An outbreak of infectious syphilis has been declared an emergency in Alberta, Canada. The oil-and-gas-rich Alberta province has Canada’s highest gross domestic per capita wealth but now has some of the country’s highest rates of gonorrhea, chlamydia, and syphilis. The province’s public health managers say the spread of syphilis is the worst since 1948. All five demarcated health zones of Alberta province are grappling with the outbreak, but regions in the center and north of the province (where indigenous Native American [also called Aboriginal] communities are bigger) have the highest count of the infection.
Of course, authorities cite the rise of casual online hookup apps and declining condom use among younger Canadians as contributing to the spread of syphilis too. But a glance at the Alberta provincial government’s newest data on sexually transmitted infections (STIs) reveals a troubling trend: The infection is more rampant in its Aboriginal communities (who comprise a tiny 6.5% of the province’s population), apart from gay and bisexual men and immigrants whose romantic networks are thin.
In a press statement on July 16, Deena Hinshaw, M.D., M.P.H., Chief Medical Officer of Health for Alberta, told reporters that all segments of society in the province are vulnerable to syphilis. While she is right, the racialized pattern of the infection is no mere coincidence. The Alberta government’s own data show that syphilis rates are 18.6 times higher among young Aboriginal women and 2.8 times higher in Aboriginal men compared to their white counterparts. In 2018, the rate of infectious syphilis sharply climbed in the province’s demarcated “North Zone” to 43.5 cases per 100,000 people, past Canada’s national average of 10 per 100,000.
This is baffling, because this “North Zone” region has the third lowest population density in the province — 484,964 inhabitants, according to Alberta Health Services figures. Why has syphilis expanded more quickly in this zone? The answer lies in knowing who lives in this so-called “North Zone.” Of all private households in the North Zone, 25% identify as Aboriginal indigenous (e.g., Metis, First Nations, North American Indians, Inuit) ethnic groups, according to sample data from Canada’s statistics agency. The zone has the second lowest life expectancy in the province, at an average of 79.9 years. There is no prize for guessing that a vortex of issues helps syphilis flourish here.
One such issue is that, apart from the syphilis outbreak, Alberta province as a whole is also battling a wave of illicit opioid abuse. This is even more prevalent among its Aboriginal groups. Government figures show accidental opioid-related poisoning took 789 lives in 2018; 3,100 emergency hospital admissions from drug use occurred in the same period. This means two people died every day from an opioid-related cause in 2018. In fact, injection drug use is cited as the cause of exposure to HIV among 71% of cases in women in Alberta in 2018. Epidemiological investigations say injection drug users are at high risk for syphilis. For instance, women injection opioid users are vulnerable to transactional sex for drugs, money, or shelter. As drug use climbs, so does syphilis.
In 2018, substance and drug abuse was the most common route of acquiring HIV infection, according to Alberta Health figures, in the nearby “Central Zone” — where syphilis rates are troubling too. Canadians identifying as Aboriginal visited the emergency room over opioid and narcotics concerns five times more frequently than people who are non-Aboriginal. In 2016, indigenous patients were far more likely to be given prescriptions for opioids than non-indigenous patients. The rate of opioid dispensing for indigenous patients was 276 prescriptions per 100,000 people compared to 150 per 100,000 for non-indigenous patients. The Alberta government’s open health data sets present a dynamic connection between injectable opioid drugs, possible intoxication, unsafe needle-sharing habits, transactional sex (for money and narcotics), and ultimately contracting all sorts of STIs.
So, Aboriginal populations are more likely to be saddled with the double jeopardy of syphilis and opioid abuse compared to white populations. As Steve Buick, a senior aide to the Alberta health minister, tells me, “[Aboriginals] have generally much poorer health, especially problems that are most directly related to poverty, homelessness, etc. I don’t mean to downplay the Aboriginal aspect, but their high syphilis rates are consistent with the disparity in overall health.”
Homeless Aboriginal persons are less likely to show up in a clinic when syphilis strikes, receive treatment, and be recorded in formal physician databases. Tom McMillan, a health communications director for the Alberta government, insists thatAlberta province has a very robust reporting system for infectious disease, including syphilis.
Steve Buick, the minister’s aide, recently illustrated the gaps in documenting syphilis data. When he was explaining the recent syphilis spike relative to other STIs, Buick said, “No one really knows” what was behind the rise in syphilis cases in this particular region.
“No one really knows” — as Buick says — is a remarkable statement from Alberta government health officers. There is no need to grope in the dark for Alberta’s health officers. Demographics show that Edmonton (the province’s second biggest city and official capital) has more Aboriginal inhabitants than Calgary, the commercial capital. It is here too in “Edmonton city Zone,” that in 2018, the highest gonorrhea infection numbers in Alberta province were seen (164.5 cases per 100,000 population). Following closely at number two was the “North Zone” (160.1 cases per 100,000 population — a 14.4% jump from 2017), as Alberta Health figures show. In contrast, in Calgary, syphilis infections only grew modestly, from 11.83 per 100,000 to 12.47 in 2018. That the STI infections appear (to a certain extent) to be harsher in racialized communities is no idle speculation. The health data show this plainly.
Lynora Saxinger, M.D., FRCPC, an infectious disease specialist with the University of Alberta, offers a deeper clue. She says a factor behind the jump in the North Zone (with its more limited economy) could also be due to the fact that the zone has a younger, transient population that often travels a lot for work.
The province has activated an outbreak investigations coordinating committee, Tom McMillan said. New mobile health vans have been launched in the North Zone (where indigenous First Nations, Metis, and Inuit communities are prominent). The vans are outfitted with an examination bed, stool, desk area, and cabinets, says Jennifer Splaine,R.N., population and public health manager at Fort McMurray, in the zone. The vans also offer health checkups, immunizations, cancer screenings (oral, prostate, and cervical), and oral health assessments for children and vulnerable populations. These conditions can be worsened by syphilis infection.
In fairness, it doesn’t mean that Aboriginal Canadians are the only subgroup oppressed by syphilis. The infection blurs ethnic boundaries. The latest data also point to high rates of infection among Alberta province’s black male population. Immigration and the complexity of travel overseas looms as a factor too, because according to Alberta government data sets, a large number of HIV diagnoses among women were classified as “acquired out of country.”
This current syphilis outbreak is the harshest since 1948, the period of the end of the Second World War. This is no time for business as usual.