Commentary: Monkeypox became an emergency because we neglected the health of the LGBTQ community | Nation
As gay men working in medicine, seeing the monkeypox virus spread through our community has been devastating.
On July 23, the World Health Organization declared monkeypox a global health emergency. But in New York, we’ve been seeing the effects of the outbreak for weeks.
Monkeypox is not a new virus. The infection, which can cause fever, headache, body aches, fatigue and a painful rash all over the body, already has a government-approved vaccine and treatment as well as a lab test established. The nation’s scientific community could not have been more prepared for an outbreak of monkeypox. The United States contained an outbreak in 2003 and experts have been warning of a potential outbreak for more than a decade.
Yet despite our resources and medical knowledge, the number of cases in the United States is growing rapidly – from one reported case in May to more than 2,000 in two months and now approaching 4,000 known cases. Data released this week shows the United States leads the world in reported cases. (The current strain has caused no known deaths in the United States, and its mortality rate has been estimated at 1% or less.)
So how did we get here? The answer is simple: Viruses spread fastest among the most marginalized, underserved and resource-poor individuals. Our public health interventions often fail to reach these people, further exacerbating health care disparities and stigma and enabling larger outbreaks.
It is no coincidence that this virus which is receiving a weak public health response is one that primarily affects men who have sex with men, many of whom identify as gay, bisexual and transgender. In fact, WHO advisers declined to declare a monkeypox emergency in June, in part because the disease has not left this primary risk group. With cases rising, WHO Director-General Tedros Adhanom Ghebreyesus overruled advisers to make the statement.
To be clear, nothing about LGBTQ people makes them biologically more susceptible to monkeypox. The current outbreak is transmitted primarily through close physical and sexual contact, although it can also be spread through respiratory secretions and contact with infected materials (such as clothing and linens). The reason this virus persists in men who have sex with men is that public health authorities have been slow to treat the risk to these people as an emergency.
To end monkeypox, we must confront the discrimination in the medical and public health systems that has enabled this preventable crisis. Clearly, having a monkeypox vaccine is not enough in the face of homophobia that is hampering the public health response. And the steps he will take to end monkeypox will also improve access to comprehensive, patient-centered primary care that largely fails to reach LGBTQ people.
The first step is to improve public health messages. Officials have been reluctant to focus a range of prevention efforts among gay and queer men because they fear any discussion of gay sex will be viewed as homophobic and counterproductive. Messaging should adopt harm reduction approaches and communicate ways individuals can avoid infection in the event of a vaccine shortage, such as taking steps for safer sexual activity.
The other key step is not to repeat the early response failures exemplified by New York City’s initial monkeypox vaccination campaign. Without notice, the city initially rolled out vaccines by advertising on the public health department’s social media accounts, reaching a limited English-only crowd. The vaccines were offered on a first-come, first-served basis at a single clinic in Chelsea, an affluent, predominantly white neighborhood of Manhattan. Yet the data shows that a disproportionately high number of monkeypox cases are in non-white people, with two of the five cases occurring outside of Manhattan.
The New York Department of Public Health has since improved access to vaccines for those at risk, including opening mass vaccination sites in other boroughs and expanding appointment times beyond the standard working day. But New Yorkers who didn’t get the vaccine in time and contracted monkeypox described encountering an expensive maze of getting care, pointing to lingering barriers in health systems.
These issues could have – and could still be – minimized by investing resources in community health centers, including LGBTQ-focused ones and safety net clinics to lead the response. With decades of experience serving vulnerable communities and protecting their privacy, these centers are most likely to reach those at risk of monkeypox. By prioritizing these organizations for vaccine supply and treatment funding, we can strengthen primary care facilities rather than creating pop-up clinics that only deal with the vaccination side of this crisis.
Indeed, these more robust community health centers can also address documented health care disparities that harm LGTBQ communities beyond monkeypox. While patients wait for monkeypox vaccines, they should be offered free HIV and STI testing and treatment, referrals to primary care providers who can prescribe PrEP antiviral drugs to prevent infection by HIV, and contact information for affordable and available mental health providers who specialize in LGBTQ issues.
Vaccination sites can distribute other public health tools such as condoms, lubricant, hand sanitizer, masks, fentanyl test strips and Narcan kits to reverse opioid overdoses. At the same time, other vaccines particularly recommended for men who have sex with men – meningitis, hepatitis B and HPV – should be made available.
Focusing solely on preventing monkeypox through mass vaccination misses a greater opportunity to confront the health care disparities and systemic biases that make this disease a global emergency.