What monkeypox alarm tells us about global health inequality

Photo: Reuters
Photo: Reuters


Epidemics that afflict developing countries need equal attention and covid made it clear nobody can be safe until we all are

India reported its first ever case of monkeypox last week from Kerala. In the past 10 weeks, this disease that was first identified in humans in 1970 has received unprecedented global attention. For five decades, the disease has been endemic in 11 countries in western and central Africa and had only temporarily received international attention, first in 2003, when around 70 confirmed cases of monkeypox were reported in humans in the US (all caused by importation). Then, in 2018-19, when imported cases were reported in the UK and Israel, and one more time after that—2021 in the US.

In the first week of May 2022, things changed with the identification of the first laboratory-confirmed case in the ongoing monkeypox outbreak, on 6 May 2022 in the UK. Since then, by mid-July 2022, around 9,100 lab-confirmed cases have been reported from 55 non-endemic countries across the globe. The emergence has been termed an ‘outbreak’ and most of the cases have been reported from high and upper middle-income countries, a majority of which had never reported monkeypox cases in the past.

The fact is that outside the countries affected in ongoing outbreak, in endemic African countries, monkeypox cases and also deaths from the disease were being regularly reported. Between January and early May 2022, the Democratic Republic of Congo alone had reported about 1,200 suspected monkeypox cases and 60 deaths. Then, a monkeypox outbreak has been ongoing in Nigeria since 2017, with around 550 lab-confirmed cases and a few deaths, as officially notified. These endemic countries were already reporting a high number of cases in spite of weak disease surveillance systems and poor laboratory capacity. Clearly, the actual number of cases would be far greater in these settings.

The phenomenon of monkeypox getting global attention only when high-income countries get affected is not an isolated story of its kind. There are a number of diseases in low- and middle-income countries that affect a large proportion of their populations, but get disproportionately less attention from the global community. This is a challenge recognized as the ‘10/90 gap’, which argues that diseases and health problems that constitute roughly 10% of the global disease burden but affect people mostly in rich countries receive 90% of the overall health research attention and funding. However, health problems that constitute 90% of the world’s burden of disease but affect mainly low- and lower-middle income countries get merely 10% of the attention and funds.

A specific example is a group of about 17 diseases, which include leprosy, Lymphatic filariasis and rabies, collectively called ‘neglected tropical diseases’ or NTDs. These diseases have long been a major health problem in low and low-middle income countries, but have not received sufficient/commensurate attention in health policies and financial allocations for years. There are more examples. A cholera outbreak in Haiti killed around 10,000 people over 2010-19; yet, the global attention this got was sub-optimal. Most of the world looked the other way.

One thing is clear. If monkeypox has been grabbing global headlines, one reason is its sudden emergence, but an arguably bigger reason is its spread in high-income countries. Otherwise, the total number of suspected cases reported by the Democratic Republic of Congo in 2022 alone are manifold more than any other country affected by the ongoing outbreak. Deaths from monkeypox are regularly reported from endemic countries in Africa, while no death has been reported from non-endemic countries in the ongoing outbreak.

Even potentially effective therapies and vaccines display inequity in their availability. A drug used to treat smallpox, Tecovirimat, was approved in the US earlier this year for the treatment of monkeypox. There are three second and third generation smallpox vaccines, a few of which have been approved for use against monkeypox, including most recently MVA-BN, approved in 2019. However, the US and some countries in Europe have almost exclusive access to Tecovirimat and smallpox vaccines, while these are hardly available in the endemic countries in Africa.

As the world hopes for an end to the covid pandemic, the emergence of monkeypox is a reminder of the challenge and politics of global public health. Covid vaccine inequity was and is still a reflection of the inward-looking approach of high-income countries and a global failure to tackle health issues as shared problems. Opposition by some countries to a TRIPS waiver for vaccines and therapies and the subsequent delay in discussions and decisions on the issue was unfortunate. Some of those countries now face a monkeypox outbreak. It is clear that we need global cooperation on health threats for everyone’s sake.

Every passing day, the probability of diseases which spread from animals to humans—or zoonotic diseases—is increasing. Between 1940 and 2004, nearly 330 new diseases had emerged, of which more than 200 were zoonotic. A recent study by the University of Georgetown in the US has estimated that if there is a 2° rise in global temperature in the next 50 years, humans could be exposed to about 10,000 to 15,000 new pathogens (bacteria and viruses) previously confined to wild animals and forests. This would result in a 4,000- times likelihood of cross-species transmission of a virus. In such a scenario, less developed countries in Africa and Asia are most likely to be impacted. It is a reminder that disease in these continents and countries should get more attention than ever.

The covid pandemic has reminded us that pathogens and diseases have no boundaries and can spread from one country to another in real time. Outbreaks and epidemics are going to be the unfortunate reality of the future. The only way to respond is with more, better and stronger global collaboration. If not now, after what we have been through, then when will we learn?

Chandrakant Lahariya is a physician and infectious diseases specialist and tweets at @DrLahariya.

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