As scientific, policy and public debate around Covid-19 gradually shifts its focus to recovery and future pandemic preparedness, a seemingly new pandemic threat has emerged on the world stage. A meeting of the WHO R&D Roadmap was held on 2-3 June to discuss the latest global infectious disease outbreak of Monkeypox, with cases now detected across four WHO regions not endemic for the virus. The Social Science in Humanitarian Action Platform contributed to a social science roundtable in advance, hosted by the WHO social science technical working group.
Like all epidemics, Monkeypox is a social as well as a biomedical phenomenon. At the most immediate level, this is clear in the narratives already circulating about it in the media and amongst publics. Some portray it as another disease threat emerging ‘out of Africa’, rather like early narratives of Ebola – and the name, circumstantially given when the disease was identified amongst research station monkeys in the 1970s, does not help.
Narratives that simplify, stigmatise and blame
Other narratives link it to sexual transmission amongst gay men in European settings in ways that reinvoke the early days of HIV. Narratives labelling Monkeypox as the latest conspiracy to target unwanted people and groups, whether by politicians or witches, are emerging too in the infodemia surrounding the disease. Such narratives, and more, simplify, stigmatise and allocate blame and responsibility differently – and often in problematic and dangerous ways. Yet they are worth probing both as a social phenomenon in themselves, and because of the elements of truth they contain – around who gets sick and why, the structural conditions that shape outbreaks, and the power relations and politics that always surround epidemics.
It is clear that there are many unknowns related to this outbreak. On the surface of it, the two current scenarios for Monkeypox appear quite distinct: cases associated with ‘spillover’ of the virus to humans from contact with animal reservoirs in endemic settings in West and Central Africa; and cases in non-endemic settings, associated with seeming human-to-human spread within networks of men who have sex with men (MSM) and with no animal contact or travel history – initially in the UK and on the Continent.
Such strong distinctions between endemic and epidemic, and between African and European settings, fuel simplified and stigmatising narratives such as those above. However, the current multi-country outbreak of the less virulent West African version of the virus, which started with an uptick in Nigeria earlier this year, might actually be more complex than meets the eye. Interconnections between the two scenarios are emerging as the key area for further investigation.
Uncertainties in the ‘science’
The uncertainties in the ‘science’ are myriad. Does the shifting pattern of disease suggest the virus might be changing? Is this picture now suggesting sexual transmission in semen, or is the human spread still related primarily to close skin-to-skin contact, as has been documented in endemic settings? Has Monkeypox in fact been circulating undetected in non-endemic countries for some time? Is it definitely confined to MSM or more likely to be detected in that population? And crucially, what has been happening in the so-called endemic settings in recent years, where detection of the disease in Nigeria in 2017 (after an absence of decades) led on to an upsurge in cases? What is the balance between new zoonotic spillovers and human-human transmission? For the former, the main animal reservoirs are thought to be rodents, but what are the changing ecologies and everyday interactions between animals and humans in peri-domestic and livelihood contexts that enhance viral circulation and spillover, and account for an upsurge? For the latter, how and between whom is transmission occurring, through what social interactions shaped by gender, age, occupation, settlement patterns, ethnicity, sexuality? Intriguingly it appears that cases amongst MSM were also noted in Nigeria but the nature of the stigma, even criminalization, would make such instances less visible.
The picture is unclear, exacerbated by seeming neglect from the global scientific and policy community of the situation in endemic countries and inadequate resourcing for surveillance and detection. Many of the questions that need addressing are social and ecological as well as biomedical and epidemiological, and will require social and natural scientists from different disciplines to work together, whilst also integrating local people’s own knowledge and expertise. This kind of interdisciplinary, participatory ‘one health’ approach has received little genuine attention and resourcing, despite growing rhetoric in global science and policy. It is further possible that the deflection of resources and attention by the Covid-19 pandemic exacerbated challenges with surveillance, health seeking and diagnostic recognition in stretched health facilities across countries.
Why is this situation of concern to WHO? After all, no-one has died since the cases came to attention in May. Yet WHO is keen to act swiftly to contain this outbreak because of fears that the disease will become established in animal reservoirs in countries where this has not to date been the case, thus making spillover events and cases more common and widespread. The concern that Monkeypox could start to circulate between people and their pets and domestic co-habitants is real. Further, there have been deaths in African settings and immune-compromised people with untreated HIV seem particularly vulnerable, alongside pregnant women and small children. Spread to countries with stretched health systems that are not familiar with the disease and with large populations of HIV positive people could also be potentially serious.
Thus containment is very much on the agenda for response. Strategies that have come from long experience in HIV care are being harnessed in the co-production of health messaging along a harm reduction approach. This is currently the mainstay of public health strategies in the non-endemic settings. ‘Covid fatigue’ is a concern with regard to receptivity to public health directives, as is stigma. Activists warn against a ‘draconian’ and disproportionate public health response that might deter the sharing of contacts. Community-engaged, participatory and citizen science approaches, such as those of PrePster with MSM London, offer routes both to co-produce vital knowledge about the disease, and to co-generate sensitive responses that are effective and stigma-reducing.
Complexity of disease ecologies
The link between the current upsurge and waning smallpox vaccination – with younger people in both African and European settings now beyond the generation vaccinated as part of smallpox eradication efforts – points to the complexity of disease ecologies. It also points to one potential solution in vaccination, as the similarities between smallpox and Monkeypox suggest that smallpox vaccines could be effective against it. Here lies a catch, however, and one which is all too familiar from the Covid-19 experience: stocks of vaccines and drugs are limited at present. The Covid-19 experience also suggests that processes for equitable global distribution and transparent R&D decision-making around vaccines and treatments are in clear need of reform.
These political and power dynamics also underlie challenges for pandemic preparedness going forward. Several voices from endemic regions and beyond have been asking why this disease has only received urgent attention now that there are outbreaks in high-income contexts. A focus on vaccines and drugs alone will not be adequate for pandemic preparedness. Detecting and responding to future pandemics will require strengthening of systems for preparedness: for surveillance, for early detection, and for the provision of healthcare and social protection. And it will require future commitments to integrating social science, local and citizen knowledge into global science and policy, both to understand how, why and when pandemics start, and how to stop them.