The Monkeypox Vaccine Rollout Is Unfair. But Not for the Reasons You Think

At 73, and with mobility issues, Jonathan Blake’s ideal Sunday doesn’t involve standing in line for three hours. 

But after seeing a post from a Facebook friend last week, Blake hurried to a walk-in vaccination clinic at Guy’s Hospital in central London, in the hopes of receiving a monkeypox vaccine – the same jab that protects against smallpox. The hospital is one of dozens around the country that has found itself dealing with another public health emergency in the form of the virus, which, though usually mild, causes fever and a painful rash.

On 23 July, in a World Health Organisation briefing declaring monkeypox a “public health emergency of international concern”, WHO director general Dr Tedros Adhanom Ghebreyesus said that efforts to contain the virus would initially focus on men who have sex with men (MSM). Monkeypox is spread via close contact and the 2022 Western outbreak has predominantly presented in this demographic; at the time of writing, 98% of known monkeypox infections were in gay or bisexual men and in 95% of cases, transmission was suspected to have occured via sexual activity.

“I’ve had a recent pox scare, I’m about to go on a huge trip,” Blake, a longtime HIV activist, told Novara Media. “I’m a man who has sex with men, so I thought I want to have as much cover as I can possibly get.” 

To combat spread, the UK Health Security Agency (UKHSA) is inviting the highest risk MSM – such as those with a recent history of multiple partners, participating in group sex or attending sex parties – to be vaccinated first. The UKHSA recently announced it’s acquired more than 100,000 monkeypox vaccine doses, in addition to existing stocks, and will deliver the first 20,000 by the “end of August”. 

But there are concerns that, since sexual health services are predominantly funded by local authorities, the response to the monkeypox outbreak could replicate existing inequalities in healthcare provision across England. 

The rollout is perpetuating inequality. 

London-based Blake is one of the luckier ones: “Relief,” he texted after receiving the vaccine. 

Unsurprisingly, as the most populous city in England, the capital counts the most cases of monkeypox – which means most doses of the vaccine are being distributed there, although access is far from guaranteed. As of 29 July, the UKHSA reported that out of 2436 “confirmed and highly probable cases” of monkeypox in England, London harboured 72% of them, followed by the broader south-east region with another 8%. 

The vaccine drive currently underway across England is being led by NHS sexual health services. On the face of it, this makes sense; these services are well placed to assess who is at high risk. But activists say it is resulting in problems that would be less likely to emerge if the effort was centralised, like the Covid-19 vaccination programme. Will Nutland, the co-founder of PrEPster, an organisation educating people about HIV and agitating for increased PrEP (the drug used to prevent the spread of the virus) access, says that although there are enough doses of the vaccine available, inequalities are being perpetuated by the logistics of the rollout. 

“We shouldn’t be surprised if in a year’s time we see the same health inequities that we see in access to HIV care and prevention,” Nutland predicts. “The gay and bi men diagnosed with HIV this year: [they’re] more likely to be a migrant, have lower eduational qualifications, not speak English as a first language, be less economically well off. 

“All these health inequities we see in other health conditions are mirrored in HIV, sexual health and – I’d be prepared to bet – will be mirrored in monkeypox.” 

General deterioration of service provision is also obstructing things, says Nutland. Sexual health services were once well integrated into the NHS, he explains, but now local authorities are responsible for commissioning services. Because councils have had their budgets slashed, it’s much harder for them to invest in sexual healthcare. 

Some drug and monitoring costs are still centrally funded and protected – such as PrEP funding, which is ring-fenced. However, with £700m stripped from public health funding between 2014 and 2020, other sexual health services have been severely eroded. According to the British Association for Sexual Health and HIV, expenditure was cut by almost £200m between 2014 and 2021, “with a disproportionate amount of the cuts falling on the most deprived areas of the country.”

