Sex-Linked Diseases : Young, Poor Suffer Silent Epidemic

Health workers were the first to see it coming. They sensed it on the street corners where prostitutes loitered. Behavior was changing. Prostitutes were no longer bothering with motels. They were out on the curb hailing tricks, working hastily out of cars.

People coming into the sexually transmitted disease clinics could not remember their partners. More and more seemed to be out of work or using drugs. Despite warnings about AIDS, health workers sensed a desperate recklessness afoot--brought on by upsurges in cocaine, poverty and social decay.

“You know it’s a matter of time until you see the statistics,” recalled Sibyl Howard, a public health nurse with Los Angeles County. “When you’re out in the field and you sense people’s despair, you can say, ‘Look, this is what’s happening.’ ”

‘Silent Epidemic’

What Howard intuited during those years in the mid-1980s is now an alarming national fact. There is a “silent epidemic” of sexually transmitted diseases. They are spreading rapidly with no sign of a slowdown. And they are falling hardest on the young and the poor.

About 12 million Americans will develop sexually transmitted diseases this year. Eighty-five percent will be under age 30. As many as 100,000 women will become infertile as a result of infections. Thousands of babies will be born infected.

Organisms barely heard of 10 years ago appear to be rampant. More than 20 viruses and bacteria are now known to be spread by sex. Meanwhile, many inner-city neighborhoods have become permeated with syphilis, a disease long thought a thing of the past.

“It is increasingly apparent that the cities of North America are more and more resembling the cities of developing countries,” Dr. King K. Holmes, a prominent researcher of sexually transmitted diseases, said in a talk at the international conference on AIDS earlier this year.

By contrast, cases of sexually transmitted disease in Orange County have been decreasing steadily, public health officials said. For instance, gonorrhea cases totaled 5,845 in 1986 but had dropped to 2,873 two years later, declining from a rate of 266.5 cases per 100,000 people in 1986 to a rate of 127.1 per 100,000 by 1988.

Because of the AIDS epidemic, “a fair number of people have changed their choices of sexual behavior, reducing the risk of getting AIDS, Hepatitis B, syphilis and gonorrhea,” said county epidemiologist Thomas J. Prendergast.

“Where that has ceased to happen--in Los Angeles where the numbers are going back up--they’re having a problem with ‘crack houses,’ with people trading sex for drugs. So far we haven’t seen that phenomenon in Orange County,” Prendergast said. “We have not seen a syphilis cluster around a crack house. . . . I’m not saying it couldn’t happen.”

Powering the grim statistics are a mix of forces, the most notorious of which is the spread of crack cocaine, the uncommonly addictive drug that has spawned a life style centered on swapping sex for drugs, inadvertently spreading disease.

Many inner-city heterosexuals have not learned the safe sex message of the AIDS era. In addition, urban and suburban teen-agers are having sex earlier and more often. Many use no protection, despite the spreading epidemic among their age group.

Meanwhile, resources for controlling sexually transmitted diseases, other than AIDS, have remained flat or declined. Many public clinics have had to cut their hours. New diseases have outsmarted old disease-control tactics. Research funding has barely grown.

The result has been a scourge of suffering borne disproportionately by women and children. Many of the diseases are linked to other conditions, including cervical cancer, and some carry with them the risk of birth defects and brain damage for babies born infected.

What’s more, some sexually transmitted diseases now entail an added danger. They appear to increase one’s risk of AIDS, either by causing sores through which the AIDS virus can be transmitted or, some researchers suspect, by accelerating the course of the fatal syndrome.

“The last thing we can allow to happen today is continued spread of those STDs which have been implicated as risk factors for sexual transmission of the (AIDS) virus,” Holmes said. “ . . . We must put control of these diseases back on the public health agenda.”

A quarter of a century ago, there were for the most part just two well-known venereal diseases: syphilis and gonorrhea. Now, new diagnostic techniques have made it possible to identify and characterize more than 20 organisms spread through sex.

Among them are chlamydia trachomatis , a cause of a painful inflammation of the urethra; incurable viruses like herpes, hepatitis B and human papilloma; the bacterium that causes genital ulcers, once rare in the United States, and various fungi and protozoa.

