December 11, 2008 News » Cover Story


Health professionals await a spike in STDs as county kills once-proud program

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Call him Don Juan. With a disease.

Over 14 months in the early 1990s, one Colorado Springs teenager shared his love and infection with about a dozen young ladies who spoke to local health officials after they developed gonorrhea.

John Potterat, who headed El Paso County's program to fight this and other STDs for nearly three decades, describes the youth's activities in the wry terms of a public health professional.

"He was very successful in the sexual marketplace," Potterat says.

Don Juan also was elusive. A team of health department investigators searched fruitlessly for a home address or a regular haunt before getting a tip one morning saying he would be playing basketball at a court in southeast Colorado Springs.

One investigator dropped everything and drove to the court, where he found this 19-year-old scourge of women and convinced him to come back to the health department. Though the teenager had no symptoms, he tested positive for gonorrhea, which can cause infertility in women and complications in childbirth, and he was treated with antibiotics.

Potterat doesn't downplay the Tom Clancy aspects of the 14-month search.

"He was the most wanted," Potterat explains. "We had our ears and our radar tuned for any sort of cue."

The STD program Potterat shaped became a model for health departments across the country, with accounts of local successes appearing in major medical journals. And even though Potterat retired in 2001, and the health department began a budget-whittling process that would continue for years, the department kept many eyes focused on the local STD scene.

Until now. On Jan. 1, the county will lay off the 11 people now tracking these diseases and hand their responsibilities to the state health department. The state already performs this task in Colorado's other counties, but Dr. Ned Calonge, chief medical officer for the Colorado Department of Public Health and Environment, does not suggest it can replace El Paso County's program.

click to enlarge Once upon a time, John Potterat and Co. fought STDs in the field. - ANTHONY LANE
  • Anthony Lane
  • Once upon a time, John Potterat and Co. fought STDs in the field.

"We're hoping to replace exceptional with good enough," he says.

Physicians who treat STDs and see their effects on women's reproductive systems are worried. Dr. David Ross, a board member of the El Paso County Medical Society, routinely sees STD cases while working shifts at Penrose Hospital's emergency room. He expects to see more when the local surveillance program goes away.

Peak Vista Community Health Centers released a statement saying that, following the cuts, "we expect the number of STD cases to increase across all socioeconomic strata residing in our community, placing further strain on remaining health care service providers in El Paso County."

A November news release from the health department also projects a "greater spread of STDs." Granted anonymity, one health department employee goes into further detail, explaining how overburdened the system is and how men, often the carriers of STDs, have few options for getting tested or treated.

The employee's thoughts on the number of local STD cases?

"It's definitely going to skyrocket."

'Shoe leather'

A recipe for spreading STDs starts with people whose sexual relations involve multiple partners.

Throw in some hormones and a touch of promiscuity, hold the condoms and, voila, the bacteria that thrive in people's nether-regions go wild. (HIV, a virus, looks for similar opportunities, hoping for a break in the skin so it can take up residence in a new host's bloodstream.)

The Pikes Peak region, with a history of lonely miners, growing military bases and multiple institutions of higher learning, has long had STD-friendly conditions. In response, El Paso County leaders established a local STD program in the late 1960s. Potterat took over in 1972.

By tracing sexual contacts in gonorrhea cases and seeing that the patients received treatment, Potterat and his team quickly helped reduce the disease known as "the clap" by between 25 and 33 percent. By 1999, the city saw a 90 percent drop in gonorrhea infections among its prostitutes. Chlamydia, another bacterial STD, was only identified in the late 1980s, but Potterat's group documented a similar decline in that disease.

The infection rate for HIV peaked in 1986 at 44 per 100,000 residents before shrinking to 7 per 100,000 in 1999.

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"We simply had, until '98, the best STD department in the country, possibly the world," says Dr. John Muth, who retired in 1996 after 16 years as the county's public health administrator.

With Muth and other colleagues, Potterat published dozens of papers about controlling the spread of STDs and mapping disease networks. He and his surveillance team practiced what he calls "shoe leather" epidemiology: They knew the city's prostitutes, tracked down the players and won the trust of the local gay community by spending time at popular nightclubs and bars.

