The Great Imitator

The scourge of syphilis re-emerges, deadlier than before

Jun 29, 2005 at 4:00 am
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.

"There's just too damn much anonymous sex going on out there," grouses Lydon. "During previous outbreaks you could look at a map of St. Louis and see disease clusters. Now if you look at a map, you'll have dots all over the place. We don't know if it was a cluster. We don't know if they had sex with each other, because most of them say it was anonymous.

"We've hit a real roadblock."

Legally bound to protect patient confidentiality, Lydon is careful to withhold personal information about cases his department handles. He tenders information haltingly, as though running each case through a mental sieve of legality. There is, however, one piece of information he'll freely proffer: Last fall a number of men flew into St. Louis from Dallas, Chicago and Los Angeles for the sole purpose of attending an orgy.

Sound far-fetched? Think about it, says Lydon. "Cheap airfare. If you're going to spend $39 on airfare to have a guaranteed sexual encounter, that becomes less expensive than going to six different bars over the course of a Friday and Saturday night. Buying people drinks? That 40 bucks [airfare] is a lot cheaper -- and the sex is guaranteed."

Of course, investigators would have remained unaware of the party had it not been for the rash of men who visited their doctors late last fall with syphilitic lesions. Physicians are legally bound to report all instances of STD infection to the state health department, and upon noting the outbreak, Lydon dispatched his investigative team. They managed to contact the vast majority of those who reported infections. What they found was troubling.

"They were African-American and white. All were professionals -- full-time, job-holding, home-owning individual males. All identified themselves as men who have sex with men between 30 and 50 years old," says Lydon. "We were dealing with a very well-educated population, who among other things understood the importance of knowing their [HIV] status."

But for all of this population's perceived affluence and education, its members were to a man uncooperative. While most of those infected admitted they'd participated in an orgy, very few named sex partners.

"Did they know each other? Since they were all at the same party, I'm assuming yes," Lydon says. But he can't be certain. "The stock answer was: 'If there's anybody [who might be infected], I'll take care of it.'"

The investigation foundered. Though his team managed to determine that "dozens" of men had attended the orgy, investigators never discovered the date or location. Because so few partners were named, health workers were unable to contact untold others who might have been infected as a result of the party but hadn't seen a doctor.

They knew that since the outbreak followed the party, whoever brought the disease had flown in from another city. They also knew that the carrier had himself recently contracted the disease.

"Did they have a penile lesion? Probably not," Lydon theorizes. "With as many people who were infected at that party, I would lean toward the thought that he had an oral lesion and was giving oral sex to multiple men."

In the end Lydon's team had to move on. Still, he knew St. Louis hadn't seen the last of that syphilitic strain.

"There were other cases popping up, but the community wasn't talking," the epidemiologist says. "So I can't give you that nice clean and tidy ending that I would have liked to have seen myself. It's been bubbling under the surface. Honestly, I think it was a precursor to what was about to happen."

First, an aside: While reading the paper at his breakfast table one morning, Saul Rabinowitz came across an item that shocked him.

"Mitzi!" he exclaimed. "The world is such a dangerous place. Like the syphilis! Oy! It's killing people!"

Patient Mitzi replied, "Saul, honey, don't worry. I read about the syphilis in the encyclopedia -- you have nothing to worry about."

"Why not?"

"It only affects the Gentiles."

Mitzi's misconception goes a long way in explaining the so-called Columbian School theory, which holds that syphilis did not exist naturally in Europe but was introduced to the continent in the late fifteenth century by Columbus' crew following a sex-fueled visit to Hispaniola, now known as Haiti. The other dominant theory, held by the Pre-Columbian School, maintains that syphilis has always existed in Europe. With few exceptions, the disease does not prey on other species. According to the pre-Columbians, early syphilis was often confused with other diseases, such as leprosy.

The uncertainty can perhaps be forgiven. Part of the difficulty in diagnosing syphilis is that its symptoms are diverse and easily confused with those of other diseases. This chameleonic quality has earned the ailment the nickname "The Great Imitator" and prompted the early-twentieth-century physician Sir William Osler to famously remark: "He who knows syphilis, knows medicine."

Infection produces a single painless lesion. It is in this so-called primary stage that syphilis is most infectious. The lesion appears at the site of infection, which means ulcers inside the vagina, rectum or mouth may easily go unnoticed. After the initial lesion heals, the skin erupts with secondary syphilis -- a particularly gruesome stage that manifests as a splotchy rash or the dreaded Condylomata lata, a discolored, wartlike growth that spreads around the area of infection.

Syphilis is most easily detected during its primary and secondary stages and is cured by a hefty dose of penicillin. It also has a well-defined evolutionary cycle, which if caught during the first two stages allows researchers to determine the time period in which a person contracted the infection.

But once the outward symptoms recede, the disease -- while still curable with penicillin -- is only detectable in the blood. No longer infectious, the blood-borne pathogen begins eating away at the body's organs. The final stage, known as neuro-syphilis, can cause blindness, deafness, even insanity -- though that is rare, and the process takes decades.

That is, until recently.

"There are a couple of keys: First, if you are HIV positive and develop syphilis, you are far more likely to progress to secondary syphilis earlier," says Kevin Fenton, chief of the Centers for Disease Control and Prevention's National Syphilis Elimination Effort. "There are also a number of reports that untreated syphilis among HIV-positive men may progress more rapidly to neuro-syphilis."

Though there is a dearth of good information regarding the interplay of syphilis and HIV, preliminary reports indicate that co-infected individuals can advance to neuro-syphilis in a matter of months. In other words: A disease that in an otherwise healthy body takes decades to affect the organs can move through an immuno-compromised body with pirhana-like speed.

That's not all. As an organism, syphilis has traditionally been limited by one severe drawback: Though highly infectious, it has a small window of time during which to switch hosts, thus ensuring the species' survival. HIV, on the other hand, is able to extend that transmission window.

"If you're HIV positive and you develop syphilis, you'll often get more ulcers," Fenton explains. "It will also elongate the secondary syphilis phase, which can be very infectious."

Syphilis infection can in turn facilitate HIV transmission. "The lesion gives HIV a sort of portal to enter the body," says Fenton, adding that white blood cells often congregate around a lesion, providing HIV direct access to the body's immune system. "If you're HIV positive and have an ulcer onboard, that can increase your risk of transmitting HIV two- to six-fold. So that's the kind of magnitude we're talking about."

But the biological relationship between the two diseases is only part of the story. The social aspect is equally important. "We know that people who acquire syphilis are individuals who tend to have far more sexual partners than the average person," Fenton says. "This means that if you have both syphilis and HIV on board, not only is your individual risk of transmitting infection increased, but you're also more likely to have sex with many more individuals."

In other words, a few highly sexual carriers can drive an epidemic.

On a recent Thursday night, Duane Westhoff has commandeered two round tables near the door at Coffee Cartel. The Central West End coffee bar hums with chatter as the latte-sipping throng spills onto the patio. Dressed in light-brown slacks and a black T-shirt, Westhoff has strewn condoms and STD-prevention literature across his tables. As the young crowd mills about, the occasional straggler offers up a guilty look before plunging a hand into Westhoff's plastic jug filled with free condoms.

At age 28, Westhoff holds the rank of "captain" in the Guardian Project, a collaborative effort between city government and community groups to raise HIV awareness. He and his fellow "guardians" hold court at the Coffee Cartel each Thursday night, offering "smart sex" education and free HIV tests. Though the project targets young gay men, Westhoff takes all comers. Tonight's crowd isn't in a buying mood. Three-quarters of the way into their two-hour session, Westhoff and his cadre of young volunteers have yet to perform a single HIV test.

"Everyone knows why we're here," he says, noting that many in the crowd have already been tested. "But an eighteen-year-old gay white male is more likely to open up to a peer, so it's important that we put a face on the message."

Effective messaging is one of the biggest obstacles community prevention groups and health department officials face when trying to reach the gay community. The population has been hearing the "safe sex" message for two decades now. They know the dangers of sexually transmitted diseases, and, theoretically, they know how to protect against them. But while syphilis and HIV rates declined during the mid- to late '90s, syphilis is spiking and HIV rates are beginning to follow suit. Health workers attribute much of the rise to a gay population that increasingly flouts safe-sex practices.

