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Tag: public-health emergency

  • Only the Emergency Has Ended

    Only the Emergency Has Ended

    Emergency responses—being, well, emergency responses—aren’t designed to last forever, and this morning, the World Health Organization declared the one that’s been in place for the COVID-19 pandemic since January 2020 officially done. “This virus is here to stay. It is still killing, and it’s still changing,” Tedros Adhanom Ghebreyesus, the director general of the WHO, said at a press conference; although the coronavirus will continue to pose a threat, the time had simply come, he and his colleagues said, for countries to move away from treating it as a global crisis.

    And, really, they already have: The United States, for instance, ended its national emergency last month and will sunset its public-health emergency next week; countries around the world have long since shelved testing programs, lifted lockdowns, dispensed with masking mandates, and even stopped recommending frequent COVID shots to healthy people in certain age groups. In some ways, the WHO was already a straggler. Had it waited much longer, the power of its designation of COVID as a “public health emergency of international concern,” or PHEIC, “would have been undermined,” says Salim Abdool Karim, the director of the Centre for the AIDS Program of Research in South Africa.

    There’s no disputing that the virus’s threat has ebbed since the pandemic’s worst days. By and large, “we are in our recovery phase now”—not perfectly stabilized, but no longer in chaotic flux, says René Najera, the director of public health at the College of Physicians of Philadelphia. Still, ending the emergency doesn’t mean that the world has fully addressed the problems that made this an emergency. Global vaccine distribution remains wildly inequitable, leaving many people susceptible to the virus’s worst effects; deaths are still concentrated among those most vulnerable; the virus’s evolutionary and transmission patterns are far from predictable or seasonal. Now, ending the emergency is less an epidemiological decision than a political one: Our tolerance for these dangers has grown to the extent that most people are doing their best to look away from the remaining risk, and will continue to until the virus forces us to turn back.

    The end to the PHEIC, to be clear, isn’t a declaration that COVID is over—or even that the pandemic is. Both a PHEIC and a pandemic tend to involve the rapid and international spread of a dangerous disease, and the two typically do go hand in hand. But no set-in-stone rules delineate when either starts or ends. Plenty of diseases have met pandemic criteria—noted by many epidemiologists as an epidemic that’s rapidly spread to several continents—without ever being granted a PHEIC, as is the case with HIV. And several PHEICs, including two of the Ebola outbreaks of the past decade and the Zika epidemic that began in 2015, did not consistently earn the pan- prefix among experts. With COVID, the WHO called a PHEIC more than a month before it publicly labeled the outbreak a pandemic on March 11. Now the organization has bookended its declaration with a similar mismatch: one crisis designation on and the other off. That once again leaves the world in a bizarre risk limbo, with the threat everywhere but our concern for it on the wane.

    For other diseases with pandemic potential, understanding the start and end of crisis has been simpler. After a new strain of H1N1 influenza sparked a global outbreak in 2009, disrupting the disease’s normal seasonal ebb and flow, scientists simply waited until the virus’s annual transmission patterns went back to their pre-outbreak baseline, then declared that particular pandemic done. But “we don’t really have a baseline” to return to for SARS-CoV-2, says Sam Scarpino, an infectious-disease modeler at Northeastern University. This has left officials floundering for an end-of-pandemic threshold to meet. Once, envisioning that coda seemed more possible: In February 2021, when the COVID shots were still new, Alexis Madrigal wrote in The Atlantic that, in the U.S. at least, pandemic restrictions might end once the country reached some relatively high rate of vaccination, or drove daily deaths below 100—approximating the low-ish end of the flu’s annual toll.

    Those criteria aren’t perfect. Given how the virus has evolved, even, say, an 85 percent vaccination rate probably wouldn’t have squelched the virus in a way public-health experts were envisioning in 2021 (and wouldn’t have absolved us of booster maintenance). And even if the death toll slipped below 100 deaths a day, the virus’s chronic effects would still pose an immense threat. But thresholds such as those, flawed though they were, were never even set. “I’m not sure we ever set any goals at all” to designate when we’d have the virus beat, Céline Gounder, an infectious-disease physician at NYU and an editor-at-large for public health at KFF Health News, told me. And if they had been, we probably still would not have met them: Two years out, we certainly have not.

