dr Hans Kluge is Regional Director of the World Health Organization/Europe. dr Anthony S. Fauci is Director of the National Institute of Allergy and Infectious Diseases.
Amid the ongoing global outbreak of monkeypox, some worry that given the nature and scale of its global spread, it may be too late to effectively control — let alone eliminate — the disease in areas where it is not endemic.
However, likely due to a combination of reduced risk behavior and the availability of diagnostics, therapeutics, and vaccines, we are currently observing that the number of new monkeypox cases is flat or gradually declining in several countries in Europe, as well as in certain areas in the United States. As a result, we are cautiously optimistic that we can end the monkeypox public health emergency in Europe and America and the ongoing human-to-human transmission.
Such cautious optimism, however, should not weaken our resolve to make a concerted effort to address this emerging public health challenge. And to that end, we can draw on lessons from the past, particularly our experience of dealing with HIV/AIDS.
In particular, the career of Dr. Fauci was shaped by significant contributions to combating the disease in the United States, and Dr. Kluge’s global public health experience includes a strong focus on HIV/AIDS and tuberculosis in East Africa, Myanmar and areas of the former Soviet Union. And over the years, HIV/AIDS has taught us never to underestimate the ultimate impact of a new infectious disease, for which there are many unanswered questions.
We should not forget that in the early years of AIDS, before there were diagnostic tests for HIV, the only patients brought to the attention of the health care system were those whose disease had progressed enough to be clinically recognizable. With the advent of diagnostic testing, it quickly became clear that these patients represented only the “tip of the iceberg” and that most people living with HIV were asymptomatic and in the early stages of their disease.
Fortunately, in the case of monkeypox, we already have sensitive and specific diagnostic tools that allow us to comprehensively screen those at risk – an important tool to prevent asymptomatic or pre-symptomatic spread of the virus. But there is still a lot to learn.
In the early days of AIDS, both in the US and Europe, we initially thought the disease was strictly confined to a specific demographic group, namely men who have sex with men (MSM). However, we soon learned that although they were the hardest-hit group in Western countries in the early stages of the pandemic, they were at risk for everyone, depending on individual behavior and circumstances.
Monkeypox is not a “gay disease” either, although the current outbreak outside of Africa has so far mostly affected MSM. However, as with HIV/AIDS, other demographic groups such as heterosexuals and those who inject drugs may also be at risk. And with monkeypox, sex workers, the homeless, those with multiple sex partners, and in some rare cases, children — who are at low risk — are also potentially at risk.
One of the most unfortunate features of HIV/AIDS over four decades has been the stigma all too often associated with it. Stigma is the enemy of effective public health efforts, and in the fight against monkeypox it is vital that we avoid any stigmatization of vulnerable populations.
In fact, in certain regions there is already anecdotal evidence that discrimination against MSM discourages some from seeking testing, vaccination and treatment, potentially leading to unbroken chains of transmission. Our interventions must be designed to identify – and counteract – stigma that could discourage vulnerable people from speaking up.
Furthermore, we must emphasize the critical importance of conducting randomized controlled trials to quickly generate robust scientific evidence for the implementation of vaccines and therapeutics. In the context of other outbreaks – such as the Ebola outbreak in West Africa in 2014 – it has already been shown that ethically and scientifically sound research can be carried out in the context of an ongoing infectious disease outbreak. And we cannot allow the circumstances of a looming outbreak to prevent us from conducting rigorous studies that will provide definitive answers to important public health questions about how best to manage it.
Also, one of the successes in fighting HIV/AIDS in the US and Europe has been our confidence-building outreach to activists and community leaders, and their significant involvement in both our public health and research response to the disease. This must be imitated with monkey pox.
Meaningful commitment means social commitment Everyone Areas of response, including reviewing epidemiological data and research, and planning, implementing, monitoring and evaluating our interventions. With the monkeypox outbreak, we have already seen positive results with behavior changes that are at least partly due to public awareness campaigns. These efforts have produced accurate, timely messages for MSM that have been adopted and shared by civil society organizations and organizers of mass events like Pride.
With HIV/AIDS we didn’t initially know what caused the virus, nor did we have reliable diagnostic tests or therapies, or to date a vaccine – countermeasures that we already have with monkeypox. But once we developed countermeasures, the challenge was their equitable global distribution and availability, particularly in low- and middle-income countries.
To date, gaps in the distribution of anti-HIV drugs result in preventable suffering and death. On monkeypox, let’s ensure countermeasures are accessible to all who need them, especially those most at risk with limited access to health care.
Countries in Africa where monkeypox has long been endemic must not be an afterthought. Equity must mean global Justice – far beyond North America and Europe. And it is critical to control and eliminate monkeypox in endemic and newly affected countries, while improving global access to diagnostics, therapeutics and vaccines.
The WHO Regional Office for Europe – covering 53 countries across Europe and Central Asia – and the US are working closely together to combat the global threat of monkeypox. Europe, where the first cases only appeared a few months ago, was the region with the highest cumulative caseload. But now the US has the most cases. Our experiences in responding to HIV and other past health crises, including COVID-19, have been similar.
Therefore, a strong transatlantic partnership between the US and the WHO Regional Office for Europe in emergency preparedness and response – and in public health more broadly – can help us respond to this public health emergency and prepare for the next emerging infectious disease serve well.
Let’s amplify our current efforts and work together across regions and countries to mobilize resources and use an integrated approach to control and ultimately eliminate monkeypox. As recent public health emergencies of international concern have reminded us once again, a public health crisis can quickly become a public health crisis anywhere – and we must be prepared for it.