Hunting a Killer: Sex, Drugs and the Return of Syphilis

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A young woman hesitantly crossed the grass. For months she had avoided health workers. Once, an investigator spotted her slipping in through a side entrance to her mother’s house; at the front door, the mother denied that her daughter was there.

Fresh-faced, her blonde hair in a ponytail, the woman looked healthier than most people Ms. Williams visits, with their grayish skin, abscesses and mottled veins.

Ms. Williams was gentle but direct: “Your blood test results came back. It’s positive for syphilis.”

The woman buried her face in her hands. “I’m so embarrassed,” she sobbed. (Bound by confidentiality rules, Ms. Williams did not disclose her name.)

“Is that why my baby died?” she asked.

Ms. Williams nodded affirmatively.

“Can my kid get it? We sometimes share the same glass.”

No, Ms. Williams said. Just your sexual partners.

The woman insisted she had slept with only two men that year — her boyfriend and her ex, the father of the baby who had died.

Ms. Williams, who knew the woman’s Facebook page revealed many friends in a gang central to the outbreak, asked her to think carefully about whether there were more. We never reveal your name, she said, just as we cannot tell you who gave us yours.

The woman shook her head.

It was time to coax the woman into treatment. Just an injection and you will almost certainly be cured, Ms. Williams said, offering to drive her to the clinic. Her boyfriend too, Ms. Williams added.

He wasn’t around, the woman said, but she promised they would be there in the morning.

Are you sure you don’t want to go now? Ms. Williams asked.

Again, the woman shook her head.

Reluctantly, Ms. Williams got in her car and drove away.

An Elusive Killer

Syphilis, caused by bacteria, has been well known for centuries, chronicled as a scourge since at least the 1400s.

In 1932, the United States government began the ignominious “Tuskegee Study of Untreated Syphilis in the Negro Male” to observe the progress of the disease in black Alabama sharecroppers. Although penicillin had become accepted as the cure by 1945, Tuskegee researchers left the men untreated until 1972, when the study was shut down.

By then, largely because of treatment and public education, syphilis was disappearing. A generation of physicians rarely learned to recognize it firsthand.

But with the AIDS epidemic, syphilis surged, peaking around 1990. It was most common — and still is — among men who had sex with men, often those whose H.I.V. status made them vulnerable to other sexually transmitted infections.

Once again, public health campaigns sent syphilis into retreat. By 2000, only 5,970 cases were reported in the United States, the lowest since 1941, when reporting became mandatory.

But in the last few years, it has crept back.

Here in Oklahoma City, 199 cases have been connected so far this year. More than half the patients are white and female. The youngest girl is 14; the oldest man, 61. Three stillbirths have been attributed to syphilis and 13 of the infected were pregnant women.

Rare permutations are now more common. Ocular syphilis, which can strike at any stage of infection, often appears as blurred vision and reddened eyes. Congenital syphilis can cause deformed bones in newborns.

Many people never suspect they have the disease. Early symptoms, including genital lesions and, later, rashes on palms and soles, have led patients and health care providers to mistake it for herpes or allergic reactions. The disease can lie dormant for decades and then affect the liver, joints, blood vessels.

Once people are treated, though cured, they will almost always test positive. It is difficult to know whether a positive result indicates a new infection. After transmission, the bacteria may take three months to register. Those who test negative may have the disease.

This spring the Centers for Disease Control called for educating doctors and nurses about symptoms, testing pregnant women considered at risk and developing a better diagnostic test.

The cure for syphilis — usually two injections of Bicillin L-A, a type of penicillin — is relatively simple. But supplies have dwindled. Recently in Oklahoma, there were only seven doses statewide. Pfizer announced that stockpiles would be replenished by the end of 2017.

Dr. Vivian L. Wilson is medical director for eight community health clinics. In 37 years of practice, she has seen perhaps two cases of syphilis. But as a black Alabamian, she knows well the Tuskegee legacy. Though she appreciated a recent refresher course the state provided for staff members, the standard education materials, she noted, are severely outmoded.

“All the photographs still show patients who are Afro-American men,” Dr. Wilson said. “What message does that send?”

Watching the Detectives

After several months, dispirited Oklahoma investigators acknowledged that old-school tactics for locating contacts, like knocking on doors and cold-calling, were not very effective. Many people they sought are transient and use disposable phones.

“But they want to stay connected to their friends and their drugs,” said Ms. King, a supervising investigator. “So they’re all on Facebook. That’s where we’re finding them.”

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