    Instead, efforts to mitigate the virus have only gotten laxer. Most individuals are no longer masking, testing, or staying up to date on their shots; on community scales, the public goods that once seemed essential—ventilation, sick leave, equitable access to insurance and health care—have already faded from most discourse. That COVID has been more muted in recent months feels “more like luck” than a product of concerted muffling from us, Scarpino told me. Should another SARS-CoV-2 variant sweep the world or develop resistance to Paxlovid, “we don’t have much in the way of a plan,” he said.

    If and when the virus troubles us again, our lack of preparedness will be a reflection of America’s classically reactive approach to public health. Even amid a years-long emergency declaration that spanned national and international scales, we squandered the opportunity “to make the system more resilient to the next crisis,” Gounder said. There is little foresight for what might come next. And individuals are still largely being asked to fend for themselves—which means that as this emergency declaration ends, we are setting ourselves up for another to inevitably come, and hit us just as hard.

    As the final roadblocks to declaring normalcy disappear, we’re unlikely to patch those gaps. The PHEIC, at this point, was more symbolic than practical—but that didn’t make it inconsequential. Experts worry that its end will sap what remaining incentive there was for some countries to sustain a COVID-focused response—one that would, say, keep vaccines, treatments, and tests in the hands of those who need them most. “Public interest is very binary—it’s either an emergency or it’s not,” says Saskia Popescu, an infection-prevention expert at George Mason University. With the PHEIC now gone, the world has officially toggled itself to “not.” But there’s no going back to 2019. Between that and the height of the pandemic is middle-ground maintenance, a level of concern and response that the world has still not managed to properly calibrate.

    Katherine J. Wu

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  • The Future of Long COVID

    The Future of Long COVID

    In the early spring of 2020, the condition we now call long COVID didn’t have a name, much less a large community of patient advocates. For the most part, clinicians dismissed its symptoms, and researchers focused on SARS-CoV-2 infections’ short-term effects. Now, as the pandemic approaches the end of its third winter in the Northern Hemisphere, the chronic toll of the coronavirus is much more familiar. Long COVID has been acknowledged by prominent experts, national leaders, and the World Health Organization; the National Institutes of Health has set up a billion-dollar research program to understand how and in whom its symptoms unfurl. Hundreds of long-COVID clinics now freckle the American landscape, offering services in nearly every state; and recent data hint that well-vetted drugs to treat or prevent long COVID may someday be widespread. Long COVID and the people battling it are commanding more respect, says Hannah Davis, a co-founder of the Patient-Led Research Collaborative, who has had long COVID for nearly three years: Finally, many people “seem willing to understand.”

    But for all the ground that’s been gained, the road ahead is arduous. Long COVID still lacks a universal clinical definition and a standard diagnosis protocol; there’s no consensus on its prevalence, or even what symptoms fall under its purview. Although experts now agree that long COVID does not refer to a single illness, but rather is an umbrella term, like cancer, they disagree on the number of subtypes that fall within it and how, exactly, each might manifest. Some risk factors—among them, a COVID hospitalization, female sex, and certain preexisting medical conditions—have been identified, but researchers are still trying to identify others amid fluctuating population immunity and the endless slog of viral variants. And for people who have long COVID now, or might develop it soon, the interventions are still scant. To this day, “when someone asks me, ‘How can I not get long COVID?’ I can still only say, ‘Don’t get COVID,’” says David Putrino, a neuroscientist and physical therapist who leads a long-COVID rehabilitation clinic at Mount Sinai’s Icahn School of Medicine.

    As the world turns its gaze away from the coronavirus pandemic, with country after country declaring the virus “endemic” and allowing crisis-caliber interventions to lapse, long-COVID researchers, patients, and activists worry that even past progress could be undone. The momentum of the past three years now feels bittersweet, they told me, in that it represents what the community might lose. Experts can’t yet say whether the number of long-haulers will continue to increase, or offer a definitive prognosis for those who have been battling the condition for months or years. All that’s clear right now is that, despite America’s current stance on the coronavirus, long COVID is far from being beaten.

    Despite an influx of resources into long-COVID research in recent months, data on the condition’s current reach remain a mess—and scientists still can’t fully quantify its risks.

