The current outbreak of monkeypox virus (MPV) is a sign that the United States failed to learn important lessons from the COVID-19 pandemic. As of late September, there have been more than 24,000 confirmed cases of monkeypox in the United States; every state is reporting cases including the District of Columbia. As with COVID-19, this number is likely a significant undercount. And while infection rates have recently lessened, an immunocompromised man in California died as a result of contracting the virus, emphasizing the risks of an insufficient response to this outbreak, especially for marginalized people.
Health experts have been critical of the Biden administration’s response, with some comparing the response to that of the Trump administration in the early stages of the COVID-19 pandemic. In June, Lauren Suar, the director of Special Pathogens Research Network, was quoted by the Washington Post as saying, “It felt like January 2020 all over again.” Similarly, members of the LGBTQ community are speaking up and speaking out against the Biden administration’s lax response to monkeypox. In an August essay for TIME magazine, LGBTQ advocate Jonathan Van Ness wrote “Once again, we’re seeing too little action until the situation has ballooned out of control.” Men who have sex with men (MSM) have been disproportionately affected by the current outbreak and many, like Van Ness, believe homophobia and transphobia are to blame for the administration’s delayed response.
If the Biden administration hopes to control the outbreak, they will need to act quickly. This commentary describes how the lessons learned from the COVID-19 pandemic, as well as other infectious disease outbreaks, can help guide the public health response to monkeypox. After this, it describes the risks of failing to act, especially for already marginalized patients who are most at risk.
The Administration Is Well-Equipped to Respond to a New Viral Outbreak
The Biden administration has the tools needed to respond quickly and adequately to the monkeypox outbreak. Unlike COVID-19, monkeypox is not a novel virus, and the strategies used to respond to the COVID-19 pandemic can easily be applied to the monkeypox outbreak.
Monkeypox is not a new virus. The first human case was reported in 1970, and the United States experienced a small outbreak in 2003. The virus is most often transmitted through skin to skin contact; people who share clothes or sleep in the same bed as an infected person are also at a higher risk of getting sick. Monkeypox is not a sexually transmitted disease, but the current outbreak is primarily spreading among MSM through sexual activity.
The first U.S. case of the current outbreak was reported on May 18, 2022. For years, public health officials expressed concern for the growing number of MPV cases in African countries like the Democratic Republic of Congo and Nigeria, but little action was taken to stop the spread. Now that several western countries have reported MPV cases, including the United States, there appears to be a renewed interest in stamping out the virus.
Fortunately, vaccines, tests, and antiviral treatments for monkeypox already exist. Unfortunately, the Biden administration has not worked to make these tools available to stop the spread of the virus. Similar to then-secretary of the U.S. Department of Health and Human Services Alex Azar’s delay in declaring a public health emergency over COVID-19 until March 2020, current Secretary Xavier Becerra did not declare monkeypox a public health emergency until August 4, 2022.
With that being said, a slow emergency declaration from the Biden administration does not mean they will continue to mirror the Trump administration’s response in the future. As a result of declaring a public health emergency, the Centers for Medicare and Medicaid Services are able to better collect testing and hospitalization data, promoting a more tailored response to where in the nation the virus is spreading. The Biden administration has also ordered nearly 2 million additional doses of the Jynneos vaccine. These vaccines are necessary to stop the spread of the outbreak.
Fortunately, the Biden administration can rely on familiar methods from the early COVID-19 response to distribute vaccines. The administration can also look to successful distribution campaigns from local and state government’s such as the District of Columbia’s monkeypox response. At the end of July, the district had the highest per capita number of monkeypox cases, which drove the district government to partner with organizations that serve the LGBT community, such as Whitman-Walker Health, to promote vaccinations through pop-up clinics across the city.
As with the COVID-19 pandemic, more can be done both to promote vaccination and treatment for monkeypox to ensure that the response is equitable. Due to New York’s higher than average LGBT population, the state had more than 25 percent of the confirmed cases in the United States as of early August, leading much of its congressional delegation to call on the Biden administration to invoke the Defense Production Act (DPA). The DPA gives the president broad authority to direct production of goods, including vaccines, and both presidents Trump and Biden invoked the act in response to the COVID-19 pandemic.
The increased production under the DPA could also be used to help promote more equity in the response to the outbreak. In addition to the overwhelming majority of cases being seen among MSM, Black and Hispanic patients are disproportionately likely to have contracted the virus, similar to the majority of the COVID-19 pandemic. Despite this, white patients were more likely to have been vaccinated for monkeypox in every state collecting racial and ethnic patient data as of late August. More work is needed to ensure that the failures to equitably distribute COVID-19 vaccines do not repeat themselves.
The Risks of Failing to Adequately Respond
As mentioned above, the overwhelming majority of monkeypox cases are among men who have sex with men (MSM), and most of those patients are contracting the virus via sexual activity. This reality has driven much of the response, for both better and worse. To date, the public health guidance for who is eligible for testing and vaccination has largely centered MSM: for example, New York City’s vaccine strategy restricts eligibility to adults who have had multiple sex partners in the past two weeks and are an MSM, are transgender, or are sex workers. The LGBT community is at higher risk both because of the reality of how monkeypox is spreading and because of the higher rates of HIV/AIDS than the general population.
However, the focus on the LGBT community, especially MSM, runs the risk of stigmatizing the disease. As we saw during the COVID-19 pandemic, associating a communicable disease with marginalized communities can result in upticks of hate speech and even violence. It is important to avoid reinforcing this stigma, much as public health officials worked to do with anti-Asian racism in 2020 and 2021. Particularly as anti-LGBT rhetoric becomes more common, public health officials should take care to emphasize that anyone can contract monkeypox, even as the disease disproportionately impacts the LGBT community.
Framing the monkeypox outbreak as a disease that solely impacts LGBT people also runs the risk of reducing vaccination rates and access to treatments. MSM who do not identify as LGBT or who are not openly gay or bisexual, for example, may be reluctant to seek vaccination. Nearly 20 percent of those vaccinated by mid-July in the District of Columbia did not identify as gay, highlighting the importance to frame vaccination in a way that does not contribute to inaccurate perceptions of who is at risk. Additionally, while the risk of death from monkeypox is relatively low, children and pregnant women are at the highest risk of a fatal case, and both of these groups were generally excluded from vaccine eligibility.
The Biden Administration Should Use All of Its Tools to Combat Monkeypox
Monkeypox is not a new disease, and the lessons learned from the COVID-19 pandemic can be used to stop its spread. The Biden administration has already used some of these by declaring a public health emergency and using its authority to help promote access to vaccines and treatments. The administration should go further, however, and use the Defense Production Act to further bolster this access. This increased supply of vaccines and treatment should then be used to improve the equity of the public health response, closing disparities in vaccination rates. Increasing the supply of vaccines and treatment will also help avoid needing to restrict eligibility for either, ensuring that the disease does not become stigmatized or unnecessarily withheld from at-risk groups.