From her base in Gallup, New Mexico, Melissa Wyaco supervises about two dozen public health nurses who crisscross the vast Navajo Nation in search of patients who have tested positive for or been exposed to a disease once nearly eradicated in the United States: syphilis.
Infection rates in this southwest region — the 27,000-square-mile reservation encompasses parts of Arizona, New Mexico and Utah — are among the highest in the country. And they’re far worse than anything Wyaco, a native of Zuni Pueblo (about 40 miles south of Gallup) and nurse consultant for the Indian Health Service in the Navajo region, has seen in her 30-year career as a nurse. ‘nurse.
Syphilis infections nationwide have increased rapidly 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 in a context of shortage of penicillin, the most effective treatment. Simultaneously, congenital syphilis – syphilis passed from a pregnant person to a baby – has also spiraled out of control. Untreated 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 cases of congenital syphilis reported that year.
And even as infections have increased in the United States, no demographic group has been hit harder than Native Americans. CDC data released in January shows the rate of congenital syphilis among American Indians and Alaska Natives was three times higher than that of African Americans and nearly 12 times higher than that of white babies in 2022 .
“This is a disease that we thought we would eradicate not too long ago because we have a treatment that works so well,” said Cherokee Nation member and health director Meghan Curry O’Connell. public of the Great Plains. Tribal Leaders’ Health Board, based in South Dakota.
Instead, 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 U.S. population in 1941 (651.1) – before doctors began using penicillin to cure syphilis. (The rate fell to 6.6 nationally in 1983.)
O’Connell said that’s why the Great Plains Tribal Leaders’ Health Council and tribal leaders in North Dakota, South Dakota, Nebraska and Iowa have asked the federal Secretary of Health and to Social Services, Xavier Becerra, to declare a public health emergency in their states. A declaration would increase staffing, funding and access to contact tracing data in their region.
“Syphilis is deadly to babies. It is highly contagious and has very serious consequences,” O’Connell said. “We need people working on the ground” now.
In 2022, New Mexico reported the highest rate of congenital syphilis among the states. Primary and secondary infections of syphilis, which are 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 is available, South Dakota had the second worst rate nationally (after the District of Columbia) – and the numbers were highest among the state’s large indigenous population.
In an October press release, the New Mexico Department of Health noted that the state had “reported a 660 percent increase in congenital syphilis cases over the past five years.” A year earlier, in 2017, New Mexico reported only one case, but by 2020 that number had increased to 43, and then to 76 in 2022.
As of 2020, the covid-19 pandemic has worsened the situation. “Public health across the country has been almost 95% diverted to covid care,” said Jonathan Iralu, Indian Health Service chief clinical consultant for infectious diseases, based at the Gallup Indian Medical Center. “It was a really hard-hit area.”
At one point early in the pandemic, the Navajo Nation reported the highest covid rate in the United States. Iralu suspects that patients with symptoms of syphilis might have avoided seeing a doctor for fear of catching covid. That said, he doesn’t think it’s fair to blame the pandemic for high rates of syphilis, or high rates of women passing infections to their babies during pregnancy, which continue four years later.
Native Americans are more likely to live in rural areas, far from hospital obstetric 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 test 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 less than half the number of visits appropriate for the infant’s gestational age in 2023 (the national average is less than 16%).
Inadequate prenatal care is particularly risky for Native Americans, who are more likely than other ethnic groups to transmit syphilis infection if they become pregnant. Indeed, within Indigenous communities, syphilis infections are as common among women as among men. In all other ethnic groups, men are at least twice as likely to contract syphilis, largely because men who have sex with men are more likely to be infected. O’Connell said it’s unclear why women in Indigenous communities are disproportionately affected by syphilis.
“The Navajo Nation is a desert when it comes to maternal health,” said Amanda Singer, a Diné (Navajo) doula and lactation consultant in Arizona who is also executive director of the Navajo Breastfeeding Coalition/Diné Doula Collective. In some parts of the reservation, patients must travel more than 100 miles to access obstetric services. “There are a very high number of pregnant women who do not receive prenatal care throughout their pregnancy.”
She says this is due not only to a lack of services, but also to a distrust of health care providers who don’t understand Indigenous culture. Some also worry that providers may report patients who use illicit substances while pregnant to the police or child welfare. But it’s also due to a shrinking network of facilities: Two labor and delivery rooms in the Navajo region have closed in the past decade. More than half of America’s rural hospitals no longer offer labor and delivery services, according to a recent report.
Singer and 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 imagines a system in which midwives, doulas and lactation consultants could visit families and provide prenatal care “in their homes.”
O’Connell added that data sharing agreements between tribes and state, federal and IHS offices vary widely across the country, but have posed an additional challenge in combating the outbreak in some Native communities, including his own. Its tribal epidemiology center is fighting to access data from the state of South Dakota.
On the Navajo Nation and surrounding areas, Iralu said, IHS infectious disease doctors meet with tribal officials monthly, and he recommends that all IHS service areas hold regular meetings between health care providers. State, tribal and IHS and public health nurses to ensure that every pregnant person in these areas was tested and treated.
IHS now recommends that all patients be tested for syphilis annually and tests pregnant patients three times. It also expanded rapid and express testing and began offering DoxyPEP, an antibiotic that transgender women and men who have sex with men can take up to 72 hours after sex and has been shown to reduce syphilis transmission by 87%. But perhaps the biggest change IHS is making is offering on-the-ground testing and treatment.
Today, the public health nurses Wyaco supervises can test and treat patients for syphilis at home – something she couldn’t do when she was one of them just three years ago. years.
“Why not bring the penicillin to the patient instead of trying to coax them toward the penicillin?” » said Iralu.
It’s not a tactic IHS uses for all patients, but it has been shown to be effective in treating those who might pass an infection to a partner or baby.
Iralu expects to see an expansion of street medicine in urban areas, and outreach services in rural areas, in the coming years, bringing more testing to communities – as well as an effort to bring testing between patients’ hands via vending machines and mail.
“It’s a radical break with our past,” he said. “But I think this is the wave of the future.”
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