Introduction by Peter M. Sandman
Michael Osterholm is a world-famous infectious disease expert and an old friend. In mid-July 2022, I emailed him some of what I was thinking about monkeypox risk communication. That led to an exchange of emails, a few phone calls, and in short order this op-ed, which Mike submitted on our behalf to the New York Times. He was a little surprised when the Times editors turned us down. We quickly sent a revised version to the Washington Post. They turned it down too – and so did three more mainstream newspapers in quick succession. Mike told me that had never happened to him before.
Some of the editors who didn’t want the op-ed were more candid than others about why. They were leery of what we had to say about gay sex. Our emphasis on multiple partners (we had taken the word “promiscuity” out in draft, but the thought was still there) was considered potentially offensive, and so was our judgment that public health officials should prioritize protecting health over avoiding stigma (or worse yet, avoiding accusations of stigmatization).
I am posting the op-ed here – with Mike’s permission, of course – a couple of weeks after we gave up on finding a home for it. In the interim, others have raised the controversial issues we were trying to raise. Many of those succeeding where we failed are public health officials, experts, and science journalists who are themselves gay men, providing at least partial protection for them and the papers that published them.
How candid to be about the role of MSM sexual activity in monkeypox transmission remains a tough issue. Many public health agencies are still pussyfooting around the issue, especially in their messaging aimed at the general public; they’re far more candid when targeting a gay audience in specialized gay media. Whether this is an acceptable compromise is now a question commentators can address. That’s progress.
The monkeypox stigma issue that still cannot be addressed is race. The percentage of monkeypox infections among blacks and Hispanics is significantly higher than among whites. It appears to be acceptable – even admirable – to note this fact only if it is interpreted as a result of systemic racism and a reason for prioritizing nonwhites in vaccine distribution. An op-ed that wondered aloud about the possible role of behavioral differences between white MSM and nonwhite MSM isn’t something mainstream media (the other MSM) would be likely to publish.
So far US government messaging about monkeypox has been unconvincingly optimistic. It is past time to stop pretending this new threat is under control and start explaining the dilemmas that make monkeypox so challenging.
An all-too-typical example is the July 24 performance of White House COVID Response Coordinator Dr. Ashish Jha on CBS’s Face the Nation. Moderator Margaret Brennan asked Dr. Jha how bad the monkeypox situation is in the US. He responded, “I do think monkeypox can be contained. Absolutely. The way we contain monkeypox is we have a very simple, straightforward strategy on this right now….”
We don’t think there is any simple, straightforward strategy to contain monkeypox. We don’t think Dr. Jha thinks so either.
Effective Biden Administration monkeypox messaging will have to be grounded in acknowledgment that the situation is daunting and definitely not under control. What also has to be acknowledged: the difficult dilemmas the White House faces as it tries to figure out the wisest course.
Here are some of the key dilemmas – and what we wish US public health officials would say about them.
Dilemma 1: allocating Jynneos. There isn’t nearly enough of the Jynneos monkeypox vaccine to vaccinate everyone who wants it and ought to get it, and there won’t be for quite a few months. Vaccine production can’t be ramped up overnight. Deciding how to allocate these scarce doses isn’t easy, and would benefit from consultation with groups representing those most affected so far, men who have sex with men (MSM).
Dilemma 2: dose-sparing. We will not contain monkeypox anywhere in the world until we have enough vaccine to protect those most at risk. Two dose-sparing strategies have been proposed to make the scarce Jynneos doses go further: administration of a single dose per person instead of the usual two (or a first dose followed by a delayed second dose when supplies allow); and intradermal (instead of intramuscular) administration of a smaller dose. Neither has been adequately studied to determine whether it provides adequate immune protection. How thoroughly to research these options before deciding to deploy them (or not) is another dilemma the public deserves to understand.
