The Ghost in the Machine: Why Mpox Still Haunts Us a Year After the Emergency Declaration

A year after the WHO declared mpox a global emergency, experts express frustration at a sluggish and inequitable response, warning the virus remains a potent threat.

A year ago, on August 14, 2024, the world collectively took a breath of relief. The World Health Organization (WHO) declared that mpox was no longer a Public Health Emergency of International Concern (PHEIC). The viral outbreaks that had swept across continents, causing widespread fear and disruption, seemed to be receding. Yet, beneath the surface of this declared victory, a deep-seated frustration simmers among health experts. They argue that the global response has been inadequate, inequitable, and ultimately, a missed opportunity to fully contain a virus that, despite its apparent lull, remains a persistent and evolving threat.

The initial outbreak in 2022 brought with it a wave of unprecedented global attention. Mpox, formerly known as monkeypox, a virus endemic to certain parts of Africa, suddenly appeared in non-endemic countries, primarily affecting men who have sex with men (MSM). This demographic specificity, while crucial for targeted public health interventions, also unfortunately became intertwined with stigma and misinformation, complicating the narrative and the response from the outset.

The declaration of a PHEIC by the WHO was a signal to the world: this was serious, it required a coordinated global effort, and resources needed to be mobilized. But as the emergency phase concluded, many health professionals felt the world’s attention, funding, and political will dissipated far too quickly. This article delves into the reasons behind this frustration, examining the context of the outbreak, the successes and failures of the global response, and why mpox continues to demand our vigilance.

Context & Background: From Endemic Concern to Global Alarm

Mpox is a zoonotic disease caused by the *Mpox virus*, a member of the *Orthopoxvirus* genus, which also includes smallpox and vaccinia virus. Historically, mpox has been endemic in several West and Central African countries, with sporadic outbreaks occurring among populations with close contact to infected animals. The symptoms typically include fever, swollen lymph nodes, and a characteristic rash that progresses through several stages.

The 2022 global outbreak marked a significant departure from previous patterns. The virus spread rapidly across continents, reaching countries where it had never been reported before. While the initial transmission was primarily linked to close physical contact, including sexual contact, it became clear that the virus could also spread through respiratory droplets and contact with contaminated materials. This broader transmission potential, coupled with increased international travel, facilitated its rapid dissemination.

The rapid spread, particularly within the MSM community, unfortunately amplified existing societal biases and contributed to the spread of stigma. Public health messaging often struggled to balance the need for targeted interventions with the imperative of avoiding discrimination and encouraging open communication and testing. This delicate balance was not always achieved, leading to fear, mistrust, and a reluctance among some affected individuals to seek care or provide vital epidemiological data.

The PHEIC declaration on August 14, 2024, was a critical juncture. It empowered the WHO to issue recommendations and guidelines to member states, encouraging them to strengthen their surveillance, improve diagnostic capacity, implement risk communication strategies, and ensure equitable access to vaccines and treatments. The expectation was that this declaration would galvanize a robust and sustained global response. However, as the PHEIC status was lifted, many observers noted that the urgency seemed to fade, leaving gaps in preparedness and ongoing efforts.

In-Depth Analysis: The Frustration Behind the Fade

The frustration expressed by health experts stems from a multitude of interconnected issues that plagued the global response to mpox. While there were undeniable successes, particularly in the rapid development of diagnostic tests and the availability of vaccines and treatments, the overall trajectory of the response has been marked by a lack of sustained commitment and a failure to address underlying inequities.

One of the primary sources of frustration is the perceived disconnect between the declaration of a PHEIC and the subsequent allocation of resources and political attention. The initial months of the outbreak saw a surge in media coverage and governmental pronouncements. However, as the virus’s impact became more localized and the initial wave of panic subsided, public and political interest waned. This led to a significant drop in funding for surveillance, contact tracing, and public health campaigns in many countries. Experts argue that this premature disengagement has left many nations, particularly those with weaker health systems, vulnerable to renewed outbreaks or persistent endemic transmission.

