NYC Health Chief: We Need Emergency Monkeypox Resources Now

BIANNA GOLODRYGA: Well, we turn now to another health concern facing Americans, and that is monkeypox. So far states of emergency have been declared in New York, Illinois, and California. New York City is the epicenter of the outbreak. According to its Mayor, Eric Adams. And our next guest, Dr. Ashwin Vasan is that city’s health commissioner. He tells Hari Sreenivasan about the risks of the virus, and what needs to be done to protect people.

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HARI SREENIVASAN, CORRESPONDENT: Bianna, thanks. Dr. Ashwin Vasan, thanks so much for joining us. First of all, this state of emergency that’s been declared by New York about monkeypox, why?

DR. ASHWIN VASAN, COMMISSIONER, NEW YORK CITY DEPARTMENT OF HEALTH: I think it’s an important signal that we’re treating this with urgency. It’s an important alignment with our state partners. The governor — Governor Hochul issued a state declaration over the weekend which opens up new resources for us as well as opportunities to bring in more workforce to vaccinate people. But it’s also a chance to signal to the federal government that we really need fuel resources and an emergency declaration from them to unlock the kind of resources we need to mount the speed of response that people expect of us. There are little concrete things around contracting and data sharing as well that are opened up as a result of the declaration. But the most important thing is that it signals to the public and to the federal government that we need emergency resources now. You know, we’re battling two pandemics. We are still battling COVID on emergency resources. We need new resources to battle monkeypox, as well.

SREENIVASAN: OK, put this in perspective for us. I mean, you’re an epidemiologist and you focus on New York City, what have you been seeing over the past few weeks that gave you enough concern to go to the mayor and the State of New York and say, this is important. We have to escalate the attention on this.

VASAN: Well, look — I mean, I think we estimate that up to 150,000 people might be at risk for getting or transmitting monkeypox or having a severe outcome if they were to get monkeypox. And so, as you can imagine, that’s 150,000 people here in New York City that we want to be protected. There are multiple ways to protect oneself. Obviously, primary prevention and behavior modification is one. But vaccination remains an important tool. And the fact that we have a vaccine that’s effective means we need to get that product out as fast as we can to as many of those 150,000 people we estimate that want it. In the last few weeks, you know, we’ve also seen testing capacity ramp up through our commercial labs, and I appreciate the federal response in trying to open up those opportunities. But as with that opening up testing, you’ve seen a dramatic increase in cases. And so, that — all of that taken together is pretty concerning.

SREENIVASAN: So, are we seeing the numbers increase because we have the testing now, or has this been in the community spreading without our ability to test? Meaning, it’s actually bigger than what the numbers show?

VASAN: I mean, I think every epidemiologist will say, quite clearly, that we’re probably still not testing enough. You know, our first case of monkeypox in the country was back in May. And New York was the first in the country — New York City was the first in the country to start vaccinating people at risk in the end of June because we knew we were underestimating the scale of this outbreak and the scale of transmission. Now, we’re starting to get a little bit of a better handle on the scale of transmission. And what we can see is that there is an enormous demand for vaccination and prevention. And there are — you know, there is a significant amount of transmission happening. I still think if we are aggressive over the next four, six, eight weeks with our vaccination campaign and our continued messaging that we can slow this thing down. But for the next few weeks are critical.

SREENIVASAN: Now, we learned this from COVID that if we were able to get vaccines out, even weeks before we did in certain areas, that we could have really stemmed the tide on this. So, if we have a vaccine for this, which was the big challenge with the coronavirus, why has it taken so long for us to, kind of, bring the alarms on this? What happened to that extra month? Why don’t — why aren’t there more vaccinations happening today?

VASAN: I mean, I think one thing I alluded to earlier, we’re dealing with two pandemics at once. When we had our first cases of MPX, monkeypox that came into the country, we were in an environment of rising COVID cases at the same time, number one. Number two, I think this raises the larger question of what are assets in terms of a public health infrastructure, a permanent public health infrastructure that can turn on a dime and deliver the scale and speed of response that the American people and New Yorkers expect of us. And we’ve been running a response for COVID on the back of emergency funds for two years. But we haven’t been able to make those permanent investments in something that’s flexible, nimble, data-driven, and can meet people where there are with the kind of speed and effectiveness that people demand. I hope that this lesson of our response to monkeypox triggers a really open and widescale public conversation about how much we believe in prevention. How much we believe in public health. We spent $4 trillion on health care. And we spent about three cents on every dollar on public health. And we need to redress that imbalance if we want the kind of responses that are effective, fast, and able to scale. It is frustrating. We had a vaccine. We have a treatment. We had a test. And all of it was kind of rolled out more slowly than we would’ve liked because of the fact that our permanent public health infrastructure isn’t – – has not been invested in for decades.

