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 control a rapidly growing monkeypox epidemic.
After decades of underfunding and 2 1/2 years into a pandemic that has severely disrupted care, clinic staff and public health officials say the clinics are ill-equipped 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’re already maxed out.”
Monkeypox—a cousin of smallpox—is not technically considered a sexually transmitted infection. But it is spread through close contact and is now mainly transmitted through networks of men who have sex with men.
- Monkeypox: what we know about the epidemic, vaccinations and treatments
With the current monkeypox outbreak causing blisters or pimples on the genitals, many patients are seeking care for what looks like herpes, syphilis or another sexually transmitted infection. Patients often prefer to seek care anonymously at public clinics rather than see their primary care physicians because of the stigma of sexually transmitted infections.
Although most people with monkeypox recover on their own in two to four weeks, about 10 percent need hospital care, said Dr. Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine.
The complication rate from monkeypox “is 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 July 14 during the 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 have bowel movements.
Sexual health clinics are so stretched that many are understaffed to perform such basic duties as contacting and treating the partners of infected patients.
These clinics are one of the most neglected safety nets of the nation’s tattered public health system, which has less authority and flexibility to fight outbreaks today than it did before the COVID-19 pandemic.
With 1,971 cases of monkeypox reported since May in the United States — and about 13,340 worldwide — doctors are warning that the outbreak may have become too large and widespread for them to contain.
Dr. Shira Heisler, medical director of the STD Clinic in Detroit, said she takes pride in 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 the bodies,” she said. “This is a complete collapse of the infrastructure.
Funding from the Centers for Disease Control and Prevention to prevent sexually transmitted infections has dropped nearly 10 percent since 2003 to $152.5 million this year, even though syphilis cases alone have more than quadrupled times during that time. Adjusted for inflation, that funding has declined 41 percent since 2003, according to an analysis by the National Coalition of STD Directors.
Meanwhile, hundreds of local and state health professionals who trace the origin, trace the trajectory and stop the spread of cases reported by sexual health clinics have left or been replaced since the pandemic began. Some quit because of exhaustion, and others were forced out of their jobs by critics protesting the unpopular mask and lockdown policies. Some federal grants to strengthen the public health workforce are just rolling out.
Data reporting systems were not updated during the pandemic, despite the glaring inadequacies they helped uncover. Public health workers are still using fax machines to deal with monkeypox cases in Florida and Missouri, public health officials told KHN.
“Even with the advantages of having a test and a vaccine, we still haven’t invested enough in the public health system to be able to respond quickly enough,” said Dr. Thao Quan-Geth, Washington state’s chief scientific officer. Many people “will tell you that we have the best health care system in the world. But I think the COVID-19 pandemic as well [the monkeypox] burst indicates that the system is damaged and needs repair.”
The White House is distributing hundreds of thousands of monkeypox vaccines now, releasing additional doses as they become available, for a total of nearly 7 million doses next year.
But Hotez said those vaccine supplies “may not be enough.”
Some cities run out of doses shortly after opening their doors. In New York, where cases of monkeypox have tripled in the past week, the vaccine rollout has been plagued by technical problems; the vaccine website crashed at least twice. San Francisco officials said their city is also running out of vaccine supplies.
Monkeypox vaccines can effectively prevent infection in humans before they have been exposed to the virus.
Experts believe vaccines can also help prevent infection after exposure. But they are most effective if administered within four days of close contact with a monkeypox patient, said Dr. Trini Mathew, medical director of antimicrobial stewardship and infection prevention and control at Beaumont Hospital in Taylor, Michigan. Vaccines given between four and 14 days of exposure can reduce symptoms but not prevent the disease.
I don’t think any health department in America could handle all the STIs being reported to them.
Yet the battered public health system is not built for speed.
Although testing for monkeypox has become easier to access in recent days, some public health systems are understaffed to quickly find and test partners of patients. And because most health professionals have never treated a case of monkeypox, patients often have to make several visits before they are accurately diagnosed.
Contact with exposed people becomes more complicated if they live across a county or state border, which may require coordinating the outbreak response with additional health departments, said Sean Kiernan, chief of the Division of Communicable Diseases at the U.S. Department of Health. Fairfax County in Virginia.
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 skilled 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 this was before covid hit. This investigation found that only 28 percent of local public health departments have statisticians or epidemiologists, the disease detectives who study the source and trajectory of infectious outbreaks.
More than 2.4 million sexually transmitted infections were reported in 2020, according to the CDC.
“I don’t think any health department in America could handle all the STIs that are reported to them,” Kiernan said.
The federal government has spent billions of dollars to combat the COVID pandemic, and some COVID-related grants will be 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 with COVID, you can’t just 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 gave Michigan millions of dollars to strengthen the public health workforce, but the Michigan Legislature appropriated only a fraction of the money. Heisler wrote to numerous state lawmakers, pleading with them to release the remaining funds. No one answered her.
Public health workers say they hope monkeypox is a wake-up call.
“I hope this leads to the need for more investment in public health infrastructure,” said Quan-Gueth of the Washington State Department of Health, “because without that investment it’s just going to happen again and again.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with Policy Analysis and Polling, KHN is one of the three main operational programs of the KFF (Family Kaiser Foundation). KFF is a charitable, non-profit organization providing information on health issues to the nation.
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