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On the Streets Where Syphilis Lives

Tracking the Epidemic One Name at a Time

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It's been pouring nearly all morning, and the chuckholes and hollows along South Federal are full of dark, greasy water. Dorann Richardson, an investigator for the city's Health Department, maneuvers her car around them as she looks for a number on the Stateway Gardens high rises. She finally sees it and pulls into a parking spot.

A tightly latticed steel grate covers the entire glassed-in entrance to the building; as we approach, a small door also armored with grating suddenly swings outward and is held open by a tall young man. Several children play in a corner of the broad lobby, their shouts ringing off the unfinished cement walls. Richardson walks straight to the security guard's booth, flashes her city ID, and signs the log. Then she strides through the hallway, past the elevators and into the dim stairwell. (Later, when she gets back to her office, she cheers when she sees that a few flashlights have finally come in.)

She's looking for Andrew Cole*, whose name was given to the Health Department by someone who thought Cole might have had sex with someone who had syphilis. Another investigator has been out a couple times looking for him with no luck. If Richardson finds him, she'll ask him to come to the city clinic on South Michigan to have his blood tested. If she doesn't, she'll leave him a card asking him to call her or report to the clinic. It's sealed in a small brown envelope on which she's neatly written his name and "urgent" and "confidential."

We climb up to the second floor and turn a couple corners. The number we're looking for is odd, and the numbers here are even. We wind around to the south side of the building, but the numbers are still even. A man standing outside his door tells us that to get to the odd numbers we have to go to the other side of the lobby.

We head back down the corridor, past a second stairwell Richardson says she won't use. "Stick your head in there," she says. I do, and yank it back as the stench of urine hits my nose.

We go down the first stairwell, cross the lobby, and head into the hallway on the other side. Several young men squat or lean against the wall, talking loud and staring as we pass.

Richardson finds the number she's looking for and pounds on the heavy metal door with her fist. No one answers, and she pounds again. She gives up and bangs on the door across the way. We hear the first door open behind us. Peering through a two-inch crack is a young teenager holding closed the front of a nightgown missing most of its buttons.

Richardson asks in her warm, busy voice if Andrew Cole is home. The girl looks puzzled and says she's never heard of anyone by that name. Richardson describes him as tall, the only detail she could glean from the department's form. The girl shakes her head.

"Is anyone else home who might know him?"

The girl shakes her head again. "But my sister might know him. I can ask her when she gets home."

"Can she call me?"

The girl nods her head.

Richardson writes down her name and phone number. "Do you have a phone?"

The girl shakes her head. Richardson gives her the number anyway, thanks her, and says someone will stop back. She's worried she may have the wrong address and wonders if she should try to double-check it with the person who gave the Health Department his name.

Later the sister calls the clinic to say she's never heard of Andrew Cole.

There's a syphilis epidemic in Chicago. Last year 4,624 cases were reported, nearly 4 times the total in 1988; the number of syphilitic babies was up 14 times. If the epidemic hasn't gotten much attention, that's partly because AIDS overshadows all other sexually transmitted diseases, partly because most of the people affected are poor and young, partly because it hasn't erupted in the white community--93 percent of the cases reported last year in the city were among blacks. In 1990 the national rate of infection per 100,000 people was 156 for black men, 116 for black women, 3 for white men, and 2 for white women.

In one way Chicago has been luckier than many other cities. In New York, Miami, Atlanta, and Los Angeles the syphilis epidemic had been exploding for two years before it hit here in 1988, the same year the federal Centers for Disease Control decided it had to hire many more people if it was going to control numerous STD epidemics around the country. One of four new training centers the CDC authorized went to Chicago, tripling the number of investigators here.

The city now has about 40 investigators, all but 7 officially working for the CDC, trying to trace everyone who could be infected with syphilis and could infect someone else. Louise Galaska, director of the city's STD-HIV prevention programs, says 40 are probably enough to control the increase in syphilis cases, and her most recent statistics suggest the numbers may well level off this year. But that would still leave us with an epidemic.

Every morning half of these workers fan out into the city's neighborhoods, trying to find people who have had sex with or may have had sex with someone who was infected. The rest work in the Health Department's five STD clinics, counseling patients and doing the tedious paperwork needed to keep track of a burgeoning caseload.

Packed into a narrow room for an early-morning meeting, most of the 14 investigators who work out of the clinic at 1306 S. Michigan--covering Roosevelt Road to 71st Street and Ashland to the lake--banter good-naturedly with each other as they race through the administrative items on their agenda and briefly turn to trading street stories. Most of them are young and zealous. Half of them are black, half white. Half are men, half women. Galaska, who started as an investigator with the CDC in 1978, says that until the 70s the CDC wouldn't hire women as investigators, assuming they could neither talk openly about sex with strangers nor handle such dangerous work.

That danger has only increased as the number of stray bullets has risen. Don't bring anything you don't want stolen, Galaska told me, and don't be late--the earlier our workers get out on the streets the safer they are. Richardson explains that the later it gets the more people there are hanging together in hallways and on street corners, and the more likely the investigators are to be targets or simply caught in cross fire. Gus Conda, who's been working as an investigator for the city off and on for 14 years and who helps train the CDC workers, had just stepped into the elevator in one of the projects late one afternoon when he heard a man call to him to hold the door open. Two men came around the corner, one of them snapping on leather gloves. Conda, sure he was about to be mugged, flipped his city ID out of his pocket. The man with the gloves stopped, said apologetically, "Oh, I didn't see that," and stepped back off the elevator.