    Recent evidence from two long-term surveys have hinted that the pool of long-haulers might be shrinking, even as new infection rates remain sky-high: Earlier this month, the United Kingdom’s Office for National Statistics released data showing that 2 million people self-reported lingering symptoms at the very start of 2023, down from 2.3 million in August 2022. The U.S. CDC’s Household Pulse Survey, another study based on self-reporting, also recorded a small drop in long-COVID prevalence in the same time frame, from about 7.5 percent of all American adults to roughly 6. Against the massive number of infections that have continued to slam both countries in the pandemic’s third year and beyond, these surveys might seem to imply that long-haulers are leaving the pool faster than newcomers are arriving.

    Experts cautioned, however, that there are plenty of reasons to treat these patterns carefully—and to not assume that the trends will be sustained. It’s certainly better that these data aren’t showing a sustained, dramatic uptick in long-COVID cases. But that doesn’t mean the situation is improving. Throughout the pandemic, the size of the long-COVID pool has contracted or expanded for only two reasons: a change in the rate at which people enter, or at which they exit. Both figures are likely to be in constant flux, as surges of infections come and go, masking habits change, and vaccine and antiviral uptake fluctuates. Davis pointed out that the slight downward tick in both studies captured just a half-year stretch, so the downward slope could be one small portion of an undulating wave. A few hours spent at the beach while the tide is going out wouldn’t be enough to prove that the ocean is drying up.

    Read: We’re bungling the COVID wind-down

    Recent counts of new long-COVID cases might also be undercounts, as testing slows and people encounter more challenges getting diagnosed. That said, it’s still possible that, on a case-by-case basis, the likelihood of any individual developing long COVID after a SARS-CoV-2 infection may have fallen since the pandemic’s start, says Deepti Gurdasani, a clinical epidemiologist at Queen Mary University of London and the University of New South Wales. Population immunity—especially acquired via vaccination—has, over the past three years, better steeled people’s bodies against the virus, and strong evidence supports the notion that vaccines can moderately reduce the risk of developing long COVID. Treatments and behavioral interventions that have become more commonplace may have chipped away at incidence as well. Antivirals can now help to corral the virus early in infection; ventilation, distancing, and masks—when they’re used—can trim the amount of virus that infiltrates the body. And if overall exposure to the virus can influence the likelihood of developing long COVID, that could help explain why so many debilitating cases arose at the very start of the pandemic, when interventions were few and far between, says Steven Deeks, a physician researcher at UC San Francisco.

    There’s not much comfort to derive from those individual-level stats, though, when considering what’s happening on broader scales. Even if immunity makes the average infected person less likely to fall into the long-COVID pool, so many people have been catching the virus that the inbound rate still feels like a flood. “The level of infection in many countries has gone up substantially since 2021,” Gurdasani told me. The majority of long-COVID cases arise after mild infections, the sort for which our immune defenses fade most rapidly. Now that masking and physical distancing have fallen by the wayside, people may be getting exposed to higher viral doses than they were a year or two ago. In absolute terms, then, the number of people entering the long-COVID pool may not really be decreasing. Even if the pool were getting slightly smaller, its size would still be staggering, an ocean of patients with titanic needs. “Anecdotally, we still have an enormous waitlist to get into our clinic,” Putrino told me.

    Deeks told me that he’s seen another possible reason for optimism: People with newer cases of long COVID might be experiencing less debilitating or faster-improving disease, based on what he’s seen. “The worst cases we’ve seen come from the first wave in 2020,” he said. But Putrino isn’t so sure. “If you put an Omicron long-COVID patient in front of me, versus one from the first wave, I wouldn’t be able to tell you who was who,” he said. The two cases would also be difficult to compare, because they’re separated by so much time. Long COVID’s symptoms can wax, wane, and qualitatively change; a couple of years into the future, some long-haulers who’ve just developed the condition may be in a spot that’s similar to where many veterans with the condition are now.

    Read: The flu-ification of COVID policy is almost complete

    Experts’ understanding of how often people depart the long-COVID pool is also meager. Some long-haulers have undoubtedly seen improvement—but without clear lines distinguishing short COVID from medium and long COVID, entry and exit into these various groups is easy to over- or underestimate. What few data exist on the likelihood of recovery or remission is inconsistent, and not always rosy: Investigators of RECOVER, a large national study of long COVID, have calculated that about two-thirds of the long-haulers in their cohort do not return to baseline health. Putrino, who has worked with hundreds of long-haulers since the pandemic began, estimates that although most of his patients experience at least some benefit from a few months of rehabilitation, only about one-fifth to one-quarter of them eventually reach the point of feeling about as well as they did before catching the virus, while the majority hit a middling plateau. A small minority of the people he has treated, he told me, never seem to improve at all.

