The Syphilis Surge: Echoes of Betrayal in a Broken Health System

Heather McSharry, PhD
11 minutes ago
11 min read

Summary

This episode explores the urgent and often-overlooked public health crisis of syphilis, with a focus on its devastating rise among pregnant people and infants in the United States. We examine why a curable infection continues to cause irreversible harm—from gaps in testing to a national shortage of the only approved treatment in pregnancy. Alongside the science of Treponema pallidum, we look at the legacy of medical abuse, including the Tuskegee Study and a recently halted hepatitis B vaccine trial in Guinea-Bissau. Syphilis is not a mystery—it’s a reflection of systems that fail to act when the solutions are already in hand.

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Full Episode

She thought everything was fine. Her pregnancy had been hard to manage—no car, no regular doctor, no one picking up the phone at the clinic. Still, she made it to a few appointments. No one mentioned anything unusual. No one mentioned syphilis.

Then came the silence. The silence in the delivery room when the baby didn’t cry. The silence after the doctor said, “We’re running more tests.” The silence when they finally told her what went wrong—and that it could have been prevented with a simple shot of penicillin she never received.

She is not alone. Across the United States and beyond, more and more people are finding out too late that they had syphilis. Their babies are being born too early, or not surviving at all. And in many cases, it’s not because the disease was hidden—but because the system failed to find it, to treat it, or to even try.

These outcomes are not rare. And they are not inevitable.

This is The Syphilis Surge: Echoes of Betrayal in a Broken Health System.

A Growing Global Public Health Crisis

Syphilis is one of the most preventable and treatable infectious diseases we know. Yet,

globally, syphilis remains a major public health problem, with an estimated 7–8 million new infections each year worldwide. It continues to be one of the leading causes of preventable stillbirth, particularly in low- and middle-income countries, but increasingly in high-income nations as well. Despite being curable, syphilis is responsible for hundreds of thousands of adverse pregnancy outcomes globally every year, including stillbirth, neonatal death, preterm birth, and lifelong disability.

Over the past decade, syphilis rates have risen across many regions, including North America, Europe, Asia, and parts of Latin America. While some of this increase reflects improved surveillance, a substantial portion represents real, ongoing transmission driven by gaps in testing, reduced access to sexual health services, disrupted prenatal care, and the long-term fallout from COVID-era interruptions to routine screening.

Syphilis is not spreading because it is difficult to diagnose or treat. It is spreading because it exploits fragmented health systems. When screening is inconsistent, when prenatal care is delayed or unavailable, when stigma discourages testing, or when treatment access is unreliable, the infection spreads quietly and persistently—often without symptoms, and often without detection.

The U.S. Emergency: Maternal and Congenital Syphilis

The situation in the United States now meets the definition of a public health emergency. According to new data from the National Center for Health Statistics, the maternal syphilis rate rose 28% between 2022 and 2024 alone, following a previously documented 222% increase from 2016 to 2022. Taken together, this represents more than a fourfold increase in maternal syphilis over less than a decade.

This surge is driving a parallel and deeply alarming rise in congenital syphilis. Since the early 2010s, cases of congenital syphilis in the United States have increased by nearly 1,000%, a reversal of decades of progress that had brought the disease close to elimination by the late 1990s. In 2023, the country recorded the highest number of congenital syphilis cases since 1992.

Congenital syphilis is among the most devastating outcomes of untreated infection. It is associated with miscarriage, stillbirth, neonatal death, preterm birth, low birth weight, and permanent damage to the brain, nerves, eyes, and bones. Without treatment, the infection is fatal in up to 40% of affected infants. Those who survive face higher rates of hospitalization and longer hospital stays in early childhood, even years after birth.

These outcomes are especially tragic because congenital syphilis is almost entirely preventable. Routine screening early in pregnancy, followed by timely treatment with penicillin, can stop transmission to the fetus.

And yet, recent U.S. data show that nearly 90% of congenital syphilis cases were linked to missed opportunities for testing or treatment during pregnancy. These infections were not hidden. They were not resistant to therapy. They were missed.

The burden of this crisis is not evenly distributed. From 2022 to 2024, maternal syphilis rates increased by more than 50% among American Indian and Alaska Native mothers, with rates exceeding 2,100 cases per 100,000 births—by far the highest of any group. Rates also rose sharply among Black and Hispanic mothers and increased across every maternal age group, including people in their 30s and 40s.

Geographic disparities are equally stark. In some states, maternal syphilis rates have risen more than tenfold over the past decade. In Mississippi, for example, maternal syphilis cases increased by 960.6% between 2013 and 2023, prompting the state to declare a public health emergency in response to rising infant mortality.

Public health experts point to multiple, compounding drivers: gaps in early prenatal care, delayed or absent screening, barriers to obstetrical services, and—critically—a nationwide shortage of injectable benzathine penicillin G, the only approved treatment for syphilis during pregnancy.

Congenital syphilis reflects a failure of access, infrastructure, and follow-through. When a curable infection resurges at this scale—killing infants and permanently harming survivors—it is not a historical echo. It is a present-tense crisis.

