Syphilis
Syphilis
Disease History, Characteristics, and Transmission
Introduction
Syphilis is one of the most significant of the sexually transmitted diseases (STDs) with an estimated 12 million new infections occurring each year worldwide. It is a deceptive condition, starting with a single, painless sore which may not even be detected but which may progress over a period of years to potentially fatal complications such as heart damage, dementia, and paralysis. Syphilis is very infectious, and most cases are caused by sexual contact with people who may not even be aware that they have themselves contracted the disease.
Syphilis is caused by the bacterium Treponema pallidum and the advent of penicillin in the late 1940s led to a dramatic decrease in the number of cases. However, syphilis has been on the increase again in recent years in the United States and in other countries, so there is a great need to treat the disease at an early stage and to educate people about the risks.
Disease History, Characteristics, and Transmission
Syphilis is caused by T. pallidum, which belongs to the spirochaete class of fine, spiral, highly motile bacteria. Its incubation time is from nine to 90 days and the disease progresses through an infectious and a non-infectious stage. The infectious stage lasts for a few months, during which time symptoms may cause little, or no, illness. The non-infectious stage, which follows if syphilis is not treated early on, may also be without symptoms—or it may be accompanied by major heart or neurological damage.
Infectious syphilis is divided into two stages. The primary stage is characterized by the appearance of a single sore, known as a chancre, either on or inside the genitals or elsewhere on the body, such as on the eyelid or lip. Typically, the chancre is firm, round, small and painless. It appears at the site of entry of T. pallidum into the body. The chancre, which those affected may be completely unaware of, lasts for three to six weeks and heals without treatment. However, if treatment is not administered, the infection will progress to the secondary stage.
A skin rash and mucous membrane lesions are the prime symptoms of the secondary stage. A non-itching rash develops, either while the chancre is healing or several weeks afterwards. This might appear as rough red or reddish-brown spots on the palms of the hands and the soles of the feet. However, a rash might appear on some other part of the body and resemble that from some other disease—especially if the primary stage has not been identified.
Sometimes the rash from secondary syphilis is so faint as to be unnoticeable. There may be other symptoms such as fever, swollen glands, weight loss, headaches, loss of appetite, and fatigue. However, this stage also resolves within a few weeks without any treatment.
Latent syphilis is untreated disease past the primary and secondary stage. It has no obvious symptoms and is known as early or late, depending on whether it develops earlier or later than two years after the first infection. This is an arbitrary cut-off time that refers to whether or not the disease is likely to still be infectious.
Late latent syphilis may lead to complications of the nervous system. Ten percent of people with latent syphilis will develop neurosyphilis, of which there are various types, depending on which part of the brain and nervous system is affected. Neurosyphilis produces early symptoms such as personality change, tremor, and impaired memory, often followed by paralysis, delusions and seizures. Another form of neurosyphilis, tabes doralis, is accompanied by sharp pains in the legs and an absence of normal reflexes. The meningovascular type of neurosyphilis is an inflammation of the covering of the brain, and headache is usually a major symptom. Neurosyphilis may not have any symptoms at all, but evidence of infection can still be found in the cerebrospinal fluid.
Another ten percent of those with late disease will develop cardiovascular syphilis, which affects the aorta— the main vessel leaving the heart to supply the rest of the body with oxygenated blood. The disease leads to aneurysm, which is a weakness in the artery, which may lead to a potentially fatal rupture. Finally, gummatous syphilis affects 15 percent of those with later disease and leads to the presence of sores on the skin and mucous membranes, many years after the primary infection.
WORDS TO KNOW
ANTIBIOTIC: A drug, such as penicillin, used to fight infections caused by bacteria. Antibiotics act only on bacteria and are not effective against viruses.
SEXUALLY TRANSMITTED DISEASE (STD): Sexually transmitted diseases (STDs) vary in their susceptibility to treatment, their signs and symptoms, and the consequences if they are left untreated. Some are caused by bacteria. These usually can be treated and cured. Others are caused by viruses and can typically be treated but not cured. More than 15 million new cases of STD are diagnosed annually in the United States.
VENEREAL DISEASE: Venereal diseases are diseases that are transmitted by sexual contact. They are named after Venus, the Roman goddess of female sexuality.
