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Saturday, April 13, 2024

The Bittersweet Defeat of Mpox

For a few weeks this summer, the world worried that monkeypox might become the next global pandemic. At the peak in early August the US was recording 600 cases a day, and the health authorities’ fumbling response echoed the early days of Covid-19. Vaccines were slow to arrive and in short supply for most of the fall. Testing was bottlenecked. Antiviral drugs, though they existed, were almost unobtainable because they hadn’t been federally authorized for the disease. While most cases were among gay and bisexual men, there were fears that the rarely fatal but often extremely painful infection, which can can take weeks to subside, might spread to the broader population. 

Things today look very different, at least for now. By mid-December, mpox, as the World Health Organization has now renamed it, had appeared in 110 countries, but the spread had dramatically slowed. The US, which had recorded 29,740 cases as of December 21—more than a third of the global total—was registering barely a handful each day. 

While one reason is that access to vaccines and testing improved, and another is that mpox is inherently much harder to transmit than Covid, the biggest, most agree, is that the people most at risk took their protection into their own hands in those crucial early weeks when the authorities were flailing. “The success was the community mobilization,” says Joseph Osmundson, a queer activist, molecular microbiologist, and clinical assistant professor at New York University.

Osmundson helped broker what might be taken as a symbol of the response to mpox: a fleet of tall, white-painted vans with windows masked for privacy. Inside, each van was a mobile vaccine clinic, operated by the New York City health department. Between Labor Day and Thanksgiving, these vans parked late at night outside bars and clubs that cater to gay and bisexual men, including some that host sex parties. (Many of those parties also shut down voluntarily for a period.) The queer community told the city where people would be most at risk, and the venue owners agreed that protecting their patrons was worth the possible stigma of having the vans parked outside. The van vaccination program administered more than 3,000 doses.

The program showed a health department being smart about where to find people who needed help, but just as much, it represented a community that wasn’t willing to wait for the health bureaucracy to find them. From the beginning of the mpox epidemic, gay and bi men as well as others in the queer community had reached out, badgered, and agitated. Some who had caught the disease posted online videos or gave press interviews describing their symptoms in intimate detail, defying the risk of social shaming (“He caught monkeypox, guess what he’s been up to”) to warn others about the risks. People posted information to social media and WhatsApp groups about which clinics still had vaccine supplies or how to get diagnosed when most physicians had never seen a case of mpox before. Those lucky enough to get antiviral treatments before they were made generally available circulated advice for people to pass on to their doctors on navigating the mind-numbing bureaucracy for an individual authorization.

Pretty much everyone agrees that queer men, particularly those with a lot of sexual partners, get the credit for that ski-slope decline in cases. As research by the US Centers for Disease Control and Prevention demonstrated in the fall, men who felt at risk voluntarily abstained from sex, kept to one or a small number of partners, signed out of hook-up apps, or skipped the kind of parties where group sex happens.

Behavior change can be a long-term strategy, if you’ve got nothing else. The set of practices grouped under “safer sex” were the first-line defense against HIV infection for years before prophylactic drug regimens arrived. But HIV infection didn’t cease in those years, because behavior change is hard. Not everyone has the knowledge or experience to insist on safer sex with a partner. Negotiation is tiring. Willpower runs out. “Micro-local response by communities, and people helping each other, really work—but that’s not public health,” says Gregg Gonsalves, an assistant professor of epidemiology at the Yale School of Public Health and longtime HIV/AIDS activist.

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This is particularly important now that the epidemic seems to be in a post-crisis phase. “The epi curve is trending downward, but it seems to have reached a floor—and that floor is not zero,” says Andrew Noymer, an epidemiologist and demographer, and associate professor at the University of California, Irvine. “Maybe by March, we’ll have zero cases. Or maybe we’ll have this simmering, hyper-low endemicity that could rebound.”

Any rebound is likely to affect the most vulnerable. From early on in the outbreak it was clear that the people who got vaccines or treatment soonest were those who had the time and resources to wait in line for appointments, research clinics and treatment options, and deal with medical bureaucracy. Those people were more likely to be white and relatively better off. For many of those who now have immunity thanks to either vaccination or infection, the outbreak is already a fading memory.

Other groups remain at risk, federal data show. “What we are seeing is that most of the cases are occurring in Black and Latino men,” says Justin Smith, a Black gay man who is director of the Campaign to End AIDS at Positive Impact Health Centers, an HIV service organization in Atlanta. “We’re trying now to make sure we’re getting into that last mile of folks that may not want to raise their hand, or come into an event where they have to attest that they’re queer—trying to figure out how to move vaccines into places where people just happen to be.”

In the disaster-response world—and the demands of a novel disease outbreak make it a form of disaster—the last mile is the most difficult, because it demands the most attention and funds. In the case of mpox, the last mile cuts through rural areas and places with few queer-friendly health services, and activists are having to traverse it just as mpox funding cuts off nationwide. The Biden administration, which declared mpox a public health emergency in August, plans to withdraw that declaration at the end of January. Congress rejected additional funding for vaccines and testing in September, and the White House did not succeed in adding fresh funding to the massive 2023 appropriations bill that is scheduled for a vote Friday. New York City’s vaccine-van program halted in November after its funding ended.

The belief that mpox no longer deserves emergency status appears to be rooted in an assumption that testing, vaccination, and case tracking can now become a routine part of health care. The problem with that assumption is that mpox is considered a sexually transmitted infection (though whether it’s actually passed via sex versus general skin contact is still undetermined). That puts it under the purview of sexual health clinics, usually operated by state and local health departments. Those clinics were already stretched before mpox began; sexually transmitted infections in the US hit their highest level ever last spring. Yet a 2021 investigation by the National Academies of Sciences, Engineering, and Medicine found that federal clinic funding has dropped by 40 percent since 2003.

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“The larger healthcare system does not deal well with sexually transmitted infections; physicians are notoriously uncomfortable dealing with sexual health matters,” says David Harvey, executive director of the National Coalition of STD Directors. “We have worries about how an already overburdened STI sector is going to handle this newest sexually transmitted infection on an ongoing basis.”

The story of mpox stands in striking contrast to that of Covid, in which the government led and many people lagged behind—refusing to accept shots, stay home to quarantine, or wear masks. In their insistence on prevention and care, queer men modeled a different way to respond to an outbreak. Maybe that doesn’t seem surprising—after all, it was gay community activism that forced the US government to respond to HIV/AIDS in the 1980s, and voluntary action by groups of queer men that shut down the Provincetown outbreak of the Delta variant of Covid in 2021. Maybe it’s reasonable to assume that a group faced with a health threat that uniquely targets them will rise in their own defense.

But it’s not reasonable to assume that group—whoever they are, in whichever epidemic—should have to take on so much of the burden. A country has public health agencies, paid for by public money, because the health of a nation is the responsibility of its government as well as its people. As much as the mpox epidemic shows us how citizens should respond to disease threats, it also shows us the limits of that expectation. Mpox isn’t gone. Instead, it is finding its way through the holes in the safety net, to places where health care is less accessible and queer men are less empowered. That is not something that activism can fix, and it shouldn’t have to.

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