1st Place

Covid, Ebola,
Monkeypox, seasonal flu —
Who needs Halloween?

— Paul Hughes-Cromwick

Inspiration: 24/7 ghosts, goblins, and pathogens

2nd Place

Surprise billing curbs,
Like the famed headless horseman,
Remain incomplete.

— Michael L. Millenson

Inspiration: “How to Avoid Surprise Bills — And the Pitfalls in the New Law”Ìý

3rd Place

Ghastly, grotesque, sick!
You mask up to trick-or-treat,
But not for covid?

— Micki Jackson

Inspiration: The ongoing mask-or-not masquerade

While Halloween may be coming to an end, KHN reporting continues year-round. Send us your haikus at any time for possible inclusion in our Morning Briefing: /contact-haiku/

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

Experts say the response to the monkeypox virus in rural America may be affected by the patchy resources and bitter politics that are a legacy of the pandemic, challenges that some worry could allow sporadic infections to gain a foothold.

“Your embers turn into a forest fire really quickly,” said Brian Castrucci, president and CEO of the de Beaumont Foundation, a national nonprofit focused on public health policy. “The challenge is: Do we have the infrastructure in place in rural America for an adequate response to monkeypox, to covid, to whatever is next on the horizon?”

In Humboldt County, local officials galvanized quickly after monkeypox was reported. The local health board issued a encouraging residents to be cautious about physical contact and outlining what symptoms to look for — painful or itchy rashes, fever, and headache, among others.

“I don’t think this is something we should be afraid of,” Dr. Charles Stringham, the county’s health officer, said in the news release, “but instead something that each of us can avoid by taking a few relatively simple precautions.”

Local health officials are in a “primary prevention role,” Stringham said during an interview. It’s a role that includes educating the community about the virus, monitoring the person who tested positive, and checking in with local physicians.

State and local public health officials in Nevada said the response in Humboldt County, where nearly 18,000 people live, and similar efforts in other rural communities follow guidelines set by the Centers for Disease Control and Prevention. State and local health leaders meet monthly to discuss public health issues, which of late have included the monkeypox virus. They said they’re confident in local responses.

Still, some residents of rural Nevada said they have been confused about where to find vaccines or whether vaccines were available in their county.

Stevie Noyes, a resident of Winnemucca, Humboldt County’s largest city, who identifies as pansexual, said she wouldn’t know where to go to get a vaccine for monkeypox. She called a local retail pharmacy, where her family usually gets vaccines, in early September and was told the pharmacy didn’t have monkeypox vaccines. The pharmacist didn’t know where she could find one in town.

Noyes, a 34-year-old hairdresser, said she’s not urgently concerned about monkeypox because no other cases have been detected in the county. Should the virus begin to spread, however, she said, members of the local LGBTQ+ community would lean on one another, rather than local county or health officials.

County and health officials “take a lot of heat from the town” on the politics of responding to public health issues, Noyes said. “What I see a lot is that political influence to where it does curb what’s released and it does curb the steps that are taken.”

Despite the venomous discourse Noyes has witnessed, Stringham said that in his experience, the monkeypox virus has not been difficult to respond to politically, especially compared with covid.

shows that non-Hispanic Black and Hispanic men who have sex with other men are overrepresented in infections across the country. LGBTQ+ advocates have said they’re concerned that the government response wasn’t reaching their communities even though they are disproportionately affected.

In larger cities, such as Las Vegas, officials have to promote awareness and to distribute educational materials and vaccines. But there is no similar center in Humboldt County, where 57% of voters in 2020 that reversed a provision in the state’s constitution that banned same-sex marriage. Statewide, the ballot measure was approved by 62% of voters.

Noyes said she’s more concerned about prejudice than the virus and fears that because the virus has been linked to men who have sex with men, it could spark retribution against people who identify as LGBTQ+ in Humboldt County. “A lot of these people, the more you interact with them, the more emboldened and, I mean, eventually dangerous they become,” she said.

Some people in Winnemucca have been outspoken about calling monkeypox a “gay virus” and making jokes on Facebook, she said.

In late September, Noyes helped host Winnemucca’s second Pride festival. Immunize Nevada, a nonprofit organization focused on providing vaccines across the state, was there to provide information about covid-19 and monkeypox.

“We’re hoping to combat it that way,” Noyes said.

Kristy Zigenis, program manager for the state’s immunization program, said responding to the monkeypox virus in rural places requires nuance. “If we were to hold a clinic in, say, a rural area, not all of those people might be ready to share with the world that they have participated in this behavior,” Zigenis said.

She added that public health officials have encountered affected people in Clark County, the home of Las Vegas, who weren’t prepared to share their sexual partners’ names during contact tracing or couldn’t identify their partners. “I think that probably crosses a bit into the rurals as far as what’s going on with the case count,” she said.

As of Oct. 26, there were 28,087 confirmed cases of the monkeypox virus nationwide, , and 298 in Nevada, putting the state in the second-highest tier for transmission. Most of the state’s cases are in Clark County, where more than two-thirds of the state’s residents live, but cases have been reported in four rural counties.

Because it’s unclear whether monkeypox has spread beyond the one detected case in Humboldt County, Stringham said he’s trying to provide enough messaging to keep residents informed, but not too much to cause burnout.

He said he thinks resources would be better directed toward prevention of covid, adding that the situation could change.

To make matters more difficult, the community health nurse, who is responsible for distributing the vaccine from a state-run clinic in Winnemucca, retired months ago, and her replacement, a nurse from Carson City, didn’t arrive until October.

“We’re working in a bit of a deficit in that respect,” Stringham said.

During the interim, Zigenis said, Humboldt County residents who met the eligibility requirements to receive a monkeypox vaccine needed to see an administrative assistant in the Winnemucca Community Health Nursing Services office, where 100 doses of the Jynneos vaccine were available. The state agency would then dispatch someone to Humboldt County to administer the vaccine.

