Cecilia Nowell | (TNS) KFF Health News

From her base in Gallup, New Mexico, Melissa Wyaco supervises about two dozen public health nurses who crisscross the sprawling Navajo Nation searching for patients who have tested positive for or been exposed to a disease once nearly eradicated in the U.S.: syphilis.

Infection rates in this region of the Southwest — the 27,000-square-mile reservation encompasses parts of Arizona, New Mexico, and Utah — are among the nation’s highest. And they’re far worse than anything Wyaco, who is from Zuni Pueblo (about 40 miles south of Gallup) and is the nurse consultant for the Navajo Area Indian Health Service, has seen in her 30-year nursing career.

Syphilis infections nationwide have climbed rapidly in recent years, reaching a 70-year high in 2022, according to the most recent data from the Centers for Disease Control and Prevention. That rise comes amid a shortage of penicillin, the most effective treatment. Simultaneously, congenital syphilis — syphilis passed from a pregnant person to a baby — has similarly spun out of control. Untreated, congenital syphilis can cause bone deformities, severe anemia, jaundice, meningitis, and even death. In 2022, the CDC recorded 231 stillbirths and 51 infant deaths caused by syphilis, out of 3,761 congenital syphilis cases reported that year.

And while infections have risen across the U.S., no demographic has been hit harder than Native Americans. The CDC data released in January shows that the rate of congenital syphilis among American Indians and Alaska Natives was triple the rate for African Americans and nearly 12 times the rate for white babies in 2022.

“This is a disease we thought we were going to eradicate not that long ago, because we have a treatment that works really well,” said Meghan Curry O’Connell, a member of the Cherokee Nation and chief public health officer at the Great Plains Tribal Leaders’ Health Board, who is based in South Dakota.

Instead, the rate of congenital syphilis infections among Native Americans (644.7 cases per 100,000 people in 2022) is now comparable to the rate for the entire U.S. population in 1941 (651.1) — before doctors began using penicillin to cure syphilis. (The rate fell to 6.6 nationally in 1983.)

O’Connell said that’s why the Great Plains Tribal Leaders’ Health Board and tribal leaders from North Dakota, South Dakota, Nebraska, and Iowa have asked federal Health and Human Services Secretary Xavier Becerra to declare a public health emergency in their states. A declaration would expand staffing, funding, and access to contact tracing data across their region.

“Syphilis is deadly to babies. It’s highly infectious, and it causes very severe outcomes,” O’Connell said. “We need to have people doing boots-on-the-ground work” right now.

In 2022, New Mexico reported the highest rate of congenital syphilis among states. Primary and secondary syphilis infections, which are not passed to infants, were highest in South Dakota, which had the second-highest rate of congenital syphilis in 2022. In 2021, the most recent year for which demographic data is available, South Dakota had the second-worst rate nationwide (after the District of Columbia) — and numbers were highest among the state’s large Native population.

In an October news release, the New Mexico Department of Health noted that the state had “reported a 660% increase in cases of congenital syphilis over the past five years.” A year earlier, in 2017, New Mexico reported only one case — but by 2020, that number had risen to 43, then to 76 in 2022.

Starting in 2020, the covid-19 pandemic made things worse. “Public health across the country got almost 95% diverted to doing covid care,” said Jonathan Iralu, the Indian Health Service chief clinical consultant for infectious diseases, who is based at the Gallup Indian Medical Center. “This was a really hard-hit area.”

At one point early in the pandemic, the Navajo Nation reported the highest covid rate in the U.S. Iralu suspects patients with syphilis symptoms may have avoided seeing a doctor for fear of catching covid. That said, he doesn’t think it’s fair to blame the pandemic for the high rates of syphilis, or the high rates of women passing infections to their babies during pregnancy, that continue four years later.

Native Americans are more likely to live in rural areas, far from hospital obstetric units, than any other racial or ethnic group. As a result, many do not receive prenatal care until later in pregnancy, if at all. That often means providers cannot test and treat patients for syphilis before delivery.

In New Mexico, 23% of patients did not receive prenatal care until the fifth month of pregnancy or later, or received fewer than half the appropriate number of visits for the infant’s gestational age in 2023 (the national average is less than 16%).

Inadequate prenatal care is especially risky for Native Americans, who have a greater chance than other ethnic groups of passing on a syphilis infection if they become pregnant. That’s because, among Native communities, syphilis infections are just as common in women as in men. In every other ethnic group, men are at least twice as likely to contract syphilis, largely because men who have sex with men are more susceptible to infection. O’Connell said it’s not clear why women in Native communities are disproportionately affected by syphilis.

