Brandt, Allan M.

Annals of Internal Medicine

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 Sexually Transmitted Disease: Shadow on the Land Revisited  (Article begins on next page)The Harvard community has made this article openly available.Please share how this access benefits you. Your story matters.Citation Allan M. Brandt. 1990. Sexually transmitted disease: Shadow onthe land revisited. Annals of Internal Medicine 112(7): 481-483.Published Version http://www.annals.org/content/vol112/issue7/Accessed February 18, 2015 2:23:10 AM ESTCitable Link http://nrs.harvard.edu/urn-3:HUL.InstRepos:3372903Terms of Use This article was downloaded from Harvard University's DASHrepository, and is made available under the terms and conditionsapplicable to Other Posted Material, as set forth athttp://nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of-use#LAAVoiume 112 Number 7 1 April 1990Annals of Internal MedicineEDITORIALSexually Transmitted Disease: Shadow on the Land, Revisitedijince Surgeon General Thomas Parran (1) began hiscampaign in the 1930s to wipe out syphilis-"the shad-ow on the land"-partner notification has been consid-ered an important element of public health policy tocontrol epidemic disease. Case finding through notifi-cation of partners was based on the common-sense no-tion that early intervention among persons who wereoften unaware that they might be infected couid leadto the control of diseases like syphilis. Parran calledfor a "Wassermann dragnet": vigorous screening, re-porting, contact tracing, and treatment to rid the na-tion of the scourge of sexually transmitted disease.When first proposed and implemented in the 1930sand 1940s, partner notification for sexually transmit-ted diseases held great promise. Typically, publichealth officers reported on field investigations whereepidemics, traced back to a single index patient, were"shut down" through dogged "shoe leather epidemiol-ogy." No doubt, Parran's program met with consider-able success, breaking the conspiracy of silence associ-ated with these diseases and attracting much neededattention and resources (2).Unfortunately, the specific aspects of these pro-grams have rarely been systematically evaluated to ex-amine their efficacy as public health policies. Partnernotification programs, for example, have typicallybeen debated on ideologic grounds: Does the Statehave a right to require reporting and aggressively tracesexual contacts or is such activity a violation of basicrights of privacy and confidentiality? On a pragmaticlevel, does the knowledge that infected individuals willbe questioned about their sexual contacts discouragepersons from seeking appropriate care? Although sup-porters of the programs typically cite the number ofnew cases discovered through notification (3), detrac-tors typically cite the fact that discovered cases mayonly represent a small proportion of actual new infec-tions (4). Do partner notification programs achievetheir goals? It is striking how little is known about therelative cost and effectiveness of these programs.In this issue, Andrus and colleagues (5) report theresults of an evaluation of the effectiveness of partnernotification in controlling epidemic syphilis. The case-control study conducted in Oregon in 1987 is impor-tant because it is one of the rare instances in which alongstanding public health program has been subject-ed to careful and rigorous assessment. The papershows that the "technologies" of public health can besubjected to scientific evaluation. How well do theavailable tools meet the demands of a particular epi-demic? To mandate such interventions without previ-ous assessment of their efficacy, as well as their costsand benefits, could lead to the substantial commitmentof limited resources (both human and financial) with-out accruing clear advantages. To invoke public healthmeasures simply because there are historical prece-dents would be the equivalent of using medicationswhose safety and efficacy have never been clearly dem-onstrated because individual clinicians are "con-vinced" they work.Andrus and colleagues (5) thus have shed empiricallight on an old debate. The authors conclude that as aresult of three factors-that the period of infectiousnessof syphilis is relatively long; that many persons report-ed multiple partners; and that those infected with thedisease were likely to exchange sex for money ordrugs-partner notification was unlikely to contributesignificantly to the control of the epidemic. For exam-ple, among persons who reported exchanging sex fordrugs or money (a major component of the epidemic),92% could not provide locating data for their part-ners. The conclusion that their paper reaches seemsmodest and clear: Partner notification must be supple-mented by other public health interventions to controlepidemic syphilis. The implications of their findings,however, are broader and touch on one of the mostvigorously contested public policies regarding the con-trol of sexually transmitted diseases and, especially,infection with the human immunodeficiency virus(HIV).Recently, a vocal debate (6) has ensued whetherthe traditional control mechanisms for sexually trans-mitted diseases are effective for the control of HIVinfection. Contact notification programs for syphilisand gonorrhea are now frequently cited as a potential-ly effective model for the control of HIV infection (7-9). It is critical that such applications be carefully re-viewed: first, to assess the evidence that they make alAprin99O • Annals of Internal Medicine - Volume 112 • Number 7 481difference for syphilis and gonorrhea control; and sec-ond, to evaluate the likelihood that they will help con-trol HIV infection. Given the findings reported in thisissue (5), there is reason to be cautious in applying theconcept of partner notification for HIV infection. In-deed, controlling HIV infection presents problems thatare common to other sexually transmitted diseasessuch as syphilis as well as significant barriers of itsown.Slate-mandated partner notification appears unlike-ly to effect positively the course of the HIV epidemic.Important social and cultural changes since the incep-tion of contact tracing have compromised the efficacyof these programs. According to reports from the1940s, most index patients named only one contact.As sexual mores have changed, the increase in multi-ple and anonymous contacts has grown. Moreover, inthe case of HIV infection, spread by both sexualcontact and needle-sharing, the possibilities of trulyeffective notification