January 22-28, 2004

cover story

But I Didn't Know…

Photo By: Michael T. Regan

One in 12 Philly teenage girls has chlamydia. Now the city is waging war against what it is calling an epidemic.

by Amy L. Webb

Alisha took a few extra minutes that night to sweep her thick brown hair into a ponytail. Standing in her family's bathroom, she wiggled her hips while Eve crooned "Irresistible Chick" from the stereo. Alisha was going to a friend's party, and the boy she liked was supposed to be there. Tonight calls for extra-shiny lips and some sparkly eye shadow, she thought.

At the party, Alisha sat on a couch with a handful of her girlfriends complaining about their English class and about how 16-year-olds have more important things to do than write some stupid paper about a book that makes no sense. Then she saw him. He walked over to her and squeezed in beside her on the couch. They talked and she giggled. He helped her get up. Got her coat. Walked outside. Kissed her when they neared his house. Moved up the stairs and into his room. Took off her pants. Slid his to the ground.

Alisha wasn't afraid. The first time she had sex was two years ago -- she was 14 then. She knew that at first it would sting, but then it would feel warm and good. She knew that afterwards he would smile at her. That she could call him tomorrow and they could be together again. But he didn’t seem interested in her the following day at school. The very next week, Alisha saw him walking around with another girl. A senior, she thought. Alisha didn’t know her name.

A few months later, the Philadelphia Department of Public Health came to Strawberry Mansion High School, where Alisha was a sophomore, to administer the little-known citywide chlamydia and gonorrhea screening program. Alisha sat with her classmates and listened to a presentation about how infection rates in Philadelphia have skyrocketed, and that now, about one in 12 girls her age was infected. That it only takes the slightest bit of contact. That it happens to someone every day.

Then her mind wandered back to that night, after the party -- to the kiss, to the condom in her purse, still in its wrapper. To the plastic cup she was now holding in her hand. Her eyes widened. "But I didn’t know," she thought. "What if it’s inside me?"

Public health experts say that Philadelphia is in the midst of a chlamydia epidemic, with infection rates growing disproportionately to other big cities. The Center for Disease Control reports Philadelphia as having the fourth highest rate in the country, behind Detroit, St. Louis and Richmond, Va. But the city’s own health department says that due to a data error, Philadelphia should actually rank second or third on the list. The majority of cases are concentrated in five zip codes around West and North Philly: 19140, 19132, 19121, 19139 and 19143. And the infection rate is increasing every year -- in the 19121 zip code alone, the number of cases spiked from 740 in 2001 to 825 in 2002.

What makes chlamydia so problematic -- and the reason it continues to spread -- is that no symptoms occur until it’s too late. Meantime, teens continue to have unprotected sex. Condoms are expensive. Educators aren’t talking frankly about sexually transmitted diseases. Now in Philadelphia, the demographic with the highest percentage of chlamydia cases is 15- to 19-year-old minority girls.

"The numbers in Philadelphia are extreme," says Dr. David Fisman, assistant biostatistics and epidemiology professor at the Drexel University School of Public Health. "There’s a lot of chlamydia here. Too many young girls are getting sick."

But maybe not for long. The Philadelphia Department of Public Health and the School District are taking unprecedented steps -- this is the first annual school-system-wide STD screening program in the nation -- to test the city’s teenagers. So far, more than 1,000 of those infected have received treatment. "The city acknowledges that it has a public health crisis and it’s working really hard to help treat it," Fisman says. "They’ve made an outstanding effort. But while they’ve figured out how to test and treat young people, the real question is whether or not they’ll be able to prevent reinfection or the possibility that more people will continue to get infected."

Chlamydia is not like other STDs -- it can be carried in the genital tract for six months or more without causing any symptoms. Nearly 75 percent of women and 50 percent of men who have chlamydia don't know they're infected. On the other hand, when Philadelphia had an outbreak of syphilis in the early 1990s, the health department knew immediately -- it's hard to ignore ulcers around genitals or an all-out rash and fever. Without symptoms, people are less likely to seek testing and treatment.

It was originally thought that chlamydia was a virus because it needs to anchor itself in a living cell in order to replicate. But scientists later discovered that, like gonorrhea (also called "the clap"), chlamydia is actually a bacteria, shaped like an irregular sphere. The cells need contact with a mucus membrane in order to transfer, and one of the most inviting spots for chlamydia to thrive is outside a woman's cervix.

Once chlamydia finds cells, it begins to attack. The bacteria breaks down healthy cells and multiplies, while the remaining cells are left to try and fight. But it's hard to mediate what, to the naked eye, is an invisible war happening inside the body.

