Clinics that treat sexually transmitted diseases — already struggling to contain the explosive growth of infections such as syphilis and gonorrhea — now find themselves on the front lines of the nation’s fight to contain a fast-growing monkeypox outbreak.
After decades of funding shortages and 2½ years into an epidemic that has severely disrupted care, clinic staff and public health officials say the clinics are ill-equipped for another pandemic.
“America does not have what it takes to adequately and completely combat monkeypox,” said David Harvey, executive director of the National Coalition of STD Directors. “We are already stretched to capacity.”
Monkeypox—a cousin of smallpox—is not technically considered a sexually transmitted infection. But it spreads through intimate contact and is now widely transmitted through networks of men who have sex with men.
Since the current outbreak of monkeypox causes genital blisters or pimples, many patients are being treated for herpes, syphilis, or another sexually transmitted infection. Because of the stigma of sexually transmitted infections, patients often choose to seek care anonymously at public clinics, rather than visiting their primary care doctor.
Although most people with monkeypox recover on their own within two to four weeks, about 10% require hospital care, said Dr. Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine.
Dr. Mary Foote, an infectious disease specialist at the New York City Department of Health and Mental Hygiene, said the rate of complications from monkeypox was “much higher than any of us expected.” Infectious Diseases Society of America. In addition to severe pain, some people with monkeypox are at risk of permanent scarring. The pain can be excruciating, making it difficult for patients to swallow, urinate or defecate, Foote said.
Sexual health clinics are so stretched thin that many lack the staff to carry out basic duties such as contacting and treating the partners of infected patients.
These clinics are the most neglected safety net in the country’s fragmented public health system, which has less authority and flexibility to fight outbreaks today than before the Covid-19 pandemic.
With 1,971 cases of monkeypox reported in the United States since May — and about 13,340 around the world — doctors warn the epidemic is too big for them to contain and could spread.
Dr. Shira Heisler, medical director of the Detroit Public Health STD Clinic, said she’s proud of the quality of care she provides but doesn’t have time to see every patient who needs care. “We don’t just have bodies,” she said. “It’s total infrastructure collapse.”
Centers for Disease Control and Prevention funding for sexually transmitted infection prevention has dropped nearly 10% to $152.5 million since 2003, even though cases of syphilis alone have quadrupled in that time. Adjusted for inflation, that funding has fallen 41% since 2003, according to an analysis by the National Coalition of STD Directors.
Meanwhile, hundreds of local and state health professionals who trace the origins, track trajectories and stop the spread of cases reported by sexual health clinics have resigned or been replaced since the epidemic began. Some left due to burnout, and others were forced out of their jobs by critics protesting the unpopular policy of masks and lockdowns. Some federal grants are being rolled out now to strengthen the public health workforce.
Data reporting systems were not updated during the pandemic, despite clear inadequacies it helped reveal. Public health workers still use fax machines to deal with monkeypox cases in Florida and Missouri, public health officials told KHN.
“Despite the benefits of testing and having a vaccine, we still haven’t invested enough in the public health system to be able to respond quickly,” said Dr. Tao Kwan-get, Washington state’s chief science officer. A lot of people will “tell you we have the best healthcare system in the world. But I think the Covid-19 pandemic, as well [the monkeypox] The outbreak shows that the system is broken and needs to be fixed.”
The White House is now distributing tens of thousands of monkeypox vaccines, releasing additional doses as they become available for about 7 million doses over the next year.
But Hotez said the shipment of the vaccine “may not be enough.”
Some cities are running out of doses soon after opening their doors. In New York City, where monkeypox cases tripled last week, the vaccine rollout has been plagued by technical glitches; The vaccine website has crashed at least twice. San Francisco officials say their city is also running low on vaccine supplies.
Monkeypox vaccines can effectively prevent infection in people before they are exposed to the virus.
Experts believe vaccines can help prevent infections after exposure. But they’re most effective if administered within four days of close contact with a monkeypox patient, says Dr. Trini Matthews, medical director of antimicrobial stewardship and infection prevention and control at Beaumont Hospital in Taylor, Michigan. Vaccines given between four and 14 days after exposure can reduce symptoms but do not prevent disease.
Yet the battered public health system was not built for speed.
Although monkeypox tests have become easier to access in recent days, some public health systems do not have enough staff to quickly identify and test partners of patients. And since most health professionals have never handled a case of monkeypox, patients often require multiple visits before being properly diagnosed.
Sean Kiernan, chief of the infectious disease division at the Fairfax County Health Department in Virginia, said contacting exposed people becomes more complicated if they live across county or state lines, which may require coordinating an outbreak response with additional health departments.
Decades of budget cuts have limited many sexual health clinics to their operating hours, making it difficult to care for patients.
The Department of Public Health has lost key members of its team in recent years, including highly trained nurses and outreach specialists.
A 2020 KHN-AP analysis found that at least 38,000 state and local public health jobs have disappeared since the 2008 recession, leaving a fragmented workforce to meet America’s public health needs — and that was before Covid hit. This investigation found that only 28% of local public health departments have statisticians or epidemiologists, disease detectives who investigate the source and trajectory of infectious outbreaks.
According to the CDC, more than 2.4 million sexually transmitted infections were reported in 2020.
“I don’t think any health department in America can handle all the STIs that are reported to them,” Kiernan said.
The federal government has spent billions of dollars fighting the Covid pandemic, and some of the Covid-related grants will be used to expand the overall public health workforce.
But the CDC and Congress often designate funds for specific purposes, said Lori Tremmel Freeman, head of the National Association of County and City Health Officers. “If you have someone working on Covid, you can’t reassign them to Monkeypox using the same bucket of money,” Freeman said.
And in some states, that money still hasn’t reached public health departments or sexual health clinics.
The CDC has given Michigan millions of dollars to strengthen its public health workforce, but the Michigan Legislature has appropriated only a fraction of the money. Heisler wrote to several state legislators urging them to free up the remaining funds. No one answered him.
Public health officials say they hope monkeypox will be a wake-up call.
“I hope this drives the need for more investment in public health infrastructure,” said Quan-Gate of the Washington State Department of Health, “because without that investment it’s going to happen again and again.”
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