Experts say that gap is emblematic of the kinds of difficulties that officials in rural communities across the country face when responding to public health issues.

“The challenge is there may be people who aren’t seeking primary care, so cases aren’t getting picked up,” Castrucci said. He added that the focus of resources on covid or monkeypox can cause other health issues to fall through the cracks, especially considering the lack of investment in local public health departments in rural America compared with departments in larger cities.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

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Click here for a transcript of the episode.

Congress is supposed to complete its annual appropriations bills before the start of the fiscal year on Oct. 1. But it rarely does, and this year is no different, as lawmakers scramble to pass a short-term funding bill so they can put off final decisions until at least December.

Meanwhile, with an eye to the midterms, House Republicans put out a “Commitment to America,” which includes only the vaguest promises related to health care. It’s yet another demonstration that the only thing in health care that unifies Republicans is their opposition to Democrats’ health policies. It’s notable that this latest Republican plan does not suggest repealing the Affordable Care Act.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Rachel Cohrs of Stat, and Victoria Knight of Axios.

Among the takeaways from this week’s episode:

• The short-term funding bill to keep the government open includes the five-year reauthorization of the FDA’s user fees, which are charged to drugmakers and help pay the salaries of many FDA employees. Democrats had hoped to add provisions to that measure that would create regulations on dietary supplements, cosmetics, and lab tests. The current authorization runs out Oct. 1, and Republicans insisted they would support only a clean bill that did not have new government directives.
• That government funding bill also will not include President Joe Biden’s request for $20 billion to help pay for additional covid-19 and monkeypox vaccines and testing. Democrats said they wanted to extend those programs, but Republicans balked and said the administration still has not accounted for all the previous appropriations.
• Biden’s comment on “60 Minutes” suggesting that the covid pandemic “is over” hurt administration efforts to persuade Congress to pass the extra covid funding.
• Biden took a victory lap this week and touted successes on administration priorities for Medicare. Among them, he said, was a reduction in next year’s Part B premium, which generally covers beneficiaries’ outpatient expenses. But that premium went down, primarily because Medicare charged too much in 2022.
• Medicare premiums this year saw a dramatic increase because officials anticipated that the federal health program would see higher costs associated with the use of Aduhelm, an expensive medication for some Alzheimer’s patients that received tentative approval in 2021 by the FDA. Medicare officials later said they would cover the drug only for patients who also enrolled in a clinical trial, and the expectations for use of the drug plummeted.
• Republican House members’ proposed agenda pledged to reverse the Democrats’ decision this year to allow Medicare to negotiate some drug prices. Although Democrats said the provision would help drive down costs, Republicans said they don’t like the government interfering in the private market and fear that the measure would hamper innovation.

Also this week, Rovner interviews filmmaker Cynthia Lowen, whose new documentary, “Battleground,” explores how anti-abortion forces played the long game to overturn Roe.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: KHN’s “Britain’s Hard Lessons From Handing Elder Care Over to Private Equity,” by Christine Spolar

Alice Miranda Ollstein: KHN’s “Embedded Bias: How Medical Records Sow Discrimination,” by Darius Tahir

Rachel Cohrs: The New York Times’ “,” by Paula Span

Victoria Knight: Forbes’ “,” by Jemima McEvoy 

Also mentioned in this week’s episode:

• House Republicans’ “”
• The New York Times’ “,” by Jessica Silver-Greenberg and Katie Thomas
• The New York Times’ “,” by Katie Thomas and Jessica Silver-Greenberg
• Politico’s “,” by Alice Miranda Ollstein and Daniel Payne
• Stat’s “,” by Aoife Brennan

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on , , , , or wherever you listen to podcasts.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

After about a week of searching online, he and three friends made an appointment in Wilton Manors, a city about 3½ hours south by car. DeChellis, who is gay, said he doesn’t understand why the vaccine wasn’t available closer to home or why getting answers about who was eligible from his local health department was so difficult.

“My biggest takeaway from our experience has been just the difference in the state of Florida from county to county,” said DeChellis, 30, a supply chain manager who lost a half-day of work while traveling to get his first vaccine dose.

The perception that the response to the monkeypox virus in the South has lacked coordination has rekindled familiar concerns about recent state policies that leave members of the region’s LGBTQ+ communities feeling marginalized and discriminated against. More urgently, it raises questions about whether state and local health departments are doing enough to protect the people principally affected by the virus: men who have sex with men.

States like New York and California have followed the to prioritize gay and bisexual men in outreach, vaccination, and treatment for monkeypox. Such states have declared a public health emergency and initiated aggressive, targeted vaccination campaigns. Although New York and California are the states with the highest number of cases, Florida, Georgia, and Texas are home to robust gay communities and together have just over a quarter of the country’s .

But in Florida, and in other areas of the South, gay men fear that the monkeypox response is not being consistently prioritized because the virus affects the health of gay men, especially those who are . And they worry that local governments are not responding with urgency to diseases that primarily affect marginalized communities.

“They are not going to go out of their way to help us,” said Hank Rosenthal, 74, a gay man and retired emergency medicine physician who lives in Fort Lauderdale, Florida.

Jeremy Redfern, a spokesperson for the Florida Department of Health and speaking on behalf of the local health departments, said the agency is “fully integrated” to respond to public health needs across the state’s 67 counties. “There are no jurisdictional boundaries to our reach in Florida,” he said. “There is no politics with monkeypox.”

But recent laws like a Florida one that prohibits instruction on gender identity and sexual orientation in some elementary school grades — referred to as the “Don’t Say Gay” bill by opponents — and the state’s for people with Medicaid have created a hyperpoliticized atmosphere around issues related to sexual orientation and gender identity, LGBTQ+ advocacy groups say. And that has some groups feeling the need to take matters into their own hands, especially in states that downplayed the covid-19 pandemic and banned face mask and vaccine mandates to limit the spread of the virus.

