As we enter our third year of the COVID-19 pandemic, much of the world is reeling from pandemic fatigue. Meanwhile, millions of people are living with HIV — our previous pandemic.
And now, monkeypox is being detected in many countries where it hadn’t been previously. The World Health Organization (WHO) and the US Department of Health and Human Services have declared monkeypox a public health emergency.
As we seek to contain the spread of monkeypox, it is critical that the need for accurate scientific communication and global public health equity are at the top of our list of lessons learned from our past.
Fortunately, monkeypox is rarely fatal as compared to COVID-19 mortality rates, especially among those who are unvaccinated. To date, there have been 12 global deaths. The strain spreading now has an estimated mortality rate of 1 percent. For comparison, there have been 587 million confirmed cases of COVID-19 worldwide and 6.4 million associated deaths as of Aug 15.
However, monkeypox can cause extremely painful skin lesions lasting for several weeks. Direct skin contact appears to be the most common way of contracting monkeypox, yet it can also be acquired by secondhand exposure through the shared use of fomites such as clothing, towels or bedding with someone who has the live virus.
The dangers of stigmatization
The vast majority of monkeypox cases have been found in communities where men have sex with men (MSM); recently the CDC confirmed that two children in the United States tested positive for the virus, most likely through household transmission. The prevalence of the virus among MSM — combined with its ability to affect anyone — is an important reminder from the US’s four decades with the HIV pandemic. Our past leaders and many others made this error in judgment when the AIDS epidemic first started, which led to a stigmatization of MSM and the broader LGBTQ community. There were many myths about HIV initially when little to nothing was known about what was causing AIDS, and this was exacerbated by the spread of misinformation. HIV was perceived as a “gay disease,” which blinded the media and healthcare providers to the fact that anyone can be affected.
However, as with the HIV, the epidemiologic risk of acquiring monkeypox is greatest at present among MSM. This risk should not be confused with the fact that viruses do not discriminate, and cases will also occur in people who are not MSM. Furthermore, stigma can affect people coming forward with symptoms, preventing them from getting timely care and treatment — and that affects our ability to contain the virus.
There are dangers with viewing monkeypox as a sexually transmitted infection (STI) that is exclusive to MSM or others in the LGBTQ community. Because monkeypox is primarily transmitted by skin-to-skin contact, or by respiratory droplets in close proximity, sexual contact with someone who has monkeypox is therefore a risk factor. This is different than monkeypox being an STI. Monkeypox can also be spread by handling bush meats that may be contaminated with the virus, or by contact with infected animals. Currently, monkeypox is not classified as a true STI like syphilis, herpes, gonorrhea, chancroid or others. I have long stated that most viruses are equal opportunity agents of infection – they have zero bias or concern about who they infect. Viruses are diabolical in this sense because they are obligate intracellular parasites that exist to infect us, amplify the infection, cause damage or death, and jump to the next host, whoever that may be. Therefore, we need to be able to talk about epidemiologic risk without stigmatizing MSM.
The importance of equity
One of the most frustrating realities today is that it appears we are still not following some of the early, critical lessons we learned from COVID-19. For example, not long ago, we were scrambling for tests, vaccines and therapeutics when SARS-CoV-2 was identified as the virus responsible. There is still the opportunity to use the infrastructure that was built for distributing COVID-19 vaccines to distribute monkeypox vaccines. Likewise, we know that it will take an equitable effort to improve the availability of monkeypox virus testing, prevention and treatment. In fact, we should be ahead of the curve on these issues because we already have vaccines, experimental treatments, education on prevention, and the knowledge of how to distribute these items.
I and most experts have continued to advocate for vaccine equity around the world. Remember, monkeypox has been endemic in West and Central Africa for decades. Global health leaders and those involved with the production and distribution of vaccines must move to vaccinate populations all over the world, not only the more economically advantaged populations. We continue to witness this truth in that most low-income nations were last to receive COVID-19 vaccines. Also, even though the monkeypox virus is a DNA virus unlike the rapidly mutating RNA virus that is SARS-CoV-2, it is still important to try to gain global immunity as quickly as possible to help slow the mutation of the virus. Equitable vaccination can help achieve this globally.