The investigators go out on their own most of the time, though Richardson says they pair up now and then if they can. "Look," she says, "how many police go out on their own?" So far no one's been seriously hurt, Galaska says, though in the four years she's been in Chicago a few people have been assaulted, several have had things taken from their cars, and one woman's car was stolen. She also thinks that more workers are being harassed, threatened, robbed, and assaulted than four years ago.

Richardson was shocked when she first saw the projects. She had been working for the CDC in Atlanta, but the agency generally doesn't keep investigators in one place for more than two years, and last spring she was up for a transfer. "They asked me where I wanted to be." She laughs. "I don't recall saying Chicago. And when I saw the projects I said, 'I have to get another job.' But I got up here and people were real friendly."

She grew up in Ohio. Tired of northern winters by the time she graduated from college, she moved to Atlanta, where she worked for a time as a teacher and then as a consultant for a reading program. After watching a close friend die of AIDS, she took a job as an educator with an HIV-prevention program whose focus was women. "Early on people were talking about homosexuals. I said, 'Let's talk about women. Let's talk about teenage girls.'" She wrote grants and organized large, festive meetings that attracted lots of young people. Two years ago she applied to the CDC, hoping to work in HIV prevention, only to find that the agency requires its workers to start with syphilis control. She signed up anyway.

Richardson says she's rarely afraid in the projects anymore, except of the elevators. But then she's always been afraid of elevators. She carries a small can of Mace on her key ring but says, "That's not for my job. That's for where I live." Still, she does pray every morning before she goes out: "I need God's protection and guidance."

She says that what gets to her far more than fear ever has is the pain of seeing people who are trapped and wasted, the pain of saying things people don't want to hear. She remembers having to tell a 22-year-old woman with five children that she'd been exposed to syphilis, then watching the woman fall apart when she realized what that said about the boyfriend she'd trusted. "When I first started this job, sometimes I'd pull over to the side of the road and start to cry."

Richardson drives south on Michigan, the windshield wipers slapping at the rain. She's looking for the address of Ron Lewis, the second person on her list of eight (a short list--she often has 15 to 20 people to try to find in a day). The mailboxes on one side of the entrance to the building where he supposedly lives have been ripped out of the wall. Inside, it's quiet except for the shrill peeping somewhere of a smoke detector that needs a new battery.

His apartment should be one of two rear units on the third floor. Richardson knocks on the door of one, but we don't hear anything. We walk down the hall and onto the back porch, where we see that the whole back of the apartment is boarded up.

We cross the porch to the other apartment. The shade is pulled down, but we can see a toaster on the sill. The door is covered with a steel accordion grate that's padlocked shut. Richardson slips her hand between the bars and knocks. No one answers. We walk back through the hallway to the front door of the second apartment, which has another accordion grate locked across it. Again no one answers, and Richardson wedges a sealed brown envelope between the door and the jamb.

The rain has stopped, and as we climb into the car the sun stings through the clouds. Lewis calls the next day to say he's already seen a doctor at another clinic.

It's often hard for the Health Department to get the names of the people it's supposed to trace. "Every patient who comes in lies about something--95 percent," says Conda. About their ages, addresses, phone numbers, and how many people they've had sex with. "That's the number-one lie," he says.

The investigators try to interview all people known to be infected, gently prying out the names of those they might have infected, pointing out that the Health Department guarantees their names won't be revealed to anyone they identify or to any other agency--a promise that's broken only when it's clear someone has been molesting a child. A person in the first stage of syphilis will be asked for the names of contacts within the past three months, and someone in the secondary stage for contacts within the past six months. Nearly half the people interviewed acknowledge at least two contacts, though one out of ten won't or can't name anybody.

When Ken Schwartz interviews a teenager at the clinic who's in the second stage of syphilis, she says angrily that she knows exactly who gave it to her but doesn't offer his name. When Schwartz presses a little, she says tersely that it was an old boyfriend home on leave from the Navy. Schwartz asks if there was anyone else, explaining how important it is that anyone who's been exposed be tested and stressing that her name will be kept confidential. She's adamant that the only other person has been her new boyfriend, who's come with her to the clinic.

Flipping the pages of a notebook full of gruesome color photographs, Schwartz describes to the woman what untreated syphilis can do. He asks how she knew she was infected, and she says she was tested when she went to a family-planning clinic. He asks if she uses drugs. "Everybody's asking me that," she says, laughing. "But no, I don't." He asks if she uses condoms, and she says she does. He keeps circling back to the sailor, carefully skirting her irritation, each time extracting one more piece of information, until he has the man's name as well as his mother's name, address, and phone number. Yet after the young woman leaves Schwartz says he's sure she didn't tell him everyone she'd had sex with.

The investigators often try to reinterview people, hoping to elicit more names. Conda recently talked to a woman in the second stage of syphilis who gave him the names of 21 contacts and their addresses and phone numbers--all from memory. Two days later, when he talked to her again, she remembered three more people.

Investigators also do "clusters," asking everyone they interview for the names of people who might have been exposed to syphilis by someone else--friends or relatives who have lots of sex partners, who trade sex for drugs, who are having sex with someone who's infected, or who have a suspicious rash. And they ask people to guess who might have given the Health Department their names, which can elicit a long list.

They frequently set up mass screenings in places where infected people are often found--homeless shelters, gang members' homes, crack houses--drawing blood from everyone who volunteers to be tested. Screenings can be very efficient. The County Jail, which tries to test everyone who comes in, accounted for 11 percent of the city's syphilis cases last year. But the state long ago gave up screening people who come in for marriage licenses, because so few cases were being found that the results didn't justify the cost; for the same reason, most hospitals have stopped routinely screening patients.