Without treatment, the cells, which should be staving off other infections, are helpless against more aggressive viruses and bacteria. The immune system starts to falter. Suddenly there is pain below the belly -- chronic pain that lasts for days. Over-the-counter drugs no longer work, and it seems as if the stomach is starting to swell a little. Then the bleeding starts -- not much, not like during the height of a menstrual cycle. But enough to cause concern. Doctors call it pelvic inflammatory disease, and it's the most common side effect of untreated chlamydia. PID is like having an abscess in the womb: The upper genital tract swells because cells start to slough off and invade others.

Chlamydia also causes scarring in the fallopian tubes, which can cause an egg to get lodged in place as it slides down to the uterus. If an egg, stuck in the scarring, becomes fertilized, the pregnancy begins in the tube rather than the womb. This is known as an ectopic pregnancy, an extremely painful, life-threatening condition. Left to multiply, chlamydia will just continue to hit other cells and cause scarring everywhere in its path. At some point, all that destruction renders the body infertile.

Men are less likely to develop severe symptoms, but for some, swollen testicles can result and eventually lead to infertility.

With a weakened immune system, other STDs can more easily infiltrate the body. "If you're chlamydia-infected and have sex with an HIV-positive partner, you're much more likely to get infected with HIV," Fisman says. "The immune cells that are fighting chlamydia are just sitting there waiting to be infected."

No one is sure when the disease began to really spread in Philadelphia, but it’s clear why so many teenage girls became infected so quickly. Because their bodies are still in development, young women are particularly vulnerable. "In mature women, certain cells are inside the cervix," says Carol Rogers, who is a physician’s assistant with the Philadelphia Department of Public Health. "But in young girls, those cells are outside. Physiologically, young women’s bodies are ideal for chlamydia to take hold, and they are at a very high risk."

In 1995, the health department recorded 7,946 cases of chlamydia for all ages throughout the city. That number doubled to 14,605 by 2002 and the case rate for 15- to 19-year-old girls was 8,251.8 per 100,000. (In order for data to be compared between cities of varying sizes, rates are scaled to the number of cases per 100,000 people.) The number of cases has increased so dramatically in part because of better test kits being used now, which yield more reliable results. At the same time, public health experts actually think that far more people are infected than the data is showing. "Kids are having sex with multiple partners," says Mary Banecker, vice president of administration for Planned Parenthood of Southeastern Pennsylvania. "Teens take a lot of risks. They get in cars and don't use seat belts. They drink alcohol. And obviously they're having unprotected sex. We have extremely high numbers of teen abortions, STDs and pregnancy."

Across the country, the average age for a first sexual experience is dropping -- and condom use seems to be less and less popular. The U.S. now has the highest rate of teen pregnancy in the developed world -- that's two times higher than England, three times higher than Australia and eight times higher than the Netherlands. Every year, one million teens, or 11 percent of all 15- to 19-year-olds get pregnant, according to Planned Parenthood. And it's a hell of a lot easier to get an STD than it is to conceive.

When someone tests positive for chlamydia, a federal law requires that she or he is reported to the local health department. That data then gets reported to the state and ultimately the CDC. When the health department hands over information, it lists demographic data in addition to age and sex. In the 2002 data, the majority of the reported 15- to 19-year-old girls were classified as "black" or "other" and are living in the city's poorest neighborhoods.

"Minority populations may be at higher risk for contracting chlamydia and other STDs," says Michael D. Smith, assistant professor of psychology specializing in HIV and STD counseling at Susquehanna University. "Minorities in general are less likely to have preventive health care options because of economic or access problems. They seek out physicians less frequently, tending to only go to the doctor when something is apparently wrong. [Minorities] are detected less often, treated less often and therefore there are more opportunities to spread an infection like chlamydia" to people in their peer groups.

To be sure, anyone who has sex without protection is at risk, regardless of age, race or economic position. The 2002 data shows that 5,319.5 women age 20 to 24 and 2,307.2 men per 100,000 in the same group tested positive. So did 72.1 women and 107 men per 100,000 age 45 to 54.

But Banecker says that the heart of the problem has to do less with demographics and more with education and the guidance teens get in high school. "There is no excuse not to offer students access to family-planning education," she says. "I'm not just talking about high schools. Beginning in kindergarten, kids should be taught how to make decisions. They should be taught anatomy. Schools should offer STD tests and treatment, pregnancy tests, birth control and access to doctors. If we would treat STDs as a public health problem rather than an issue of morality, then we'd be able to stop the spread of disease."

Philadelphia does have 10 family planning centers located in public high schools, which give students options for health care, condoms and counseling about sex. This year, the School District is in the process of developing a new, standardized family health cirriculum that will be woven in with science classes. On the other hand, schools in Europe already require mandatory sex education, which include medically accurate information about the body and ideas on how to make responsible choices. Students are also given access to contraception.

