New STD chief faces rising rates in SF
by Matthew S. Bajko
The city's new STD chief, Dr. Susan Philip, finds herself tasked with eradicating sexually transmitted diseases as San Francisco once again experiences a spike in rates of both syphilis and Chlamydia.
Through September of this year, syphilis cases alone have increased 22 percent compared to the first nine months of 2009. The majority of the cases, 90 percent, remain among men who have sex with men, more than a third of whom have been previously diagnosed with syphilis.
At the same time, Philip has fewer resources to do her job as governments at every level grapple with budget deficits. Her funding from the Centers for Disease Control and Prevention has been cut 25 percent since 2007 and her section lost nearly eight full-time employees since 2009. Her staff now totals 65 people and a budget of $6.1 million for 2010.
She has turned to using social media and mobile technology to better reach gay, bisexual, and transgender men. This month her section premiered a free downloadable application for iPhones and other hand-held devices called STD411 that allows users to check their risk for STDs based on their sexual activities.
Her philosophy toward the job remains the same as her predecessor, said Philip, which is to focus on and promote sexual health.
"I am not, and my section is not, in the business to tell people what kind of sex to have. We don't see ourselves as the sex police," said Philip. "We want to give people the best information to take care of their health and their partners' health. That is our focus."
Outgoing Health Director Dr. Mitch Katz named Philip a deputy health officer and director of the health department's STD Prevention and Control Services as of July 1. She had been the acting director of the section since July 2009, when Dr. Jeffrey Klausner took a leave of absence to conduct a research study in Africa. Her salary of $196,924 was cut 5 percent this year and next due to budget cuts.
During his more than a decade overseeing the city's STD control programs, Klausner built up a national reputation for his oftentimes aggressive and controversial stances. He battled with everyone from local gay men upset with his policies and owners of Internet hookup sites he accused of not doing enough to combat the spread of STDs to drug companies that make erectile dysfunction drugs, which he wanted to reclassify as illegal substances.
The media savvy Klausner was also an innovator and early adopter of using online tools to help combat the spread of STD. He fought to have his staff be given access on hookup sites where they could answer questions about STDs and promoted an online site where people could download a slip for free screening for STDs and HIV. [It failed to attract many users and was shut down last year due to budget cuts.]
Klausner resigned earlier this year when he opted to extend his stay in Africa. He is currently the chief of the HIV Care and Treatment Branch for the CDC's Global AIDS Program in South Africa.
Since 2005 Philip has been the medical director of the health department's City Clinic and had reported to Klausner. She hopes to announce her replacement in mid-December but plans to continue treating HIV patients at the clinic half a day each week.
Incoming Health Director Barbara Garcia said she has no plans to replace Philip as the city's STD chief.
"Dr. Philip will continue as the director of STD, before being appointed to this role she directed our city clinic where she has been an excellent administrator and clinician. She continues to be a strong STD director and works well with other important sections including HIV and TB," wrote Garcia in an e-mailed response.
Philip, 38, is a married straight woman who lives in San Francisco. She attended both the medical school at Washington University in St. Louis, Missouri and the Harvard School of Public Health. She also trained as an internal medicine resident at the University of Chicago and was a fellow in adult infectious diseases at UCSF.
She is an assistant clinical professor of medicine in the division of infectious diseases at UCSF and spends two weeks each year at San Francisco General Hospital as an attending doctor seeing patients with various infectious diseases.
She also serves on the executive committee of the California STD Controllers Association and on the board of the National Coalition of STD Directors. She had been serving on the San Francisco HIV Health Services Planning Council, also known as the CARE Council, but stepped down after being appointed the acting STD director.
Having spent the last five years treating gay men at the City Clinic and working alongside various community partners, Philip said she doesn't see her own sexual orientation or gender as impediments to doing her job. It was a criticism Klausner often received from his detractors, who questioned how a straight married man could set policies that impacted gay men.
"I can't change that about myself. What I can tell people is I have spent time in this area, in San Francisco, in STDs since 2005. Before I shaped policy I had time to sit back and learn from a lot of community people and advocates," said Philip. "My time on the CARE Council was very valuable."
Steve Gibson, the director of Magnet, the gay men's health clinic in the Castro, has worked with Philip since she joined the health department. His clinic is partially funded by the STD section and works collaboratively with City Clinic, and Gibson expects the relationship will continue under Philip.
"When she started as the medical director in 2005, we had a really great relationship with her, quite frankly," said Gibson. "She is very practical and results oriented."
He predicted Philip's top priority would be ensuring her section has the financial support it needs to combat STD rates.
"Funding, funding, funding," said Gibson. "The state's economy is getting worse. I think that is going to be her biggest challenge."