SREENIVASAN: Brief biology reset for people. How’s monkeypox work? What are the symptoms? Why is it so dangerous?

VASAN: So, monkeypox is an orthopoxvirus. It predominately affects the — it’s a dermatological condition predominantly. So, it results in pox or lesions across the body. And it can result in flu-like illness. It’s usually self-limited and self-resolving though it can result in pretty significant scarring and disfiguration. And what we’re seeing in this current outbreak is that — is not so much a predominance of lesions on the torso and face and hands which was — which is characteristic of the pandemic version in West Africa and Central Africa, but rather more associated with the genital and anal and perianal regions which is extraordinarily painful. So, while this may not be a fatal disease in the way that we think of COVID or anything else, it is an extremely painful and unpleasant experience. And frankly, from a public health standpoint, you know, we shouldn’t just be allowing a virus like this to enter our country and become endemic even if it’s not fatal. It’s still presenting a significant burden on people.

SREENIVASAN: How long are people contagious?

VASAN: Well — so, the challenge with monkeypox, of course, is that there is a pretty long incubation period. It can be up to 21 days. And people can be contagious if they have lesions until such time that those lesions are fully cresting over and healing and there is evidence of new skin regrowth underneath those scars. And so, we recommend isolation of up to 21 days until such — or until such time that people are asymptomatic in those lesions are healing, which is — which what makes, you know, diagnosis difficult. It makes contact tracing difficult because the time between exposure and onset of symptoms is longer than something like COVID or something that moves more quickly. So, that’s all quite challenging for sure. We still believe that the predominant mode of contact — transmission is skin-to-skin. Prolonged skin-to-skin contact. So, not just the casual brushing by and shaking of hands, but prolonged skin-to-skin contact. And there is increasing evidence that the virus does — is present in bodily fluids like saliva, semen, and blood, which — but it isn’t entirely clear yet whether it’s formally sexually transmitted. Though intimate contact and sex is certainly the most high-risk activity that we’re seeing associated with transmission in this outbreak.

SREENIVASAN: What have been the challenges over the past month to get people to realize that this is serious and that they need to get medical care?

VASAN: I think it’s important to step even further back and look at how we viewed this virus from the beginning. We’ve known about monkeypox, MPX, orthopoxvirus from the ’70s. And it was really thought to be an African illness. One that is in West and Central Africa. Not a problem for us in the global north, in Western Europe, in North America. And so, our preparation for it was not prepared for widespread transmission, but rather potentially weaponization and bioterrorism. Which is why in our strategic national stockpile, we had relatively small amounts of vaccine, tens of thousands rather than the bigger amounts that we really need. We had a test, but it wasn’t approved for widespread clinical use. And we had a treatment — we have a treatment but it’s only available under investigational use. And so, what you’re seeing is an entirely, you know, misaligned, in the sense, preparation and now response. But you’re seeing the gears turn on and you’re seeing the federal government step up to try to meet that challenge. But I think we have to start with that fundamental framing that this was a disease over there. Not a problem over here. And there is inherent structural inequity, racism behind that as well that really makes us feel like we’re not connected.

SREENIVASAN: The health data says something around 60 percent of the cases here are in the LGBTQ community, more specifically the male population. So, what are some of the internal challenges and debates that you’ve been facing in trying to mobilize for this?

VASAN: I think we’ve — you know, we have a long history of engaging the LGBTQ community in public health responses. And they have a long history of fighting for their health and human rights. Bills off, particularly, the HIV/AIDS Movement. And that’s certainly where I started my career learning from the global HIV/AIDS Movement, around how to center the needs of the LGBTQ community in a global response. We have a network, certainly, of community partners, and organizations, and advocates that we lean on heavily in terms of developing our messaging. Really understanding how the science and how people are interpreting that science and how we can deliver the best primary prevention approaches. You know, I’m also quite aware, and we are all quite aware here at the health department, and frankly, at health departments and all across the country, of needing to balance the identification of the behaviors that are most at risk and most associated with transmission and the populations. Because behaviors and identities are two different things. And we’re really trying to focus on the behaviors and what we know and what we don’t know. And that’s especially important for the LGBTQ population, that has had their sexual behaviors, their social behaviors dissected and prescribed and judged and, frankly, discriminated against for decades. We take that very seriously because we know stigma and discrimination, it’s not just an issue of politics and language, it’s an issue of public health because it pushes people farther into the shadows. It causes them to delay care and worsens outcomes.

