Baltimore's syphilis epidemic is showing the first signs of ebbing since it took off in the early 1990s, though the city continues to post the highest rate of any major U.S. municipality.
Based on a tally through September, the city health department projects no more than 500 cases through the end of 1998 -- down from 667 last year. This would mark the first downturn since 1994, when soaring caseloads prompted criticism of public health efforts.
"Obviously, we're too high for comfort, but I'm confident we're headed in the right direction," said Dr. Peter L. Beilenson, the city health commissioner. He said the improvement came after the city restored its depleted force of health workers responsible for syphilis detection, treatment and contact tracing.
A top official from the Centers for Disease Control and Prevention said she was encouraged by the reversal, but warned that the epidemic could escalate again if control efforts are relaxed.
"This effort has got to be sustained over time because these bugs are going to push back," said Dr. Judith N. Wasserheit, director of the CDC's division of sexually transmitted disease prevention.
Driven by Baltimore's problem, Maryland holds the grim distinction as the state with the highest syphilis rate. Last year, 887 people were diagnosed across the state -- a rate of 17.6 per 100,000, more than five times the national average. Prince George's, Wicomico, Somerset and Baltimore counties far exceeded the national average, but their rates were much lower than Baltimore's.
Syphilis is a bacterial disease spread mainly by sexual contact. In its early stages, the disease causes genital sores and a skin rash, and later, widespread organ damage and even death. When caught early, it is easily cured by a single shot of penicillin.
The disease can also be spread from pregnant women to their babies. Through September, Baltimore recorded 27 cases of congenital syphilis -- a likely sign that the 1998 total will be less than last year's 57, Beilenson said.
Nationally, syphilis cases have reached all-time lows, with the condition confined to 1 percent of U.S. counties. CDC officials have said they hope to eradicate the disease by 2005 through intensive public health efforts. Syphilis remains endemic in more than a dozen large cities.
In 1997, Baltimore counted 667 cases, a rate of 99 cases per 100,000 population. This was more than double Memphis' rate, the second highest at 39.5 cases per 100,000. The cities with the next highest rates were, in order, Nashville, Tenn.; Atlanta; New Orleans; Richmond, Va.; and Washington.
Even with this year's improvement, it is doubtful that Baltimore -- will fall below Memphis or any other city battling syphilis, Beilenson said. But he added, "Our goal is, possibly by next year, to fall to 1992 levels." That year, Baltimore had about a quarter as many cases as it did last year.
Public health experts say Baltimore's syphilis problem is a spinoff of other urban ills -- drug addiction, prostitution and poverty -- but are puzzled why syphilis struck Baltimore harder than other cities with similar problems and demographics.
"All of the right ingredients were there and some community had to be the worst, and this time, unfortunately, it's ours," said Dr. Martin P. Wasserman, Maryland health secretary.
Wasserman and Beilenson speculated that a major culprit is the practice of selling sex for crack cocaine, thereby spreading the disease. The crack epidemic hit Baltimore later than many cities.
"I don't know why Baltimore," Beilenson said. "But we have this very inbred drug population. They are all interrelated and they share things."
The CDC official, likening Baltimore's disease rates to those of an undeveloped country, also blames the city health department.
"At the end of the 20th century, in the wealthiest country in the world, the persistence of high levels of syphilis is a sentinel event," Wasserheit said. "It tells us these are communities in which there is a breakdown in the most basic public health functions."
Formerly the assistant director at one of the city's health clinics, Wasserheit described the city's clinics as among the best in the country in the late 1980s. Since then, she cited a deterioration of "basic public health infrastructure" as contributing to the epidemics of syphilis and gonorrhea.
Beilenson said federal budget cuts in the mid-1990s were responsible, dropping the number of full-time health care providers in the city's sexually transmitted disease clinics from 15 to 10.
"We had desperately tried in a city that doesn't get adequate federal resources to make do. We cannot make them up with the city budget," Beilenson said.
Earlier this year, using $700,000 in city, state and federal funds, the city added more doctors, nurse practitioners and physician's assistants, bringing the staff to 16. The health department sent letters to doctors throughout the city, warning them to watch for a disease that is often missed.