Title : The congenital syphilis crisis and health inequity in South Dakota’s native American communities

Congenital syphilis (CS) poses a global challenge, with cases in the US increasing by 845% in the past 10 years. Despite widespread understanding of prevention strategies and readily available definitive treatment it continues to carry a high burden of infant mortality (7%) and morbidity (33%) in the US. Native American communities in South Dakota have the highest CS rate of any US demographic, with a rate of 680.8 cases per 100,000 births, and have experienced an increase in rate by 300% since 2019. This epidemiological study evaluates trends in CS rates in South Dakota (SD) at the county level and explores the effectiveness of current intervention strategies. An epidemiological analysis was conducted using surveillance data from the Centres for Disease Control and Prevention, South Dakota Department of Health, informed by a narrative review of peer-reviewed literature. Analysis focussed on temporal trends in congenital syphilis rates and geographical distribution within Native American populations in South Dakota from 2019-2025. Data is limited by CS often being diagnosed long after birth, thus rates are provisional and will likely increase. Between 2019 and 2023 CS cases in SD rose sharply from 2 to 54 cases, cases have since declined but remain around 20 times pre-2019 levels. CS disproportionately affects Native American populations, 93% of CS cases since 2019 were in Native American infants, despite comprising only 12% of the total births in SD. In 2023 CS affected 1 in 42 live births to Native American women in South Dakota, almost 10 times the rate for white women (1 in 3988). This difference is only partially explained by the disparity in prevalence of syphilis between Native American and white women. Healthcare inequity in Native American populations is well established, however, in SD they face several additional barriers. Indian reserve communities suffer from poor access to maternity services due to their rurality, among CS cases from 2022-2025, 80% were in rural counties, of these, 47.5% received no pre-natal care. This is compounded by reduced healthcare engagement, stemming from factors including punitive measures for substance use in pregnancy and a historical mistrust of healthcare institutions by Native Americans. A 31% reduction in cases since 2023 likely reflects the impact of new targeted education and outreach by community organisations, social media campaigning, and the expanded screening programmes in primary care and emergency settings. Sustained progress will require culturally competent, community-driven strategies, improved access to prenatal services in rural areas, and policy approaches that reduce stigma and structural barriers to care. Without this, current gains are unlikely to be sustained, and congenital syphilis will remain disproportionately concentrated in Native American communities.

Dr James Young is a Resident Doctor with a strong interest in Public Health Medicine and health inequalities. His work in Native American health began through public health outreach on the Rosebud Indian Reservation in South Dakota, where he worked alongside the Massachusetts General Hospital Rural Medicine team. This experience informed his subsequent work in Public Health in Cheshire East, where he spent two years leading research projects and needs assessments, presenting his work at a national level. Meanwhile, Dr Young is involved in delivering healthcare and health education in refugee settings in Greece, further developing his interest in global health and underserved populations.