Copied from The Advocate #214. April 20, 1977 edition, page 12-13 

A New Plague on Our House: Gastro-Intestinal Diseases
By Randy Shilts

Though they appear to be health problems only in New York and San Francisco today, sexually-transmitted gastro-intestinal diseases may soon be the next major gay health problem---and startlingly little is known about them. 
	In New York, a physician with a large gay clientele spent two weeks thumbing through medical libraries on some strange tropical diseases that had been hitting increasing numbers of his patients--apparently via sexual contacts.
	The maladies: amebiasis, shigellosis, salemonellosis.
	The physician--Dr. Dan William, the medical director of New York's Gay Men's Health Project and an official in that city's V.D. program--searched through scores of books and journals to find out about any sexual implications these diseases might have. His findings consisted of a) a letter to the editor of a medical journal, b) one case report of a sexually transmitted case of amebiasis and c) one article discussing the gastro-intestinal illnesses as possibly sexually related illnesses--but that article was found only after William has scoured three medical libraries to find the obscure medical journal in which it had appeared.
	These three opuses, William says, represent "the sum total of information on these disease in the United States of America."
	William's experience is hardly unique. In San Francisco, Dr. Selma Dritz--assistant director of the Bureau of Disease Control for San Francisco's Public Health Department--was trying to explain an alarming rise in these formerly tropical disease in her city. "Amoebic dysentery. Shigella. You have those in India, Pakistan and the Philippines, but not in the United States," she groaned.
	This dramatic rise in enteric--or gastro-intestinal (G-I)--diseases has little to do with the traditional causes of these maladies, such as hygiene or poor water. Like hepatitis, these bugs have become sexually transmitted diseases and are rapidly becoming the chic illnesses of the New York and San Francisco gay communities.
	
"NO LONGER JUST AN EPIDEMIC" 
	Statistics for these diseases are hard to come by--especially statistics on their incidence in the gay community. According to Dr. Aubert Dykes of the federal government's Center for Disease Control (CDC) in Atlanta, numerous reporting factors make it nearly impossible to trace how widespread these disease are. Only amebiasis must be reported to federal health authorities, and even the 200,000-plus amebiasis cases reported to the CDC for 1975 represent a small fraction of the total national problem, Dykes says.
	The number of carriers in the general population, however, indicates the vast numbers of people affected by these diseases. According to Dykes, one in 10 Americans is a chronic carrier of giardia lamblia, the nation's most common form of amebiasis. In the Rocky Mountain states, the number of carriers reaches 20 per cent, Dykes says. Another one or two per cent of the population carry the more common form of amebiasis. The nation's major cities now are seeing the effects so large an infectious pool can have as these diseases enter the realm of the sexually transmittable.
	In New York,. Where three tropical disease clinics report nearly half the nation's tropical G-I disease, Dr. Dan William says "a significant percentage" now comes from the gay community. 
	In San Francisco, cases of reported shigellosis rose over 300 per cent between 1974 and 1976 alone--and Dr. Dritz says that reported cases represent 25 per cent, at most, of the existing cases in that city. Public health figures also show that men between the ages of 20 and 30 have six times the chance of falling victim to the soaring shigellosis rate than women, while the amebiasis rate for the same male group is 40 times that of their female counterparts.
	Such statistics lead Dritz to talk of these maladies' "geometric increase" in the gay male community. "It's no longer just an epidemic--which means that a disease comes, spreads around and burns itself out," she says. "It's endemic--which means that it's in the population and continuing to rise in both incidence and prevalence."
	The disease does not seem to have made major inroads into the gay populations of inland cities. Dr. Walter Lear, a Philadelphia gay physician, says outbreaks of these illnesses have not yet hit his city. In Chicago, David Ostrow, medical director of the gay Howard Brown Memorial Clinic, says, "It may be going on here, but we haven't heard much about it."
	William thinks the diseases are first appearing in the major port cities because of the large tropical populations common to those areas. These populations bring the disease into the country and then spread them into the gay communities. From the time it hits the gay communities of these gay meccas, it's only a matter of time before it plays to the inland gay crowds, many gay health authorities warn. Says Chicago's Ostrow, "Things that are spread sexually seem to come from the coasts--the East and West Coast ports--and then move inland."

"WE'RE SHY ONE ORIFICE" 
	The public health problem posed by the spread of these disease in the gay community are more complex than even the problems of the standard venereal diseases or the more serious threat of hepatitis (see Issue 207).
	The diseases in question long have been associated with hygiene, as they primarily are spread through contact with fecal matter in bad water supplies. Their high incidence among the gay population, however, stems from nothing more than the gymnastics of gay sex. As Dr. William put it, "We're shy one orifice." Because of this--and the subsequent use of anal sex--gay men are brought into contact with fecal matter either via genital-anal or oral-anal sex. Such fecal contact is nearly unavoidable during any form of anal sex.
	The introduction of these diseases into the gay community, therefore, has transformed what once were hygienic diseases into sexually transmittable diseases and created a whole panorama of new gay illnesses. Not only are hepatitis, shigellosis, amebiasis and salmonellosis increasing because of such contact, but even cases of typhoid are beginning to surface in the gay community, according to San Francisco's Dritz.

