How the Covid-19 pandemic prepared the White House to respond to monkeypox

WASHINGTON — The man at the center of the White House’s biodefense strategy is only four months into his job, but he’s already facing down a fresh crisis.

The Covid-19 pandemic led President Biden to recreate a position at the White House’s National Security Council to oversee global health security — and none too soon, since the man in the position, Raj Panjabi, is now in charge of the White House’s response to monkeypox. When Panjabi, a physician with extensive public health experience in Liberia was named to TIME magazine’s list of most influential people in 2016 for his work during the Ebola epidemic, his entry was written by former President Bill Clinton.

Now, with monkeypox, Panjabi faces a major test: whether he — and the federal government’s entire public health infrastructure — have learned the lessons of Covid-19.

In some ways, the monkeypox threat is much different. It’s a known disease and it spreads less easily than Covid. But there are parallels, too, with difficult public communication about transmission, limited supply of medicines and vaccines, and global inequities.

Panjabi sat down with STAT to talk about how the Covid-19 pandemic has informed the White House’s response to monkeypox, writing a new pandemic playbook, and the budget he wants to achieve his goals. This interview has been edited for length and clarity.

Your job hasn’t always existed at the White House over the years. It’s looked different ways at different times. What advantages have you seen to having this White House position where it was obviously your job to take on part of the monkeypox response?

So you’re right. There’s been a cycle of panic and neglect when it comes to pandemics and the president has not neglected this. I mean, by virtue of his action, he restored our office on day one of the administration and that was very deliberative because he takes infectious diseases seriously.

So on the one hand, having an office focused on pandemic preparedness in the NSC, really with the leadership of Jake Sullivan as a national security adviser and of the president and the empowerment that brings, has allowed us to focus on the current fires. But it’s also allowed us to focus on making investments and working across the agencies to prevent future fires. And of course, by that I mean infectious disease outbreaks or pandemics.

When you look at the other fires, what [we are] working on is less reported in the news, with the exception, of course, of monkeypox. Monkeypox is one, when you look at the other work we’ve been doing, it has been to ensure the United States is prepared for any infectious disease event that could be at a pandemic level or could get there.

You touched on this idea that you’re learning lessons from Covid-19. There was a pandemic playbook last time around and it got pushed to the side and ignored. Are you revising that playbook for the future? Can you explain to me what those lessons learned are, in action?

When the president came into office he tasked Jake Sullivan to do a biodefense posture review, so that meant learning lessons from Covid, and learning lessons from other epidemics so we can chart a new way forward for how the nation is prepared to stop future pandemics.

And that has resulted in a soon-to-be revised National Biodefense Strategy with a clear implementation plan about where measures and lines of efforts are. I can’t share too much about that now, as it’s not public yet, but that’s one example of what’s been done in terms of revising the so-called playbook.

The other is, of course, actually putting money where our mouth is and asking Congress to fund biodefense at a historic level. We have requested $88.2 billion in fiscal year 2023 for areas like laboratory surveillance, like countermeasure development, vaccines, tests and treatments. The funding is largely distributed amongst [the Assistant Secretary for Preparedness and Response (ASPR)], the group that’s actually purchased the vaccines for monkeypox right now; [the Centers for Disease Control and Prevention], which is doing the laboratory surveillance and making sure we’re tracking this new outbreak of monkeypox and Covid, and which is doing investigations on acute hepatitis for children; as well as [the National Institutes of Health] and [the National Institute of Allergy and Infectious Diseases] which, of course, have been critical for developing the vaccines that we have for both here now and around the world.

So these are institutions and agencies that always have more work to do, but are proving themselves in this fight right now.

There has been a massive investment over the past two years of money by Congress in pandemic response. Do you have any concrete examples so far in responding to the monkeypox outbreak of how Covid-19 has enabled you to get things up and running?

I mean, the Laboratory Response Network is a critical one. I wouldn’t underestimate just how important that has been. I’ve seen this in Liberia during the Ebola epidemic, and I was here on the Covid frontlines in a parking garage in Massachusetts a couple of years ago. If you don’t do enough testing you are flying blind in a pandemic. So the fact that we have 68 labs that are able to provide basically almost 1,000 tests a day at the beginning of an outbreak, of course we’re working on plans to surge that, to get ahead if we need to, but that’s our starting point. So that’s critical.

Another example is that we’ve put investments through the American Rescue Plan into BARDA to develop new countermeasures and into ASPR. You know, the procurement functions, the contracting functions that were developed and used are the same as the Strategic National Stockpile functions, and those are the same functions we’re using to procure vaccines for monkeypox today.

I would say the other thing is that we have Covid so recently in our memory, so the collaboration that’s been catalyzed between federal, state, and local actors has been vital for this epidemic as well.

You mentioned diagnostics and how difficult testing was in the Covid-19 pandemic. Is there any way you’re incorporating things that didn’t go so well at the beginning of the Covid-19 pandemic?

For example, February 2020 was a lost month in terms of testing [for Covid] globally, not only here in the United States. We didn’t do enough testing at the time. So we’re having conversations within the agencies as recently as [Friday] about making sure we don’t repeat that here.

So we’re looking at our best-case scenario, and asking, do we have the capacity for that now? It seems so, given the testing. The challenge, on the other hand, is that we need to get more people to present for testing. So we need, you know, messaging that gets out to the public.

Let’s talk about the international side as well. You worked in Liberia for so long, and you’ve really been on the frontlines of the global equity conversation in health. How has the discourse about equity and Covid-19 with sharing supplies, how has that framed the conversation that we’re having now with monkeypox?

Globally, you can say just historically, it’s more cases of monkeypox in more places that have never had it than ever before. That’s an unprecedented scale of an outbreak. So in either of those situations, you’re going to need countermeasures either to be developed and or scaled up. And what we learned from Covid is that, on the one hand, sharing Covid vaccines is important. And we did that because at the beginning of an outbreak, the capacity wasn’t there for manufacturing it in many places, but you also then have to invest in manufacturing.

And one of the things that’s been underreported about a global Covid response, I would argue, is the fact that the United States has invested hundreds of millions of dollars in companies in places like South Africa, in places like India, to ensure that there’s more factories and more places in parts of the world that are low- and middle-income, to manufacture their own vaccines. We’re also using that capacity now to insure against those same companies that are trying to build polio vaccines or the new malaria vaccines, right? So that’s one thing we’ve learned is we got to distribute manufacturing capacity.

When we look at monkeypox, we’re having conversations about how to make sure that that manufacturing capacity is actually distributed, and that we’re not relying just on one place or on one factory for those products. And we’ve actually already done some of that with smallpox as well.

You’ve mentioned funding a couple times. I’m someone who spends a lot of time in Congress, and I sense some spending fatigue with Covid. You’re asking for a lot of money. Do you think that all the spending on Covid has created a difficult climate moving forward to achieve some of these larger goals?

Well, I think the way to ask it is really to reframe it and ask, what return are we getting on any investment budget? The president has asked for $88.2 billion in this fiscal year 2023. It’s a mandatory request. So over multiple years you break it down to $16 billion to $17 billion per year on average. That investment, when you look at it, has a thousand-to-one return.

So I think I think the way to get out of pandemic fatigue is not to think of it as one chest of money that then needs to be drawn down, but really a force multiplier, something that we pay for today, so that we don’t have to pay more later not only in economic losses, but in lives lost.

It’s not just the right thing to do. It’s the safe thing to do, it’s the smart thing to do. And these things pay for themselves pretty quickly.