No one expected otherwise, right?

At this stage of national disillusionment with America’s public health bureaucracy, after two years of COVID failures, the question was never whether monkeypox would spread and turn endemic. The question was simply which specific opportunities the CDC and local health agencies would miss to contain it.

The current strategy to limit transmission is “ring vaccination,” in which all close contacts of an infected person are quickly immunized with the monkeypox vaccine to try to stop the virus cold. If Gottlieb’s right, though, it’s a matter of time before we start hearing about a national vaccination campaign.

Maybe they can fold it into the updated COVID vaccine this fall and spare us all an extra trip to CVS.

Former FDA Commissioner Dr. Scott Gottlieb says “we’ve failed to contain” the spread of monkeypox, adding that the window for controlling and containing the virus "probably has closed."

"If it hasn't closed, it's certainly starting to close," Gottlieb says. pic.twitter.com/0ZvXPFxE0W

— Face The Nation (@FaceTheNation) July 17, 2022

So that makes Biden 0 for 2 on his 2020 campaign pledge to “shut down the virus.”

It’s not looking good in the Big Apple, where spread is “exponential”:

The window for containing the spread of monkeypox in NYC is closing fast. Cases have more than doubled in the past week.

In a bad case of deja vu we are again confronting shortages of testing, treatment & vaccine.

Here’s our plan for aggressive action to meet this challenge. 🧵 pic.twitter.com/afZ1DKzIFL

— Mark D. Levine (@MarkLevineNYC) July 18, 2022

Demand for the Jynneos monkeypox vaccine is so high there that the City has decided to make its entire supply available as first doses rather than holding some back to be administered as second doses after 28 days. The feds are scrambling to get more supply in the meantime with another 780,000 doses expected from Denmark, where the vaccine is manufactured, before the end of the month.

How did we get here? The usual reasons — slowfootedness in the government’s response, bureaucracy impeding efficient treatment, and irresponsible personal behavior that’s accelerating the spread. “It is shocking that, after all we have learned with COVID-19, we have let another virus escalate to the point of becoming a global health emergency,” said one expert to the Daily Beast. An epidemiologist wondered to the Times, “Why is it so hard for something that’s even a known pathogen? How many more times do we have to go through this?”

First came — what else? — a testing problem. Early in the outbreak, suspected cases of monkeypox had to be sent to the CDC for confirmation. That meant the infected and their acquaintances had to wait before knowing if they were at risk or not, with local health agencies unwilling to trace contacts without a positive diagnosis. Initial wait times for results were as long as 15 days in some cases, per the NYT. Only lately has testing expanded to include commercial laboratories.

Meanwhile, it’s not entirely clear who’s in charge of getting vaccines sent out to hot spots:

The United States estimated in 2010, for example, that in the event of a bioterrorist attack, 132 million doses of a vaccine for smallpox and monkeypox would be required for those who cannot safely take an older-generation vaccine with harsh side effects. Yet two months after the current outbreak began, the strategic national stockpile holds just 64,000 doses…

It’s often unclear which agency is ultimately responsible for a particular aspect of the response. The strategic national stockpile used to be under the purview of the Centers for Disease Control and Prevention, for example. The Trump administration handed it to a different agency, yet the C.D.C. still makes decisions about who should get the vaccine and when.

State and county-level health departments often set their own rules and priorities, sometimes at odds with federal guidance.

The feds used to have 28 million doses of the Jynneos vaccine stockpiled — but all of them expired some time ago. There are another 800,000 doses frozen in bulk form in Denmark, but the FDA failed to approve those doses sooner because it neglected to inspect and approve the Danish factory during the COVID pandemic. The inspection was finally completed recently after a two-month process. “My impression is that there is very little coordination and leadership across the U.S. government about what’s going on here,” one former senior U.S. official told New York magazine. “It feels to me like there’s nobody in charge of this. Who is driving this forward?”

As for treatment, there’s bureaucracy retarding that too. It’s currently “nearly impossible” for patients in NYC to get an antiviral drug designed to treat smallpox because current rules require that patients be enrolled in a clinical trial. That means doctors who want to prescribe it are forced to “go through more than 100 pages of paperwork each time they prescribe it, and between the forms and administrative requirements, a patient visit to initiate this medication can take between one and three hours.”

There’s another factor fueling the spread. Science journalist Donald McNeil, who’s already been canceled and therefore at no risk of further cancellation, published a piece today wondering if it’s too much for the most at-risk population to avoid superspreader events while the western world struggles to get a handle on this.

This May, it appeared among gay men, especially those who had visited four venues: the Darklands leather fetish festival in Belgium; the annual Pride Festival in Spain’s Canary Islands; a gay rave at Berlin’s Berghain techno club; and the Paraiso sauna in Madrid, which, since it had darkened cubicles for orgies, a bondage cell and a bar, was really more of a huge sex club than a spa.

Even though one “sex-positive” party after another has turned into super-spreader events, there has been no willingness by the organizers of such parties to cancel or even reschedule them until more men can be vaccinated. June was Pride Month in New York and cases are surging in the city now. Two recent parties in San Francisco, Electroluxx Pride and the Afterglow Blacklight Discotheque had cases linked to them. And yet more events, like Provincetown Bear Week are going forward anyway.

No one’s out there trying to get monkeypox, obviously, but the people who ditched masks and flouted restrictions during the pandemic weren’t trying to catch COVID either. And they took plenty of heat for not doing what they could to help slow the spread from those of us who insisted on following the rules. McNeil will get an earful about blaming the victim and stigmatizing gays who attend those events but he’s merely being logically consistent. If we’re now in a second (albeit much slower-moving and less dangerous) pandemic, he writes, it’s not too much to ask that “Bear Week” be rescheduled for later this year, after more people have had a chance to be vaccinated.

Mercifully, no one in the west has died yet from an infection. But some who’ve caught the virus report that the pain has been excruciating, which has surprised doctors in NYC. The momentary lack of fatalities may also be a function of the virus circulating mainly among young men, a healthy cohort, so far; per McNeil, in Africa it’s been children and pregnant women are most likely to die of monkeypox. If the virus continues to transmit only through sustained close contact then America’s vulnerable older population should be mostly safe from it. But you know how infection works — each new case is an opportunity for the virus to mutate into something more infectious, which would have an easier time reaching those who are less able to fight it off.

I’ll leave you with this clip of a woman who may or may not have monkeypox. She isn’t sure because, well, bureaucracy.

Monkeypox is about to spread like wildfire because we’re not prepared. pic.twitter.com/B6TQjEIuDe

— #FreeMarvinGuy (@GNCordova) July 18, 2022