But if schools aren't doing the best job of educating teens about sex, some argue that the onus is on parents to be honest and open with their children about STDs, contraception and making good decisions. "Many parents refuse to believe that their teenagers are having sex," Rogers says. "That's a fundamental mistake, because it supposes that their kids are totally immune to STDs. Parents need an excuse, they need to feel like they have permission to talk to their children."

The summer of 2001 was unusually hot and muggy. While families piled into their cars and headed down to the Jersey Shore, a handful of health department workers braved the heat in their offices downtown, surrounded by stacks of tattered, yellowing papers, heavy STD manuals and data tables. They had been researching the spread of chlamydia and other STDs for years, trying to get ahead of the problem. But they needed research. More numbers. A bigger sample.

"Our group knew that it was affecting young girls, and we knew that teenagers were having unprotected sex," says Martin Goldberg, STD Control Program manager. "We'd been trying for years to get into the schools to do screenings, but we were always told no. The only way to get people to listen to us was to collect as much data as we could and prove it to them."

It's not easy to track down an unruly bacteria, test it, then treat it and hopefully stave off a public health crisis. Until very the late 1990s, the usual way to screen for chlamydia involved a very painful exam. For women, the doctor would insert a speculum into the vagina and lock it open in order to take a tiny scraping of cells off the cervix. For men, the process was even more invasive -- to get the cells, a doctor would insert a swab through the head of the penis and into the urethra. Then the doctor would carefully wrap the swab and send it off to a lab, where technicians would try to grow the organism. It was hard to determine whether or not the test was positive, because at the time it was hard to find the chlamydia in the sample.

Today, all that's required of the patient is a small cup of urine. Labs are now using very sensitive tests to check for infection, and the process is less costly and time-consuming. Goldberg wanted to take that test to the city's rec centers and pools, where kids would be cooling their heels.

He sent teams of young health department staff members out with clipboards and Gatorade to recruit teens for screening. The staff filled out a form with demographic information and sent kids off to the bathroom with plastic cups. They were given a card and a number to call a week later for results.

The department went out 112 times that summer, eventually testing 547 boys and 91 girls. "The positivity rates were extremely high, just in that sample," Goldberg says. "We found 37 males and 41 females that were positive. Wherever we were going to test young people, we found substantial positivity rates. But we weren't reaching enough kids to have an impact on the public health crisis."

Goldberg's team took the data -- and supporting evidence from the CDC showing that the average age of first-time sex was dropping annually -- to the health department commissioner. Then the commissioner met with Philadelphia School District CEO Paul Vallas. "Our commissioner had to convince Vallas that this was a public health emergency," Goldberg says. "It took time to bring everyone on board."

Chlamydia at work: Chlamydial organisms found during a cervical smear exam. Slides courtesy of C. Solomides, M.D., Temple University School of Medicine.

One problem was logistics: How would Goldberg's team test all of the city's 54,000 public high-school students at their schools without disrupting class time? What happened if parents protested? Then concerns about privacy: Schools doubted the health department's ability to guarantee that testing would be anonymous and without stigma. And what of the treatment? What happened if in fact there was a high number of infected students? How would the health department treat them? Where would the money come from? Would it be legal?

"The health commissioner presented me with data, and to put it lightly, I was alarmed," Vallas says. "The law is very clear about when information is confidential and when it's not, and we wanted to lean on the law. I felt clearly that we had to ensure confidentiality, but that we needed to test students."

Vallas and the health commissioner drafted a letter about the screening and sent it to 30,000 parents. "I got two complaints about the letter," Vallas says. "The letter and testing served as a wake-up call to students and parents."

With Vallas behind the screening program, Goldberg and his colleagues developed a way to get kids educated, tested and treated -- and it would become the first high-school screening program of its kind in the nation.

A handful of staff members would visit a school. Sixty students at a time would be released from one class period and gather as a group for a short presentation, where health department staff would explain how chlamydia is contracted and how it devastates the body. They'd advocate for abstinence, but also acknowledge that 60 percent of students are sexually active. So they'd talk frankly about the importance of condoms and how to have safe sex.

Then staff would pass around brown paper bags that had been rolled up and taped closed. Students would open the bags and find clear plastic cups with labels and yellow lids, white forms and green cards with a phone number. They would fill out the forms, writing down their names, addresses, phone numbers, birthdays, race, sex, grade and school. One blank would also ask for a secret code, which would be the only way to identify the sample. Students would be told that the test was voluntary -- that everyone had the exact same paper bag, that the group would be led into the school's bathrooms, and students had to decide for themselves whether or not to fill the cup with a urine sample. Everyone would put their forms and cups back in the brown bags, tape them closed and hand them to a staff member on their way out of the bathroom.

