From her base in Gallup, New Mexico, Melissa Wyaco oversees about two dozen public health nurses who crisscross the vast Navajo Nation looking for patients who have tested positive for or been exposed to a disease once nearly eradicated in the US: syphilis.
Infection rates in this region of the Southwest — the 27,000-square-mile reservation includes parts of Arizona, New Mexico and Utah — are among the highest in the country. And they’re far worse than anything Wyaco, who is from Zuni Pueblo (about 40 miles south of Gallup) and is the nurse consultant for the Navajo Indian Health Service, has seen in her 30-year nursing career.
Syphilis infections nationwide have risen sharply in recent years, reaching a 70-year high in 2022, according to the most recent data from the Centers for Disease Control and Prevention. This increase comes amid a shortage of penicillin, the most effective treatment. At the same time, congenital syphilis—syphilis passed from a pregnant person to a baby—has similarly gotten out of control. Without treatment, congenital syphilis can cause bone deformities, severe anemia, jaundice, meningitis, and even death. In 2022, the CDC recorded 231 stillbirths and 51 infant deaths caused by syphilis, out of 3,761 congenital syphilis cases reported that year.
And while infections have increased in the US, no demographic has been hit harder than Native Americans. CDC data released in January show that the rate of congenital syphilis among American Indians and Alaska Natives was three times the rate for African Americans and nearly 12 times the rate for white babies in 2022.
“This is a disease that we thought we were going to eradicate a while ago because we have a treatment that works really well,” said Meghan Curry O’Connell, a member of the Cherokee Nation and chief of public health in the Great Plains. Tribal Leaders’ Health Board, based in South Dakota.
In contrast, the rate of congenital syphilis infections among Native Americans (644.7 cases per 100,000 people in 2022) is now comparable to the rate for the entire US population in 1941 (651.1)—before doctors began using penicillin to treat syphilis. (The rate dropped to 6.6 nationally in 1983.)
O’Connell said that’s why the Great Plains Tribal Leaders’ Board and tribal leaders from North Dakota, South Dakota, Nebraska and Iowa have asked federal Health and Human Services Secretary Xavier Becerra to declare a state of emergency of public health need in their states. A declaration would expand staffing, funding and access to contact tracing data across their region.
“Syphilis is deadly for babies. It’s highly contagious and causes very serious effects,” O’Connell said. “We have to have people doing work with boots on the ground” right now.
In 2022, New Mexico reported the highest rate of congenital syphilis among states. Primary and secondary syphilis infections, not transmitted to infants, were highest in South Dakota, which had the second highest rate of congenital syphilis in 2022. In 2021, the most recent year for which demographic data are available, South Dakota it had the second-worst rate nationally (after the District of Columbia) — and the numbers were higher among the state’s large domestic population.
In an October press release, the New Mexico Department of Health noted that the state had “reported a 660% increase in cases of congenital syphilis over the past five years.” A year earlier, in 2017, New Mexico reported just one case — but by 2020, that number had risen to 43, and then to 76 in 2022.
Starting in 2020, the Covid-19 pandemic made things worse. “Public health across the country was almost 95 percent focused on providing care for the coronavirus,” said Jonathan Iralu, the Indian Health Service’s chief clinical adviser for infectious diseases, who is based at the Gallup Indian Medical Center. “This was a really hard-hit area.”
At one point early in the pandemic, Nation Nation reported the highest covid rate in the US, Iralu suspects that patients with syphilis symptoms may have avoided seeing a doctor for fear of contracting Covid. That said, he doesn’t think it’s fair to blame the pandemic for the high rates of syphilis, or the high rates of women passing infections to their babies during pregnancy, that continue four years later.
Native Americans are more likely to live in rural areas, far from hospital maternity units, than any other racial or ethnic group. As a result, many do not receive prenatal care until later in pregnancy, if at all. This often means providers cannot screen and treat patients for syphilis before delivery.
In New Mexico, 23% of patients did not receive prenatal care until the fifth month of pregnancy or later or received fewer than half of the visits appropriate for the infant’s gestational age in 2023 (the national average is less than 16%).
Inadequate prenatal care is particularly dangerous for Native Americans, who are more likely than other ethnic groups to transmit syphilis infection if they become pregnant. This is because, among indigenous communities, syphilis infections are just as common in women as in men. In every other ethnic group, men are at least twice as likely to contract syphilis, mainly because men who have sex with men are more susceptible to the infection. O’Connell said it is unclear why women in indigenous communities are disproportionately affected by syphilis.
“The Navajo Nation is a maternal health desert,” said Amanda Singer, a Diné (Navajo) doula and lactation consultant in Arizona, who is also executive director of the Navajo Breastfeeding Coalition/Dine Doula Collective. In some parts of the reservation, patients must drive more than 100 miles to reach obstetric services. “There are too many pregnant women who do not receive prenatal care throughout pregnancy.”
He said this is due not only to a lack of services, but also to a distrust of health care providers who do not understand indigenous culture. Some also worry that providers may report patients who use illegal substances during pregnancy to the police or child welfare. But that’s also due to a shrinking network of facilities: Two of Navajo Territory’s labor and delivery rooms have closed in the past decade. According to a recent report, more than half of US rural hospitals no longer offer labor and delivery services.
Singer and the other doulas in her network believe New Mexico and Arizona could combat the syphilis epidemic by expanding access to prenatal care in rural Native communities. Singer envisions a system in which midwives, doulas and lactation consultants can travel to families and provide prenatal care “in their homes.”
O’Connell added that data-sharing arrangements between tribes and state, federal and IHS offices vary widely across the country, but have posed an additional challenge to addressing the outbreak in some Native communities, including her own. Her Center for Racial Epidemiology is fighting for access to South Dakota state data.
In and around the Navajo Nation, Iralou said, IHS infectious disease doctors meet with tribal officials monthly, and he recommends that all IHS service areas hold regular meetings of state, tribal and IHS providers and public health nurses to ensuring that every pregnant woman in these areas is tested and treated.
The IHS now recommends that all patients be screened for syphilis annually and screens pregnant women three times. It also quickly expanded and began offering DoxyPEP, an antibiotic that trans women and men who have sex with men can take for up to 72 hours after sex and that has been shown to reduce the transmission of syphilis by 87 percent. But perhaps the most significant change IHS has made is offering field testing and treatment.
Today, Wyaco-supervised public health nurses can test and treat patients for syphilis at home — something she couldn’t do when she was one just three years ago.
“Why not bring the penicillin to the patient instead of trying to drag the patient onto the penicillin?” Iralou said.
It’s not a tactic the IHS uses for every patient, but it has been effective in treating those who may pass an infection on to a partner or baby.
Iralu expects to see an expansion of street medicine in urban areas and vans in rural areas in the coming years, bringing more tests to communities – as well as an effort to get them into the hands of patients through vending machines and mail order.
“This is a radical departure from our past,” he said. “But I think this is the wave of the future.”
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