    Letícia Soares, a long-hauler in Brazil who caught the virus near the start of the pandemic, falls into that final category. Once a disease ecologist who studied parasite transmission in birds, she is now mostly housebound, working when she is able as a researcher for the Patient-Led Research Collaborative. Her days revolve around medications and behavioral modifications she uses for her fatigue, sleeplessness, and chronic pain. Soares no longer has the capacity to cook or frequently venture outside. And she has resigned herself to this status quo until the treatment landscape changes drastically. It is not the life she pictured for herself, Soares told me. “Sometimes I think the person I used to be died in April of 2020.”

    Even long-haulers who have noticed an improvement in their symptoms are wary of overconfidence. Some absolutely do experience what could be called recovery—but for others, the term has gotten loaded, almost a jinx. “If the question is, ‘Are you doing the things you were doing in 2019?’ the answer is largely no,” says JD Davids, a chronic-illness advocate based in New York. For some, he told me, “getting better” has been more defined by a resetting of expectations than a return to good health. Relapses are also not uncommon, especially after repeat encounters with the virus. Lisa McCorkell, a long-hauler and a co-founder of the Patient-Led Research Collaborative, has felt her symptoms partly abate since she first fell ill in the spring of 2020. But, she told me, she suspects that her condition is more likely to deteriorate than further improve—partly because of “how easy it is to get reinfected now.”

    Last week, in his State of the Union address, President Joe Biden told the American public that “we have broken COVID’s grip on us.” Highlighting the declines in the rates of COVID deaths, the millions of lives saved, and the importance of remembering the more than 1 million lost, Biden reminded the nation of what was to come: “Soon we’ll end the public-health emergency.”

    When the U.S.’s state of emergency was declared nearly three years ago, as hospitals were overrun and morgues overflowed, the focus was on severe, short-term disease. Perhaps in that sense, the emergency is close to being over, Deeks told me. But long COVID, though slower to command attention, has since become its own emergency, never formally declared; for the millions of Americans who have been affected by the condition, their relationship with the virus does not yet seem to be in a better place.

    Read: Trying to stop long COVID before it even starts

    Even with many more health-care providers clued into long COVID’s ills, the waiting lists for rehabilitation and treatment remain untenable, Hannah Davis told me. “I consider myself someone who gets exceptional care compared to other people,” she said. “And still, I hear from my doctor every nine or 10 months.” Calling a wrap on COVID’s “emergency” phase could worsen that already skewed supply-demand ratio. Changes to the nation’s funding tactics could strip resources—among them, access to telehealth; Medicaid coverage; and affordable antivirals, tests, and vaccines—from vulnerable populations, including people of color, that aren’t getting their needs met even as things stand, McCorkell told me. And as clinicians internalize the message that the coronavirus has largely been addressed, attention to its chronic impacts may dwindle. At least one of the country’s long-COVID clinics has, in recent months, announced plans to close, and Davis worries that more could follow soon.

    Scientists researching long COVID are also expecting new challenges. Reduced access to testing will complicate efforts to figure out how many people are developing the condition, and who’s most at risk. Should researchers turn their scientific focus away from studying causes and cures for long COVID when the emergency declaration lifts, Davids and others worry that there will be ripple effects on the scientific community’s interest in other, neglected chronic illnesses, such as ME/CFS (myalgic encephalomyelitis or chronic fatigue syndrome), a diagnosis that many long-haulers have also received.

    The end of the U.S.’s official crisis mode on COVID could stymie research in other ways as well. At Johns Hopkins University, the infectious-disease epidemiologists Priya Duggal, Shruti Mehta, and Bryan Lau have been running a large study to better understand the conditions and circumstances that lead to long COVID, and how symptoms evolve over time. In the past two years, they have gathered online survey data from thousands of people who both have and haven’t been infected, and who have and haven’t seen their symptoms rapidly resolve. But as of late, they’ve been struggling to recruit enough people who caught the virus and didn’t feel their symptoms linger. “I think that the people who are suffering from long COVID will always do their best to participate,” Duggal told me. That may not be the case for individuals whose experiences with the virus were brief. A lot of them “are completely over it,” Duggal said. “Their life has moved on.”

