Portal de Periódicos da CAPES

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

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

10.1097/00007435-200002000-00002

1537-4521

David Satcher,

Syphilis Diagnosis and Treatment

I AM DELIGHTED to be back in Nashville. I think it was John Gardner, the US Secretary of Health Education and Welfare in the early 1960s, who used to say, “Life is full of golden opportunities carefully disguised as irresolvable problems.” We have a golden opportunity here, and it is not even disguised. It is pretty clear that when it comes to syphilis, we have an opportunity that we can not pass up. This has been a great century. Life expectancy of Americans has increased from 47 to approximately 77 years. We have seen deaths from cardiovascular diseases decrease by 60% since 1950. We have even seen lead levels in children come down precipitously as a result of changes in lead content of gasoline, paint, and other things. When it comes to infectious diseases, it has really been a great century. In the early part of the century, we had the great influenza pandemic of 1918 that killed approximately 21 million people in the world, and more than 600,000 people in the United States. But since that time, with the advent of antibiotics and vaccines, we have made tremendous progress with infectious diseases. We have eradicated smallpox worldwide, which is really the only naturally occurring disease that we have eradicated to date. We have eliminated polio in the Western Hemisphere as of 1991. We have made tremendous progress with diseases like measles; and even with Haemophilus influenzae, a disease for which we have just had a vaccine in the last 12 to 15 years. It is rare now to see a child with invasive Haemophilus influenzae. We have made a lot of progress. Now, we have the opportunity to eliminate syphilis. This is very important for several reasons, as it relates to the Surgeon General and the major priorities we have set for the nation. One of those priorities is to eliminate disparities in health on the basis of race and ethnicity, and syphilis is one of the most striking examples of disparities confronting us. Dramatic differences exist in the prevalence of this disease among African Americans as compared with the majority of populations; much more dramatic than the prevalence of HIV, AIDS, diabetes, or cardiovascular diseases. Although these dramatic disparities do exist, the good news is that we have made so much progress with syphilis since 1990. The fact that the disease has settled in a very small number of communities in this country means that we have a real opportunity for elimination, which is very important to us in terms of our commitment to eliminate disparities in health in this country by the year 2010. The other reason I think that it is so important is that compared with other disparities, syphilis elimination is very possible. We still have a lot of questions to answer in terms of the best strategies for eliminating disparities, and we are calling on communities to help us find the answers to those questions. Through REACH 2010 (Racial and Ethnic Approaches to Community Health), we have just announced funding to help plan model programs for eliminating disparities in 32 communities throughout this country. It just so happens that Nashville is one of the communities that received one of the REACH grants to focus on learning ways to close the gap on cardiovascular and diabetic diseases. It is going to take a lot of work in those areas to do what we need to do; however, the challenge to eliminate syphilis is different, because we know what to do. We know, for example, that it is going to take a great deal of strong community cooperation, partnerships, and support. Nashville is so exemplary when it comes to community organization and mobilization and forging partnerships with the public health system, and I am sure that these are some reasons why we are here tonight. This is what it is going to take to eliminate disparities in all of these areas, and it is certainly what it is going to take to eliminate syphilis. The other priority of the Surgeon General that is really relevant here is our commitment to a balanced community health system in this country. What is a balanced community health system? It is a health system that balances health promotion, disease prevention, early detection, and access to quality health care. We do not do this very well in this country. We spend $1.3 trillion a year for our health system, and most of that is for treating diseases, many of which are in late stages. Many funds are spent treating complications of diseases, such as diabetes and cardiovascular diseases. We need more balance. We need more investment in public health, health promotion, disease prevention, and early detection of diseases. The model being used here for eliminating syphilis takes that into account. It takes into account the need for community involvement. If you are going to have a balanced community health system, you need community institutions. You need the church, for example, which Reverend Sanders represents so well, both here in Nashville and throughout the country. He has been a very strong supporter of public health as it relates to the HIV/AIDS epidemic, and a strong advisor to us in the public health system. We need strong community organizations working with the school system, the criminal justice system, and the public health system. In addition, it is critical that we forge a stronger partnership between public health and medicine. We have been working on this strategy for improving partnerships between public health and medicine for a few years now. I started it before I left the CDC. In 1996, we had a national meeting to talk about partnerships between public health and medicine in Chicago. I had to be in Africa at the time, so I missed that meeting. But Donna Shalala, Secretary of Department of Health and Human Services, said something at that meeting that is relevant tonight. She said public health and medicine are like two trains running on parallel tracks. On one side, public