Mpox, Numbers, and Reality

Public health responses are most effective when they are grounded in reality. This is particularly important if the response is intended to address an “emergency,” and involves the transfer of large amounts of public money. When we reallocate resources, there is a cost, as the funds are taken from some other program. If the response involves buying lots of products from a manufacturer, there will also be a gain for the company and its investors.
So, clearly, there are three obvious requirements here to ensure good practice:
1. Accurate information is required, in context.
2. Those gaining financially can have no role at all in decision-making.
3. The organization tasked with coordinating any response would have to act with transparency, publicly weighing costs and benefits.
“… during the first six months of 2024, the 1854 confirmed cases of Mpox reported by States Parties in the WHO African Region account for 36 percent (1854/5199) of the cases observed worldwide.”
Mpox is endemic to central and west Africa, being present in species of squirrels, rats, and other rodents. While it was identified in monkeys in a Danish lab in 1958 (hence the misnomer “monkeypox”), it has probably been around for thousands of years, causing intermittent infections in humans between whom it is spread by close physical contact.
The WHO is a large organization, and while some there have been on the hustings asking for money, others have been working hard to accurately inform the public (a core responsibility of the WHO, which retains some dedicated people). Like much of the WHO’s work in the past, this is thorough and commendable. Some of this information is summarized in the following graphics:
These charts provide data on confirmed cases, where someone with somewhat non-specific symptoms has been tested and shown to have evidence of Mpox virus in blood or secretions. Clearly, not everyone suspected can be tested, as Mpox is a very small issue for people facing civil wars, mass poverty, and vastly more dangerous diseases.
However, the WHO has absorbed a lot of money for outbreak investigation, and so have partner organizations, so we can assume there is a fairly good effort going on to detect and confirm numbers (or where has this money gone?).
In the past 2.5 years, the WHO has confirmed 223 deaths in the whole world, with just six in July 2024 (the time when the WHO director-general warned the world of a rapidly increasing threat). Note here that 223 deaths are just 0.2 percent of the 102,997 confirmed cases. In Africa, just 26 deaths have been confirmed in 2024 among 3,562 cases (0.7 percent), spread across 5 countries (and 12 countries with cases). They are influenza-like mortality rates, not Ebola-like.
As is obvious from the third graphic below, nearly all the global deaths listed above were from the previous outbreak in 2022. This was a different clade (variant) and mostly occurred outside of Africa.
Why has the WHO declared an international emergency? Some claim it helps mobilize resources, which is a bit pathetic. Firstly, grownups should be able to discuss a situation that has persisted for two years in a rational manner and decide what might be needed, without banging a drum. Secondly, an outbreak that is killing a tiny fraction of malaria (or tuberculosis, or HIV) deaths, and far less than those currently dying in war, may not be an international emergency.
And what should be done? Diverting resources from DRC’s major priorities would undoubtedly kill far more than are currently dying from Mpox. It is quite probable that direct adverse events from vaccination alone will kill more than the 19 DRC Mpox victims confirmed this year. We likely undercount Mpox deaths, but we also undercount pharmaceutical deaths.
Perhaps a useful response would be to improve immune competence through nutrition, providing very broad benefits (but completely failing in terms of Pharma profit). Gavi’s half-billion dollars would provide vast and broad-based benefits if applied to sanitation. Perhaps limited, well-targeted vaccination may also help some communities, but there is no business case for such approaches.
What is clear, as noted above, is the following:
1. The data on Mpox, and other competing priorities, must continue to be shown in context, along with costs and opportunity costs of the response.
2. Those who will gain financially from vaccinating millions of people must not be part of the decision-making process (whether or not such a huge resource transfer can possibly be supported for such a small disease burden).
3. The WHO should continue to act with transparency, as the public has an absolute right to know what they are paying for, and the harm (and perhaps benefit) they can expect from it.
The number of Mpox deaths will rise as more are infected, and perhaps as some suspected cases are confirmed. However, we are facing a small problem in an area with far larger ones. It is posing low local risk and minimal global risk. It is not a global emergency, by any sane, rational, public health-based definition.
The rest of the world can respond by sending vaccines and lots of foreigners who need looking after, diverting local health and security personnel and almost certainly killing more DRC residents overall. Or, we can recognize a local problem, support local responses when local populations ask, and concentrate, as the WHO once did, on addressing the underlying causes of endemic disease and inequality. They are the things that make the lives of people in DRC so difficult.