The numbers, being accumulated by federal agencies and researchers, are stunning:

- Chlamydia infection, barely known a decade ago, has become the most common bacterial infection in the United States. There are as many as 4 million new cases a year. Up to 2 million new cases of gonorrhea occur annually, one quarter of them among teen-agers.

- There are half a million new cases of genital herpes each year; 30 million Americans are believed to be affected by the often-painful, incurable disease. Studies suggest that the number of cases of chancroid, a rare bacterial infection, increased sevenfold between 1984 and 1988.

- The number of doctor visits each year for treatment of genital warts has jumped more than sevenfold since 1966. An estimated 750,000 cases are diagnosed annually. The virus that causes warts, human papilloma virus, may also be linked to cervical cancer.

- The largest leap in cases of infectious syphilis in a quarter century in the United States occurred in 1987. The number of babies reported to have been born with congenital syphilis, a potentially fatal condition, climbed from 150 in 1983 to nearly 700 in 1988.

“If you had asked me two years ago would the day ever come that you’d see 1,000 cases of (infectious) syphilis in Connecticut,” said Gordon Joachim, director of the state’s sexually transmitted disease control program, “I would have bet my house that that would never happen.”

So far, the burden of disease appears to be spreading unevenly.

Among whites, syphilis rates have dropped in this decade, thanks largely to safer sex among gay men. But among blacks, the incidence of the disease has jumped sharply since 1985. Among black women, the rate is now 50 times higher than among white women.

Gonorrhea peaked in the United States in 1975. Among whites, it has declined steadily since. But among blacks, the decline reversed itself in 1985, and by last year the reported incidence among black women was 21 times higher than among whites.

Similar patterns appear to be occurring with chancroid and a vaginal infection, trichomoniasis, according to Holmes. Like syphilis and gonorrhea, those are among the more easily detectable and treatable of the sexually transmitted diseases.

Some viruses, on the other hand, such as herpes and human papilloma viruses, appear to be moving quickly among whites and the middle class. They are currently incurable, though their symptoms can be treated.

Holmes, a professor of medicine at the University of Washington, traces the growing concentration of disease in the inner cities to several factors--from economic and demographic shifts to drug abuse and the growing pinch in resources devoted to public health.

Black and Latino populations are growing faster than the white. Meanwhile, poverty is increasingly concentrated in certain pockets of the United States. More and more blacks and Latinos find themselves living in those communities, plagued by abuse of drugs like crack.

At the same time, funding for public clinics and other health services catering to those communities has failed to keep up with the workload. Health care resources have shifted steadily away from the public to the private sector, Holmes and others contend.

“I attribute the increase in syphilis to two things, one of which is drug use,” said Dr. Robert Rolfs of the federal Centers for Disease Control. “The second reason is that in a number of areas . . . there’s a real problem of access to STD care.”

Philadelphia was one of the first cities to see a dramatic increase in infectious syphilis. In 1985, there were just 317 reported cases. That number has leaped every year since, to 1,293 in 1988, a figure expected to nearly double this year.

Reported gonorrhea cases also increased--from 17,345 in 1985 to 22,976 in 1988. The actual numbers may be higher since public health officials believe as many as 50% to 80% of all syphilis and gonorrhea cases go unreported.

Support for Control Drops

At the same time, city support for sexually transmitted disease control dropped.

The sole public clinic for sexually transmitted disease screening and treatment in Philadelphia reduced its hours by 20% between 1986 and 1988. With clinic registration stopping earlier and earlier and more patients being turned away, patient visits dropped nearly 10%.

“It’s not a matter of demand,” said Martin Goldberg, senior public health adviser with the city’s Department of Public Health. “ . . . It’s a reflection of the limited number of hours. What increases is the number of patients turned away without service.”

There have been similar problems in Los Angeles County, where the infectious syphilis rate climbed from 1,558 in 1984 to 2,770 in 1986 to 4,198 in 1987. The syphilis incidence per 100,000 population in Los Angeles County was 55.6 in 1988, nearly four times the national average.

Part of the funding problem, officials say, is traceable indirectly to AIDS.

Since the early 1980s, AIDS has dominated sexually transmitted disease control funding. Money for other diseases has remained virtually flat. Many health workers and researchers trained in sexually transmitted diseases have shifted to the fight against the human immunodeficiency virus that causes AIDS.

