Dr. Gail Skowron, chief of the division of infectious diseases at Roger Williams Medical Center, has worked in a small HIV clinic at the hospital for 21 years. And before last year she had rarely, if ever, stumbled across a case of syphilis.
Then, something strange happened. In a matter of months, she saw five cases.
"Shocked," she says, describing her reaction. "I emailed everyone and said, 'am I missing something? Is there a syphilis outbreak around here, because I'm seeing one in my practice.'"
It turned out there was. The Rhode Island Department of Health reports cases of syphilis in three earlier stages of the disease — primary, secondary, and early latent — more than doubled from 25 in 2008 to 61 in 2010.
But if there is something jarring about the return of a disease that most think of as a relic of the past or, at least, a problem for the Third World, the Rhode Island outbreak is hardly an anomaly.
The disease, which can start with a single, painless sore and progress to serious brain, nerve, and heart damage, has made a nationwide comeback in the last decade, particularly in the South and the West.
Indeed, Rhode Island — however alarming its outbreak — ranks 32nd in the country in rate of infection, according to the Centers for Disease Control and Prevention, with neighboring Massachusetts far ahead and Connecticut just behind.
The sexually transmitted disease has hit gay and bisexual men particularly hard. Of the 61 documented Rhode Island cases last year, 58 were in men. And 54 of those men reported having sex with men.
No one can be entirely sure what is behind the outbreak here and nationwide. But most doctors and public health professionals point to two factors: easy access through the Internet to anonymous sex and, as treatment for HIV improves, increasingly lax attitudes about unprotected sex.
Even those who are a bit more cautious can find themselves in trouble; unprotected oral sex, while safer than unprotected anal sex vis-à-vis HIV, is fertile ground for transmission of syphilis.
Doctors always advocate for safer sex. But that can be a difficult sell — particularly when it comes to oral sex. The next defense: more frequent testing. Caught in time, syphilis can be effectively treated with penicillin.
Dr. Tim Flanigan, chief of the division of infectious diseases at Miriam and Rhode Island hospitals and professor of medicine at Brown University, says the relative paucity of testing is, in part, a doctors' problem.
There is discomfort in the medical community around asking patients about sexual activity, he says, particularly in a small state like Rhode Island, where everyone knows everyone.
That makes it all the more important for gay and bisexual men, in particular, to bring the issue up with their doctors, Flanigan says.
The state has taken some preliminary steps to confront the outbreak. In February, Dr. David Gifford, then director of health, and Dr. Nicole Alexander, medical director with the state's division of infectious diseases and epidemiology, sent a letter to medical providers alerting them of the rise in syphilis cases among men having sex with men.
