When there had been about 100 cases of “monkey pox” confirmed or suspected in Europe in May it was clear that the virus was spreading beyond the areas where it was previously seen. Some on social media suggested it could now soon spread to communities in Europe and the United States. These reports should have been code red for federal infectious disease response.
But it wasn’t until the end of June that the Centers for Disease Control and Prevention expanded monkeypox testing to major commercial labs such as Quest Diagnostics and Labcorp for increased capacity and access. The CDC had gone through its standard playbook and gone through its lengthy checklist.
Compared to the agency’s failed unroll from a test for the coronavirus, the monkeypox test came to warp speed. But the virus spread even faster. If US leaders wanted to stop the outbreak, the United States should have tested all people who presented with suspected atypical cases of diseases such as genital herpes and zoster infection; both can cause a rash that sometimes resembles monkey pox. My rough estimate would have required maybe 15,000 tests per week. From mid-May to the end of June, the United States tested only about 2,000 samples.
Our country’s response to monkey pox has been plagued by the same shortcomings we had with Covid-19. If monkeypox now gains a foothold in the United States and becomes an endemic virus to join our circulating repertoire of pathogens, it will be one of the greatest public health shortcomings in modern times, not just because of the pain. and the danger of the disease, but also because it was so avoidable. Our mistakes extend beyond political decision-making to the agencies responsible for protecting us from these threats. We don’t have a federal infrastructure capable of handling these emergencies.
The failures that have brought us here fit into a now familiar pattern.
In the beginning, similar to the early days of Covid, access to monkeypox testing was limited, despite ample evidence that monkeypox was spreading in the United States. The Strategic National Stock was intended as a cover against virus accidents, but when the coronavirus hit, it lacked sufficient supplies of testing equipment, ventilators and masks. With monkeypox, the government hadn’t 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 on hand less than 2,400 doses in mid-Mayusually as a hedge against the risk of smallpox, which was the other indication of the vaccine.
There are more parallels between our failure to fight Covid and monkey pox. Each time, the reflex has been to blame political leadership on poor planning, lack of urgency, and clumsy execution. True, both responses were plagued by a lack of coordination among federal agencies such as the Food and Drug Administration, which I led during the first two years of the Trump administration; the CDC; and the Health and Human Services units responsible for various aspects of response. But systemic shortcomings also lie with the bureaucracy charged with countering these threats.
The CDC should lead the US response to viral emergencies. But the agency is not a crisis organization. It lacks the infrastructure to react quickly and is too reserved and process-driven to act quickly. His cultural instinct is to take an informed approach and discuss every decision. With Covid, the virus has quickly gained ground. With monkeypox spreading more slowly, usually through very close contact, the shortcomings of CDC’s cultural approach have not been so acute. But the shortcomings are the same.
Take the scant information available about the domestic outbreak and how it spread. The CDC has publicly complained that it cannot enforce sufficient reporting from states and that it lacks insight into the magnitude and nature of reported cases of monkeypox. That’s true. But the CDC still has information from states that do share case reports, which the agency could have used to provide a better clinical mosaic of how the virus spread and presented to doctors.
It is very difficult for the agency to organize itself around a new mission in the context of a crisis or to lead an internal effort to reform long processes. But it has proved equally difficult for Congress to take meaningful action to reorganize the agency to make it more robust and more responsive. Proper reform would require empowering public health agencies with new tools, funding and authority, but my conversations with congressmen and their staff show that there is little interest in such a move, not only on the political right, but also on the left. After Covid, there is an opinion among some that public health authorities have used flawed analysis and miscalculated their advice. Reaching a political consensus that the CDC should be further empowered to complete its mission — invested, for example, with the power to enforce reporting from states — is politically unachievable.
That leaves it to the Biden administration. But the belated attempt at reform also falls short. It has effectively created a desk from an office within the Department of Health and Human Services charged with, among other things, coordinating the federal response to bioterrorism. The reshuffle places the new Administration for Strategic Preparedness and Response on an equal footing with the CDC. It’s Washington’s classic answer to a problem: create a desk around it. The move will only add to the mess.
The pandemic mission should remain with the CDC, which has the necessary tools and expertise to respond to these crises. I know from my time at the FDA that it is the agencies that have the operational know-how and capabilities. The CDC has the boots on the ground that the front lines need to attack these types of outbreaks, with its advanced detection and surveillance tools. What it lacks is the authority and a mindset of national security.
The Biden administration needs to return the CDC to its disease control roots, by transferring some of its disease prevention work to other agencies. The FDA can handle smoking cessation using its regulatory toolbox. The National Institutes of Health can tackle cancer and heart disease. Focus the CDC more on its core mission of response to outbreaks. And imbued the agency with the national security mindset it had at its origin. If the CDC’s mission were more tightly focused on the elements needed to deal with contagion, Congress would be more willing to invest it in the robust authority to properly carry out that focused mission. Congress would have to reprogram budget lines to make it happen, but someone has to start that conversation.
Time is running out. Diseases such as Zika, Covid and monkeypox are a serious warning that dangerous pathogens are advancing. The next could be worse – a deadly flu or something more sinister like the Marburg virus. We have now amply noticed that the nation is still unprepared and that 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 serves on the board of directors of Pfizer and Illumina. He is also the author of “Uncontrolled Spread: Why Covid-19 Crushed Us and How We Can Beat the Next Pandemic.”
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