When a Yakima County hospital in rural Washington state couldn’t track down a patient who had tested positive for gonorrhea last month, they knew who to call. Lisa Baldoz, one of four sexually transmitted disease (STD) field investigators working for the state health department, followed up on every address and number she could find, checked every clinic, scoured every record and social media network. “No luck,” the 46-year-old says.
So Baldoz tried another trick of her trade: finding out whether anyone else went to that same ER around the same time and tested positive for gonorrhea. A woman had—and the man Baldoz had been looking for was listed on Facebook as the woman’s fiancé. After knocking on doors and interviewing acquaintances, Baldoz’s persistence finally paid off. More than a month after the case had started, she found the couple living in an RV behind a church with no electricity or running water and treated them both in her car, helping to contain an STD that is spreading at alarming rates in the Northwest.
Washington state is in the midst of a gonorrhea outbreak that officials fear could spread across the region. Cases are up 20% in Oregon and up more than 15% among men in California, as well as on the rise in northern Idaho. In Washington, Yakima County has seen a 75% increase in cases so far this year.
Officials are still investigating the cause. Some state health department employees suspect that the condition is being treated improperly or that a new strain is becoming resistant to certain types of medication. Others believe the central problem is behavioral, that people have become more complacent about STDs and condom usage now that the AIDS epidemic has subsided.
In Washington, any positive test for gonorrhea is reported to county health officials. When the patient can’t be found, officials tap employees like Baldoz. The investigators have two missions: finding the person to make sure that they’ve gotten treatment and convincing that person to share the names of their sexual partners. Men might walk around oblivious that they have gonorrhea, also know as “the clap,” because they don’t necessarily display any symptoms. But if the disease goes untreated in women, it can affect their ability to have children.
Washington state STD Controller Mark Aubin says the state’s notification program is critical to stemming any STD outbreak. “This is a burden that public health [takes on],” he says. To illustrate the importance, he gives an example of a recent case. “There was a young man who had 37 partners,” he says, “and if public health isn’t doing this, those 37 people could be exposing others.”
As the case of Baldoz’ missing man shows, tracking down a patient isn’t as simple as punching an address into a GPS. And even if Baldoz can walk right up to their door and flash her health department badge, she knows there may be a combative, awkward encounter awaiting her on the other side.
“When I started this job I thought, Who would talk about their sex life?” she says. It turns out that young people in their teens and 20s were much more willing. “They want to know,” she says. “That group is easy.” More difficult are older men in their 30s and 40s, especially ones who answer the door next to wives or who have stepped out of a heterosexual marriage to have sex with another man—a phenomenon Baldoz has been seeing more in recent years. “When I work with an individual, I have to relate to them,” she says. “They have to really understand that I’m there because I’m concerned about their health, that I don’t care about judging them.”
Baldoz, who worked with HIV patients in the 90s, counsels those who have tested positive about where to get treatment, and if they’re resistant to seeking care at a clinic, she can give them medicine in the field. Then she encourages them to tell their partners that they need to get tested—or to give her the names, so she can deliver the news anonymously.
Baldoz says that about 80% of people willingly divulge their partners’ names once they know that someone else will break the bad news. “It’s that 20%,” she says, “that get us in trouble.” Baldoz persists in hopes of locating those sexual partners, something she may have to do with just a first name and a cell phone number or stray leads like a neck tattoo or a place of work.
When she finds them, the first question is almost always the same: a demand to know who exposed them to gonorrhea. Baldoz is prohibited by federal health privacy laws from answering and state officials say they go to great lengths to protect confidentiality. Sometimes Baldoz will route phone calls through other areas of the state, using an unfamiliar area code to create distance between the first patient and their partner who is getting the news.
Governments have long used some form of partner notification to help stem the spread of disease. Great Britain was tracing sexual partners in the 1800s, and in the U.S., Congress voted to fund STD “control programs” as early as the 1930s. It was also an important and somewhat controversial part of health officials’ response to the HIV epidemic in the 1980s, giving rise to debates about how a person’s right to privacy is balanced with a public health official’s duty to warn those who might be in danger.
When Baldoz first started the job in 2009, she was mainly tracking down people who had contracted syphilis. “There wasn’t a lot of concern with gonorrhea,” she says. “Today, I’ve got five new cases.”