    Kate Porter, a Massachusetts-based marketing director, told me that she worries about her family’s future, should long COVID fade from the national discourse. She and her teenage daughter both caught the virus in the spring of 2020, and went on to develop chronic symptoms; their experience with the disease isn’t yet over. “Just because the emergency declaration is expiring, that doesn’t mean that suddenly people are magically going to get better and this issue is going to go away,” Porter told me. After months of relative improvement, her daughter is now fighting prolonged bouts of fatigue that are affecting her school life—and Porter isn’t sure how receptive people will be to her explanations, should their illnesses persist for years to come. “Two years from now, how am I going to explain, ‘Well, this is from COVID, five years ago’?” she said.

    A condition that was once mired in skepticism, scorn, and gaslighting, long COVID now has recognition—but empathy for long-haulers could yet experience a backslide. Nisreen Alwan, a public-health researcher at the University of Southampton, in the U.K., and her colleagues have found that many long-haulers still worry about disclosing their condition, fearing that it could jeopardize their employment, social interactions, and more. Long COVID could soon be slated to become just one of many neglected chronic diseases, poorly understood and rarely discussed.

    Davis doesn’t think that marginalization is inevitable. Her reasoning is grim: Other chronic illnesses have been easier to push to the sidelines, she said, on account of their smaller clinical footprint, but the pool of long-haulers is enormous—comprising millions of people in the U.S. alone. “I think it’s going to be impossible to ignore,” she told me. One way or another, the world will have no choice but to look.

    Katherine J. Wu

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  • Biden White House Plans To End COVID-19 Public Health Emergency In May

    Biden White House Plans To End COVID-19 Public Health Emergency In May

    The Biden administration said Monday it plans to end the nation’s COVID-19 public health emergency in May, more than three years after the virus first began circulating in the country.

    The White House plans to renew the existing emergency declarations once more before they expire on May 11, allowing local governments and health care providers to transition back to pre-pandemic operations and avoid any chaos caused by an abrupt end to the declarations. Under the public health emergency, programs such as Medicare and Medicaid are able to provide extra funding to states to address pandemic-related care. Millions of Americans were able to receive free COVID-19 tests, and many are able to receive virus-related treatments without co-payments.

    The emergency has been renewed every 90 days since the Trump administration first declared it in 2020, with the most recent renewal on Jan. 11. The Biden White House had said it would provide at least 60 days’ notice before ending the declaration.

    “An abrupt end to the emergency declarations would create wide-ranging chaos and uncertainty throughout the health care system — for states, for hospitals and doctors’ offices, and, most importantly, for tens of millions of Americans,” the White House’s Office of Management and Budget said in a statement. “If the PHE were suddenly terminated, it would sow confusion and chaos into this critical wind-down.”

    The end of the public health emergency will also end the controversial Title 42 border policy, which allows the government to expel foreign nationals and limit asylum seekers hoping to enter the U.S.

    The plan signals the federal government is ready to move back into some semblance of normality. Many Americans are now vaccinated, including with booster shots, and the country has widespread access to updated inoculations and treatment regimens that dramatically reduce the risk of death and serious illness associated with the virus.

    Still, on average more than 500 people in the U.S. are dying of COVID every day.

    The World Health Organization said Monday that the COVID-19 pandemic remained a global health emergency but said it may change that declaration in the near future as the virus nears an “inflection point.”

    “We remain hopeful that in the coming year, the world will transition to a new phase in which we reduce hospitalizations and deaths to the lowest possible level,” WHO Director-General Tedros Adhanom Ghebreyesus said Monday.

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  • Should Everyone Be Masking Again?

    Should Everyone Be Masking Again?

    Winter is here, and so, once more, are mask mandates. After last winter’s crushing Omicron spike, much of America did away with masking requirements. But with cases once again on the rise and other respiratory illnesses such as RSV and influenza wreaking havoc, some scattered institutions have begun reinstating them. On Monday, one of Iowa’s largest health systems reissued its mandate for staff. That same day, the Oakland, California, city council voted unanimously to again require people to mask up in government buildings. A New Jersey school district revived its own mandate, and the Philadelphia school district announced that it would temporarily do the same after winter break.

