Stigma and the return of syphilis

Syphilis, one of the oldest infections known to humans, has returned to the U.S. at epidemic rates that have been climbing since 2001. In 2022, the last year with complete data, the highest number of infections were recorded in more than 70 years. It’s not yet clear why syphilis is spreading faster than other sexually transmitted infections. Recent shortages of single injection penicillin needed to treat this infection threatens to make matters worse.

Stemming the return of syphilis will take more than manufacturing more penicillin. It will require counteracting stigma, a longstanding problem that has resulted in critical failures in health care access and delivery. The stigma of syphilis is strikingly powerful, even compared to other historically stigmatized conditions like HIV and cancer. While stigma isn’t the single cause driving the surge of syphilis, failing to address it will only worsen the epidemic. Addressing it means receiving supportive care in a health system that offers easy, equitable, and nonjudgmental access to treatment.

Syphilis is a diagnosis shrouded in shame and secrecy. There’s not a single patient advocacy group that places the word “syphilis” in the organization’s name. Public health officials have expressed skepticism that a “faces of syphilis” campaign, patterned after the “faces of AIDS” and red ribbons of the 1990s, could ever get off the ground.

Stigma can make a person diagnosed with syphilis feel set apart from others and isolated. Social messages that associate syphilis with immoral or risky behavior make them feel responsible for being exposed to an infection through sex. They may conceal a diagnosis, even after it has been treated, for fear it would discredit them in the eyes of others, including sexual partners.

Stigma inhibits individuals from seeking care in a timely way. Stigmatizing views harbored by health care providers can prevent them from treating certain patients effectively and compassionately. The history of sexually transmitted infection campaigns shows that blaming people affected by (or at risk for) syphilis has stymied testing and treatment, promoting the further transmission of a disease that has been highly treatable since the antibiotic revolution of the 1940s and 1950s.

At the policy level, stigma produces indifference. Due to the stigma associated with sexually transmitted infections, there has been little political enthusiasm to adequately fund prevention and treatment programs. Even as rates of sexually transmitted infections have risen over the past decade, the Center for Disease Control and Prevention’s budget for them has remained essentially flat. Many STI clinics are facing layoffs with looming cuts in public health funding.

That forces chronically underfunded public health agencies to prioritize their efforts on targeted subgroups. Native Americans and Alaska Natives, Black Americans, men who have sex with men, substance users, and other minoritized groups are most affected by the current syphilis epidemic. But rates have also been increasing among women, illustrating the fallacy of associating an infectious disease with a particular population.

The precipitous rise in cases of congenital syphilis — which can cause stillbirth, infant death, and life-altering birth defects — reveals fundamental weaknesses in how U.S. health systems deliver prenatal care to at-risk pregnant women, especially in minoritized communities. Babies born to Black, Hispanic, and Native American mothers are eight times more likely to have congenital syphilis than those born to white mothers.

The current epidemic of syphilis can be best explained as a critical breakdown in health care delivery. The rise of congenital syphilis marks not a change in individual risk behavior, but rather fundamental systems failures; it represents that public health interventions are not getting to people in a timely way. The bitter irony is that the U.S., where science has produced so many remarkable new therapies, does such a poor job delivering them equitably to populations that are vulnerable, historically marginalized, and have limited or no access to health services.

The CDC points to how the Covid-19 pandemic drew resources away from syphilis control programs. Shifting inadequate resources from disease to disease — Whac-a-Mole medicine — ensures failure. It obscures the syndemic interactions between diseases and underlying social drivers of health. It also overlooks how systematically addressing structural issues in health and health care promises not only to reduce the current rates of syphilis but also to support the development of a robust and integrated health care and public health system. Treating syphilis requires the integration of public health and clinical care.

Public health and medicine possess the tools to stop the resurgence of syphilis. What’s needed is providing fast access to testing and treatment. Approaches for STI prevention and treatment include integrating sexual, reproductive, and prenatal health into primary care; access to home testing; expedited treatment; and post-exposure prophylaxis with the antibiotic doxycycline. All of these are premised on a vision articulated by the Department of Health and Human Services that “every person has high-quality STI prevention, care, and treatment while living free from stigma and discrimination.”

Although the problem of stigma is a recognized obstacle in public health, many destigmatization efforts have taken the form of “end the stigma” advertising campaigns suggesting that individuals should choose to stop stigmatizing people for a health condition. But treating stigma as an individual psychological response discounts the formidable sociocultural and political bases that underlie bias, discrimination, and neglect.

Instead, the stigma of syphilis and other sexually transmitted infections is best countered by enhancing access to effective treatment. A pivotal moment in the HIV-AIDS pandemic arrived with the introduction of the antiretroviral “treatment as prevention” paradigm. The effort to respond to syphilis should recognize how the delivery of effective treatment reduces stigma. Providing access to care is a powerful form of destigmatization. Combating stigma is necessary not merely to reduce the physical and psychological harms of syphilis, but also to achieve the social solidarity necessary for health to prosper.

While no single variable can explain the recent rise in syphilis cases, diseases are a sensitive and critical measure of social policies and cultural beliefs. The return of syphilis is a powerful indicator that U.S. approaches to health care delivery, public health, and equity have failed. Delivering essential public health services to people with undiagnosed and untreated infections will not only help reduce new cases of syphilis; it also will support addressing the causes of many other infectious and non-infectious diseases.

Stigma blocks appropriate policies, resources, and care. Destigmatization through treatment is imperative for achieving public health equity.

Jacob D. Moses, Ph.D., is an assistant professor of bioethics and health humanities at the University of Texas Medical Branch at Galveston. Allan M. Brandt, Ph.D., is a professor of the history of medicine and public health at Harvard University and is the author of “No Magic Bullet: A Social History of Venereal Disease Since 1880” (Oxford University Press, updated edition 2020).