So … What’s the Plan for a Monkeypox Emergency?

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Seventy-eight days and more than 7,000 documented cases into the United States’s 2022 outbreak of monkeypox, federal officials have declared the disease a nationwide public-health emergency. With COVID-19 (you know, the other ongoing viral public-health emergency) still very much raging, the U.S. is officially in the midst of two infectious-disease crises, and must now, with limited funds, wrangle both at once.

The two viruses and diseases are starkly different, as are the demographics of the populations most at risk. But simultaneous outbreaks will compete for overlapping sets of resources, and put a subset of people at especially high peril of contracting both viruses, perhaps even in some cases simultaneously. They will also demand distinct responses, from both the nation’s leaders and the public. For most Americans, today’s declaration changes little: The take-home can be “don’t panic,” says Taison Bell, a critical-care and infectious-disease physician at UVA Health. Avoid stigmatizing men who have sex with men, who remain at greatest risk, but “be aware that everyone is at risk.” Today on a press call HHS Secretary Xavier Becerra urged every American “to take monkeypox seriously and to take responsibility to help us tackle this virus.”

The trick will be to do that while ensuring that resources go to those most in need. Although federal officials have repeatedly reassured the public that the country has all the resources it needs to keep the outbreak under control, the nation is clearly not living up to containment potential. Many experts have criticized the country’s relatively timid steps toward action in the outbreak’s early days, when stamping out the virus was, in fact, relatively feasible. Now, as tests, treatments, and vaccines continue to be in short supply and remain difficult to access, allowing case numbers to balloon, the window of opportunity to beat the virus back seems narrower than ever.

[Read: America should have been able to handle monkeypox]

Today’s declaration will mobilize more resources toward outbreak containment, allowing federal leaders to dole out vaccines and treatments more quickly, and source more data from state and local governments. But perhaps this move has already come too late. In the press briefing, CDC Director Rochelle Walensky noted that about 1.6 million to 1.7 million people in the U.S.—including men who have sex with men who are living with HIV—had been designated as “at highest risk of monkeypox right now,” and should be prioritized for vaccination. That number far exceeds the 600,000 or so doses of the two-shot Jynneos vaccine that have been rolled out nationwide; acquiring and shipping more will still take the U.S. months, stretching into the fal and beyond. In the meantime, federal officials are mulling whether they can split Jynneos doses into five, and administer them intradermally instead of subcutaneously—a “dose sparing” approach.

I caught up with Gregg Gonsalves, an epidemiologist and AIDS activist at Yale University, and an adviser to the WHO on the monkeypox outbreak, to make sense of today’s declaration, and the epidemic’s prognosis in the United States. Gonsalves has been a vocal critic of the U.S.’s approach to COVID; in this new outbreak, he and others already see an encore of past failures playing out. Today, Demetre Daskalakis, the White House’s national monkeypox-response deputy coordinator, described the American reaction to monkeypox as “aggressive, responsive, and ongoing since day one.” There is little to suggest that this is true.

Our conversation has been edited for clarity and length.

Katherine J. Wu: How would you describe the current state of the monkeypox outbreak in the United States?

Gregg Gonsalves: We’re not in a good place. We’ve been hearing refrains, similar to COVID, about having all the tools we need to deal with this—enough for all jurisdictions in the U.S. It is patently untrue. We keep seeing mounting cases. We’re likely under-testing. And we certainly have a shortage of vaccines, despite what the secretary says. And so we’re not in a very good position to contain this, which gives us the sad distinction of potentially having two viruses go endemic in the United States over the course of the past three years.

Wu: And that’s been clear for some time now—that the outbreak has been ballooning, and that resources are scarce. Should we have declared a public-health emergency sooner? Would that have helped?

Gonsalves: A declaration of a public-health emergency gives us some ability to do certain things that ordinarily we can’t. But what’s instructive to me is that we’ve had a public-health emergency for COVID. And two COVID czars! And we were the leaders in COVID deaths per capita among the G7, and now we’re the leaders in absolute numbers of monkeypox cases. So appointing leaders and declaring declarations is one thing.

But when you have leaders saying this has been an aggressive response since day one, and this is where we are? That doesn’t make you feel confident in our nation’s response to this new, emerging outbreak. It would be much more useful to say, we got out of the gate slow, but we are now bringing in all relevant federal actors. We are talking with local and state health departments. We are talking with community-based organizations. And we’re going to use all resources of government in a strategic operational campaign to deal with this. Right now, I’m still not sure what their plan is. We’re going to cut the vaccine doses into five pieces? We need research to evaluate that, or think about ACAM2000 [an older smallpox vaccine with more side effects] as a fallback.