A pregnant woman with syphilis might pass the disease on to her unborn child. Congenital syphilis leads to stillbirth, death shortly after birth, physical deformity, or neurological problems. Increasing awareness of the dangers of syphilis can decrease the risk of all these complications, by treating cases at the earliest possible stage with antibiotics.
Transmission of syphilis is by direct contact with a chancre, which usually occurs through sexual contact. Since the sore may be inside the body—on the cervix, for instance—it is possible that neither person will realize the danger of infection. It is also possible to become reinfected with syphilis at some later stage—unlike with some other infectious diseases, one infection does not confer lifelong immunity.
Scope and Distribution
According to the World Health Organization, there are around 12 million new syphilis infections each year. South and Southeast Asia account for about four million, sub-Saharan Africa for another four million. Other areas where syphilis is a significant health problem include Eastern Europe and the United States.
IN CONTEXT: SCIENTIFIC, POLITICAL, AND ETHICAL ISSUES
In 1932, the U.S. Public Health Service (USPHS). Venereal Disease Division began an experiment in Macon County, Alabama, to determine the natural course of untreated, latent syphilis in African American men. The experiment, known as the Tuskegee Syphilis Study, involved 400 men with syphilis, as well as 200 uninfected men who served as controls. The men were told that they were ill with “bad blood,” a rural Southern colloquialism for syphilis and anemia, but were never informed that they were participants in a study. The USPHS was investigating the possibility that anti-syphilitic treatment was unnecessary.
Despite the fact that major medical textbooks in 1932 advocated treating syphilis at the latent stage, the USPHS actively prevented the men enrolled in the study from receiving treatment. They were never given a clear diagnosis. In 1934, the USPHS advised local black hospitals not to treat the study subjects, and when the Alabama Health Department took a mobile venereal disease unit into Macon County in the early 1940s, the USPHS advised the health officials to deny treatment to the test subjects. At the start of World War II (1941–1945), several of the men were drafted for military service and were told by the Army to begin anti-syphilitic treatment. Concerned about the continuation of the experiment, the USPHS gave the names of 256 study members to the Alabama state draft board and asked that they not be drafted and, thus, receive treatment in the military. The draft board complied with the request. When penicillin became widely available by the early 1950s as a cure for syphilis, the men enrolled in the study did not receive treatment.
No effort was made by the USPHS to protect the wives and families of the diseased men from syphilis. The officials in charge of the experiment presumed that syphilis existed naturally in the black community, presumed that African American men were promiscuous, and presumed they would not seek or continue treatment even if given the choice.
The first published report of the Tuskegee Syphilis Study appeared in 1936, with subsequent papers issued every four to six years throughout the 1960s. Each report noted the ravages of untreated syphilis. In 1969, a committee from the Centers for Disease Control decided that the study should be continued. However, by this time, some of the test subjects had received antibiotics for other illnesses, thereby compromising the syphilis study. Only in July 1972, when the Associated Press reported the story, did the Department of Health, Education, and Welfare (HEW) halt the experiment amid great public outrage. At that time, 74 of the test subjects were still alive. Many of the subjects had died from untreated syphilis with estimates of the dead ranging from twenty-eight to one hundred men. In August 1972, HEW appointed an investigatory panel, which subsequently found the study to be “ethically unjustified.” HEW declared that penicillin should have been provided to the men. None of the physicians who participated in the study were ever prosecuted for any crimes, although the United States did settle a lawsuit brought by the survivors and their families for $10 million.
The Tuskegee Syphilis Study led to new standards for experiments that employ human subjects. In U.S. Senate hearings on human experimentation held in the wake of publicity about the study, physicians were reminded that the goal of human experimentation must always be to advance the human condition and to improve the situation of the subjects of the study. Institutional review boards were established to guarantee that studies are grounded in scientific principles and that the rights of study participants are protected.
In May 1997, President Bill Clinton issued a formal apology for the Tuskegee Syphilis Study on behalf of the United States government.
According to the Centers for Disease Control and Prevention (CDC), where data on syphilis infection is collected, the disease fell to an all-time low in 2000 but has been increasing since then. Accordingly, there were 7,940 reported cases of primary and secondary syphilis in 2004 and 8,724 in 2005. But there has been a decrease in congenital syphilis during that time period from 9.1 to 8.0 per 100,000 births.
