We are still trying to recover from collective fatigue and exhaustion as a result of an ongoing Covid-19 pandemic and, recently, a new disease made headlines across the globe. Monkeypox, a disease caused by a virus closely related to smallpox and which results in a milder smallpox-like disease, was diagnosed in a patient in the United Kingdom who had recently travelled to Nigeria, where the disease is endemic. Soon, an outbreak would be confirmed when clusters of cases were diagnosed in the UK, as well as Portugal and Spain. As of June 12, the disease has been confirmed in 34 countries and territories and is suspected in an additional 8 across Europe, the Americas, North Africa, Asia and Australia. The virus was first discovered in monkeys in 1958, the first case in humans was diagnosed in 1970 in Democratic Republic of Congo.
Clearly, this isn’t a new disease like Covid-19 was. So it is natural to wonder: what is monkeypox? What is different about this new outbreak? How does it relate to stigma in global health? What can we do? And, finally, what have we learned from previous pandemics and epidemics, especially about social reactions to new diseases?
What do we know about monkeypox?
While monkeypox is closely related to smallpox, the virus is less deadly and less transmissible. The virus is endemic to western and central Africa and it causes a zoonotic disease potentially found in rodents, not monkeys as the name suggests. The reason it is called monkeypox, however, is because the virus that causes it was first discovered in monkeys in a Danish laboratory in 1958. Since then, the disease has become endemic to Western and Central Africa and the virus has occasionally caused outbreaks of less than 100 cases in other parts of the world.
The first well known outbreak outside endemic countries occurred in the United States, where a total of 71 cases of monkeypox were reported from May to June 2003. All cases were linked to imported rats coming from Ghana with the help of a Texas exotic animal distributor. Another outbreak of only four cases occurred in the UK in 2018-2019, another person in 2019 was diagnosed with monkeypox in Singapore, and in 2021 another three persons were diagnosed in the UK. All of them came from or had recently traveled to Nigeria, where the disease is endemic. What makes the 2022 outbreak different from previous ones?
Monkeypox: pandemic or not?
Do not panic. The spread of monkeypox across countries has been slow and the numbers are so small we are not even close yet to classifying this as another pandemic. Nevertheless, there are still a few things that make this outbreak different from previous outbreaks of monkeypox.
First, a few of the first few cases diagnosed could not be linked to endemic countries or people previously infected. Additionally, previous outbreaks have been isolated to specific countries, even communities and households. This time around, however, more and more countries keep reporting cases at the same time. Lastly, most cases (particularly at the beginning of the outbreak) were being diagnosed in men who have sex with men (MSM) and linked to places like saunas, pride events, and even fetish festivals. Despite not being a sexually transmitted infection—monkeypox spreads through close contact, whether sexual or not—the general public might jump to quick and damaging conclusions. Lack of expert knowledge or even basic knowledge about the disease spread and transmission has led to stigma towards sexual minorities.
Why do global and public health experts care about stigma?
Epidemics and pandemics are not a new thing introduced by Covid-19. Humans have been exposed to numerous infectious diseases in high numbers throughout history. All of them have, to different extents, been associated with stigma and, consequently, negative social consequences. Stigma has been defined as “an identifying mark of disgrace or one defining characteristic that is related to a particular context, quality, or person”. One clear example is the HIV pandemic back in the 80s. The disease was initially exclusively linked to MSM. The rampant discrimination against this population that followed, caused delays in funding, diagnosis and, sadly, timely treatment. The problem with stigma is that these delays translated into many avoidable deaths.
Research has shown that stigma leads to fear, social disruption and negative health outcomes. How? Well, people who might be experiencing symptoms or who suspect that they might have been exposed to a particular stigmatized disease might delay seeking health care due to fear of being stigmatized. Of course, this fear can vary from setting to setting, and from person to person. As a better understanding of how HIV is transmitted was developed, and with the help of activism, stigma around HIV has greatly decreased. This decreased stigma, however, does not mean new or relatively new diseases won’t be stigmatized. What we know is: stigma is never a good thing. Therefore, stigma around monkeypox will not be a good thing. More so given that it is directed towards vulnerable minorities who already face discrimination on a daily basis. MSM, where the current outbreak is mostly happening as of today, need to be able to seek timely treatment if we want to stop the spread of this disease. What can we do as a society to stop stigma from happening? We can start by making the public aware of what monkeypox really is: an infectious disease that can be transmitted by and to anyone by close contact. Therefore, clear communication is key and all of us, health experts, the media, politicians and regular people, are responsible for it.
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