M. Nael Mhaissen hadn't been in California long when he saw his first case.
Mhaissen is a pediatrician who specializes in infectious diseases, and he moved from Memphis in 2015 to take a faculty position at the Stanford University School of Medicine. The job included seeing patients at a hospital near Fresno, in the heart of the food-producing San Joaquin Valley. He knew the Valley had challenges compared to the rest of California—more unemployment, less education, lingering farm chemicals, and bad air quality—and he expected to be treating problems arising from poverty and pollution.
But he didn't expect what he encountered when he was called to the neonatal intensive care unit of Valley Children's Healthcare. His patient was a baby girl, 10 weeks premature, who was showing the symptoms of a disease out of the 19th century: congenital syphilis, passed to her by her mother before she was born.
"I was shocked," Mhaissen says. "I thought this was something you only read about in history books."
But in California—and, increasingly, across the United States—history's back. The Centers for Disease Control and Prevention reported in October that sexually transmitted diseases are at an "unprecedented high." Every one of the STDs that the agency tracks occurred more frequently in 2015, and one of them, chlamydia, racked up more cases in one year—1.52 million—than any disease the CDC has ever studied.
Buried in the big numbers was a smaller one with outsized significance. In 2015, there were 487 known cases of children born with congenital syphilis, a number that rose by more than a third in four years.
Syphilis in an infant is hard to imagine, but it's very serious. During pregnancy, the infection can cause miscarriages and stillbirth. Babies that make it to delivery can be premature and underweight, and may have a range of health problems at birth. If the disease isn't detected and treated, babies can also develop lifelong problems as they grow: fluid retention that puts pressure on their hearts, blindness, hearing loss, bone deformities, and breathing and nervous-system abnormalities.
That goes for their mothers too. If it isn't detected early, through a test or the signs of infection—first a painless sore and later a rash and fever—syphilis can linger in the body for years without causing symptoms, only to erupt decades later. "Late syphilis" can affect almost any organ, and lead to blindness, paralysis and dementia.
Ten days of penicillin, administered by IV, can cure the infection, but it can't reverse whatever damage has already been done—and also can't prevent the side-effects of prematurity. Mhaissen's patient, whom he took care of for a year, stayed in intensive care the first two months of her life, still struggles with breathing problems, and is developmentally delayed.
That's especially tragic because congenital syphilis is 100 percent preventable. Babies are born with syphilis because their mothers transmit it to them during pregnancy, so an infected infant also indicates an infected, untreated mom.
"Congenital syphilis is a red flag for failures in the public health system and the healthcare system," Sarah Kidd, from the CDC's division of STD prevention, says. "The rate goes up when female syphilis rates go up. A pretty constant percent of pregnant women with syphilis don't get prenatal care, or receive prenatal care very late in their pregnancies."
And because a pregnant woman acquires her infection from someone else, congenital syphilis is also points to the way that the traditional system for preventing STDs is breaking down as funding goes away.
"One baby born with syphilis is too many, but numbers like this show we're not doing enough to safeguard people," says David Harvey, executive director of the National Coalition of STD Directors. He points out that STD prevention appropriations sent to the CDC and on to states have been flat-funded for years, and state STD programs have been forced to close clinics or cut their hours, and have lost the personnel who track down the partners of infected people and try to get them treatment.
"If there were more resources in the system, this would not be happening," Harvey says.
Out of all the states, California has the highest occurrence of congenital syphilis: 142 babies last year, almost a third of all the cases in the United States. Within California, the Central Valley, where Mhaissen works, is the hardest hit.
"For many years, we had anywhere from no cases to, at most, three," says Ken Bird, the health officer for Fresno County. "And then, three years ago, we started seeing some really drastic increases. We've had 55 cases so far this year." The cases exploded so suddenly that the county called in CDC investigators from Atlanta to help.
Because its main business is agriculture, the Valley has a transient population of farmworkers who move back and forth as crops come to harvest. But when the Fresno Department of Public Health started investigating its syphilis cases, it realized that infected mothers were transient, and thus not getting healthcare, for a different reason: not because of farm work, but because of drug use. Most of the women and their partners were involved with meth, says Joe Prado, the department's community health division manager.
"They don't call themselves homeless, but they go from house to house, and since they're never in the same place for two weeks, they're difficult to find," Prado says. "We try to find people who are receiving public assistance, and we developed a relationship with the jail, because if they show up there, we can get them the treatment they need."
Treatment for syphilis in adults is similar to what infants get: long-acting penicillin, given by injection once or over several weeks depending on how advanced the disease is. Unlike gonorrhea, another STD that is becoming more common, syphilis is not antibiotic-resistant; penicillin still works to cure it. But the penicillin formula that is used for syphilis, called bicillin, is in short supply—on its STD site, the CDC has posted a warning about shortages—and not cheap: So far this year, Bird says, Fresno County has spent $62,000 on doses.
To seek treatment, people have to know they are infected, and for women in particular, that can be difficult. Syphilis starts with a painless sore that erupts wherever the bacterium invaded the body. Men usually spot it, because it's on or around their genitals, but for women, it can be internal, or easy to overlook. Syphilis infection ought to be caught when a woman has a prenatal visit—and in California's health care system, all women are entitled to prenatal care regardless their immigration status or whether they can pay.
But in Los Angeles, where syphilis cases are the highest they have been in a decade, "59 percent of the women who delivered babies with congenital syphilis last year had not had any prenatal care," says Susie Baldwin, the associate medical director of the Los Angeles County Department of Public Health. "And some women show up one time and then disappear."
Women might be distracted by addiction, she suggests, or might be scared of being judged for using drugs while pregnant. And among some patients, there are rumors of prenatal clinics imposing mandatory drug tests, causing women to stay away out of fear they will be prosecuted, or have older children taken away by the state.
That starts a chain of invisibility. First the mother's infection isn't detected or treated; then, if a baby is born without visible symptoms, the child isn't treated either. For both of them, syphilis that is left to progress can cause devastating illness years later. That makes it urgent that women giving birth in areas where rates of congenital syphilis are high—California, Louisiana, Nevada, Illinois, Florida—be tested during pregnancy, or at delivery if they have not been tested earlier. If there's any question whether they are infected, health officials recommend their newborns be tested as well.
Mhaissen was so struck by that first syphilis-affected baby—he's seen others since, though none so gravely ill—that he has started doing educational talks at obstetric and family-medicine practices, trying to alert fellow doctors to the threat.
"A lot of them think, 'Syphilis was a problem in the 1940s and '50s, but it's so easily treated with penicillin, it can't be a problem anymore,'" he says. "That was right until recently, but now it's wrong. Now it is a problem, and it's a hidden problem, and the numbers are getting higher and higher."