When the monkeypox outbreak was first detected in the United States, it seemed, as far as infectious-disease epidemics go, like one this country should be able to handle. Tests and antivirals for the virus already existed; the government had stockpiled vaccines. Unlike SARS-CoV-2, monkeypox was a known entity, a relative softball on the pathogenic field. It wasn’t hypertransmissible, moving mainly through intimate contact during the disease’s symptomatic phase; previous epidemics had, with few interventions, rather quickly burned themselves out. The playbook was clear: Marshal U.S. resources and ensure they go to those most at risk, send aid abroad, and knock it out of the park. “If there was one virus that would lend itself to containment,” says Boghuma Kabisen Titanji, a virologist and infectious-disease physician at Emory University, this should have been it.
Two months later, global counts have crested above 21,000 confirmed cases, nearly a fourth of which are in the United States, which now ranks first among countries keeping track. Infections, most among men who have sex with men, have been documented in 46 states, D.C., and Puerto Rico; New York State and San Francisco have declared the outbreak a health emergency, as has the World Health Organization, on a global scale. Controlling the virus isn’t yet out of reach, says Jay Varma, the director of the Cornell Center for Pandemic Prevention and Response. But as the outbreak grows, so, too, does the challenge of combatting it. “It didn’t have to be this hard,” Varma told me.
Years of similar snafus surrounding SARS-CoV-2—a far, far more difficult virus to fight—should have taught the U.S. something about its own weak points. Instead, the lackluster response to monkeypox is making clear that the country’s capacity to deal with infectious disease may be even worse than it was at the start of 2020. Monkeypox, the country’s second infectious crisis in three years, isn’t just an unfortunate fumble. It’s confirmation that, although the U.S. might have once seemed like one of the nations best equipped to stop and prevent outbreaks, it is, in actuality, one of the best at squandering its potential instead.
For years, the warning signs about monkeypox have been there. Decades of sporadic outbreaks in Central and West Africa had made the virus’s toll clear: It can cause a painful, debilitating sickness, with bouts of fevers and rashes, and in numerous cases leaves permanent scars behind; on occasion, certain strains of the pathogen can even kill. And though in many places the virus has infected indiscriminately, striking communities in close physical proximity to wildlife, a 2017 outbreak among young men in Nigeria hinted that sex could pose a particular risk.
So when case numbers began to erupt in several parts of Europe in May, indicating that the epidemic was already widespread, “it should have been obvious” that the epidemic had massive potential to expand, Varma told me. Multiple nations were already involved; the upcoming summer travel season posed a high risk. Infections were also concentrating in communities of men who have sex with men—networks that sexual-health experts know to be “dense, and where infectious diseases propagate very fast,” he said. And still, amid ringing alarm bells, the United States “underreacted,” Varma said, again and again.
Through much of May and June, monkeypox tests remained siloed within the CDC and its network of public-health labs, already stretched by the pandemic response. Health-care providers had to shuttle specimens to these centers for diagnosis, leaving patients on tenterhooks for days, even weeks, and delaying treatment, vaccination, and contact tracing. Even now, after testing capacity has climbed with the help of commercial labs, typical result turnaround times are stretching long. In Missouri, for instance, “they’re still telling us three to four days” at best, Hilary Reno, the medical director of the St. Louis County Sexual Health Clinic, told me.
Shots, too, have been troublingly scarce. America’s strategic national stockpile has millions of doses of smallpox vaccine (which also works against monkeypox), but most are ACAM2000, an inoculation that’s been linked to rare but serious side effects and shouldn’t be taken by certain vulnerable groups, including people living with HIV. Another shot, branded as Jynneos in the U.S., is safer, though, as a two-doser, may be trickier to administer post-exposure. Since spring, manufacturers of this shot have been turning the crank on assembly lines to bolster supply. But American officials hemmed and hawed for weeks before flying in much-needed doses from abroad, and then only in spurts.
The issue at hand certainly isn’t about vaccine demand. “Evey gay man I know is very ready for this vaccine and is willing to stand in line to get it,” says Steven Thrasher, a journalist and the author of The Viral Underclass, which examines the intersection of infectious disease and social inequality. Even though more vaccine doses are headed out, however, as cases balloon, the country still might not have enough. And with testing still strained, it won’t necessarily send doses to the right places. In Missouri, for instance, only a handful of cases has been reported so far, Reno told me. But with plenty of transmission likely going undetected, the state’s original order of shots might not cover its true needs. The country dawdled so long at the start line that even the relatively slow-moving monkeypox took its chance to race ahead—leaving the gap more and more difficult to close.
