A shortage of vaccines.
Confusing messages about who is at risk.
Challenges accessing diagnostic testing and appropriate treatments.

The public health response to monkeypox looks too much like our nation’s incomplete and inequitable response to COVID-19.  For my patients who are living with HIV in New York City, long waits for vaccines and stigmatizing messages have confirmed longstanding fears that the government is uninterested or incapable of responding to the needs of the LGBTQ+ community and people of color. 

Yet my patients have a resource too few Americans possess: a relationship with a trusted primary care provider who can answer their questions, connect them with needed care, and fight fear with facts.  When my patients ask me, “Is the monkeypox vaccine safe?” they can count on a response from a doctor they trust.  They are supported by a care team who can schedule vaccine appointments and help them problem-solve concerns about cost, transportation, and other barriers to care.

As monkeypox spreads quickly, so too have calls for more vaccines and information from trusted community messengers.  What should also be emphasized is the role of primary care providers who provide both vaccines and trusted information.  As our nation reassesses our public health capacity and strategies, ensuring patients have a relationship with a primary care physician should be a public health priority.

It starts with trust. As an HIV primary care physician, building trust is as essential to my work as using a stethoscope or writing prescriptions.  Before patients step into my office, they’ve faced racism and discrimination endemic to our health care system as well as stigma over their HIV status.  Knowing their fears and the obstacles that impact their care is as important to me as knowing their vital signs.

Unfortunately, our health care system is not set up to support trusted relationships between primary care providers and patients.  Despite a landmark 2021 National Academy of Sciences, Engineering and Medicine report that called primary care “the only health care component where an increased supply is associated with better population health and more equitable outcomes,” the U.S. spends half of what other highly developed nations devote to primary care as a share of total healthcare spending.

Underinvestment in primary care has clear implications for health equity. A recent poll from National Opinion Research Center (NORC)/California Health Care Foundation (CHCF) found that those without a primary care provider were more likely to report access, language, and distance barriers.  They were also more likely to report negative experiences with health care providers, such as condescension, being asked to repeat information or testing, or having a doctor refuse a test or medication that the patient thought they needed.

Treating immunocompromised patients during the COVID-19 pandemic, I saw firsthand that disconnection from trusted providers can be dangerous in a public health crisis.  Now that my patients are facing the new threat of monkeypox, treating them effectively means combating the stigma and discrimination that WHO Director-general Tedros Adhanom Ghebreyesus said, “can be as dangerous as any virus." 

To address the challenges presented by emerging pathogens such as monkeypox, we need everyone at the table, including our public and private health care payers, who can help us craft a system where primary care is centered in our delivery system and where we incentivize our providers to deliver high-quality, trust-based care.   If we’re asking our primary care providers to do more, we need to increase our investment in them, and do so in a way that drives meaningful value. Funding should incentivize action on inequities in access and outcomes and advance whole-person care that addresses behavioral health and social needs like access to healthy food, housing, and employment. We know this is possible. As an example of payers taking the initiative and collaborating to improve primary care, five of California’s largest health insurance companies recently signed a memorandum of understanding as a pledge to boost investment in and measure the delivery of advanced primary care.

Strengthening the primary care connections patients need throughout their lives will put them in a better position to overcome chronic diseases and newly emerging health threats. In a public health crisis, these relationships will make a life-saving difference. As we’ve seen from COVID-19 and now monkeypox, what happens at the individual level has an impact on the collective public health and wellness of us all.


Author’s Note
Stella Safo, MD, MPH is a Harvard-trained, board-certified HIV primary care physician and the founder and CEO of Just Equity for Health, providing expertise in equitable health program design.