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Behind the headlines
Very few people had heard of monkeypox a month ago. Now – despite tough competition from other major global events – it is high in the headlines.
Monkeypox is interesting.
It is not primarily a disease of humans. It normally affects a whole range of small mammals that you have likely never seen, or even heard of - sun squirrels, rope squirrels, elephant shrews, potamogales, hyraxes – and of course Mangabey monkeys. But the virus is zoonotic, meaning that it can spread between animals and people. People are normally infected by being bitten or scratched by an infected animal.
Infection between humans has been rare, requiring close contact.
Monkeypox is caused by an orthopoxvirus. This is the same family of viruses that caused smallpox. Smallpox is (to date) the only virus affecting humans that has been globally eradicated. With smallpox gone, monkeypox is now the most common orthopoxvirus.
How would you know if you had monkeypox? The first symptoms to appear are difficult to distinguish from any other viral illness – fever, headache, and muscle aches. The rash that follows makes the diagnosis much easier. It typically starts on the face, and then spreads to other parts of the body including the palms of the hands and soles of the feet. It is a maculopapular rash – meaning that it starts as small spots (macules) which then turn into small fluid-filled blisters (papules). It is somewhat similar to the rash of chickenpox, and can be confused for it. For most people, the illness lasts a few weeks but is not serious. But a minority do get a more serious illness, and some die.
So why is it suddenly in the news?
Monkeypox is normally confined to a small number of countries in Africa. But over the last month, that has changed. A full 28 countries that do not normally have monkeypox suddenly have cases. It is popping up in the USA, Canada, Australia, Argentina, and 21 countries in Europe. A total of 1285 confirmed cases have so far been reported to WHO.
What has caused this sudden change?
Nobody knows for sure.
It is possible that the virus itself has mutated in some way, making it transmit more easily between humans than it usually does. There is not any direct evidence of this currently, but it’s a possibility.
It is also quite possible that the virus hasn’t changed at all.
Many of the cases so far have something in common – those affected are men who have sex with men. The virus is known to spread by close skin-to-skin contact. So the explanation may be, essentially, chance – that the virus has ‘found’ a transmission niche, and is being passed between men who have sex with men, some of whom have moved internationally.
Particularly in Europe, there are concerns that music festivals this summer could act as super-spreader events.
During the COVID pandemic, people around the world have learned what we public health doctors have known all along – that public health is always interesting and complex! Monkeypox is illustrating this again.
Three things about this outbreak strike me as very familiar. Three common themes in public health:
First, there a double bind between the urgent need for public education vs. the danger of creating stigma.
For public health officials, the fact that the virus is being particularly spread between men who have sex with men provides a communication challenge. This facts of transmission need to be publicly shared – particularly so that people who may be at greater risk of contracting the disease are aware of this and can protect themselves and/or seek early medical attention if they become unwell.
But there is a very real risk of stigma – which could prevent people who have been infected from seeking help, and can stoke (in this case) homophobia. Of course this is nothing new. In the early years of HIV, men who have sex with men were particularly affected – and there was enormous stigma. In many people’s minds, HIV continued to be associated with homosexual spread – even when this was not at all the case.
Second, beware the law of unintended consequences: a victory in one area of global health can open up a vulnerability elsewhere.
The smallpox vaccine offers good protection against monkeypox. But the smallpox vaccine is no longer used routinely. The reason for that is that smallpox has been eradicated. Smallpox eradication is a wonderful thing. But who would have thought, in 1980 when the world achieved that great feat, that an unintended consequence would emerge more than 40 years later – an unusual global outbreak, which probably would not have happened if we hadn’t eradicated smallpox.
Third, concentrated investment on medicine for wealthier countries creates opportunities for a global pandemic to sneak in through the “back door,” with outbreaks that begin in Low- and Middle-Income Countries.
There are many diseases that do not normally affect people living in the richer countries of the world. A full 17 of these maladies are normally classified as “neglected tropical diseases” – neglected because they do not affect the people who allocate billions of dollars to research priorities, and because there is no rich market ready to purchase newly developed treatments. Monkeypox is not officially considered as a neglected tropical disease, but the scenario is the same. In all honesty, we do not know very much about monkeypox. If it was normally endemic in Europe, we would know much more than we do.
This outbreak of monkeypox may grow and grow.
Or it may not.
Regardless, there is a message –
Many people are (wrongly, in our view) talking about COVID as a battle won, a thing of the past. We are seeing governments, agencies, and companies congratulating themselves on their fast response. This complex monkeypox outbreak is a sharp reminder at a timely moment. Infectious diseases will continue to come at any time, from anywhere, and sweep the globe. When they do, they will be complicated, and unforeseen in at least some ways.
Is the world in better shape to respond than it was before COVID? Yes. Are we in the shape that we could or should be? Absolutely not.
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