“We mobilize, and we try to make stuff happen because our job is to take care of our community,” said Ricardo Martinez, CEO of Equality Texas, an advocacy group for LGBTQ+ rights. “We can’t depend on the state to provide the relief and safety that we need, so we have to organize ourselves.”

Florida’s of monkeypox was reported in Broward County in late May. Since then, the health department has reported that most of the state’s more than 2,200 cases — — have occurred in South Florida’s Miami-Dade and Broward counties, where DeChellis and his friends traveled to obtain a monkeypox vaccine.

The vaccine, called Jynneos, ships from the directly to five county health departments. From there, the state sends vaccines to doctors, hospitals, and other county health departments “as needed,” Redfern said.

The national stockpile ships vaccines to five sites per state and at first used a distribution system that was unfamiliar to state officials; it required them to track doses manually and place orders by email instead of through an automated system, creating a bottleneck. On Sept. 6, the U.S. Department of Health and Human Services announced it had awarded a $20 million contract to a private wholesale company to vaccine distribution to more sites in the coming weeks.

As government responses improve, LGBTQ+ advocates and people who have tried to get vaccinated in Florida say vaccine access and information during the first months of the virus’s spread were inconsistent. They said local health departments used different eligibility criteria, appointment scheduling systems, and public outreach.

Brandon Lopez of Orlando said that when he first tried to get vaccinated through his local health department in June, he was told that only health care workers in laboratories and those who draw blood were eligible. Lopez, 30, said he considered driving to Miami after hearing that friends there got the shots but was told appointments were only for local residents.

Some counties announced in mid-July, but many people who tried to sign up said that no slots were available or that they received an error message prompting them to create a new email account.

“I’m looking at my friends that live in Chicago, that live in San Francisco, that live in Washington, D.C., and they’re able to just walk up to a place,” said Josh Roth, 33, of Orlando, who waited nearly three weeks to get his first vaccine dose. “They may have a couple of hours to wait, but they’re able to get the shots.”

Advocates are also concerned that people with more education, money, and time might be better able to access the shots.

suggests that Black and Hispanic men are disproportionately affected by monkeypox cases, yet non-Hispanic white patients have received more first doses of the vaccine than any other group, .

More appointments began to open up in Florida in mid-August after the FDA authorized a new method of giving the vaccine that required training and special equipment but stretched the nation’s limited supply.

DeChellis did not have to drive to Wilton Manors for his second shot on Aug. 23, and Roth received his second dose as scheduled. After trying for weeks to get an online appointment, Lopez got vaccinated in early August at the Orange County health department in Orlando.

But the experience made him feel as though monkeypox was not an urgent matter for local health officials. “My expectation is that if it doesn’t affect a mass group of people, it’s not going to be a priority,” Lopez said.

After the monkeypox outbreak began, some health departments in the South began partnering with so-called trusted messengers in the LGBTQ+ community to raise awareness and host vaccine clinics.

In South Florida, for example, Broward County’s health department reached out to high-risk groups in the community for help getting people vaccinated, said Robert Boo, CEO of the Pride Center at Equality Park, a nonprofit that provides health and social services for LGBTQ+ people and that hosted a vaccine drive. In Texas, Equality Texas held a webinar with doctors and other experts who answered questions from the public.

But in other areas, gay and bisexual men said they could not get answers, not even from their local health departments.

Florida, Georgia, and Texas together make up 26% of the nearly 22,000 confirmed cases reported as of Sept. 9, but their response has been unlike California’s and New York’s, where emergency declarations from governors have allowed more health care workers to administer the vaccine and local health departments to access more money from the state for vaccinations, education, and outreach.

“An emergency declaration does nothing for the response,” said Redfern, the spokesperson at the Florida health department, which is responding to a concurrent outbreak of also primarily affecting gay and bisexual men.

“There is nothing a new state of emergency order would do for Georgians that isn’t already being done,” said Andrew Isenhour, a spokesperson for Republican Gov. Brian Kemp. He also said the Georgia Department of Public Health has been raising awareness about monkeypox and recently launched a .

In Texas, Austin and Dallas officials declared local emergencies in early August. The Texas Department of State Health Services declined to comment on whether a declaration is warranted statewide.

Some providers, like Dr. Ivan Melendez of the Hidalgo County Health Authority in South Texas, agree that because monkeypox is spreading primarily among men who have sex with men, a statewide declaration is not needed. Lab testing, vaccines, and guidance for both clinicians and the public are available.

But others say an emergency declaration would signal that a threat exists, free up funding, require additional reporting, and cut bureaucratic red tape.

“It gives us a concerted response,” said Jill Roberts, an epidemiologist and associate professor at the University of South Florida. “It allows for more information: Where are vaccines going? Where are cases happening? Where are the hot spots we can hit?”

Dr. Melanie Thompson, an Atlanta physician who provides care for people living with HIV, said she would like the state and governor to play a stronger role in coordinating a uniform response across Georgia’s 159 counties. Not all local health departments are adequately staffed or funded, Thompson said.

“They’re all out there doing their own thing,” she said. “Some counties do a really good job with that. Other counties don’t.”

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

Last week, the FDA told health care providers to split a one-dose vial of the monkeypox vaccine . The shift was good news for vaccine-strapped cities throughout the country because it meant what little supply is available could be stretched much further.

But then L.A. County and other cities and states were told that they would get significantly less vaccine than they’d requested. L.A. County expected to receive 14,000 vials of the vaccine this week, which would have yielded, when split, 70,000 doses for eligible residents. Instead, the county will receive 5,600 vials, which will yield only 28,000 doses.

