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Lesson Learned?

There Is a Right Way and a Wrong Way to Respond to Monkeypox

Monkeypox and Covid aren’t a zero-sum game. They’re more connected than they first appear. Acknowledging that can help us fight both.

A health worker examines a woman's hands at an airport checkpoint.
Health workers screen passengers arriving from abroad for monkeypox symptoms at Anna International Airport in Chennai, India, on June 03.

When the first case of monkeypox raised alarm in the United Kingdom on May 13 and the headlines about potential spread began circulating, many people wondered: Is this the new pandemic, the next threat to worry about, even more than Covid-19, which is currently at some of its highest peaks in the United States? Or is this a distraction from the primary public health crisis—a “charismatic” new pathogen stealing attention because privileged Americans have decided they are done with Covid? The answer, unfortunately, is neither—and both. Monkeypox and the Covid pandemic aren’t as separate as they might at first appear, and they’re not either/or. Instead, experts have told me, the two diseases have arisen out of similar mechanisms, and the disinterest the rich now feel with Covid could make monkeypox harder to stop.

Around the globe, 1,000 cases of monkeypox have now been confirmed. Although monkeypox has been around for decades, this is the first time it has spread outside of countries where it’s usually found, surprising experts and leaving health officials scrambling to understand and contain the scope of the outbreak.

But we’re not just facing a more widespread emergence of a virus that’s behaving in unusual ways. This new threat is hitting a nation wearied by Covid-19, with greater limitations on public health measures than before the pandemic began. More than half of U.S. states have introduced new restrictions on public health powers, while some school districts are no longer allowed to require masks—to prevent Covid or any other disease. At the same time, a changing environment, strained health systems, and a lack of disease monitoring are creating dangerous opportunities for new viruses to emerge and spread. We know how to stop monkeypox. But will we?

It can be difficult to understand exactly how worried the public should be about monkeypox—especially compared to the relative risks of one of our largest Covid surges yet and an unusually long flu season. For now, the individual risk of contracting monkeypox is pretty low, but it’s essential that we take rapid action to quash this outbreak before it continues circulating in people and animals, perhaps permanently.

“The general public needs to be aware and alert,” said Boghuma Titanji, infectious disease doctor and scientist at Emory University, “without at the same time panicking and worrying that this would be a same scenario like Covid-19, where we’ve had millions and millions of cases and also millions and millions of deaths around the world. It’s a very different type of outbreak.”

The general public should have “a heightened sense of awareness” of the unfolding outbreak and the risks of infection, Titanji said. “What is emerging in the ongoing outbreaks is that transmission through close contacts, such as the close contacts that happen during sex, appears to be an important mode of transmission.” The type of behavior that happens during sex—long periods of skin-to-skin contact—also seems to spread this virus without sex.

So far, many of the cases have been identified among men who have sex with men, so it’s vital to reach out to this group to make sure they understand and respond to the risks. But cases have also been identified in other communities, and anyone who is in close contact with many people should be aware of the warning signs of the disease—especially since it’s not clear how long and where the virus has been spreading up to this point.

Especially compared to other harmful viruses in circulation right now, the chances of avoiding monkeypox are pretty encouraging—for now, at least. “For the average American, the risk is low, but when it comes to risk levels, that will continue to change if the epidemic continues to expand,” said Syra Madad, an infectious disease epidemiologist at Harvard’s Belfer Center and senior director of the special pathogens program at NYC Health + Hospitals.

But from a public health standpoint, “it’s very concerning that we’re seeing so many cases pop up in over 30 countries in a very short period of time,” Madad added—particularly because monkeypox can spill back into animals and continue circulating for years, spilling over into humans periodically and creating long-term outbreaks in places where it was never endemic before. And it raises questions about the adequacy of our pathogen surveillance infrastructure: “How long has this outbreak been going on?” she asked. “Has it been weeks, months, or even years?”

Previous outbreaks of monkeypox have usually happened in rural communities bordering forests. “These outbreaks have tended to be contained mostly by virtue of geography,” Titanji said. Once they burn through a small community, there’s nowhere else for the virus to go. But now that the virus is spreading in larger communities, it’s showing new sides—like the ability to spread through sexual contact.

“Viruses, bacteria, or any pathogen—sometimes all it needs is the optimal condition to be able to transmit more efficiently,” Titanji said. “If you then take that pathogen and you give it a niche in sexual networks, maybe that is facilitating its transmission.”