Making public health a priority
Public health professionals are dedicated to reducing infant mortality, developing and distributing vaccines, tracking infectious outbreaks, curbing antimicrobial resistance, preparing us for natural disasters, and so much more. We as a world must begin to understand the critical and necessary support for public health. When I was working with the Texas Department of State and Health Services – Bureau of Laboratories and Zoonosis Control while assisting the CDC, I would look around and see large teams of diverse and highly trained professionals – public health and medical laboratorians, epidemiologists, physicians, nurses, veterinarians, emerging infectious disease fellows and so many others. Now, when I walk into a medical laboratory in a hospital or public health agency, I see that the practice of “doing more with less” has taken on a completely new meaning. It is ridiculous how we expect our public health agencies, healthcare providers and medical laboratories to handle large-scale outbreaks, much less the daily workload, on a shoestring budget and a skeleton crew.
Simply put, public health funding must be prioritized at the level of concern of defense spending: We must learn the lesson that microbes can kill more people globally than wars and acts of terror. In the US, the public health infrastructure is underfunded and understaffed. As monkeypox cases continue to climb, we have insufficient vaccine supplies, poor access to testing, and a less than robust communication effort from the public health community.
However, the public must also understand that it will always be difficult to predict and prepare for an infectious disease outbreak with 100% accuracy. For example, in the US, many have criticized the CDC and other leaders for the lack of a monkeypox vaccine stockpile. Yet it must be understood that vaccines, therapeutics, and other critical medical supplies have a shelf life as well as possible cold chain requirements. In this case, various factors made it impossible to roll out the vaccine quickly. The US let its stockpile of doses expire instead of sending them to monkeypox endemic countries, officials did not reorder vaccines, research into a freeze-dried version of the Jynneos vaccine was delayed, and plant inspection wasn’t done.
If HIV and COVID-19 taught the world anything, certainly they provided a crystal-clear message that a fragmented response to a global health crisis will lead to fear, finger-pointing, stigmatization and disaster. We need our elected leaders to be logical, purposeful, supportive of public health funding and infrastructure, and adaptive and open to real-time data and science as it unfolds. In the US, the recent declaration of monkeypox as a national emergency is a start because it opens up resources for distribution and funding for a coordinated approach to confront it.
Prevention of disease is much more cost-effective than treatment, though both are certainly needed. Simply stated, our public health systems have been underfunded for decades. We can and must do better. Until we get serious about prioritizing public health in an ongoing, logical, purposeful way, we will continue to fight these deadly causes with fewer people in the public health, healthcare and medical laboratory spaces. In addition, professionals will be overworked and rushed onto the “battlefields” too soon because we are not properly sustaining the pipeline of highly trained professionals. Funding for new research on vaccines and creative ways of attacking disease will suffer. Cutting educational scholarships and programs for ushering in a new generation of these professionals is shortsighted. Utilizing simulations and modeling to try to prepare better for the next outbreak is critical.
Restoring trust in science
What else can we do that would help? There is a lot of power from the media and public perspective. In addition to the good, solid, cautionary journalism that details and discusses the ongoing threats and outbreaks, we must improve the dissemination of accurate information. In fact, social media and the new order of instant information exchange can be powerful weapons in our war on disease.
However, we need to ask for and demand perspective. We need media outlets to report and support the science and data that has been vetted by experts in the field. Likewise, we need the public to be more discerning – especially on social media. This usually means checking the credentials of those experts as well as the scientific rigor and reporting of the sources of information. Yes, you guessed it. Your local (non-scientific, non-medical) layperson may not be the best source to start with on this topic.
When did we start accepting that science is not to be trusted? Experts base scientific facts on the careful gathering of data and the reproduction of those findings. Gravity is not an opinion any more than a microbe becoming resistant to an antibiotic. Vaccines save lives. And lessons learned from past challenges can almost certainly guide us to a more effective and equitable response.