From a hidden to a vividly illustrated disease

What global factors, what long-term phenomena make a disease invisible? Like other STIs, syphilis is marked by secrecy and shame. It affects population groups that are themselves invisible (migrants, clandestine prostitutes). On a microbiological level, syphilis enters tissues, escapes the immune response, has an exceptionally long latency period, and multiplies slowly. Today, as in the past, syphilis has been termed the “great simulator” for its ability to challenge clinical observation by mimicking the manifestations of many other diseases. Syphilitic lesions can also be spectacular and their location on the genitals makes them difficult to depict, particularly in health prevention campaigns seen by a wide public. People with syphilis are often seen as “bad patients”: the prostitutes, “men who have sex with men” (MSM), and migrants from certain regions of the world. Often depicted as a punishment for the lifestyle of the other, the outcast, the foreigner, it struggles to mobilize political attention. We are leading clinical research (HUG) on serious yet currently socially invisible forms of syphilis: congenital and neurological syphilis.

At the same time, we are interested in the visual storytelling of syphilis at the turn of the 20th century. We are researching literary and cultural sources that have been neglected in the past, such as anti-venereal theatre, antisyphilitic novels (UniGe), as well as films (Unistra MedFilm). Like AIDS more recently, syphilis led to the production and circulation of a specific iconography, on the edge of arts and sciences (Paris I). Particular emphasis will be placed on the figure of the sick Venus (BodmerLab). Moreover, we will evaluate mental image of syphilis and its symbolic representations in the context of a prospective clinical study on psychological consequences of the infection in patients and their sexual partner(s) (UniGe, HUG).

At the crossroads between art and science

Through its examination of syphilis wax moulages and films, our project highlights how the disease has generated conversations between art and scientific expertise. Our analyses will feed a collaborative reflection on past and contemporary ways of building and archiving knowledge.

Being both works of art and medical tools, life-sized wax models have long been used for medical education, and exhibited in medical museums as well as on fairgrounds. Filmed and photographed, they have been widely disseminated among the general public. These ancient pieces are still admired today by dermatologists for their precision, realism and quality. We have developed a partnership with the Musée d'histoire des sciences in Geneva, which holds a collection of syphilitic ceroplasties. Some particularly noteworthy pieces will be restored with the expertise of the Wax Moulagen Museum in Zürich. These pieces will be digitised in 3D (UZH IEM) and made available on a specific web platform aimed at clinicians, art historians and a wider public.

Films have also historically been an important medium of syphilis knowledge. Bare ten years after cinema had been invented, anti-syphilis propaganda films displayed technological prowess, including for instance scenes of Treponema pallidum moving over a microscope slide. Artists, such as painters and playwrights, who had already appropriated syphilis as a visual, literary and even poetic object, began collaborating with physicians on posters and prevention films. We examine the significance of these films as objects of art and science (Unistra MedFilm).

Clinical expertise, biological (un)certainty, and the construction of knowledge

A “great simulator”, syphilis does not only challenge modern clinical diagnostic methods; it also continues to elude positive microbiological identification. Microbiologists must contend with a strange bacterium, which cannot be cultivated and is studied through animal models. Current syphilis tests were developed during the Second World War, and although new automated tests exist, more clinical studies are needed to validate them. The positive diagnosis of certain forms of syphilis, such as latent and neurological syphilis, remains difficult today.

Our research on syphilis testing combines clinical, microbiological and molecular approaches with the political and cultural history of testing. The Wasserman test, developed in 1906 - i.e. just one year after the discovery of the pale treponema - is the direct ancestor of more recent serological tests such as VDRL or RPR. Its lack of specificity has raised many epistemological issues: as early as the 1930s it became a paradigmatic case in a cultural approach to the discovery of a scientific fact. We interrogate the historic reasons for the failure to modernise syphilis testing in the second half of the twentieth century (HUG; Unige; Unistra). Our aim is also to develop more accurate diagnostic methods, through the joint use of the old antibodies and new laboratory tests based on specific recombinant anti-Treponemal immunoglobulins. Analysis will be done in combination with clinical observations of severe syphilis presenting neurological, ophtalmological and/or auditive symptoms (HUG). We also aim to better understand pathogenesis in human fixed tissues thanks to a collaboration with archeogeneticians (Unistra IML). Late stages of syphilis and different organs collected before and after penicillin era will be analysed by molecular biology.

