Stop Saying Monkeypox Is ‘Almost Over’
It’s down from its summer peak, but it’s creeping into new sexual networks — ones that will be harder to reach than leather bondage fetishists
The United States now has about 25 monkeypox cases per week, according to the C.D.C. — down from the early August peak of 450 a week.
Journalists are declaring the outbreak all but over. Success is being attributed to a combination of vaccine and “behavior change” (a euphemism for less sex with strangers).
Yes, the graphs do look good for the moment. But I think a victory dance is premature. The virus is crossing into new sexual networks — networks that are harder to reach with both sound medical advice and vaccine than gay white men are. It could easily plateau or even surge again. That’s happened before.
As H.I.V. did more than a decade ago, monkeypox is becoming a disease of black and Hispanic Americans. It is shifting from gay-friendly coastal states to gay-phobic Southern ones. It’s also beginning to infect women and children and adolescents — and not the ones who attend schools with LGBTQ pride clubs.
As you can see from the data above, taken from the C.D.C. technical report published on October 27, the first 1,000 or so cases — those up to early July — were mostly among whites. That’s when the media coverage of monkeypox was most intense.
Since then, white, black and Hispanic men have been infected at roughly the same rates, with the white share declining fastest. From the tone of recent coverage, I don’t think that’s general knowledge.
What does that mean on a per-capita basis? According to a report released last month by the Kaiser Family Foundation, black Americans now have five times the monkeypox case rate of whites. Hispanics have three times the rate and native Hawaiians four times.
Also, while the epidemic first hit New York, San Francisco, Los Angeles, Boston, Washington and Chicago (all media-heavy cities), it is now, according to C.D.C. case maps, spreading in Texas, Arizona, Florida, Georgia, North Carolina and the rest of the South and Southwest.
This could easily presage a major setback in the epidemic. When any disease becomes predominantly one of black Americans, Southern Americans, poor Americans, homeless Americans or otherwise marginalized Americans, the media mostly loses interest in it. Assertive demonstrations in medical venues that garner sympathetic headlines cease. Editors no longer personally know anyone suffering from it. They are no longer asked about it at dinner parties. They order up fewer stories.
Back in the 1980’s and 1990’s, at least three of my former New York Times colleagues died of AIDS. In those days, the paper covered H.I.V. far more intensely than it does now. In the 2000’s, when I covered it, I was occasionally asked questions like: “Is H.I.V. still a thing?” The answer is yes. Even though we are 40 years into the epidemic and 10 years since the approval of PrEP (a daily preventive pill, the closest thing we have to a vaccine), more than 30,000 Americans still get infected each year. Only about a quarter of them are white. Very few sip Sauvignon Blanc with media insiders.
As you can see on the graph above, taken from recent C.D.C. data on H.I.V. infections from 1981 to 2019, new infections among whites dropped below those among blacks as early as 1987 and below those among Hispanics in 2012. Amazing as PrEP is, it has just not protected minorities as it has whites (for entirely politico-cultural-media reasons, not genetic ones, of course.)
There’s a synergy to this. When the media stops writing about a disease, public health agencies shift it to the back burner. Politicians lose interest. Funding dries up. Vaccinations and the public service ads to promote them shrink. Result: infections spread. You get a slow, steady burn of new infections — among the very people who are more likely to die of them, those with untreated or under-treated H.I.V.
What prompts newspaper coverage? Personal contacts. The infamous Tuskegee syphilis study began in 1932. It was 40 years until an Associated Press reporter learned of it and spilled the beans, which killed it almost instantly. Had it been tried on Harvard students instead of Alabama sharecroppers, it would have been over in weeks. How many NYT editors are ex-sharecroppers versus how many are ex-Crimson editors?
On top of that racial shift, an even-more-worrying aspect has been added.
More children and teenagers are getting infected. It’s still a smallish number — the C.D.C. just released a report on 83 confirmed cases. That is less than one percent of all cases so far. But the details are disturbing.
Most of the children under 12 had trunk lesions and were infected by routine skin-to-skin household contact such as bathing or diapering. But of those aged 12 to 17, almost 90 percent were boys; about two-thirds appeared to have been infected through sex; many had anal or genital lesions and reported male-male sexual contact. About 10 percent were in enough pain to need hospitalization. Some of the girls had also been infected through sex. Of all the child and adolescent cases, 82 percent were black or Hispanic.
This shifts the debate onto touchier ground that will make it harder to fight the disease. Health officials are supposed to be objective scientists, but they are often squeamish. Last spring, when the epidemic erupted in Europe, some officials were clearly terrified of being accused of being homophobes or of not appearing “sex-positive.” Epidemiologists who told the truth about risk factors were forced out of their jobs. Top officials repeated platitudes like “anyone can get it” and avoided even mentioning the original super-spreader events — fetish festivals like Darklands and International Mr. Leather. The C.D.C. initially put out utterly ridiculous advice about avoiding rodents and bushmeat and wearing masks. (It later did do better, frankly discussing anal sex, fetish gear and sex toys.)
Now officials may shut up for fear of sounding racist — especially if they have to discuss sexual predation on boys and girls by older men.
Many journalists have the same woke qualms.