OVER-SQUEEZING THE TOOTH-PASTE TUBE 
	Understanding these diseases and the serious threat they pose to gay men's health requires a look at the entire gastro-intestinal system they effect. All the disease enter the body orally through contact with fecal matter. The contact can be direct, as with analingus, or indirect, as with eating food that has been contaminated. The dose does not need to be large. According to Dritz, a bustling case of shigellosis needs only 10 to 20 of the shigellae to establish itself.
	According to Dritz, the pathogens, whether amebae, which are parasites, or shigellae or salmonellae, which are bacteria, first go to the stomach and then into the intestines. If they begin to irritate the intestines near the beginning of the G-I tract, the body will respond by trying to throw the offending matter out of the body via vomiting. This, therefore, is often the first symptoms of these--as well as many other--gastro-intestinal diseases.
	Throwing up, however, rarely does the job of ridding the body of the offenders. The bacteria or parasites therefore continue through the intestines with the food, which is slowly pushed through this organ by the intestinal muscles' tooth-paste tube type of squeezing. As they multiply, the pathogens attach themselves to the intestinal walls. The type of damage they inflict from this point on, however, has to do with the breed to which they belong.
	As Dritz explains it, the amebae parasites, for example, feed directly on the intestinal walls. The salmonellae and shigellae bacteria also grow on the intestinal walls but do a lot of their damage through the waste products they secrete on the wall's surface. These waste products are toxic and destroy the intestinal walls, says Dritz.
	No matter what the cause of trouble, however, the intestines react to the foreign invasion by secreting fluid to try to wash off the pathogens. It also speeds up its tooth-paste tube squeezing to work the matter out of the body. This produces diarrhea, another G-I symptom of disorder. The dramatically increased muscle movements of the intestinal walls sometimes causes cramps in those muscles, which again are symptoms of these diseases.
	The diarrhea itself will induce more troubles. Dehydration is one result. The wholesale loss of water upsets the blood's electrolyte balance as well as the calcium-phosphorus and sodium-potassium ratios. These disturbances in the blood--which go on to upset the rest of the body--shy in comparison, however, to the havoc the unabated pathogens can wreak on your guts.
	While releasing noxious toxins, the shigella bacteria will chew away at the intestine wall. The erosion will first show itself through mucous, which will appear on the stool.. As the shigella continue to erode the wall, they eventually will get into blood vessels surrounding the intestines. Blood then will appear on the stool--still another shigellosis symptom. Now the shigella are in the blood stream and the body will react to this infection, as it does to other blood diseases, with fever and chills.
	The end result of such diseases offer little to snicker about. Amebiasis can kill via dehydration. The amebae parasites also can get into the liver and cause a fatal abscess in that organ.
	Medical authorities, however, caution that cases of death are not common for these disorders--but the ramifications are serious enough to warrant immediate attention. "They can be anything from a nuisance to a fatal case in the hospital," says Dritz.
	Treatment is not difficult for most of the maladies. But they aren't your typical shoot-it-up-with-penicillin venereal diseases. Says Dritz, "We're not talking about 5,000 people dying in the city from these disease in a week. But we are talking about a tremendous pain, misery, financial loss, medical cost, time loss-- plus a continuing threat to the general community from these diseases."

PROBLEMS WITH DIAGNOSIS 
	The route to treatment, however, can be followed only if the disease is diagnosed--and the dearth of information relating to the newly acquired venereal aspects of these formerly tropical diseases makes diagnosis the exception and not the rule. "The horror story of all this is that most physicians don't suspect these diseases, so they don't look for them," says New York's Dr. William. "I've seen people who have been carried along for years with treatment or something else when they had parasites all along."
	The diagnosis problem reflects only part of the over-all ignorance throughout the medical and public health communities concerning these new venereal diseases. Gay physicians in the two major coastal gay centers now are just beginning to catch wind of this health problem while mainstream physicians in the same areas generally remain ignorant about these diseases.
	The problems for gay people outside these cities who may catch one of these rare diseases are exacerbating. "Even in big cities like Seattle or Cleveland, there isn't a sector of physicians who deal largely with gay male patients," says William. "You don't get the sharing of information there that you do in bigger cities."
	A number of other factors also adds to this problem. Because of the sexual gymnastics necessary for spreading the diseases venereally, these maladies remain a primarily gay problem. Cases are rare in the over-all population except for those who have picked up the diseases in tropical lands. Few doctors, medical centers or public health agencies, therefore, are familiar with the diseases--or their menace to the gay community.
	Even when these diseases are suspected, they are difficult to confirm. Symptoms vary greatly between patients. Tests are difficult and expensive, requiring cultures taken directly from fecal matter. Hospitals and laboratories sometimes do not have the facilities or expertise to handle diseases that once were restricted to underdeveloped countries. Says CDC's Dykes, "There just aren't many people in this country who are educated about parasitology at all--much less about this particular aspect of it."
	The ignorance of the mainstream public health profession about the gay lifestyle also contributes to the problem. William points to a case where top health officials in New York City discovered that two amebiasis cases had been to the same Manhattan bath house. The officials then slyly decided that the bath house's pool must be contaminated.
	"It hadn't crossed their minds that probably no one had been in that pool for 20 years," says William. "They didn't know that gay people did not go to that bath for the pool. But you talk to public health officials about amebiasis and they'll just say they check the water and make sure food handlers wash their hands. Information about the special problems of the gay community hasn't filtered down to them yet."
	Many gay health workers, however are mystified about what can be done to thwart this growing problem--which may soon spread through the gay community of the entire country. Little can be done to prevent the disease short of total abstinence from anal sex. According to Dritz, scrubbing with a deodorant soap may reduce some germ counts, but for many of theses diseases it doesn't take much fecal matter to spread the infection and washing just won't do the job.
	As William put it, "The more meticulous the personal hygiene, the less chance of getting them there is. But that's not very good, because if you're going to stick your tongue in somebody's anus, no amount of hygiene will help."