    The reinstated mandates are by no means widespread, and that seems unlikely to change any time soon. But as we trudge into yet another pandemic winter, they do raise some questions. What role should masking play in winters to come? Is every winter going to be like this? Should we now consider the holiday season … masking season?

    These questions don’t have simple answers. Regardless of what public-health research tells us we should do, we’ve clearly seen throughout the pandemic that limits exist to what Americans will do. Predictably, the few recent mandates have elicited a good deal of aggrievement and derision from the anti-masking set. But even many Americans who diligently masked earlier in the pandemic seem to have lost their appetite for this sort of intervention as the pandemic has eased. In its most recent national survey of health behavior, the COVID States Project found that only about a quarter of Americans still mask when they go out, down from more than 80 percent at its peak. Some steadfast maskers have started feeling awkward: “I have personally felt like I get weird looks now wearing a mask,” Saskia Popescu, an epidemiologist at George Mason University, told me.

    Even so, masking remains one of the best and least obtrusive infection-prevention measures we have at our disposal. We haven’t yet been slammed this winter by another Omicronlike variant, but the pandemic is still here. COVID cases, hospitalizations, and deaths are all rising nationally, possibly the signs of another wave. Kids have been hit especially hard by the unwelcome return of influenza, RSV, and other respiratory viruses. All of this is playing out against the backdrop of low COVID-19-booster uptake, leaving people more vulnerable to death and severe disease if they get infected.

    All of which is to say: If you’re only going to mask for a couple of months of the year, now is a good time. “Should people be masking? Absolutely yes, right now,” Seema Lakdawala, a flu-transmission expert at Emory University, told me. That doesn’t mean masking everywhere all the time. Lakdawala masks at the grocery store, at the office, and while using public transportation, but not when she goes out to dinner or attends parties. Those activities pose a risk of infection, but Lakdawala’s goal is to reduce her risk, not to minimize it at all costs. A strategy that prevents you from enjoying the things you love most is not sustainable.

    Both Lakdawala and Popescu were willing to go so far as to suggest that masking should indeed become a seasonal fixture—just like skiing and snowmen, only potentially lifesaving and politically radioactive. Even before the pandemic, influenza alone killed tens of thousands of Americans every year, and more masking, even if only in certain targeted settings, could go a long way toward reducing the toll. “If we could just say, Hey, from November to February, we should all just mask indoors,” Lakdawala said, that would do a lot of good. “The idea of the unknown and the perpetualness of two years of things coming on and off, and then the confusing CDC county-by-county guideline—it just sort of makes it harder for everybody than if we had a simple message.” Universal mandates or recommendations that people mask at small social gatherings are probably too much to ask, Lakdawala told me. Instead, she favors some limited, seasonal mandates, such as on public transportation or in schools dealing with viral surges.

    David Dowdy, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health, is all for masking season, he told me, but he’d be more hesitant to resort to mandates. “It’s hard to impose mandates without a very strong public-health rationale,” he said, especially in our current, hyperpolarized climate. And although that rationale clearly existed for much of the past two crisis-ridden years, it’s less clear now. “COVID is no longer this public-health emergency, but it’s still killing thousands of people every week, hundreds a day … so it becomes a more challenging balancing act,” Dowdy said.

    Rather than requirements, he favors broad recommendations. The CDC, for instance, could suggest that during flu season, people should consider wearing masks in crowded indoor spaces, the same way it recommends that everyone old enough get a flu shot each year. (Although the agency has hardly updated its “Interim Guidance” on masks and the flu since 2004, Director Rochelle Walensky has encouraged people to mask up this winter.) Another strategy, Dowdy said, could be making masks more accessible to people, so that every time they enter a public indoor space, they have the option of grabbing an N95.

    The course of the pandemic has both demonstrated the efficacy of widespread masking and rendered that strategy so controversial in America as to be virtually impossible. The question now is how to negotiate those two realities. Whatever answer we come up with this year, the question will remain next year, and for years after that. The pandemic will fade, but the coronavirus, like the other surging viruses this winter, will continue to haunt us in one form or another. “These viruses are here,” Lakdawala said. “They’re not going anywhere.”