Awkward silences will endanger victims. From the epidemic’s earliest days, out-loud-and-proud white men have gotten most of the vaccines. Even today, as you can see from the technical report data below, although whites, blacks and Hispanics are getting infected at roughly the same rates, whites are still getting most of the first vaccine doses. (And they’re way ahead on second doses.) .
Black and Hispanic Americans need to fight for equal access and for accepting the vaccine. Some state health departments have made valiant efforts. In Georgia, for example, more than 4,000 doses were given out at Atlanta Black Pride events over Labor Day weekend; 48 percent of the recipients were black, eight percent were Hispanic.
Black and Hispanic men also need to advocate for “behavior change” by their peers.
Instead, something bad is happening. Monkeypox victims are clamming up. The next C.D.C. chart shows a worrying trend. It describes how people got infected. See the problem? The “missing sexual contact history” category just keeps getting bigger and bigger.
Some will say there are simple statistical explanations for this: it takes time to get sexual histories, maybe the epidemiologists who do the interviews aren’t doing as many now, etc. I doubt it can be waved off that easily. That’s a very sharp drop. In the epidemic’s early weeks, most infectees may not have known the name of the person/persons they had sex with (attendees at orgies rarely share business cards). But they did know whether it had been a man or a woman. Now most people infected just plain don’t want to talk about it, period.
That’s bad. Epidemics thrive in the shadows, especially STD epidemics. And this virus is on the move. In six months, it has jumped from Nigerian cities to European leather fests — which, with everyone dressed like Charlotte Rampling in “The Night Porter,” resemble Aryan skinhead raves — to the twinkly Comfort & Joy post-Burning-Man party to Atlanta Black Pride. That’s some serious network-switching. It’s also on its way to infecting 100,000 humans, which means it is probably finding mutations favoring greater transmissibility.
Gay and bi black and Hispanic American men, especially in conservative states, are caught in those dangerous shadows. They are less likely than whites to have health insurance, to have a personal doctor, to regularly get health information, to belong to a gay rights organization or otherwise to be within the orbits that white-dominated health agencies have historically felt comfortable working in. Some are more likely to have been in prison, where male-male sex is often involuntary and not talked about. If they are from conservative or religious families, they may have to lead double lives. Even mentioning wanting a monkeypox vaccine might be dicey. Many have little trust in the medical system: early in the Covid pandemic, when black men were asked why they wouldn’t vaccinate, they often answered with one word: “Tuskegee.”
We saw the stifling effects of stigma in the 2017 monkeypox outbreak in the Niger Delta region of Nigeria.
The world barely noticed that 38-case cluster (considered large at the time). But patients in it told researchers who interviewed them later that they hadn’t wanted to disclose having it. They feared their families would reject them. Many reported being treated badly by hospital staff. One committed suicide.
Stigma even helped prevent a medical professional from warning the world. According to an NPR article by the talented Michaeleen Doucleff, Dr. Dimie Ogoina, the Nigerian medical professor who investigated the outbreak, realized that it was spreading sexually and most likely through male-male sex. (Many of the patients were adult males with anal or genital lesions). But when he tried to reveal that at a major international medical conference, he said, he was told to keep quiet.
Just because a disease peaks and drops does not mean it cannot accelerate again. The next six months may be harder than the first six. For example, more women are also getting monkeypox. As of late October, the C.D.C. said, more than 600 women had symptoms or lab-confirmed cases; 19 of them were pregnant or breastfeeding.
There are big sexual networks in this country — like high school and college students — where sexually transmitted diseases like herpes and HPV and saliva-transmitted diseases like mononucleosis (the “kissing disease”) are common. It still remains to be seen to what extent monkeypox will stay mostly corralled among gay men. Don’t assume it’s H.I.V. Unlike that virus, it does seem to have demonstrated an ability to mutate in favor of greater transmissibility.
Since there is such an effective and safe vaccine, I think health authorities would be wise to broaden their target audiences for it, in a ring-fencing tactic. Anyone, male or female, who visits an STD clinic would be an obvious start. So would all prison inmates, parolees and their partners. So might military bases. College freshmen might eventually be another. There has been success on that front: meningitis B vaccine mandates for colleges helped suppress a bacteria spread by oral contact that was usually harmless but occasionally led to horrible outcomes like amputation or death.
And we absolutely must get millions of doses to Africa and fight the epidemic there. It’s a huge reservoir, there are at least two clades circulating. Virtually no one there is protected. I recently met a Ghanian lab scientist at a medical conference in Seattle who routinely worked with positive monkeypox samples but could not get immunized — either at home or in Seattle, because she wasn’t local.
The news at the conference was not good — one paper described changes in the variant circulating in remote regions of the Democratic Republic of Congo that has a high fatality rate. The researchers reported that its R or reproduction number — the number of people infected by each index case — had doubled between 2013 and 2017, going from 0.4 to 0.8. (That’s equivalent to saying that if ten people got the virus, they once spread it to only four people but now spread it to eight.). In itself, that’s not very threatening — an R below 1 means clusters die out instead of spreading (Measles, by contrast, has an R of 12 or more; smallpox was sometimes estimated at 5 to 7.) But it’s going in the wrong direction.
If the virus keeps circulating there, it will keep coming here. For American taxpayers, protecting Africa is just as much an act of self-preservation as it is of charity.
But in any case, we shouldn’t talk as if it’s almost over and we can stop worrying.