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Sexual Healing (continued)

By Jim Duffy

To illustrate the complexity this creates, Jonathan Zenilman, MD, scrawls a wavy line representing the nation's syphilis rates over the last 70 years. Zenilman is a professor of Medicine and chief of the Division of Infectious Diseases at Johns Hopkins Bayview Medical Center and has joint appointments at the Bloomberg School in International Health, Epidemiology and PFRH.

The line starts out at a high level in the 1940s, then sweeps down in a slope that signals the arrival of penicillin. From there, it settles in a low, lingering rate until popping up in the 1970s ("Gay liberation," Zenilman hypothesizes.), dropping down in the 1980s ("AIDS. People changed their sexual behaviors.") and popping back up again in the 1990s. ("At this point, syphilis is largely an African-American disease, fueled by crack cocaine.")

But such broad national trends say only so much about local realities. CDC experts tried to pin the 1990s epidemic in Baltimore on crack cocaine, but local experts never bought it. "Out in the clinics [in Baltimore], we never saw that many crack users," Zenilman says. Several theories surrounding the epidemic are discussed in The Tipping Point, a bestseller by journalist Malcolm Gladwell. Zenilman is quoted advancing a theory that a severe recession in the early 1990s led to funding cutbacks that gutted essential public health services in Baltimore.

Zenilman likes one of the other theories advanced in Gladwell's book, too, this one developed by the maverick Colorado-based epidemiologist John Potterat. It centers on Baltimore's decision to raze several high-rise public housing projects during the 1990s.

"These places were densely populated, with well-established and quite limited social networks, as well as a lot of disease," Zenilman says. "All of a sudden these folks were spread out all over the city. Guess what? They found new sex partners. So this epidemic may have been an unintended collateral effect of tearing down those horrible projects."

The bottom line? When dealing with STIs, raw numbers and historical cycles sometimes tell you next to nothing about what's actually going on in the streets of a specific city and what strategies public health practitioners need to employ.

"These diseases are always such a complex integration of disease, social science, behavior and public policy," Zenilman says. "That's what makes this field so fascinating."

So how has the city of Baltimore achieved a striking, if incomplete, measure of progress since its syphilis epidemic peaked?

One key strategy is upgraded outreach efforts to at-risk populations, says Laura Herrera, MD, MPH '05, a former Hopkins faculty member who is now chief medical officer at the city Health Department. The department bolstered its surveillance staff and outfitted mobile vans with diagnostic equipment.

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