They got to know the patients who regularly contracted STDs, and made connections in the military. To control the spread of HIV and other diseases, they handed out condoms at the health department office and at bars and events around the city.

The first troubles

A tumultuous period followed Muth's retirement from the health department. Between 1997 and 2002, the county board of health hired and fired two health administrators, Dr. Steven Englender and Dr. Tisha Dowe. When Potterat left, he cited disagreements with Dowe.

In 2001, the year Potterat left, county commissioners had allocated $5.1 million to the health department. That money, then as now, covers basic services such as restaurant inspections, disease investigations and the STD program.

But budget pressure, traced to the tax limitations of the TABOR amendment and the ethos of conservative county leaders, was beginning to build, as was the sentiment among some that the health department was doing too much. In early 2002, Commissioner Tom Huffman accused the department of practicing "socialized medicine."

That year, the department saw a $200,000 reduction. Over the next six years, county commissioners sliced off another $1.6 million. The department cut prenatal care for expectant mothers, closed its methadone clinic and eliminated more than a dozen other programs and services.

In 2009, county funding for the health department is expected to drop another $500,000, to $2.8 million. (The health department's total budget for 2009 is actually around $15 million, with a small slice coming from the state and most of the rest coming from federal and private grants. Most of that money must be used to fund specific services such as the federal Women, Infants and Children, or WIC, program for low-income families.)

As funding has shrunk, local cases of chlamydia and gonorrhea have increased. In 2003, chlamydia was reported at a rate of 354 cases per 100,000 residents; that jumped to 475 by 2006 before dropping slightly in 2007 to 444. (The national average rate of chlamydia infections in 2006 was 348 per 100,000.)

El Paso County's gonorrhea rate per 100,000 residents went from 65 to 96 over the same period, with a 2006 peak of 124.

Kandi Buckland, the health department's acting administrator, says the increases might have stemmed from personnel cuts within the STD surveillance and investigation program several years ago. But the program had escaped major changes until this year.

click to enlarge Kandi Buckland has dealt with big cuts to the departments budget. - BRIENNE BOORTZ
  • Brienne Boortz
  • Kandi Buckland has dealt with big cuts to the departments budget.

An ominous sign came in late spring, when the offices of workers in STD surveillance and investigation were moved away from the STD clinic. Condoms, once handed out freely, were only handed out to those with appointments at the clinic.

The announcement that the surveillance and investigation program would be eliminated entirely came in late November.

Potterat marvels at the cutbacks. He calls the decision not to make condoms easily available "public health malpractice," and notes that the health department is keeping a staff of three communications people to drive what he calls a "propaganda machine."

Buckland defends both decisions. By only giving out condoms to those who come in for appointments in the STD clinic, she suggests, employees can also give advice about how to stay safe. She says she is not in favor of returning to the days when a basket of condoms was available to anyone arriving at the STD clinic.

"I don't see that as a public health priority," she says.

And the health department's communications department, she says, plays a vital role by working with the media and reaching out to educate the public.

Potterat's not satisfied. One challenge fighting STDs has always been countering what he calls the "Old Testament mentality" that people who get these diseases deserve them. Potterat says people need to realize that STDs can affect anyone's friend or family member.

"By not controlling these diseases, you're literally playing Russian roulette with your daughter's reproductive potential," Potterat says. "If you don't control these diseases, we all suffer."

Lots of empty offices

It's solemn inside the building at 301 S. Union Blvd.

Tammy Maldonado-Long, the health department's STD surveillance coordinator, occupies a basement office in a section of the health department building that used to house drug and alcohol education and prevention programs. She and the STD investigation and surveillance staff moved in after the other program was cut last year. Many nearby offices appear empty.

Even flowers from a recent birthday celebration aren't cheering the 39-year-old. Maldonado-Long's position and those of 10 co-workers will disappear next month. The elimination of their program will save the county $613,000.

After 18 years in the department, Maldonado-Long seems almost mournful as she ponders what's next.

"I've enjoyed helping people," she says quietly.

Maldonado-Long sits next to Buckland at a brief meeting with the Independent to talk about the cuts and what they mean to the community.