“The Navajo Nation is a maternal health desert,” said Amanda Singer, a Diné (Navajo) doula and lactation counselor in Arizona who is also executive director of the Navajo Breastfeeding Coalition/Diné Doula Collective. On some parts of the reservation, patients have to drive more than 100 miles to reach obstetric services. “There’s a really high number of pregnant women who don’t get prenatal care throughout the whole pregnancy.”

She said that’s due not only to a lack of services but also to a mistrust of health care providers who don’t understand Native culture. Some also worry that providers might report patients who use illicit substances during their pregnancies to the police or child welfare. But it’s also because of a shrinking network of facilities: Two of the Navajo area’s labor and delivery wards have closed in the past decade. According to a recent report, more than half of U.S. rural hospitals no longer offer labor and delivery services.

Singer and the other doulas in her network believe New Mexico and Arizona could combat the syphilis epidemic by expanding access to prenatal care in rural Indigenous communities. Singer imagines a system in which midwives, doulas, and lactation counselors are able to travel to families and offer prenatal care “in their own home.”

O’Connell added that data-sharing arrangements between tribes and state, federal, and IHS offices vary widely across the country, but have posed an additional challenge to tackling the epidemic in some Native communities, including her own. Her Tribal Epidemiology Center is fighting to access South Dakota’s state data.

In the Navajo Nation and surrounding area, Iralu said, IHS infectious disease doctors meet with tribal officials every month, and he recommends that all IHS service areas have regular meetings of state, tribal, and IHS providers and public health nurses to ensure every pregnant person in those areas has been tested and treated.

IHS now recommends all patients be tested for syphilis yearly, and tests pregnant patients three times. It also expanded rapid and express testing and started offering DoxyPEP, an antibiotic that transgender women and men who have sex with men can take up to 72 hours after sex and that has been shown to reduce syphilis transmission by 87%. But perhaps the most significant change IHS has made is offering testing and treatment in the field.

Today, the public health nurses Wyaco supervises can test and treat patients for syphilis at home — something she couldn’t do when she was one of them just three years ago.

“Why not bring the penicillin to the patient instead of trying to drag the patient in to the penicillin?” said Iralu.

It’s not a tactic IHS uses for every patient, but it’s been effective in treating those who might pass an infection on to a partner or baby.

Iralu expects to see an expansion in street medicine in urban areas and van outreach in rural areas, in coming years, bringing more testing to communities — as well as an effort to put tests in patients’ hands through vending machines and the mail.

“This is a radical departure from our past,” he said. “But I think that’s the wave of the future.”

___

(KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs of KFF — the independent source for health policy research, polling and journalism.)

©2024 KFF Health News. Distributed by Tribune Content Agency, LLC.

KANSAS CITY, Mo. — The Twins and Pablo López were in the infancy stages of their relationship when the two sides decided to commit to each other long term.

López had spent months learning about his new organization. He saw how many staff members were from Minnesota, how long they had been a part of the organization. He noticed all the Twins legends — like Bert Blyleven, Joe Mauer and his childhood hero, Johan Santana — who still hung around, long after their playing careers had ended. He felt, very quickly, that the entire organization was built on family values.

The Twins had spent those same months learning about López, whom they acquired in a trade in January 2023. They noted his work ethic, how he was the first one in the building. His makeup was off the charts. His ability was, too.

On April 21, the Twins officially announced they had signed López to a four-year contract extension worth $73.5 million. They had never given a pitcher that much money in franchise history.

But this, they believed, was the right pitcher — and person — to invest in.

The extension kicks in this year, and López, who will take the ball on Thursday afternoon for Opening Day against the Kansas City Royals and lead the Twins into the 2024 season, is out to prove he’s worth every penny.

“It meant a lot to me,” López said. “Every time teams are willing to make investments in players … there’s responsibility that comes with it, but there’s the aspect like it’s a mutual decision to have a relationship, a long-lasting one that hopefully we can turn into something special and we’re able to then accomplish a lot of things on the field.”

López already knew what the Twins thought of him. When they traded Luis Arraez, the reigning American League batting champion, to the Miami Marlins to get him, it told him how highly they valued him and instilled some confidence in him, as well.

“That already made me aware of, ‘OK, these people must see something in me. They have to be mindful of something that maybe I’m not mindful of right now,’ ” López said.

The Twins believed that they had acquired one of the best pitchers in baseball.

