Monkeypox: The Newest Failure of Public-Health Policy

T he arrival of the Covid-19 virus in late 2019 shocked an unprepared world. As the virus quickly spread and raged across every continent inhabited by humanity, people everywhere asked, “Couldn’t we have done better?” After the initial waves of the pandemic were over, health-care authorities promised to handle the next pandemic with more competence.

The response to the new surge of the monkeypox virus, however, is not reassuring in this regard.

Unlike the novel coronavirus of 2019, monkeypox is a well-known and extensively studied disease. A relatively rare virus, it is a member of the Orthopoxvirus family, the same family of viruses that causes smallpox. Until 2022, most reported cases of the disease were tied directly to Africa.

The usual course of the disease initially causes fever, headaches and muscle aches, swollen lymph nodes, and chills. But it most famously causes a rash that results in extensive blisters all over the body. The rash can erupt before other symptoms. In some patients, the rash and blisters are actually relatively mild, sometimes so much so that they can be misdiagnosed as other diseases transmitted by sexual activity such as herpes or syphilis. This also can lead to misdiagnosis and a higher risk of transmission for the unaware viral carrier. Monkeypox is not deadly and is mostly a self-limiting disease. There is higher risk of severe disease in young children and those with compromised immune systems. In rare occurrences, pneumonia is a possible symptom. The most common long-term symptom is scarring from the rash.

The virus spreads by human-to-human contact. It is possible to contract the infection by respiratory droplets, but only with extended indoor exposure. The most common method of spread, however, is physical contact, including sexual contact.

And thus we come to the crux of the issue. The World Health Organization’s director-general, Tedros Adhanom Ghebreyesus, recently declared that monkeypox was a public-health emergency of international concern (PHEIC), the most severe warning the WHO can make. However, even that was clouded with controversy. The WHO’s own dedicated emergency committee on monkeypox could not come to a unanimous consensus on the matter. Ghebreyesus unilaterally decided to move forward with the warning, which had many questioning the scientific processes the WHO uses.

In the U.S., public-health leaders have been reluctant to sound warnings, out of fear of possible backlash against communities hardest hit by the disease — in particular, gay and bisexual men. Discussing the Biden administration’s efforts to stop the spread, White House health-policy adviser Dr. Ashish Jha spoke specifically to this concern. “I think very clear at this point that the community most affected is the LGBTQ community,” he said. “It’s really important that we do not use this moment to propagate homophobic or transphobic messaging, and stick to the science.”

This is absolutely the right way to walk the fence. It is essential to point out who is being hit hardest by the virus. Communicating to those populations will be essential to getting the disease under control. Meanwhile, it is prudent to be wary of the prejudices that exist in our society, and how those people may abuse the facts in these cases to target at-risk populations for their own ends.

This is a far cry from others in the health-policy arena. Former Biden White House senior adviser Andy Slavitt, for example, tweeted, “The myth that sexual activity is the cause of monkeypox & that reducing it is a valid strategy for managing a disease does not, on its face, make any sense.” This was moral preening of the worst order. The facts are obvious: Right now, monkeypox is mostly infecting gay and bisexual men. This isn’t opinion; this is fact.

Monkeypox traditionally has had no sexual, racial, or cultural predilection. But this current outbreak clearly does, as Dr. Jha admitted. And it is totally reasonable for health professionals to consider that stigma created over describing any illness as being associated with a singular minority group of any kind. But by trying to eliminate the risk of prejudice caused by the evidence in this case, health-policy experts are prioritizing fighting the social ills of prejudice and hate over focusing on stopping the virus.

Here are the data as of right now: About 95 percent of the afflicted in the United States and Europe are homosexual men. Traditionally, viral outbreaks in Africa have been more common among family members living in close quarters. But in this particular outbreak, that has not been the case. A study by the United Kingdom Health Security Agency reported that half of men screened for monkeypox tested positive; women, by contrast, tested positive only 0.6 percent of the time. No one under the age of 18 tested positive. A recent WHO update stated that cases in Western countries have primarily been among “men who have had recent sexual contact with a new or multiple male partners.” In Europe, just 0.2 percent of the men who have gotten the disease identify as heterosexual.

The hard truth is that in this current viral surge, the rate of viral replication and spread is largely being driven by sexual activity between men. Skin-to-skin contact by other populations in these countries is unlikely to drive significant transmission. However, health departments around the world have been reluctant to openly state this fact. The New York Times reported on a dispute within New York City’s health department centered on this very issue:

The Health Department’s guidance to the public has often highlighted nonsexual routes of potential transmission, such as hugging or contact with bedding. While those are certainly possible routes of transmission, the result — Dr. Weiss [a doctor at the department] said — was to make people overly concerned about casual physical contact and not sufficiently aware that most monkeypox infections in New York appeared to be transmitted through sex.

The fear of stigmatization of the gay community is appropriate. Several decades ago, the AIDS crisis was used to castigate and marginalize the afflicted homosexual groups. But right now, it is, in fact, a public-health necessity to pay special attention to these communities to effectively stop the virus in its tracks — for their own well-being. This should begin with a dedicated campaign to educate and protect those at highest risk. Then, we will need to prioritize the sparse stocks of vaccines to prophylactically protect homosexual men first. The U.S. uses two types of smallpox vaccines to fight monkeypox. These vaccines are in short supply, and rationing of the vaccines to those at highest risk of contracting and transmitting the disease is essential. It is impossible to do that without accepting the major characteristic driving infections right now.

The monkeypox contagion is a new problem, but not a new concern. After the Covid-19 pandemic, and the scourge of deaths that occurred over the last two years, we have had to struggle with our numerous failures as health professionals. But again and again, we come back to one simple truth: We fail repeatedly to tell the public the hard truths, and to explain to people what we do and do not know about these new diseases. Doctors must openly admit their gaps of knowledge, which allows the public to understand our limitations as health-care professionals. The more facts and truths we communicate to the public, the more the public can be prepared, and the more likely that the health-care community will build trust with a public that has had every reason to distrust the experts over the past few years.

With Covid, we failed to focus on those most at risk: the elderly. Early on in the pandemic, countries and states that faced the virus first did a poor job of protecting the vulnerable populations, leading to mass deaths. Meanwhile, those same communities focused on closing schools and day-care centers, which targeted the lowest-risk cohort in our population, children. With monkeypox, the virus is right now targeting homosexual men, especially sexually active ones. Admitting that fact is essential to protect the population from further spread of this disease. Inconvenient truths are sometimes essential to a competent, effective public-policy effort.

The best way to protect our friends and loved ones most at-risk, as well as the public at large, is to be honest about the nature of the threat from the monkeypox virus. We should always be concerned about propagating hate and prejudice, considering our past history. But if we as public-health leaders cannot communicate the realities of this health emergency in order to better treat our gay patients, then we will have truly failed once again.