After World Health Organization (WHO) head Tedros Adhanom Ghebreyesus intervened to overrule a stymied committee, monkeypox has been declared a global public health emergency. It was an important intervention—but fighting the spread of a painful and distressing disease requires clear public health messaging about who is most at risk right now and why.
Smallpox drove physician Edward Jenner to make the vaccine in 1796 by using cowpox, a less lethal member of the pox family. Smallpox eradication in 1980 is considered by many experts to be the greatest public health success of the 20th century.
For decades, vaccination against smallpox provided protection from monkeypox, smallpox’s little-known sibling, which had been discovered in 1958 among laboratory monkeys. But with smallpox declared eradicated after the 1967 to 1977 vaccination campaign, vaccinations stopped. And as immunity waned, monkeypox emerged, first in small numbers among young children beginning in 1970 and then increasingly in surges among young adults by the turn of the century. Monkeypox is now endemic in Central and West Africa, with Nigeria having recorded human-to-human transmission since 2017.
But it is in the Democratic Republic of the Congo that monkeypox is most concentrated. It has recorded over 11,000 confirmed and suspected cases since 2020 and is estimated to have 180,000 unreported cases. Eastern Congo, the epicenter of the outbreak, is remote, inaccessible, impoverished, close to porous international borders, and plagued by intractable armed conflict. The upsurge in violence, mass sexual assault, and forced displacement this year—the result of the Rwanda-sponsored M23 militia’s return—may have facilitated monkeypox’s international journey.
Currently, monkeypox’s primary route of transmission is sexual —not exclusively, but predominantly. Gingerness by public health officials in stepping around sensitive issues, especially around sex and identity, is undermining the clear communication and firm direction that are essential to stop the disease from spreading far more widely and potentially becoming endemic.
In New York City, the epicenter of the U.S. monkeypox crisis, growth is exponential, but vaccines and clear communication are in short supply. Public health officials keep insisting that anyone can catch monkeypox, cautioning that spread can occur via the air, surfaces, bedsheets, and close contact. That is all technically true, but it muddles the message that sexual transmission is the main avenue for its spread. In Europe, for example, 99.5 percent of known cases are with men, and of the ones whose sexual practices are known, 97.5 percent are with men who have sex with men. In Britain specifically, 99.3 percent of known cases are with men, of whom 96.5 percent were identified as gay, bisexual, or men who have sex with men.
Nor is the usually broad contact tracing—another recommended tool—terribly helpful unless the relevant contacts are limited to sexual contacts, since the most significant risk factor by far is anal sex. Rectal tissue is rich in cells that are susceptible to infection, and the act of sex is abrasive, which can give the monkeypox virus an additional foothold. Unlike HIV, monkeypox spreads mainly from contact with infected areas rather than through bodily fluids. Asymptomatic spread seems to occur.
Although monkeypox is rarely lethal outside of Africa, infection can be extremely painful. There is widespread concern that anal scarring could affect defecation and intercourse. As of yet, few women are infected, but there is no reason to think that infection will be less painful or problematic. There is particular concern about how monkeypox will spread among people living with HIV or other immunosuppressed people. Monkeypox can have particularly tragic consequences for someone who is pregnant, leading to miscarriages, preterm deliveries, stillbirths, and congenital devastation, based on the limited literature and my clinical experience over several years in eastern Congo.
On the plus side, there is no recorded transmission to health care workers or nosocomial (health care-oriented) infection in the United States or Europe. That suggests that, unlike intercourse, casual contact is not a threat, and airborne transmission is not happening. That fits with my personal experience, caring for children and mothers with monkeypox but never catching it.
The spread of monkeypox around the world and across the United States resembles the early spread of HIV, though the effects are far less severe. That’s because pathogens with pandemic potential follow familiar routes depending on the mode of transmission.
Like HIV, monkeypox’s spread out of Africa has been fueled by men who have unprotected sex with men, multiple partners, and in high-risk environments. HIV initially spread through bathhouses and clubs, where men had numerous partners and unprotected sex in an era of sexual liberation and international travel. Fifty years later, that same dynamic is playing out for monkeypox, accelerated by the short incubation period and the sudden surge of post-COVID-19 travel and partying.
