had, and in the fewest places. That is worth noting, because you really want to have a leg up on a serious problem like this one-one that is hard to defeat. It is as if you go out to your lawn or your garden and notice a couple of sprigs of poison ivy. If you recognize them and pull them out while there are just two sprigs, you have saved your garden. Do you say to yourself, “No, there are lots of other problems in the garden. We've got to fertilize and worry about the plants for next year. Let's not look at it right now…let's come back to it later?” If you come back later and the weed killer you would have used no longer works, you waited too long. That is the situation we are in now with syphilis. We have the fewest cases of syphilis in the fewest places. We have a drug that works; there is no resistance to it, and it is cheap. You do not have to be a space-age scientist, a neurosurgeon, or a molecular biologist to figure this out. This is an opportunity crying to be taken advantage of. All of us in public health-and by that I mean everyone in this room, because we are all public health workers now, whether you are a teacher or a clergy member or a student-would be remiss to have this opportunity and then say, “Well, we've got something else that's important.” Of course, a lot of things are important. But here is an opportunity we cannot let pass. This year, there were less than 7,000 cases of syphilis in the United States. This represents a 20% drop from just one year ago, and almost a 90% drop from 1990. But, as with many other diseases, there is a periodicity or cycling with syphilis. Every 7-10 years, that low period becomes a high period. We are at a low period right now, one that is as low as it has ever been. We can not miss this opportunity. Now is the time when there are just two sprigs of poison ivy. It is time to put on our gloves and pull them out. Geography is an issue in this battle. This disease clusters in just a few places. More than half of the cases occur in 28 of the more than 3,100 counties in the United States. So, we can target our efforts. Nashville is one of the locations that still has a fairly large number of cases. It is a place where, if we put forth effort, we can claim a victory; but we can not claim a victory yet. There has been a tendency, as we have lowered the occurrence of many infectious diseases, for us to say, “It's not a problem anymore.” I think that this is a tendency in the larger community around us. That is human nature; if we do not see it, it does not affect us necessarily, so we do not do much about it. We have to do something about human nature and we have to do something about the nature of the disease, because syphilis will spring forth again if we do not intensify our efforts now. Syphilis has other nonmedical characteristics that are worth noting. In many ways, it is an indicator of much broader health and societal issues in this country. It is one of a large number-an unacceptably large number-of diseases and conditions for which there is a racial disparity in outcome. AIDS and HIV are examples of diseases that disproportionately affect African Americans, at a rate 9 times greater than that of whites. Infant mortality rates are 2.5 times higher in the African American community. Heart disease deaths are 1.5 times higher. Syphilis rates are 34 times higher-and that is despite a decade of improvement. We have cut the differential in half; but half, while progress, still leaves us with a 34-fold disparity. As we have concentrated on this health problem, people ask, “Why is that the case? Why is syphilis focused in this community?” I think the answers are pretty straightforward. This disease, like others, serves as a sentinel for broader health and societal problems that we need to address. People who live in poverty, lack employment, and who lack access to quality health care are vulnerable to this and other diseases. So, as we target our efforts and work at strengthening and involving the state and local health departments, community groups, and communities of faith, we should see a difference not just in syphilis rates, but in a range of other health conditions that go hand in hand with it. Syphilis takes a great toll in and of itself; it affects newborn infants, it ravages many of the systems of the body, and it has huge costs for society. But as we focus on this disease, we are going to make a difference in the community as a whole. One way we are focusing on the disease is by creating the National Plan to Eliminate Syphilis from the United States. That is just the start. In the plan, we have set a goal for syphilis elimination. This goal is concrete and specific; it is to get to less than 1,000 cases of syphilis per year by 2005. This would, for all practical purposes, eliminate the disease. Remember, we had approximately 7,000 cases this year. Our goal is to get down to 1,000 cases. We are focusing our efforts on the 28 counties where most of the cases-or at least a disproportionate number of cases-are occurring. We are going to use five key strategies: 1) Strengthen community involvement and partnerships. The first strategy has not been used much before and is in terrific evidence right here in this room. This is the new look of public health. When I started in public health, partnerships usually involved the federal government-usually the CDC-and the state health department. Although together we have accomplished many things, we can accomplish much more by working with community partners too. It is striking to me today to talk with you and to hear other people talk about this issue. It brings to mind that overused word, “empowering.” It feels empowering to me as someone whose whole career has been in public health to realize how much more we can accomplish as a team with people like the folks in this room contributing. If we, in public health agencies, tried to accomplish this alone, I can assure you our goal would be the year 3005, not the year 2005. We need you, and health problems like this need your involvement. That is the way we are going to solve them. The other strategies in the plan are strategies we have used before. We hope to enhance them and contribute new energy to them. 2) Enhance surveillance. The second strategy involves finding the cases, reviewing where the cases occur, and targeting our efforts there. 3) Respond rapidly to outbreaks. 4) Expand clinical and lab services. Before we can treat syphilis, we need to be able to diagnose it. 5) Enhance health promotion services. We must enhance these services for patients, sexual partners, and others at high risk. This package of five strategies will bring about syphilis elimination. It is not going to be easy. People do not like to talk about this disease, let alone try to eliminate it. But this community is already talking about it, and in places where it was not discussed before. You are already well on your way. I think I have a right to be optimistic. I have been involved in an eradication program before for a disease that ravaged the world and now no longer exists. When that program started, there was not enough money for it. Everyone said it could not be done. How could you do things in countries that are at war? How could you eliminate smallpox in a country like Bangladesh, where people are more worried about how they are going to get a meal the next day? And where there are floods every year and you can not get around? How are you going to do it in countries like the Sudan that have been in civil war for the last 15 years, and where you can not cross from one area of the country to the other? How can you do it in the Amazon river area, where you can not traverse the geography easily? The objections went on and on like this. And the answer is just what you have here. When you put the right number of people together, with the right amount of energy and caring and desire, when you have the biological basis to do it, and when it is a just and right cause, you will get it done. Do not worry about the money today. The money will come, or you will not need it; but this will get done. We have seen it before in public health, and you are going to demonstrate it again right here in Nashville. Those obstacles will look very small a year or two from now when you have made considerable strides in controlling syphilis in this city. You have a unique opportunity to eliminate syphilis in your community, and you are the ones who are going to do it. It is easy for me to come up here and talk. A year or two from now, I will still be talking somewhere, but you will be eliminating this disease in your community. You will have done it, and you will get the credit for it-as you should. This is a landmark time in history. It is a unique point when we can make a difference. There are lots of other big issues, and we should work on multiple things to try and correct them; things that are wrong in our society and wrong in health. But here is a very concrete opportunity on which we can all focus and, in short order, make a real and concrete difference. We in public health can not tolerate the continued spread of syphilis for a variety of reasons. That means all of us, because now the public health community in Nashville is the clergy, the teachers, the students, the health workers-a range of partners working to get it done. We at CDC have to worry about many health issues in the country as a whole; but you do not. You have to worry about Nashville. You do not have to worry about Baltimore, Chicago, Seattle, or Memphis. (Well…maybe you ought to worry about Memphis a little bit.) You can focus on this place. It is possible, and I think that you are going to do it. I look forward to being back here to celebrate with you the dramatic reductions in syphilis rates-all the way to zero. Thank you.