Published by: Re'Neisha Lee, MPH & Brittny A. James, DrPH, CHES
Here's the thing...
The monkeypox virus has recently been communicated as a “novel” disease; however, it first emerged in humans in the Democratic Republic of the Congo in 1970.
Similar to HIV/AIDS, which has historically impacted brown, Black, and gay communities disproportionately, there was little awareness, reporting, or understanding of monkeypox until it began to impact white communities.
If individuals continue to fear discrimination associated with having monkeypox, we will continue to see instances of under-ascertainment and underreporting - both of which ensure that the health and safety of communities are met, and assists in identifying areas and populations that are disproportionately impacted.
Introduction
Recent communication might make it seem like monkeypox is a new condition; it is not. Its existence dates back almost 65 years, initially emerging in 1958 in a Danish animal laboratory (Centers for Disease Control and Prevention [CDC], 2022a). Monkeypox in humans dates back to 1970, in regions where healthcare has not historically been accessible for most inhabitants, including 11 African countries (World Health Organization, 2022). The monkeypox virus is part of the same family of viruses as the smallpox virus, one of the most devastating diseases known to humanity, causing hundreds of millions of deaths before being eradicated in 1980 (World Health Organization, n.d.). In 1970, the Democratic Republic of the Congo identified the first human monkeypox case in a 9-month-old boy, where smallpox had been eliminated in the country for almost two years (World Health Organization, 2022).
While the disease’s burden has historically been in Africa, Asia, and South America, monkeypox has recently gained notoriety as its spread reached America. Given monkeypox is no longer exclusive to countries that are home to historically marginalized groups, its burden has quickly become a public health priority. Evidence from the last American smallpox outbreak in New City in 1949 demonstrates that the spread was stopped within 30 days of discovery. Over 6 million Americans were vaccinated, and this rapid response limited the outbreak to 12 individuals, 2 of whom succumbed to the disease (Thorpe et al., 2004). With similar symptoms to a deadly virus that once killed millions of people annually, where was the urgency to research monkeypox and promote vaccinations among Americans during the 2022 outbreak?
Do You Remember the Time...?
As history shows, official reaction to a disease largely depends on how it impacts the wealthy, who are also often predominantly white. For example, in 1981, at the beginning of the HIV epidemic, a rare lung infection, Pneumocystis Carinii Pneumonia (PCP), first emerged in five young, previously healthy, gay men in Los Angeles and began to spread quickly throughout the gay, Hispanic, and Black communities (National Institutes of Health [NIH], 2022). By the end of 1981, there were 337 reported cases of individuals with a severe immune deficiency in the United States - almost half of whom died by December 1981. It was not until May 18, 1983 - almost two years after the first case - that the U.S. Congress passed the first bill that included funding for AIDS research and treatment (NIH, 2022). By this time, hundreds of people excluded from research had already succumbed to the disease. Later, Ryan White, a white teenager with hemophilia who contracted AIDS through a blood transfusion in 1984, spoke out against AIDS-related discrimination that had previously only been experienced and reported by mostly gay Black and Hispanic men. His story was nationally televised in 1989, and the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act was enacted in 1990. This was, and continues to be, the most extensive federal program designed specifically for people with HIV, serving over half of all those diagnosed (Kaiser Family Foundation [KFF], 2020). This begs the question: Without Ryan White’s story being the catalyst for funding of research and programs that benefit those with HIV/AIDS, how much longer would its main constituents (those who are low-income, male, people of color, and/or sexual minorities [KFF, 2020]) have gone without life-saving attention?
History Repeats Itself
Monkeypox had a similar trajectory in terms of research, public awareness, and understanding. The CDC reported the first case of Monkeypox in the U.S. on May 17, 2022 (CDC, 2022b). At the beginning of the outbreak white men, who reported having sex with other men, had a higher incidence of monkeypox cases compared to other racial/ethnic and sexual orientation groups. During the first week of transmission (May 2022), out of the 1,056 confirmed U.S. cases, 428 (40.6%) were white men (CDC, 2022b); however, cases began to decrease for white people overall, while numbers began to quickly increase for Black Americans over time (CDC, 2022b).
