Dr. Hans Kluge is the regional director of the World Health Organization/Europe. Dr. Anthony S. Fauci is the director of the National Institute of Allergy and Infectious Diseases.
Amid the ongoing global monkeypox outbreak, some worry it may be too late to effectively control — let alone eliminate — the disease from areas where it’s not endemic, given the nature and extent of the global spread.
However, likely due to a combination of reduction in risk behaviors and the availability of diagnostics, therapeutics, and vaccines, we’re currently observing numbers of new monkeypox cases plateauing, or gradually declining, in several countries in Europe, as well as certain areas in the United States. As a result, we are cautiously optimistic we can eventually end the public health emergency of monkeypox in Europe and the Americas, and end sustained human-to-human transmission.
Such cautious optimism shouldn’t weaken our resolve to implement a concerted effort to address this emerging public health challenge, however. And to this end, we can draw on lessons from the past, notably our experience addressing HIV/AIDS.
Dr. Fauci’s career in particular has been shaped by major contributions in combating the disease in the U.S., and Dr. Kluge’s global public health experience includes a strong focus on HIV/AIDS, as well as tuberculosis in eastern Africa, Myanmar and areas of the former Soviet Union. And throughout the years, HIV/AIDS has taught us to never underestimate the ultimate impact of a new infectious disease for which there are many unanswered questions.
We shouldn’t forget that in the early years of AIDS, before we had diagnostic tests for HIV, the only patients brought to the attention of the health care system were those with disease advanced enough to be clinically apparent. With the advent of diagnostic tests, it soon became clear that these patients represented the very “tip of the iceberg,” and that most people with HIV were asymptomatic and in the early stages of their disease.
With monkeypox, we fortunately already have sensitive and specific diagnostics that allow us to widely screen at-risk individuals — an important tool for preventing asymptomatic or pre-symptomatic spread of virus. But there is still much to learn.
In the first days of AIDS, both in the U.S. and Europe, we’d initially thought the disease was strictly limited to a certain demographic group, namely men who have sex with men (MSM). However, we soon learned that although they were the most affected group in Western countries during the pandemic’s early stages, anyone was at risk depending on their individual behavior and circumstances.
Similarly, monkeypox isn’t a “gay disease,” although the current outbreak outside of Africa has so far primarily affected MSM. However, as with HIV/AIDS, other demographic groups, such as heterosexuals and injection drug users, also may be at risk. And with monkeypox, sex workers, homeless people, anyone with multiple sexual partners and, in some rare circumstances, children — in whom the risk is low — are also potentially at risk.
One of the most unfortunate features of HIV/AIDS over four decades has been the stigma too often associated with it. Stigma is the enemy of effective public health efforts, and as we fight monkeypox, it is critical we avoid any stigmatization of at-risk populations.
Indeed, anecdotal evidence has already emerged in certain regions that discrimination against MSM is discouraging some from coming forward to get tested, vaccinated and treated, possibly leading to uninterrupted chains of transmission. Our interventions must be designed to recognize — and counter — stigma that might discourage those at risk from coming forward.
In addition, we must emphasize the critical importance of conducting randomized controlled trials to rapidly generate robust scientific evidence for implementing vaccines and therapeutics. It has already been demonstrated in the context of other outbreaks — such as the Ebola outbreak in West Africa in 2014 — that ethical and scientifically sound research can be conducted in the context of an ongoing infectious diseases outbreak. And we cannot allow the circumstances of an emerging outbreak to deter us from conducting rigorous studies, which will yield definitive answers to important public health questions on how to optimally manage it.
One of the successes in addressing HIV/AIDS in the U.S. and Europe was also our trust-building outreach to activists and community representatives, as well as their meaningful involvement in both our public health and research responses to the disease. This must be emulated with monkeypox.
Meaningful involvement means community engagement in all areas of the response, including review of epidemiological data and research, as well as planning, implementing, monitoring and evaluating our interventions. With the monkeypox outbreak, we have already seen positive results with behavioral modification due, at least in part, to public awareness campaigns. These efforts have featured accurate, timely messaging targeting MSM that has been adopted and disseminated by civil society organizations and organizers of mass events, such as Pride.
With HIV/AIDS, we initially were unaware of the etiologic agent, nor did we have reliable diagnostic tests or therapies or, even to this day, a vaccine — countermeasures that we already have with monkeypox. But once we had developed countermeasures, the challenge was their equitable global distribution and availability, particularly in low- and middle-income countries.
To this day, gaps persist in the distribution of anti-HIV drugs, leading to avoidable suffering and death. With monkeypox, let us ensure that countermeasures are accessible to all who need them, particularly the most vulnerable people with limited access to health care.
Countries in Africa where monkeypox has long been endemic cannot be an afterthought. Equity must mean global equity — stretching well beyond North America and Europe. And it is crucial to control and eliminate monkeypox in endemic as well as newly affected countries, while enhancing global access to diagnostics, therapeutics and vaccines.
WHO/Europe — which covers 53 countries across Europe and Central Asia — and the U.S. are working together closely to address the global monkeypox threat. Europe, where the initial cases emerged just a few months ago, was the region with the highest cumulative case load. But now, the U.S. has the largest number of cases. Our experiences in responding to HIV and other health crises in the past, including COVID-19, have been similar.
Thus, a strong transatlantic partnership in emergency preparedness and response — and public health more broadly — between the U.S. and WHO/Europe can serve us well in responding to this public health emergency, and in preparing for the next emerging infectious disease.
Let us galvanize our current efforts and work together across regions and countries to mobilize resources, and use an integrated approach to control and, eventually, eliminate monkeypox. As recent public health emergencies of international concern have reminded us yet again, a public health crisis anywhere can quickly become a public health crisis everywhere — and we must be prepared.