Monkey Pox: From Endemicity to Global Emergency

The recent global outbreak of the mpox virus, formerly known as monkeypox, has presented the world with a complex and concerning public health challenge. What was once considered a relatively rare disease largely confined to parts of Central and West Africa has now spread to dozens of countries across the globe, sparking fears of a new pandemic and highlighting the continued vulnerability of the world’s health systems.

The origins of the current mpox outbreak can be traced back to 2022, when cases began cropping up in North America, Europe, and other regions far from the virus’s typical geographic range. By mid-2022, the World Health Organization (WHO) had declared the situation a Public Health Emergency of International Concern, the highest level of global health alert.

As of August 2023, over 100,000 mpox cases have been reported worldwide, with the Democratic Republic of the Congo (DRC) and Nigeria bearing the brunt of the outbreak in Africa. Disturbingly, the true number of infections is likely significantly higher, as testing and surveillance capacities remain inadequate in many parts of the world.

What makes the mpox outbreak so concerning is not just its scale, but the unique challenges it has exposed in the global health landscape. Unlike the COVID-19 pandemic, which spurred an unprecedented, if uneven, mobilisation of scientific and medical resources, the mpox response has been hampered by a lack of global solidarity, an unwillingness to share critical supplies, and persistent inequities in access to vaccines and treatments.

These failings are not new; they are the same obstacles that have plagued the international community’s approach to past outbreaks and public health crises, including the HIV/AIDS epidemic and the West African Ebola outbreak of 2014-2016. The mpox crisis, therefore serves as a stark reminder that the world remains ill-equipped to address emerging infectious diseases in an equitable and effective manner.

Mpox, also known as monkeypox, is a zoonotic viral disease that was first discovered in 1958 in a colony of research monkeys in Denmark. The first documented human case of mpox occurred in 1970 in the DRC, where a 9-month-old infant was infected, likely through close contact with an infected animal.

Since then, mpox has been primarily confined to parts of Central and West Africa, where it is endemic in several countries. The virus is typically transmitted from small rodents, such as squirrels and rats, to humans, with outbreaks often sparked by human-animal interactions, such as hunting, butchering, or handling infected animals.

Historically, mpox outbreaks in Africa have been relatively limited in scale, with case numbers typically ranging in the hundreds or low thousands per year. However, in recent years, the situation has become increasingly concerning, with the DRC reporting thousands of suspected cases annually since 2005, and neighboring Nigeria also experiencing frequent mpox outbreaks since 2017.

What remains puzzling about the current global outbreak is why the virus has suddenly spread so widely and rapidly beyond its traditional geographic boundaries. Some researchers have suggested that genetic mutations may have made the virus more transmissible between humans, a theory that is supported by the discovery of over 40 genetic changes when comparing the 2022 mpox genome to a sample collected in 2017.

In September 2023, an entirely new mpox clade I variant, tentatively called clade IB, was discovered in the DRC, further complicating the picture. The WHO has not yet confirmed whether this new variant causes more severe disease or is more easily spread.

However, other experts, such as Rosamund Lewis, the mpox technical lead at the WHO, have proposed alternative explanations. Lewis suggests that the virus may have simply begun infecting new populations, such as sex workers and men who have s3x with men, which in turn has fueled wider transmission. This scenario is reminiscent of the early stages of the HIV/AIDS epidemic, when the virus took hold in urban centers like Kinshasa before spreading globally.

Interestingly, in the DRC, around 70% of mpox cases recorded in 2023 were among children, who were likely exposed through close contact with infected animals or household members. This underscores the complex and multifaceted nature of mpox transmission, which can occur through a variety of pathways, including direct contact, respiratory droplets, and even contaminated materials.

As the mpox outbreak has unfolded, the global response has been marked by stark inequities and a concerning lack of solidarity. While vaccine doses were rapidly disseminated in the US and Europe in 2022, the situation in Africa has been far more dire, with only a few hundred thousand doses made available for a population of over 100 million in the DRC alone.

This disparity in access to life-saving resources is not a new phenomenon; it is a pattern that has repeatedly played out during past outbreaks and pandemics, including the COVID-19 crisis. Wealthy nations have often hoarded critical supplies, leaving lower-income countries to fend for themselves, a dynamic that has exacerbated suffering and undermined the effectiveness of global health efforts.

