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A remote epidemic

Two years ago, press headlines declared remote communities in northern Australia to be experiencing the “worst syphilis outbreak in 30 years”. It appears the situation is worsening. The outbreak — which originated along the Northern Territory/north-west Queensland border in 2011 — has since crossed into Central Australia and the Kimberley region of Western Australia. And now, according to a public health alert, South Australia is recording a “clustering of infectious syphilis cases among Indigenous persons in the Port Augusta region” with “potential for spread to other regions of SA”.

Which begs the question: why is an easily curable disease — to quote one health expert — “pretty much out of control”? “It really is a failure of health systems in Aboriginal communities and Aboriginal healthcare generally that we have such an outbreak in 2017,” says Darren Russell, Clinical Associate Professor at the University of Melbourne. James Ward, Associate Professor at the South Australian Health and Medical Research Institute, agrees. “Outbreaks like this one are related to the inappropriately low level of investment in sexual health in remote areas,” he says. “They highlight the lack of high-quality education, primary healthcare and specialist outreach programs, all of which could stop these high rates of infection.”   

Australia is not alone in reporting syphilis outbreaks among its Indigenous populations. Globally, Native Americans, African Americans and First Nations people have all been affected. And, says Ward, they all share a common problem: “Lack of access to affordable, appropriate and culturally acceptable healthcare.”

Syphilis rates among Australia’s Aboriginal and Torres Strait Islander populations have long been disproportionately high. Indeed, in 2015, rates of syphilis were six times that of non-Indigenous people. “It’s a national shame,” says Ward. “There’s just a huge disparity between the two populations.” (The only other areas outside remote Australia affected by syphilis are urban gay communities in capital cities; among the general population, syphilis remains rare.)

Syphilis can be cured with a single injection of penicillin, but if left untreated it can have serious health impacts. Pregnant women, particularly, are a cause for concern with untreated syphilis leading to stillbirths, disabilities, and deaths. Since the epidemic began, at least four babies have died of congenital syphilis. "In a country like Australia, in this day and age, it’s almost unbelievable — it shouldn’t occur,” says Russell.

Such catastrophic outcomes, says Ward (pictured), “highlight the urgent need for investment in sexual health services for young Aboriginal Australians living in remote regions”. Funding, of course, is crucial — yet the problem goes deeper than that. The current approach, argues Patricia Fagan, Associate Professor at James Cook University in Queensland, is “ineffective and wasteful, being characterised by poorly or inappropriately resourced, uncoordinated, piecemeal and often ill-conceived interventions”. Success, Fagan believes, will ultimately hinge on wisely deployed resources and commitment — “The commitment of health systems, communities and families to safeguard their youth.”

With the unacceptable level of other STIs well documented among Aboriginal youth, the capacity of syphilis to readily gain a foothold in so many remote locations comes as no surprise to Fagan. After all, remote Australian youth face specific disadvantages in relation to their sexual health as evidenced in lower levels of knowledge about STIs; significant levels of sexual risk behaviours; poor access to condoms; and inadequate access to skilled sexual health services. “In my view,” says Fagan, “good luck alone has to date prevented HIV/AIDS from becoming a significant issue in these settings. If the future only holds more of the same, the question must be: when will this luck run out?”

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