Buckland recounts the history of budget cuts, and explains that the department has kept many core programs running by spending reserve funds. That's not an option anymore, she says.

As she looks toward the state investigating STD cases the details of which are still unclear Buckland predicts that new HIV cases will command attention, but gonorrhea and chlamydia probably won't. Still, she won't predict what that will mean for the community.

click to enlarge Dr. Paul Magarelli has seen past cases of chlamydia haunt female patients. - ANTHONY LANE
  • Anthony Lane
  • Dr. Paul Magarelli has seen past cases of chlamydia haunt female patients.

"We don't have a crystal ball," she says.

The upward trend for chlamydia and gonorrhea seems to be continuing. Though El Paso County's 2008 numbers won't be finalized until well into next year, Maldonado-Long says she hasn't seen the numbers drop off.

"I think it's probably on the same pace as it was in 2007," she says.

'Silent sterilizer'

Fallopian tubes, which are the pathways for eggs to travel into a woman's uterus, should look like pencil-thin lines in an X-ray. When healthy, these tubes are lined with microscopic cilia that usher eggs on their way.

In pictures taken using specialized cameras, the inside of a Fallopian tube should look like the "beautiful lawn that you see on a golf course," says Dr. Paul Magarelli, a Colorado Springs fertility specialist.

Images from inside tubes damaged by chlamydia and gonorrhea evoke less pastoral descriptions.

"It looks blotchy," Magarelli says, expanding on his "beautiful lawn" analogy: It can look like a "lot next to a tenement house where there's patches sometimes you see green, sometimes you see weeds, sometimes there's nothing but dirt."

X-rays for women with a history of these infections can immediately show a Fallopian tube is damaged.

"It really looks like a sausage," Magarelli says, with the tube's swelling resulting from blockages and accumulated fluid.

Chlamydia is sometimes called a "silent sterilizer," since it often produces few, if any, symptoms that would prompt a woman to seek treatment, but leaves behind real destruction. Magarelli guesses that 60 percent of women with a history of chlamydia have damaged Fallopian tubes. Blockages and damaged cilia can stop the passage of eggs entirely, resulting in infertility, or stall a fertilized egg, resulting in an ectopic pregnancy, a dangerous condition in which the fertilized egg implants outside the uterus, cannot survive and must be removed via drug injections or surgery.

Tubal problems account for perhaps a quarter of the difficulties bringing couples into Magarelli's office. Many result from past STD infections, he says, and the best solution for those intent on having a baby is often in vitro fertilization, or IVF, where eggs are harvested from the woman and fertilized in a Petri dish. A fertilized egg is then implanted back in the woman's uterus.

The price tag for IVF averages somewhere around $13,000 to $15,000. It's not generally covered by health insurance, but it's considered the best solution to overcome a tubal problem; Magarelli says repairing the Fallopian tubes is now considered expensive and ineffective.

As one might expect or hope from a doctor focusing on fertility problems, Magarelli is warm and sympathetic. He doesn't moralize about STDs, instead suggesting they're often a sign that people are in love.

Of course, love becomes safer when people use condoms. And STDs can often be controlled when they are detected. But that'll happen less without local health workers searching for disease-carriers' sex partners and taking community-level looks at the problem.

Many doctors, particularly those specializing in obstetrics and gynecology, are concerned.

"I think they are making a huge mistake," says Dr. Dick Brusenham, a retired obstetrician/gynecologist, "particularly in a community that has such a big military presence."

Ross, the Penrose ER physician and El Paso County Medical Society board member, says the shift away from funding local public health services makes little sense. He suggests they are relatively cheap and provide a huge benefit.

Without El Paso County's STD surveillance and investigation program, Ross expects more patients with STDs. They'll get treated, he says, but hospitals and clinics will get busier. Ross says he and other physicians already have full plates, and he can't see who will take on the role of the health department.

"We don't have time for that," he says.

Calonge, the state's chief medical officer, is blunt when asked if state health officers will be shifted to El Paso County.

"No," he says. "There are no additional state resources for this activity."


STDs 101

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Condom minimum

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