Apoorva Mandavilli
Thu, September 29, 2022
From left: Dr. Rochelle Walensky, the CDC director, Dr. Anthony Fauci, the Biden administration's top medical adviser, and Dr. Robert Califf, the FDA commissioner, during a Senate hearing on monkeypox, on Capitol Hill in Washington on Sept. 14, 2022. (Anna Rose Layden/The New York Times)
If it wasn’t clear enough during the COVID-19 pandemic, it has become obvious during the monkeypox outbreak: The United States, among the richest, most advanced nations in the world, remains wholly unprepared to combat new pathogens.
The coronavirus was a sly, unexpected adversary. Monkeypox was a familiar foe, and tests, vaccines and treatments were already at hand. But the response to both threats sputtered and stumbled at every step.
“It’s kind of like we’re seeing the tape replayed, except some of the excuses that we were relying on to rationalize what happened back in 2020 don’t apply here,” said Sam Scarpino, who leads pathogen surveillance at the Rockefeller Foundation’s Pandemic Prevention Institute.
No single agency or administration is to blame, more than a dozen experts said in interviews, although the Centers for Disease Control and Prevention has acknowledged that it bungled the response to the coronavirus.
The price of failure is high. COVID has killed more than 1 million Americans so far, yielding untold misery. Cases, hospitalizations and deaths are all falling, but COVID was the third leading cause of death in the United States in 2021 and seems likely to keep killing Americans for years.
Monkeypox is spreading more slowly now, and has never posed a challenge of COVID’s magnitude. But the United States has reported more monkeypox cases than any other country — 25,000, about 40% of the global total — and the virus is likely to persist as a constant, low-grade threat.
Both outbreaks have revealed deep fissures in the nation’s framework for containing epidemics. Add to that plummeting public trust, rampant misinformation and deep schisms — between health officials and those treating patients, and between the federal government and states. A muddled response to future outbreaks seems almost inevitable.
“We really are poorly, poorly prepared,” said Larry O. Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University.
New infectious threats are certainly on the way, mostly because of the twin rises in global travel and vaccine hesitancy, and the growing proximity of people and animals. From 2012 to 2022, for example, Africa saw a 63% increase in outbreaks of pathogens that jump to people from animals, compared with the period from 2001 to 2011.
“In people’s minds, perhaps, is the idea that this COVID thing was such a freak of nature, was a once-in-a-century crisis, and we’re good for the next 99 years,” said Jennifer Nuzzo, director of the Pandemic Center at Brown University School of Public Health.
“This is the new normal,” she added. “It’s like the levees are built for the one-in-a-100-years crisis, but then the floods keep happening every three years.”
Chronic Underfunding
Ideally, here’s how the national response to an outbreak might unspool: Reports from a clinic anywhere in the country would signal a new pathogen’s arrival. Alternatively, ongoing wastewater surveillance might sound the alarm for known threats, as it has recently for polio in New York state.
The information would flow from local health departments to state and federal authorities. Federal officials would rapidly permit and offer guidance for the development of tests, vaccines and treatments, rolling them out equitably to all residents.
Not one of these steps worked smoothly in the two recent outbreaks.
“I’m very familiar with outbreak response and pandemic preparedness, and none of it looks like this,” said Kristian Andersen, a virologist at the Scripps Research Institute in San Diego who has spent years studying epidemics.
Andersen said he had assumed that the flaws exposed by the coronavirus would be repaired as they became apparent. Instead, “we’re worse prepared now than we were early in the pandemic,” he said.
Public health in the United States has always operated on a shoestring. The data systems used by the CDC and other federal agencies are laughably out of date. Many public health workers were abused and attacked during the pandemic and have fled their jobs, or are planning to.
More money won’t solve all the problems, several experts said. But additional funding could help public health departments hire and train staff, update their aging data systems and invest in robust surveillance networks.
But in Congress, pandemic preparedness remains a tough sell.
President Joe Biden’s budget request for fiscal year 2023 includes $88 billion over five years, but Congress has not shown any inclination to approve it.
The United States spends between 300 to 500 times more on its military defense than on its health systems, and yet “no war has killed a million Americans,” noted Dr. Thomas R. Frieden, who led the CDC under former President Barack Obama.
Renewed Urgency
The United States was supposed to be the very best at managing outbreaks. An assessment of global health security in 2019, a year before the arrival of the coronavirus, ranked the nation first among all others — best at preventing and detecting outbreaks, most adept at communicating risk and second only to the United Kingdom in the rapidity of its response.