At a news conference last week, L.A. County health officials said they expected the full shipment and with it could fully vaccinate up to 90,000 people — about half of what it believes to be the at-risk population. Now with far fewer vaccine doses, that goal may take weeks to achieve.

Monkeypox cases in L.A. County have . Most cases are among men who have sex with men. California has reported , ranking it second among states in case numbers after New York, according to the Centers for Disease Control and Prevention.

The vaccine, named , is a smallpox vaccine that can also be used to prevent monkeypox amid the ongoing outbreak. The full-vial dose is injected into muscle tissue, but giving a smaller dose between layers of the skin — known as an intradermal injection — is also effective in preventing the painful viral infection.

The shift by federal officials from allotting vials to allotting doses took local public health officials by surprise. The Administration for Strategic Preparedness and Response within the Department of Health and Human Services is responsible for .

Other places with active outbreaks also got word to expect significantly fewer vaccine vials in the next shipments. Philadelphia officials expected to receive 3,600 vials but will instead receive just over 700.

“We have thousands of people who are at risk that should be vaccinated preventively before they get exposed,” Dr. Cheryl Bettigole said Tuesday. “We are advocating to our federal partners to reconsider and restore Philadelphia’s allocation of vaccine, which is urgently needed.”

L.A. County was an early adopter of the new dosing and injection strategy.

“We communicated that Public Health would implement these changes when the next tranche of doses were received, but if providers felt ready to implement the new strategy, they could proceed,” said the department’s statement.

The L.A. County Public Health department said it received assurances from federal leadership that more doses would be available in the coming weeks. But fewer doses means will remain tight.

L.A. County has a population of 10 million people, and public health officials estimate about 180,000 are at elevated risk for monkeypox. The virus causes painful skin lesions and is spread through skin-to-skin contact with someone who has the lesions. Although anyone can contract monkeypox, gay and bisexual men who have had multiple partners in the past two weeks are at the highest risk in this outbreak. The U.S. has more than 13,500 identified cases as of Aug. 17, .

This story is part of a partnership that includes , , and KHN.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

Before the covid pandemic, wastewater sludge was thought to hold promise as an early indicator of community health threats, in part because people can excrete genetic evidence of infectious diseases in their feces, often before they develop symptoms of illness. Israel has for decades monitored wastewater for polio. But before covid, such risk monitoring in the U.S. was limited largely to academic pursuits.

With the onset of covid, a research collaboration that involves scientists at Stanford University, the University of Michigan, and Emory University pioneered efforts to recalibrate the surveillance techniques for detection of the covid-19 virus, marking the first time that wastewater has been used to track a respiratory disease.

That same research team, the , or SCAN, is now a leader in expanding wastewater monitoring to detect monkeypox, a once-obscure virus endemic to remote regions of Africa that in a matter of months has infected people globally and across the U.S. The Biden administration last week declared the monkeypox outbreak a , following similar decisions by health officials in California, Illinois, and New York.

And SCAN’s scientists envision a future in which wastewater sludge serves as a reservoir for tracking a slew of menacing public health concerns. “We’re looking at a whole range of things that we might be able to test for,” said Marlene Wolfe, an assistant professor of environmental health at Emory.

Since expanding its surveillance in mid-June, the SCAN team has in several of the 11 Northern California sewersheds it is monitoring, including Palo Alto, San Jose, Gilroy, Sacramento, and two locations in San Francisco. Funded by grants from the National Science Foundation and the CDC Foundation, SCAN is doing similar monitoring in Colorado, Georgia, Michigan, and four and wants to scale up to 300 U.S. sites.

It is one of a growing number of sewage surveillance projects across the U.S. run jointly by universities, public health agencies, and utilities departments that are feeding covid findings to state and federal agencies. How many of those networks have expanded their search to monkeypox is unclear. SCAN sites in California, Georgia, Michigan, and Texas and a in Nevada are among the few that have reported sludge samples that tested positive for the monkeypox virus.

As with covid, data on monkeypox can be used to compare trends across regions, but there are limits to what this kind of monitoring can accomplish. Wastewater monitoring doesn’t pinpoint who is infected; it reveals only the presence of a virus in a given area. And it takes a specialist to analyze the samples. Researchers consider wastewater surveillance a complement to other public health tools, not a replacement.

“We’re still really on the front end in terms of discovering the potential here,” said Heather Bischel, an assistant professor in civil and environmental engineering at the University of California-Davis, which included wastewater monitoring as part of its Healthy Davis Together covid testing program for the campus and surrounding community. “But what we’ve seen already shows that this type of monitoring is adaptable to other public health threats.”

Some U.S. communities were sampling sewage before the pandemic to figure out what kinds of opioids residents were using. More recently, along with covid and monkeypox, the technology has shown promise for and respiratory syncytial virus, or . The federal Centers for Disease Control and Prevention is planning pilot studies to see whether sewage can reveal trends in antibiotic-resistant infections, foodborne illnesses, and , a fungal infection.

Much of the wastewater testing that ramped up during the pandemic’s first year was done in concert with universities or county offices and reliant on funding provided through federal covid relief legislation. On Bischel’s campus, those funds were combined with university donor money to put together a comprehensive testing and treatment program for the school and the city of Davis that included wastewater surveillance. The sewage testing is ongoing under a separate grant.

Currently, the CDC is reporting only covid results on its , a reflection of the limited number of sewersheds that so far are testing for monkeypox.

The global spread of monkeypox was first detected in the United Kingdom in May and prompted conjecture that this virus, too, might shed into wastewater, either through feces or when an infected person with an open sore takes a shower. Sewersheds in areas with infected people might then “light up” with evidence of the disease — if the wastewater testing could pinpoint it.

“It did light up,” said Brad Pollock, who chairs public health sciences at UC Davis Health. “It acts as a warning system, and you don’t have to persuade people to take individual tests in order to use the information; it’s collected passively, so you get a more broad community look.”