A storytelling exercise

Commissioned by public health institutions, medical doctors and artists have been collaborating and proposing often innovative means of venereal prophylaxis, in the form of poems, fiction and drama. These documents impose a storytelling of syphilis whose cultural history is yet to be written (Unige), in close dialogue with epidemiological and clinical knowledge. Can prevention be improved by a better understanding of the psychological and social dimensions of patient infection? A psychologist will study how syphilis may impact on sexual health in infected people and their sexual partner(s) (Unige, Fac. of psychology). The resulting database will be used in the routine follow-up of syphilis patients seen during public-health nurse counseling  and the venereology consultations (HUG). We are also interested in the material and visual approach to history of health propaganda posters and antisyphilis films (UniStra). Produced in large numbers during wartime, they mix health, politics, morals and ideology. With the introduction of penicillin, and thus the end of the centuries-long fear of syphilis, this knowledge on how to communicate about sexuality has been lost, and had to be rediscovered in the AIDS years.

The “Miracle drug” disenchantment

Today syphilis tends to be considered as a benign, non-lethal disease that can be easily treated. And indeed, treatment by intramuscular injections of penicillin is efficient, affordable, and theoretically easy to administer. Yet the long-term history of syphilis and current approaches to its treatment reveal a much more complex picture.

Our research shows that syphilis has a long history of galvanising pharmaceutical and therapeutic experimentations, from immunisation to the first chemotherapies using mercury and arsenic, and finally to antibiotherapy through penicillin (Unige; Unistra). Yet, due to a lack of financial incentive, the production of penicillin, and pharmaceutical research into other possible treatments, have largely stalled in recent decades. This has occasionally led to international drug shortages. Antibiotic treatment itself raises questions. The untreated disease can be asymptomatic for decades after a primary infection. Therefore, patients presenting with early forms are given high doses of penicillin. We interrogate some of the consequences associated with these issues, such as potential microbial resistance, decreased antibiotic efficacy, and safety or adherence considerations (HUG).

Networks of knowledge, moral control, and health politics

For much of the twentieth century, syphilis was a major concern for public health authorities, governments, and colonial administrations around the world. In some countries the screening, declaration and treatment of syphilis were made mandatory. However the penicillin revolution of the 1950s and the onset of the AIDS epidemics in the 1980s heralded the political, social, and medical demise of past antisyphilis efforts. Syphilis became a disease without a public health policy, and this demobilisation resulted in a loss of technological, clinical, and public health knowledge regarding its prevention and treatment.

Our project addresses the decline in the epidemiological knowledge of the disease (HUG) by conducting an epidemiological analysis of congenital syphilis in Switzerland but also at international level in high- and lower-income countries (Unistra). It also explores the national and international politics of syphilis-related public health policies (Unige). Governments wanting to make a dignified impression on the global stage have an interest in keeping the epidemiology of syphilis in check, considering the low costs of tests and treatment. International organisations, such as the League of Nations during the inter-war period and the World Health Organization, have been important players in the transnational circulation of public health knowledge and practices, as have been imperial powers.

The main goals of our project are to:

• connect older and recent knowledge on infections with Treponema pallidum and develop a model for the analysis of diseases that experience degrowth without disappearing
• introduce biomedical and social/socio-historical approaches into the analysis and management of the resurgence of syphilis in the twenty-first century
• describe and analyse the biomedical evolutions of one of the main non-eradicated STIs to this day through the investigation of three social science research areas (an invisible disease/a disease without qualities/a moral disease)