As of October 21, 2022, not only do Black people make up the majority of monkeypox cases in the U.S., but those who are Black and living with HIV/AIDS contribute to the majority of monkeypox cases (CDC, 2022c). We know that HIV/AIDS has historically impacted brown and Black communities disproportionately, with 40% of new HIV cases occurring among Black people. With new monkeypox cases quickly shifting from white communities to Blacks, the once urgent communication of pertinent information regarding monkeypox has waned to being less of a priority amidst the fall/winter season (CDC, 2022b).
Based on these examples, race and gender supersede sexual orientation in terms of escalating a health need as “urgent.” With HIV/AIDS, we saw that gay men (primarily Black and/or Hispanic) have been affected disproportionately since its discovery; however, it was not until a white teenager contracted the condition and spoke out on the discrimination he received related to his diagnosis, that the importance of reducing transmission and treating the disease was escalated to a national emergency. Age and individual behavior likely played the most significant role in how the broader community perceived the risk of contracting HIV with Ryan White’s condition being highlighted - this young man was not part of the LGBTQIA+ community nor associated with anyone with HIV/AIDS; and therefore, represented the “innocent” who were not viewed as at risk for the disease. Ryan White soon became the face of a movement against a disease that was already destroying Black, brown, and gay communities. Despite his unfortunate passing from AIDS complications in 1990, his name lives on as the landmark case related to discrimination based on health diagnosis.
Closing Remarks
Monkeypox impacted African countries for years in various outbreaks, but no prevention research or implications of how the condition affects humans was documented or used in awareness messaging until it was prominent among white communities. During the American Public Health Association’s August 2022 webinar, Monkeypox: State of the Science, Dr. Boghuma Kabisen Titanji stated a key fact: we still are unaware of the actual natural reservoir of the monkeypox virus. Aired approximately three months after the first U.S. monkeypox case was identified, it was clear that there should have been a more proactive approach in garnering research on monkeypox from its discovery. Monkeypox spread quickly to new communities, and there was an immediate reaction to its impact until the disease further spread to affect mostly minoritized people. Given the historic details here, the question persists: If white people were not affected by monkeypox in 2022, would this still be viewed as an essential topic for researchers or a public health priority for prevention and treatment?
Blacks and browns continue to have a higher incidence of monkeypox, and from history, once a condition establishes itself in these communities, the urgency of addressing it seems to wane. Suppose individuals continue to fear discrimination associated with having a monkeypox? In that case, we will continue to see instances of under-ascertainment and underreporting - both of which ensure that the health and safety of communities are met, and assists in identifying areas and populations that are disproportionately impacted (Lee, 2022). History will be destined to repeat itself.
References:
Centers for Disease Control and Prevention. (2022a). About Monkeypox. Retrieved from Centers for Disease Control and Prevention.
CDC. (2022b). Epidemiologic and Clinical Characteristics of Monkeypox Cases. Retrieved from Centers for Disease Control and Prevention.
CDC. (2022c). Severe Monkeypox in Hospitalized Patients — United States, August 10–October 10, 2022. Retrieved from Centers for Disease Control and Prevention.
Kaiser Family Foundation. (2020). The Ryan White HIV/AIDS Program: The Basics. Retrieved from the Kaiser Family Foundation.
Lee, R. (2022). We don't know what we don't know: The impact of under-ascertainment and underreporting on public health surveillance. Retrieved from Healthcare Equity Solutions.
National Institutes of Health. (2022). Office of AIDS Research - History. Retrieved from National Institutes of Health.
Thorpe, L. E., Mostashari, F., Karpati, A. M., Schwartz, S. P., Manning, S. E., Marx, M. A., & Frieden, T. R. (2004). Mass smallpox vaccination and cardiac deaths, New York City, 1947. Emerging Infectious Diseases, 10(5), 917–920. https://doi.org/10.3201/eid1005.040119.
World Health Organization. (2022). Monkeypox. Retrieved from World Health Organization.
World Health Organization. (n.d.). Smallpox. Retrieved from World Health Organization.