The virus is thought to be spreading primarily through intimate skin-to-skin contact and exposure to symptomatic lesions, although researchers are exploring other potential means of transmission. For now, the U.S. outbreak is concentrated largely in gay communities among men who have sex with men.

The discovery of monkeypox in San Francisco’s wastewater system in June, the first such finding in the nation, set off alarms in a city with a thriving LGBTQ+ population. On July 28, San Francisco declared monkeypox , urging the federal government to step up its distribution of vaccines.

For its Northern California surveillance, SCAN partners with local health officials and universities to collect samples and then sends them to Verily Life Sciences — a health tech company owned by Google’s parent company, Alphabet — for analysis. In the Atlanta area, SCAN is working with Emory and .

Not all public health agencies are moving as fast. A wastewater monitoring plan for the virus is only now being put together in Los Angeles County, which had confirmed cases of monkeypox by the end of July.

And though California is collecting monkeypox data from its surveillance partners, it’s not available for all regions, underscoring that wastewater monitoring for viruses is still an emerging methodology.

“With every new thing that we add to the testing platform, we are learning things,” said SCAN’s Wolfe. “The pandemic really cracked open our imagination for a tool that already existed but that hadn’t been developed to its full capacity. That’s changing now.”

This story was produced by , which publishes , an editorially independent service of the .

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

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Click here for a transcript of the episode.

Voters in Kansas told the rest of the country this week that they don’t want their state to ban abortion. In a nearly 60%-40% split, voters turned back an effort by anti-abortion activists to amend the state constitution to remove its right to abortion, which would have allowed the legislature to ban the procedure.

Meanwhile, in Washington, Congress is in its pre-recess push to pass legislation. A bill to provide health benefits to veterans injured by breathing in toxic substances from military burn pits finally made it to President Joe Biden’s desk. But talks continue on the Democrats’ health care-climate-tax bill that would, among other things, allow Medicare to negotiate some prescription drug prices and extend expanded subsidies for insurance under the Affordable Care Act.

This week’s panelists are Julie Rovner of KHN, Tami Luhby of CNN, Sandhya Raman of CQ Roll Call, and Rachel Cohrs of Stat.

Among the takeaways from this week’s episode:

• At least four other states — California, Kentucky, Montana, and Vermont — will have abortion questions on their ballots in November. Michigan is likely to have one, too, but the petitions required are still being certified.
• The Department of Justice has sued Idaho, arguing that its nearly-total abortion ban — set to take effect later in August — conflicts with federal law guaranteeing patients access to emergency medical care. If the case were to be appealed all the way to the Supreme Court, it could endanger the emergency care law, which has not faced that sort of legal challenge before.
• Biden signed an executive order this week that among other things could allow Medicaid to cover the travel expenses of women seeking out-of-state abortion care if their state restricts it. But the White House did not provide many details about how such a program would work or be paid for. The so-called Hyde Amendment, named for abortion opponent Rep. Henry Hyde, who died in 2007, forbids federal funding of most abortions. Supporters of the president’s move suggested that restriction applies only to medical care and not transportation, but any effort by Medicaid to set up such a transportation program would likely be litigated.
• New data released this week by the Department of Health and Human Services finds that the number of uninsured Americans has fallen to an all-time low of 8%. That estimate comes as the Senate is considering funding to continue enhanced premium subsidies for people who buy insurance on the Affordable Care Act’s marketplaces. If that legislation falters, the number of people without insurance is expected to rise sharply, as premiums will become unaffordable for many.
• Biden’s rebound of covid-19 symptoms reminds the country that the standards on when a patient has recovered are not firm and raises questions about how patients should handle reentry after battling the disease.

Also this week, Rovner interviews KHN’s Bram Sable-Smith, who reported and wrote the latest KHN-NPR “Bill of the Month” installment about a single-car accident that resulted in three wildly different ambulance bills. If you have an enormous or outrageous medical bill you’d like to send us, you can do that here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: KHN’s “They Lost Medicaid When Paperwork Was Sent to an Empty Field, Signaling the Mess to Come,” by Brett Kelman

Rachel Cohrs: The Washington Post’s “,’” by Joseph Menn and Lenny Bernstein

Tami Luhby: KHN’s “Hospices Have Become Big Business for Private Equity Firms, Raising Concerns About End-of-Life Care,” by Markian Hawryluk

Sandhya Raman: KHN’s “Nursing Homes Are Suing the Friends and Family of Residents to Collect Debts,” by Noam N. Levey

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And subscribe to KHN’s What the Health? on , , , , or wherever you listen to podcasts.

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“Everything started rapidly getting worse,” the Emeryville, California, resident said. “I started to get more spots, on my face, more redness and they started leaking fluid. The rash expanded to my elbows and my hands and my ankles.”

It took Kwong, 33, six virtual appointments with doctors and nurses, one call to a nurse hotline, a trip to an urgent care clinic, two emergency room visits, and two incorrect diagnoses before an infectious disease specialist diagnosed him with monkeypox in early July.

Despite taking two tests, he never tested positive.

As the number of monkeypox cases has exploded in the U.S. in the past month, the public health system is struggling to spread the word about the virus’s danger and distribute a . But the problem extends even further. People who may be infected are grappling with dead ends, delays, incorrect diagnoses, and inappropriate treatments as they navigate an unprepared and ill-informed health care system.

The once-obscure virus has hospitals racing to teach emergency room staffers how to correctly identify and test for it. Dr. Peter Chin-Hong, the infectious disease specialist at the University of California-San Francisco who ultimately diagnosed Kwong, said his case was a tipping point for the research hospital.

“Kevin came in the middle of the night when a lot of resources weren’t available. So I think after his case, we’re doing a lot more education of the general condition. But I think your average clinician doesn’t always know what to do,” Chin-Hong said.