They worked with him to introduce a sweeper, an offering that quickly became one of his most effective pitches (opponents hit just .173 against it last year). They showed their faith in him once more by naming him the 2023 Opening Day starter for the first time in his career. He responded with 5 1/3 scoreless innings against the Royals, striking out eight.

Just a few weeks into the regular season, the two sides came to their agreement.

“You’re not going to make that kind of investment in someone, especially before you have to, unless you feel very highly about their ability. But when you combine the ability with really very much absolute, top-of-the-scale character and makeup and work ethic and desire and all of these other factors, then it actually became a pretty easy decision on our end,” manager Rocco Baldelli said.

All of these “other factors” quickly became apparent once coaches and teammates started spending time around him. They saw how he meticulously planned, how he set his schedule and the executed it to a T. Everything he did was intentional and aimed at improvement.

“He works harder than anybody. This guy is the first one to show up to the clubhouse every day and the last one to leave, and I really mean that,” shortstop Carlos Correa said. “A lot of people say that just to say it, but it’s true. I show up early, and when I think I’m too early, he’s already sweating.”

That work ethic might have even kicked into overdrive after signing the extension. Lopez couldn’t help but put some extra pressure on himself. He felt the need to justify the team’s investment in him.

As a self-proclaimed overthinker, the Twins’ ace said he “went down that hole” and had to remind himself that the job hadn’t changed and neither should he.

The only thing that changed was that he and his wife, Kaylee, had the certainty of knowing where they would be living, a luxury in an industry in which players are constantly on the move.

“I really had to understand, take a step back and realize it’s just a very beautiful opportunity to come to the field with a little less pressure on things that take a lot of toll on our minds sometimes and then obviously come to the field and just play the game a little more freely,” López said. “Now I get to focus more attention to my craft, to what I do on the mound.”

And what that is, is being one of the best pitchers in baseball.

In his first year in Minnesota, López posted a 3.66 earned-run average in 194 innings. He finished the year tied for third in the majors with 234 strikeouts, and helped lead the Twins in the postseason, giving up one run across 12 2/3 innings in the two games he started.

Last year, he finished the season seventh in American League Cy Young voting. This year, he’s among the favorites to win the award, which would further cement him as one the sport’s elite.

“Most decisions that are going to cost you a lot of money are difficult decisions,” Baldelli said of Lopez’s extension. “I think that was probably one of the easiest decisions that we made to invest in a person like Pablo López, who also happens to be one of the best pitchers anywhere.”

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The Gophers men’s basketball program is expected to welcome former North Dakota State big man Andrew Morgan for a visit to campus this week.

Morgan is the one guest the U have scheduled as of Wednesday afternoon, a source told the Pioneer Press.

Morgan, a to-be senior from Waseca, Minn., has one year of eligibly remaining after entering the NCAA transfer portal this week.

At 6-foot-10 and 245 pounds, Morgan averaged 12.9 points and 5.0 rebounds in 32 games, 29 starts, for the Bison in the Summit League last season. He was named second team all-conference in 2023-24.

Morgan averaged only 0.3 blocks per game and only 1.0 3-point attempt per game but made 36 percent from deep last season. He shot 58 percent from inside the arc a year ago.

His stiffest completion came against Creighton last November. He scored nine points on 4 for 14 from the field, with one rebound, one assist and two steals in 23 minutes in a loss.

Morgan, a Mr. Basketball finalist in Minnesota in 2020-21, would factor in as a back-up center to rising junior Pharrel Payne, with last year’s reserve Jack Wilson out of eligibility.

The Gophers currently have one vacant scholarship spot with sophomore forward Josh Ola-Joseph entering the NCAA transfer portal on Wednesday.

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By ERIC TUCKER (Associated Press)

WASHINGTON (AP) — The case against Donald Trump seemed relatively straightforward in August 2022 when FBI agents searched his Mar-a-Lago estate, with authorities citing evidence that the former president hoarded enough classified documents to fill dozens of boxes and obstructed the government’s efforts to retrieve them.

But nine months after he was indicted, there are mounting doubts that the case can reach trial this year.

The Trump-appointed judge in the case has yet to set a firm trial date despite holding two hours-long hearings with lawyers this month. Multiple motions to dismiss the case are still pending, disputes over classified evidence have spanned months and a bitterly contested defense request to disclose the names of government witnesses remains unresolved. Complicating matters further is a recent order suggesting that the judge, Aileen Cannon, is still entertaining a Trump team claim about his rightful possession of the documents that she had appeared openly skeptical of days earlier.

“This does seem to be moving more slowly and less sequentially than other cases that I have seen” concerning classified information, said David Aaron, a former Justice Department national security prosecutor.

