Clinics treating sexually transmitted diseases, already struggling to contain an explosion in infections such as syphilis and gonorrhea, now find themselves on the front lines of the nation’s battle to contain a fast-growing monkeypox outbreak.
After decades of underfunding and a 2.5-year pandemic that severely disrupted care, clinic staff and public health officials say clinics are ill-prepared for another outbreak.
“America does not have what it needs to adequately and fully combat monkeypox,” said David Harvey, executive director of the National Coalition of STD Directors. “We are already capable.”
Monkeypox—a cousin of smallpox—is not technically considered a sexually transmitted infection. However, it spreads through close contact and is now mainly spread through networks of men who have sex with men.
With the current monkey outbreak causing blisters or pimples on the genitals, many patients are seeking help for herpes, syphilis or other sexually transmitted infections. Because of the stigma attached to sexually transmitted infections, patients often prefer to go anonymously to public clinics for help rather than seeing their primary care physician.
Although most people with monkeypox recover on their own within two to four weeks, about 10% require hospitalization, said Dr. Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine.
The rate of complications from monkeypox “has been much higher than any of us expected,” said Dr. Mary Foote, an infectious disease expert at the New York City Department of Health and Mental Hygiene, who spoke at a July 14 webinar presented by the Infectious Diseases Society of America. In addition to severe pain, some people with monkeypox are at risk of permanent scarring. Foote said the pain can be excruciating, making it difficult for patients to swallow, urinate or defecate.
Sexual health clinics are stretched so thin that many lack the staff to perform basic tasks such as communicating with and treating the partners of infected patients.
These clinics are among the most neglected safety nets in the nation’s tattered public health system, which today has less authority and flexibility to fight outbreaks than it did before the COVID-19 pandemic.
Doctors warn that since May, 1,971 cases of monkeypox have been reported in the United States and about 13,340 cases worldwide.
Dr. Shira Heisler, medical director of Detroit Public Health’s STD Clinic, said she prides herself on the quality of care she provides, but she simply doesn’t have time to see every patient who needs care. “We just don’t have any bodies,” he said. “It’s a total infrastructure collapse.”
Funding for the Centers for Disease Control and Prevention to prevent sexually transmitted infections has fallen nearly 10% since 2003, to $152.5 million this year, even as syphilis cases alone have more than quadrupled in that time. Adjusted for inflation, that funding has dropped 41% since 2003, according to an analysis by the National Coalition of STD Directors.
Meanwhile, since the pandemic began, hundreds of local and state health workers have been tracking the origins, trajectories, and stemming the spread of cases reported by sexual health clinics. Some quit due to burnout and others were fired by critics who protested the unpopular policy of masks and closures. Some federal grants to strengthen the public health workforce are being awarded right now.
Data reporting systems have not been updated during the pandemic, despite glaring gaps that helped reveal them. Public health workers in Florida and Missouri are still using faxes to handle monkeypox cases, public health officials told KHN.
“Even with the benefits of the test and the vaccine, we still haven’t invested enough in the public health system to be able to respond quickly enough,” said Dr. Tao Kwan-Gett, Washington State’s chief research officer. Many people will tell you that we have the best health care system in the world. But I think both the Covid-19 pandemic and the [monkey pox] outbreak show that the system is broken and needs to be fixed.
The White House is currently distributing hundreds of thousands of monkeypox vaccines, releasing additional doses as they become available, for a total of nearly 7 million doses over the next year.
But Hotez said those vaccine shipments “may not be enough.”
In some cities, the doses start to run out soon after the doors open. In New York, where monkeypox cases have tripled in the past week, vaccine development has been plagued by technical glitches; the vaccine website has crashed at least twice. San Francisco officials said their city is also running low on the vaccine.
Monkeypox vaccines can effectively prevent people from becoming infected before they are exposed to the virus.
Experts believe that vaccines can help prevent infection even after exposure. But they are most effective if given within four days of close contact with a monkeypox patient, said Dr. Trini Mathew, medical director of antimicrobial therapy and infection prevention and control at Beaumont Hospital in Taylor, Ill. Vaccines given within 4 to 14 days of exposure may reduce symptoms but not prevent the disease.
Yet the battered public health system is not built for speed.
Although monkeypox tests have become easier to access in recent days, some public health systems are understaffed to quickly find and test patients’ partners. And since most healthcare professionals have never dealt with a case of monkeypox, patients often have to make multiple visits before receiving an accurate diagnosis.
Contacting exposed people becomes more difficult if they live across a county or state border, which may require coordinating an outbreak response with additional health departments, said Shawn Kiernan, chief of the infectious disease division at the Virginia Fairfax County Health Department.
Decades of budget cuts have forced many sexual health clinics to limit their hours, making it harder for patients to get care.
Public health departments have lost key members of their teams in recent years, including highly trained nurses and outreach specialists.
A 2020 KHN-AP analysis found that at least 38,000 state and local health care jobs have been lost since the 2008 recession, leaving a stretched workforce to face 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 study 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 sexually transmitted infections that are reported to them,” Kiernan said.
The federal government has spent billions of dollars to fight the covid pandemic, and some covid-related grants are being used to expand the overall public health workforce.
But the CDC and Congress often earmark funds for specific purposes, said Lori Tremmel Freeman, head of the National Association of County and City Health Officials. “If you have someone working on covid, you can’t reassign them to monkeypox with the same money,” Freeman said.
And in some states, that money has yet to reach public health departments or sexual health clinics.
The CDC gave Michigan millions of dollars to strengthen its public health workforce, but the Michigan Legislature appropriated only a fraction of the money. Heisler wrote to several state legislators asking them to release the rest of the money. No one answered him.
Health officials say they hope to eradicate monkeypox.
“I hope this highlights the need for more investment in public health infrastructure,” said Kwan-Gett of the Washington State Department of Health, “because without that investment, this is going to happen again and again.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health topics. Along with policy analysis and surveys, KHN is one of the three major operational programs of the Kaiser Family Foundation (KFF). KFF is a non-profit organization that provides information to the public about health problems.
