A ‘slow and bureaucratic’ response that saw monkeypox spread rapidly across the United States – with more than a thousand cases in New York alone – reveals how local health agencies have been battered since the Covid pandemic, advocates said.
Once a rare African virus, monkeypox has taken hold amid the jagged patchwork of municipal, county, state and federal agencies that make up America’s public health infrastructure.
“Unfortunately, the delayed actions mean that monkeypox has spread within the gay community and among other men who have sex with men,” said David Harvey, executive director of the National Coalition of STD Directors.
“This outbreak has become a public health crisis in America. We are still in a very chaotic state and local situation with an organized response.
To explain the chaos, many observers point to how Covid has reshaped the landscape for public health officials. Once seen as neutral arbiters of information, many health officials have come under political attack over unpopular mask and vaccination policies.
Across the country, public health officials have been harassed, threatened, fired, or simply felt burnt out and quit. The situation has not been helped as resources that were once spent on things like tracking communicable diseases, like tuberculosis, or running routine vaccination clinics, have suddenly been diverted to Covid-19.
Sexual health clinics have also struggled as testing and staffing resources have been devoted to Covid-19, hurting organizations that had already suffered from years of underfunding.
The result has been deteriorating health outcomes for many basic public health services: routine immunizations for children have plummeted; overdose deaths have skyrocketed; and the United States recorded a record rate of sexually transmitted infections for the sixth consecutive year.
As monkeypox spread, the Biden administration tried to respond by releasing about 1.1 million vaccines and increasing testing capacity from about 6,000 to 80,000 per week. The World Health Organization declared monkeypox a global health emergency this week, and the United States could follow suit by declaring monkeypox a national public health emergency, freeing up more resources for local agencies.
“The system is tired, it’s overworked, it’s underpaid, it’s understaffed,” said Lori Tremmel Freeman, executive director of the National Association of County and City Health Officials. “All of the same issues that plagued us during the pandemic are still with us and have not gone away.
“Adding to that, with monkeypox and beyond, is that we also have a workforce that has documented post-pandemic mental trauma.”
Public health advocates want the president and Congress to allocate more funds to respond to the outbreak and for sexual health clinics generally. Public facilities have proven to be the first line of defense against monkeypox, even though federal prevention funding for this work has dropped 41% since 2003.
“Local sexual health providers are urged to respond to monkeypox on top of an already out of control STI epidemic in America,” Harvey said. “We are at the breaking point: We need the Biden administration and Congress to immediately fund public health programs and STI clinical services.”
Although anyone can get monkeypox, the virus has primarily affected men who have sex with men. Sexual health clinics have often been frontline responders to the outbreak due to the way monkeypox can present its symptoms, with lesions around the genitals and anus – although sex is not only a means of spreading monkeypox. Any close contact with an infected person can spread the disease, including touching, kissing and cuddling, as well as sharing glasses, utensils, bedding and towels.
Although the virus, which belongs to the same family as smallpox, is rarely fatal, symptoms can be excruciating, with painful lesions and flu-like symptoms, according to the Centers for Disease Control and Prevention. Up to 10% of people would need hospitalization, and many show up to the emergency room with severe pain, Freeman said.
The situation is exacerbated because testing for monkeypox is limited. There is no home test and results can take days. There is, however, a vaccine that people at increased risk may be eligible for; they may also benefit from treatment with the drug tecovirimat, sold as TPOXX. But the barriers are high, obtaining it can be tricky, and tecovirimat – usually reserved for people with severe symptoms – must be requested by doctors from the government’s National Strategic National Stockpile, which involves significant paperwork.
Additionally, people without insurance likely don’t have access to vaccines and medications, Freeman said; about 12.7% of the LGBTQ+ community lacks health insurance compared to 11.4% of the general population, according to an analysis by federal officials. Even if you have insurance, there are hurdles in the US healthcare system, like trying to navigate between urgent care clinics, primary care providers, and state health departments.
Freeman shared a story she did about a local health department asking her state for information about a monkeypox outbreak. The state responded to check with the CDC; the CDC then redirected local officials to the state.
“There’s a lot of finger pointing here,” she said. “We should have learned. We should know more now than three years ago thanks to our Covid response [about] what we need to do here.