State and city governments are walking a fine line as they move to confront the monkeypox outbreak, trying to spread awareness of the disease — which has thus far predominantly affected men who have sex with men — while avoiding stigmas.  

“The tightrope you’re trying to walk is making sure that people don’t see it as just a gay men’s illness, but not alarming people so that they use up resources that need to go to the people who need the most right now,” Will Goedel, a professor at the Brown University School of Public Health, told The Hill.  

The first American cases of monkeypox were detected in Massachusetts nearly three months ago, and, on Thursday, Health and Human Services Secretary Xavier Becerra officially declared monkeypox to be a public health emergency in the United States.

The number of total monkeypox cases in the U.S. has reached more than 7,000, with concentrations in the states of New York, California and Illinois. Each of these states has issued their own emergency orders to distribute resources such as vaccines and testing more efficiently amid growing demand. 

But even in tandem with emergency declarations, officials have been cautious in their messaging.

A nuanced approach

“We know that this virus impacts everyone equally — but we also know that those in our LGBTQ community are at greater risk right now. Many people in our LGBTQ community are scared and frustrated,” San Francisco Mayor London Breed (D) said in a statement last week, after declaring a public health emergency for the city.  

San Francisco public health officer Susan Philip told The Hill in an interview that it is crucial to bring awareness and education to vulnerable communities most at risk.  

“… We have not had confirmed cases yet in children under eight or people who are pregnant; the health of men, gay men, and others and LGBTQ communities is extremely important. And that was — that was a key point that we wanted to message alongside the importance of understanding about monkeypox,” Philip said.  

She added that, in San Francisco, the virus is disproportionately impacting Latinos, making it crucial to strengthen relationships between those communities and the Department of Public Health.  

“It’s really important for us not to stigmatize any groups so that they feel comfortable getting information from us or from community partners, that they understand how they can access services, including vaccine and treatment and testing.”  

Massimo Pacilli, deputy commissioner of the Chicago Department of Public Health, who is leading the city’s monkeypox strategy, said his focus is on awareness, education and intervention. 

Pacilli said his department’s messaging is based around “ensuring that we don’t blame those who are affected by the virus” and instead make it so “the focus is about protecting and intervening, to kind of interrupt transmission.” 

No more abstinence-only

Part of the effort not to perpetuate social stigma has been a messaging strategy that doesn’t ask members of the LGBT community to limit their sexual partners. This strategy was commonly used by government officials during the height of the HIV/AIDS crisis in the 1980s and ’90s, when the virus was referred to as the “gay plague.”  

“It’s very easy for a government to want to want to very quickly police same-sex sexual behavior. It’s very — it’s second nature to them,” Brown University’s Goedel said.  

Monkeypox is spread through prolonged contact with its characteristic lesions. While sexual contact is believed to have preceded many infections, authorities have repeatedly stressed that the virus is not a sexually transmitted disease, and contact with sexual fluids is not necessary for it to spread.

Philip noted that adopting abstinence as a public health strategy doesn’t work, and can often be counterproductive because community members will stop listening to other guidance from officials.  

Philip said the Department of Public Health’s outreach includes information how the disease is transmitted, what the virus is and what the symptoms are, how to best protect against transmission, and “the importance of a vaccine.”  

CEO of the San Francisco AIDS Foundation Tyler TerMeer said that his organization has been working with the city’s Department of Public Health closely on messaging that encourages sex positivity.  

“We have a perspective that [it] isn’t our role to tell people what they should or shouldn’t be doing or to tell them to stop having sex with the threat of monkeypox,” TerMeer said, adding his organization is working on messaging that “gives people some concrete tips” on how to stay safe. 

By contrast, the head of the World Health Organization last week recommended that men who have sex with men reduce the number of sexual partners they have “for the moment,” and reconsider having sex with new partners. 

A community primed for viral preparedness 

The LGBT community’s history with the HIV/AIDS epidemic was ugly. As TerMeer puts it, a generation was wiped out because of a lack of response by the federal government.  

“The initial response to HIV in our country is a very complicated and tragic story, one that deserves its own memoir and is truly a stain on American history,” he said. 

The legacy of HIV has led to generations of LGBT community members who are actively engaged in health interventions and preventative care, though experts acknowledge that the community is not “monolithic,” and there are members who may still be apprehensive about vaccines and treatments. 

Public health departments across the country have partnered with organizations such as TerMeer’s to reach members of the community.

Pacilli says these STI and HIV partners are in turn “naturally connected to many community-based organizations and venues that have reached this community as well.” 

“The experiences and learnings from the HIV/AIDS epidemic are many and deep, and they have fundamentally shaped public health, the careers of people who serve in the field, including my own, and the entire approach to how we engage with communities and provide affirming, dignified care,” Ashwin Vasan, commissioner of the New York City Department of Health and Mental Hygiene, said in a statement to The Hill. 

“A human rights-based approach that honors people’s dignity is essential and these lessons are hardwired into our planning and execution of the monkeypox response, whatever the operational or logistical challenges,” Vasan said. 

Where the U.S. stands on the monkeypox response now 

The federal government’s response to monkeypox has been fraught as local health departments wait for more vaccines and treatments to become available through the federal government.  

The Biden administration has been hit with criticism from advocates and lawmakers who say that the federal response to the outbreak has been inadequate as the number of cases increase and demand for vaccines and testing soared.  

Sens. Patty Murray (D-Wash.) and Alex Padilla (D-Calif.) are among those who’ve voiced concerns. Padilla encouraged top officials from the Centers for Disease Control and Prevention and Health and Human Services to increase the flow of monkeypox vaccines to his state.  

Thus far, the Food and Drug Administration (FDA) has approved the use of an additional 800,000 Jynneos vaccines, a smallpox shot made in Denmark by company Bavarian Nordic that is also used to prevent monkeypox. The FDA has also proposed a way of splitting the Jynneos vaccine into fifths to increase supply of the shot.  

But TerMeer said the damage that has resulted from a slow federal response has already been done.  

“What can’t be overstated in this moment is that monkeypox is causing extreme distress and fear, anxiety and real pain to our community, and that there will be unfortunate lasting consequences to the communities that it’s impacting the most right now because of the federal government’s slow response to the outbreak,” he said. 

Becerra said Thursday as he declared a public health emergency that the White House is prepared to take the U.S. response “to the next level.” With the declaration officially made, resources to combat the spread of monkeypox are expected to become more easily accessible.

The difference that this makes will have to be seen.