The green cards would have a phone number, saying to call between 9 a.m. and 4:30 p.m. and to "ask for Zelda." Staff would tell the students to keep the cards in a private place, like their wallets or backpacks, and to remember their secret codes. Later, when students would call in for results, they'd have to give their secret codes along with their date of birth and name -- to prevent someone else from breaching their privacy.

At first there was backlash -- plans were already being made to go into the first high school and rumors leaked about the program. "We found out via the grapevine," says Home and School Council President Patricia Raymond. "Parents were furious. They threatened to close down the school. We were very concerned, especially when we found out that the health department didn't need our permission or parental consent to test and treat our kids."

Health department staff met with the Home and School Council and held meetings to explain why the testing was necessary and how they could guarantee privacy. "Ultimately, they did such a good job during those presentations that parents from the middle schools were begging them to come in and test their kids."

During the 2002-2003 school year, the health department went to 53 of the city's 54 public high schools and presented to about 30,000 out of a possible 54,000 students. The one school left out was a primarily special-education school, and the department felt that those students did not have the capacity to decide for themselves whether or not to take the test.

"It wasn't good that we weren't a part of the decision-making process initially," says Raymond, who is also a parent. "But the bottom line is that we got so many students tested and treated. The feedback has been positive, and I'm proud of the screening program and the health department's efforts." She says that as a parent, it is comforting to know that children have a means to get screened.

"We would have liked to reach more kids, but the other 24,000 were out because they cut class, or because there was a snowstorm, or because there was a class conflict," says Melinda Salmon, STD Control Program assistant manager. "This was the first time we've ever had a school do something like this."

The health department collected 19,713 samples, or about 60 percent, and found that 1,052 were infected. "That's an 8 percent rate, which is very high," Salmon says. "We had rates as high as 25 percent in some high schools. The rate should be zero."

Goldberg is restricted by a confidentiality agreement he made with the School District from divulging any data on specific high schools. But students are willing to talk about their experiences. "I was really happy that the health department came here," says Monica, a junior at Strawberry Mansion High School. Her twin sister, Marie, nods in agreement. "We're both sexually active, so it was good to have the option of taking a test. And it was convenient for a lot of the students here who wouldn't maybe go to a clinic to get the test on their own. All we had to do was to call up to get the results. And they said that if anyone was positive, the treatment would be free."

Neither of the girls tested positive, but if they had, the nurse would have sent a note for them to come to the office on an undisclosed date. Under Vallas, Philadelphia students have unprecedented access to various health screenings -- so students are called out of class regularly. In order to guarantee privacy and prevent stigmatizing students, the health department decided not to announce when it would be back to administer treatment, only that at some point positive students would be contacted.

Treatment consists of a single dose of azithromycin, which is a powerful antibiotic in tablet form. "Medical providers, not the school nurse, administer the medication," says Salmon. "Since it's a one-dose treatment, kids don't have to take anything home with them, they don't have to remember to take a medication every day. It's extremely effective."

And it's at no expense to the student. So far, azithromycin dosages have been donated by New York-based pharmaceutical company Pfizer. "They're donating it so far, knock on wood," says Salmon. "The treatment otherwise is very expensive."

According to a 1971 Pennsylvania state law, medical providers working with the health department can administer treatment -- along with tests for STDs and pregnancy -- without parental consent.

While kids are getting tested and treated, reinfection rates have been as high as 30 percent, meaning that the message isn't getting through to everyone. "It's hard to decide sometimes whether or not to use a condom," says Travis, a senior at Simon Gratz High School. "Some people think its uncool if you use one like you're weak or something. I don't really know anyone who got pregnant or got some disease, so I'm not really worried, I guess."

"Unfortunately, we don't know what happened," says Salmon. "We don't know if the kids started out using condoms and then stopped. We don't know if they just never used them or if they had multiple partners at an earlier age. Kids think that they've never had sex if they only had it once, or if they just did half-penetration for a couple of seconds or if they had oral sex once. So many girls gave us the same story -- it was just that one time, he was only in me for a few seconds."

Standing in the shadows of the giant concrete pillars at Strawberry Mansion High School, a group of boys are hanging out, talking about the weekend. Alisha is standing opposite them in yellow corduroys and a heavy powder-blue coat, waiting for the first bell. It’s been almost a year since the night of the party and the health department’s presentation.

"I remember standing in the bathroom, trying to decide what to do," she says. "I gave them a sample that day. I took the test. Then I had to make the phone call. It turns out that I was positive."

Alisha hadn't been with any other boys since that night, but the health department wanted to make sure that he knew, so that he could get tested and treated. They asked for his name, and after a few seconds, she said it aloud.

When Alisha hung up the phone, her jaw relaxed and she exhaled a long, slow breath. "I knew that I'd be OK," she says. "And as scared as I felt, I knew that I wouldn't make the same mistake next time."