By Jazmin Orozco Rodriguez for KFF Health News.
Broadcast version by Kathleen Shannon for Greater Dakota News Service reporting for the KFF Health News-Public News Service Collaboration

Natalie Holt sees reminders nearly everywhere of the serious toll a years-long syphilis outbreak has taken in South Dakota. Scrambling to tamp down the spread of the devastating disease, public health officials are blasting messages to South Dakotans on billboards and television, urging people to get tested.

Holt works in Aberdeen, a city of about 28,000 surrounded by a sea of prairie, as a physician and the chief medical officer for the Great Plains Area Indian Health Service, one of 12 regional divisions of the federal agency responsible for providing health care to Native Americans and Alaska Natives in the U.S.

The response to this public health issue, she said, is not so different from the approach with the coronavirus pandemic — federal, state, local, and tribal groups need to “divide and conquer” as they work to test and treat residents. But they are responding to this crisis with fewer resources because federal officials haven’t declared it a public health emergency.

The public pleas for testing are part of health officials’ efforts to halt the outbreak that has disproportionately hurt Native Americans in the Great Plains and Southwest. According to the Great Plains Tribal Epidemiology Center, syphilis rates among Native Americans in its region soared by 1,865% from 2020 to 2022 — over 10 times the 154% increase seen nationally during the same period. The epidemiology center’s region spans Iowa, Nebraska, North Dakota, and South Dakota. The center also found that 1 in 40 Native American and Alaska Native babies born in the region in 2022 had a syphilis infection.

The rise in infections accelerated in 2021, pinching public health leaders still reeling from the coronavirus pandemic.

Three years later, the outbreak continues — the number of new infections so far this year is 10 times the full 12-month totals recorded in some years before the upsurge. And tribal health leaders say their calls for federal officials to declare a public health emergency have gone unheeded.

Pleas for help from local and regional tribal health leaders like Meghan Curry O’Connell, the chief public health officer for the Great Plains Tribal Leaders’ Health Board and a citizen of the Cherokee Nation, preceded a September letter from the National Indian Health Board, a Washington, D.C.-based nonprofit that advocates for health care for U.S. tribes, to publicly urge the Department of Health and Human Services to declare a public health emergency. Tribal leaders said they need federal resources including public health workers, access to data and national stockpile supplies, and funding.

According to data from the South Dakota Department of Health, 577 cases of syphilis have been documented this year in the state. Of those, 430 were among Native American people — making up 75% of the state’s syphilis cases, whereas the group accounts for just 9% of the population.

The numbers can be hard to process, O’Connell said.

“It’s completely preventable and curable, so something has gone horribly wrong that this has occurred,” she said.

The Great Plains Tribal Leaders’ Health Board first called on HHS to declare a public health emergency in February. O’Connell said the federal agency sent a letter in response outlining some resources and training it has steered toward the outbreak, but it stopped short of declaring an emergency or providing the substantial resources the board requested. The board’s now months-old plea for resources was like the recent one from the National Indian Health Board.

“We know how to address this, but we do need extra support and resources in order to do it,” she said.

Syphilis is a sexually transmitted infection that can result in life-threatening damage to the heart, brain, and other organs if left untreated. Women infected while pregnant can pass the disease to their babies. Those infections in newborns, called congenital syphilis, kill dozens of babies each year and can lead to devastating health effects in others.

Holt said the Indian Health Service facilities she oversees have averaged more than 1,300 tests for syphilis monthly. She said a recent decline in new cases detected each month — down from 92 in January to 29 in September — may be a sign that things are improving. But a lot of damage has been done during the past few years.

Cases of congenital syphilis across the country have more than tripled in recent years, according to the Centers for Disease Control and Prevention. In 2022, 3,700 cases were reported — the most in a single year since 1994.

The highest rate of reported primary and secondary syphilis cases in 2022 was among non-Hispanic American Indian or Alaska Native people, with 67 cases per 100,000, according to CDC data.

O’Connell and other tribal leaders said they don’t have the resources needed to keep pace with the outbreak.

Chief William Smith, vice president of Alaska’s Valdez Native Tribe and chairperson of the National Indian Health Board, told HHS in the organization’s letter that tribal health systems need greater federal investment so the system can better respond to public health threats.

Rafael Benavides, HHS’ deputy assistant secretary for public affairs, said the agency has received the letter sent in early September and will respond directly to the authors.

“HHS is committed to addressing the urgent syphilis crisis in American Indian and Alaska Native communities and supporting tribal leaders’ efforts to mobilize and raise awareness to address this important public health crisis,” he said.

Federal officials from the health department and the CDC have formed task forces and hosted workshops for tribes on how to address the outbreak. But tribal leaders insist a public health emergency declaration is needed more than anything else.

Holt said that while new cases seem to be declining, officials continue to fight further spread with what resources they have. But obstacles remain, such as convincing people without symptoms to get tested for syphilis. To make this easier, appointments are not required. When people pick up medications at a pharmacy, they receive flyers about syphilis and information about where and when to get tested.

Despite this “full court press” approach, Holt said, officials know there are people who do not seek health care often and may fall through the cracks.

