For the past several years, Fresno County, which had 63 cases of congenital syphilis in 2017, had the highest rate in California. In 2018, Fresno fell to fourth, behind Yuba, Kern and San Joaquin counties. But the epidemic is far from under control. "I couldn't even tell you how soon I think we're going to see a decrease," said Jena Adams, who oversees HIV and STD programs for Fresno County.
Syphilis was once a prolific and widely feared STD. But by the 1940s, penicillin was found to have a near-perfect cure rate for the disease. By 2000, syphilis rates were so low in the U.S. that the federal government launched a plan to eliminate the disease. Today, that goal is a distant memory.
Health departments once tracked down every person who tested positive for chlamydia, gonorrhea or syphilis, to make sure they and their partners got treatment. With limited funds and climbing caseloads, many states now devote resources only to tracking syphilis. The caseloads are so high in some California counties that they track only women of childbearing age or just pregnant women.
"A lot of the funding for day-to-day public health work isn't there," said Dr. Jeffrey Klausner, a professor at the University of California, Los Angeles who ran San Francisco's STD program for more than a decade.
The bulk of STD prevention funding is appropriated by Congress to the CDC, which passes it on to states. That funding has been largely flat since 2003, according to data from the National Coalition of STD Directors, which represents health departments across the country. Take into account inflation and the growing caseloads, and the money is spread thinner. "It takes money, it takes training, it takes resources," Klausner said, "and policymakers have just not prioritized that."
A report this year by Trust for America's Health, a public health policy research and advocacy group, estimated that 55,000 jobs were cut from local public health departments from 2008 to 2017. "We have our hands tied as much as (states) do," said Bowen of the CDC. "We take what we're given and try to distribute it as fairly as we can."
San Joaquin County health officials have reorganized the department and applied for grants to increase the number of investigators available as congenital syphilis has spiked, said Hemal Parikh, county coordinator for STD control. But even with new hires and cutting back to tracking only women of childbearing age with syphilis, an investigator can have anywhere from 20 to 30 open cases at a time. In other counties, the caseload can be double that.
In 2018, Jennifer Wagman, a UCLA professor who studies infectious diseases and gender inequality, was part of a group that received CDC funding to look into what is causing the spike in congenital syphilis in California's Central Valley.
Wagman said that, after years of studying health systems in other countries, she was shocked to see how much basic public health infrastructure has crumbled in California. In many parts of the Central Valley, county walk-in clinics that tested for and treated STDs were shuttered in the wake of the recession. That left few places for drop-in care, and investigators with no place to take someone for immediate treatment. Investigators or their patients must make appointments at one of the few providers who carry the right kind of treatment, and hope the patients can keep the appointment when the time comes.
In focus groups, women told Wagman that working hourly jobs, or dealing with chaotic lives involving homelessness, abusive partners and drug use, can make it all but impossible to stick to the appointments required at private clinics.