Three possible futures of the monkeypox epidemic

But that path will become even messier if nothing is done for the countries in west and central Africa where monkeypox was first identified decades ago and has been spreading since 2017. Vaccines don’t get there; Western nations, including the US, have snapped up the limited supply. Nigeria is believed to be the source of the current international outbreak via a long chain of transmission that snaked through several European countries before arriving in the US. If this epidemic cannot be controlled, monkeypox will not be controlled there or anywhere else. “If the issues of global justice aren’t addressed, if vaccines and therapeutics don’t find their way to Nigeria and the Democratic Republic of the Congo, then that has implications for accidental re-imports to other places,” Goedel says.

On this middle ground, monkeypox continues to spread in low-income countries that cannot afford to buy vaccines or build the infrastructure for testing. It is regularly re-imported into rich countries, whose populations may or may not be protected depending on how widespread their vaccination programs have been. There remains an ongoing threat to men having sex with other men, particularly in places where cultural pressures to appear heterosexual or structural racism or simple poverty make it difficult to receive health care that is responsive to sexual identity. Crazy enough, the rest of the world is okay with that.

Choice 3: The Dead End

Then there’s the worst case: we don’t control monkeypox. In this imagined future, monkeypox slips through the imperfect containment created by insufficient vaccine supplies and seeps out of the social networks of men who have sex with other men, through other sexual partners and household members, and into the rest of society — particularly those with vulnerable ones Immune systems, including the elderly, pregnant people and children.

“The epidemiological worst case is that there is sustained, efficient human-to-human transmission outside of sexual intercourse,” says Jay Varma, physician and director of the Cornell Center for Pandemic Prevention and Response at Weill Cornell Medicine in New York City. “And then it spreads like chickenpox in schools and day care centers. And we will be faced with a vaccine that has never been tested on children.”

This is the path the US will take if it refuses to share national vaccine stocks and interfere with patent exclusivity so other countries can make them too. In this way, the federal government is not urging the Food and Drug Administration to move quickly to test this new split-dose regimen, nor is it asking gay community organizations to participate in adaptively designed clinical trials that would help deploy the regimen more rapidly. Nor is it persuading drug and device manufacturers to develop cost-effective point-of-care tests that can further reduce time to diagnosis.

Epidemiologist Mary Bassett, director of the François-Xavier Bagnoud Center for Health and Human Rights at Harvard University and currently commissioner of health for the state of New York, who has declared a public health emergency outside the White House, is famous among health experts for declaring, that epidemics follow disruptions in society. That was true of Covid: the illness, disability and death it caused across the country hit hardest on people of color, people in poor neighborhoods, people without political access to speak up for themselves. The startling reality of the monkeypox epidemic is that it could dig those cracks even deeper, causing the greatest harm to those least able to bear it.

In the economic and political chaos caused by Covid, the inability to organize an effective response might have been inevitable. Encountering the same problems a second time shouldn’t be. “If there’s a crucial lesson here,” Frieden says, “it’s — as if we need another reminder — we’re really connected. A weak link is a threat anywhere.”

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