Public Health Officials Should Be Clearer About Who Isn't at Risk for Monkeypox

'Anyone can get Monkeypox' is not a useful message. Plus: The real argument against repealing DOMA.

Dear readers,

I’ve seen a spate of pieces in recent days flagging the problem with “anyone can get monkeypox” messaging from public health authorities. (See, for example, Jerusalem Demsas in The Atlantic.) And part of what makes that message extra galling is that it’s not the only one public health officials are sending.

When public health officials know they’re talking to gay men, they are pretty frank about monkeypox being a particular risk to gay men. Where I sit — splitting my time between a gay neighborhood in Manhattan and a gay beach town on Fire Island — I am seeing extensive messaging about how gay men are at particular risk for monkeypox. Suffolk County, which has over 1.5 million residents, allocated its entire first allotment of monkeypox vaccine to the two small gay beach communities on Fire Island. They’ve been loud and clear: You’re at particular risk, you should get vaccinated, and here’s what you should know about how it spreads through sexual contact.

But people other than gay men don’t necessarily know about this messaging because it’s not directed to them. And when public health authorities think they’re talking to the public at large, they’ve often been hiding the ball about how exactly the virus is mostly spreading.

For example, I got a push notification this morning from the Excelsior Pass app — that’s the app New York State created so New Yorkers can present digital proof of COVID vaccination. The notification invited me to “sign up for monkeypox text alerts,” and it also provided a link to a New York State Department of Health page with monkeypox information.

I gather from Twitter this message wasn’t targeted to me as a gay man — it was just blasted out to all sorts of people who have the app, regardless of their monkeypox risk level. And boy is the messaging the state provides at its linked web page beyond useless.

“Anyone can get monkeypox,” it says, in a section entitled “Who is at risk for contracting monkeypox?” It adds that “certain populations are being affected by monkeypox more than others, including men who have sex with men.” Okay. But then it adds “some groups may be at heightened risk for severe outcomes if they contract monkeypox,” identifying four such groups: “people with weakened immune systems, elderly New Yorkers, young children under 8 years of age, and pregnant people.”

This is just terrible messaging that’s going to scare a lot of people for no reason.

Danger level in the event you get infected isn’t necessarily important information, if the odds that you will get infected in the first place are extremely low. And monkeypox is currently spreading almost exclusively among men who have sex with men — a fact that largely takes “pregnant people” and children under 8 (!) off the table for risk. An elderly man could theoretically face significant risk of getting monkeypox, depending on his activities, but we’re mostly talking about a younger demographic that’s getting it so far.

Indeed, demographic information from the New York City Department of Health (whose messaging has been a lot better than the State DOH) makes clear how focused this outbreak is:

nychealthy @nycHealthy

As of today, 778 people have tested positive for orthopoxvirus in NYC, which is presumed to be monkeypox. According to our latest data: 🔹97.7% are men 🔹50.7% are 30 to 39 years old 🔹54.1% live in Manhattan See all the data: on.nyc.gov/3zkndVA

A more detailed release with slightly older data (through July 19) shows there have been no confirmed cases in New York City in people under 20, and that less than 10% of cases have been in people 50 or over. People disclosing their sexual orientation as straight made up 1.4% of cases (52% were LGBQ+ and another 46% were unknown). Just one case — of 639 reported through that date — was in a person who identified as a woman. This is surely a severe undercount of cases (testing is still somewhat difficult to get) and the data may shift some as more confirmed cases come in. But it gives a general view of the shape of the outbreak and of who is, and is not, getting monkeypox.¹ So “anyone can get monkeypox,” while true at some theoretical level, is a talking point that mostly serves to obfuscate about who is and is not at significant risk.

Worse, after saying that anyone can get it, the State DOH does not say much that is useful about what to do about monkeypox risk. Their information page says “vaccines exist that can help reduce the chance and severity of infection in those who have been exposed” (emphasis mine) but doesn’t say anything about getting a vaccine before exposure to prevent monkeypox. The page probably doesn’t say anything about that because it’s aimed at a general public that largely isn’t eligible for monkeypox vaccination — and when it comes time to allocate scarce vaccine doses, the public health authorities are clear that the target demographic is adult men who have sex with men and who have multiple recent or anonymous sex partners, not pregnant women or young children or any of the other groups told here they should worry.

What exactly are we doing here?

I think when public health authorities hide the ball, they are doing so partly, as Demsas notes, in a misguided effort to avoid creating “stigma.” But I think it’s also part of a general pattern of dishonest framing by public health authorities who want to nudge the public into taking more precautions against disease spread. If you’re at above-average risk, they’ll gladly tell you so, in hopes it will get you to focus on their advice. But if you’re at below-average risk, they don’t want to harp on that too much, because then you might not do what they tell you. And of course, it’s likely some gay men who actually are at elevated risk will see the messaging intended for the whole public, and they’ll come away misinformed and under-alarmed.

At this point, the vast majority of people who are not men who have sex with men need not be changing their behavior in any way to address monkeypox risk. They shouldn’t be asked to stress about the remote risk that they or their children will get sick. I am skeptical that this epidemic will ever reach a level of transmission in the general public that requires general vigilance in the way COVID has, but in any case we are not at that point yet. The main thing straight people should be afraid of is what this episode has shown about how little our government agencies have learned from COVID.

Monkeypox should have been a layup for the public health apparatus — precisely because it affects a relatively small and defined community, it should have been quick and easy to deploy an effective vaccine and educational response. Instead, the response has been late and insufficient at almost every turn. Now imagine how screwed we would be if this virus were more easily spread and/or caused more severe disease — the inadequacy of the government response would have been so much more dire. And that could be the nature of a future, different orthopoxvirus epidemic.

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The real argument against repealing DOMA

National Review has an editorial out today saying Republicans should reject the House-passed bill that would repeal the Defense of Marriage Act and ensure governments at all levels continue to recognize same-sex marriages (and also interracial marriages) in the event that the Supreme Court precedents in Obergefell or (less likely) Loving were to be overturned.

I’m seeing a lot of people making fun of this editorial, but I think we should welcome the forthrightness of its argument: National Review doesn’t want DOMA repealed because its editors continue to believe marriage equality is bad public policy.