A Legacy of Betrayal: The Tuskegee Syphilis Study

But any conversation about syphilis in the United States must acknowledge the enduring impact of the Tuskegee Syphilis Study—a 40-year-long government experiment that withheld treatment from hundreds of Black men with syphilis, even after penicillin became the standard cure.

Beginning in 1932, the U.S. Public Health Service enrolled more than 600 Black men in Macon County, Alabama, under the guise of offering free medical care. In reality, the study’s purpose was to observe the natural progression of untreated syphilis. Participants were never told they had syphilis, and they were denied access to effective treatment—even as they suffered and died, and even as penicillin became widely available by the mid-1940s.

The study was not officially halted until 1972, after public outcry forced its termination. By then, more than 100 men had died, and countless others—including wives and children—were affected by transmission and neglect.

This was not just a failure of medical ethics. It was a profound betrayal of trust. The very institutions charged with protecting public health used deception to conduct lethal research on a vulnerable population. The scars of this history run deep.

To this day, the Tuskegee Study remains a source of justified mistrust, particularly in Black communities. It has become shorthand for medical exploitation and a powerful symbol of how structural racism operates through systems that claim to serve. Its legacy is not only emotional—it shapes behavior: delayed care, fear of testing, reluctance to engage with health systems.

In addressing today’s syphilis crisis, especially among marginalized populations, public health must contend with this legacy—not dismiss it. Rebuilding trust requires more than outreach. It demands honesty, accountability, and deep structural change.

And yet this exact typ of betrayal continues to be echoed in real-world decisions.

In early 2026, a controversial U.S.-funded study in Guinea-Bissau (A small tropical country on the West African coast)—pushed by RFKjr—was halted after international outcry. The trial would have withheld birth-dose hepatitis B vaccines from thousands of newborns in a country with one of the highest hepatitis B burdens in the world.

Researchers argued the study could expand access, but critics—including African bioethics experts and global health leaders—called it a damaging echo of Tuskegee: a randomized trial knowingly depriving infants of a life-saving vaccine. Public pressure led to the trial's suspension and a promise to redesign it under stronger ethical oversight.

As Paul Offit, an infectious diseases physician at the Children’s Hospital of Philadelphia and former member of the FDA vaccines and related biological products advisory committee, said to The Guardian: “You can’t treat children like this. You can’t treat people like this.”

These events make one thing unmistakably clear: Black communities have every reason to distrust U.S. health institutions—and that includes the current administration.

This distrust is not irrational. It is not rooted in misinformation. It is grounded in lived experience and a history of systemic abuse—from Tuskegee to Guinea-Bissau, from forced sterilizations to the denial of care. When institutions treat Black lives as expendable or experimental, they forfeit trust. Rebuilding it requires more than statements—it requires action, transparency, and a willingness to confront the systems that made that distrust necessary.

And I fully recognize that knowledge doesn’t undo harm. But it can help prevent it. So let's talk about what we know—about syphilis, the bacteria, and how it works.

What Causes Syphilis: The Bacterium

Syphilis is caused by a bacterium called Treponema pallidum. This organism belongs to a group known as spirochetes—thin, spiral-shaped bacteria that move through tissue by corkscrew-like motion.

Treponema pallidum has several characteristics that make it particularly dangerous. It replicates slowly, produces very few surface proteins that the immune system can recognize, and triggers only a weak and incomplete immune response. As a result, infection does not lead to lasting immunity, and people can become reinfected even after successful treatment.

The bacterium is also notoriously difficult to culture in the laboratory, which historically limited research and still complicates diagnosis in some settings. Its stealth is central to its success.

Transmission and Incubation

Syphilis is transmitted primarily through sexual contact, including vaginal, anal, and oral sex, via direct contact with infectious lesions.

After exposure, the incubation period typically ranges from 10 to 90 days, with an average of about three weeks. During this time, individuals are infected but asymptomatic. This delay contributes to unrecognized spread and delayed diagnosis.

Maternal and Congenital Syphilis

Syphilis can also be transmitted vertically, from a pregnant person to their fetus at any stage of pregnancy by crossing the placenta . Infection can lead to miscarriage, stillbirth, premature delivery, low birth weight, or congenital infection.

Babies born with congenital syphilis may appear healthy at birth or may show signs such as rash, anemia, liver enlargement, bone abnormalities, or neurologic damage. Some complications emerge months or years later, including hearing loss, vision problems, and developmental delays.

These outcomes are tragic because they are largely preventable. Universal prenatal screening, repeat testing when indicated, and timely treatment save lives. Congenital syphilis often occurs when these steps fail to happen.

The Four Stages of Syphilis—and Why Symptoms Can Be Misleading

Syphilis progresses through four clinical stages if left untreated. These stages are not just academic distinctions; they explain why the disease is so often missed and misunderstood.

