What can we learn from a failed attempt to eradicate "the Great Pox" in the U.S.?

A medical assistant closes bottles of patients' urine submitted for STD testing in Hollywood, California, on May 18th, 2018. (Photo: Frederic J. Brown/AFP/Getty Images)

On Tuesday, the Centers for Disease Control and Prevention's (CDC) Division of Sexually Transmitted Disease Prevention released its 2017 Sexually Transmitted Disease Surveillance report. The news is bleak: Syphilis, chlamydia, and gonorrhea rates are climbing, and cases of congenital syphilis—babies born with the disease—have more than doubled since 2013.

But perhaps most shocking is that this is not a steady, inevitable rise: Twenty years ago, the landscape was very different. In fact, in 1998, public-health experts in the United States thought syphilis was on the brink of elimination.

This was an incredible victory against a disease so prolific that, in 1937, then-Surgeon General Thomas Parran called it a "shadow on the land." Before its first successful treatment with penicillin in 1943, that "shadow" disfigured and blinded victims, and carried a great deal of stigma. In the following decades, public-health officials in Europe and America employed effective strategies to identify and treat syphilis infections, and though rates fluctuated, aggressive treatment of a 1980s surge linked to the crack cocaine epidemic brought rates down dramatically. By the end of the 20th century, everything was in place for a true public-health win.

By 1998, syphilis cases had declined 86 percent from their peak in 1990; penicillin was cheap, effective, and widely available; and the genome of T pallidum—the syphilis bacterium—had recently been sequenced. "The timing is right for a concerted effort to eliminate endemic transmission of syphilis in the U.S.A.," wrote Edward Hook in the medical journal The Lancet. In 1999, the CDC launched the Syphilis Elimination Effort to take advantage of "a narrow window of opportunity to eliminate this disease" and to "significantly decrease one of this Nation's most glaring racial disparities in health." Another optimistic report mentioned that other countries had already achieved that goal.

But it didn't work. In December of 2013, the efforts of the SEE officially ended.

There's no single answer as to why we failed. Sarah Kidd, a medical epidemiologist in the CDC's STD prevention division, says a key issue is that there are really two epidemics to deal with: localized, endemic transmission in heterosexual communities, and more recent scattered transmission in the sexual networks of men who have sex with men (MSM).

For decades, public-health experts have known about high rates of syphilis in specific counties in the South, primarily poor, black communities. The interventions for those patients often occurred in local, publicly administered STD clinics, which provided community outreach, education, immediate treatment, and case follow-ups to a certain geographic area. But that model doesn't work as effectively for cases in MSM, who often receive treatment through private providers that aren't thinking in the same big-picture, epidemiological way public clinics are, Kidd says. And both high-risk groups are rightfully wary of government health initiatives after decades of mistreatment, especially during the Tuskegee Syphilis Study and the AIDS epidemic.

So, after reaching a record low in 2000, syphilis cases are once again on the rise. Dating apps, budget cuts, and condomless sex have all been blamed. Syphilis is no longer close to eradication. "Right now, when cases are going up, we're just trying to get a handle on stemming the increases," Kidd says.

What does that look like? For MSM, the plans are to integrate services with HIV care (syphilis and HIV very commonly occur together) and to educate providers—some of whom never expected to treat many syphilis patients in their careers. Men should be screened annually for syphilis, Kidd says. For heterosexual communities, most of the attention is on congenital syphilis, which can cause miscarriage, stillbirth, and infant death. That means prenatal care—and early prenatal syphilis screening—is crucial. "Even one congenital syphilis case is too many," Kidd says.

But the takeaway, if there is any, is that we must be conscientious about how our health system cares for our most vulnerable populations. "The success of efforts to eliminate syphilis transmission will hinge on the way larger inequities in health care are addressed," Hook warned the medical community in 1998. That remains true today.