Doctors, hospitals, and labs are required by law to report to the Health Department the names of people they determine have syphilis, many of whom then have to be interviewed. State law also requires pregnant women to be tested twice; syphilis is easily passed to a fetus and often causes developmental problems, brain damage, even death--if not treated, half of all infected babies will die in the womb or shortly after birth. One-fifth of the women treated for syphilis in the city STD clinics are pregnant. Because so many women who are at risk of being infected also don't get prenatal care, investigators ask people they interview if they know anyone who's pregnant who might like a free blood test.

The investigators create a file for each person who tests positive, then compile the related files and chart a contact tree, which shows who infected whom. One of Sherra Scott's cases is a woman who was pregnant and had had symptoms when a screening test showed she was infected. She named as a contact only one man. When he came in he tested positive but hadn't had symptoms; he named four women, though not the pregnant woman. One of the four came in and also tested positive without symptoms; she named him as well as her new boyfriend. Using all the bits of information the seven had given her, Scott calculated when each of them had probably been exposed--and saw that the pregnant woman was almost certainly infected before she had sex with the man she named. Scott realized she had to go back to the woman and ask who her other partner was.

As the names are gathered, the people most likely to be infected are immediately assigned to an investigator, who will try to find them as quickly as possible: each day lost can mean the person has infected someone else. But finding people can be difficult. Investigators are often given only a first name, a prostitute's street name, a rough map, a street corner, a vague physical description. The clinic's "name unknown" file is enormous, and the proliferating "Unk" family is a running joke. Yet of the 3,874 contacts and 1,153 cluster suspects investigators traced between January and June this year, two-thirds were found and persuaded to go to the clinic.

Richardson often relies on a sixth sense when trying to track down someone she doesn't have much information on. "Stick around. Socialize. Talk to the neighbors." She says when people understand she's trying to help--and isn't associated with the police--they're usually willing to tell her what they can. "You'd be surprised the information people will give you. It's kind of like being a police detective--but we don't have any right to the information." It once took her three weeks to find a "hype," someone who'll do anything for drugs, because she knew only the woman's street name. When Richardson finally caught up with the woman, who was pregnant, she simply snapped, "I'm hungry." Richardson made her a deal. She fed her breakfast, and the woman went to the clinic with her.

Richardson pulls up in front of a neat yard and house on a side street lined with bungalows. She's already talked to the man who lives here, Andre Walker, listed as a contact on the form. He promised to go to the clinic, but she wants to make sure he does. A woman answers the door and goes to call Walker, a man of medium build who looks to be in his early 30s. He politely invites us into a tidy living room with cream-colored sofas and carpeting and a large vase of silk flowers on the coffee table.

He thanks Richardson for coming and says he plans to go to the clinic this afternoon, his sister's going to drive him down and wait for him. He squats next to the coffee table, keeping silent for a long moment, his gaze drifting from his hands to the floor and back. Finally he says softly, his mouth tightening, "I just have to ask you, why can't I know who it was that gave you my name--so I don't mess with this person again?"

Richardson gently asks him how he'd like it if he were infected and gave her the names of the people he'd had sex with, and then she went around telling them he'd given out their names. It just wouldn't work, she says, adding that some people might get angry, and then people could get hurt.

Walker nods, his eyelids drooping and then lifting.

Richardson launches into her little matter-of-fact lecture on the importance of being careful when having sex. Walker listens, slowly nodding. Suddenly he looks puzzled and says the last time he remembers having sex was last winter.

What about blow jobs? she asks. You can get it from that.

His head tips back. "Oh. That's probably how it happened--a blow job." He looks embarrassed. "Oh, sorry."

Richardson, fishing in her jacket pocket, asks if he wants some condoms. He looks embarrassed again but says yes. She hands him several, warning him not to keep them in his pants pocket because his body heat might deteriorate the latex. And she says safer sex, not safe sex.

She asks him if he has any questions.

He shakes his head, then says quietly, "I really appreciate you coming by."

She asks if he would have gone to the clinic if she hadn't.

He straightens up. "Yes. I want to take care of myself."

Nodding, he thanks her again and again as we move toward the door. "I appreciate it. I appreciate it."

He does go to the clinic that afternoon. He tests negative.

People often tell Richardson they'll go to the clinic but don't. They say they'll go to their own doctor but don't. They say they've been to another clinic but haven't. Some don't think they're infected because they don't have symptoms. Some don't want to believe they might have syphilis. Some, especially drug addicts, simply don't care.

Some people want to be paid to go or want investigators to at least buy them cigarettes or lunch. Richardson is a little suspicious when people want money. "While I'm out here I want to be contributing, I want to help if I can. But that doesn't mean aiding and abetting. If they tell me they want money for beer, they're not getting any money from me."

She usually finds that persistence is enough. "It's like being a bill collector," she says, laughing. "You keep on bugging the person." She warns people that if they don't go she'll keep coming back to their house--and then the neighbors will start to notice. If she can't induce them to go, she offers to draw their blood herself; all the investigators carry a small kit that allows them to take "field bloods."

The clinic building on South Michigan is gray and inconspicuous. A currency exchange in a trailer a few feet from the entrance has a sign on its door that reads "No standing. No sitting. No soliciting. Police will be called." The stairs to the third-floor clinic are lined with signs asking patients not to write on the walls. The clinic rooms and hallways are institutional mint green, with rows of chairs and stacks of brochures. It's first come, first served.

All tests and treatments are free to patients, whether they've been notified by an investigator or just walk in. They may be interviewed and offered counseling about preventing HIV infection. Their blood is drawn, and they're examined by one of the clinic's four doctors. "One of our teachings is that STDs travel together," says Jane Schwebke, the medical director, who also does research on STDs as a member of Northwestern's faculty. "When you've got one thing, look for another. If a known syphilis patient comes into our clinic, we don't just treat them for syphilis. We get them up on the table. We do a complete examination. We look for all the other STDs."

If they're infected with syphilis--as 11 percent of the contacts and cluster suspects the investigators trace are--they'll most likely be given a painful shot of penicillin, after which they'll probably feel lousy. But even if they test negative they may be given a shot. Patients who've been exposed to a syphilis chancre may not test positive for several weeks, yet one-third of them will develop the disease. Because there's no way to tell which ones those are, the clinic doctors--unlike many private physicians--give them shots as a preventive. A private doctor's first priority is the individual patient, Louise Galaska explains. A public health doctor's first priority is the public. A private doctor can choose to wait until a patient tests positive before treating him; a clinic doctor can't risk sending someone back onto the streets not knowing whether he'll return for further tests or treatment.

The clinic is open weekdays, a couple evenings a week, and Saturdays, but still it's sometimes so crowded that people have to be asked to come back the next day for their examinations, though at least their blood can be drawn. Galaska guesses that every month the five city clinics ask some 300 people to come back.

Richardson drives up to another small bungalow on another narrow side street. Two dogs behind the fence wag their tails as we approach, then start barking. Angela Carver, who's listed as a cluster suspect, had earlier promised she'd go to the clinic this morning. Richardson had a hunch she wouldn't.

Carver pushes open the screen door and yells at the dogs to shut up. She looks vaguely annoyed to see Richardson but slowly walks up to the gate. She has the slight build of a teenager, but her face is clearly older.

Richardson, her voice amiable, asks if Carter's still going to the clinic.

"I had to stay home and baby-sit," Carver says sullenly. "My mother had to go to the clinic."

An older woman looks out through the screen door and disappears. Richardson tips her head in the woman's direction and asks why she couldn't baby-sit.

Carver says the woman has to leave.

Richardson asks if she can draw her blood here, and Carver nods.

"Do you have good veins?" Richardson asks cheerfully.

Carver stretches out her arm, exposing the soft crook of her elbow and a few small, faint scars. "I don't use," she says quickly. "I have eczema."

Richardson barely pauses, then says she'll get her blood kit. "And you'll lock up those dogs, won't you?"

Carver calls the dogs into the house, and Richardson goes to her car, pulls a black zippered bag from the floor behind her seat, and stuffs a handful of condoms into her jacket pocket.

The inside of the house is dim. The curtains and shades in the living room are drawn, the linoleum is deep brown, and the furniture is dark. The older woman is frying lunch in the kitchen, and several children are clustered around the table behind her. They watch us as we walk into the living room, and one little boy softly tells us we may sit down.

Carver reappears and sits down silently in the middle of the sofa. A cockroach skitters across the floor. Richardson unpacks the blood kit, pulls on latex gloves, then ties a tourniquet around Carver's upper arm and swabs the inside of her elbow. The children squeeze together against the kitchen door frame, staring.

Carver winces and twists her face away from Richardson, who deftly slides the needle into a vein. "That didn't hurt," Carver says, looking surprised.

The glass vial fills, and Richardson presses a cotton ball on top of the needle and slides it out. Carver reaches out to hold the cotton ball, but it falls onto her dress and blood runs down her arm. Richardson grabs the ball, pressing it hard on the puncture as she carefully sets the syringe on the table. A drop of blood hangs from the end of the needle, then falls.

Richardson stretches a Band-Aid across Carver's arm. She snaps the needle off into a small red plastic canister, then takes off one glove, drops the cotton balls and Band-Aid wrapper into it, and ties the ends together. She writes Carver's name, address, birth date, and phone number on a slip of paper and wraps it around the vial. Later Richardson says she doesn't worry that she'll get AIDS, then smiles. "But my mother does."

Richardson asks Carver if she wants any condoms. Carver nods, and quickly stashes a handful in the cabinet next to the sofa. Richardson warns her to be sure to use them whenever she has sex, including oral sex, tells her what kind to buy, tells her to be careful about who she sleeps with. Carver doesn't look at her, but she occasionally nods.

Richardson says she's going to take the blood kit to the car and asks if she may use the phone when she comes back. Carver says yes, then disappears. The older woman, scowling, walks into the room carrying a phone, fishes a cord from behind the cabinet, plugs the phone in, and walks back out.

When Richardson returns she calls Tyrone Reed, another cluster suspect. She'd left a brown envelope on his door two days before, and he'd called her. He refused to come to the clinic, saying he knew he didn't have anything, but she persuaded him to meet her so she could draw his blood. He said he'd be home from work at lunchtime and would meet her at noon at the entrance to his building.

He isn't home, his father tells her. She asks him to remind his son if he sees him that he promised to meet her and that she'll be there.

The children, who are still pressed together against the kitchen doorway, watch as we walk out. Carver thanks Richardson for coming by, and for the first time she smiles.

As we get into the car, two men walk up to the gate and into the house. Richardson shakes her head. "A lot of things going on in that house."

Later she drops the vial off at the clinic lab. Carver tests negative.

During the last syphilis epidemic, in the late 70s and early 80s, almost half the people infected were homosexual men. But the numbers in that community dropped sharply when the safe-sex message was pushed hard in response to AIDS.

The message didn't make it to the poor parts of the city, where syphilis has hung on for decades. And when crack hit Chicago in 1988, the number of cases among poor minorities exploded--just as it had on the east and west coasts when crack hit there, two years earlier.

Crack, and its variants, is apparently still the preferred drug in the poor sections of Chicago. Cheap and highly addictive, it seems to increase the desire for sex, decrease inhibitions, and prolong the length of time needed to reach orgasm--but only when used in binges and not habitually.

Poor men tend to commit crimes to get money to buy drugs. Poor women tend to trade sex for it. In crack houses--which are sometimes divided into high houses and sex houses--people may have sex, often oral, with dozens of partners. One person with syphilis can quickly infect a lot of people--and not remember who they are. Twenty percent of the male clinic patients in 1991 said they'd had contact with a prostitute, paying with drugs or cash; 13 percent of the female patients said they'd been paid for sex with drugs or cash.

Not everyone who's getting syphilis is a crack addict; less than half the people interviewed last year admitted to using drugs. Yet crack houses do seem to be at the vortex of the epidemic--because people who frequent them often have sex with people who don't. But whether they visit crack houses or not--and whether they use drugs or not--the people most at risk have a lot in common.

King Holmes, primary author of Sexually Transmitted Diseases, the standard text, writes that in the inner-city black community the age pyramid closely resembles that of a third-world country: there's a high percentage of young people and few older adults. Louis Galaska says, "Young people tend to be unattached emotionally. They're not married. They tend to experiment with all kinds of things, whether it's drugs or sex or life-styles." And that kind of behavior becomes dangerous when a lot of people in the community have syphilis. In 1991 57 percent of the syphilis cases in Chicago were among people 10 to 29 years old.

Young people in the inner city are often unemployed, poorly educated, and transient. They live in violent, unstable neighborhoods and are often pessimistic. All of which can give them the sense they don't have much to lose if they take risks. And if they do become infected they're less likely to go to a doctor until a problem is severe; even those who are working often don't have health insurance and are reluctant to run up a bill or lose pay by taking time off work to see a doctor.

Yet plenty of poor, young blacks in the inner city don't behave in ways that put them at risk of getting syphilis, Galaska points out. A survey of high school seniors from 1985 through 1989, for instance, showed that black males were half as likely to use cocaine as white males. She also notes that the sexual behavior of many young whites would put them at risk if syphilis happened to be rampant in their social groups. A recent study of 467 young women, 72 percent of them white, at the University of California at Berkeley seems to support her premise: it showed that nearly half the women were infected with human papilloma virus, an STD that often causes genital warts and is closely linked to cervical cancer. Moreover, 20 percent of whites are infected with herpes by the time they're 40, and some upper-middle-class groups have even higher rates of infection.

The number of syphilis cases among whites is probably also underreported. Whites are more likely to go to private doctors than to public clinics, and surveys have shown that a lot of cases seen by private doctors are never reported to the Health Department. Galaska says that not reporting cases is dangerous, largely because doctors can't ensure that their patients will tell all their sex partners that they've been exposed. She says a man may tell his doctor he got syphilis from a one-night stand and hasn't had sex with his wife since, so she doesn't need to be told or tested. Maybe it was a one-night stand, Galaska says, but probably it wasn't--and anyway, she asks, doesn't the wife have the right to decide whether she wants to be tested?

Richardson is pushing lights up State Street. Drawing Carter's blood took longer than she expected, and she's nearly five minutes late for her appointment with Reed. She and another investigator once set up a time and place to draw blood from a group of Disciples, but the two of them showed up five minutes late and the gang members were gone.

Richardson whips into a side street just north of the Hilliard Homes, turns around, and parks on State. We stride up to one of the curved high rises and walk around the elevator area. Only a couple children are there. We walk to the building office, and Richardson flips out her city ID and asks to use the phone.

"He isn't there?" Richardson says, then listens for a moment and states firmly, "It's confidential . . . I can't tell you. I could lose my job if I told you . . . I understand your concerns as a parent, but I have to talk to him first . . . He was supposed to come home from work and meet me downstairs at lunchtime . . . He lied? . . . When's a good time to call back?"

She finally hangs up and says Reed's mother said he didn't go to work today. Richardson says she's sorry that his mother is now upset with her and with Reed.

She asks two young men sitting outside on the walkway if they know Reed. They say he's eating in the lunchroom, pointing to a screen door. "What'd he do?" they call after us as we walk away.

She pokes her head into the lunchroom and asks for Reed. A tall, slim teenager steps out carrying his lunch in a paper bag. Richardson steers him down the walk toward her car, telling him she talked to his mother, who's upset. She suggests he think of some explanation. Reed stares straight ahead and says nothing.

"Where would be a good place to draw your blood?" she says, trying to sound cheerful.

Reed shrugs. "I don't care. Anywhere." He sweeps his arm across the yard and playground.

"We'll go someplace private."

We all get in Richardson's car and drive around to the parking lot behind the complex, the smell of Reed's pizza filling the air.

Richardson pulls on a new pair of latex gloves and swabs his outstretched arm. He squints and looks away, and the blood washes into the vial. She starts to unwrap a Band-Aid, but he says he doesn't want one. "Oh, you think if people see you with a Band-Aid they'll know who you've been with?" she says, amused. "Well, you can take it off when you leave me, but I have to put it on." He silently holds his arm out for her.

"Will you find out today?" he asks in a flat voice.

She says it might take longer, but she'll call. She asks if he wants some condoms. He shakes his head.

"You're not having sex with anyone?"

"No."

She writes down her name and number on a scrap of paper, in case he wants to talk to her about anything, in case he thinks of anyone else who could benefit from being tested. "Now don't put this in your jeans pocket where your mom will find it when she does the wash," she says jokingly as she hands him the piece of paper.

"My mom doesn't do my wash," he says, opening the car door. "My girlfriend does." He thanks Richardson and walks quickly across the parking lot.

Her face falls. She watches him for a long moment, then drives out of the parking lot and heads south. In the middle of the street at the light is a man with one leg and crutches. His eyes are bloodshot, and he's shaking a paper bag up and down. "I'm not sure I'm ready for this," she says. "He's here every day." But she picks up the few coins on the console, adds the little change I've brought, rolls down the window, and drops the money in the bag.

The man looks at the sum and half snorts. "You better not be laughing at that," she snaps. The light changes, and she puts the car in gear, calling back to him, "You shouldn't beg!"

The spirochete that causes syphilis isn't happy anywhere but in the human body or in rabbit testicles, which makes it difficult to study. A lot of things about how it lives and reproduces are unknown.

Treponema pallidum is so small that its tight, angular spirals are hard to see under an ordinary microscope. It rotates rapidly, probably with the help of numerous flagella, though it's not clear how because the flagella are covered by a membrane. The spirochete can't penetrate the human skin or mucous membranes, and researchers assume it usually enters the body through microscopic tears caused by intercourse.

The spirochetes immediately begin multiplying at the site where they enter. But they replicate very slowly--a cycle takes around 30 hours--and no one knows how they survive the attack the body's white blood cells quickly launch.

But the white blood cells do manage to kill large numbers of the spirochetes, creating within two to three weeks the first clear symptom of the primary stage of syphilis: a painless, oozing chancre at the site of the infection, usually on the genitals, anus, or mouth. Women often can neither see nor feel the sore, which is teeming with live spirochetes.

That the chancre heals within one to six weeks would seem to indicate the body's immune system is winning. But the spirochetes somehow elude it and spread throughout the body, erupting again three to six weeks later, usually in smaller lesions all over the skin. This rash, which is extremely infectious, is often accompanied by a low-grade fever, headache, sore throat, or general feeling of malaise. The secondary stage is often misdiagnosed: few doctors know a syphilis case when they see one, and the symptoms mimic those of many other diseases, from contact dermatitis to ringworm. When Ken Schwartz interviewed the teenager at the clinic, she said she'd called a hospital when her rash appeared and a doctor told her she must have chicken pox and prescribed calamine lotion.

This rash too heals within a couple of weeks or months, which would seem to indicate the immune system finally has the disease under control. But the spirochetes have simply retreated into the blood and lodged in the tissues and organs, where they can lie dormant for years. Many people have relapses, during which they can again infect someone they have sex with; and the spirochetes can still be passed from one person's blood to another's, a hazard for IV drug users who share needles.

This latent stage can last from 1 to 20 years, but when the disease reappears it's often with ugly symptoms: large ulcers in the muscles, bones, or lungs; aneurysms of the heart where the elastic tissue has been broken down and calcified; blindness, paralysis, insanity, strokes, seizures because of damage to the brain or spinal cord. But this tertiary stage is rarely seen in this country anymore, thanks to penicillin.

The syphilis spirochete was identified in 1905, but it wasn't until 1943 that scientists discovered that penicillin stops it from reproducing, and it wasn't until the early 50s that the antibiotic was widely used. So far the spirochete has shown no sign of developing resistance to it. Researchers continue to look for a vaccine, but it's still a long way off because so little is known about the spirochete.

"This woman is never home," Richardson says as we walk into a limestone six-flat. "If I can catch her, I can draw her blood." But today Jill Jackson opens the door. A thin woman in her early 20s who's a cluster suspect, she smiles warmly when Richardson says she's the one who's been leaving brown envelopes and messages with her mother.

Jackson invites us in, and we follow her down the hall to a sparsely furnished living room while she apologizes for not having been home, explaining that she was in the hospital for two and a half weeks for a bleeding ulcer. "They drew my blood, checked for everything--HIV, gonorrhea, everything," she says, her finger tapping a hospital report.

Richardson tries to find a date on the report so she can call the hospital and make sure a syphilis test was done. Then she moves on to her safe-sex talk, and asks Jackson if she uses condoms every time she has sex.

Jackson says she does, nodding vigorously. "I want to protect myself."

Jackson asks who told the Health Department she might have syphilis, and Richardson explains that someone had only suggested it might be good for her to have her blood tested. Jackson smiles and says gently, "Oh, that was probably my father."

When Richardson finally stands up, Jackson seems disappointed, as if she's sorry to lose the company. She thanks Richardson for coming and for keeping after her, and invites her to stop by whenever she likes. Her mother comes out of the kitchen to say thank you, and the two of them stand smiling together in the doorway as we leave.

Syphilis is the primary STD the Health Department traces, partly because it can be so destructive, partly because it's curable, partly because the department can handle the number of cases with the workers it has. Yet other STDs affect many more people: there are 13 million new STD cases in the U.S. every year, only 130,000--1 percent--of them syphilis.

At one time public health departments around the country traced gonorrhea cases the way they now trace syphilis cases. But the numbers became overwhelming--today there are 1.4 million cases of gonorrhea a year. There were 21,605 cases in Chicago in 1991, more than four times the number of syphilis cases. But the city doesn't have enough workers now to trace even resistant gonorrhea cases, which are the hardest to cure; they've been spreading rapidly--22 percent of the cases last year. The city does, however, fund a screening program at hospitals and clinics.