It’s also possible the virus is spreading in new ways because it has picked up some helpful mutations, and it could be spreading more because more people are susceptible now that our collective immunity against smallpox, a cousin in the same virus family, has waned. Population growth could be another reason, as remote areas become more developed and better connected to densely populated cities.

Monkeypox has long been an example of the diseases that could become more common in a heated climate and changing land, as people push into forested areas for agriculture or living space. The expansion and development of previously uninhabited spaces, along with the migration of species in a warming world, are proving a dangerous petri dish for the emergence of viruses—both new, as with Covid, and previously documented, as with monkeypox.

All of these factors have likely given rise to the monkeypox outbreak, Titanji said. “That’s what pathogens do: They find a loophole, and if the loophole favors their transmission, then they’re able to cause outbreaks.”

And now, in the wake of the still-surging Covid pandemic, we may have discovered another way to facilitate the emergence of viruses: by putting new limits on public health measures. “Restrictions on the authority and the power given to public health is not only concerning, it is frustrating, it is frightening, and it’s going to not only hurt us in the short term, it’s also going to hurt us in the long term,” Madad said.

A rising chorus of experts has called for stopping new infections at the source and monitoring potential new pathogens in people before they spread across the globe. But monkeypox illustrates how far behind we are in this task. African researchers, who have immense experience with monkeypox and other pressing diseases, have frequently been marginalized in conversations and research around infectious disease—even now, during this outbreak.

“You have to think about tackling the ongoing outbreaks in Europe and America and other regions, but you also have to think about how you allocate and share these resources to allow scientists who have been working on this in Africa for 50 years to actually deploy the same strategies to protect the populations and curb the outbreaks in these areas,” Titanji said. “If we had taken monkeypox more seriously as a global health threat, there would have been more investment in the research to help us understand these very complex dynamics between humans, the environment, and the animals with which we share this environment.”

Only addressing the outbreaks in some countries, without tackling outbreaks in endemic countries, means we will continue seeing the same problems again and again. A recent monkeypox case in Virginia, for instance, was linked to a traveler returning from Nigeria. “These introductions are still happening,” Titanji said. “We can’t only begin to worry about these diseases when they reach the shores of wealthier countries.”

Anyone who has survived the past two years can’t help but see echoes of Covid-19—the uncertainty around the way this virus behaves, the extent to which it has already spread, the way in which inattention to inequality prolongs the pandemic, the way our nation’s public health system seems unprepared to deal with an outbreak. (The U.S. Centers for Disease Control and Prevention did not respond to inquiries about its system for tracking monkeypox and how long it has been in place.)

And another outbreak, amid the fatigue, confusion, and misinformation around Covid, could threaten to engulf or short-circuit our attention. “There’s always the risk that when you’re dealing with multiple public health issues, especially infectious disease outbreaks, at the same time, it can be overwhelming,” Titanji said. That’s true both for the people tasked with responding to these outbreaks—the already exhausted health workers and public health officials—and for a public navigating “a maze of information on very different outbreaks and new pathogens,” she said.

But many of the precautions employed against Covid and other respiratory viruses also help against monkeypox: washing hands, wearing masks, staying home when you’re sick, getting tested if you notice anything unusual. And our language around disease prevention and knowledge of the spread of disease has expanded significantly in the past two years. Because of the Covid pandemic, Madad said, “people are much more aware of global health.” We better understand incubation periods, how to quarantine and isolate, why it’s important to get tested and seek health care services. “It’s going to our favor,” said Madad, “because now [when] we talk about monkeypox, or any other type of emerging and reemerging infectious disease, people have a better understanding of what it is and what they can do to protect themselves.”

And there’s still time to stop this outbreak and keep the virus from gaining a foothold in new places. “If we do basic public health measures, like contact tracing, case investigation, case management, prevention, we’re able to contain this epidemic,” Madad said. “If we have better surveillance, more people looking out for this disease; the earlier we can catch cases, the more we can isolate and quarantine, and the more that we can prevent further onward spread of this virus.”

Despite the parallels with Covid-19, monkeypox is different. We have the time and resources—vaccines, treatments, monitoring networks—to stop monkeypox in its tracks. The question is whether we will be able to deploy these resources in an already stretched health system and among a public that is rapidly losing trust in officials.

That’s not a question scientists can answer. Policymakers and the public are the ones who get to decide whether the lessons from Covid help us in the fight against monkeypox—or whether we decide, disastrously, to treat the diseases vying for our attention as a zero-sum game.