Monkeypox is Giving Us Another Lesson in Medical Stigma

Looks like we've learned nothing from recent history.

by Dr Rita Issa & Dr Melissa Chowdhury

3 June 2022

The disease is spreading across the UK, EU and US. Dado Ruvic/Reuters

You’d be forgiven for only having heard about monkeypox in the past couple of weeks, but the virus spreading across the UK, EU and US isn’t new. The first human cases of monkeypox were detected in the 1970s, and the viral disease has been endemic since, with outbreaks in West and Central Africa. 

But until now, monkeypox has been largely ignored by western governments. This oversight – a myopic and selective approach to global health and disease – is so consistent that it has a name: neglected tropical diseases (NTDs). While monkeypox isn’t officially listed as an NTD, it shares its key characteristic: it’s an infectious disease that, due to its geography and the populations it impacts, is of disinterest to western governments and the pharmaceutical industry who could, with relative ease, support developing a cure.

Monkeypox is caused by the monkeypox virus, closely related to the virus that causes smallpox. Smallpox is the only human disease we’ve successfully eradicated through vaccination, with the last naturally occurring case diagnosed in 1977. For most, monkeypox is a mild illness that gets better on its own. However, for those with weakened immune systems, pregnant or the very young, it can be more serious. Regardless, the risk of dying from monkeypox – compared to smallpox – is very low. 

Monkeypox is usually transmitted by rodents, and unlike Covid-19, person-to-person spread is relatively limited. Transmission between humans requires close contact which includes ​​touching skin, coughing and sneezing, touching infected bedding, or sharing utensils. This includes the skin-to-skin contact that occurs during sexual contact.

Most of the cases so far in this outbreak have been among men who have sex with men, likely accelerated by a number of ‘super-spreader’ events, including a fetish festival in Belgium and an adult sauna event in Spain. This has understandably caused concern within the LGBTQ+ community, both in terms of the risk of contracting the virus, and of social stigma – the shadow of the moral panic surrounding Aids looms large. Already some socially conservative organisations are pointing the finger – without warrant – at certain sexual behaviours associated with queer communities. This week the LGB Alliance, a trans-exclusionary organisation, uploaded a demand for “all commercial sex venues, such as saunas, leather/fetish bars and clubs with dark rooms to be closed for a month” to social media, a call that was quickly denounced as advancing a “rightwing morality agenda”. 

Black Africans have also experienced stigma around the western monkeypox outbreak, precipitated by the media, where images of the rash have been almost exclusively pictured on black skin. It’s important here not to conflate epidemiology – the study of the distribution and determinants of disease – with stigma. The former allows us to consider patterns in exposure and risk; it can be a useful tool for us as individuals to consider the measures we take to protect ourselves and our communities. The latter is a method of discrimination that excludes, others and stereotypes. Stigma causes more overall harm to both the communities targeted and those who aren’t. It’s worth reiterating that anybody who comes into contact with an infected animal or person is at risk of infection, and that early disease clusters in an outbreak may not remain as such. 

We know far more about monkeypox than we did about Covid-19 at the outset of the pandemic. The proximity of monkeypox to smallpox means that although there isn’t a specific vaccine for monkeypox, the smallpox vaccine offers about 85% protection against contracting it. It’s been proposed that this outbreak is due to waning levels of immunity to smallpox in the population, as the vaccine hasn’t been offered since its eradication. 

While a smallpox vaccine exists, it is distributed unequally, and is stockpiled by rich nations. The US spent over $1bn (£793m) on smallpox vaccine development after fears in the early 2000s that smallpox could be used as a biological weapon, and currently stores over 100 million doses as part of its ‘strategic national stockpile’. Such an approach exemplifies our collective failure to truly address epidemic preparedness in the context of an interconnected world. Meanwhile, the vaccine apartheid that played out with Covid-19 has long been in place where diseases like monkeypox are concerned – an illustration of how the health of someone in a country like the UK or US is valued very differently to someone in the Congo. 

This inequity and injustice doesn’t stop with vaccines and treatment. Neocolonialism plays out in healthcare and the medical industry through research, education, the health workforce, and who is given a voice. Much of the research and policy response to the monkeypox outbreak will be led by researchers and medics in places like Europe, when those with experience of treating this virus in West and Central Africa will be largely ignored. Instead, places like the UK will continue to poach trained healthcare workers, contributing to an ongoing brain drain leaving these regions inadequately underserved by necessary medical care. What’s more, like with Covid-19, monkeypox conspiracy theories have rapidly gained traction, with themes around Bill Gates and vaccines resurfacing. 

When it comes to monkeypox, it seems our collective memory is very short indeed. Ongoing reflection on recent lessons when it comes to stigma and exclusion, fair access to medicines, information-sharing, agency and collective care, learnt from previous global health challenges such as the HIV/Aids epidemic and Covid-19, must be carried through to this outbreak. Otherwise with each new virus will come the same old forms of discrimination. 

  • This article was amended on 8 June 2022 to clarify that smallpox is the only human disease to have been eradicated through vaccination (there are animal diseases that have also been eradicated).

If you are concerned you have symptoms of monkeypox, call 111 or your local sexual health clinic.

Rita Issa is a GP and global public health academic.

Melissa Chowdhury is a hospital doctor specialising in infectious diseases.

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