Before the invention of preexposure prophylaxis (PrEP), a highly effective medicine that blocks HIV transmission, condoms were the key tool for preventing HIV infection. Today, however, condom use has sharply decreased among men who have sex with men as an anti-HIV precaution because they are taking PrEP pills instead. Unfortunately, the pills do nothing for other sexually transmitted diseases (STDs)—including monkeypox. Against a backdrop of not only monkeypox but also huge spikes in gonorrhea (including drug-resistant strains), syphilis, and hepatitis C, the use of condoms would be highly effective in preventing transmission, but public health officials seem barely to be mentioning the word for fear of reviving a tool that no one likes.
The HIV epidemic in the United States was marked by cruel homophobia, some of it from the government and medical institutions. One of the legacies is that today, especially amid a wave of renewed bigotry against LGBTQ+ communities, public health officials are reluctant to be seen as sexually prescriptive by advising people to abstain for a few weeks, to restrict partners, or to get checked and treated for extant STDs (even though these increase the risk of contracting monkeypox and people living with HIV in particular account for around one-third of current monkeypox cases). But the job of public health officials isn’t to be popular. It is to communicate clearly, provide people with the information they need to protect themselves, and suggest the best available tools to fight infection.
The reality is that men who have sex with men (known as MSM in clinical usages) in fact are currently at enormously high risk for contracting and spreading monkeypox. Does fear of stating that truth really justify needlessly condemning so many men to a dangerous and debilitating disease? Failing to speak plainly about the threat to MSM also makes it harder for the community to unleash the advocacy and educational capabilities that were critical to saving lives during the HIV epidemic. Plain and honest language will be critical in informing and protecting MSM.
As we learned from HIV, SARS, and COVID-19, stopping a disease early is essential, or it will, according to the appropriately named term, go viral. Monkeypox is no more a “gay disease” than it was a “Congolese disease” in previous years. HIV ultimately moved well beyond MSM to infect heterosexual partners. Monkeypox will pursue a similar trajectory unless we move rapidly to stop it.
Some people will inevitably use the fact of monkeypox transmission among MSM as evidence in support of their bigotry. But that bigotry should not be allowed to drive public health communications strategies with MSM and the broader LGBTQ+ community, which will ultimately suffer even more if we fail to adequately inform those individuals and mobilize to contain the disease.
Beyond the likelihood that monkeypox will spread to broader segments of the human population, we should be alert to its spread within the animal kingdom. Despite the disease’s name, monkeys are far from the only possible animal host. Identified carriers include squirrels, apes, rats, bats, and chimpanzees. Other possible carriers are cats and mice. A 2003 outbreak happened after Gambian pouched rats and two other small mammals imported from West Africa to the United States infected prairie dogs in pet shops, which in turn infected 47 children and adults. Rats and squirrels, a common denominator in many outbreaks, are likely to provide a welcoming home.
Unlike smallpox, which has no animal reservoir, monkeypox thus poses a high risk of becoming endemic. New York’s subways, basements, and streets are overrun with rats. Eradicating them has never proven remotely possible. If they become a host to monkeypox, it will be a permanent threat.
Insufficient vaccines have led the New York City health department to adopt a one-dose-only strategy for what would normally be a two-dose vaccine. Although the supply of vaccines is now increasing, it remains insufficient to serve even high-risk men, let alone women, as they become exposed—and especially people of all genders who are living with HIV and seem to be particularly vulnerable to monkeypox infection.
We should learn from the COVID-19 pandemic and ramp up vaccine production now. Governments should insist on using all productive capacity rather than prioritizing the profits of a few patent holders in high-income countries. A selective approach to global biosecurity contradicts our interdependency.
But we should also remember that we have never vaccinated our way out of any pandemic. In the West, measles, scarlet fever, and other childhood diseases stopped killing kids decades before vaccines—our preferred tool of mass salvation—arrived in the late 1950s. Smallpox was similarly largely controlled by the turn of the 20th century through public health measures.
We need to stop subordinating people to the virus. A single approach of surveillance, isolation, contact tracing, and vaccination worked very well for smallpox, which relied exclusively on a human host, could be diagnosed at 10 paces, and was prevented with a single vaccination. But even that approach relied not only on tests and vaccines but also, most of all, on trust—to be tested and vaccinated. Candor is a prerequisite for trust.
The emergence of monkeypox as smallpox vaccinations waned should also lead us to think about reviving smallpox vaccinations. Although the smallpox virus no longer exists in the wild, various laboratories have retained samples. Its release would be a devastating biological weapon, albeit one that would be impossible to control.
All of this speaks to the need for urgent and honest action. Dancing around sensitive discussions cannot come before effective public health messaging. With another pandemic looming, now is the time to replace euphemisms with communication and fear with trust.