Monkeypox is , though it’s not as transmissible or fatal. Typically, patients have a fever, muscle aches, and then a rash on their face, mouth, hands, and possibly genitals that can last for several weeks.

The current outbreak is spreading via , such as touching a lesion, or exchanging saliva or other bodily fluids. People can also become infected by touching objects or surfaces, such as sex toys or sheets, shared with someone with the illness.

The first U.S. monkeypox case of this outbreak was reported May 17, and since then, the number has grown to probable or confirmed cases representing almost every state, plus Washington, D.C., and Puerto Rico.

California Gov. Gavin Newsom on Monday to coordinate response and bolster the state’s vaccination efforts. have been concentrated in the San Francisco Bay Area.

Although anyone can get infected, the outbreak appears to have largely affected men who have sex with men. Kwong said he likely contracted monkeypox from a sexual encounter during New York Pride events.

“This is the first-ever multicontinental outbreak, so it’s not just going to vanish,” said , an associate professor at the University of California-Irvine who studies infectious diseases.

“This is not going to blow up like covid, but this outbreak is going to have legs,” he said. “It may be like syphilis and it’ll just sort of be around.”

But most doctors don’t know how to recognize it. In late June, when Kwong began experiencing symptoms, most of the doctors and nurses he spoke with during virtual visits didn’t even mention monkeypox. That doesn’t surprise Dr. , a professor of medicine and epidemiology at UCLA.

“Even though I’ve worked on and off in several sub-Saharan African countries over the last 25 years, I’ve actually never treated a case of monkeypox,” Brewer said. “Before this current outbreak, monkeypox was a very unusual disease.”

A rash limited to the genital or rectal area may be mistaken for a sexually transmitted infection. But even if doctors haven’t been trained to recognize monkeypox, Brewer said, their advice to patients could help contain the spread.

“You would be advising people to not engage in sexual activity until their lesions are healed and treated,” Brewer said.

Although many cases are mild and resolve on their own, some rapidly become serious — like Kwong’s.

“Your body is being taken over by this thing that you don’t understand. And you have nowhere to go, so it’s both painful and terrifying,” Kwong said.

Kwong initially treated the rash with the topical steroids he uses for eczema. When that didn’t work, he attended an online appointment with a nurse who diagnosed him with herpes and prescribed an antiviral medication.

Over the next few hours, the rash quickly spread to more of his body. Alarmed, Kwong went to an urgent care clinic. The doctor agreed with the herpes diagnosis, and added another: scabies, . “My spots were concentrated on my hands and my wrists and feet and elbows, which are prime locations for scabies,” Kwong said.

The urgent care doctor had considered monkeypox but Kwong’s spots were clustered together and looked different from the monkeypox rash pictures the doctor had seen. “Depending on where I was with my symptoms, and who I was speaking to, I was getting different answers,” Kwong said.

Over the July Fourth holiday weekend, Kwong frantically reached out to anyone he thought could help as his symptoms worsened.

“I tried to contact doctors, I knew friends of friends who were dermatologists,” he said. “After each time I spoke with someone, I just got rapidly worse. And it was really freaky.”

During another virtual appointment, in the middle of the night, a nurse noticed the rash had spread toward his eyes and told him to go to the emergency room immediately. It was there, at the Alta Bates Summit Medical Center in Oakland, that doctors said Kwong may have monkeypox.

“They were researching while I was in this room, and back-and-forth on the phone with the CDC. I expected myself, as a patient, to be in the dark, but I didn’t realize how little information was also given to providers and how unprepared they were as well,” he said.

He spent 12 hours in the emergency room, where nurses swabbed his lesions for a monkeypox test. They told him to come back if he developed a fever or started vomiting.

“At this point, I was just miserable. I had sores in the back of my throat, in my mouth, all over my body,” he said. “I was just delirious because I couldn’t sleep more than an hour or two at any given time.”

Later that night, Kwong decided to make the trip to the . He’d heard through a friend that UCSF Health was treating monkeypox cases, and a virtual care nurse had urged him to go.

When he arrived, he was separated from the other patients, received oxycodone for pain, and was swabbed for another monkeypox test.

The next day, Chin-Hong started treating Kwong for monkeypox. “I thought, wow, this is really, really extensive disease,” Chin-Hong said. “I’ve seen other cases of monkeypox before, but they’re very limited. I would say Kevin is probably in the top 5% of severity of diseases.”

Because the rash was close to Kwong’s eyes, Chin-Hong feared he could go blind if the disease were left untreated. He prescribed Tecovirimat, an antiviral medication branded as TPOXX, that has received special clearance from the FDA to treat monkeypox in certain circumstances.

After the first day on the drug, Kwong noticed that his rash stopped spreading. Over the next two days, the hundreds of swollen spots flattened into red disks. “I was shocked by how fast Kevin improved. It was almost like he was a turbo-rocket on the way to recovery,” Chin-Hong said.

As Kwong started to heal, he got his first test result back: negative. Then the second: negative.

Chin-Hong said health workers might not have rubbed his lesions hard enough to get live cells for the monkeypox test. “It’s very difficult as a clinician to really get a good sample in these kinds of lesions because the patient is often in pain. And you don’t like to see people suffer,” Chin-Hong said.

Cases like Kwong’s may be missed if tests aren’t conducted correctly. The Centers for Disease Control and Prevention’s is adequate, Brewer said, but only if you take the time to read all 59 pages.

Clinicians need to collect at least two samples from multiple locations on the patient’s body, he said. The key, Brewer said, is to sample lesions “at different stages of development” and not concentrate only on the early bumps.

For two weeks, Kwong took six antiviral pills a day to rid his body of the virus. He no longer needs pain medication. “My face was the first to heal, which I think helped me a lot, to be able to recognize who I was in the mirror again,” Kwong said.