"People are tired of hearing the same message. They've been hearing this message for twenty years," says Carolyn Guild, prevention supervisor for the community-based St. Louis Effort for AIDS. "They're tired of dealing with it as a community. It's not a gay disease, but I think that white men who have sex with men are tired of feeling like it's something they need to own."

Health workers also cite "condom fatigue" as an impediment to getting gay men to practice safe sex. For two decades the population has been admonished to use condoms, and while a negative status is a laudable goal, it also has the drawback of not making a person's life better than it had been.

"No matter how badly we try to make safe sex fun, it's not," says Thomas Adams, executive director of the AIDS Foundation of St. Louis. "You're in the moment of passion, you want to go and break out the condoms? There are hundreds of tapes that have been filmed throughout the ages trying to make safe sex fun. They've all failed."

But health workers must confront another, more insidious problem. With the advent in the mid-'90s of effective anti-AIDS medicines such as protease inhibitors, researchers soon began finding that the public was increasingly regarding HIV as a manageable disease on the order of diabetes, rather than a death sentence.

"People aren't dying the way they used to," says Adams. "You don't see the people who weigh 97 pounds. You don't see the open lesions all over the face."

Like many AIDS activists, Adams places part of the blame for the shift in public perception on the companies that initially marketed the drug regimens.

"Sex permeates the gay community. It's in our videos. It's in our bars. If you look at the early pharmaceutical advertising for HIV medications, the guys were gorgeous. They were hunky muscular gym bunnies. The message? 'I take this pill and I'll look like that,'" he says. "A friend of mine called them G.O.D.S.: Gays On Disability and Steroids."

Whatever the cocktail of causes, researchers are finding that gay men are increasingly engaging in high-risk sexual activity. And as the January syphilis outbreak demonstrated, many of those having unprotected sex know they're HIV positive.

"It's a real mixture: Fear of HIV has declined. Behavioral studies are showing that gay men are practicing more and more unsafe sex and reporting more and more sexual partners," says the CDC's Fenton. "We have not seen as much of an increase in HIV in some of these big cities. We think what is happening is that positive men are having sex with positive men, and therefore the STD-transmission risk is high but HIV-transmission risk is lower."

Any epidemic is like smoldering coals," says Hilda Chaski Adams, epidemiologist for the City of St. Louis Department of Health. "There's always a baseline level of disease, but then a behavior, or an event, or a practice changes. It can be like throwing gasoline on the coals."

In the case of syphilis among the nation's gays, researchers point to two key environmental shifts: widespread use of the Internet and the rise of methamphetamines.

Point your browser toward the "Men Seeking Men" section of St. Louis' page of the popular Web site and you'll find the following offer: "Monthly All Male Hotel Sex Party." The poster, who does not reveal his name, adds the following incentive: "LOCATION: DOWNTOWN ST. LOUIS HOTEL. All guys are welcome. No one is discriminated against."

There are dozens of similar sites:, and, to name just a few. One of state epidemiologist Frank Lydon's favorites is, which among its many services reviews cruising spots across the U.S.

"I go here to try to get a feel for what's going on," says Lydon, opening The state monitors its employees' Internet use, so Lydon must make note of the date and time. "Someone who doesn't know what I do for a living might think that this was a nonwork-related Web site," he says, navigating his browser to the site's Missouri section. "It gets pretty graphic."

Today's hunt nets an anonymous poster who recounts a racy encounter with an assistant manager for an area Wal-Mart. Apparently the latter works nights and has a taste for fellatio near the "tire and lube area."

"You've got to question some of this stuff," says Lydon. "Is someone just posting to get a reaction out of people? Are they a frustrated author? But you've also got to worry about whether it's true."

Lydon is all but convinced that the Internet fueled January's spate of infection. Unlike previous outbreaks, the rash of syphilis didn't emanate from an adult bookstore, bar or bathhouse. Whereas epidemiologists used to be able to look at a map and find a locus -- a particular neighborhood, business or social circle -- this outbreak was characterized by its diffusion: Those infected live all over the metro area.

"It used to be that when people would come up positive for HIV or STDs, health workers would ask the names of who they've been with," says AIDS Foundation director Adams. "Now I'm hearing reports that people can't tell them their [partners'] names but they can tell them their screen names. It's anonymous sex taken one step way further."