health looks out the window and sees populations and opportunities for prevention; and on the other side, medicine looks out and sees individual patients and diseases to treat. The only problem is that it is the same community. We need to bring together our commitment for preventing diseases and promoting health; and, when diseases occur, we must treat them aggressively. That is the system we need. A partnership between public health and medicine, and a partnership that involves the community from beginning to end. Early detection is certainly critical. The commitment here to a strong system of surveillance for this disease, a rapid response to outbreaks, and strong clinical laboratory support is really critical to early detection and response. The other part of that balanced equation is access to care. Access is a difficult issue. Yesterday, the US Bureau of the Census reported that the number of uninsured people in this country continues to increase. In fact, during the last year, the number increased by approximately one million people. There are now somewhere between 44 and 45 million uninsured people in this country. Despite the fact that the cost is going up, we have more people hanging out there who are uninsured. There are also people who are underinsured, beginning with many elderly persons who can not afford prescription drugs, even though they are covered by Medicare. But it does not end with the elderly; there are a lot of other people who are underinsured. So, often it is not enough to be insured to have access to care. Recently, we had a press conference to talk about the need to get older persons immunized against influenza and pneumococcal bacteria. We are having such a problem when it comes to the pneumococcal vaccine-only approximately 45% of persons older than 65 years in this country are being immunized. Even with influenza, 67% of the white population, 50% of the black population, and 58% of the Hispanic population older than 65 years are being immunized. These low immunization rates are not due to cost; Medicare covers both vaccines. Yet, we have thousands of people dying every year, and a half million people being hospitalized for illnesses that we could prevent with these vaccines. So what is the access problem? In addition to being uninsured, some people in this country live in underserved communities. Even if they have insurance, they do not necessarily have ready access to quality care. Other people are underrepresented in the system, and this influences how they approach it. If you are a non-English speaking Hispanic person, and your language is not spoken at the health center or the healthcare workers do not understand your native culture, then you will not be clear on what is going on, and the healthcare workers will not understand what is going on with you. It is a barrier to access if you do not trust the system. The other “uns” among the uninsured, underserved, and underrepresented are the uninformed. There are a lot of people who are simply uninformed, who do not know enough about how one gets syphilis. Unfortunately, a lot of our young people out there do not know enough about the dangers of irresponsible sexual behavior. These dangers are increasing every day as we speak-not just for syphilis, of course. The HIV/AIDS epidemic is a very deadly epidemic, and a lot of our young people still do not understand that even though sex is something very beautiful and very special, it also can be very dangerous if it is not approached with the kind of respect that it deserves and in the context of committed relationships. There is another area of the uninformed that includes people who do not really understand the full range of services that are available to them; for example, there are those who do not know that Medicare covers influenza and pneumococcal vaccines. That message really came home to us last year after Congress passed and President Clinton signed the Child Health Insurance Program. We worked with states throughout the country to approve their Child Health Insurance Plan. We then asked them to go out and sign up those 11 million children who are uninsured in this country, and said that we would share the cost of covering these children. One of the first things that became very obvious was that approximately half of those children were already eligible for Medicaid; they just were not signed up. Children whose health is dependent on immunizations and other health services were not getting access, because information was not getting to the right place. In addition to being uninsured and uninformed, some people are just uninspired. I think this epidemic, to a great extent, is settling more and more into communities where people are uninspired, in many cases, about their health. Health for many people is not a high priority. It certainly is not a high priority for people who are addicted to drugs and trying to get their next “fix.” There are people out there struggling to survive. There are people who are hopeless about their future. Together we have to deal with that-the health profession can not deal with that alone. We can not deal with hopelessness alone. We can not deal with the lack of inspiration to respond to opportunities alone. We need the help of the church and the communities if we are going to attack the problem. We have a tremendous opportunity here. It has global implications because, for the most part, the rest of the industrialized countries have solved this problem. So we know it can be done. I wish you the best as we work together. I wish you the best in Nashville, and obviously in the nation. We will be looking to you for leadership. I have a lot of confidence in this community. I know what you can do and, therefore, I am just delighted that syphilis elimination is beginning here. It is going to take hard work, cooperation, and a lot of faith. Langston Hughes said, “Hold fast to dreams, for if dreams die, life is like a broken winged bird that cannot fly. Hold fast to dreams, for if dreams go, life is like barren land covered with snow.” Hold fast to dreams and let's get this done.