Early shortages in testing and care have also made the scope of the American outbreak difficult to estimate, or communicate—another parallel to the botched COVID response. A lack of tests means a lack of accurate numbers, which can make a devastating epidemic look deceptively contained. “That amplifies the cycle of neglect,” Varma told me, a pattern to which the U.S. has been particularly prone. Piling on to the problem is the ongoing dearth of funds for America’s sexual-health services, coincident with a recent rise in STIs. People with genital symptoms have struggled to reach providers, opening up even more cryptic channels for the virus to spread through.
Monkeypox is also a particularly challenging outbreak to be grappling with in the U.S., where sex is still a polarizing taboo, and men who have sex with men remain a marginalized community. And this is an especially charged time to be discussing the LGBTQ community in America, as the recent rolling back of abortion protections has stoked anxiety that other federal civil liberties may soon be on the chopping block. “We’re at this profoundly anti-gay, anti-trans moment,” Thrasher told me, at a time when those communities need more protection, not less.
Experts have praised some of the CDC’s efforts to avoid stigmatizing at-risk groups, which, at this juncture, remains essential. Monkeypox certainly doesn’t need sex to spread, Ina Park, a sexual-health expert at UC San Francisco, told me. Kissing, cuddling, and other situations that put bodies in close proximity for prolonged periods can also transmit the virus. So can contact with clothing or bed linens, because monkeypox can persist on unsanitized surfaces for days. Which does mean that men who have sex with men are definitely not the only ones in danger. At the same time, some people have been so fearful of casting monkeypox as an exclusively “gay disease” that sex has almost been censored from discussions, “giving people a misperception of the different risks that populations are facing right now,” Thrasher said. Especially while supplies remain so limited, we need to be “vaccinating people where the virus is moving.” Which means “we need to give both messages simultaneously,” Park said, “that this is not something that only affects gay men” while nodding to the fact that monkeypox is still “primarily affecting certain communities,” a trend that should influence the distribution of shots. Calls for the mass vaccination of “children or cis-het suburban moms,” Titanji told me, are “not where you’re going to get the most impact.”
To communities of men who have sex with men, how the Biden administration acts in this moment is revealing unspoken priorities and values. “In June, when it’s time to put rainbow flags up, they do,” says Keletso Makofane, an epidemiologist at Harvard’s School of Public Health, who’s been tracking the outbreak’s progression via an LGBTQ-community-led survey. “But when it’s time to give us resources? To prevent what some people describe as the worst pain they’ve ever felt in their lives? They choose not to.” Now, some experts are even bogged down in debates over whether monkeypox should be described as a sexually transmitted infection. But underlying the squabble is the far more important question of resource allocation, Makofane told me. This is “really a conversation about, Do these people deserve compassion and care?” Continuing to draw vital tools and resources away from at-risk populations, he said, would suggest the nation believes that the answer is no.
As long as the virus continues to move predominantly through networks of men who have sex with men, the U.S. still has the opportunity to swiftly intervene, track transmission, and dole out resources in a targeted way, Varma told me. But monkeypox’s current pattern may not hold. Already, the virus has begun to hop across genders and age groups, leveraging other, nonsexual forms of close contact. Infections in young children, who likely contracted the infection in their households, and among people incarcerated in prisons, where contagion is particularly difficult to quash, are starting to appear. And across geographies, familiar inequities in access to tests, vaccines, and treatments have begun to appear.
Monkeypox’s overlapping tenure with SARS-CoV-2 has aggravated matters as well. “This virus could not have picked a worse time to make its grand entrance to the global scene,” Titanji said. Still reeling from one outbreak, people are weary, and have “very little appetite for taking on another,” Thrasher told me. Numbed by COVID’s persistent toll, the public has also latched onto comforting comparisons that, although based in kernels of truth, have been warped into misleading extremes: Monkeypox might be less transmissible and less deadly than the coronavirus, but it is not an ignorable nuisance that’s guaranteed to dissipate. The larger the swath of society that’s affected, Titanji told me, the unwieldier the outbreak gets.
The top priority now, experts told me, should be funneling funds toward distributing vaccines and scaling up testing. Health workers and patients need continued guidance on the disease’s often-subtle symptoms and the possibility of silent transmission, as well as the resources to administer speedy care. Paid sick leave and housing support would also help ease the burden of monkeypox isolation, which, given the lengthy course of symptoms, can last for weeks. Should such efforts fall short, as they clearly have with SARS-CoV-2, monkeypox could become the second virus to set up permanent residence in the U.S. in the span of three years—giving it all the more opportunity to find new ways to spread, shape-shift, and propagate disease. Preventing that means acting decisively now, to make up for the time we’ve already lost.