    Jacob Stern

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  • The Future of Monkeypox

    The Future of Monkeypox

    The World Health Organization has recommended a new name for monkeypox, asking countries to forget the original term in favor of a new one, “mpox,” that scientists hope will help destigmatize the disease. But in the United States, the request seems to be arriving late. The outbreak here has already been in slow retreat for months—and has already left many Americans’ minds.

    About 15 cases are now being recorded among Americans each day, less than 4 percent of the tally when the surge was at its worst. After a sluggish and bungled early rollout, tests and treatments for the virus are more available; more than a million doses of the two-shot Jynneos smallpox vaccine have found their way into arms. San Francisco and New York—two of the nation’s first cities to declare mpox a public-health emergency this past summer—have since allowed those orders to expire; so have the states of New York and Illinois. “I think this is the endgame,” says Caitlin Rivers, an infectious-disease epidemiologist at the Johns Hopkins Center for Health Security.

    But “endgame” doesn’t mean “over”—and mpox will be with us for the foreseeable future. The U.S. outbreak is only now showing us its long and ugly tail: 15 daily cases is not zero daily cases; even as the number of new infections declines, inequities are growing. Black and Latino people make up a majority of new mpox cases and are contracting the disease at three to five times the rate of white Americans, but they have received proportionately fewer vaccines. “Now it’s truly the folks who are the most marginalized that we’re seeing,” says Ofole Mgbako, a physician and population-health researcher at New York University. “Which is also why, of course, it’s fallen out of the news.” If the virus sticks around (as it very likely could), and if the disparities persist (as they almost certainly will), then mpox could end up saddling thousands of vulnerable Americans each year with yet another debilitating, stigmatized, and neglected disease.

    Read: America should have been able to handle monkeypox

    At this point, there’s not even any guarantee that this case downturn will persist. “I’m not convinced that we’re out of the woods,” says Sara Bares, an infectious-disease physician at the University of Nebraska Medical Center, in Omaha. Immunity, acquired through infection or vaccines, is now concentrated among those at highest risk, says Jay Varma, a physician and epidemiologist at Weill Cornell Medicine. But researchers still don’t know how well those defenses can stave off another infection, or how long they might last—gaps in knowledge that may be tough to fill, now that incidence is so low. And although months of advocacy and outreach from the LGBTQ community have cut down on risky sexual activities, many cautionary trends will eventually reset to their pre-outbreak norm. “We know extensively from other sexually transmissible infections that behavior change is not usually the most sustained response,” says Boghuma Kabisen Titanji, an infectious-disease physician at Emory University.

    At the same time, this year’s mpox outbreaks are stranger and more unwieldy than those that came before. A ballooning body of evidence suggests that people can become infectious before they develop symptoms, contrary to prior understanding; some physicians are concerned that patients, especially those who are immunocompromised, might remain infectious after the brunt of visible illness resolves, says Philip Ponce, an infectious-disease physician at the University of Texas Health Science Center at San Antonio and the medical director of San Antonio’s Kind Clinic. (Some 40 percent of Americans who have been diagnosed with mpox are living with HIV.) Researchers still don’t have a good grip on which bodily fluids and types of contact may be riskiest over the trajectory of a sickness. Cases are still being missed by primary-care providers who remain unfamiliar with the ins and outs of diagnosis and testing, especially in people with darker skin. And although this epidemic has, for the most part, continued to affect men who have sex with men, women and nonbinary people are getting sick as well, to an underappreciated degree.

    Read: What should worry most Americans about our monkeypox response

    Intel on the only mpox-fighting antiviral on the shelf, a smallpox drug called tecovirimat, also remains concerningly scant, even as experts worry that the virus could develop resistance. The treatment has been given a conditional greenlight for use in people who are currently, or at risk of becoming, severely sick. Anecdotally, it seems to work wonders, shaving days or weeks off the painful, debilitating course of symptoms that can send infected people into long-term isolation. But experts still lack rigorous data in humans to confirm just how well it works, Bares, who’s among the scientists involved in a nationwide study of the antiviral, told me. And although clinical trials for tecovirimat are under way, she added, in the U.S., they’re “struggling to enroll patients” now that infections have plummeted to such a sustained low. It’s a numerical problem as well as a sociocultural one. “The urgency with which people answer questions declines as case counts go down,” Varma told me.