Prior to the monkeypox outbreak, sexual health services across the country were struggling to provide enough appointments in the face of government funding cuts, with the Independent reporting in 2017 on those “fearing they have contracted an infection facing agonising waits for appointments and results.” This situation was only exacerbated by Covid-19, with the same paper reporting in 2020 that clinics were running a “skeleton service” since staff were deployed to other parts of hospitals to help with the pandemic. 

The spread of monkeypox, however, hasn’t resulted in any more money to clinics (nor sick pay to those who contract it, allowing them to self-isolate). “The latest challenge has come with no extra money, the government has assigned zero extra pounds to these services to deal with monkeypox,” says Danny Beales, head of policy and campaigns at the National Aids Trust.

The cost of fully vaccinating someone is roughly £62.63 per person. Experts estimate 125,000 people need to be vaccinated in order to prevent monkeypox becoming endemic in the UK, at a cost of £51m. Some clinics have shuttered up to 90% of their standard services in order to cater to vaccine demand, says Beales.

If you’re hoping to secure a vaccine, London is the place to be. But the current rollout – walk-in clinics and the odd pre-booked appointment for those at the top of the risk chart – could prove an access barrier, says Nutland. Members of the community who are not publicly ‘out’ may not be willing to stand in a visible queue that flags up sexual habits. Provision depends on how good local services are, a standard that wildly varies across the city. And if you’re not able-bodied enough to queue for hours, or lack the resources to get to London for the weekend, this process is also exclusionary.

Outside of the capital however – where cases are lower, but the risk is growing – progress is even slower. “It’s almost impossible to get a vaccine [beyond London],” says Nutland. However, he notes “there are some centres in Birmingham, Manchester and Brighton where there are more vaccines available than in other parts of the country.”

Regional rollouts.

Manchester, home to the largest LGBTQ+ community outside of London and 126 monkeypox cases, is struggling with crumbling health infrastructure. “Sexual health services in Manchester and PrEP services in Manchester have been dire for the last five years,” says Greg Owen, PrEP officer at sexual health charity, the Terence Higgins Trust. “People can’t even get access to a standard sexual health screening, people can’t get through on the phone, they can’t get PrEP refills.

“You can’t hope that an underfunded service will deliver a worldbeating approach to monkeypox.” 

High risk men in Manchester told Novara Media they were “surprised” not to have had any communication regarding monkeypox from their local sexual health services. 

“There’s not really been much communicated in how to go about it, anything I’ve heard has been word of mouth and information varies,” says JR Lappin, 30. Lappin is a sex worker – an occupation he’s disclosed to his local clinic  – is on PrEP and has sexual health screenings every three months. Yet, despite being part of the high risk group identified as first in line for a monkeypox vaccine, he hasn’t been contacted about securing one.

Jack Chadwick, 23, describes access to the vacacine in Manchester as “terrible”.  His attempt to contact individual clinics for information failed – all directed him to the same monkeypox vaccine hotline. After hours of being placed on hold on various phone lines, Chadwick got through to a “very talkative” staff member from the Hathersage sexual health centre who was manning the hotline. According to Chadwick, the staffer claimed that a lot of high-risk people who had been invited to vaccination appointments at the Manchester Royal Infirmary (MRI) “hadn’t turned up” and that there was no current mechanism in place to offer up their places to others instead at short notice. 

“They’re not doing a good job of making sure they’re at capacity,” Chadwick says. He plans to see if he can get an MRI walk-in spot. If this fails, he wants to head to London, but finds the disparity in access unfair: “London has fewer sex parties per capita than Manchester and very few dark rooms, whereas the [gay] village has loads,” he claims (which is unsubstantiated). 

Chadwick’s resentment of London speaks to a communication breakdown, says Will Nutland. “Things aren’t being explained to people [outside of London],” he says. “If the NHS told Manchester, ‘here’s why we’re focusing on London, wait three weeks and then we’ll send more vaccines to the north west’, it would be more palatable. 

