When around 100 cases of monkeypox were confirmed or suspected in Europe in May, it was clear that the virus was spreading outside of areas where it had previously been seen. Some on social media have suggested that it may already be spreading rapidly in communities in Europe and the United States. These reports should have been code red for the federal infectious disease response.
But it wasn’t until late June that the Centers for Disease Control and Prevention expanded monkeypox testing to large commercial labs like Quest Diagnostics and Labcorp for more capacity and access. The CDC had gone through its standard playbook, ticking off its lengthy checklist.
Compared to the agency’s botched rollout of a test for the coronavirus, the monkeypox test has arrived with lightning speed. But the virus spread even faster. If US leaders wanted to stifle the outbreak, the US should have tested everyone who had what were presumed to be atypical cases of diseases like genital herpes and shingles; both can cause rashes that sometimes look like monkeypox. That might have required 15,000 tests per week, by my rough estimate. From mid-May to the end of June, the United States only tested about 2,000 samples.
Our nation’s response to monkeypox has been plagued by the same shortcomings we had with Covid-19. Now, if monkeypox gains a permanent foothold in the United States and becomes an endemic virus that joins our circulating repertoire of pathogens, it will be one of the worst public health failures of modern times, not only because of the pain and peril of illness, but also because it was so preventable. Our failings extend beyond political decision-making to the agencies tasked with protecting us from these threats. We do not have a federal infrastructure capable of dealing with these emergencies.
The failures that brought us here fit a now familiar pattern.
At first, as in the early days of Covid, access to testing for monkeypox was limited, despite ample evidence that monkeypox was spreading in the United States. The strategic national stockpile was designed as a hedge against virus eventualities, but when the coronavirus hit it lacked adequate supplies of testing equipment, ventilators and masks. With monkeypox, the government had not stocked enough of the only vaccine, Jynneos, which was indicated for the prevention of the disease and considered safe to use. The United States had fewer than 2,400 doses as of mid-May, mainly to guard against the risk of smallpox, which was the other indication for the vaccine.
There are more parallels between our failures to fight Covid and monkeypox. Each time, the knee-jerk reaction has been to blame political leaders for poor planning, lack of urgency and clumsy execution. Admittedly, both responses were plagued by a lack of coordination between federal agencies like the Food and Drug Administration, which I led for the first two years of the Trump administration; the CDC; and the components of the Department of Health and Human Services that are responsible for different aspects of the response. But systemic failures also lie with the bureaucracy tasked with countering these threats.
The CDC should lead America’s response to virus demands. But the agency is not a crisis organization. It lacks the infrastructure to mobilize a rapid response and is too narrow-minded and process-oriented to act quickly. His cultural instinct is to take a deliberative approach, debating every decision. With the Covid, the virus quickly gained ground. With monkeypox spreading more slowly, usually through very close contact, the shortcomings of the CDC’s cultural approach have not yet been so acute. But the shortcomings are the same.
Take the scant information available about the national outbreak and how it has spread. The CDC has publicly complained that it cannot compel states to make sufficient reports and that it lacks information on the scope and nature of reported cases of monkeypox. It’s true. But the CDC still has information from states that share case reports, which the agency could have used to provide a better clinical mosaic of how the virus was spreading and presenting to doctors.
It is very difficult for the agency to self-organize around a new mission in the context of a crisis or to lead an internal effort to reform long-standing processes. “But it has proven equally difficult for Congress to take meaningful steps to revamp the agency to make it more robust and quick to respond. Proper reform would require equipping public health agencies with new tools, funding, and authority, but based on my conversations with members of Congress and their staffs, I believe there is little appetite for such a decision, not only from the political right, but also from the left. After Covid, some believe public health agencies used faulty analysis and miscalculated their advice. Achieving political consensus that the CDC needs to be given more power to carry out its mission — for example, vested with the power to compel states to report — is politically unobtainable.
That leaves it up to the Biden administration. But his late attempt at reform also failed. He effectively created an agency out of an office within the Department of Health and Human Services that is tasked with coordinating the federal response to bioterrorism, among other things. The reorganization puts the new Administration for Strategic Preparedness and Response on a par with the CDC. It’s a classic Washington response to a problem: to create an agency around itself. The move will only add to the confusion.
The pandemic mission must remain with the CDC, which has the tools and expertise to respond to these crises. I know from my time at the FDA that it is the agencies that have the know-how and the operational capabilities. The CDC has the boots on the ground that meet the frontline needs to attack these types of outbreaks, with its sophisticated detection and surveillance tools. What he lacks is authority and a national security mindset.
The Biden administration must return the CDC to its disease control roots, shifting some of its disease prevention work to other agencies. The FDA can manage smoking cessation by leveraging its regulatory toolkit. The National Institutes of Health can fight cancer and heart disease. Focus the CDC more on its core mission of responding to outbreaks. And imbue the agency with the national security mindset that it had at its origins. If the CDC’s mission were more narrowly focused on the elements needed to manage the contagion, Congress might be more willing to invest it with the solid authority to do this focused mission well. Congress should reprogram the budget lines to achieve this, but someone needs to start this conversation.
Hurry up. Diseases like Zika, Covid and monkeypox are a dire warning that dangerous pathogens are on the way. The next could be worse – a deadly strain of flu or something more sinister like the Marburg virus. We have now been widely warned that the nation continues to be unprepared and our vulnerabilities are enormous.
Dr. Scott Gottlieb served as commissioner of the Food and Drug Administration from May 2017 to April 2019. He is a senior fellow at the American Enterprise Institute and sits on the board of directors of Pfizer and Illumina. He is also the author of “Unchecked Spread: Why Covid-19 Has Crushed Us and How We Can Beat the Next Pandemic”.
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