A “slow and bureaucratic” response that has seen monkeypox spread rapidly across the US — with more than a thousand cases in New York City alone — shows how hard hit local health authorities have been since the Covid pandemic, proponents say.
Once a rare African virus, monkeypox has caught on amid the tattered patchwork of city, county, state and federal agencies that make up America’s public health infrastructure.
“Unfortunately, delayed actions mean 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 situation at the state and local level with an organized response.”
To explain the chaos, many observers point to how Covid has reshaped the landscape for public health officials. Once considered neutral arbiters of information, many health officials have been politically attacked over unpopular masking and vaccination policies.
Across the country, public health officials were harassed, threatened, fired or simply felt burned out and stopped. The situation was not helped as funds once spent on things like tracking communicable diseases, such as tuberculosis, or running routine vaccination clinics, were suddenly diverted to Covid-19.
Sexual health clinics have also struggled, as testing and staffing was spent on Covid-19, hurting organizations that had been underfunded for years.
The result has been poorer health outcomes for many basic health services: Routine childhood vaccinations have fallen; overdose deaths have exploded; and the US has recorded a record number of sexually transmitted diseases for the sixth consecutive year.
As monkeypox has spread, the Biden administration has tried to respond by releasing about 1.1 million vaccines and ramping up testing capacity, which has grown from about 6,000 to 80,000 a week. The World Health Organization this week declared monkeypox a global health emergency, and the US 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, general manager of the National Association of County and City Health Officials. “All the same problems that plagued us during the pandemic are still with us and have not gone away.
“What’s added, with monkey pox and beyond, is that we also have a workforce that has documented mental health trauma after the pandemic.”
Public health advocates want the president and Congress to allocate more money to respond to the outbreak and to sexual health clinics in general. Public facilities have proven to be the first line of defense against monkeypox, even though federal prevention funding for such work has fallen 41% since 2003.
“Local sex workers are being asked to respond to monkey pox 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 STI public health programs and clinical services.”
Although anyone can get monkey pox, the virus mainly affects men who have sex with men. Sexual health clinics have often been primary care providers in the outbreak because of the way monkeypox can present its symptoms, with lesions around the genitals and anus — although sex is just one way monkeypox can spread. Any close contact with an infected person can spread the disease, such as touching, kissing, and hugging, as well as sharing glasses, cutlery, bedding, and towels.
Although the virus, which belongs to the same family as smallpox, is rarely fatal, its 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 are reported to require hospitalization, and many show up in the emergency room because of severe pain, Freeman said.
The situation is made worse as monkey pox testing is limited. There is no home test and the results can take days. However, there is a vaccine for which people at increased risk may qualify; they may also be eligible for treatment with the drug tecovirimat, sold as TPOXX. But the barriers are significant, getting it can be tricky, and tecovirimat — usually reserved for those with severe symptoms — must be requested by doctors from the government’s national strategic stockpile, which involves a lot of paperwork.
In addition, people without insurance are unlikely to have access to both vaccine and medicine, Freeman said; about 12.7% of the LGBTQ+ community has no health insurance, compared to 11.4% of the general population, according to an analysis of federal officials. Even if you do have insurance, there are hurdles in the U.S. health care system, such as trying to navigate between emergency care clinics, primary care providers, and state health departments.
Freeman told a story about a local health department asking the state for information about a monkeypox outbreak. The state responded to contact the CDC; the CDC then sent local officials back to the state.
“There’s a lot of finger pointing here,” she said. “We should have learned. We should know more now than we knew three years ago from our Covid response [about] what we have to do here.”