Now more than a month since the ordeal began, Kwong’s hands and feet are finally healing. His cuticles and the skin on his hands peeled off and are in the process of regrowing, while his fingernails have turned black and started to fall off, he said.

Kwong said the psychological toll will take longer to overcome. “I feel less invulnerable, because it was such a rapidly debilitating disease. And so I’m still working on my mental state more than my physical one.”

This story is part of a partnership that includes , , and KHN.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

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Click here for a transcript of the episode.

The Democrats’ on-again, off-again budget bill is apparently on again, and it’s bigger than expected. In a surprise move, Senate Majority Leader Chuck Schumer announced an agreement with Sen. Joe Manchin (D-W.Va.) to expand the scope of the limited health bill that was headed to the Senate floor to also include climate change and some tax increases for corporations and certain wealthy Americans.

But the measure is still a fraction of what President Joe Biden and Democratic leaders had hoped for and does not include such high-profile health priorities as new Medicare benefits or expanded eligibility for insurance for people in states that did not opt to expand the Medicaid program.

Meanwhile, the Biden administration restored anti-discrimination protections in health care for LGBTQ+ individuals that the Trump administration had rolled back, while the Affordable Care Act returned to court in Texas, this time to hear a case challenging the health law’s requirement for preventive benefits.

This week’s panelists are Julie Rovner of KHN, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, Sarah Karlin-Smith of the Pink Sheet, and Alice Miranda Ollstein of Politico.

Among the takeaways from this week’s episode:

• The blockbuster announcement late Wednesday that Manchin had changed his mind and was willing to support a broader party-line bill to fund some of the president’s key priorities did not unveil any major changes to the health provisions agreed to earlier. Manchin previously said he’d sign on to Senate Democrats’ plan to allow Medicare to negotiate drug prices and keep the enhancements to premium subsidies for health policies purchased on the Affordable Health Care marketplaces.

• The outline of the new Senate legislation, however, would extend those premium enhancements for three years, a year longer than what Manchin and Senate Majority Leader Chuck Schumer had previously agreed on. That means a renewal of those subsidies will not become a 2024 campaign issue.
• Several big-ticket health items that progressives had sought in this legislation were left off, including new funding for home health care and a popular provision to lower consumers’ out-of-pocket costs for insulin. A separate bill would do that, but it has hit roadblocks in the Senate.
• Passage of the bill is not assured. First, the Senate parliamentarian must confirm that its provisions are allowed under complicated rules that allow the Senate to pass spending and tax measures without the threat of a filibuster. Under that process, all 50 of the senators in the Democratic caucus must support the bill and the vice president would have to cast the tie-breaking vote. It’s not yet clear whether all senators are on board or if they can all be present for a vote in the next week. Several, including Manchin and Sen. Dick Durbin (D-Ill.), have announced they have covid and are in isolation.
• Biden has recovered from his covid infection, according to the White House physician. While recuperating, he was careful to show that he continued to work and was doing quite well. And he made a point of noting that federal efforts he helped spearhead to make more vaccine and treatment options easily available would help others beat back an infection, too.
• Some critics, however, suggested that Biden’s message about working while recuperating sent a bad signal because patients should be encouraged to rest and recuperate.
• A new survey by KFF found that 4 in 10 parents of children under age 5 say they will not get their kids vaccinated against covid. This appears to be a byproduct of parents assuming the disease is not as threatening to little ones, their confusion about the studies of the vaccine, and their long wait for a vaccine.
• In a surprising twist, it appears that Congress may pass a bill enshrining the right to gay marriage but not be able to pass a bill guaranteeing a woman’s right to contraception. The contraception bill has passed the House but has hit a roadblock in the Senate. Conservatives are concerned about complaints from anti-abortion groups who think some forms of contraception cause abortion.
• A federal judge in Texas who has ruled against portions of the ACA before is presiding over a challenge to the law’s provision that guarantees insured people have no out-of-pocket costs for preventive care. The case could make its way to the Supreme Court, which has turned aside other efforts to undermine the ACA. But the power center has shifted in the court, so it’s not clear how the justices might look at this case.

Also this week, Rovner interviews Dr. Céline Gounder, an infectious disease doctor, a KFF senior fellow, and KHN’s editor-at-large for public health, about the ongoing monkeypox outbreak in the U.S. and around the world.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: NPR’s “,” by Carrie Feibel

Alice Miranda Ollstein: The Hill’s “,” by Nathaniel Weixel

Joanne Kenen: Science’s “,” by Charles Piller

Sarah Karlin-Smith: NPR’s “,” by Sydney Lupkin

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on , , , , or wherever you listen to podcasts.

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Behind those questions are concerns about stigma and how best to allocate scarce resources. But they also reflect an individualistic understanding of public health. Rather than asking what the monkeypox outbreak means for them now, the public could be asking how the monkeypox outbreak could affect them in the future and why and how it could be contained now.

The longer monkeypox transmission goes unchecked, the more likely it is to spill over into other populations. There have already been a handful of cases among women and a couple of cases in children because of household transmission. In otherwise healthy people, monkeypox can be extremely painful and disfiguring. But in pregnant women, newborns, young children, and immunocompromised people, monkeypox can be deadly. Those groups would all be in danger if monkeypox became entrenched in this country.

Stopping transmission among men who have sex with men will protect them in the here and now and more vulnerable populations in the future. But with a limited supply of monkeypox vaccine available, how can public health officials best target vaccines equitably for impact?

It won’t be enough to vaccinate close contacts of people with monkeypox to stop the spread. Public health officials have been unable to follow all chains of transmission, which means many cases are going undiagnosed. Meanwhile, the risk of monkeypox (and other sexually transmissible diseases) isn’t evenly distributed among gay and bisexual men and trans women, and targeting all of them would outstrip supply. Such a strategy also risks stigmatizing these groups.