Gonorrhea is a bacterial infection that can be transmitted until the individual is cured. It causes painful urination in most men, which usually sends them to a doctor, but perhaps three-quarters of infected women don't notice they have the disease. Untreated, it can cause pelvic inflammatory disease (PID), scarring women's fallopian tubes and causing sterility. Like syphilis, with which it's frequently found, gonorrhea has become disproportionately a disease of the young, poor, and black--87 percent of the cases reported here last year were among blacks. But while the number of syphilis cases has been rising, the number of gonorrhea cases has been dropping. No one's sure why.

Chlamydia is also often found with gonorrhea, but it's far more common--more than four million new cases a year in the U.S. A curable bacterial disease that seems to be most prevalent in the middle class, it causes a discharge and painful urination in men but often goes unnoticed in women. It's the most common preventable cause of PID, yet it's not routinely screened for during pelvic exams.

Chancroid is a bacterial infection that was rare in this country before 1984. It has quickly become resistant to many drugs, and Chicago has recently had an outbreak, with 60 cases so far this year. It causes an oozing sore that, again, men generally notice and women often don't.

Most hepatitis B infections are now sexually transmitted. Every year 300,000 people are infected with this virus, which attacks the liver and causes persistent flulike symptoms, and 5,000 of them will die. People generally think of this as a disease homosexuals get, but the rate of infection among heterosexuals is rising fast.

The most common STDs in the U.S. now are incurable: herpes and human papilloma virus (HPV). Some 20 to 40 million Americans may have herpes, and there are 500,000 new cases each year. Infected adults periodically have painful lesions, though many people are asymptomatic. But the virus can be passed to a fetus, causing blindness, brain damage, or death. The rate of infection among blacks is two to three times higher than among whites, and the disease is most likely to be found in the inner city.

There are more than 50 types of HPV, some of which cause the genital warts associated with cancer in both men and women. More than 12 million Americans may have this highly infectious disease, which can be given to a baby as it passes through the birth canal. It seems to affect the same population herpes does and seems to hit the young hardest--most of the 500,000 to one million new cases each year are among 16- to 25-year-olds.

AIDS is of course the STD that looms over all the rest, though it can't be neatly separated from them. It has, for instance, striking parallels with syphilis. Before syphilis became a curable disease it carried the stigma AIDS now does, and society's response to those who had it was contemptuous and censuring. "We're still fighting that legacy--the idea that only dirty people have an STD," says Galaska.

The diseases also have a dangerous synergy. A person who has the lesions caused by syphilis, chancroid, or herpes and has sex with someone who's HIV-positive is far more likely to contract HIV, which now infects an estimated one million Americans. A person with chlamydia or gonorrhea is three times more likely to get HIV. People with HIV are often also infected with other STDs, and in them the curable STDs frequently don't respond well to standard treatment while the incurable ones can be far more pernicious.

The population most at risk of getting HIV increasingly resembles the population most at risk of getting many STDs: poor, young minorities. The current syphilis epidemic may be an omen for them just as the last syphilis epidemic was for gay men.

Sheila Mason, a contact, lives in a small split bungalow, but it isn't clear which of the two doors is hers. Richardson calls out to three little boys playing on the stoop next door, "Do you know which one is Ms. Mason's?" Two of the boys run over to the bottom of the steps and stand pointing at the north door.

Richardson thanks them and pounds on it. There's no answer. She knocks on the other door, but no one's there either. She sticks a brown envelope in the first door.

As we walk back to the car, a white-haired man approaches us from across the street. In a polite voice he asks Richardson whom she's looking for. She tells him, and he says Mason's at work. "Who should I tell her came by?" he asks.

"Dorann," Richardson says, smiling.

"Nosy people," she says as we drive away. Then she laughs. "But I guess if they're nosy, at least they're looking out for her."

Mason comes into the clinic on Saturday, and her blood tests negative.

In 1991 the CDC spent $84.9 million on non-AIDS STD prevention and control, most of which went directly to states and cities. Galaska's '91 budget--40 percent federal, 60 percent city--was just under $5 million, not a lot of money considering how labor-intensive the work is.

Education is particularly labor-intensive, and the number of cases it prevents is impossible to gauge. Most of the Health Department's effort is aimed at the people who come into the clinics, who may be shown videos, given brochures, and talked to by a doctor and an investigator. The budget also pays for a health-care worker who makes the rounds of the public schools, writes a column for the Chicago Daily Defender, talks on radio stations, and helps neighborhood organizations put together plans to inform their communities. But most of the clinic's effort is after the fact, and one educator can't prevent large numbers of new cases.

Galaska believes that the people most likely to be exposed to syphilis are pretty complacent about their risk. Richardson agrees. She says that if the city wants to end the syphilis epidemic--and prevent a new AIDS epidemic--it will have to find more funds and get a lot more creative about educating the hard-core at-risk population. Driving down Pershing Road, she points disgustedly at the liquor and cigarette billboards lined up on roofs and walls. "Our priorities as a society are all off," she says. "If we can get the message out that having a Colt 45 is fun, we could get out the message about STDs. They should take some of these posters down and have safe-sex ads. No one complains about liquor, but when it comes to sex--" She flips her hand off the steering wheel. She'd like to see signs on buses and grocery bags, and suggests that corporations could be persuaded to donate funds as well as the kind of things--makeup, records, food--that could be used to lure young people into meetings. She also thinks public health educators need to be sent where people hang out. "Go into the barbershops. Go into the pool halls. Educate people on the street."