To a certain extent, the delays are the product of a broader Trump team strategy to postpone the four criminal cases confronting the presumptive Republican nominee in this year’s presidential race. But the case in Florida is unique because of the startlingly few substantive decisions that have been made to move closer to a trial. That raises the prospect that a resolution in the case may be unlikely before this year’s presidential election. If he were to win the White House, Trump could appoint an attorney general who would dismiss the federal charges against him in Florida and other jurisdictions.

Prosecutors on special counsel Jack Smith’s team have strenuously fought to press the case forward. Though they’ve taken care not to mention the upcoming election, they’ve repeatedly cited a public interest in getting the case resolved quickly and have pointed to what they say is overwhelming evidence — including surveillance video, a defense lawyer’s notes and testimony from close associates — establishing Trump’s guilt beyond a reasonable doubt.

“This case should be over already,” said Jeffrey Swartz, a professor at Cooley Law School and former judge in Florida. “There was nothing in this case that complex.”

That’s what distinguishes the classified documents case from the other — more legally intricate — criminal cases against Trump, which revolve around everything from allegations of hush money paid to a porn actress to complex racketeering charges and his role in seeking to overturn the 2020 election.

But defense lawyers see it differently, and Cannon — a former federal prosecutor who was appointed to the bench in 2020 and has limited trial experience as a judge — has proved receptive to some of their arguments since even before the case was filed last June.

The judge first made headlines weeks after the FBI search of Mar-a-Lago when, responding to a Trump lawsuit seeking to recover the seized documents from the federal government, she appointed an independent arbiter to sift through all the records. That appointment was overturned by a unanimous federal appeals panel, which said Cannon had overstepped her bounds.

“My sense of it is, when she did get reversed by the 11th Circuit that made her gun-shy, so she’s gone at a very slow pace” and issued “very few public, written decisions about important issues,” said John Fishwick, Jr., a former U.S. attorney for the Western District of Virginia.

Soon after Trump was charged, Cannon set the case for trial on May 20, 2024. But last fall she signaled she would reconsider that date during a March 1 hearing. The hearing took place as scheduled — but no replacement date was picked, even though both sides operating on the assumption that the May 20 date is moot have suggested the trial could begin this summer.

That’s not the only unresolved question. Defense lawyers have filed about a half-dozen motions to dismiss the case, including on grounds that the prosecution is vindictive and that Smith’s appointment as special counsel was illegal.

Cannon this month heard hours of arguments on two of the dismissal motions — whether Trump was entitled under a statute known as the Presidential Records Act to retain the classified documents after he left office and whether the Espionage Act law at the heart of the case was so vague as to be unconstitutional.

Cannon appeared skeptical of the defense assertions and, after the hearing, issued a terse two-page order rejecting the vagueness argument while permitting Trump to raise it again later.

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She has not yet acted on the Presidential Records Act motion, but legal experts noted her direction last week to lawyers for both sides to weigh in on proposed jury instructions that appeared to tilt in Trump’s favor. She asked them to respond to a premise that said in part: “A president has sole authority under the PRA to categorize records as personal or presidential during his/her presidency. Neither a court nor a jury is permitted to make or review such a categorization decision.”

That wording was notable because it echoes arguments Trump’s lawyers have been making for months. They insist that law allowed him to designate the records he was charged with retaining as his own personal files. Smith’s team, by contrast, says the law has no relevance in a case concerning illegal possession of top-secret information, including nuclear secrets.

“It seems a little early in the game to be talking about jury instructions when there are substantial questions of law that have been raised that need to be resolved,” said Aaron, though he said the jury instructions order could be a way to tee up those resolved questions.

Besides the pending motions to dismiss, Cannon has yet to rule on a defense motion seeking to compel prosecutors to turn over a raft of information they insist would show that President Joe Biden’s administration had “weaponized” the criminal justice system in bringing the Trump case.

That assertion is in keeping with campaign-trail claims by Trump and his allies that he’s a victim of political persecution by the Biden Justice Department. He’s complained that he was charged when Biden, who was also investigated for retaining classified information, was not — prompting Smith’s team to lay out the abundant differences in the investigations.

An even more contentious dispute centers around a defense request to file on the public docket a motion that would identify potential prosecution witnesses. Cannon initially consented to the filing but paused her order after prosecutors argued that such a disclosure could jeopardize the safety of the witnesses.

“It may be that the judge is just afraid of making a mistake, but delaying it just puts it off,” said Kevin McMunigal, a Case Western Reserve University law professor. “Eventually she’s going to have to make a decision about these.”