It just keeps coming back. For more than 60 years, syphilis was largely on the decline. But in recent years, the venereal disease has been on the rise again — particularly in the post-recession South.
In Forsyth County, N.C., where the number of cases so far in 2009 — 140 — is more than triple all those reported in 2008, health officials have chosen an unlikely weapon to fight against it: Wal-Mart gift cards.
To tamp down the biggest outbreak the state has seen in years, health workers from that county spent a recent weekend canvassing neighborhoods, asking people to get tested for syphilis and HIV in exchange for a $10 card.
About half of the 603 people tested during the campaign were motivated by the Wal-Mart cards, estimated officials at the Forsyth County Department of Public Health. In fact, the program was so successful that the cards ran out. (Wal-Mart had no comment on being used as a popular lure for syphilis testing, says Daniel Morales, the company’s director of communications for the southeast region.)
The tanking economy may be behind some of the rise in syphilis cases, officials say, and the reason that a practical draw like a Wal-Mart card is a valuable incentive.
When people are unemployed and living in poverty, they’re more likely to be desperate enough to engage in behaviors that contribute to the spread of sexually transmitted diseases, like trading sex for money or drugs, says Dr. C. Timothy Monroe, director of the Forsyth County Department of Public Health.
Monroe says he’s also seen an uptick in infectious diseases such as HIV and tuberculosis.
The rising number of syphilis cases is worrisome on several counts. First, while syphilis can be cured with antibiotics, it too often goes undiagnosed. After an initial stage in which small lesions can break out in the genitals, mouth, or anus, the disease can seem to go away or show only subtle signs like a rash on the palms of the hands or the bottoms of the feet. But the disease re-emerges years later and can cause brain damage and death.
Newborns who become infected in utero and go untreated die up to 40 percent of the time. Syphilis also facilitates the transmission of HIV.
Number of cases nearly double since 2000
An ancient STD, syphilis has long been a scourge. The United States has suffered periodic spikes, including one in the 1980s and 1990s. In response, federal and state health officials mounted a program called The National Plan to Eliminate Syphilis. By 2000, the rate of infection, 2.1 cases per 100,000 people, was the lowest it had been since 1941. But then the rates began to edge upward. By 2007, the rate was 3.8 cases per 100,000. That year, the most recent for which CDC totals are available, there were 11,094 cases of primary and secondary syphilis reported in the U.S. In 2000, there were 5,979.
The South has been hit especially hard, accounting for half of all U.S. cases as of 2007. According to a report from the Centers for Disease Control and Prevention issued in May of this year, for example, Jefferson County, Ala., which had nine cases in 2002, had 238 cases by 2006.
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The state's damaged economy is likely connected to the rising syphilis rates, experts say. With 11.1 percent unemployment as of late August, North Carolina's rate is higher than the national average; at 10 percent, Forsyth County's is slightly higher.
“In the South we have more people living in poverty. They have little or no health insurance,” says Evelyn Foust, director of the communicable diseases branch of the North Carolina Department of Public Health. In her state, transportation to medical providers, especially in rural areas, is also a big problem, she says.
Practical incentives like the Wal-Mart cards, which Forsyth County says it may employ again, have been part of other public health interventions, too. A North Carolina STD program called Get Real, Get Tested, has used McDonald’s cards.
“I was in Rocky Mount [N.C.] where we screened 500 people in one weekend,” recalled Foust, “when a woman came up to me and said, you know, with their dollar menu, I can get five meals out of this.”
According to Get Real, Get Tested coordinator Holly Watkins, that sentiment is common. People are happy to trade a little blood for a burger and fries.
Lack of funding hampers testing
But the cards and the blitz campaign cost money. The state purchased the Wal-Mart cards using federal dollars and relied on its own funds to supply the mobile testing van and the workers who went door-to-door in targeted neighborhoods.
The expense is well worth it because such interventions do work. But that’s exactly what frustrates both Monroe and Foust about this most recent outbreak.
Once the resources were mustered to fight syphilis in 1999, public health workers made great progress. They tested incoming jail inmates, alerted private doctors to screen for syphilis, mounted interventions like the one in Forsyth County, boosted awareness. Baltimore, Md., dropped its high syphilis rate by creating a mobile field testing force to go into the streets.
Then funding started to dry up. North Carolina was a victim of its own success, Foust says. “In one year, I lost close to $1 million,” Foust says. “We brought cases down so low they took funding away for some of the community programs we had down in Forsyth County. I wrote a letter to the CDC and said ‘this is going to be problematic.’”
Jail screening in Forsyth County was one of those programs interrupted last year. “I could not fund the jail program,” Foust says. “So right now I am looking at — today — one of the biggest increases in syphilis I have seen. I am not shocked by it. I am saddened.”
Trying to save money in the short term can have disastrous long-term consequences, she says. An unchecked syphilis epidemic in the 1980s, especially in the South, heavily contributed to the later takeoff of an incurable disease: HIV, and all of its related public expenditures.
Handing out some gift cards, maintaining strong surveillance, education and testing campaigns, actually saves money. People go to public emergency rooms less often, newborns require less intervention and hospitalization, workers get sick less frequently and are more productive. Preventing the spread of a disease like syphilis, Foust argued, benefits everyone, not just those people most likely to catch it.
“The good news is that it is entirely curable,” Foust says, “but you can also prevent people from coming down with it in the first place. It’s sad that it is still a serious public health problem because we should not even have it any more.”
Brian Alexander is the author of the book “America Unzipped: In Search of Sex and Satisfaction," now in paperback.
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