Lessons From a Failed Syphilis Elimination Strategy

Peter Leone

Syphillis is easily diagnosed and treated. Yet efforts to eliminate syphillis in specific geographic areas have failed because they ignored deep economic, social, and racial disparities that perpetuate the risks of infection and disease.

April is National STD Awareness Month and sexual and reproductive health organizations throughout the country urge you to Get Yourself Tested.  Rewire has partnered with The National Coalition of STD Directors (NCSD) to produce a series of articles on the importance of STD prevention and treatment among populations throughout the United States.  Other articles in this series include one by Sandra Serna-Smith and Dana Cropper Williams.

Tantalus, a son of Zeus and the king of Sipylos, was cursed by the Greek gods by having to stand to his neck in a pool of water. He was thirsty, but when he bent his head to drink, the level of water quickly receded. He was also hungry, but the fruit that hung above his head was always just beyond his reach. Fulfillment was always so close, but could never be reached.

Tantalus’ curse in many ways epitomizes the multiple efforts for syphilis elimination in the United States. The CDC, in conjunction with state and local health departments, undertook syphilis elimination efforts (SEE) in the early 1960’s and again in 1999. The later effort occurred during a period of historically low syphilis rates and when cases were highly concentrated in specific geographic areas. Efforts were targeted in the southern United States where disease rates were the highest and racial health inequalities were the greatest. In 1998, just 25 counties accounted for half of all early syphilis cases in the United States. North Carolina had five of these “high morbidity” counties and was selected for one of three national demonstration sites for syphilis elimination. The task seemed credible since syphilis was and still is easily diagnosed with cheap, widely available tests and can be treated, in most cases, with a single dose of penicillin.

The national plan was built around five complementary strategies including the following components:

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  • enhanced surveillance;
  • promoting community involvement and organizational partnerships;
  • rapid outbreak response;
  • expanded clinical and laboratory services; and
  • enhanced health promotion.

The idea was to invert the “triangle” by putting community involvement at the top and having local health departments follow the lead of the community.

It worked–well sort of–for awhile. In North Carolina, the rates of syphilis dropped to an all-time historic low in 2003. Forsyth County, one of the five designated elimination counties in North Carolina, reported 54 cases of Primary and Secondary (P&S) syphilis with a case rate of 18.6 per 100,000 in 1998. SEE funding peaked in 2003 at $1.8 million for the sate of North Carolina and $167,000 for Forsyth County.  Starting in 2004, SEE funding was cut and reached a nadir in 2009 of $57,000 (a 66 percent reduction in funding for Forsyth County and a 80 percent reduction in state funding). In 2003, at the highest point of federal funding support, Forsyth County reported 1 case of P&S syphilis with an overall rate of infection well below 1 per 100,000. Numbers remained low in Forsyth County over the following several years but, after the money all but dried up, came roaring back in 2009 with 195 cases and a case rate of 34.3 per 100,000.  These numbers are even higher than at the start of the syphilis elimination effort. 

The failure of syphilis elimination was, in hindsight, predetermined. Although the national program was steeped in community involvement it still followed a basic medical model. The concept was primarily one of “test-and-treat.” Prevention was a necessary and essential part of the program but was not coupled with plans to address the many social contextual factors that set the stage for the racial and ethnic inequities seen for syphilis as well other sexually transmitted infections and chronic health conditions. Since syphilis was not eradicated (i.e. did not go to zero cases) the embers for reinfecting vulnerable sexual networks remained intact. The plan was also not coupled with systematic, acroos-the-board efforts to address the racism, sexism, homophobia, high rates of incarceration for minority males, poverty and segregation that led to distortive mixing of low- and high-risk populations and to concurrency. Both of these factors are bound to other contextual factors that persisted even while rates hit historic lows.

Further complicating elimination efforts were the predictable federal loss of will–and money. When syphilis elimination seemed on the verge of success, case rates dropped which unfortunately meant money got shifted away to other priorities or jurisdictions. The latter is what occurred in North Carolina and Forsyth County. The reduction of funding created a permissive environment for the re-emergence of syphilis, but it alone is not to blame.  The loss of money was but a symptom of a flawed approach.

Syphilis warrants the attention given to it by past elimination efforts. But prevention programs should be viewed in the boarder framework of contextual factors. Efforts to “eliminate” disease can only be rightfully–and sustainably–addressed in conjunction with strategies to eliminate social and economic disparities, address the racial, ethnic and sexual minority status conferred on specific groups of people at risk, and reduce poverty throughout our society. A “test-and-treat” model will bring epidemic levels of syphilis under control, but won’t eliminate endemic disease thus setting the stage for reemergence of this most historic infection. If we recast SEE into the models of sexual health and social justice, maybe elimination of health disparities in general will finally be in our grasp.