As with earlier syphilis epidemics, St. Louis still dawdles a few years behind the national trend. But if the past few years are any indication, the city is primed for a massive syphilis outbreak in the homosexual community.

In 1999 the national syphilis rate was at its lowest level since 1941, the first year the CDC began collecting infection-rate data. That year researchers saw an 88 percent decrease in syphilis rates from their 1990 peak. Nearly 75 percent of those cases occurred in only 9 percent of the nation's counties, prompting then-U.S. Surgeon General David Satcher to become the latest in a long line of public health officials to dream of eradicating the disease.

In October of that year, Satcher announced the formation of the National Plan to Eliminate Syphilis. The plan funnels money to affected state and local governments, which then work with community-based organizations to stamp out the disease. (St. Louis was among the CDC's so-called Syphilis Elimination Zones. The state awarded its most recent syphilis-elimination grant to the Community Wellness Project, a nonprofit healthcare organization that serves minority populations.)

Within a year of Satcher's announcement, researchers began seeing infection rates climb in New York City and Los Angeles. Ever since, the epidemic has slowly but surely been making its way into the nation's interior. By 2003, the last year for which national data are available, primary and secondary syphilis infection rates had risen more than 7 percent from their 1999 low.

At first blush, the jump is unimpressive. What that figure conceals, though, is that while infection rates among African Americans and women have steadily declined since 1990, primary and secondary syphilis rates have soared among men. During the five-year period between 1999 and 2003, male syphilis rates climbed more than 43 percent.

Although the CDC doesn't currently collect information regarding sexual orientation, National Syphilis Elimination Effort chief Kevin Fenton says the data are clear: "There's been a steady increase among gay men, but because we have more heterosexual men than we do gay men -- although syphilis was increasing among men who have sex with men -- it still didn't overcome the declines in the heterosexual male population. But by 2003 we really began to see an upturn in the epidemic curve. Five years ago most of the syphilis in this country was among heterosexuals. Today we estimate that about 60 percent of cases are among men who have sex with men."

The other lesson area health workers are taking from the national story is best encapsulated by an announcement made on February 11, 2005. On that day authorities with the New York City Department of Health made public the discovery of a gay man who'd contracted a drug-resistant strain of HIV. First diagnosed late last year, the man had progressed to full-blown AIDS -- a process that often takes a decade or more -- a mere twenty months after testing HIV negative.

The announcement also brought to light that the man -- described as gay and in his forties -- had reportedly slept with more than 100 partners in the six months before his diagnosis. He met many of his partners over the Internet and routinely engaged in unprotected sex while high on methamphetamine.

Cheap and readily available, meth is a chemical stimulant and mood enhancer. It's known to induce euphoria, increase awareness and reduce fatigue. It also jolts the libido.

"It is an enormous problem here. It's been a problem for a long time. If you go to a Web [chat room], you can see people in there who will say they're looking for 'Tina,' or 'Tina' just left -- which means they're hungover," says Adams, invoking a common meth nickname in the gay community. "It's five o'clock in the morning, they haven't slept in a day or two, and they're still looking for sex."

Health workers say meth's libido-heightening, fatigue-resisting combo is particularly dangerous, enabling users to engage in daylong sexual marathons while under the influence.

While meth may initially increase a user's sex drive, it eventually causes impotence. But with the introduction of erection-inducing drugs such as Viagra, men are able to counteract "crystal dick."

The result, says Lydon, is a public-health nightmare. "Methamphetamine and Viagra is a particularly deadly combination," the epidemiologist maintains. "Viagra provides an erection for hours upon hours, so you can just go and go and go."

There is very little hard data regarding meth use among gays. But at this year's National HIV Prevention Conference in Atlanta, CDC officials highlighted a survey of more than 19,000 men who have sex with men in the Los Angeles area. In that survey, researchers found that meth use nearly doubled between 2001 and 2004, to 10.3 percent. The rise was even greater among the HIV-positive contingent, which jumped from 11.7 percent in 2001 to more than 30 percent in 2004. Similarly, the number of meth users who reported using the drug during sex grew from roughly 73 percent to more than 86 percent.

"It's a huge effect," says the CDC's Fenton. "Individuals who use methamphetamines are up to six times more likely to be infected with syphilis than those who don't."

