BERLIN — As I stayed home in late July, listening to the director general of the World Health Organization declare monkeypox a public health emergency of international concern, many of my friends were out celebrating Pride. The decision to affirm an emergency about two months into a global outbreak was the right one. But it felt far too late.
As an infectious disease reporter and a gay man, I’ve grown increasingly frustrated with the global public health response to monkeypox and the communication around it. More than 25,000 cases have been confirmed so far in countries that had not been previously affected by the disease. Those infected are overwhelmingly found among gay men and our sexual networks. Friends of mine from Madrid, Paris, São Paulo and just down the street have told me about their infections. They were in pain — monkeypox has been described as excruciating — scared, and had a lot of questions.
Any successful response to an outbreak needs to be grounded in facts, and the facts are clear. Out of the cases recently reported to the W.H.O., data on sex is available for about three-quarters. Of these, about 99 percent are male. Data on sexual orientation is available for only about 7,500 cases, but of these, 97.5 percent are men who have sex with men.
This isn’t simply because cases in women or children are being overlooked. The U.K. Health Security Agency, for example, has published the number of tests performed for monkeypox and how many of them were positive. In adult men, more than half the tests were positive. Far fewer women were tested, but only 2 percent of them were positive, and in children 0.6 percent were positive. If many cases were being missed in these groups, those percentages would be expected to be much higher.
But public health officials in many places seem so unsure of how to talk about this disease in a nonstigmatizing way that they prefer to speak only in vague terms. Some — whether out of complacency, callousness or homophobia — just do not seem to see much urgency. Others avoid mentioning altogether that men who have sex with men are by far the most vulnerable at the moment.
A two-page leaflet by German health authorities to inform the public about monkeypox does make clear that spread is happening in places like sex clubs. But it does not mention the words “gay” or “men who have sex with men” once. In fact, the word “men” does not appear at all. In Mexico, Brazil and other countries, health officials have also been reluctant to emphasize the risk to men who are intimate with other men.
Even within my own community, some have argued that stating that the disease was mostly affecting men who have sex with men was homophobic. Others were simply afraid of worsening the stigma many gay men already face. On the other end of the spectrum, social media accounts that have gained huge numbers of followers during the coronavirus pandemic are spreading the false information that monkeypox is transmitting widely through handshakes, the food we eat and the air we breathe. The result has been confusion, with some people wrongly thinking they are at high risk and others not knowing about their very real risk or how to lower it.
As an infectious disease reporter, I have seen how deadly stigma can be. And as someone living with H.I.V., I have experienced the suffering that stigma can cause. But the solution is not to fall silent or to act as if the risk from monkeypox is the same across different groups. The solution is to choose words carefully, to engage the communities that are most at risk and to listen to those affected by this disease. That work will make the difference between public health and homophobia by neglect.
Yes, monkeypox can infect anyone. Yes, this virus can spread in a variety of ways, including through touching an object handled by an infected person or even through a prolonged face-to-face conversation. But that is not what experts are seeing as the primary mode of spread for this outbreak. For now, the virus appears rather bad at using less intimate routes of transmission. Even close household contacts of people who have monkeypox have rarely gotten infected. Instead, the virus appears to be spreading mostly through very close and prolonged contact during sexual encounters, and it is doing so overwhelmingly in communities of men who have sex with men.
In order to spread, viruses exploit the connections between humans. The more connections there are, the more likely a virus is to find a new host to infect. Monkeypox is not terribly efficient at transmitting from human to human. The virus has been causing illness and deaths in some African countries, where animals carry the virus, for decades, but has gone largely ignored in the West. When the virus made it to places like Singapore, Israel and Britain in the past, it rarely led to any further cases. Most people do not have enough close skin-to-skin contacts for the virus to transmit. But those men who do have a lot of male sexual partners are more vulnerable. We have seen this with some other pathogens, like MRSA and drug-resistant shigella. Now we are seeing it with monkeypox.
The world needs to take the threat of monkeypox seriously. Around 7 percent of cases so far have resulted in hospitalization, usually for pain treatment, and several countries have reported deaths from the disease. Even in many patients who are never hospitalized the virus causes immense suffering. On top of this, poxviruses have adapted to numerous species over time, and as the monkeypox virus continues to circulate it may evolve in unpredictable ways. Researchers have already reported signs of the virus’s genome changing. In the worst-case scenario, monkeypox could become more transmissible and more deadly. And even without any changes, the virus may yet make its way into other densely connected networks where it can spread.
To control the outbreak, those most vulnerable to infection need to have information that allows them to make decisions to stay healthy until there are enough vaccine doses available. That includes talking about reducing the number of sexual partners, creating “pods” of sex partners (where people keep sexual activity within a group) and other strategies to reduce the risk. It means communicating that scientists do not yet know how well one dose of the vaccine — or indeed two — will protect people, a crucial knowledge gap that needs to be addressed quickly. And it also means combating misinformation about the virus that is circulating widely on social media.
Public health responders need to make sure that the production of vaccines and drugs is ramped up, and that they are distributed quickly to those who need them most — especially in the countries that have long been affected by this disease. And we need to talk clearly and honestly about all this.
Keeping the focus on gay men and our sexual networks carries a risk, especially in those countries and communities where gay men are discriminated against and persecuted. Part of the public health response needs to be watching out for attempts to use this health crisis as a pretext for stigmatization and discrimination.
Today, in countries not previously affected, this virus is spreading predominantly in my community, and we need to focus efforts there. Talking about thousands of children being infected or millions of cases is not where the disease is right now. But, however unlikely, it is one possible future. The way to prevent it is by fighting this disease, not one another.
Kai Kupferschmidt (@kakape) is a contributing correspondent for Science magazine based in Berlin. He writes about infectious diseases and other science topics.
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