    Recent CDC reports show that a growing proportion of new infections aren’t being reported with a known sexual-contact history, stymieing efforts at contact tracing. That might in part be a product of the outbreak’s gradual migration from liberal, well-off urban centers, hit early on in the epidemic, to more communities in the South and Southwest. “In small towns, the risk of disclosure is high,” Bares told me. In seeking care or vaccination, “you’re outing yourself.” When mpox cases in Nebraska took an unexpected nosedive earlier this fall, “a colleague and I asked one another, ‘Do you think patients are afraid to come in?’” Those concerns can be especially high in certain communities of color, Ponce told me. San Antonio’s Latino population, for instance, “tends to be much more conservative; there’s much more stigma associated with one being LGBT at all, let alone being LGBT and trying to access biomedical interventions.”

    Hidden infections can become fast-spreading ones. Monitoring an infectious disease is far easier when the people most at risk have insurance coverage and access to savvy clinicians, and when they are inclined to trust public-health institutions. “That’s predominantly white people,” says Ace Robinson, the CEO of the Pierce County AIDS Foundation, in Washington. Now that the mpox outbreak is moving out of that population into less privileged ones, Robinson fears “a massive undercount” of cases.

    Americans who are catching the virus during the outbreak’s denouement are paying a price. The means to fight mpox are likely to dwindle, even as the virus entrenches itself in the population most in need of those tools. One concern remains the country’s vaccination strategy, which underwent a mid-outbreak shift: To address limited shot supply, the FDA authorized a new dosing method with limited evidence behind it—a decision that primarily affected people near the back of the inoculation line. The method is safe but tricky to administer, and it can have tough side effects: Some of Titanji’s patients have experienced swelling near their injection site that lasted for weeks after their first dose, and now “they just don’t want to get another shot.”

    The continued shift of mpox into minority populations, Robinson told me, is also further sapping public attention: “As long as this is centered in BIPOC communities, there’s going to be less of a push.” Public interest in this crisis was modest even at its highest point, says Steven Klemow, an infectious-disease physician at Methodist Dallas Medical Center and the medical director of Dallas’s Kind Clinic. Now experts are watching that cycle of neglect reinforce itself as the outbreak continues to affect and compress into marginalized communities, including those that have for decades borne a disproportionate share of the burden of sexually associated infections such as syphilis, gonorrhea, and HIV. “These are not the groups that necessarily get people jumping on their feet,” Titanji told me.

    Some of the people most at risk are moving on as well, Robinson told me. In his community in Washington, he was disappointed to see high rates of vaccine refusal at two recent outreach events serving the region’s Black and American Indian populations. “They had no knowledge of the virus,” he told me. Titanji has seen similar trends in her community in Georgia. “There’s some sense of complacency, like, ‘It’s no longer an issue, so why do I need to get vaccinated?’” she said.

    Read: America is zooming through the pandemic panic-neglect cycle

    The tide seems unlikely to shift. Even tens of thousands of cases deep into the American outbreak, sexual-health clinics—which have been on the front lines of the mpox response—remain short on funds and staff. Although the influx of cases has slowed, Ponce and Klemow are still treating multiple mpox patients a week while trying to keep up the services they typically offer—at a time when STI rates are on a years-long rise. “We’re really assuming that this is going to become another sexually associated disease that is going to be a part of our wheelhouse that we’ll have to manage for the indefinite future,” Klemow told me. “We’ve had to pull resources away from our other services that we provide.” The problem could yet worsen if the national emergency declared in August is allowed to expire, which would likely curb the availability of antivirals and vaccines.

    Rivers still holds out hope for eliminating mpox in the U.S. But getting from low to zero isn’t as easy as it might seem. This current stretch of decline could unspool for years, even decades, especially if the virus finds a new animal host. “We’ve seen this story play out so many times before,” Varma told me. Efforts to eliminate syphilis from the U.S. in the late ’90s and early 2000s, for instance, gained traction for a while—then petered out during what could have been their final stretch. It’s the classic boom-bust cycle to which the country is so prone: As case rates fall, so does interest in pushing them further down.

    Our memories of public-health crises never seem to linger for long. At the start of this mpox outbreak, Titanji told me, there was an opportunity to shore up our systems and buffer ourselves against future epidemics, both imported and homegrown. The country squandered it and failed to send aid abroad. If another surge of mpox cases arrives, as it very likely could, she said, “we will again be going back to the drawing board.”

    Katherine J. Wu

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