The equitable distribution of vaccines and treatments was another major point of contention. While high-income countries were able to procure sufficient supplies of the limited mpox vaccine doses, many low- and middle-income countries struggled to access them. This mirrors the stark disparities witnessed during the COVID-19 pandemic, where vaccine nationalism and supply chain issues left vast populations unprotected. The argument is that by not ensuring equitable access from the outset, the global community missed an opportunity to significantly curtail the virus’s spread and evolution, thereby prolonging the pandemic phase and increasing the risk of future resurgences.

Furthermore, the response often failed to adequately address the social determinants of health and the impact of stigma. The virus’s disproportionate initial impact on the MSM community, coupled with pre-existing societal biases, meant that public health messaging and interventions sometimes inadvertently reinforced stigma or failed to reach those most in need due to fear of judgment or discrimination. Public health campaigns were often slow to adapt to cultural sensitivities or to effectively counter misinformation, leading to confusion and distrust. The lack of comprehensive sexual health education and support services in many regions also contributed to the challenges in controlling transmission.

The WHO’s decision to lift the PHEIC status, while based on a decline in reported cases, has been interpreted by some as premature. Critics argue that mpox is still circulating widely in many parts of the world, particularly in regions where surveillance is limited, and that the virus continues to evolve. The endemic nature of mpox in certain African countries means that new spillover events from animal reservoirs remain a constant risk, and a weakened global infrastructure for detecting and responding to these events increases the likelihood of future widespread outbreaks.

The lack of sustained research and development investment is also a concern. While vaccines and treatments were available, the focus on these specific interventions sometimes overshadowed the need for broader research into the virus’s long-term effects, its precise transmission dynamics in diverse settings, and potential new therapeutic avenues. This limited investment could hinder future responses to emerging variants or new outbreaks.

Pros and Cons: A Measured Assessment of the Response

It is important to acknowledge both the successes and shortcomings of the global mpox response. A balanced perspective reveals a complex picture of a world grappling with a novel public health challenge under immense pressure.

Pros:

• Rapid Vaccine and Treatment Development: Within months of the widespread outbreak, effective vaccines and treatments were identified and made available. This rapid scientific response was a significant achievement, demonstrating the power of global scientific collaboration.
• WHO Guidance and Coordination: The WHO played a crucial role in providing guidance, issuing recommendations, and coordinating international efforts. The declaration of the PHEIC, while debated, did serve to mobilize some resources and attention.
• Increased Public Awareness: The outbreak significantly increased global awareness of mpox, its symptoms, and modes of transmission. This awareness, though sometimes fueled by fear, likely contributed to some individuals seeking care and adopting preventive measures.
• Targeted Public Health Interventions: Public health agencies were able to implement targeted vaccination campaigns and risk communication strategies, particularly within at-risk communities, which helped to slow the spread in many areas.
• Data Sharing and Surveillance Improvement: The outbreak prompted many countries to improve their surveillance systems and data sharing capabilities for mpox, which could benefit their preparedness for future outbreaks of similar diseases.

Cons:

• Inequitable Vaccine Distribution: A significant imbalance existed in access to vaccines and treatments, with high-income countries often securing supplies before lower-income nations, mirroring inequities seen during COVID-19.
• Premature Declaration of End to Emergency: Many experts believe the lifting of the PHEIC status was premature, given the virus’s continued circulation in many regions and the potential for evolution.
• Stigma and Discrimination: The response was often marred by stigma and discrimination, particularly against the MSM community, which hampered effective public health communication and access to care for some.
• Insufficient and Unsustained Funding: Funding for mpox response, including surveillance, contact tracing, and public health campaigns, often saw a sharp decline after the initial peak of the outbreak, jeopardizing long-term control efforts.
• Inadequate Preparedness in Many Regions: Many countries, especially those with weaker health systems, lacked the necessary infrastructure, trained personnel, and financial resources to effectively manage the outbreak and its aftermath.
• Gap in Research and Long-Term Monitoring: Sustained investment in research into the virus’s long-term health impacts, its evolution, and new therapeutic strategies has been insufficient.

