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Mai Yang, a communicable disease specialist, searches for Angelica, a 27 year-old pregnant woman who tested positive for syphilis, in order to get her treated before she delivers her baby.

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Yang drives to Huron, a rural town an hour outside of Fresno, Calif., in search of Angelica. Patients in rural areas like Huron often have less access to care.

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‘This bacteria is still in your body’

Yang first received Angelica’s lab report on June 17. The address listed was a P.O. box, and the phone number belonged to her sister, who said Angelica was living in Huron. That was a piece of luck: Huron is tiny; the city spans just 1.6 square miles. On her first visit, a worker at the Alamo Motel said she knew Angelica and directed Yang to a nearby homeless encampment. Angelica wasn’t there, so Yang returned a second time, bringing one of the health department nurses who could serve as an interpreter.

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Yang drove to Huron knowing that if she helped Angelica get treated with three weekly shots of penicillin at least 30 days before she gave birth, it was likely that her baby would be born without any symptoms of the disease.

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Left: Communicable disease specialists Yang (left) and Hou Vang walk to the Fresno County Department of Public Health in Fresno. Right: In Huron, Yang looked for Angelica near a former homeless encampment where she used to live.

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They made their way to the barren patch of land behind Huron Valley Foods, the local grocery store, where people took shelter in makeshift lean-tos composed of cardboard boxes, scrap wood and scavenged furniture, draped with sheets that served as ceilings and curtains. Yang stopped outside one of the structures, calling a greeting.

«Hi, I’m from the health department, I’m looking for Angelica.»

The nurse echoed her in Spanish.

Angelica emerged, squinting in the sunlight. Yang couldn’t tell if she was visibly pregnant yet, as her body was obscured by an oversized shirt. The two women were about the same age: Yang 26 and Angelica 27.

Yang led her away from the tent, so they could speak privately. Angelica seemed reticent, surprised by the sudden appearance of the two health officers. «You’re not in trouble,» Yang said, before revealing the results of her blood test. (NPR and ProPublica chose not to use Angelica’s last name to protect her privacy.)

Angelica had never heard of syphilis.

«Have you been to prenatal care?»

Angelica shook her head. The local clinic had referred her to an obstetrician in Hanford, a 30-minute drive away. She had no car. She also mentioned that she didn’t intend to raise her baby; her two oldest children lived with her mother, and this one likely would, too.

Yang pulled out the CDC cards, showing them to Angelica and asking if she had experienced any of the symptoms illustrated. No, Angelica said, her lips pursed with disgust.

«Right now you still feel healthy, but this bacteria is still in your body,» Yang pressed. «You need to get the infection treated to prevent further health complications to yourself and your baby.»

The community clinic was just across the street. «Can we walk you over to the clinic and make sure you get seen so we can get this taken care of?»

Angelica demurred. She said she hadn’t showered for a week and wanted to wash up first. She said she’d go later.

Yang tried once more to extract a promise: «What time do you think you’ll go?»

«Today, for sure.»

Missed opportunities to eliminate a curable ‘scourge’

Syphilis is called The Great Imitator: It can look like any number of diseases. In its first stage, the only evidence of infection is a painless sore at the bacteria’s point of entry. Weeks later, as the bacteria multiplies, skin rashes bloom on the palms of the hands and bottoms of the feet. Other traits of this stage include fever, headaches, muscle aches, sore throat and fatigue.

These symptoms eventually disappear and the patient progresses into the latent phase, which betrays no external signs. But if left untreated, after a decade or more, syphilis will reemerge in up to 30% of patients, capable of wreaking horror on a wide range of organ systems. Dr. Marion Sims, president of the American Medical Association in 1876, called it a «terrible scourge, which begins with lamb-like mildness and ends with lion-like rage that ruthlessly destroys everything in its way.»

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Yang carries syphilis cards issued by the Centers for Disease Control and Prevention that she shares with people to show them what syphilis symptoms, like lesions on a tongue or a dotted rash on a baby, can look like.

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By 1937 in America, when former Surgeon General Thomas Parran wrote the book Shadow on the Land, he estimated some 680,000 people were under treatment for syphilis; about 60,000 babies were being born annually with congenital syphilis. There was no cure, and the stigma was so strong that public health officials feared even properly documenting cases.

Thanks to Parran’s ardent advocacy, Congress in 1938 passed the National Venereal Disease Control Act, which created grants for states to set up clinics and support testing and treatment. Other than a short-lived funding effort during World War I, this was the first coordinated federal push to respond to the disease.

Around the same time, the Public Health Service launched an effort to record the natural history of syphilis. Situated in Tuskegee, Alabama, the infamous study recruited 600 black men. By the early 1940s, penicillin became widely available and was found to be a reliable cure, but the treatment was withheld from the study participants. Outrage over the ethical violations would cast a stain across syphilis research for decades to come and fuel generations of mistrust in the medical system among Black Americans that continues to this day.

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An exam room in the Fresno County Department of Public Health displays info packets about syphilis.

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Yang meets with a patient who has come to the public health department for a penicillin shot.

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As a communicable disease specialist with the public health department, Yang meets patients whenever and wherever they are available. She informs them about syphilis, gathers names of sex partners and encourages treatment.

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Jena Adams, Yang’s supervisor, has worked in public health since the early 1990s.

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Downtown Fresno

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Yang (right) and colleague Jorge Sevilla looking for Angelica, who sometimes stays in a small house in the yard behind this house.

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Syphilis can be cured with injectable penicillin. One or three shots are given, depending on the stage of the patient’s infection.

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Left: Yang seeks out patients who have tested positive for syphilis to help them get treated and asks about sexual partners to make sure anyone exposed is also tested. Right: The waiting room in the Fresno County Department of Public Health.

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Yang found Angelica outside a yellow house in Huron and took her to a clinic to get treatment. But the clinic was too busy to treat her and asked her to return later.

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Yang found Angelica outside a yellow house in Huron and took her to a clinic to get treatment. But the clinic was too busy to treat her and asked her to return later.

Talia Herman for ProPublica

Postscript: A reporter visited Huron twice more in the months that followed, including once independently to try to interview Angelica, but she wasn’t in town. Yang has visited Huron twice more as well — six times in total thus far. In October, a couple of men at the yellow house said Angelica was still in town, still pregnant. Yang and Sevilla spent an hour driving around, talking to residents, hoping to catch Angelica. But she was nowhere to be found.

Doris Burke of ProPublica contributed research to this report.