Monkeypox: A Reality Check Based on Evidence
Public Health Responses and Their Effectiveness
Public health responses are most effective when they are based on reality. This is especially true in the case of 'emergency' responses, which often involve the reallocation of large amounts of public funds. When resources are reallocated, there is a cost, as the money is taken from another program. If the response involves purchasing a large number of products from a manufacturer, this can also result in financial gain for the company and its investors.
To ensure good practice, three key requirements need to be met:
1. Accurate and contextual information is needed.
2. Financial beneficiaries should not have any role in decision-making.
3. The organization coordinating the response must act with transparency, publicly weighing the costs and benefits.
The World Health Organization and Monkeypox
The World Health Organization (WHO), which is tasked by countries to help coordinate international public health, has declared monkeypox (Mpox) an international emergency. They have identified an outbreak in the Democratic Republic of Congo (DRC) and nearby Central African countries as a global threat, necessitating an urgent global response. According to the WHO, there have been 537 deaths among 15,600 suspected cases this year.
However, the Lancet and other journals have suggested that the mortality rate could be much lower if adequate care were provided. The Africa CDC has reported more than 17,000 cases (2,863 confirmed) and 517 suspected deaths of Mpox across the continent.
Understanding Monkeypox
Monkeypox is endemic to central and west Africa, where it is found in species of squirrels, rats, and other rodents. While it was identified in monkeys in a Danish lab in 1958, it has likely been around for thousands of years, causing intermittent infections in humans.
Small outbreaks in Africa have largely gone unnoticed by the rest of the world, mainly because they have been small and confined. Mass smallpox vaccination may also have suppressed numbers a few decades ago, as smallpox is in the same Orthopoxvirus genus of viruses. Therefore, we may be seeing an upward trend of this generally milder illness over recent decades since smallpox vaccination ceased.
The WHO's Response to Monkeypox
The WHO's announcement that 5,000 (or less) suspected Mpox cases is a Public Health Emergency of International Concern allows it to fast-track vaccines through its Emergency Use Listing program. This bypasses the normal rigor required to approve such pharmaceuticals. At least one drugmaker is already discussing a supply of 10 million doses before year-end.
However, a mass vaccination program of this nature requires redirection of millions of dollars and thousands of health workers who would otherwise be addressing diseases of far larger burden.
The Data on Monkeypox
In the past 2.5 years, the WHO has confirmed 223 deaths in the whole world, with just six in July 2024. Note here that 223 deaths are just 0.2% of the 102,997 confirmed cases. In Africa, just 26 deaths have been confirmed in 2024 among 3,562 cases (0.7%), spread across 5 countries.
As severe cases are more likely to be tested than mild cases, the infection fatality rate may be far lower. Most in Africa are reported to be children, so it is likely they are malnourished, otherwise immunocompromised (e.g. HIV), and have susceptibilities that could be addressed.
Addressing the Monkeypox Issue
Diverting resources from DRC’s major priorities would undoubtedly kill far more than are currently dying from Mpox. It is quite probable that direct adverse events from vaccination alone will kill more than the 19 DRC Mpox victims confirmed this year.
A useful response might be to improve immune competence through nutrition, which would provide very broad benefits. Perhaps limited, well-targeted vaccination may also help some communities, but there is no business case for such approaches.
Transparency and Data in Public Health
It is clear that the data on Mpox, and other competing priorities, must continue to be shown in context, along with costs and opportunity costs of the response. Those who will gain financially from vaccinating millions of people must not be part of the decision-making process. The WHO should continue to act with transparency, as the public has a right to know what they are paying for, and the harm (and perhaps benefit) they can expect from it.
Bottom Line
While the number of Mpox deaths will rise as more are infected, and perhaps as some suspected cases are confirmed, we are facing a small problem in an area with far larger ones. It is posing low local risk and minimal global risk. It is not a global emergency, by any sane, rational, public health-based definition.
The rest of the world can respond by sending vaccines and lots of foreigners who need looking after, diverting local health and security personnel and almost certainly killing more DRC residents overall. Or, we can recognize a local problem, support local responses when local populations ask, and concentrate on addressing the underlying causes of endemic disease and inequality.
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