How Syphilis Sneaked Up on Americans

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In 2018, rates of sexually transmitted diseases in the United States increased for the fifth year in a row, and combined cases of syphilis, gonorrhea, and chlamydia reached a record high, a Centers for Disease Control and Prevention report released today showed. The number of primary and secondary syphilis cases—the disease’s most infectious stages—increased 14 percent from 2017 to 2018, to more than 35,000 cases, the highest number reported since 1991. Gonorrhea and chlamydia cases are also on the rise, with a 5 and 3 percent increase, respectively, since 2017.

The past year has also seen a 40 percent rise in congenital syphilis, the type passed from mothers to their babies. Congenital syphilis can cause neurological problems, deformity, and death, and in 2018, 94 babies died from the disease. Five states—Texas, California, Florida, Arizona, and Louisiana—accounted for 70 percent of congenital-syphilis cases.

In its report, the CDC points to several reasons behind the ongoing STD surge. The opioid epidemic, along with other types of drug use, can lead to risky behavior, including unprotected sex and avoiding medical care. Young people and gay and bisexual men are using condoms less, in part because pre-exposure prophylaxis medications that can prevent HIV transmission are more broadly available. And in recent years, more than half of local STD treatment and prevention programs have faced budget cuts. Together, all of these factors point to roughly the same sentiment: Americans have stopped taking STDs seriously.

[Read: Why are STDs on the rise if Americans are having less sex?]

Local health departments play a crucial role in preventing the spread of STDs. Preventing congenital syphilis requires testing pregnant women for syphilis the first time they see their doctor. Then, health-department employees have to follow up with them to be sure they get treated—with as many as three doses of an antibiotic.

But since the 2008 recession, the municipal-health-department workforce has shrunk by almost a quarter, says Adriane Casalotti, the chief of government and public affairs at the National Association of County and City Health Officials. That makes it harder for officials to follow pregnant women to be sure they’re getting their antibiotic doses, or to reach out to doctors and community leaders to raise awareness about the rise of syphilis. And the overall lack of funding means many health departments can’t pay for all the tests and medications they need to catch other types of STDs.

With tax revenue low during the recession, states and municipalities were looking for programs to cut, Casalotti and others say, and in the late Aughts, STD prevention seemed like a reasonable area for savings. Certain STDs had been declining in the 1990s, and in 2000 syphilis was close to being eliminated. STDs simply weren’t seen as much of a threat. And to the extent that they were, it was easy to blame the victims. “There’s a lot of assumptions that these are adults and they should be making better choices, and if they did, there wouldn’t be the spread of STDs,” Casalotti says.

[Read: The overblown stigma of genital herpes]

But after the recession ended, state and local funding for STD programs never came back. Federal funding for syphilis, gonorrhea, and chlamydia prevention has also remained far below the level that public-health advocates have requested, as my colleague Russell Berman and I reported in 2016. “We’re doing less with less,” Bill Smith, the executive director of the National Coalition of STD Directors, told us then. “The public’s health is in danger.” Three years later, the consequences of doing less are becoming even more clear.

Public-health advocates say policy makers are essentially asleep at the wheel as STDs creep up slowly and claim more lives. “There’s a lack of public, provider, and policy-maker knowledge about what’s happening in STDs, and many consider these to be infections of a bygone era,” Matthew Prior, the communications director of the National Coalition of STD Directors, told me via email. “Like, who gets syphilis anymore?” Last year, 486 school buses’ worth of people did.

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