The last person on Richardson's list is "Beady Unk." A woman in the secondary stage of syphilis told workers at the Lakeview clinic he'd paid her for sex. She knew only his nickname, but she gave a scant description of him and drew a map of where he lived, on a side street three houses up from Garfield.

We stand outside the car, trying to decide whether the woman started counting with the big building on the corner or after the alley behind it and whether she counted a pair of two-flats that are smack up against each other as one or two. Rain has started to fall again.

A woman is standing in front of the first house after the alley, and Richardson asks her if she knows anyone named Beady.

The woman walks toward us. "What's his last name?"

Richardson says she doesn't know, she only knows that he's supposed to live in the third house from the corner.

"I don't know who he is," the woman says, and laughs. "But I know who you are. You're the Health Department."

Richardson is startled. "Why would you say that?"

The woman smirks and points at Richardson's jacket. "You've got that brown envelope in your pocket."

Richardson shoves down the corner of the envelope that's sticking out of her pocket.

"You're the Health Department," the woman says again, chuckling. "I know it."

"Now don't do that," Richardson says. "It's not nice. Are you sure you don't know anyone named Beady? Older? Jheri-Kurls?"

"Beady. Beady." She shakes her head. "That name does sound familiar though." She calls toward the house. "Carlos!" A man pushes up a window and leans toward the screen. "Do you know a guy named Beady? Older? Jheri-Kurls?"

He shakes his head and says no. The woman says a middle-aged man does live in the third house up from hers, though she doesn't think he has Jheri-Kurls.

We head up the street, and Richardson pounds on the door of the bottom apartment of a two-flat. No one answers. She bangs on the door of the upstairs apartment. We're turning to leave when a man's voice calls down, "Who is it?"

"Dorann."

"Who?"

"Dorann."

His feet thump down the stairs, and he pushes aside the curtain that covers the window in the door. She tells him she's looking for an older man with Jheri-Kurls named Beady. The man opens the door six inches and glowers at her. He's wearing a dirty T-shirt and brown pants, but doesn't have Jheri-Kurls. She tells him a woman down the street thought he might know Beady.

The man's lip lifts. "I don't associate with those people," he says, and closes the door.

She knocks on a couple more doors, but no one's home. She wonders if the woman who drew the map got the side of the street wrong. We cross, and she knocks on the door of the third house up from Garfield. An older man comes out and politely tells us he's never heard of Beady.

She stands on the sidewalk, looking up and down the street, her hand shielding her face from the rain. She finally suggests trying the block south of Garfield, and if he isn't there she'll call the woman and try to get better directions.

The woman who knew Richardson was from the Health Department is still out on the sidewalk watching us. Richardson tells her no one else seemed to know Beady either, thanks her for her help, and gets into the car.

"Beady. Beady," the woman says. "Wait!" she shouts. "B.D.! It's B.D.!" Carlos is walking out of the house, and the woman calls to him, clearly pleased with herself, "It's B.D.! B.D. Martin."

"Oh, B.D. Martin," he says. "Yeah. I know B.D. He used to live over there, but he moved two months ago." The last he knew, B.D. was living over a barbershop a few blocks away.

Richardson laughs as we drive down the block where Carlos told us to look, excited that she might find B.D. We pass a grocery, a beauty-supply shop, a church, a restaurant, another church, but no barbershop. She keeps driving down the next block. "There it is!" she yells, and pulls to the curb.

She asks a woman coming down the stairs if she knows B.D. "No. I don't know him," the woman says, pushing past us.

We climb to the second floor, where Richardson knocks between the bars of a locked accordion grate. Without opening the door, a woman says she's never heard of any B.D. No one answers at the apartment next door.

We go on to the third floor, another smoke detector in need of a battery squeaking above us. Richardson bangs on one of the two doors. "Let me get some pants on," a man yells over a blasting radio. When he finally comes to the door, she asks if he knows B.D. He shakes his head. She asks if he might live next door. He says he thinks a woman lives there. She thanks him, then pounds on the other door. No answer. She decides to leave the envelope on the second-floor door.

Back on the street Richardson pokes her head into the barbershop and asks the man cutting hair if he knows B.D., who was supposed to have moved into an apartment upstairs a couple months ago. The man thinks for a long moment, then says he doesn't.

We go back to the car and sit for a minute, the rain smearing down the windshield. Maybe Carlos was wrong, she says. She puts the key in the ignition, then sees the barber standing in the door of his shop, motioning us to come back.

Inside, he points to a man in dirty blue coveralls we hadn't seen sitting at the side of the shop. "We thought he was sleeping, but he was listening," the barber says.

The man, his eyes bleary, tells us B.D. lives on the third floor in the rear.

We climb back up to the third floor, and Richardson, smiling, seals another card in an envelope, marks it with his name and "urgent" and "confidential," and jams it in the door.

That evening B.D. calls the clinic and leaves a message that she gets the next morning. He's furious because his sister opened the envelope and knows that he's been asked to report to the clinic. When the person who took the message told him he'd been exposed to syphilis he said, "Is that all?"

Richardson calls the number he left and asks the child who answers to please wake B.D. up. The child goes away for a long time, then returns and says no one's home. She asks to speak to an adult, and the child again says no one's home. She says thank you and hangs up. "He's there," she says, staring at the phone. "I know he's there."

*The names of all the people traced by the Health Department have been changed.

Art accompanying story in printed newspaper (not available in this archive): photos/Lloyd DeGrane.

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