The Centers for Disease Control and Prevention recently for monkeypox vaccination to include people who know that a sexual partner in the past 14 days was diagnosed with monkeypox or who had multiple sexual partners in the past 14 days in a jurisdiction with known monkeypox cases. But this approach depends on people having access to testing. Clinicians are testing much more in some jurisdictions than in others.

Alternatively, public health officials could target monkeypox vaccinations to gay and bisexual men and trans women who have HIV or are considered at high risk for HIV and are eligible for , or PrEP (medication to prevent HIV infection). After all, there’s a lot of overlap between these populations and those at risk for monkeypox. But only 25% of people eligible for PrEP in the U.S. , and that proportion drops to 16% and 9% among Hispanic and Black people, respectively. This approach risks missing many people who are at risk and exacerbating racial and ethnic disparities.

This is why some LGBTQ+ activists are advocating for more aggressive outreach. “We talk about two kinds of surveillance,” said Gregg Gonsalves, an epidemiologist at the Yale School of Public Health and a longtime AIDS activist. “Passive surveillance, where I show up to my doctor’s office. Active surveillance is where we go out and we seek cases actively by going where people are at. There are parties, social venues, sex clubs where we could be doing monkeypox testing.”

This will be especially critical , where both patients and providers may be less informed and gay sex more stigmatized.

In New York City, the epicenter of monkeypox in the U.S., disparities in access to monkeypox vaccines have already emerged. The city’s health department offered appointments for first doses of the vaccine through an online portal and promoted them on Twitter. Those initial doses were administered at a sexual health clinic in the well-to-do Chelsea neighborhood.

“It was in the middle of the day,” Gonsalves said. “It was in a predominantly gay white neighborhood. … It really was targeted at a demographic that will be first in line for everything. This is the problem with relying on passive surveillance and people coming to you.”

Michael LeVasseur, an epidemiologist at Drexel University, said, “The demographics of that population may not actually reflect the highest-risk group. I’m not even sure that we know the highest-risk group in New York City at the moment.”

Granted, of the city’s cases had been reported in Chelsea, a neighborhood known for its large LGBTQ+ community, but that’s also a reflection of awareness and access to testing. Although are offering monkeypox testing, are still unaware of monkeypox or unwilling to test patients for it. You have to be a strong advocate for yourself to get tested, which disadvantages already marginalized populations.

The health department opened a second vaccination site, in Harlem, to better reach communities of color, but most of those accessing monkeypox vaccines there have been . And then New York City launched in the Bronx, Queens, and Brooklyn, which were open for one day only. To get the vaccine, you had to be in the know, have the day off, and be willing and able to stand in line in public.

How can public health officials do the active surveillance that Gonsalves is talking about to target monkeypox vaccination equitably and to those at highest risk? Part of the answer may lie in efforts to map sexual networks and the spread of monkeypox, like the Rapid Epidemiologic Study of Prevalence, Networks, and Demographics of Monkeypox Infection, or . Your risk of exposure to monkeypox depends on the probability of someone in your sexual network having monkeypox. The study may, for example, help clarify the relative importance of group sex at parties and large events versus dating apps in the spread of monkeypox across sexual networks.

“A network map can tell us, given that vaccine is so scarce, the most important demographics of folk who need to get vaccine first, not just to protect themselves, but actually to slow the spread,” said Joe Osmundson, a molecular microbiologist at New York University and co-principal investigator of the RESPND-MI study.

During the initial phase of covid-19 vaccine rollout, when vaccines were given at pharmacies and mass vaccination centers, a racial gap emerged in vaccination rates. Public health officials closed that gap by meeting people where they were, in approachable, community-based settings and through mobile vans, for example. They worked hard with trusted messengers to reach people of color who may be wary of the health care system.

Similarly, sexual health clinics may not be a one-size-fits-all solution for monkeypox testing and vaccination. Although sexual health clinics may feel welcoming to some, others may fear being seen there. Others may not be able to go to sexual health clinics because of their , on weekdays only.

It isn’t new for public health officials to meet members of the LGBTQ+ community where they are. During a 2013 outbreak of meningitis among gay and bisexual men and trans women, health departments across the country with community-based LGBTQ+ organizations to distribute meningitis vaccines. Unlike New York, Chicago is now leveraging those relationships to vaccinate people at highest risk for monkeypox.

Massimo Pacilli, Chicago’s deputy commissioner for disease control, said, “The vaccine isn’t indicated for the general public nor, at this point, for any [man who has sex with men].” Chicago is distributing monkeypox vaccines through venues like and bars to target those at highest risk. “We’re not having to screen out when people present because we’re doing so upstream by doing the outreach in a different way,” Pacilli said.

Monkeypox vaccination “is intentionally decentralized,” he said. “And because of that, the modes by which any individual comes to vaccine is also very diverse.”

Another reason to partner with LGBTQ+ community organizations is to expand capacity. The New York City Department of Health and Mental Hygiene is one of the biggest and best-funded health departments in the country, and even it is to the monkeypox outbreak.

“Covid has overwhelmed many public health departments, and they could use the help, frankly, of LGBTQ and HIV/AIDS organizations” in controlling monkeypox, Gonsalves said.

But even as public health officials try to control the transmission of monkeypox among gay and bisexual men and trans women in this country, it’s important not to forget that monkeypox has been spreading in West and Central Africa for years. Not all of that transmission has been occurring among men who have sex with men. Strategies for controlling monkeypox will need to be informed by the local epidemiology. Social and sexual mapping will be even more critical but challenging in countries, like Nigeria, where gay sex is illegal. Sadly, wealthier nations are already hoarding monkeypox vaccine supply as they did covid vaccines. If access to monkeypox vaccine remains inequitable, it will leave all countries vulnerable to resurgences in the future.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .