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The legendary Marie Brenner tells me it's "a tonic at this frightening moment in our history":

In "The Desperate Hours: One Hospital's Fight to Save a City on the Pandemic's Front Lines" (out tomorrow), Brenner draws on 200+ interviews for a gripping account of NewYork-Presbyterian's heroics — with too little federal help — as COVID smothered the city. 

Why it matters: "COVID would reveal everything — the pressure that made some crumble but also the valor that meant confronting the fragility of the big-business hospital system, with its marble halls and gleaming towers paid for by New York titans," Brenner writes. Brenner writes that Dr. Steven Corwin, the hospital system's president and CEO, had said somberly as he addressed thousands of NewYork-Presbyterian employees at an all-hospital briefing in March 2020:

"We are in this together — the cavalry isn’t coming."

"But Corwin was wrong," Brenner writes. "The cavalry rushed in from every department in the hospital": 

Accountants worked as transporters, wheeling the dying and the dead. At the height of the surge, Corwin got authorization to pay for three thousand hotel rooms around the city, food for the extended families of all employees who needed help, day care, and transportation — a billion-dollar outlay. In one call, he snapped, "I don’t give a damn what it costs." He insisted on an unlimited line of credit to fund the hiring of doctors and nurses and former Air Force pararescue medics and to make sure that the hospital had a field hospital and oxygen farms.

"I found 200 N95s in a storage cabinet," a Goldman Sachs partner texted Corwin. We will take them, the CEO replied, Brenner continues:

Cosmetics companies and gourmet markets delivered crates of skin creams and delicacies for everyone working on the front lines. Surgeons, urologists, medical students, cardiologists, retired NewYork-Presbyterian internists fanned out through the corridors of the system’s ten hospitals, emptying trash cans and relearning how to titrate medicines in the ICU — a skill many of the older doctors had not used since medical school. 

Brenner's cast of characters includes a first-year internal medicine resident ... a security guard ... a housekeeper ... a morgue attendant ... and the hospital system's director of supply chain. 

🎧 Podcast: NewYork-Presbyterian CEO Steven Corwin tells Axios' Dan Primack about the COVID "tsunami."

Sneak peek: Inside one New York hospital's fight against COVID-19

Marie Brenner's new book recounts hundreds of interviews with NewYork-Presbyterian workers as COVID overtook NYC.

COVID-19

Coronavirus

Public health

The U.S. faces a range of health care flashpoints — unaffordable drugs, opioids, vaping — as we debate whether to adopt universal care. For now, the Affordable Care Act is the law of the land, but Republicans want to issue it a final death blow.

Health

China is becoming the most formidable rival America has faced, and the risk of confrontation with Russia, North Korea or Iran still looms. Authoritarians are rising, the chaotic Afghanistan exit revealed the limits of U.S. power, and the pandemic, climate change and other critical challenges continue to pose grave threats.

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A look at the scientific breakthroughs changing the world, explorations in space and in worlds beyond our own and the threats posed to us by our own planet, both out of our control and of our own making.

Science

A lack of testing is keeping public health officials in the dark about how widespread monkeypox is in the United States and posing new uncertainties for the medical system.

Why it matters: The lack of robust disease-tracking harks back to the troubled early response to COVID-19 and could bode ill for local health systems still grappling with the virus, its aftereffects and the impending flu season. 

The onus is on primary care providers, including sexual health clinics, to track an unfamiliar disease that manifests itself in different ways.

By the numbers: The CDC says 556 samples have been sent to labs for testing for monkeypox as of June 13, and as of last week, 2% of national lab capacity is being devoted to the outbreak, per the Association of Public Health Laboratories.

"We must increase testing for those with a characteristic, pimple-like or blister-like rash so we can make swift diagnoses," CDC director Rochelle Walensky said on Friday. 

Experts say the true number of U.S. cases is significantly higher than the 49 confirmed so far and question why the federal government isn't doing more.

"The sheer geographic spread of cases means this is a bigger outbreak than we are capturing right now," David Harvey, executive director of the National Coalition for STD Directors, told Axios. "So we are very worried about this; we're worried about a lack of an effective federal response, and we think we need to kick into high gear to deal with this."

How it works: The 69 public health laboratories in the Laboratory Response Network in the United States have the capacity to test 6,000 to 8,000 specimens per week for orthopoxvirus, the family of viruses to which monkeypox belongs.

But under a two-step process, specimens must be sent to one of those laboratories for confirmatory testing before being sent on to the CDC, STAT reports. 

This process takes time and can delay the response at the local level, where contact tracing is used to find high-risk contacts and offer them vaccines in some cases.

Some companies are already racing to develop PCR testing for monkeypox, though there is not yet a need for hundreds of thousands of tests, which was the case when COVID emerged, Reuters reports.

Yes, but: Some believe that a wave of testing demand is headed our way, pointing to the experience in England, where more than 300 cases have been confirmed and contact tracing has already become a challenge.

"We are still learning a lot about monkeypox; we've never seen anything like this with this particular virus in the United States," Sarah Turbett, infectious disease physician and microbiologist at Massachusetts General Hospital, told Axios.

Monkeypox is presenting differently than it typically does in parts of Africa where it is endemic, with a rash that is limited to certain areas of the body and mild symptoms in those infected so far. 

In Africa, monkeypox can be deadly, but the current outbreak has to date not resulted in any deaths.

Between the lines: Because the disease is spread through intimate contact, finding new cases is falling to front-line clinicians, as well as patients who report telltale rashes.

The San Francisco Health Department started to get inquiries about the virus and testing last week, and local health officials anticipate that demand to increase in the coming weeks.

"We need to ramp up and help sexual health clinics in the U.S. prepare for what we think will be an onslaught of patients seeking testing," Harvey, with the National Coalition of STD Directors, said.

While the public health labs can handle the current amount of testing for monkeypox currently, the CDC is working with the FDA and CMS to explore how commercial labs might help expand testing capacity. 

Go deeper: The virus has a longer incubation period than the virus that causes COVID-19, giving public health officials up to three weeks to ask people to isolate and identify close contacts. 

So far, the majority of people who have tested positive identify as men who have sex with men, but the virus is not unique to that group — anyone can test positive if they come in close contact with someone who has it. 

Threat level: The majority of confirmed cases have been traced to international travel or direct contact with a person who has a confirmed case. But a few cases have no connection to a confirmed case, implying there is some community spread.

"We don't have one area where we feel like there's community transmission happening," Jennifer McQuiston, CDC deputy director of pathology, told reporters Friday.

What we're watching: While local health departments say they're prepared to respond, the outbreak could grow beyond their capacity, Lori Tremmel Freeman, CEO of the National Association of City and County Health Officials, said.

"If you have a larger type of outbreak, then it becomes less manageable," Freeman said. "Although health departments know how to source it, whether or not they have the funding and money to do that and can do it quickly, is another question."

Editor's note: This story has been updated to reflect new testing numbers the CDC provided to Axios after deadline.

Testing squeeze keeps the scope of monkeypox a mystery

Health officials are calling on clinicians and local health departments to increase surveillance of monkeypox.

Illustration of vials getting progressively taller

Monkeypox

Monkeypox offers new cause for contact tracing

Public health workers throughout the country are using contact tracing to attempt to contain the monkeypox outbreak.

Illustration of a gloved hand holding a petri dish with a question mark.

The growing monkeypox outbreak may appear alarming to people — potentially triggering bad memories of the rapid spread of COVID over the globe — but it does not contain the same threat level as a pandemic, experts tell Axios.

The big picture: How monkeypox is spreading around the world — with nine U.S. cases confirmed so far — is "new and certainly concerning" but the virus isn't behaving completely unexpectedly, says the CDC's poxvirus epidemiology team lead, Andrea McCollum.

"This is definitely not like COVID. ... We are still in a framework where this is controllable," McCollum tells Axios.

"People are seeing these cases every day pop up on multiple continents, and this feels very much like the early days of COVID," says Jennifer Nuzzo, director of the Pandemic Center at Brown University's School of Public Health. 

But, "what made COVID so incredibly challenging is the fact that people could be infected and have no knowledge of it and then go on to spread it to others — there's much less of a chance it will happen with this virus," Nuzzo says.

Confirmed new monkeypox cases outside of Africa

Note: Monkeypox is more common and locally transmitted in west and central Africa; Data: WHO, Axios reporting; Map: Axios Visuals

What's happening: Monkeypox patients typically develop flu-like symptoms and a blistering rash. 

But, initial reports about how this strain is affecting the body are slightly unusual — and that's always a bit of a concern, says David Freedman, president-elect of the American Society of Tropical Medicine and Hygiene. People are reporting not feeling as ill at the start of an infection as is normal and the blistering rash may not be spreading on the body as much.

"That's what's a bit mysterious about this and why they are doing all this genetic sequencing to see if there's something unique about this particular strain of the virus," Freedman adds. More definitive genetic insights will take at least several weeks, he adds. 

Another unusual aspect is that a majority of these recent cases have been linked to sexual contact during mass gatherings or festivals, with more reports of genital lesions than seen in prior outbreaks, Nuzzo says.

Between the lines: Some symptoms may be unusual but the way the virus is spreading between people is "very consistent with what we know about monkeypox," McCollum says. It is being transmitted through close, prolonged contact with an infected individual. "I don't know if we'd say that it's spreading more effectively [than normal] in terms of viral transmission."

Lesions tend to be the biggest concern, McCollum says, as they "are chock-full of the virus," remaining infectious through all of their stages including once a scab falls off. A closely related virus, smallpox, has shown scabs can contain live virus for 13 years or more under certain conditions.

The "larger risk to the overall community is extraordinarily low" and respiratory transmission is not seen as its primary method of transmission, but McCollum says "COVID precautions make a lot of sense for a lot of things," such as wearing a mask and not sharing clothing or bedding.

Be smart: Scientific knowledge of monkeypox is relatively small. "The number of cases documented in the literature since 1970 are like a few thousand," Freedman says.

And, the COVID pandemic has taught us all that viruses can quickly change.

"I’m in Team Cautious,” Virginia Tech aerosol expert Linsey Marr recently told The Atlantic. “We can’t use what happened with previous monkeypox outbreaks to make sweeping statements. If we’ve learned anything from COVID, it’s to have humility.”

What's next: It's unknown when the spread will become contained and case numbers can be expected to drop, even though awareness among doctors has been raised. 

McCollum says the U.S. plans to work with other countries to gather fine-scale data that will allow forecasting models to "get a better sense of what we should be expecting moving forward and when we'll start seeing declining numbers instead of increasing numbers."

Patients are expected to stay in isolation for three weeks, and efforts should be made for contact-tracing and to possibly give smallpox vaccinations to those directly exposed and at highest risk.

The CDC plans to start tracking and updating cases in the U.S. on a daily basis on their website soon, McCollum says.

What we know about the new monkeypox outbreak

Biden: "Everybody should be concerned" about monkeypox spread

WHO concerned monkeypox could accelerate during summer

Monkeypox is not another COVID

The rapid global spread may be triggering bad memories of the early days of COVID — but monkeypox does not contain the same threat level.

Collage of a photo of the monkeypox virus on the left side and SARS-CoV-2 on the right side.

The monkeypox virus, on left, and SARS-CoV-2. CDC Images: Alissa Eckert, Dan Higgins and Cynthia S. Goldsmith

Deaths per 100,000 children, by cause

Firearms were the leading cause of death for kids one and older for the first time in 2020, the most recent year for which CDC data is available.

Why it matters: The firearm death rate among children is steadily rising, as more kids are involved in gun-related homicides like Tuesday's mass shooting in Uvalde, Texas, as well as suicides and accidents.

By the numbers: Nearly two-thirds of the 4,368 U.S. children up to age 19 who were killed by guns in 2020 were homicide victims, per the CDC. Motor vehicle crashes, formerly the leading cause of death for kids one and older, killed nearly 4,000 children.

Another 30% of firearm-related child fatalities were suicides, 3% were accidental and 2% were of undetermined intent.

Male youths were significantly more likely to be killed by guns, while vehicle crashes claimed more females.

There were also stark racial disparities. The firearm death rate for Black children was more than four times that of white children, and white children were still more likely to be killed by motor vehicles than guns.

D.C. had the highest firearm death rate, followed by Louisiana, Alaska and Mississippi. 

States with highest firearm deaths per 100,000 children in 2020

Data: CDC; Note: States with unreported or unstable data not included; Includes unintentional, violence-related and undetermined firearm deaths; Chart: Thomas Oide/Axios

Of note: Among children younger than 1, congenital anomalies — or birth defects — were the leading cause of death in 2020, resulting in 4,043 fatalities, per the CDC.

What they're saying: "As the progress made in reducing deaths from motor vehicle crashes shows, we don’t have to accept the high rate of firearm-related deaths among U.S. children and adolescents," researchers recently wrote in a New England Journal of Medicine article that highlighted the trend.

The study noted that while the National Highway Safety Administration could take the lead addressing road-traffic fatalities, firearms are one of the few products whose safety isn't regulated by a designated federal agency.

It has taken 20 years to build a database of firearm-related deaths that includes data from all 50 states, the researchers wrote. 

The bottom line: School shootings have become tragically common in the U.S., but constitute only a small fraction of gun deaths among children.

Guns have become the leading cause of death for American kids

In 2020, more kids were killed by guns than motor vehicle crashes. for the first time in recent history

Gun violence

President Biden has made the COVID-19 crisis and a post-Trump return to national unity and traditional democratic ideals his top priorities. From vaccinations to stimulus to schools, Biden is seeking bipartisan compromise while showing a willingness to use executive authority and bare Democratic majorities in the U.S. House and Senate to implement his policies. Republican leaders are navigating deep party divisions over if and how to move beyond former President Trump.

Politics & Policy

Seattle

Axios Seattle

Public health officials in Washington announced Monday they’re investigating the state’s first presumptively positive case of monkeypox.

Details: The case involves an adult man who recently traveled to an undisclosed country where other monkeypox cases have been reported, state and local health officials said.

Driving the news: Washington now joins a handful of other states to report confirmed and possible cases, including Massachusetts, New York and Florida.

Several countries also have reported confirmed or presumptive monkeypox cases, including  Australia, Canada, Belgium, Italy, the United Kingdom, Portugal, Sweden, Spain, Netherlands, Germany and France, per the World Health Organization.

What they’re saying: Dr. Jeff Duchin, health officer for public health for Seattle and King County, said in a statement Monday that the public and health care providers “should be aware of the growing international monkeypox outbreak.”

The person believed to be infected with monkeypox is isolating and poses no risk at this time, Duchin said.

"At this time, we have no evidence that monkeypox is spreading locally, but if there are unrecognized cases, that is a possibility,” he added.

Why it matters: Health experts have said the current international outbreak is not likely to cause a global pandemic as COVID did, but some officials are increasingly voicing concern and raising public awareness about the virus.

President Biden, in his first public remarks about the monkeypox outbreak, said Sunday said the recent international outbreak is "something that everybody should be concerned about."

WHO concerned monkeypox could accelerate during summer months

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Health officials investigating possible monkeypox case in Washington

The case involves an adult man who recently traveled to an undisclosed country where other monkeypox cases have been reported.

Dr.Jeff Duchin, Health Officer for Public Health -- Seattle & King County, announced the first presumptive case of monkeypox in Washington state.

Dr. Jeff Duchin, health officer for public health for Seattle and King County. Photo: Jason Redmond/AFP via Getty Images

Washington State

Pedestrian deaths reached a 40-year high last year, according to preliminary data from the Governors Highway Safety Association.

By the numbers: Drivers struck and killed more than 7,400 people in 2021, and the percentage of children killed by speeding drivers more than doubled since 2018.

Pedestrian traffic fatalities, 2000–2021

Data: Governors Highway Safety Association; Chart: Jacque Schrag/Axios

State of play: Impaired driving and increased speeding contributed to the rise in pedestrian deaths, said Russ Martin, GHSA’s Senior Director of Policy and Government Relations.

"You also have this thought that well, I could be on a ventilator by the end of the week, I should take advantage of the time that I have. I think everyone's out there trying live their best life with an increased sense of urgency," he said. 

"So when it comes to the roadway, maybe that has contributed to more of a me first kind of attitude." 

Martin also pointed to larger vehicles on the road and crumbling infrastructure. Separating cars from pedestrians is one of the most effective engineering interventions, he said.  

The big picture: Data out this week from the Department of Transportation also revealed that an estimated 42,915 people died in motor vehicle traffic crashes in the U.S. in 2021, the highest number of traffic fatalities since 2005.

That's a 10.5% increase from 2020, when 38,824 deaths were reported.

Pedestrian deaths hit 40-year high

Pedestrian deaths reached their highest levels in four decades in 2021.

A graphic of a car moving into a crosswalk.

Deaths

People walk down a street in Philadelphia, Pennsylvania.

A monkeypox outbreak in several European countries and one U.S. state may become the largest outbreak of the virus outside of Africa, but it's not likely to cause a global pandemic like COVID, an infectious disease expert tells Axios.

Why it matters: The CDC has confirmed at least  nine cases in the United States. The current outbreak is small so far and scientists continue gathering data, but there may be community transmission of the virus.

"I'm sure that ultimately this will be the largest outbreak of monkeypox that we've had outside of the endemic areas in Africa," says Daniel Bausch, infectious disease expert and president of the American Society of Tropical Medicine & Hygiene.

"I don't think there's a reason for panic. I don't think we're going to have tens of thousands of cases," he tells Axios.

What's happening: Various countries are reporting confirmed and possible cases, including Australia, Canada, Belgium, Italy, the United Kingdom, Portugal, Sweden, Spain, Netherlands, Germany and France, per the World Health Organization.

Argentina on Friday reported its first case of monkepox and announced another suspected case of the disease, according to Reuters.

Related to smallpox, monkeypox has two main types: the West African clade with a fatality rate of around 1% and the Congo Basin (Central African) clade, with a fatality rate of around 10%.

The current circulating strain appears to be the milder West African type that often starts with flu-like symptoms and swelling lymph node, progressing to a blistering rash. 

The smallpox vaccine is believed to be effective against monkeypox.

Details: Monkeypox, which can be transmitted by droplets and by close contact with infected skin lesions or contaminated materials, usually incubates in people for 6 to 13 days before symptoms appear.

Transmission can come from animals or human-to-human but "it is generally documented among very close contacts. So family members, people taking care of ill patients. Or health care providers," Andrea McCollum, the poxvirus epidemiology team lead at the CDC, told STAT News. 

Children are at higher risk, and monkeypox can cause pregnancy complications or stillbirth, per the WHO.

In the U.S., there have been reports of individuals infected with monkeypox before, particularly in international travelers from Nigeria, including a case in Texas and one in Maryland last year. 

Per the CDC, monkeypox re-emerged in Nigeria in 2017 after more than 40 years with no reported cases. 

Between the lines: The improvement in the global infectious diseases surveillance system is paying off with not only COVID but disease like monkeypox, Bausch adds.

What's next: WHO is scheduled to meet next week to discuss pox viruses, per STAT. 

Go deeper: First U.S. monkeypox case confirmed in Massachusetts

Editor's note: This post was updated to include countries that announced new confirmed cases of monkeypox.

This could become the largest outbreak of monkeypox in countries outside of Africa — but there's no need to panic, an infectious disease expert says.

If abortion were illegal and you had an unwanted or unplanned pregnancy, what would you do?

Data: Generation Lab; Chart: Simran Parwani/Axios

Over half of young women aged 18-29 say they would get an abortion if they had an unwanted or unplanned pregnancy — even if it were illegal, according to a new Generation Lab flash poll first provided to Axios.

Why it matters: Last week's news that the Supreme Court is prepared to overturn Roe v. Wade has raised questions on what access would look like without a federal right to an abortion. Even in states where they remain legal, abortions could be harder to access because those clinics could be flooded with patients from states that have cracked down.

Women in their 20s accounted for the majority of abortions between 2010 and 2019. 

By the numbers: 56% of respondents who identified as women said they would seek out an abortion provider even if it was illegal and they had an unwanted or unplanned pregnancy.

34% said they would have the baby in the event abortion was illegal, while 10% said they'd attempt to end the pregnancy at home.

45% of respondents who identified as men said they would take additional precautions like using physical contraceptives more often if abortion were illegal, while 43% said they would not change anything and 11% said they would be more likely to get a vasectomy.

49% of all respondents said abortion should be legal in all cases, 27% said it should be legal in most cases, 16% said it should be illegal in most cases and 8% said it should be illegal in all cases.

46% of respondents said they have a "mostly unfavorable" opinion of the Supreme Court, while 22% said their opinion was "very unfavorable." 28% said it was "mostly favorable," and only 4% said they had a "very favorable" opinion.

Poll: Over half of young women say they would get an abortion even if it were illegal

Women in their 20s accounted for the majority of abortions between 2010 and 2019.

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