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Monkeypox should have been easily controllable. How did we fail so badly?

Why muddled messaging helped monkeypox become a public health emergency.

A protester carrying a sign with a picture of President Biden and the words, “Where are the shots?”
People protest during a rally calling for more government action to combat the spread of monkeypox at Foley Square on July 21, 2022, in New York.
Jeenah Moon/Getty Images

Editor’s note, August 5, 11:45 am: This piece was originally published on July 29, 2022, before the US declared monkeypox a public health emergency. The following story has been updated on August 5 to account for that declaration.

Monkeypox has come a long way since the first human case was diagnosed in the Democratic Republic of Congo in 1970. In the decades that followed, the virus was mostly contained within a handful of African countries, only to break out this year in Europe and increasingly the US, with over 26,000 confirmed cases in more than 80 countries.

On August 4, as efforts to contain the virus faltered, the US declared the outbreak a public health emergency. Health and Human Services Secretary Xavier Becerra told reporters that the decision meant that the administration was “prepared to take our response to the next level in addressing this virus.”

Despite that announcement, it’s important to understand that monkeypox isn’t a worst-case scenario virus. If anything, it is close to a best-case-scenario virus — at least in terms of its controllability.

First off, we had endless warnings it was going to be a problem. As worldwide immunity to smallpox waned — a closely related virus that confers immunity against monkeypox as well — Nigeria saw more and more monkeypox cases, with outbreaks in recent years numbering in the hundreds of patients. The US experienced, and contained, a minor monkeypox outbreak in 2003. This was not a virus that appeared out of the blue; it was on any list of worrying viruses that were around and occasionally striking humans.

But no one was too worried because monkeypox is not very contagious and has an effective vaccine. While what’s currently active is likely a new variant, which spreads more easily through very close contact with infected people, it’s still not anywhere near as contagious as a respiratory virus like Covid-19 can be. That means that public health staples like contact tracing and ring vaccination of at-risk populations should have been more than enough to stop it.

Monkeypox was disease containment on easy mode, and yet it’s looking very likely that we’re going to fail to contain it, with over 7,100 confirmed cases and counting in the US alone. As we do so, we’re speed-running many of the errors that were characteristic of our Covid response, making it clear we’ve learned very little.

Some of the most glaring errors have been in communication, where people are getting sick because of reluctance to tell them they’re at higher risk.

Our troubled monkeypox response

The way to contain a not-very-contagious disease for which a good vaccine exists looks like this: Make sure everyone knows the disease is spreading, identify who is most at risk, and ensure they can access health care if they have it. Test expansively, and when you find a case, contact trace.

That means relentlessly tracking down the people whom the sick person has been in close contact with and encouraging them to get tested as well. For some diseases with a long incubation period and an immediately effective vaccine, you can even vaccinate close contacts and thereby prevent them from getting sick.

The US response to monkeypox is falling down badly on nearly every one of those fronts. First, testing: Too often people showing symptoms of monkeypox are being told by doctors that they shouldn’t get a test, or tests are delayed so long as to be nearly useless by rules that the sample for a test has to be taken from a lesion, which may develop late in the course of illness.

Next, vaccines: As a New York Times article last week revealed, 300,000 monkeypox vaccine doses sat in Denmark for most of a month because the US hadn’t placed an order for them yet, even as at-risk people struggled to access vaccination appointments. The US government has finally procured those overseas doses, but at this point it has shipped a little more than 600,000 doses, far short of the 1.6 million that would cover who the CDC identifies as most at risk. Given that delay, the window to fully contain monkeypox has probably already closed.

Finally, as Jerusalem Demsas wrote for the Atlantic, our public health officials have been replicating the Covid failures in another crucial way: being too concerned with managing public opinion to provide the public with accurate information about the situation.

A failure to communicate

According to an international study last month in the New England Journal of Medicine, 98 percent of documented cases were found in gay or bisexual men. While the disease isn’t a sexually transmitted infection like syphilis, which spreads nearly exclusively through sex, monkeypox transmission requires close physical contact, and sex appears to be a major opportunity for the virus — 95 percent of the transmissions documented in the study occurred during sexual relations.

Because of testing shortfalls, it’s hard to tell precisely what share of monkeypox cases in the US are in the population of men who have sex with men. And health officials rightly want to avoid spreading the false message that monkeypox can only spread from sex or among gay and bisexual men, lest that cause us to miss cases in other populations. There are worries people have been turned away from monkeypox testing under the impression it’s a “gay disease,” and worries others might refuse to seek treatment because they fear they’ll be presumed to be gay.

But there is no question that the current approach puts gay and bi men in danger, and is not meeting the needs of that community or any other.

And while it might seem obvious that the best way to serve the population of men who have sex with men is by getting them truthful information, high-quality health care, and priority vaccine access, public health agencies are too often failing to communicate clearly about this.

We can handle the truth

Many public health officials have instead emphasized that anyone can get monkeypox, a message LGBTQ+ health journalist Benjamin Ryan called in the Washington Post “so egregiously misleading it amounts to misinformation.” While it’s technically true that anyone can get monkeypox, some people are at highly elevated risk — and they deserve to know that.

In New York, as the city’s monkeypox outbreak spiraled out of control, the medical professionals who worked there fought over whether to advise people to avoid anonymous sexual encounters to reduce the risk of the disease. Instead, in an effort to avoid stigma against gay and bisexual men, the city’s public health department put out advice to cover sores and avoid kissing if having sex while sick with monkeypox. As some doctors within the department argued, that’s not medically sound advice.

The shadow of the abysmal public health response to HIV looms over any effort to give advice about another epidemic that seems at this point to be primarily spreading among gay and bisexual men.

But the way to avoid the mistakes of HIV isn’t to say nothing, or give subpar medical advice to influence public opinion. It’s to move mountains to make vaccines available, while speaking clearly and plainly about which populations are at elevated risk and advising sick people to avoid high-risk activities.

The WHO, at the very least, seems to be learning its lesson — last week WHO Director-General Tedros Adhanom Ghebreyesus urged men who have sex with men to at least temporarily consider reducing their number of partners to protect themselves and limit further monkeypox spread.

During Covid, we tried the approach where public health officials tell partial truths and limit information in an attempt to reduce stigma or get better behavior from the public. What we learned was that it doesn’t work. People don’t like being manipulated, and they look to non-official sources if they think official forces aren’t telling it straight.

Public trust is a scarce and valuable resource. Our plans to combat stigma, avoid panic, and inform the public have to build that trust, not squander it, or we’ll be handicapped when we need our institutions most.

A version of this story was initially published in the Future Perfect newsletter. Sign up here to subscribe!