The monkeypox situation keeps getting worse

The virus isn't particularly deadly, but the bad public health response is terrifying

Here’s some good news about monkeypox.

Back in the 1980s, an outbreak in the Democratic Republic of Congo had a reported case fatality rate of 10 percent, but the current global outbreak is significantly less deadly. We don’t know exactly why that is. Monkeypox in West Africa had a reported CFR of about one percent, leading to speculation that it was a different, less deadly strain, and what’s spreading now has an even lower CFR than this. That might be due to subsequent mutations, or it might be due to better reporting in Europe and North America, with mild cases more likely to go unreported in the earlier outbreaks. Or it might be because rich countries’ health systems are better-resourced. We don’t really know.

It’s also possible that CFRs might spike in the future. Right now, rich country cases seem to mostly be in gay men with vigorous social lives who, I assume, are on the younger side. Wider spread might sicken more elderly people or young children and cause more fatalities.

But we’re not in the kind of dire situation that a read of the older literature would suggest. That’s the good news.

The bad news is basically everything else. Back on June 1, I criticized the “don’t panic” posture of monkeypox media coverage arguing that, yes, it’s always a bad idea to panic. But the monkeypox situation had been steadily deteriorating for years in the absence of serious global action, and this struck me as a “stitch in time saves nine”-type scenario. Now, after two months of not panicking, monkeypox cases continue to increase and the odds of containing the virus have gotten much worse. Again, to panic is by definition not the right response. But when an infectious disease threat emerges, the world needs timely and decisive action before the virus “goes viral” and becomes too big to contain.

But even after living through Covid-19, and even though an Orthopoxvirus outbreak is a scenario global public health officials are supposedly prepared for, we’re totally failing.

The mangled message on sex

As a bystander, one of the most disturbing aspects of this has been watching officialdom flail around on the issue of the relationship between monkeypox and men having sex with men.

The actual facts here do not appear to be particularly complicated or in dispute:

1. There is nothing “gay” about the virus; experiencing same-sex attraction does not make you uniquely vulnerable to infection, nor does having sex with women offer any guarantee of protection.

2. The virus spreads primarily through close physical contact, most of all direct skin-to-skin contact with someone else’s sores, but most people simply don’t touch very many other people in that way.

3. The vast majority of the currently infected people are men who have sex with men. Because men are more sexually promiscuous on average than women, the gay social scene lends itself to a relatively rapid dissemination of sexually transmitted diseases.

4. Because the virus can spread non-sexually and because some men who have sex with men also have sex with women, if enough gay men are infected, the virus will almost certainly spread to many women and straight men as well.

This is essentially the scenario the world went through with HIV/AIDS in the 1980s and 1990s — a virus that is disproportionately a concern for gay men but certainly not one to which straight people are invulnerable or that is caused by being gay. Threading that needle seemed challenging, message-wise, in an era of relatively high homophobia, but a plain discussion of the facts should be much easier in the 2020s when there is a lot less stigma around homosexuality.

Instead, as Jerusalem Demsas recounts, the messaging has gotten tangled in a vortex of leftist thought about when it is and isn’t appropriate to draw attention to the fact that a problem disproportionately impacts a vulnerable minority group.

I tend to think the holdup here is solution aversion. A realistic late-May assessment of the situation carried the implication that public health types should have urged gay men to hold off on a summer of fun until vaccine supplies were ample. Indeed, given the very recent context of mandatory non-pharmaceutical interventions to curb SARS-CoV-2, you might have seen some suggestions that we ought to ban certain kinds of big parties. It’s a little strange that people who were relatively gung-ho about shutting down schools and bars and restaurants might shy away from that solution. But the gay angle raises the specter of discrimination and stigmatization, so instead many officials opted for obfuscation and a lack of clarity.

Meanwhile, unlike with Covid-19, we actually had the basic science of an effective monkeypox vaccine ahead of the outbreak — yet this has done us remarkably little good.

We have the vaccine but not the doses

Smallpox, which is related to monkeypox, is the original-use case of vaccination. People discovered that deliberate exposure to cowpox, which usually causes only mild symptoms, provided useful cross-immunity to smallpox (the term “vaccine” derives from the Latin “vacca” for cow). Over the course of 19th-century culturing of cowpox samples for vaccination purposes, the strain seems to have diverged evolutionarily from cowpox to the point where scientists now refer to it as its own species — the vaccinia virus. And just as vaccinia delivers cross-immunity to smallpox, it delivers cross-immunity to the related monkeypox.

The big downside to all of this is that because the vaccination process involves the use of a live virus, the side effect profile of traditional smallpox vaccination isn’t great.

Since smallpox itself is super deadly, smallpox vaccination easily passed cost-benefit muster. But once smallpox was eradicated, we stopped vaccinating people due to both the costs and the risks. That meant that for decades there’s been this kind of lurking nightmare scenario whereby smallpox somehow gets loose despite eradication and humanity’s deadliest foe is back upon us. The American and Russian governments have the world’s only remaining smallpox samples under lock and key. But accidents happen. And sometimes governments do reckless things.

Even worse, about five years ago, some Canadian scientists deliberately re-created the extinct horsepox virus using about $100,000 worth of materials they were able to order online. These scientists were not being reckless or trying to stage a terrorist attack; they were trying to make the point that a technically sophisticated terrorist could probably create smallpox and the world ought to do something about it.

