When four Navajo patients came into Jonathan Iralu's hospital with syphilis all in the same week, Iralu made a plea rarely heard on the reservation: Spread the word about the disease, and quickly. The call from Iralu, the infectious disease consultant for the Navajo Area Indian Health Service, sent tribal and health officials scrambling to build awareness about STDs -- both syphilis and HIV -- among the 200,000 people living on the reservation.

The challenges for working with traditional tribal values and the realities of disease prevention are many. Long-held Navajo attitudes about public openness on issues such as sexuality, cultural taboos about homosexuality, and discussing diseases for which there are no words for in the Navajo language present real hurdles to public prevention campaigns. Setting the tone, Navajo President Joe Shirley Jr. was pictured in a full-page ad in the Navajo Times encouraging fellow Navajos to practice safe sex, educate themselves about STDs, and get tested. Public health workers call Shirley's active role an important symbolic step.

The current outbreak began to emerge in 2000, when the number of syphilis cases in the Navajo Nation grew from two in 1999 to nine that year. In 2001, there were 34 cases. By 2002, another 34 cases were reported, causing the Navajo syphilis rate to increase sevenfold compared to the national rate. Another disturbing trend to emerge was the spike of a rare infection known as Acute Retroviral Syndrome, which sets in weeks after a person becomes HIV-infected. This indicates that HIV is no longer being imported solely from border towns and is now being spread locally.

Syphilis was a problem within the Navajo community in the late 1970s and early 1980s with as many as several hundred cases per year, said Larry Foster, STD coordinator for the Navajo Nation Division of Health's Social Hygiene Program, but the tribe managed to stamp it out in the late 1980s and began the focus on HIV. "I think we got complacent," said Dr. Diana Hu, the Navajo Area Indian Health Service's chief clinical consultant for maternal and child health.

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