The Great Imitator

The scourge of syphilis re-emerges, deadlier than before

Fresh sheets of plywood now mask the first-floor windows of the Better Donut Drive In. One story up, shards of glass give view to the red brick building's abandoned interior, and weeds sprout freely from its pitted concrete parking lot.

The doughnut shop's best days may be well behind it, but like any building, the phantom crumbling at the corner of Grand Boulevard and Cass Street occupies its own little place in history. During the crack cocaine boom of the early 1990s, this north St. Louis shop was ground zero for the city's syphilis epidemic.

"On Social Security check day, a lot of old men would meet there, drink coffee and eat doughnuts," recounts Frank Lydon, an epidemiologist for the Missouri Department of Health and Senior Services. "But there'd also be a big batch of young girls who'd prostitute for those checks. We had a lot of syphilis coming out of that old doughnut shop."

A few years earlier, crack cocaine had begun working its dark magic on the nation's urban cores. The notorious street war between the Crips and Bloods spilled out of southern California, and by 1990 the U.S. syphilis rate had crept to its highest peak in nearly 50 years.

St. Louis was behind the national curve, and it would take another two years for the disease to arrive here in earnest. But when it did, the city quickly grappled its way to the top. By 1993 the total syphilis infection rate within the city limits soared by more than 2,100 percent, earning St. Louis the dubious distinction of Syphilis Capital, USA.

To public-health workers, this was an epidemiological inevitability. "Look at the eastern U.S.: All roads eventually lead to St. Louis," says Lydon, who came to the city as a greenhorn disease investigator in 1993. "Coming up from the coasts, you could see the outbreak popping up along the highways. The numbers kept getting higher and higher as they converged on St. Louis."

The city held the nation's highest syphilis infection rate for four years running, from 1992 through 1995, though rates dropped after the 1993 peak. The brunt of the outbreak was borne almost exclusively by the city's African-American population. More than 94 percent of all reported cases in 1993 were among blacks, and investigators determined the disease had followed crack cocaine into the city.

"St. Louis was a drug-redistribution site. People could easily take the highway to St. Louis, break down their drugs and redistribute them," Lydon explains. "These guys are coming in with diseases. Eventually that ends up getting to your prostitutes, and from them into the general population."

Twelve years later, Frank Lydon now heads the team of state disease investigators who cover the city of St. Louis and ten outlying counties. His cramped, windowless midtown office is festooned with the detritus of disease prevention, including plastic bags that spill over with HIV test kits, copious prevention literature and a small red-and-white cooler ominously marked "STD." He's a slight man, impeccably groomed, with straight brown hair, delicate hands and wispy eyebrows that gather mass only at their outer reaches. Style be damned, he dresses tidily in chinos, a short-sleeve Oxford shirt and sensible brown leather shoes. He's also unfailingly polite, which might throw you off when he holds forth about oral dams or deviant sexual behavior with the same informality most reserve for the weather.

"That was good old-fashioned epidemiological work. Real shoe-leather stuff," he says, recalling the difficulty health workers had coaxing sex-partner information from the syphilitic patients who turned up at city health clinics. "It was a really difficult population to work with, because they were afraid. Take a crack addict with syphilis: Are they going to tell you where they caught it? Most likely, no. They're afraid that if they give us the name John Doe, and that's their dealer, they're going to lose their source of drugs."

By enlisting the help of dealers and pimps, investigators eventually managed to get prostitutes and drug users to open up. "One of the ways we tried to sell them was, 'You know, a healthy customer is going to keep coming back to you. If they're sick, they're not going to buy drugs,'" Lydon says.

Ultimately the age-old techniques of interviewing and networking prevailed: Within a few years, health workers were able to trace the progress of the epidemic and slow the spread of the disease.

But that was more than a decade ago. At age 40, Lydon again finds himself battling a syphilis outbreak in St. Louis. Only now the rules have changed. Long a scourge on the black community, syphilis is shifting populations and surging among the nation's gays. Fueled by methamphetamines, the Internet and a secretive culture poorly understood by the larger epidemiological community, the current outbreak confounds Lydon and his colleagues. Their techniques of disease tracking and prevention -- critical tools in controlling an outbreak -- are proving inadequate as investigators encounter this affluent, mobile and often promiscuous population.

What's more, this archetypal venereal disease has grown more treacherous as it synergizes with HIV, the virus that causes AIDS. The problem hit home in January, when seventeen St. Louis men reported syphilis infections over the course of a few weeks. Each told health workers they'd recently had unprotected sex with men. Twelve of them were HIV positive; only a handful could name sex partners.

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