Treatment and Prevention
Penicillin is still the mainstay of treatment for syphilis. Doxycycline and erythromycin are alternatives for those who are allergic to penicillin. Early cases can be treated by a single injection of penicillin but the more the disease progresses, the longer the duration of treatment must be. Treatment is effective and it halts progression to the later stages of syphilis and its progression.
Prevention of the disease includes the tracing of the sexual contacts of those in the infectious stages of syphilis. If they are found to be infected, they should be treated promptly. Sexual abstinence, or having monogamous sexual contact with a partner known not to be infected, are the most effective way of avoiding infection with syphilis.
Impacts and Issues
During World War I (1914–1918), many involved nations launched public campaigns to combat the spread of sexually transmitted diseases (then commonly called venereal disease or VD) that often rose dramatically during and immediately after wartime. Posters and pamphlets warned soldiers of contracting venereal disease from prostitutes and transmitting venereal disease to wives back home. Syphilis was the focus of most anti-VD campaigns since it then was the most devastating and difficult to treat venereal disease. Anti-VD, and especially anti-syphilis campaigns were again launched during World War II (1939–1945), but the advent of antibiotics shifted their focus to one of wartime rationing and conservation—saving precious antibiotics for those most in need by reducing the risk of exposure to venereal disease.
The Tuskegee Syphilis Study (1932–1972) documented the effects of untreated syphilis in approximately 400 African-Americans living near Tuskegee, Alabama. Most of the subjects of the study were poor and had scant access to health care. Many were illiterate, or had little formal education. The study was kept secret for almost four decades, with minimal concern for the welfare of participants. Individuals who volunteered for the study were told they would receive free meals and medical care for their “bad blood.” The families of participants who died were eligible to receive $35 for funeral expenses. When the Tuskegee Syphilis Study began in 1932, antibiotic penicillin had been discovered but was not yet commonly available for medical use. Standard treatments for syphilis were neither effective of safe, many involved toxic substances that damaged the liver, kidneys, and nervous system.
The originators of the Tuskegee Syphilis Study claimed that it might be more beneficial for patients to receive no treatment at all than to be subjected to the syphilis remedies then available. However, the Study continued long after penicillin became commonly available after World War II (1939–1945), and patients were denied antibiotics or information about antibiotic treatments. Participants were never fully informed that they had syphilis or that treatment was available. Throughout the course of the study, participants were subjected to repeated injections of non-medicinal solution, routine examinations, and medical testing. Many participants suffered painful symptoms for many years; many died from complications related to untreated syphilis. The experiment terminated abruptly in 1972 after information about the Tuskegee Study was leaked to the press.
While incidence of syphilis in the United States, especially in young adults, reached a new low in the 1990s, an isolated outbreak in 1996 garnered national media attention when public health officials documented 17 cases of syphilis in teenagers in a suburban county near Atlanta, Georgia. Health officials asserted that as many as 250 teens may have been exposed to syphilis. Testing and disease tracking found that many of the teens routinely engaged in high-risk sexual behaviors including having multiple partners, group sex, and unprotected sex.
Much of the increase in syphilis cases in recent years has occurred among men who have sex with men who now account for nearly half of all cases. There has also been an increase in syphilis cases among women, for the first time in more than ten years, and among African-Americans.
Syphilis infection is a major risk for those who already have HIV infection. The presence of the chancre makes it easier for the virus to enter the body. Studies have shown that the risk of HIV transmission is two to five times higher among those who already have syphilis. The symptoms of HIV and syphilis tend to overlap one another, which may confuse the diagnosis. Also, people who are HIV positive might progress quicker to the complications of syphilis. For these reasons, those who are diagnosed with syphilis are recommended to have an HIV test and those who are HIV positive should be tested for syphilis, so treatment can be given as soon as possible.