SREENIVASAN: So, even in targeting the behaviors in, maybe, a specific group of people, there seems to be inequity in medical policies over the decades on how, say, for example, gay men in a certain socioeconomic class or race to get access to care versus people who might be a greater risk, but not living in the same neighborhood.

VASAN: Look, I think we’ve tried — especially with our vaccination campaign, really tried to focus on urgency and equity. And there are tools we have in our disposal — at our disposal to try to work on that. You know, we focus a lot on the optics of long lines of people potentially from certain socioeconomic and racial and demographic groups waiting in line for vaccination. But what’s talked about less are the thousands of doses we are reserving for community-based organizations that really target communities of color, BIPOC, men who have sex with men, and other LGBTQ communities. We don’t talk much about the thousands of doses that we’re reserving for HIV providers and LGBTQ-affirming clinical providers which are trusted and have long-term relationships. And we’re not talking too much about our upcoming mobile vaccinations work to go out into communities, to go to community events, parties, social gatherings where we can meet people where they are. So, I understand there’s this baked inequity in our society that often rears its head. It’s extremely hard to preserve equity in an environment of constrained — extremely constrained supply. But we’re using the tools that we have to, kind of, try to create a multidisciplinary approach to get people multiple doors of entry into preventive care, as well as testing and treatment.

SREENIVASAN: How are you going to be able to measure whether the response to this has been more equitable? I mean, given that you are familiar with the HIV populations, this is for some of them very painful. This is, you know, bringing back a lot of memories on the types of, sort of, have discreet differences in how they were not just treated, but what kind of access they have to medicines.

VASAN: Yes, I understand how traumatizing this must be for the gay community and the LGBTQ community. And we also just can’t disentangle this from the fact that we’re still dealing with COVID and its aftermath. And so, people are extremely frustrated, extremely tired, and extremely traumatized from the last several years built on top of this history. So, that’s why we’re trying really hard to reach out to our community partners, with whom we have long-term relationships, on things like condom promotion, on prep for HIV. We’re leaning into those relationships because those are long-term trusted relationships with organizations and people that, certainly the City of New York, is trying to leverage. And I think health departments and authorities across the country are doing the same thing. Trying to bring in community leaders from the beginning, as we design our response. Again, a lot of this ends up being extraordinarily hard in an environment of constrained supply. Both the vaccine, but also testing and treatment. And so, we’re encouraged by what steps that Washington is taking to unlock those barriers. But I think at the end of the day we have to go to the root cause and the fact that these core aspects of the intervention are still taking time to turn on and to be as available as people, rightfully expect.

SREENIVASAN: So, the Biden administration has, at least, appointed leadership to try to mount this response. What are you saying on your calls, or whatever, to the federal government? What is it that you need now to try to get a handle on this? And I’m sure that your colleagues in other States that have also declared emergencies are thinking the same thing.

VASAN: Yes, they’ve been good partners to us. They’ve been — we’ve had open lines of communication from the beginning of this response. The bottom line is we need more vaccines. We need more access to testing. And we need easier access to treatment. That makes it easier for clinicians to start people who test positive on treatment that can reduce the symptom burden, reduce the painful side effects of — the painful effects of the infection. And we need to do that ASAP. You know, we need to be thinking ahead. It’s encouraging that we got approximately 750,000 new doses into the country. What’s next? What’s coming after that? Where is the next tranche of vaccines coming from? You know, we need their support for emergency resources. I said at the outset, we’re funding this on our own local funds in the midst of also funding a COVID response on emergency funds. None of which is building that permanent infrastructure that we need. So, we need a federal declaration of emergency. And we need to be able to unlock the FEMA reimbursable fund so we can stand up to this kind of multidisciplinary vaccination campaign. So, we can stand up our media and outreach campaigns and community engagement campaigns that I described. All of this requires resources. And we certainly need those resources now. We’re very grateful to the — to their efforts — for their efforts but I think we all, everyone in this country can say, pretty definitively, we need more.

SREENIVASAN: Dr. Ashwan Vasan, commissioner of the New York City Department of Health and Mental Hygiene, thanks so much for joining us.

VASAN: Thanks for having me.