“I think that both in terms of financial resources and human resources, there is no question that the AIDS epidemic has been a mixed bag,” said Dr. Judith Wasserheit of the federal National Institute on Allergy and Infectious Diseases, which conducts sexually transmitted disease research.

“There has been a real siphoning of funds from STD control to HIV-related work,” said Wasserheit, chief of the sexually transmitted disease branch. “I think that is reflected as well in the availability of people to provide STD services.”

She emphasized that research funding has remained flat and has not been actually cut.

Some physicians, too, have let down their guard. Routine screening for syphilis ceased in many places during the 1970s when it appeared to many to be no longer a threat. Now that it has resurfaced, some have responded slowly. Cases have gone undetected.

For example, congenital syphilis can be prevented if diagnosed early in a woman’s pregnancy; it can also be treated successfully if the newborn is tested. But pregnant women are going untested, despite laws requiring testing, and babies are going untreated.

Not Tested in Prenatal Care

A review by Los Angeles County health officials of the 75 reported cases of babies born with syphilis in 1988 turned up a disturbing fact. Some of the mothers had received prenatal care but appeared never to have been tested for syphilis.

In 20 cases, the mothers had tested positive for syphilis. But the opportunity to cure the baby was missed at delivery. The babies, born without obvious symptoms, went untested or untreated, developing symptoms only after leaving the hospital.

The county study also found two babies born symptomatic by mothers who had been treated improperly. They had been given erythromycin, an antibiotic that does not cross the placenta well and therefore cannot be counted on to cure syphilis in the fetus.

“The management of syphilis is kind of a lost art,” said Dr. Deborah Cohen, who headed the county study. “ . . . I think there’s still a lot of physicians that don’t know what all the tests mean and how to interpret the lab results.”

The burden of the epidemic falls disproportionately on women and children.

An estimated 1 million American women a year develop pelvic inflammatory disease when infections like chlamydia spread into the uterus and Fallopian tubes. According to federal statistics, most of the women are under age 25 and have not yet had children.

The disease leaves them 10 times as likely as other women to experience a pregnancy occurring outside the uterus. The rate of so-called ectopic pregnancies per 1,000 reported pregnancies in the United States has nearly quadrupled since 1970.

Pelvic inflammatory disease is also linked to infertility; one in four women with the disease lose their ability to conceive. Sexually transmitted diseases account for one-fifth of all cases of infertility, a condition affecting 2.4 million married couples.

Risk of Cervical Cancer

Another possible risk for women may be cervical cancer, long suspected to be linked to sexually transmitted diseases--in particular, several strains of human papilloma virus, the virus that causes genital warts.

Infants face some of the gravest risks.

Most organisms spread by sex can be passed on to a fetus, often with debilitating consequences. Congenital syphilis, for example, can result in fetal death, prematurity, blindness, neurological disease and abnormalities of soft tissue and bone.

Exposure to herpes in the womb can in some cases result in growth retardation in the uterus and prematurity. And some babies exposed to human papilloma virus develop a potentially life-threatening obstruction of the upper airway.

Only with screening and treatment can such cases be averted.

One morning recently in the living room of a bungalow in South-Central Los Angeles down the street from the Little Flock Primitive and Greater Revelation Baptist churches, a 58-year-old woman sat, ankles folded, on a piano bench discussing her 14th child.

Lula Chism raised 13 children of her own. At age 57, she was not expecting more. But when she went to visit her daughter and new granddaughter at Los Angeles County-USC Medical Center 16 months ago, the county sent the baby home with Chism.

The baby had been born carrying the bacterium that causes syphilis. According to Chism, her daughter is a cocaine addict who had not sought prenatal care. The infant would probably recover, the nurses said, if Chism would ensure she got daily shots of penicillin.

For 10 days, Chism took the child across town to a county clinic. The child is healthy and appears to have suffered no permanent harm. But Chism regrets bitterly that her grand-daughter’s introduction to the world included those daily clinic visits.

“It made me feel bad that it had gotten into my family,” said Chism, who places the responsibility squarely with her daughter. “ . . . If my daughter would take care of her body and be careful who she goes out with, it could have been avoided.

“If I’d have had anything to do with it, she would have used birth control and not got pregnant to begin with. Maybe they get this cocaine and don’t think about this sort of thing.”