Primary Source Connection
In the aftermath of the Tuskegee Experiment revelations, calls for government investigations, reparations, and apologies were met with Congressional hearings. The Henderson Act of 1943 had required that all forms of venereal disease be documented and treated; the U.S. Surgeon General had sent letters of commendation to men enrolled in the study on its twenty-fifth anniversary in 1957; and the study violated the 1964 World Health Organization's Declaration of Helsinki, in which informed consent is required. All of these events pointed to a level of government involvement and neglect that led the National Association for the Advancement of Colored People (NAACP) to file a 1973 class-action lawsuit that resulted in a financial settlement.
President William Jefferson Clinton's apology was part of an effort on the part of the Clinton administration to further correct the omission of an apology from the federal government. In 1997, when President Clinton issued his apology, only 8 of the 399 study participants who had syphilis were still alive.
President William Jefferson Clinton's apology on behalf of the United States of America
The East Room.
2:26 P.M. EDT.
THE PRESIDENT: Ladies and gentlemen, on Sunday, Mr. Shaw will celebrate his 95th birthday. I would like to recognize the other survivors who are here today and their families: Mr. Charlie Pollard is here. Mr. Carter Howard. Mr. Fred Simmons. Mr. Simmons just took his first airplane ride, and he reckons he's about 110 years old, so I think it's time for him to take a chance or two. I'm glad he did. And Mr. Frederick Moss, thank you, sir.
I would also like to ask three family representatives who are here—Sam Doner is represented by his daughter, Gwendolyn Cox. Thank you, Gwendolyn. Ernest Hendon, who is watching in Tuskegee, is represented by his brother, North Hendon. Thank you, sir, for being here. And George Key is represented by his grandson, Christopher Monroe. Thank you, Chris.
I also acknowledge the families, community leaders, teachers and students watching today by satellite from Tuskegee. The White House is the people's house; we are glad to have all of you here today. I thank Dr. David Satcher for his role in this. I thank Congresswoman Waters and Congressman Hilliard, Congressman Stokes, the entire Congressional Black Caucus. Dr. Satcher, members of the Cabinet who are here, Secretary Herman, Secretary Slater, members of the Cabinet who are here, Secretary Herman, Secretary Slater. A great friend of freedom, Fred Gray, thank you for fighting this long battle all these long years.
The eight men who are survivors of the syphilis study at Tuskegee are a living link to a time not so very long ago that many Americans would prefer not to remember, but we dare not forget. It was a time when our nation failed to live up to its ideals, when our nation broke the trust with our people that is the very foundation of our democracy. It is not only in remembering that shameful past that we can make amends and repair our nation, but it is in remembering that past that we can build a better present and a better future. And without remembering it, we cannot make amends and we cannot go forward.
So today America does remember the hundreds of men used in research without their knowledge and consent. We remember them and their family members. Men who were poor and African American, without resources and with few alternatives, they belived they had found hope when they were offered free medical care by the United States Public Health Service.
They were betrayed.
Medical people are supposed to help when we need care but even once a cure was discovered, they were denied help, and they were lied to by their government. Our government is supposed to protect the rights of its citizens; their rights were trampled upon. Forty years, hundreds of men betrayed, along with their wives and children, along with the community in Macon County, Alabama, the City of Tuskegee, the fine university there, and the larger African American community.
The United States government did something that was wrong—deeply, profoundly, morally wrong. It was an outrage to our commitment to integrity and equality for all our citizens.
To the survivors, to the wives and family members, the children and the grandchildren, I say what you know: No power on Earth can give you back the lives lost, the pain suffered, the years of internal torment and anguish. What was done cannot be undone. But we can end the silence. We can stop turning our heads away. We can look at you in the eye and finally say on behalf of the American people, what the United States government did was shameful, and I am sorry.
The American people are sorry—for the loss, for the years of hurt. You did nothing wrong, but you were grievously wronged. I apologize and I am sorry that this apology has been so long in coming.
To Macon County, to Tuskegee, to the doctors who have been wrongly associated with the events there, you have our apology, as well. To our African American citizens, I am sorry that your federal government orchestrated a study so clearly racist. That can never be allowed to happen again. It is against everything our country stands for and what we must stand against is what it was.
So let us resolve to hold forever in our hearts and minds the memory of a time not long ago in Macon County, Alabama, so that we can always see how adrift we can become when the rights of any citizens are neglected, ignored and betrayed. And let us resolve here and now to move forward together.