Dilemma 3: the smallpox vaccine. The US has plenty of an earlier vaccine, ACAM2000, that was developed for smallpox and should work against monkeypox too. But it has a bad side effect profile, especially for immunocompromised people. We’re undecided whether to offer it at all. If we do, we will somehow have to figure out how to offer the “good” vaccine to some people and a more dangerous vaccine to others. That’s awful. It may be sufficient reason not to use the smallpox vaccine at all.
Dilemma 4: TPOXX. There’s an antiviral treatment for monkeypox, TPOXX. The evidence says it’s effective and safe enough to be worth offering to every monkeypox patient. But the Food and Drug Administration hasn’t licensed it yet, and that means complicated paperwork every time a doctor wants to prescribe it. The dilemma: How much more can we do to speed up the licensure and reduce the paperwork without cutting corners that shouldn’t be cut?
Dilemma 5: sex. Gay and bisexual men who routinely have sex with multiple partners are the people mostly spreading the virus, and of course they’re also the people most at risk of catching the virus. Some are temporarily changing their behavior in response to this new risk. But many are not. They expect us to be able to protect them – and we can’t. Should we expect them to change their behavior, at least until they’re vaccinated or have recovered from monkeypox? Should we ask them to, for their own protection and everyone else’s? Do we have that right? After two years of controversy over COVID precautions, how many would listen?
Dilemma 6: stigma. When talking to and about MSM, avoiding stigma is important. Protecting health is even more important. We know monkeypox messaging should focus not just on MSM, but on MSM who routinely have multiple sex partners, especially anonymous ones. Paradoxically, just saying “MSM” arguably stigmatizes gay men in stable monogamous relationships. Without condemning (or praising) sexual behavior, can officials find ways to identify it more clearly as a monkeypox risk factor? Officials rightly don’t want to provoke anti-gay stigma, and they’re certainly not looking forward to accusations of provoking anti-gay stigma. And still we need clarity on how MSM can best prevent monkeypox transmission.
Dilemma 7: how little we know. What we think we know about monkeypox is based almost entirely on endemic monkeypox in Africa. Monkeypox is now playing out globally in vastly different ways, attaching big question marks to everything we thought we knew. We think the death rate is extremely low; in the U.S. so far it’s zero. We think in most cases the infection resolves in two to three weeks. We think previously infected or vaccinated people rarely if ever get infected again. That’s all tentative good news. Some equally tentative bad news: Some experts are worried that monkeypox may start to spread more widely to people other than gay men with multiple partners. And they’re worried that it may become endemic globally, as it already is in parts of Africa, yet another disease we will have to get used to. Some of the bad news is not tentative. Monkeypox can be horribly painful. And even though it doesn’t spread easily the way COVID does, it is spreading a lot faster than we hoped and expected.
Dilemma 8: preparedness. Should the U.S. government have been better prepared for the possibility of an unprecedented monkeypox outbreak in the United States? Some experts think we should have prepared more for this outbreak – and for outbreaks of all the other rare diseases that might suddenly, unexpectedly go pandemic. This is a debate worth having – not mostly to assess blame, but to figure out a longer-term path forward: What should we do, and how much should we spend, to try to be better prepared for future unexpected disease outbreaks?
The bottom line is that we were not prepared for monkeypox. Our people – especially men who have sex with multiple male partners – are paying the price now. And the U.S. government is struggling now, as it tries to figure out how best to address the monkeypox crisis. There are no good answers, only difficult choices among the bad answers. The “very simple, straightforward strategy” to contain monkeypox that Dr. Jha said the White House was pursuing doesn’t exist.
Honest messaging will help only a little, but continued dishonest messaging can hurt a lot. And honest messaging requires telling the American public about the many difficult dilemmas our monkeypox crisis poses.
Dr. Osterholm is an epidemiologist and director of the Center for Infectious Disease Research and Policy at the University of Minnesota. Dr. Sandman is an internationally recognized risk communication consultant.
Copyright © 2022 by Michael T. Osterholm and Peter M. Sandman
