Analysis: New Infectious Threats Are Coming. The U.S. Still Has Problems in Containing Them.

The price of failure is high. Covid has killed more than one million Americans so far, yielding untold misery. Cases, hospitalizations and deaths are all falling, but Covid was the third leading cause of death in the United States in 2021 and seems likely to keep killing Americans for years.

Monkeypox is spreading more slowly now, and has never posed a challenge of Covid’s magnitude. But the United States has reported more monkeypox cases than any other country — 25,000, about 40 percent of the global total — and the virus is likely to persist as a constant, low-grade threat.

Both outbreaks have revealed deep fissures in the nation’s framework for containing epidemics. Add to that plummeting public trust, rampant misinformation and deep schisms — between health officials and those treating patients, and between the federal government and states. A muddled response to future outbreaks seems almost inevitable.

“We really are poorly, poorly prepared,” said Larry O. Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University.

New infectious threats are certainly on the way, mostly because of the twin rises in global travel and vaccine hesitancy, and the growing proximity of people and animals. From 2012 to 2022, for example, Africa saw a 63 percent increase in outbreaks of pathogens that jump to people from animals, compared with the period from 2001 to 2011.

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Ideally, here’s how the national response to an outbreak might unspool: Reports from a clinic anywhere in the country would signal a new pathogen’s arrival. Alternatively, ongoing wastewater surveillance might sound the alarm for known threats, as it has recently for polio in New York State.

The information would flow from local health departments to state and federal authorities. Federal officials would rapidly permit and offer guidance for the development of tests, vaccines and treatments, rolling them out equitably to all residents.

Not one of these steps worked smoothly in the two recent outbreaks.

“I’m very familiar with outbreak response and pandemic preparedness, and none of it looks like this,” said Kristian Andersen, a virologist at the Scripps Research Institute in San Diego who has spent years studying epidemics.

Dr. Andersen said he had assumed that the flaws exposed by the coronavirus would be repaired as they became apparent. Instead, “we’re worse prepared now than we were early in the pandemic,” he said.

Public health in the United States has always operated on a shoestring. The data systems used by the C.D.C. and other federal agencies are laughably out of date. Many public health workers were abused and attacked during the pandemic and have fled their jobs, or are planning to.

More money won’t solve all the problems, several experts said. But additional funding could help public health departments hire and train staff, update their aging data systems and invest in robust surveillance networks.

But in Congress, pandemic preparedness remains a tough sell.

Mr. Biden’s budget request for fiscal year 2023 includes $88 billion over five years, but Congress has not shown any inclination to approve it.

The United States spends between 300 to 500 times more on its military defense than on its health systems, and yet “no war has killed a million Americans,” noted Dr. Thomas R. Frieden, who led the C.D.C. under former President Barack Obama.