Public Health

Syphilis symptoms and causes, Bicillin shortage, cancer cases rise, and why sitting is so bad for us


AMA Update covers a range of health care topics affecting the lives of physicians, residents, medical students and patients. From private practice and health system leaders to scientists and public health officials, hear from the experts in medicine on COVID-19, medical education, advocacy issues, burnout, vaccines and more.

Why are syphilis cases on the rise? In this episode: what doctors need to know about syphilis transmission, how to treat syphilis, plus congenital syphilis.

AMA's Vice President of Science, Medicine and Public Health, Andrea Garcia, JD, MPH, also shares the latest cancer statistics, why cancer cases are on the rise and tips to reduce the harmful effects of sitting. AMA Chief Experience Officer Todd Unger hosts.


  • Andrea Garcia, JD, MPH, vice president, science, medicine & public health, American Medical Association

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Unger: Hello and welcome to the AMA Update video and podcast. Today, we have our weekly look at the headlines with the AMA's Vice President of Science, Medicine and Public Health, Andrea Garcia. I'm Todd Unger, AMA's chief experience officer. Welcome back, Andrea.

Garcia: Thanks, Todd. It's great to be here as always.

Unger: Well, last week, it was measles. But this week, it's another disease that we thought we wouldn't have to worry about again, and that is syphilis. Andrea I've been reading articles about this for a while. And a big one out this week from the New York Times with a lot of detail. Tell us more about what's going on.

Garcia: Yeah, Todd. So last week, we actually saw the CDC release their 2022 STI Surveillance Report. That's the latest year that we have comprehensive STI data for. Multiple news sources, including, as you mentioned, the New York Times, highlighted that CDC report and noted that we're now seeing the highest rates of new syphilis infections here in the U.S. really since the—since 1950.

I think, significantly, as we look at those numbers, more than 207,000 cases were reported in 2022 alone. That's about an 80% increase since 2018, a 17% increase over the previous year. And we're seeing increases across every age group, including newborns.

As you might remember, back in November, the CDC said more than 3,700 cases of congenital syphilis were reported in 2022. That's about 11 times the number that we saw recorded a decade ago. It tragically led to 231 stillbirths and 51 infant deaths.

Unger: That's very sad news. And from what I understand, the number of cases had declined to around 5,000 at one point. Now, we're back at 200,000. That's not kind of record that obviously we're hoping for. Do you have any sense of what's driving the increase?

Garcia: Well, there were several reasons talked about in that New York Times article. I think, for one, it could be linked to the increase we're seeing in substance use disorders, which is often, as we know, tied to risky sexual behavior. Also, with better prevention for HIV, we're seeing condom use decrease. We know that it fell by about 8% between 2011 and 2021 among high school students alone.

We've talked before about the COVID pandemic leading to disruptions. That's also true for STI-related prevention and care. We saw a redirection of some STI program resources to COVID activities. So now, there are fewer sexual health clinics along with disease intervention specialists and nurses who staff them.

I think, as many physicians know, we've also been facing a nationwide shortage of Bicillin LA, which is the first line recommended treatment for syphilis. And it's the only one recommended for some patients. We know this STI can spread quickly. If you miss one case, it can lead to several others and so on. And that obviously makes it more difficult to contain.

Unger: Absolutely. And I think you mentioned that we're seeing this kind of surge across multiple groups of people, and probably across the whole country. Tell us more about the extent.

Garcia: Yeah. So it's definitely worse in some states. So South Dakota, for example, had the highest rate of syphilis infections. That's more than double the number in New Mexico, which has the next highest rate. Arkansas, Oklahoma and Mississippi were also in the top 5.

Also, while those infections were found about in every community, they definitely disproportionately impacted some groups. According to that report, Black Americans comprise about 30% of primary and secondary syphilis cases. But with 67 cases per 100,000 people, Native American and Alaska Native people have the highest rates. I just want to be clear, those higher rates of STI infections in these populations are tied to social and economic marginalization that they experience.

Unger: Well, thank you for that perspective. You mentioned before about treatments. What happens if syphilis goes untreated?

Garcia: Well, Todd, it can be very serious. The infection can damage the heart and the brain, can cause blindness, deafness and paralysis. And as we've talked about before, infection during pregnancy is particularly serious. It can lead to miscarriage and stillbirth. And in those infants who do survive, they may be blind or deaf or have severe developmental delays.

Last summer, we know the Department of Health and Human Services did set up a national task force for syphilis, which, according to Admiral Rachel Levine, is focusing on those 14 jurisdictions with the highest rates.

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We've seen the CDC develop draft guidelines on the use of STI post-exposure prophylaxis with doxycycline or DoxyPEP. And that's for preventing some bacterial STIs. And then we've seen the FDA temporarily allow the importation of an alternative to the syphilis treatment, Bicillin LA. And that's to help address that national shortage that we're seeing.

Unger: So obviously, physicians are going to be very important in terms of addressing this problems. Andrea, what do they need to know?