News Politics

Ohio Legislator: ‘Aggressive Attacks’ May Block Voters From the Polls

Ally Boguhn

Efforts to remove voters from state rolls and curb access to the polls could have an outsized impact in Ohio, which has seen a surge of anti-choice legislation under the state’s Republican leadership.

Ohio Rep. Kathleen Clyde (D-Kent) said she is worried about the impact of what she called “aggressive attacks” on voting rights in her state.

Ohio voters who have not engaged in voter activity in a fixed period of time, generally two years, are considered by the state to have moved, which then begins the process of removing them from their rolls through something called the “Supplemental Process.” If a voter fails to respond to a postcard mailed to them to confirm their address, they become “inactive voters.” If an inactive voter does not engage in voter activity for four years, they’re automatically unregistered to vote and must re-register to cast a ballot. 

Though other states routinely clean voting rolls, most don’t use failure to vote as a reason to remove someone.

“We have two million voters purged from the rolls in the last five years, many in the last four years since the last presidential election,” Clyde said during an interview with Rewire

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Ohio Secretary of State Jon Husted (R) dismissed concerns of the voter purges’ impact during an interview with Reuters. “If this is really important thing to you in your life, voting, you probably would have done so within a six-year period,” he said.

Ohio’s removal of voters through this process “is particularly problematic in the lead-up to the November 2016 federal election because voters who voted in the high-turnout 2008 federal election (but who did not vote in any subsequent elections) were removed from voter rolls in 2015,” according to an amicus curiae brief filed by the U.S. Department of Justice’s (DOJ) Civil Rights division in support of those who filed suit against Ohio’s law. 

The DOJ has urged the 6th U.S. Circuit Court of Appeals to reverse a lower court’s ruling in favor of the state, writing that Ohio’s voter purge violates the National Voter Registration Act of 1993 and the Help America Vote Act of 2002.

Since 2012, at least 144,000 voters have been removed from Ohio’s voter rolls in its three biggest counties, Reuters reported. The secretary of state’s office said 2 million registered voters had been taken off the rolls in the past five years, though many had been removed because they were deceased.

Husted contends that he is just enforcing the law. “Ohio manages its voter rolls in direct compliance of both federal and state laws, and is consistent with an agreement in this same federal court just four years ago,” Husted said in an April statement after the ACLU of Ohio and Demos, a voting rights organization, filed a lawsuit in the matter.

In predominantly Black neighborhoods near downtown Cincinnati, “more than 10 percent of registered voters have been removed due to inactivity since 2012,” reported Reuters. The outlet found that several places where more voters had cast ballots for President Obama in 2012 were the same locations experiencing higher percentages of purged voters.

“Some of the data is showing that African Americans voters and Democratic voters were much more likely affected,” Clyde said when discussing the state’s purge of registered voters. 

Clyde has requested data on those purged from the rolls, but has been turned down twice. “They’ve said no in two different ways and are referring me to the boards of elections, but there are 88 boards of election,” she told RewireWith limited staff resources to devote to data collection, Clyde is still searching for a way to get answers.

In the meantime, many otherwise eligible voters may have their votes thrown away and never know it.

“[P]eople that had been purged often don’t know that they’ve been purged, so they may show up to vote and find their name isn’t on the roll,” Clyde said. “Then, typically that voter is given a provisional ballot and … told that the board of elections will figure out the problem with their voter registration. And then they don’t really receive notice that that provisional ballot doesn’t eventually count.” 

Though the state’s voter purges could continue to disenfranchise voters across the state, it is hardly the only effort that may impact voting rights there.

“There have been a number of efforts undertaken by the GOP in Ohio to make voting more difficult,” Clyde said. “That includes fighting to shorten the number of early voting days available, that includes fighting to throw out people’s votes that have been cast—whether it be a provisional ballot or absentee ballot—and that includes purging more voters than any other state.” 

This could make a big difference for voters in the state, which has seen a surge of anti-choice legislation under the state’s Republican leadership—including failed Republican presidential candidate Gov. John Kasich.

“So aside from the terrible effect that has on the fundamental right to vote in Ohio, progressives who maybe are infrequent voters or are seeing what’s happening around [reproductive rights and health] issues and want to express that through their vote may experience problems in Ohio because of these aggressive attacks on voting rights,” Clyde said. 

“From our presidential candidates on down to our candidates for the state legislature, there is a lot at stake when it comes to reproductive health care and reproductive rights in this election,” Clyde added. “So I think that, if that is an issue that is important to any Ohioan, they need to have their voice heard in this election.” 

Commentary Contraception

The Promotion of Long-Acting Contraceptives Must Confront History and Center Patient Autonomy

Jamila Taylor

While some long-acting reversible contraceptive methods were used to undermine women of color's reproductive freedom, those methods still hold the promise of reducing unintended pregnancy among those most at risk.

Since long-acting reversible contraceptives (LARCs), including intrauterine devices and hormonal contraceptive implants, are among the most effective means of pregnancy prevention, many family planning and reproductive health providers are increasingly promoting them, especially among low-income populations.

