Do you remember the Greek myth of Sisyphus? He was condemned to rolling a boulder up to the top of a steep hill, only to have it roll back down and for him to repeat the process again and again. Forever. What would have happened if Sisyphus had the option to look at the problem differently? If he could have arranged a pulley system? Or recruited people to help him? Or even dug out the hill little by little until the hill no longer existed?

Eliminating congenital syphilis appears a lot like the story of Sisyphus. Congenital syphilis is when a pregnant woman who has syphilis transmits it to her baby. If she does not get treatment during pregnancy, she can run the risk of a stillbirth, preterm birth, or terrible lifelong health consequences for her baby if born with the infection. Just like Sisyphus, we have been depending on doing only one thing to eliminate the transmission of syphilis from a mom to her baby, and doing it for years: antenatal care.  

Syphilis can be readily diagnosed and treated during antenatal care, so the elimination of congenital syphilis is an actual possibility. It has been on the global health agenda for decades, with waves of interest, partnerships and international campaigns organized to bring needed attention and support for it, such as the WHO initiative and the Global Congenital Syphilis Partnership, launched in March of this year.

But, just like Sisyphus, we have been doing essentially the same things for years. And the numbers show why. There are 10 countries where syphilis is highly prevalent, most in sub-Saharan Africa, affecting up to 14 percent of the population in some areas. About 73 percent of pregnant women in sub-Saharan Africa will visit a clinic for prenatal care at least once during her pregnancy. Of those women who make it to a clinic, the estimates of those who get screened for syphilis in this region are between 38 percent and 59 percent. And then it is unknown how many women who test positive and their partners actually get treatment.

It’s an unfortunate cascade of missed opportunities.

If we are serious about eliminating congenital syphilis, then it’s time to hitch Sisyphus to a pulley system or to start reshaping that interminable hill. This challenge calls for interventions beyond what we already know. And what we know—eliminating congenital syphilis only through screening of pregnant women—is not working.

There are other innovative ideas that need exploration. The idea of a vaccine is being pursued. Syphilis may need to be examined through a war-room approach, including use of a localized lens, finding the hot spots and high prevalence areas and intervening in those communities differently than areas with almost no risk. This would involve decentralized planning down to a municipality-type level. Modeling could be done to identify alternative strategies based on the characteristics of those communities, including mass and targeted epidemiological treatment for high prevalence populations or intense outreach efforts for prenatal care. These are just ideas at this point, but they are worth exploring.

Improving the quality of care provided during prenatal consults is a major component of this challenge, to ensure that all pregnant women who present at a clinic will get tested and treated for syphilis when necessary. If all we did was fill gaps in the management cascade, starting from presentation for ANC, we would have made great progress. But until we can guarantee that 100 percent of pregnant women will visit a nurse, 100 percent will get that important test done, and 100 percent of those women and their partners testing positive get treated, we need different approaches.

The goal has been set: to eliminate congenital syphilis. Now the global health community needs to be more innovative in order to change the course of congenital syphilis and give Sisyphus a rest.