Pulling into one of the city's many parks, Carolyn Guild and Jeremy Beshears are careful not to attract attention. Although their vehicle, a white Ford F-450 camper they've christened "Priscilla," is plenty conspicuous, the pair quickly ducks into one of the park's many wooded glades.

As employees of the St. Louis Effort for AIDS, Guild and Beshears are officially taking Priscilla on an STD-prevention tour of St. Louis. This afternoon's quarry: men on their lunch break cruising for sex. Unofficially, however, the pair is on the hunt for new outdoor hookup spots in the city's parks.

As AIDS-prevention workers, Beshears and Guild are something of an odd couple. Olive-skinned with a wide face, Beshears keeps his hair closely shorn and cultivates a patch of stubble just shy of a beard. Guild, meanwhile, has light red shoulder-length hair, green eyes and is given to wearing ripped jeans and leopard-print Birkenstocks. Together they have an infectious banter: Beshears teases Guild about her phobia of dairy products (it can't touch the skin?); Guild fires back about Beshears' dulcet new ring tone: a polyphonic rendition of Def Leppard's hard-rocking 1987 ode to sexual abandon, "Pour Some Sugar on Me."

But for all of their good humor, the AIDS-prevention workers are dead serious about one thing: They insist on keeping their outreach locations secret. They say many of the men in the park are on the "down low" and may have wives or families at home. They're concerned that if word got out that they knew men frequented a certain park, their "clients" would disappear. They have good reason to worry: This is a population that often deflects the advances of AIDS counselors.

"It's natural to lie on a risk assessment," says Guild, bending slightly as she ducks into the woods. "A lot of these guys aren't doing the things they know they should [to protect themselves]."

Inside the overgrown thicket, the foliage opens onto a canopied network of trails. Sunlight dapples the wooded interior, the rumbling of passing motorists fades away and the fresh-smelling air is still. As they plunge into the urban forest, Guild and Beshears are looking for the hallmarks of sexual activity: spent condoms, empty bottles, shooting kits.

"Looks like someone had a good time," quips Beshears, pointing to an empty fifth of Jose Cuervo tequila. Pushing deeper into the tracery of footpaths, the team finds several spent condoms, a filthy blue sheet laid on the ground and plenty of discarded fast-food bags. Obviously people have recently availed themselves of the park's more private areas, but the site is devoid of activity today. A few men are parked solo along the roads, but it's nothing approaching a critical mass, and the prevention workers decide to move on.

They next stop at a gay bar in Soulard. It's just shy of two o'clock in the afternoon, and the handful of assembled barflies gladly accepts the pair's proffered safe-sex kits. But again, it's not crowded enough for the AIDS workers to stick around. Beshears hands a fistful of condoms to the bartender, who promises to distribute them to his "best customers." Still, no one signs on for an HIV test. No one signs on for counseling.

"It's hard to go just anywhere in St. Louis and access the [gay] population," Beshears had remarked before heading out for the day's outreach. As if to illustrate his point, he and Guild have been navigating Priscilla through town for more than two hours when they finally decide to cut their losses and head to the disease's old stomping grounds in north St. Louis.

Pulling up to a rundown liquor store only a few blocks from the husk of the Better Donut Drive In, the team spots a black woman walking aimlessly down the street. She appears middle-aged and sports a short Afro, floral print jeans and a tentlike T-shirt. She's also straining to make eye contact with each passing car -- a telltale sign of a streetwalking sex worker, Beshears and Guild agree.

After parking Priscilla, Guild heads into the liquor store to quiz the clerk about the best time to do an outreach in the area. Meanwhile, Beshears approaches the woman, who has been skeptically eyeing the camper from a distance. With a little coaxing, he persuades her to step into Priscilla for an oral HIV test. But when the woman reveals she isn't carrying any ID, Beshears says he can't test her. Without missing a beat, she bums a cigarette, grabs a safe-sex kit and is on her way.

Within minutes, a man who's just stopped by to pick up a safe-sex kit approaches her. He's older and walks with the aid of a cane. They talk at the corner. He shows her what looks like a wallet, and then they part ways. Having witnessed the exchange, Beshears and Guild fire up Priscilla and start back for the office.

It is midday. They haven't performed a single test, but they've done the best they can. After all, there's always tomorrow.