Syphilis is on a comeback

Ghosts, the 1881 Henrik Ibsen play in which syphilis signifies “the tragedy of heredity,” was a death knell for the 19th century. The 19th century did not take it well. Ibsen was met with pan-European abuse for his “dirty act,” his “almost putrid indecorum.” The funny thing, to the modern reader, is that Ghosts never explicitly mentions syphilis. In 1881, theatregoers understood doomed Oswald Alving when he described the inherited contagion that surfaced “down there” and spread to his brain. Today’s undergraduates need annotation; they live in a world of high-quality public health care where syphilis, a disease knocked out readily by penicillin, is almost never encountered.

In contemporary Canada it still flares up occasionally among high-risk groups, particularly gay men. But now Alberta, suddenly plagued with the pre-antibiotic horrors of adult neurosyphilis and congenital syphilis among newborns, has had to launch a shock campaign of public awareness. As in Ibsen’s time, so in ours: debate within Alberta has concentrated on the message, with scant attention paid to the crisis itself—a crisis as anachronistic in the 21st century as a cholera epidemic caused by a contaminated water pump.

Alberta made syphilis a reportable disease before the Second World War and introduced mandatory screening for expectant mothers shortly thereafter. But beginning in 2005, with an economic boom creating high mobility, crack cocaine enjoying a renaissance, and strains increasing on Alberta’s health care system, syphilis broke into the heterosexual population, with “street-involved” Aboriginal women hit particularly hard.

Since 2005, the province has seen an extraordinary 25 infants born with syphilis—a problem essentially absent from Canada during the preceding decade. Of these babies, 22 were born in Edmonton. Nine have died. Equally extraordinary are the 56 reported cases of neurosyphilis, a complication described in the medical literature as “extremely rare in the antibiotic era.” Symptoms can appear any time after the initial infection, but anywhere from five to 25 years without treatment are usually required for the neurological effects of syphilis to take hold.

Alberta doctors are nearly alone in the developed world in having witnessed cases of general paresis—sudden-onset psychosis caused by syphilis—in the 21st century. Other half-forgotten manifestations of late syphilis are reappearing. Men in their 40s have exhibited stroke-like symptoms because of meningovascular syphilis; at least one developed cardiovascular syphilis and needed heart surgery. These sufferers of secondary or tertiary syphilis—who might easily have missed the genital lesions that marked the first stage of the disease—will need ongoing care. Some neurosyphilitics will have incurable dementia or gait difficulties, and 18 of the 56 have had at least partial vision loss.

Mercifully, the outbreak seems to have peaked in the face of aggressive surveillance and outreach. Alberta doctors have learned to consider syphilis when an infant presents with a severe rash or when an adult male freaks out in a grocery store. The province has intensified screening of pregnant women, adding a second test at 28 to 32 weeks to the traditional first-trimester test. Trained peer educators are being sent into tough neighbourhoods, and front-line doctors are using new rapid test kits, not yet formally licensed, to perform spot screening. After years of inertia, the provincial government has gone ahead with a controversial awareness campaign, dominating the airwaves during the NHL playoffs with lurid TV commercials depicting bedroom-eyed youths with sore-riddled faces.

Why have Ibsen’s ghosts been stalking Alberta, and why now? A December report from the province’s chief medical officer speaks elliptically about hasty mass recruitment of male workers by the oil patch. It also emphasizes the public-health gap within the churn of humanity between Indian reserves and the inner city. Of the mothers who have delivered babies with congenital syphilis since 2005, only three had accessed prenatal care at all.

Others wonder if conservative mores have been part of the drama. “Our sex ed is a patchwork, with little strong guidance from the top,” warns Pam Krause of Calgary’s Sexual Health Centre. “People are okay to deal with certain things, but we’re still suffering from a lack of normalization of the harder topics.” Even medical education in Alberta, she suggests, has allowed Victorian morality to interfere with the struggle for teaching resources.

Alberta deputy chief medical officer Martin Lavoie admits there may be something to the idea. “Parts of Alberta are very conservative, and it may lead to a reluctance to arm children with the knowledge we’d like them to have,” he says. “Pushing forward the age of first sexual contact is a positive thing, but you have to protect those who aren’t going to succeed at abstinence.” He adds, however, that rates of sexually transmitted disease are steadily increasing across the country. Economic factors may have made Alberta especially vulnerable, “but our concern is not being unique. It’s being the first.”