The WHO says we must work together to fight monkeypox. African doctors are skeptical

·6 min read
A man receives a monkeypox vaccine at an outdoor walk-in clinic in Montreal on  July 23. Canada, the U.S. and European countries are vaccinating people at risk of contracting the disease, yet immunization has not been an option in African countries where it has been endemic for decades.  (Graham Hughes/The Canadian Press - image credit)
A man receives a monkeypox vaccine at an outdoor walk-in clinic in Montreal on July 23. Canada, the U.S. and European countries are vaccinating people at risk of contracting the disease, yet immunization has not been an option in African countries where it has been endemic for decades. (Graham Hughes/The Canadian Press - image credit)

As an infectious diseases specialist in Atlanta, Dr. Boghuma Kabisen Titanji spent much of 2020 on the front lines of the COVID-19 battle raging in the U.S.

When a vaccine arrived in December that year, she felt some relief. But also, fear.

"I had seen what COVID was capable of doing to people the age of my parents," Titanji said.

"I was absolutely terrified because from the moment I had access to vaccination up until the moment my parents had access to vaccination, it was eight months."

In Cameroon, where Titanji is from, her parents didn't get a first coronavirus jab until August 2021. By that time, most Canadian and American adults were well past their second shots.

"It was the most nerve wracking experience of living in fear that they would get COVID," she said.

Despite the World Health Organization's pleas to rich countries to stop stockpiling COVID vaccines and share with the lower-income nations – particularly in Africa – global health experts agree that we failed.

Boghuma Kabisen Titanji
Boghuma Kabisen Titanji

They also aren't surprised, because the same inequitable distribution of vaccines and treatments has been a pattern for decades.

On July 23, the WHO declared monkeypox a "public health emergency of international concern" – and doctors fear the same pattern will repeat itself as Canada, the U.S. and European countries rush to vaccinate at-risk populations.

They're using a vaccine originally manufactured for smallpox, which has been eradicated. In Canada, it's called Imvamune, and small quantities were stockpiled years ago in case smallpox ever returned. Imvamune is also approved to vaccinate people against monkeypox.

Yet monkeypox has been endemic in several African nations for 50 years. Dozens have died this year alone, Titanji said, but no vaccine has ever been made available, except for targeted studies involving health-care workers.

When she dealt with monkeypox outbreaks in Cameroon, she said there was also no access to antivirals to treat the disease.

"If you diagnose someone with monkeypox [in Africa], you provide supportive care. So basically, you make the diagnosis and you tell them to isolate and, you know, take paracetamol for their fever … and to rest and recover."

Although anyone can become infected through close contact with someone who has monkeypox or with personal items like bed linens, in countries outside Africa, the most at-risk population right now is men who have sex with men. In Africa, it has historically been spread primarily through contact with infected animals.

Lack of concern for illness in Africa

If a pandemic the scale of COVID didn't galvanize a global response that was equitable, Titanji said, she's skeptical that the response to monkeypox — not to mention future outbreaks of other diseases — will treat Africa any differently.

"The issue is that there has been a generalized neglect of health equity in Africa," said Dr. Githinji Gitahi, head of Amref Health Africa, a Nairobi-based group working to improve health-care access across the continent.

"The view is that as long as the health threats are limited to African communities, it is all right for the world not to worry."

But if rich countries want to end epidemics that affect their own citizens, it's in their best interest to ensure low and middle income nations have the resources to stop the spread of disease, Gitahi said.

"Pandemics and disease threats start in a community," he said. "If you have one community that isn't safe, the whole world isn't safe in our current connectedness."

In a statement issued in June, WHO director general Tedros Adhanom Ghebreyesus acknowledged that African nations have "been neglected in terms of research, attention and funding."

"This must change for not just for monkeypox but for other neglected diseases in low-income countries as the world is reminded yet again that health is an interconnected proposition," the WHO chief said.

What's the solution?

One of the things that has to change is the monopoly that rich countries hold on vaccines and medications, including antivirals, African physicians and global health experts said.

During COVID-19, donations through the vaccine-sharing program COVAX helped, but they arrived in African countries too late, said Gitahi. "People died as they waited for vaccines."

In many cases, vaccines were unusable because they landed with "very little shelf life remaining."

In addition, by the time they arrived, people who would previously have lined up to get vaccinated had lost both the sense of urgency and trust in the health-care system, with a perception that they were receiving vaccines rejected by rich countries, Gitahi added.

LISTEN | African doctors say monkeypox response is another example of vaccine inequity: 

The path to even the playing field for low and middle-income countries, according to some experts, is to remove intellectual property protections on essential vaccines and treatments.

Rich countries invest enormous amounts of money in vaccine manufacturing companies during emergencies, said Titanji. That gives them leverage to make funding contingent on giving lower and middle income countries an equal chance to buy them at a fair price, she said.

Dr. Mary Stephen
Dr. Mary Stephen

But an even better solution, experts said, is to make sure Africa is able to mount its own emergency responses to epidemics, rather than being forced to wait for charities and rich nations to act.

"If we want to build a resilient system, there is much, much, much to do beyond just the donation of vaccines," said Dr. Mary Stephen, technical officer with the Health Emergencies Program at the WHO Regional Office in Brazzaville, Republic of Congo.

"Just imagine if …  countries on the continent were able to produce their own PPE, were able to produce their lab reagents, their test kits. [If] they were able to produce vaccines, medicines … it will go a long way," she said.

An important step in building that self-reliance has been the opening of the "mRNA Vaccine Hub for Africa" in Capetown, South Africa, supported by WHO. Scientists there have produced its first batches of COVID-19 mRNA vaccine.

As Africa works toward health care self sufficiency, it's important for the world to remember that the continent has already made significant contributions to global health, Titanji said.

For instance, African participants in many clinical trials have enabled the development of HIV/AIDS treatments received by patients in rich countries, she said.

Now that the world is confronted with monkeypox, Africa has decades of knowledge about the virus that wealthy nations are relying on, Titanji said.

"It's 50 years of research by African scientists, sometimes with incredible challenges to publish this data," she said of monkeypox studies, including one on health-care workers in Congo that tested the effectiveness of the Imvamune vaccine.

"We are building on that now to be able to address outbreaks in non-endemic countries, meanwhile, leaving the very people who contributed to that body of knowledge behind."

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