The mpox outbreak has also highlighted the persistent weaknesses in public health infrastructure and technical capacity in many parts of the world, particularly in Africa. Decades of underinvestment and reliance on donor funding have left national health systems ill-equipped to respond rapidly and comprehensively to emerging threats.

In the DRC and other affected countries, testing and surveillance capabilities remain woefully inadequate, hindering efforts to accurately track the spread of the virus and implement targeted interventions. Furthermore, the lack of access to vaccines and treatments has compounded the challenge, leaving vast swaths of the population vulnerable and unable to access the tools needed to protect themselves.

Recognising the gravity of the situation, the African CDC took the unprecedented step in 2023 of designating the mpox outbreaks a regional health emergency. This move was intended to spur a more coordinated and resource-intensive response across the continent, but its ultimate impact remains to be seen.

The question now is whether this designation, coupled with the growing global attention on the mpox crisis, will be enough to catalyze the kind of robust, equitable, and sustained international response that is so urgently needed. The stakes are high, not just for the affected populations, but for the world as a whole, as the mpox outbreak serves as a stark reminder of the interconnected nature of global health challenges.

The mpox crisis has exposed deep-seated flaws in the global health system, flaws that have persisted for far too long. The failure to mount a coordinated, solidarity-driven response to the outbreak is not just a missed opportunity, but a profound betrayal of the principles of equity and universal access to health care that should underpin any effective global health strategy.

To address the mpox outbreak and prevent future health emergencies from spiraling out of control, the international community must urgently re-evaluate and overhaul the existing global health architecture. This will require a multi-faceted approach that tackles the systemic challenges at the root of the problem.

First and foremost, there must be a renewed commitment to global health solidarity and the equitable distribution of critical medical resources. The hoarding of vaccines and treatments by wealthy nations during the COVID-19 pandemic must not be repeated, as it only serves to prolong outbreaks and perpetuate the suffering of the most vulnerable populations.

Mechanisms for rapid and fair allocation of supplies, as well as transparent and accountable global supply chains, must be established and reinforced. This will involve not just the coordination of national governments, but also the active participation of the private sector, international organisations, and civil society.

Alongside these efforts, there must be a concerted push to strengthen public health infrastructure and technical capacity, particularly in low- and middle-income countries. This will require sustained, long-term investments in areas such as disease surveillance, epidemiological data management, laboratory testing, and emergency preparedness and response.

The African Union and other regional bodies have a crucial role to play in this regard, working to coordinate and support national-level capacity building efforts, while also advocating for increased global funding and technical assistance. The recent designation of the mpox outbreaks as a regional health emergency by the African CDC is a step in the right direction, but far more must be done to translate this into tangible, on-the-ground improvements.

Critically, the global health community must also prioritize the development of robust, adaptable, and equitably distributed medical countermeasures, such as vaccines, treatments, and diagnostics. The success of the COVID-19 vaccine rollout, while uneven, has demonstrated the power of scientific innovation and international collaboration when resources and political will are mobilized.

The mpox outbreak should serve as a wake-up call to redouble efforts in this area, ensuring that the fruits of medical progress are not reserved only for the wealthiest nations. This will require new models of research and development, as well as innovative financing mechanisms and mechanisms for technology transfer and local production.

Finally, the global health community must work to address the underlying social, economic, and environmental factors that contribute to the emergence and spread of zoonotic diseases like mpox. This will involve tackling issues such as deforestation, habitat loss, and the disruption of natural ecosystems, as well as addressing poverty, inequality, and the drivers of human-animal contact.

By taking a comprehensive, holistic approach to global health security, the world can build a more resilient and equitable system capable of responding effectively to future outbreaks and pandemics. The mpox crisis represents yet another critical juncture, a moment to learn from past failures and chart a new course towards a future where no one is left behind in the fight against infectious diseases.

Time is of the essence. The mpox virus continues to spread, and the window of opportunity to contain the outbreak is narrowing. The international community must act with a renewed sense of urgency, collaboration, and shared responsibility. Only then can we hope to overcome the mpox challenge and safeguard the health and wellbeing of people around the world.