But all of that assumed that leaders would move quickly and decisively when faced with a new pathogen, and that the public would follow instructions. The analyses did not account for an administration that underplayed and politicized every aspect of the COVID response, from testing and masks to the use of vaccines.
Too often in a crisis, government officials look for easy solutions, with dramatic and immediate impact. But there are none for managing pandemics.
“A pandemic is by definition a problem from hell. You’re vanishingly unlikely to be able to remove all of its negative consequences,” said Bill Hanage, an epidemiologist at the Harvard T.H. Chan School of Public Health.
Instead, he added, officials should bet on combinations of imperfect strategies, with an emphasis on speed over accuracy.
In both the coronavirus pandemic and the monkeypox outbreak, for example, the CDC at first tried to maintain control over testing, instead of disseminating the responsibility as widely as possible. The move led to limited testing, and left health officials blind to the spread of the viruses.
The Food and Drug Administration was slow to help academic labs develop alternatives for testing, and encouraged the highest quality of diagnosis. It may be reasonable for officials to ask which test is faster or which one produces the least errors, Hanage said, but “all of them are better than not doing anything.”
Gostin, of Georgetown University, has worked with the CDC for most of his career, and was among its staunchest defenders early in the pandemic.
But he became increasingly disenchanted as the United States was forced to rely on other countries for vital information: How effective are boosters? Is the virus airborne? Do masks work?
“Virtually in every case, we got our information and acted on it from foreign health agencies, from the U.K., from Israel, from South Africa,” Gostin said. The CDC “always seemed to be last and weakest,” he said.
Many at the CDC and other health agencies seemed to be paralyzed, fearful of being held accountable if things go wrong, he added: “They’re covering their rear ends trying to follow the procedure. It all boils down to a lack of fire in their bellies.”
Divided Responsibilities
The most intractable hurdle to a coordinated national response arises from the division of responsibility and resources between federal, state and local governments, along with gaps in communications between the public health officials coordinating the response and the doctors and nurses actually treating the patients.
The complex laws that govern health care in the United States are designed to protect confidentiality and patient rights. “But they are not optimized for working with the public health system and getting the public health system the data that it needs,” said Dr. Jay Varma, director of the Cornell Center for Pandemic Prevention and Response.
Generally, states are not obligated to share health data, such as the number of cases of infection or demographic details of vaccinated people, with federal authorities.
Some state laws actually forbid officials from sharing the information. Smaller states like Alaska may not want to hand over details that leave patients identifiable. Hospitals in small jurisdictions are often reluctant to surrender patient data for similar reasons.
Health care systems in countries like Britain and Israel rely on nationalized systems that make it much easier to collect and analyze information on cases, said Dr. Anthony Fauci, the Biden administration’s top medical adviser.
“Our system isn’t interconnected like that,” Fauci said. “It isn’t uniform — it’s a patchwork.”
A CDC official said the agency understood the perspective of the states, but the current rules on data sharing created “constraints and hurdles.”
“I don’t think it’s a matter of scapegoating states,” Kevin Griffis, a spokesman for the agency, said. “It’s simply a statement of the fact that we don’t have access to the information that we need to optimize a response.”
Legislation introduced in Congress might help remove those barriers, he added. The measure would require health care providers, pharmacies, and state and local health departments to report health data to the CDC.
Epidemics are managed by public health agencies, but it is clinicians — doctors, nurses and others — who diagnose and care for patients. An efficient outbreak response relies on mutual understanding and exchange of information between the two groups.
The sides did not communicate effectively in either the COVID pandemic or the monkeypox outbreak. The disconnect has led to absurdly convoluted procedures.
The CDC has not yet included monkeypox in its disease reporting computer system, for example. That means state officials must manually type in data from case reports, instead of simply uploading the files. A request for testing must often be faxed to the state laboratory; the results are often routed through a state epidemiologist, then to the provider, then to the patient.
Few public health officials understand how health care is delivered on the ground, some experts said. “Most people in the CDC don’t know what the inside of a hospital looks like,” said Dr. James Lawler, co-director of the University of Nebraska’s Global Center for Health Security.
Frieden, who once led New York City’s health department, suggested that embedding CDC staff into local health departments might help officials understand the obstacles involved in responding to an outbreak.
Frieden has also proposed what he calls a “7-1-7” accountability metric, loosely modeled on a strategy employed to address the HIV epidemic. Every new disease should be identified within seven days of emergence, reported to public health authorities within one day and responded to within seven days.
The strategy may give the government a clearer sense of the problems impeding the response, he said.
In the United States, “what we have is repeated cycles of panic and neglect,” Frieden said. “The single most important thing we have to do is break that cycle.”
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