But the promotion of LARCs must come with an acknowledgment of historical discriminatory practices and public policy related to birth control. To improve contraceptive access for low-income women and girls of color—who bear the disproportionate effects of unplanned pregnancy—providers and advocates must work to ensure that the reproductive autonomy of this population is respected now, precisely because it hasn’t been in the past.

For Black women particularly, the reproductive coercion that began during slavery took a different form with the development of modern contraceptive methods. According to Dorothy Roberts, author of Killing the Black Body, “The movement to expand women’s reproductive options was marked with racism from its very inception in the early part of [the 20th] century.” Decades later, government-funded family planning programs encouraged Black women to use birth control; in some cases, Black women were coerced into being sterilized.

In the 1990s, the contraceptive implant Norplant was marketed specifically to low-income women, especially Black adults and teenage girls. After a series of public statements about the benefits of Norplant in reducing pregnancy among this population, policy proposals soon focused on ensuring usage of the contraceptive method. Federal and state governments began paying for Norplant and incentivizing its use among low-income women while budgets for social support programs were cut. Without assistance, Norplant was not an affordable option, with the capsules costing more than $300 and separate, expensive costs for implantation and removal.

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Soon, Norplant was available through the Medicaid program. Some states introduced (ultimately unsuccessful) bills that would give cash rewards to entice low-income women on public assistance into using it; a few, such as Tennessee and Washington state, required that women receiving various forms of public assistance get information about Norplant. After proposing a bill to promote the use of Norplant in his state in 1994, a Connecticut legislator made the comment, “It’s far cheaper to give you money not to have kids than to give you money to have kids.” By that year, as Roberts writes, states had spent $34 million on Norplant-related care, much of it for women on Medicaid. Policymakers thought it was completely legitimate and cost-effective to control the reproduction of low-income women.

However, promoting this method among low-income Black women and adolescents was problematic. Racist, classist ideology dictating that this particular population of women shouldn’t have children became the basis for public policy. Even though coercive practices in reproductive health were later condemned, these practices still went on to shape cultural norms around race and gender, as well as medical practice.

This history has made it difficult to move beyond negative perceptions, and even fear, of LARCs, health care, and the medical establishment among some women of color. And that’s why it’s so important to ensure informed consent when advocating for effective contraceptive methods, with choice always at the center.

But how can policies and health-care facilities promote reproductive autonomy?

Health-care providers must deal head on with the fact that many contemporary women have concerns about LARCs being recommended specifically to low-income women and women of color. And while this is part of the broader effort to make LARCs more affordable and increasingly available to communities that don’t have access to them, mechanisms should be put in place to address this underlying issue. Requiring cultural competency training that includes information on the history of coercive practices affecting women of color could help family planning providers understand this concern for their patients.

Then, providers and health systems must address other barriers that make it difficult for women to access LARCs in particular. LARCs can be expensive in the short term, and complicated billing and reimbursement practices in both public and private insurance confuse women and providers. Also, the full cost associated with LARC usage isn’t always covered by insurance.

But the process shouldn’t end at eliminating barriers. Low-income Black women and teens must receive comprehensive counseling for contraception to ensure informed choice—meaning they should be given information on the full array of methods. This will help them choose the method that best meets their needs, while also promoting reproductive autonomy—not a specific contraceptive method.

Clinical guidelines for contraception must include detailed information on informed consent, and choice and reproductive autonomy should be clearly outlined when family planning providers are trained.

It’s crucial we implement these changes now because recent investments and advocacy are expanding access to LARCs. States are thinking creatively about how to reduce unintended pregnancy and in turn reduce Medicaid costs through use of LARCs. The Colorado Family Planning Initiative has been heralded as one of the most effective in helping women access LARCs. Since 2008, more than 30,000 women in Colorado have chosen LARCs as the result of the program. Provider education, training, and contraceptive counseling have also been increased, and women can access LARCs at reduced costs.

The commitment to LARCs has apparently yielded major returns for Colorado. Between 2009 and 2013, the abortion rate among teenagers older than 15 in Colorado dropped by 42 percent. Additionally, the birth rate for young women eligible for Medicaid dropped—resulting in cost savings of up to an estimated $111 million in Medicaid-covered births. LARCs have been critical to these successes. Public-private partnerships have helped keep the program going since 2015, and states including Delaware and Iowa have followed suit in efforts to experience the same outcomes.

Recognizing that prevention is a key component to any strategy addressing a public health concern, those strategies must be rooted in ensuring access to education and comprehensive counseling so that women and teens can make the informed choices that are best for them. When women and girls are given the tools to empower themselves in decision making, the results are positive—not just for what the government spends or does not spend on social programs, but also for the greater good of all of us.

The history of coercion undermining reproductive freedom among women and girls of color in this country is an ugly one. But this certainly doesn’t have to dictate how we move forward.

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