Covid-19 revealed many embarrassing deficiencies in the US public health system. The CDC fought early in the pandemic for it get usable tests to doctors and health clinics. The data reporting was terriblewhich means our public officials were flying blind trying to put an answer together. Public health officials initially told us to worry about the flu instead of Covid, they underestimated value of masks to the public in an effort to save supplies for healthcare workers and often failed to communicate effectively about booster shots or vaccines for children. Confidence in our public health agencies fell down in response to the growing perception that their announcements did not match reality.
As the number of Covid-19 started to decrease, there were many on an empty stomach conversation about how much the public health field had to learn from Covid, and how much better they had to perform, before the next virus struck.
Then came monkeypox. After the first human case was diagnosed in the Democratic Republic of Congo in 1970, the virus was largely contained to a handful of African countries before breaking out this year in Europe and increasingly in the US, with over 20,000 confirmed cases in more than 60 countries. Last week the World Health Organization (WHO) stated monkeypox a global health emergency.
Let’s be clear: Monkeypox is not a worst-case scenario virus. If anything, it’s close to a best-case scenario virus — at least in terms of its controllability.
First, we had endless warnings that it would be a problem. As worldwide immunity waned against smallpox—a closely related virus that also confers immunity against monkeypox—Nigeria saw more and more cases of monkeypox, with explosions in recent years counting hundreds of patients. United States with experience, and contained a small outbreak of monkeypox in 2003. This was not a virus that appeared out of nowhere; it was on every list of annoying viruses that were around and hit people from time to time.
But no one was too worried because monkeypox is not too sticky and there is an effective vaccine. While what is currently active is likely a new variant, which spreads more easily through very close contact with infected people, is still not as contagious as a respiratory virus like Covid-19 can be. This means that key elements of public health such as contact tracing and vaccination rings of at-risk populations should be more than enough to stop it.
Monkeypox was the mild mode of disease control, and yet it seems very likely that we will fail to control it, with over 4,900 confirmed cases and counting in the US alone. As we do so, we are rapidly making many of the mistakes that characterized our response to Covid, making it clear that we have learned very little.
Some of the most obvious mistakes have been in communication, where people get sick because of reluctance to tell them they are at higher risk.
Our troubled response to monkeypox
The way to contain a non-communicable disease for which there is a good vaccine looks like this: Make sure everyone knows the disease is spreading, identify who is most at risk, and make sure they can access health care if they have it. Test widely and when you find a case, contact the trail.
This means relentlessly tracing people with whom the sick person has been in close contact and encouraging them to get tested as well. For some diseases with a long incubation period and an immediately effective vaccine, you can vaccinate close contacts and thus prevent them from getting sick.
The U.S. response to monkeypox is failing miserably on nearly every one of those fronts. First, testing: Very often people show symptoms of monkeypox doctors tell them they don’t have to do testsor the tests are delayed so long as to be almost useless the rules that the sample for a test must be taken from a lesion, which can develop late in the course of the disease.
Next, the vaccines: As a New York Times article revealed this week, 300,000 doses of monkeypox vaccines sat in Denmark for most of a month because the U.S. had not yet placed an order for them, even though people at risk struggled to get to vaccination appointments. The US government has finally bought those doses overseas, but the window to completely contain monkeypox may already be closing.
Finally, as Jerusalem Demsas wrote for the Atlanticour public health officials have repeated the failures of Covid in another fundamental way: being too concerned with public opinion management to provide the public with accurate information about the situation.
Failure to communicate
According to one international study this week IN New England Journal of Medicine, 98 percent of documented cases were found in gay or bisexual men. While the disease is not a sexually transmitted infection like syphilis, which is spread almost exclusively through sex, transmission of monkeypox requires close physical contact, and sex appears to be a major opportunity for the virus — 95 percent of transmissions documented in the study occurred during sexual intercourse.
Because of testing deficiencies, it is difficult to say exactly what percentage 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 with sexually transmitted or among gay and bisexual men, so that we don’t miss cases in other populations. There are concerns that people have had turned his back from testing for monkeypox under the impression that it is a “gay disease” and worries that others may refuse to seek treatment because they fear they will be assumed to be gay.
But there is no doubt that the current approach puts gay and bi men at risk and is not meeting the needs of that community or any other.
And while it may seem obvious that the best way to serve the population of men who have sex with men is by getting them real information, high-quality health care, and access to priority vaccines, health agencies public are very often. failure to communicate clear about that.
We can handle the truth
Many public health officials have instead emphasized that anyone can get monkeypox, a message from LGBTQ+ health journalist Benjamin Ryan called the Washington Post “So extremely misleading is misinformation.” While it’s technically true that anyone can get monkeypox, some people are at very high risk—and they deserve to know that.
In New York, as the city’s monkeypox outbreak spiraled out of control, medical professionals working there struggled with whether to advise people to avoid anonymous sex encounters to reduce the risk of disease. Instead, in an effort to avoid stigma against gay and bisexual men, the city’s public health department issued advice to cover sores and avoid kissing if you have sex when you have monkeypox. As several doctors within the department argued, this is not sound medical advice.
The shadow of the dismal public health response to HIV seems above any attempt to provide advice about yet another epidemic that seems to be spreading primarily among gay and bisexual men at this point.
But the way to avoid HIV mistakes is not to say nothing, or to give condescending medical advice to influence public opinion. It’s moving mountains to make vaccines available, talking clearly and clearly about which populations are at high risk and advising sick people to avoid high-risk activities.
The WHO, at least, appears to be learning its lesson – on Wednesday, WHO Director-General Tedros Adhanom Ghebreyesus promote men who have sex with men should at least temporarily consider reducing the number of partners to protect themselves and limit the further spread of monkeypox.
During Covid, we tried the approach where public health officials tell partial truths and limit information to try to reduce stigma or get better behavior from the public. What we learned was that it doesn’t work. People don’t like to be manipulated and they look to unofficial sources if they think the official forces are not saying it directly.
Public trust is a scarce and valuable resource. Our plans to combat stigma, avoid panic and inform the public must build that trust, not erode it, or we will be underpowered when we need our institutions most.
A version of this story was originally published in the Future Perfect newsletter. Sign up here to subscribe!