The official plan in the event of a catastrophe was to unleash the U.S. government’s 100 million doses of a vaccine known as ACAM 2000. This is not the smallpox vaccine that was used in the eradication campaign (that’s a now-obsolete vaccine called dryvax), but like dryvax, it involves a live virus and requires the use of a special two-pronged needle. But then in 2019, the FDA licensed a whole new vaccine, JYNNEOS, which has a better safety profile and can be administered more conventionally. The problem is that even though JYNNEOS became the default plan for dealing with a potential pandemic threat, no country launched a crash program to manufacture and stockpile doses in large quantities. As a result, vaccines are still in short supply three years later both in the United States and around the world.

Bad pandemic incentives

It should be said that even though the monkeypox epidemic didn’t start spreading in rich countries until this year, back in 2019 there were already plenty of monkeypox cases in Africa. Nigeria, in particular, seemed to have a fairly serious monkeypox outbreak, but there was relatively little media interest or surveillance because it’s a poor country. But in 2018, there was a monkeypox case in the UK brought by a traveling Nigerian citizen. In 2019, an English person went to Nigeria and got monkeypox there. Another traveler brought monkeypox from Nigeria to Singapore.

Oyewale Tomori was warning people in 2021 that Nigerian monkeypox cases were being massively undercounted due to Covid-19. That year we also saw cases in Wales and the United States linked to travel to Nigeria.

So while community spread in the West is new this year, for years the rich world ignored a growing public health problem in Nigeria in a way that eventually led to spillover.

Back in 2019, we should have spent a lot of money manufacturing JYNNEOS doses and deploying them to Nigeria and neighboring countries while advising travelers to the region to get ACAM 2000.

If you read Keren Landman’s rundown of why we’re not using ACAM 2000 right now, it’s semi-convincing. The vaccine is a bit logistically laborious to administer. And due to its safety profile, there are large swathes of the population for whom it’s not recommended. But since there’s not really that much travel from the west to Nigeria, there wouldn’t really have been a logistical problem with giving it to travelers. And if a significant minority couldn't take it, that’s still better than nobody taking it.

But most of all, the world invented a better vaccine and then just utterly failed to spend money on manufacturing and using the vaccine when it would have been timely. And this speaks to the fundamental political difficulty of pandemic prevention. The most egregious failure here was really by the Trump administration, which was in office at the time JYNNEOS was licensed and should have immediately mobilized to put it into the field. But at the time, nobody in the United States cared about this, and by the time it became a problem, it was Joe Biden’s problem. And then Team Biden itself was too slow for the exact same reason. The best time to act on building stockpiles and developing logistical plans is before anyone cares. We seem to be fortunate that this monkeypox outbreak is not that lethal. It’s important to understand, though, that this is somewhat surprising — based on previously available information, we would have expected to see more people die. There’s no good excuse for this level of lethargy.

We need fundamental change

The paralysis around monkeypox should be a wake-up call that while Donald Trump deserves a fair amount of personal blame for blundering during the crucial early months of the Covid-19 outbreak, there are some much more fundamental issues in play here.

One is that we are much too tightfisted with spending on this kind of thing. I sort of get why rich countries weren't that interested in massively scaling-up JYNNEOS manufacturing back in 2019. The odds of an Orthopoxvirus outbreak occurring in any given year were low, so a slow and steady approach to production would probably let everyone get adequate stockpiles before it was needed. A big rush to increase production would have required large expenditures that would probably look unnecessary ex-post. But at the end of the day, the cost of “wasting” money on overproduction of useful vaccines and therapeutics is tiny compared to the cost of letting new pathogens become endemic.

The other is that ignoring public health problems in Africa is really short-sighted and bad. Even if monkeypox itself isn’t a particularly compelling African public health cause, in a purely self-interested sense we ought to be much more on the ball about dealing with emerging pathogens in the places where they emerge.

Last but not least, it seems to me that the public health community has a very harmful bias against voluntary action. We’ve let 100 million ACAM 2000 doses go unused because the risk profile of the vaccine is poorly suited to a mass vaccination campaign. That’s fine as far as it goes. But why not let the providers who want to administer it provide it to the patients who want to take it rather than waiting around for JYNNEOS? There’s a concern, I should say, that getting ACAM 2000 leaves you with a sore that sheds vaccinia virus and that if other people touch the sore they can contract vaccinia. In the vast majority of cases this is harmless (that’s the whole point of the vaccine), but for vulnerable classes of people it could be damaging. So giving people the ACAM 2000 shot is in part a bet on their willingness to behave responsibly — a bet the medical community isn’t willing to take. Yet in other arenas, we let people walk to the hardware store to buy bleach, rat poison, insecticide, weed-killing sprays, and plenty of other substances that are both useful and harmful-if-misused. So I understand the concern about ACAM 2000, but I think this is a standard we rightly reject in most walks of life.

More broadly, it seems like communicators didn’t want to speak clearly about where the risks lay because they didn't want to be seen as arguing for a shutdown of Pride events.

But I think there’s a very deep and broad bias against voluntarism. I’ve written before about how we could make a lot of public health progress by allowing more voluntary transactions around blood plasma, kidneys, and clinical research. Letting people have access to vaccines if they want them rather than stockpiling them for use if and only if the government decides to try to make everyone get it seems like part of the same pathology. You couldn’t have shut down the gay party circuit in 2022, and there’d have been no good reason to try. But that was no reason not to inform people of the elevated risk climate and the likelihood that vaccines would be widely available in future years, so a prudent person might want to stay away.

Would any of this have fixed the problem? Probably not. I think monkeypox is fundamentally just not scary enough to spur dramatic changes in behavior. But the nonchalance of the official response and the over-emphasis on telling people not to panic represents a real problem. We need to invest much more money in pandemic prevention, but also find a way to reform these institutions away from their inaction bias and hostility to simple provision of information and voluntary action. We actually should be panicking about the poor state of our preparedness and public health defenses.