Primary Syphilis: Primary syphilis usually begins with the appearance of a chancre, a firm, painless sore that develops at the site of infection. Because it does not hurt and often occurs in areas that are not easily visible, it is frequently overlooked. The chancre heals on its own within a few weeks, even without treatment.

This spontaneous healing creates a dangerous illusion: many people assume the infection has resolved. In reality, the bacterium has simply moved deeper into the body.

Secondary Syphilis: Weeks to months later, secondary syphilis develops as the infection spreads systemically. Symptoms may include a widespread rash—often involving the palms of the hands and soles of the feet—along with fever, fatigue, sore throat, swollen lymph nodes, and muscle aches.

Because these symptoms resemble many other illnesses, syphilis has earned the nickname “the great imitator.” Once again, symptoms may resolve without treatment, reinforcing the false belief that the infection is gone.

Latent Syphilis: After secondary symptoms disappear, syphilis enters the latent stage. During this phase, there are no symptoms at all, but the bacterium remains in the body. Early latent syphilis is still infectious; late latent syphilis is less likely to be transmitted sexually but remains dangerous.

Latent syphilis is especially hazardous during pregnancy. Even in the absence of symptoms, the infection can cross the placenta and infect the fetus.

Tertiary Syphilis: Years or even decades after initial infection, untreated syphilis can progress to tertiary disease. This stage can involve the heart, blood vessels, brain, eyes, and nervous system. Complications include neurosyphilis, cardiovascular syphilis, blindness, paralysis, and cognitive impairment.

These severe outcomes are less common today due to antibiotic availability, but they still occur—particularly in people who were never tested or treated.

Testing: The Only Way to Know

Syphilis cannot be reliably diagnosed based on symptoms alone. Because the disease can be silent for long periods, blood testing is essential.

Modern syphilis testing is accurate, widely available, and relatively inexpensive. Screening is recommended for sexually active individuals at increased risk and universally during pregnancy, with repeat testing when risk persists.

Also...prior infection does not give you immunity, so you can be reinfected multiple times. This is why regular testing is so important.

And testing is not a moral judgment. It is a public health tool—and often the only line of defense.

Treatment: Effective, Simple, and Underused

Syphilis is curable. The standard treatment is the long-acting high-dose injectable form of benzathine penicillin G, or what we usually refer to as just plain penicillin...this antibiotic remains highly effective against Treponema pallidum at all stages of infection. And the long-acting injection maintains therapeutic levels in the blood over time, which is essential to eliminate the slow-replicating syphilis bacterium. Oral penicillin does not work for syphilis, it has to be the shot. Also...the number of doses required depends on the stage of disease: early syphilis requires one shot while late-stage requires 3 shots.

Now, penicillin is safe during pregnancy and when administered promptly, it can prevent transmission to the fetus and avert devastating outcomes.

But this injected form of penicillin is the only antibiotic that is effective against syphilis during pregnancy. So, pregnant women with syphilis at any stage who are allergic to penicillin have to be desensitized to, and then treated with, penicillin.

For people who are not pregnant but have a penicillin allergy, there are a few alternative treatments for early syphilis, though the data supporting them are more limited.

The most commonly used option is doxycycline (100 mg by mouth twice a day for 14 days), which is generally preferred over tetracycline due to fewer side effects and easier dosing. Another option is ceftriaxone, given by injection (1 gram daily for 10 days), though the best dose and duration are still being studied.

Azithromycin was once considered, but due to rising resistance and treatment failures, it is no longer recommended in the U.S.

Regardless of the alternative, close follow-up is essential to ensure the treatment worked. And for anyone who can’t be reliably followed—or is at high risk of complications—penicillin desensitization is recommended over alternatives so they can still receive benzathine penicillin G safely.

But as demand rises and supply chains falter, many clinics—especially in underserved areas—are left without access. The result: missed treatments, delayed care, and preventable congenital infections.

This isn’t just a supply issue—it’s a systems issue. A shortage of a 70-year-old drug should not be the reason babies are born with syphilis. And yet, here we are.

Prevention and Protection

What treatment cannot do is reverse damage that has already occurred. This is why early diagnosis matters so profoundly. Preventing syphilis requires a combination of routine testing, accessible healthcare, prompt treatment, and partner notification. Condoms reduce risk but do not eliminate it, as lesions may occur outside covered areas. There is currently no vaccine for syphilis, making screening and treatment the cornerstone of prevention.

Most importantly, prevention depends on normalizing testing and removing barriers to care. Silence, stigma, and delayed diagnosis allow syphilis to persist.

Syphilis is not a mystery disease. It is not incurable. It is not subtle because it is harmless—it is subtle because the bacterium has evolved to hide.

When babies are still harmed by a curable infection, the problem is not a lack of medical knowledge. It is neglect of public health systems, inequitable access to care, and failure to treat silence as a warning rather than reassurance.

Protect yourself and those you love...use protection, get tested regularly and if positive get treated right away and tell your partners so they can get treated too.

Thanks for being here. Until next week, stay healthy, stay informed, and spread knowledge not diseases.