Assessing the Response to Monkeypox

As the monkeypox pandemic wanes, lessons emerge.

Stateside, the monkeypox pandemic is under control. That it only took a few months to reach this happy state means we can breathe a collective sigh of relief, especially compared to the pandemic immediately preceding it. But the SARS-CoV-2 virus was a different beast. Monkeypox doesn’t spread as easily and is rarely lethal. It is also a known virus, such that protection and mitigation techniques could be grabbed right off the shelf. In spite of that, the public health response left much to be desired.

Addressing the Gorilla in the Room

Early in the monkeypox pandemic, public health leaders were called out for their reluctance to provide specific and targeted advice to the public about what causes the virus to spread. If the government chooses to declare a public health emergency, it should provide clear guidance to those most at risk of catching the illness, namely men having sex with other men. “We know that this virus impacts everyone equally,” said San Francisco Mayor London Breed in July when issuing a declaration of local public health emergency, “but we also know that those in our LGBTQ community are at greater risk right now.” Declaring a public health emergency while telling people the virus “impacts everyone equally” undoubtedly stoked fears in the population. Then, Dr. Fauci, the federal government's top contagious disease specialist and the don of America's public health community, stated that monkeypox posed “a profound risk” to pregnant women and children, contradicting the facts on the ground.

Pressure mounted on public health officials to speak clearly, both from conservatives and from the progressive milieus that were most affected by the virus. Now, progressive cities are doing victory laps after successfully targeting messaging, vaccines and treatments at LGBT-identifying people in their jurisdictions. That’s because focusing on those at risk was the right idea all along.

Lesson: Targeting messaging to specific groups because they are at higher risk of exposure is just common sense. Tiptoeing around hard problems out of fear of offending social sensitivities, which could be political among some groups or religious among others, hurts more than it helps.

Deploying Resources on the Ground

In 2020, the federal government ordered over 1 million doses of Jynneos, a smallpox vaccine that is effective against monkeypox, to be equipped in the face of an accidental or intentional reintroduction of smallpox. Stockpiling was unquestionably a good idea. However, at the onset of the monkeypox epidemic, it quickly became clear that there wasn’t going to be enough vaccines to go around, in part because the majority of the doses ordered by the federal government were stuck in Denmark waiting for approval from the U.S. Food and Drug Administration (FDA). They were finally approved in late July, but the allocation and distribution of the doses was a slow-moving process. The reaction to that shortage receives a mixed assessment in my books.

The Good

In August, the government went the creative route with a decision to split monkeypox vaccine doses into five and administer them intradermally, that is, into the top layer of the skin. That would allow the then-441,000 available vaccine doses to be given to all 1.7 million patients estimated to be at elevated risk of infection. As we will discuss later, it was easier said than done. Time will tell if this modified dosage provided sufficient protection – the data aren’t in yet – but the idea was eminently pragmatic and innovative. The federal government looked at reality in the eyes and crafted a realistic plan of action, and for this, it should be commended.

Lesson: Make do with what you have. The ideal scenario rarely pans out in a crisis, so the key is to determine what the second-best option is based on the tradeoffs.

The Bad

The announcement of the vaccine-splitting strategy took the medical community, local public health leaders, and even the vaccine’s own manufacturer by surprise. Medical staff don’t routinely administer intradermal shots and needed extra training, and the technique requires medical equipment that wasn’t readily available. It also quickly turned out that vaccinating five people with a single vial was too ambitious – three or four seemed more likely. Then, obtaining Tpoxx, a drug to treat smallpox cases, for use beyond smallpox turned out to be astoundingly onerous for doctors, requiring over 100 pages of paperwork. Requesting tests was difficult, too.

Lesson: If the solution depends on the cooperation of third parties, those entities should be involved throughout preparation and rollout. The authorities in charge of implementing the pandemic response strategy should proactively lower barriers standing in the way of a successful rollout and establish feedback channels so they can hear about and remove unexpected roadblocks.

The Ugly

At the beginning of the outbreak, people with monkeypox had the burdensome and downright humiliating task of making the case for why they needed Tpoxx. They were also made to keep photographic records of their symptoms. If the original hesitancy to target messaging and cures to at-risk groups was rooted in a fear of stigmatizing people, then these measures seem at odds with that logic.

Lesson: Innocuous-looking regulations have real-world implications for people subjected to them. Any intrusive measures included in an epidemic response strategy should be justified only when grounded in evidence of an outsized benefit.

Delineating Clear Responsibilities

During the COVID-19 pandemic, critics were quick to blame the spread on state governments with laxer COVID policy responses. In a national emergency, federalism doesn’t work, people said. But the more monkeypox spread, the more comfortable federal health authorities seemed to feel blaming the botched epidemic response on the states. HHS Secretary Xavier Becerra told executive branch officials in August that all they could do was provide tools and guidance to slow the spread – a 180-degree turn from the principles underlying the government’s response to COVID, when federal authorities had no problem, for example, issuing a nationwide eviction ban on public health grounds. Blame games based on political concerns and success levels further weaken public health authorities’ credibility in the eyes of skeptics. Significant responsibility rests on the federal government when the country is faced with public health threats involving communicable diseases, yet it took almost two months for the White House to appoint a national monkeypox response coordinator. It is incumbent upon the White House and the CDC to assign clear roles to themselves and entities at all levels of governments so that each one can focus on their own tasks and be held accountable adequately in case of failure.

Lesson: Clearly delineating specific expectations from the federal, state, and local governments involved in epidemic response establishes accountability and a more efficient rollout of protective measures.

Conclusion: Lesson in Pandemic Lessons

Many people have derived lessons from the COVID pandemic, as have my colleagues and I. And here we are, deriving more lessons from monkeypox. Current public health leaders will learn from the latest pandemics, hopefully, but a future pandemic will arise when all the lessons of COVID and monkeypox will have been forgotten. This is why two things matter a great deal in the thick of a public health emergency: Experts and critics should be given the space and voice to advise decision makers in real time, and deference should be given to people closest to the issue so that they can react to pressing problems without waiting for permission from the top. These, if any, are the lessons to promote as we emerge from the second pandemic of the decade.