And there’s still no real articulation of how we’re going to continue to ramp up diagnoses so that we can figure out where lingering cases are. Commercial vendors are now testing, but we’re still mostly in the passive surveillance [phase], where people are coming to sexual-health clinics, their primary-care physicians. How much active testing is going on in the community, working with organizations funded by the Ryan White HIV/AIDS program [which provides resources to low-income people living with HIV], for instance? To get out into gay bars, sex clubs, gay parties, and offering people who might have suspicious lesions or pimples or bumps the privacy of a mobile-health van to get tested, or a referral for testing at a nearby location? Also, you have to be in [isolation] for 21 days with this infection. Many people can’t afford to do that. And some of the men who are catching this are either underinsured or uninsured. And there are still lingering problems with access to [the antiviral] Tpoxx.

And there’s no new money coming down the pike. The administration floated the idea that they need $7 billion for a monkeypox response. But for some strange reason, they didn’t tell that to Congress formally before they left on recess. This is an emergency without a budget. So this does not give you the sense that there’s an aggressive response since the beginning. We don’t need to be coddled. Some straight talk would be nice.

Wu: How should the public be reacting at this point? The nation has been asked to respond; monkeypox has been categorized similar to COVID, in one sense. And yet, risk levels are so different across populations. What does that mean for us?

Gonsalves: My friend Joe Osmundson, a microbiologist, has said, for all the people telling the gay community they should get on the ball, the gay community’s been responding valiantly. And the article that Kai Kupferschidmt wrote today in The New York Times has a message that is really, really important: This is not a gay disease, but it’s happening to men who have sex with men [MSM], and we need to start thinking about how we can address the pandemic ourselves.

That’s what happened during the AIDS epidemic. Gay men understood the collective threat to them, and changed sexual behavior. Kai was saying we maybe need to reduce partners, to forgo certain kinds of sexual activities or events until we’re vaccinated, to think of limiting our sexual partners into pods, sort of like the early days of COVID socializing. So I think the gay community is responding well, and they understand the risks.

For the general community right now, the possibility of another endemic virus in the United States should worry them. But more out of solidarity and empathy for people in the LGBT community who are facing this, and bearing the brunt of it right now. Could it jump to other populations in which there’s close physical contact? Prisons, homeless shelters, university dormitories and athletic facilities? Potentially. But right now, they should just keep an eye on it.

What should concern people is the government’s response. Don’t flip the burden on the American people, again, as we’ve done with COVID—a make-your-own-adventure version of the pandemic. We need the government to deliver, and they haven’t been delivering. It’s been this creaking, bumbling, sclerotic response. And now they put two people in charge, declare a public-health emergency—they have no money—and they’re saying everything’s fine.

Wu: Do you think monkeypox has a high likelihood of moving into non-MSM populations, or becoming endemic here in the U.S.?

Gonsalves: This has been largely circulating among MSM, and we haven’t seen a lot of jump to household contacts, et cetera. But the longer this persists, the greater the chances for even sporadic cases outside of the context of men who have sex with men.

[Read: Squirrels could make monkeypox a forever problem]

And there’s a worry that this will also start to follow the fractures in our social geography. For somebody who’s followed the AIDS epidemic for 40 years … even when some people get access to the interventions they need, many people don’t. You could easily see this sort of ending up exactly where HIV is—in the rural South, in communities of Black men who have sex with men, who have some of the highest HIV rates in the world. We could see monkeypox become a disease of marginalized neglected populations, like everything else in the U.S.

That’s the biggest fear over the long term. That we’re going to be dealing with this for quite a while, and that it’s going to go to places where there’s less robust public-health or health-care infrastructure, and people have far less access to resources. And so it lingers.

Wu: What would a future like that reflect of America’s approach to public health?

Gonsalves: I wrote a piece in The Nation that talked about the backsliding we’re seeing in the AIDS response after 40 years. And, again, we have the highest COVID excess deaths per capita in the G7, and a quarter of the cases of monkeypox around the world. That tells us we are desperately unprepared and desperately unserious about the threat of infectious diseases. It tells us we’re not willing to invest in what we need to keep our neighbors safe, to keep our families safe in the long run. One of the startling things I’ve seen over the past few weeks? A report in The Lancet about American life expectancy [being set to drop in world rankings over the next couple decades]. There is this epiphenomenon that represents something much more deeply, structurally wrong in the American way of life. And it doesn’t give you a good feeling about our prospects for something that might come around the corner that is far more deadly, far more contagious than what we’ve seen thus far.