O’Connell said the ongoing outbreak is a perfect example of why staffing, funding, data access, and other resources need to be in place before an emergency develops, allowing public health agencies to respond immediately.

“Our requests have been specific to this outbreak, but really, they’re needed as a foundation for whatever comes next,” she said. “Because something will come next.”


Jazmin Orozco Rodriguez wrote this story for KFF Health News.


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A newly installed rooftop solar power system will help the Free Clinic of Simi Valley keep its doors open and the lights on for the area's disadvantaged patients.

The Ventura County facility annually serves more than 10,000 uninsured or underinsured, low-income residents. Funding for the project was provided through a grant from the global nonprofit humanitarian aid organization Direct Relief.

Fred Bauermeister, executive director of the clinic, said being mostly "off the power grid" allows them to fund other priorities.

"Despite the fact that we got this building donated, we still have to pay $3,000 a month in electricity, which from a nonprofit point of view, is hard money to raise," Bauermeister, explained. "It's not very compelling when I go out in the community and say, 'Hey, would you give money so we can pay the electricity bill?'"

He pointed out the solar array, combined with soon-to-be-completed battery backup, will provide 53 kilowatts of power, enough to make the clinic officially net-zero in terms of carbon emissions.

The $165,000 grant from Direct Relief comes through the group's Power for Health Initiative, born amid the aftermath of Hurricane Maria in Puerto Rico.

Sara Rossi, managing director of the group's Health Resiliency Fund, said health providers' biggest need was to get the power back on.

"That could include making them more resilient to the effects of climate change through rooftop solar and battery backups that help them weather power outages," Rossi outlined. "Or helping them increase their ability to store cold chain medications and vaccines."

Bauermeister added Direct Relief's solar power system is a gift to their patients that will keep on giving.

"They were generous enough to give us a grant to install 135 solar panels on our roof," Bauermeister noted. "So far, we saved $8,249.87 and that will go on forever. We're forever going to save money on electricity."

Nebraska was among the states affected by the recent E. coli outbreak traced to onions in McDonald's hamburgers. Federal officials said they are now certain about the source but broader questions about the overlap with beef production linger.

The outbreak caused at least one death and sickened dozens of people. This week, key federal agencies closed the investigation, which pinpointed onions from a Colorado farm, while also ruling out burger patties. Ahead of the conclusion, some food safety experts wondered more about bacteria in manure from factory farms, where livestock is raised, finding its way to produce operations.

Prashant Singh, associate professor of health, nutrition and food science at Florida State University, explained the problem with having the different farming operations so close to each other.

"Manure, sometimes, if not properly processed in large operations, can spill over into a fresh produce area," Singh pointed out.

More specifically, contaminated dust particles from waste at concentrated animal feeding operations can land on fields of lettuce, for example, or get into irrigation canals. Separately, a California carrot company last month launched a voluntary recall because of an E. coli outbreak. Environmental groups noted many carrots in California are grown near factory farms.

Singh emphasized meat production has accelerated under evolving technology, with regulations enforced by the U.S. Department of Agriculture but produce is monitored by the Food and Drug Administration and he said the resources are vastly different.

"On the FDA side, they lack everything," Singh observed. "Their hands are very full. "

Even with the resource imbalance, other food safety experts note the meat lobby has focused heavily on avoiding strict regulations under the USDA, and existing laws have limits. Meanwhile, data from the Centers for Disease Control and Prevention show there have been nine multistate foodborne illness outbreaks in 2024.

This story is based on original reporting by Nina Elkadi for Sentient.


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A new report found New York hospitals are in a precarious financial state.

The New York State Hospitals Fiscal Survey Report showed statewide hospitals are projecting an operating budget margin of 0.0% percent. While it is a slight improvement, hospital administrators said it is still insufficient for hospitals to handle patient care.

Bea Grause, president of the Healthcare Association of New York State, said government reimbursements do not cover the costs of administering health care.

"Those reimbursements are fixed and do not change," Grause pointed out. "They grow a little bit year over year but they're not keeping up with the expense growth that all hospitals are experiencing."

She noted hospitals cannot raise their commercial expenses with the expectation it will make up the difference, arguing the best way to help hospitals is to close the gap on Medicare and Medicaid payments so they keep up with expense growth. Prescription drugs are the largest continuously increasing expense hospitals face since such prices run 83% above the rate of inflation.

Staffing issues are being exacerbated by New York hospital's fiscal challenges. The report found labor expenses have grown more than 36% since 2019. While it is the second year of declining contract labor expenditures, they are double what they were in 2019.

Grause emphasized not having sufficient staff can affect the services hospitals offer.

"If a hospital is going to have a dialysis unit, you need a nephrologist. You'd probably need more than one nephrologist," Grause observed. "But you also need specially trained nurses, you need the right equipment, you need all the medication, you need the IV solution and the peritoneal solution."

Another factor in hospitals' declining operating margins is insurer demands. The report showed some surveyed hospitals project insurers' actions will cut their 2024 operating revenues by 5% or more. Estimates showed it would result in $1.3 billion or more in lost revenue for the hospitals.


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