“Overlapping Pandemics” and why other viruses should have prepared us for monkeypox
There has been some debate over the name for monkeypox and The WHO has initiated a renaming process. Why is language important here?
We need to rename this virus. It has been proven wrong that this virus originated from monkeys in the Congo; the monkeys were in a laboratory in Europe. The virus was then found in rodents and humans in Central Africa. The name is reminiscent of many things heart of darkness Images of Central and West Africa causing serious harm.
We need a more neutral language. I’ve seen MPV and MPX and they’re both a definite improvement (I’ll call it MPV). When HIV/AIDS was dubbed GRID – Gay-Related Immune Deficiency – the name of the virus and disease was associated with a queer identity that included both gay people who were ill by associating their identity or behavior with an illness equated, as well as harming people living with HIV who were not queer, who were associated with that identity by the virus. Viruses have no identity! They’re just little packets of genetic information!
In the United States, monkeypox is spreading primarily among gay and bisexual men and their sexual networks—a community shaped by the AIDS epidemic. Are there teachings that can be applied to monkeypox?
Of course. As this epidemic continues, it is important to state that MPV can infect anyone. Any place where there is a lot of touching — sports like wrestling spring to mind — or confined spaces — like dormitories — can spread the virus. And we cannot blame gay men for this outbreak, even though we are one of the groups where the virus is spreading.
There are essential lessons from HIV that need to be applied in this crisis. We’re very fortunate with MPV: we have tests, treatments, and vaccines that are FDA approved and in stock. People need these tools! This was a great lesson from HIV: once effective drugs were developed, it took a decade to ensure that those drugs were available in South Africa. Even today, fewer than 25 percent of people qualify for HIV PrEP [a medication taken to prevent HIV] have access to the drug. Blacks make up 8 percent, while 63 percent of eligible whites have access to PrEP. Biomedicine is necessary but not sufficient. People must have access to biomedicine and trust that it was designed for them.
At the beginning of the COVID-19 pandemic, the CDC infamously botched tests by the proliferation of flawed tests that made it difficult to identify early cases and contain the spread of the virus. It sounds like the monkeypox tests got off to a slow start as well.
I wrote a New York Times Statements in late May calling for both an increase in MPV testing and a framework for building that capacity immediately. But just like the response to COVID-19, there was a lack of urgency to make these changes. Between June and mid-July, testing capacity in New York City — a city with a million queer people hosting Pride and hundreds of thousands more attending — was limited to fewer than 20 MPV tests per day.
This was a choice. The lack of testing meant we were undercounting cases. The fact that we were undercounting cases prompted the federal government to delay vaccine shipments until after Pride.
Speaking of vaccines, how does monkeypox vaccination work?
MPV should have been an easily contained virus in the United States. We stock millions of doses of two effective vaccines. And yet it seems that this virus will most likely remain in our communities for some time, if not forever, until late summer.
In 1980, the WHO announced that smallpox had been eradicated from the planet. In this context, it became unethical to vaccinate extensively against smallpox; However, this decision also impacted MPV immunity, as smallpox is closely related to MPV. From 1980 to 2010, MPV immunity increased from near universal to near nonexistent in the region of Africa where MPV is endemic. MPV outbreaks increased. In Nigeria, there has been a municipal spread of MPV in urban centers from 2017 to present. We could have vaccinated in the endemic region to prevent this spread and if we had done that we probably would not have seen the virus spread around the world.
One of the frustrating things about viruses is that they are all very different from each other. All living organisms, from bacteria to bears, write their genetic information into DNA. Not so with viruses. And each virus infects a different cell type with different consequences. All of these differences make some viruses relatively vulnerable to strong immunity to vaccines — like measles, for which a vaccine is over 95 percent effective — and some viruses resist vaccine-based immunity altogether, like HIV.
Access to vaccines also feels like the first COVID-19 vaccines when booking an appointment felt like winning the lottery. You said Wired“With such scarcity, justice is impossible.” What needs to be done to improve vaccination efforts?
Global infectious diseases need global solutions. There are short, medium and long-term answers. Right now, vaccines need to get into guns. The new CDC/FDA strategy of using one-fifth of the dose intradermally may help here, but it also raises another variable about how effective this vaccine will be in this epidemic.
In the medium and long term, the world will need more MPV vaccines. Some colleagues and I argued in January 2021 that the globe deserves COVID-19 vaccines. We had the momentum in the Biden administration to make this happen, using the PEPFAR model, which funded HIV drugs for everyone worldwide. Ultimately, this did not happen and SARS-CoV-2 continued to evolve and mutate, which may have helped prevent global vaccination with the highest potency vaccines.
HIV, COVID and MPV show us that infectious diseases are global in nature. MPV vaccination will help prevent more painful infections and loss of life wherever the virus is found, particularly in the endemic region. We need to make more vaccine and we need to act urgently.
Harm reduction is used in public health efforts to reduce adverse outcomes without encouraging abstinence — for example, the use of monitored injection sites to avoid overdoses and encouraging”pandemic pods‘ during early COVID waves to allow for small group socialization. Does monkeypox mitigation matter?
Damage reduction is the name of the game! Indeed, calls for sexual behavior change came first from within the queer community. Public health officials are afraid of it, but I’ve worked and spoken to a few people who throw big parties and so many people in their friend groups have had MPV. They closed voluntarily and I’m proud of them.
From the people most affected by MPV, we’re beginning to hear that until more vaccine is available, perhaps we should all change our sexual behavior: talk to your dates, wear more clothes to the party, avoid skin-to-skin contact with large ones Groups. It was only after the community began this work that the CDC and the New York City Department of Health issued the same guidance.
See, you cannot and will not stop people from dating or having sex, especially in the long term. It just won’t work. HIV research has shown us that. You need to provide people with information about the risk of different infections, prevention through biomedicine when we have it, and knowledge about what the infection looks like, how to get tested and how to be treated.
Are there other lessons from COVID that can be applied to monkeypox?
We should talk more about how miserable it is to isolate yourself when infected with MPV. Even with milder courses of infection, people are asked to isolate themselves completely at home for weeks.
COVID has taught us how painful just five to ten days of isolation can be. Here people have to isolate for double or more. And we haven’t built in any support – financial, practical, or emotional. We must support people during and after infection and work to reduce the stigma of those who have recovered.
You are a co-investigator on RESPND-MI, a survey on monkeypox distribution and networks produced by the LGBTQ+ community. What are you hoping to learn?
RESPND-MI was designed and led by my dear friend Keletso Makofane, a Harvard-trained epidemiologist who studies how social networks drive differential health outcomes. It’s a web-based survey that we’re going to try to get every queer person in New York City to participate in. It asks questions about MPV symptoms, whether you’ve been vaccinated, who you’re friends with, and who you have sex with. This will ultimately provide some information on how widespread the virus is in our city and who is most likely to have had it. We will also create a map of sexual and social networks – anonymously, of course. This map can be used to target immunizations to those most at risk and/or where immunization uptake is lagging. [People administering vaccines] can show up in a gay bar, gym, or even a coffee shop, for example, if that location overlaps with the people you need to find.
In New York, we know that blacks are disproportionately getting MPV compared to their access to vaccines: while blacks make up 31 percent of the queer community, only 12 percent of eligible black queer people have received a single dose of vaccine. RESPND-MI, led by a black epidemiologist along with co-investigators who are mostly queer and trans people of color, is one of many essential ways to end this terrible inequality.