“With a complete lack of knowledge, people assume the worst: ‘The lives of queer people in London matter more than mine. We’ve been forgotten again. We always get [a] poor deal’.”

Securing a vaccine in Greater Manchester seems to be down to the luck of the draw over anything else. Ben Eckersley, 31, describes getting a vaccine as “a complete fluke – being in the right place at the right time.” On showing up at the Choices Centre in Stockport on 20 July for a routine PrEP checkup, he was offered a vaccine based upon his recent medical history. “Because I’d been to Gran Canaria recently and had X number of partners in the last few weeks, [the nurse] said, ‘I’ll jab you now if that’s OK’,” Eckersley recounts. After Eckersley’s experience, his flatmate rang up to ask if he could get the vaccine, too, and was told to stop by the following week, “then he went in and there were none left.” 

While NHS England declined to confirm exact figures, the amount of vaccines in circulation in the north-west sounds notably limited. Chadwick was told by the staff member on the monkeypox hotline that the vaccination centre at the MRI, the only one in Manchester city centre, had access to just 300 vaccines for the entire week. Ant Hopkinson, CEO of Merseyside-based HIV charity Sahir House, told Novara Media that for the foreseeable future, the city of Liverpool has access to about 200 vaccine doses – in total. Hopkinson estimates the initial cohort of men who would need the vaccine in the city would number around 3,000.

“I would like to see a hell of a lot more vaccines up north,” he says, citing both Liverpool’s recent Pride celebrations and the forthcoming Manchester Pride (taking place from 26-29 August) as reasons for urgency. “Both Liverpool and Manchester are gateways to Europe, we’re international cities and that needs to be factored in.”

Also frustrating vaccination efforts are confused communications. In a Greater Manchester Combined Authority Meeting on 29 July, deputy mayor Paul Dennett observed an issue in the UK with take up as well as supply. This suggests, he argued, that relevant authorities need to “look at our communications and information, advice and guidance around how we’re encouraging people to participate in the monkeypox vaccine.”

Confusing communication.

Dennett has pinpointed an issue that comes up again and again in interviews: the system seems labyrinthine to navigate, with little clear information available. Rob*, 22, a gay man in Warrington, Cheshire speaks to Novara Media with obvious frustration about his inability to get clear answers. He knows he got the smallpox vaccine as a child – but would he need a booster shot now? He assumes so, but neither his doctor, nor the nurse practitioner he was directed on to, could give him a conclusive answer. 

Rob has also heard conflicting accounts as to whether the monkeypox vaccine will or will not be available at his local sexual health clinic and remains none the wiser. “People are going down to London to get the vaccine but I’m not travelling 178 miles one way to get the vaccine,” he says. He “skipped” Liverpool Pride to be on the safe side. 

At the moment, too much of the onus of the monkeypox vaccine rollout is being placed on the community, says Danny Beales. “There’s a huge reliance on the community, who are doing really good work – just look at social media,” he observes. But that isn’t an adequate public health response, he says. “Those for whom English isn’t a first language, [or are] not active online or don’t have devices to connect to the internet, often don’t get those messages effectively,” he says.

Greg Owen is also unimpressed with the inclusivity of the communication strategy. There are a “significant cohort” of MSM who don’t identify as gay or bisexual, who may be in heterosexual relationships and won’t go to sexual health clinics or be exposed to health messaging, he says. “Those people will fall through the cracks”. 

Ultimately, Owen wants more transparency: clear information available in terms of how many vaccines there are, where they are in terms of regions, cities and clinics. Owen understands why London is getting the lion’s share of vaccine deployment – “we get more bang for our buck” – but says lack of centralised information is causing unnecessary stress. 

“It’s caused huge confusion and a massive inequity for people who aren’t on Twitter and live anywhere beyond the M25,” he observes. “If you’re on Twitter and you’re lucky, you might see information about where someone got theirs locally. This shouldn’t be the communication strategy.”

*Names have been changed