The legacy of the study at Tuskegee has reached far and deep, in ways that hurt our progress and divide our nation. We cannot be one America when a whole segment of our nation has no trust in America. An apology is the first step, and we take it with a commitment to rebuild that broken trust. We can begin by making sure there is never again another episode like this one. We need to do more to ensure that medical research practices are sound and ethical, and that researchers work more closely with communities.
Today I would like to announce several steps to help us achieve these goals. First, we will help to build that lasting memorial at Tuskegee. (Applause.) The school founded by Booker T. Washington, distinguished by the renowned scientist George Washington Carver and so many others who advanced the health and well-being of African Americans and all Americans, is a fitting site. The Department of Health and Human Services will award a planning grant so the school can pursue establishing a center for bioethics in research and health care. The center will serve as a museum of the study and support efforts to address its legacy and strengthen bioethics training.
Second, we commit to increase our community involvement so that we may begin restoring lost trust. The study at Tuskegee served to sow distrust of our medical institutions, especially where research is involved. Since the study was halted, abuses have been checked by making informed consent and local review mandatory in federally-funded and mandated research.
Still, 25 years later, many medical studies have little African American participation and African American organ donors are few. This impedes efforts to conduct promising research and to provide the best health care to all our people, including African Americans. So today, I'm directing the Secretary of Health and Human Services, Donna Shalala, to issue a report in 180 days about how we can best involve communities, especially minority communities, in research and health care. You must—every American group must be involved in medical research in ways that are positive. We have put the curse behind us; now we must bring the benefits to all Americans.
Third, we commit to strengthen researchers’ training in bioethics. We are constantly working on making breakthroughs in protecting the health of our people and in vanquishing diseases. But all our people must be assured that their rights and dignity will be respected as new drugs, treatments and therapies are tested and used. So I am directing Secretary Shalala to work in partnership with higher education to prepare training materials for medical researchers. They will be available in a year. They will help researchers build on core ethical principles of respect for individuals, justice and informed consent, and advise them on how to use these principles effectively in diverse populations.
Fourth, to increase and broaden our understanding of ethical issues and clinical research, we commit to providing postgraduate fellowships to train bioethicists especially among African Americans and other minority groups. HHS will offer these fellowships beginning in September of 1998 to promising students enrolled in bioethics graduate programs.
And, finally, by executive order I am also today extending the charter of the National Bioethics Advisory Commission to October of 1999. The need for this commission is clear. We must be able to call on the thoughtful, collective wisdom of experts and community representatives to find ways to further strengthen our protections for subjects in human research.
We face a challenge in our time. Science and technology are rapidly changing our lives with the promise of making us much healthier, much more productive and more prosperous. But with these changes we must work harder to see that as we advance we don't leave behind our conscience. No ground is gained and, indeed, much is lost if we lose our moral bearings in the name of progress.
The people who ran the study at Tuskegee diminished the stature of man by abandoning the most basic ethical precepts. They forgot their pledge to heal and repair. They had the power to heal the survivors and all the others and they did not. Today, all we can do is apologize. But you have the power, for only you—Mr. Shaw, the others who are here, the family members who are with us in Tuskegee—only you have the power to forgive. Your presence here shows us that you have chosen a better path than your government did so long ago. You have not withheld the power to forgive. I hope today and tomorrow every American will remember your lesson and live by it.
Thank you, and God bless you.
CLINTON, WILLIAM J. APOLOGY FOR STUDY DONE IN TUSKEGEE. WHITE HOUSE OFFICE OF PRESS SECRETARY,1997.
See AlsoSexually Transmitted Diseases.
BIBLIOGRAPHY
Books
Adler, Michael, et al. ABC of Sexually Transmitted Diseases. London: BMJ, 2004.
Web Sites
Centers for Disease Control and Prevention (CDC). “Trends in reportable sexually transmitted diseases in the United States, 2005.” December 2006 <http://www.cdc.gov/std/stats/trends2005.htm#trendssyphilis> (accessed May 1, 2007).
World Health Organization. “Sexually Transmitted Infections.” <http://www.who.int/reproductive-health/stis/docs/sti_factsheet_2004.pdf> (accessed May 1, 2007).
Susan Aldridge