Neonatologist Gurvir Khurana had only read about it in textbooks. Seeing it in real life has been a shock: baby after baby born severely anemic, lungs filled with fluid, bodies covered with rashes. Some only lived minutes; others died within days or weeks.
The cause: congenital syphilis.
They are all born to mothers with syphilis. Many of the mothers arrive at the hospital to give birth never having had prenatal care, unaware they have the disease — let alone that they could pass it on to their unborn babies. The infants who survive carry an elevated risk of long-term health problems.
"It’s been an absolute explosion," said Khurana, who works at four Bakersfield hospitals. "It’s just spreading very, very quickly. Kern County has a huge public health problem on its hands."
The Central Valley — a vast agricultural and mostly low-income swath of California — has seen an unprecedented spike in congenital syphilis over the past few years. It’s part of an overall rise in syphilis and other sexually transmitted diseases across California and the nation.
"STD rates aren’t going to just stop," said Natasha Felkins, a health educator for Planned Parenthood in Bakersfield. "When health coverage goes away or when things are cut, we are going to see numbers increase, and that’s going to affect all of us."
Across the U.S., sexually transmitted diseases are at an all-time high, according to the Centers for Disease Control and Prevention. The rate of syphilis among women increased 27 percent from 2014 to 2015, and congenital syphilis increased by 6 percent. Preliminary data show the trend continued in 2016, with syphilis among women rising another 21 percent and congenital syphilis another 4 percent.
"There was great hope for syphilis elimination in the United States," said Gail Bolan, director of the CDC’s division of sexually transmitted disease prevention. "Unfortunately, our national data now show that syphilis is thriving."
Bolan said CDC officials are closely monitoring the epidemic of syphilis in California and around the nation. They are watching with particular concern the spike in cases among women, and encouraging more testing, treatment and education. In California, about two-thirds of syphilis cases are still among men who sleep with men, but the number of cases among women between ages 15 and 44 quadrupled from 2011 to 2015, according to the state Department of Public Health. Department officials said the rise in the number of syphilis cases means that more women are at risk of giving birth to babies with the disease.
In California, congenital syphilis cases tripled from 2011 to 2015. In 2015, nearly half of them were in Fresno and Kern counties. Kern County had 28 cases of congenital syphilis in 2015, up from one in 2011. Nearby Fresno County had 40 in 2015, up from two four years earlier. The rates in both counties dwarf others around the state.
California’s rate of syphilis among newborns is the second highest in the United States after Louisiana, and the state ranks third after Louisiana and Georgia for syphilis among women, according to the CDC.
Local and state health officials and providers are uncertain of the precise reason for the sharp rise in such cases. One factor, they believe, is that many women get prenatal care too late, or not at all. They also attribute the problem to drug use that leads to risky sexual behavior, poverty and a lack of awareness of the risks of syphilis and other STDs. Also to blame, they say, are changes in sexual behavior, including reduced condom use and a tendency to have more partners.
Many sexually transmitted infections are asymptomatic and go undiagnosed until they start to cause damage. Untreated, they can lead to serious health problems, including blindness and infertility.
"We see very, very severe complications," said Heidi Bauer, chief of the STD control branch at the California Department of Public Health. "And as we see these rates increase, we are inevitably going to see … these complications increase and have devastating health consequences."
California recently awarded $5 million to counties around the state in an effort to reduce STD rates. The state is also promoting more widespread screening, which Bauer said has become more difficult as county clinics have closed their doors. She said some of the hardest-hit areas are in the Central Valley.
In the early stages of syphilis, symptoms are mild and can be mistaken for something less serious. They include sores, rashes and fevers. In some cases, there are no early symptoms at all. Advanced syphilis, however, can cause severe medical problems, including of the brain and heart.
The public health department has embarked on a massive information campaign with the slogan "Know Your Risk." Staff members have posted billboards around the county, distributed fliers and produced public service announcements. Many feature an image of a pregnant woman with the words: Syphilis. A Silent Killer.
"Babies were dying," said Michelle Corson, who helped design the campaign for Kern County Public Health Services. "That was the heart of the crisis."
Felkins, of Planned Parenthood, travels around Kern County talking to people about STDs. She said when she explains that the rates in Kern are among the highest in the state, "there are always gasps."
Renee Nichols, 22, said she regularly comes to Planned Parenthood for birth control and STD testing. About four years ago, Nichols was treated for syphilis, which she contracted while she was addicted to methamphetamine. Nichols, who is now clean and studying to be a physical therapist, said that, at the time, STDs were the last thing on her mind.
"You’re just busy thinking about drugs," she said. "You’re not thinking about if I have sex with this person that I might get a disease."
That’s what worries Khurana, the neonatologist. He said many of the women who have passed along syphilis to their babies were drug users. "The elephant in the room is always going to be substance abuse," he said. "It is a huge problem in this town."
All states require pregnant women to be tested once for syphilis during pregnancy, but CDC officials say that to minimize the risk, pregnant women should be tested a second time in the third trimester.
Vyn Wayne, a nurse practitioner at the Bakersfield site of Clinica Sierra Vista, a community health center, said girls as young as 16 or 17 are showing up pregnant with syphilis. Wayne said she currently has seven pregnant patients with the disease. "We’ve just been floored. It’s terrifying," she said.
One afternoon in February, Wayne saw 18-year-old Serenity Thomason, who wore slippers with hearts on them. Wayne ordered a syphilis test for Thomason, who was six months pregnant.
She explained to Thomason that syphilis is contracted through sex and can be treated. But people often don’t know they have it, and if the mother is not treated, it can be passed to the fetus during pregnancy and be "deadly to babies," she said.
"That’s scary," said Thomason as she rubbed her stomach. "I never heard about syphilis."