Syphilis Snafu

Patricia Nell Warren’s Left Field

After 9/11, public health supposedly became a national-security concern. But there’s been an ominous syphilis snafu, dating back to 1993, that involves government, corporations, and medical professionals. It’s not a shining example of swift response in wartime.

Syphilis is deemed an important co-factor in AIDS, and can be fatal if untreated. In 1998, federal health authorities became aware that some STD clinics were confusing two popular penicillin drugs from the same manufacturer. Bicillin L-A and Bicillin C-R both contain the same amount of benzathine penicillin G. The packaging, brand name, and list price of both were similar. But the two drugs are formulated differently. C-R delivers higher levels of penicillin quickly, creating a knock-out punch that is effective against streptococcal and other bacterial infections. On the other hand, L-A acts over a longer period, and has been the CDC’s recommended treatment for syphilis since 1993. According to an experienced healthcare practitioner whom I interviewed, the longer half-life of L-A is needed to completely destroy the slowly reproducing syphilis organism, Treponema pallidum, in a person’s body.

C-R’s package literature always stated clearly that the shorter-acting drug should not be used to treat syphilis. But some doctors, nurses, and pharmacists evidently weren’t bothering to read the instructions. Plus a belief that “syphilis was almost eradicated in America” may have contributed to carelessness and poor education. My practitioner informant remarked: “I think most physicians would not even know the difference between the two drugs, though they should.”

In 1998, the CDC learned that, over several months, two Maryland clinics had treated seventy-three syphilis patients with C-R. The agency’s Morbidity and Mortality Weekly Report saw fit to warn the nation, saying: “Findings of this investigation indicate that inadvertent Bicillin C-R use is more frequent than previously known and that preventive measures should be taken to minimize such use.” By 1999, the CDC had discovered nine more programs whose “inadvertent” C-R misuse dated back to 1993. The CDC’s MMWR admitted that the programs “might have failed to report such use because of concerns over liability or performance evaluation.” Its investigation revealed that many clinical staff are shockingly unfamiliar with syphilis treatment protocols.

By 1999, a flurry of stories in the Journal of the American Medical Association and other publications echoed the warning through the medical world. In April 2002, the FDA announced that the problematical packaging was being changed. But these announcements went unheard at the Los Angeles Gay & Lesbian Center’s clinic, where at least 300 syphilis cases were treated with C-R between 1999 and 2004. In spring 2004, when this latest snafu was uncovered, there was another media flurry. As other clinics had done, LAGLC tried to get clients back for proper treatment. Unfortunately, some had been homeless or transient, and can’t be contacted now.

Meanwhile, during the years when these “inadvertencies” were happening, the nation was seeing alarmist press releases from the CDC and local health departments that “syphilis is on the rise across the country.” By 2001, Los Angeles County health authorities were reporting an “outbreak” among local gay men—187 new syphilis cases, up from eighty-eight in 1999. With several hundred “inadvertencies” at LAGLC, why is anybody surprised?

The health establishment insists that they don’t know if under-treatment with C-R had “harmful effects.” Said the L.A. County DHS: “There are no scientific data on whether Bicillin C-R is adequate treatment for syphilis.” But my doctor interviewee tells me: “All the good studies demonstrate that sustained blood levels of penicillin over a course of three weeks is more important than the initial high peak serum concentration achieved with Bicillin C-R.” To put it another way, a person treated with the weaker half-dose may still harbor live treponemes. Worse, he or she may evolve a drug-resistant strain of syphilis—the organism’s natural response to inadequate treatment.

Since it was clear from the beginning that clinics and pharmacists were confused by the Bicillin packaging, why didn’t the FDA have the manufacturer alter the packaging back in 1998, when problems first surfaced? Why did Washington seemingly let hundreds of Americans possibly be put at risk by sex partners whose syphilis had been improperly treated?

Most important question: Why should we have to look to government to regulate the practice of medicine? My doctor informant adds: “The real failure here is an uninformed medical community with a dismal record in the area of medical control and medical quality.”

Patricia Nell Warren, author of fiction bestsellers like The Front Runner, also writes provocative commentary. Her writings are archived at www.patricianellwarren.com. Reach her by

e-mail at patriciawarren@aol.com.

July 2004