become highly problematic. Con-siderable evidence exists that the actual number ofcontacts has increased at the same time that an indexpatient's ability to adequately identify his or her con-tacts has decreased (even presuming a cooperative in-dex patient). The demands that this problem places onresources are, of course, considerable and must bemeasured against other potentially more effective in-terventions. Finally, the long period of infectiousnessof HIV as well as the current inabihty to render per-sons noninfectious further diminishes the potential ad-vantages of tracing contacts (10). It is important torecognize that the problem with partner notification inthis instance is not that it violates civil liberties or thatit is intrusive or stigmatizing (although these are im-portant concerns), but the great uncertainty that iteffectively serves the goals of public health and wel-fare.Skepticism about partner notification programs as ameans of controlling epidemic syphilis or HIV infec-tion, of course, should not discount the significance offinding newly infected persons and assuring that theyreceive optimal treatment. In this respect, it is criticalto distinguish the importance of warning ongoing sex-ual partners unaware of their risk of infection-and itsimplications-from legislatively mandated contact trac-ing programs (11). There is a compelling social inter-est to ensure that persons who may unknowingly be atongoing risk for infection be told of the possibihties fortesting and treatment.Meeting social and ethical obligations to persons atrisk should follow the basic ethical principles of clini-cal responsibility. Obviously, all persons found to beinfected with HIV should be counseled and encour-aged to identify ongoing contacts. They should be as-sisted by clinicians or public health officials to ensurethat their contacts have the opportunity to be coun-seled and tested, and if infected, treated. Moreover,with the growing recognition of the possible benefits ofearly treatment among asymptomatic HIV-infectedpersons, the need to ensure that individuals at continu-ing risk be adequately warned is critical (12).In framing public health policies, the emphasis mustbe on policies likely to be optimally inclusive, thatdraw individuals to the institutions of medicine andpublic health where desirable services, counseling, andtreatment may be provided (13). Only policies broad-ly protective of the rights and privacy of infected per-sons are likely to achieve the public health goal ofattracting at-risk individuals to be tested. Not to rec-ognize the very particular properties of this epidemicwill lead to policies which are unlikely to have a posi-tive effect.Those currently calling for comprehensive pro-grams of partner notification have not adequately rec-ognized the cultural meanings and significances of thisepidemic. We must begin to set priorities in the devel-opment of social policies to meet tbe demands posedby the HIV epidemic. For example, to "find" new cas-es through partner notification only to discover that itis not possible to adequateiy meet the needs for coun-seling, treatment, social services, and care, places thecart before the horse. To ask persons to voluntarilyname contacts when neither the index patient nor thepartner are adequately protected from discriminationor assured of adequate services will lead to suspicionand justifiable skepticism among those at greatest risk.No one would contest that the institutions of publichealth must reach out to those at risk for infection andassure that those infected receive optimal care andthat those who are not infected change their behaviorto reduce risk. What seems to be required is carefullytargeted, voluntary, confidential notification of on-going sexual partners of HIV-infected persons. Suchprograms may take various forms but the emphasismust be on out-reach and the provision of quality serv-ices.Today, we are confronted by new shadows on theland, HIV infection and a resurgence of epidemicsyphilis. The time has come, as Andrus and colleaguesshow, for a dispassionate evaluation of historic pro-grams, programs that may have been effective underother circumstances, but in the contemporary context,fail to achieve their important goals.Allan M. Brandt, PhDHarvard Medical SchoolBoston, MA 02115Requests for Reprints: Allan M. Brandt, PhD, Department of SocialMedicine, Harvard Medical Schooi. 25 Shattuck Sireet. Boston, MA02115.Annals of Internal Medicine. i990;112:481-483.References1. Farran T, Shadow on the Land: Syphilis. New York: Reynal &Hiichcock; 1937,2. Brandt AM. No Mugic Bullet: A Social Hmory of Venereal Diseasein lhe United States Since 1880. New York: Oxford UniversityPress; 19K7.3. Toomey KE. Cahill K, Blount JH, Havlak GR, Cates W Jr. AEDS:politics and science [Letter]. N EnglJ Med. 1988;319:441-3-4. Osborn JE. AIDS; politics and science. N F.ngl J Med.1988;318:444-7.5. Andrus JK, Fleming DW, Harger DR, et al. Partner noiification:can it control epidemic syphilis? Ann Intern Med. 1990;112:539-43.6. Lambert B. In war on AHJS a langle of rules aboul tracing, tcslingand telling. New York Time.^. 9 July t989, E6.482 1 April 1990 • Annals of Intemal Medicine • Volume 112 • Number 77. Toomey KE, Cates W Jr, Partner notification for the prevention ofHIV infection. A/Z>5. 1989;3{Suppl I):S57-S62.8- Wykoff RF, Heath CW Jr, Hollis SL, et al. Contact tracing toidentify human immunodeficiency virus infection in a rural commu-nity. JAMA. 1988;259:3 563-6.9. Potterat JJ, Spencer NE, Woodhouse DE, Muth JB, Partner notifi-cation in the control of human immunodeficiency virus infection.Ant J Public Health. 1989;79:874-6.10. Rutherford GW, Woo JM. Contact tracing and the control of hu-man immunodeficiency virus infection. JAMA. 1988;259:3609-10.11. Brennan TA. AIDS and the limits of confidentiality: the physiciansduty to warn contacts of seropositive individuals./Gen Intern Med.1989:4:242-6.12. Levine C, Bayer R. The ethics of screening for early intervention inHIV dhesise. Am J Public Health. 1989;79:166l-7.13. Francis DP, Anderson RE, Gorman ME, et al. Targeting AIDSprevention and treatment toward HIV-1-infected persons. The con-cept of early intervention. JAMA. 1989:262:2572-6.© 1990 American College of Physicians1 April 1990 • Annals of Internal Medicine • Volume 112 • Number 7 483

Sexually Transmitted Disease: Shadow on the Land Revisited

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Sexually Transmitted Disease: Shadow on the Land Revisited

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