Garcia: Well, we're seeing about 86% of syphilis cases in that report diagnosed outside of sexual health clinics. This means that, to control this epidemic, we're going to have to have primary care physicians, emergency departments, community health centers and then correctional and drug treatment programs engaged in screening for these infections. And this really needs to be a public health priority.

Unger: All right, Andrea. Thank you so much for that information. Of course, we're going to continue to track that. On a separate front, something else that's on the rise, despite better screening and treatments, is cancer. Andrea, what can you tell us about that?

Garcia: Yeah. Last Friday, we saw the World Health Organization come out with new estimates that suggest that global cancer diagnosis will reach 35 million in the year 2050. So to put that in perspective, it's about a 77% increase from the 20 million cases we saw diagnosed in 2022.

The data supporting these estimates was released by WHO's International Agency for Research on Cancer. It covers about 185 countries and 36 different forms of the disease. Researchers found that lung cancer was the most common form of cancer in the world in 2022.

That was followed by female breast cancer, colorectal, prostate and stomach cancers. Lung cancer was also responsible for the most cancer deaths, which is 1.8 million or almost 19% of the total.

Unger: Andrea, a figure like 77%, it's just shocking in terms of the number. Did the report suggest what is going to drive that increase?

Garcia: Yeah. Researchers pointed to several factors. So obesity, tobacco use, alcohol use, and then environmental factors like air pollution—and none of those are especially surprising. In the U.S., though, we do have a little bit of good news.

While that incidence rate of certain types of cancer is increasing, the number of people dying from cancer continues to decline. And according to a report—that's according to a report released last month by the American Cancer Society. From 1991 to 2021, cancer deaths in the U.S. fell 33%. And that's largely due to drops in tobacco use, earlier detection and then major improvements in treatment.

However, as is the case globally, we're still seeing those racial disparities with people of color being disproportionately affected. I think also worrisome is cancer patients are becoming younger. So if we looked at colorectal cancer, for example, diagnosis in adults under 55 rose from about 11% in 1995 to 20% in 2019.

Unger: And I know that's a somewhat mysterious trend. And we'll be, of course, tracking that carefully as we learn more. Andrea, this past weekend marked the two-year anniversary of President Biden's relaunch of his Cancer Moonshot Initiative. How does that initiative fit into all of this?

Garcia: Yeah. So that initiative is aimed at cutting the cancer death rate in half by 2047. We know NASA, the EPA have been engaged in this initiative, in addition to, of course, the Department of Health and Human Services and the VA. But these agencies, I think, certainly have their work cut out for them.

We've made a lot of progress on early detection and treatment of many cancers. But there are still huge disparities in outcomes between high and low income countries, and then as well as we know within countries. And I think one physician in that CNN article said where someone lives should not determine whether they live. Unfortunately, we have a long way to go before that becomes our reality.

Unger: Absolutely. And we also have a new insight that suggests how someone lives can affect longevity. What do we need to know about that?

Garcia: Todd, there was a study published in JAMA Network Open earlier in January. And it looked at people who mostly sit at work. And it found that they have a higher risk of mortality. CNN did a report on this article, noting the big takeaway is that most people who sit for their jobs need to exercise more in order to counter those effects.

So if we look at those numbers, people who sit at work have a 16% higher risk of mortality from all causes and a 34% higher risk of mortality from cardiovascular disease. To counter these increased risks, people would have to engage in an additional 15 to 30 minutes of physical activity per day.

Now, that's not 15 to 30 minutes total. It's an extra 15 to 30 on top of your regular exercise. This was a large study, 480,000 participants. And the researchers followed them over an average of nearly 13 years.

Unger: That's a lot of exercise. I don't know if I can have another 15 to 30 minutes on top of what I do already in the morning. What's the suggestion for people to get in 15 or 30 more minutes in?

Garcia: Yeah. So in that CNN article, Dr. Leana Wen helped analyze those results. And she suggested that there are some other studies that have shown that even light activity to break up those periods of prolonged sitting can help reduce risk. So that could even be like a slow walk on your treadmill.

Another study found that simply replacing 30 minutes of sedentary activity with light activity like walking or standing led to improvements in those key measures such as BMI and cholesterol levels. Now of course, higher intensity exercise has the bigger benefit. But light activity for small periods of time produced a difference, too.

So this isn't necessarily huge changes we're talking about. Dr. Wen referred to them as exercise snacks. I think the bottom line is when it comes to exercise, the more, the better. But a little can go a long way, too.

Unger: Well, Andrea, those were not exactly the kind of snacks I was thinking about. That's why I'm exercising in the first place for more snacks. But I'll have to change that, maybe even replace this desk with a treadmill.

That's it for today's episode. Andrea, thanks so much for being here. To all of you out there that are listening, if you appreciate public health leadership from a trusted source, then I encourage you to consider joining the AMA at

We'll be back soon with another AMA Update. In the meantime, you can find all our videos and podcasts at Thanks for joining us today. Please take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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