Her methods could also generate scrutiny again from federal lawmakers now that Republicans have regained control of the House. The switch in leadership could also bring with it more pressure to cut spending even further on STD services.
"I think it is a cause for some concern. We will have to watch closely and work with our partners who do advocacy for us," said Philip. "There are going to be challenges and will be people who would like to take this opportunity to try to decrease funding for services like STDs."
On the local front, Philip plans to hold public meetings to meet community members sometime in early 2011. Up until now she has not had the time to do so because of her being both the medical director at City Clinic and the STD chief.
She also has not made any major changes to the STD section over the last year and a half. She did make waves last year when she instituted limitations on asymptomatic straight men accessing STD tests at city clinics.
She justified the cost-saving move by pointing to data that shows few straight men in San Francisco test positive for STDs. The bulk of the city's STD cases are found in women or gay and bisexual men.
"In the current climate, we want to focus our resources on the populations that most need care," she told the SF Weekly at the time.
More of her imprint will likely be felt over the coming year as she is able to devote more time to focusing just on being the city's STD chief.
"The changes we have been making have been more gradual and somewhat in response to recognizing the high rates of STDs and in recognition budgets are smaller. We have had to consolidate and cross train staff but haven't made any large policy initiative changes yet," said Philip. "I feel the need to continue to evaluate what we are doing and strategically decide where we are going to move. Over the next year I expect to do more of that as I step back from my role at the clinic."
The most visible difference in the gay community since Philip came on board as STD chief has been a de-emphasis on the phallus and syphilis sore comic book characters in her section's "Healthy Penis" social marketing campaign. While the penis characters maintain Facebook pages, as does City Clinic itself, the campaign's focus has turned toward more text-heavy advertisements about STDs.
"We haven't abandoned the healthy penis. We are looking at this as more of a pivot," she said. "We are keeping the brand but really expanding on the knowledge we have in the section with staff and emphasize what we see as important areas."
Due to the budget situation, Philip said she doesn't plan to launch any new marketing campaigns anytime soon.
"I don't think we are planning for any large advertising campaign given the limited resources," she said. "We are excited about looking at ways technology and social media can help us with what we do."
Uptick in STD rates
For now Philip's main concern is the latest upswing the city has seen in STD rates. Along with syphilis, cases of gonorrhea and Chlamydia have been on the rise this year.
According to the latest data, the city reported 1,486 cases of gonorrhea during the first nine months of 2010. It is 112 more cases than during the same timeframe in 2009.
Should the trend continue it would mark a reversal from last year, when the STD section reported that the rate of gonorrhea had declined by 10 percent in 2009 compared to 2008. Between 2009 and 2005 the city's gonorrhea rate had dropped by 25 percent.
Cases of Chlamydia also climbed during the first nine months of 2010, jumping 432 cases over the 3,049 cases reported during the same timeframe in 2009. Between 2005 and 2009 the city's Chlamydia rate has increased 13 percent.
The city's syphilis rates continue to yo-yo after being relatively stable for several years. The number of reported cases of early syphilis in 2009 totaled 519, which marked an 8 percent decrease in the early syphilis rate from 2008.
But compared to the rates in 2005, there has been a 26 percent increase in the city's early syphilis rate.
During the first nine months of 2010, the city reported 543 total cases of syphilis, including both primary and secondary as well as early latent cases. That was a 71-case increase over the same period last year.
Philip said it is near impossible to determine what is causing the periods of declines and then upswings from year to year.
"It is hard to pinpoint a single reason why things decline. We would love to take credit and say we did that," she said. "At the same time, it is hard to give one reason why rates went up."
STD rates historically have been shown to fluctuate, she said, and outbreaks of various STDs tend to be cyclical in nature.
"There is usually a natural rise and fall to syphilis rates that occurs," she said. "This is not isolated to San Francisco. This is happening in other large cities in the United States, in Europe and Australia."
The current upswing locally could be partly due to the fact that with decreased funding her section has had to downgrade its presence, causing rates to spike upwards. Or it could be that more gay and bi men are seeking out STD screenings, she said.
So far there has been no indication that an increase in risky sexual practices is the cause, added Philip.
"It isn't any one particular thing we are doing or not doing or the community is doing. It is multiple factors," said Philip. "There is more demand so there are lots more tests that are happening, so people are getting picked up and treated. If that is the case, that is a good thing."
The best prescription Philip can provide remains the same message that Klausner had long urged men who have sex with men heed. Any sexually active gay or bi men should be tested for STDs at least twice a year.
"Getting screened every three to six months, as we continue to recommend, is really important," said Philip.