Key Takeaways

• The declaration of mpox as a Public Health Emergency of International Concern by the WHO in August 2024 was a significant moment, but the subsequent global response has been characterized by frustration due to perceived inequities and a lack of sustained commitment.
• Mpox, while no longer a global PHEIC, remains a persistent threat, circulating in many regions and carrying the risk of future outbreaks due to its zoonotic nature and potential for evolution.
• The equitable distribution of vaccines and treatments was a major challenge, with high-income countries largely securing supplies ahead of lower-income nations.
• Stigma and discrimination, particularly against the MSM community, complicated public health efforts, hindering effective communication and access to care.
• Many health experts believe the lifting of the PHEIC status was premature, arguing that continued vigilance, sustained funding, and robust surveillance are necessary to prevent future resurgences.
• The pandemic highlighted the critical need for strengthened global health security infrastructure, equitable access to medical countermeasures, and comprehensive strategies that address both the virological and social determinants of health.

Future Outlook: A Lingering Threat and a Call for Sustained Action

The lifting of the PHEIC status does not signify the end of mpox. Instead, it marks a transition to a phase where the virus is managed as an ongoing public health concern, much like other endemic or re-emerging infectious diseases. However, the current global infrastructure and political will to manage this ongoing threat appear fragile.

The future outlook for mpox is uncertain, but several scenarios are plausible. Without sustained global attention and investment, we risk seeing a resurgence of significant outbreaks, potentially in regions with limited healthcare capacity. The virus could also continue to evolve, potentially leading to new variants with altered transmissibility or virulence. The ongoing endemic circulation in parts of Africa, with the inherent risk of zoonotic spillover, means that mpox will likely remain a potential threat for the foreseeable future.

The experience with mpox, much like the earlier experience with COVID-19, offers critical lessons for global health security. The pandemic preparedness gap, particularly in low-resource settings, has been starkly exposed. Addressing this requires not just reactive measures during emergencies but proactive investment in resilient health systems, robust surveillance networks, and equitable access to essential health tools.

The scientific community will likely continue to monitor mpox closely, with ongoing research into its epidemiology, immunology, and potential for further evolution. However, the sustainability of these research efforts, and their translation into effective public health interventions, will depend on continued funding and political support.

The danger lies in complacency. The perception that mpox is “no longer a problem” is precisely what makes it a persistent threat. Public memory is short, and the urgency that characterized the initial response can easily fade, leaving us vulnerable. The frustration among health experts is a warning sign – a plea to not repeat the mistakes of the past and to recognize that global health security is a shared responsibility that requires unwavering commitment.

Call to Action: Rebuilding Trust and Fortifying Defenses

The frustrations voiced by health experts are not merely academic complaints; they are urgent calls to action. To effectively manage the ongoing threat of mpox and to better prepare for future pandemics, a multi-pronged approach is necessary:

• Sustain and Increase Funding: Governments and international bodies must commit to sustained funding for mpox surveillance, research, vaccine development, and public health programs. This funding should prioritize support for countries with weaker health systems.
• Strengthen Global Surveillance and Data Sharing: Robust, real-time surveillance systems are crucial for early detection of outbreaks and monitoring of viral evolution. This requires improved data sharing protocols and capacity building in all nations.
• Ensure Equitable Access to Countermeasures: Mechanisms must be put in place to guarantee equitable access to vaccines, treatments, and diagnostics for all populations, regardless of their economic status or geographic location. This may involve global manufacturing capacity building and transparent allocation frameworks.
• Combat Stigma and Misinformation: Public health campaigns must be inclusive, culturally sensitive, and designed to build trust. Efforts to counter misinformation and address the social determinants of health that exacerbate vulnerability are essential.
• Invest in Primary Healthcare and Pandemic Preparedness: Strengthening primary healthcare systems and investing in broader pandemic preparedness measures are not optional; they are fundamental to safeguarding global health. This includes training healthcare workers, ensuring adequate supplies, and developing effective response plans.
• Foster International Collaboration: The lessons learned from mpox underscore the need for enhanced international cooperation and solidarity. Nations must work together to share knowledge, resources, and best practices to build a more resilient global health architecture.

The narrative surrounding mpox has shifted from an international emergency to a more localized concern, but the virus itself has not disappeared. It lurks in the background, a testament to our collective failures and a reminder of the interconnectedness of global health. The frustration of health experts is a powerful signal: the fight against mpox is far from over, and it demands a renewed commitment to equity, vigilance, and sustained global action. Failure to heed this warning could leave us exposed to future threats, with even greater consequences.