Let's Talk About Monkeypox

Maybe you’d rather not. Hard same, friend. But that’s how we got into our current escalating-crisis situation: ostriching about uncomfortable things happening far away to other people. That’s how we humans get into messes far too often. It’s always someone else’s problem, until the day it becomes ours, too. So, let’s talk about monkeypox. Because this problem is all of ours now. 

This disease’s pace, unlike Covid’s stealthy sprint, is slow. It spreads through close contact, and we can feel fairly certain that’s true because so far during this outbreak, mostly men have contracted it, and mostly through sex. If it spread mostly through breathing, talking, or singing like Covid does, or if it was spreading rampantly via restaurant seats and hotel shower surfaces, we’d see more women with monkeypox by now. 

That’s where things stand right now. We’re still early in the outbreak, and risks of casual contact could change as the number of people with monkeypox rises. There are some women with monkeypox, and limited fomite and respiratory spread could be happening. It’s just not certain yet.

I don’t even want to hear this. 

No one does. But that’s a huge risk, too. If you can think of Covid as similar to pollen drifting on the air, you can think of monkeypox as grains of sand after a day at the beach. You’re less likely to huff a lungful of them, but they’re hard to clean up.

If monkeypox spreads widely—and by widely I mean a significant percentage of people in most towns eventually contract it—get used to wiping down groceries and gym equipment again. If dealing with paranoia about fomites sounds horrifying to you (it does to me!), we need to get on top of monkeypox and ramp up responses even more now, while it’s still a series of dust devils, rather than waiting until it coalesces and blankets the world in a storm.

I don’t like sand. Wasn’t that a movie quote?

One of the worst movie quotes ever. Though, apparently, that’s debatable. Anyway.

If we can get a handle on this monkeypox outbreak (and that’s a big if), then the next steps are the steps we should have taken back in 2019 when safer third-generation smallpox vaccines first got licensed: 

• We need to vaccinate people who live in endemic areas (including any new endemic areas that result from the current outbreak).  

• We need to begin routine childhood vaccination for people who live in endemic areas. 

• We need to offer vaccination in travel clinics, like we do for yellow fever, typhoid, and other endemic but preventable diseases. 

We’ve ignored the suffering of people in endemic countries as if they don’t exist or matter (and we’re still doing it! No one in Nigeria has received a monkeypox vaccine yet), but that worldview is awful, and we are reaping the harvest of those callous decisions. Everybody matters. No one deserves to suffer. And we cannot pretend viruses understand national boundaries. Wealthy nations need to invest in global health as a long-term strategy.

And, more broadly, we need to improve our identification of potentially critical risks—and our willingness to respond while they are still small. Even if they aren’t directly affecting us yet.

So how do we find these needles in haystacks before they stab us?

An important anomaly isn’t “a needle in a haystack,” at least not for long. It’s often hundreds of needles, all surfacing at once, glinting in the sunlight if we’re willing to look and accept what we see.

In general, important anomalous risks start under the radar, like the initial Covid outbreak in early January 2020, the 2014 Ebola outbreak, and early reports on climate change from the 1970s to the 1990s. But they have a few distinctive characteristics:

1. They are unusual. They break from the patterns of the past. In an outbreak, for example, doctors notice something unexpected and flag it up the chain of reporting:

• Maybe a disease is appearing in urban areas instead of rural areas. 

• Maybe it is appearing in greater numbers than expected. 

• Maybe cases appear milder than expected, with different patterns of symptoms. (Yes, a good difference can be an early-warning flag!)

All three of these things are true for monkeypox.

To give another example, in looking at climate data, scientists noticed divergence from long-term trends decades ago. That was a flag, one we should have heeded as an opportunity to take early action.  

2. They are suddenly widespread in small numbers. Early in 2020, it was easy to think of the Covid outbreak in Wuhan as contained by heavy lockdowns. But then cases popped up in Iran, in Italy, and all over the world. That was a massive flag, and we could have acted earlier. (Even if we had, it’s still uncertain whether we could have contained Covid, since it’s so contagious. But we squandered some opportunities to try before it evolved to make that impossible.)

Early in the monkeypox outbreak, it was easy to think of the outbreak as contained within MSM populations (men who have sex with men). But small numbers of cases were appearing simultaneously in many countries globally. That pattern implied a super-spreader event or events and warranted greater alarm and louder warnings. Governments could have acted decisively to contain the disease then. 

With climate change, temperatures aren’t rising in lockstep everywhere, and that may always be true because climate isn’t a single monolithic entity; it fluctuates day to day, season to season, year to year, place to place. But on average, more places are recording higher temperatures than ever before. Warming is widespread. We could have acted earlier when we saw this trend, before we recorded the seven highest global average temperatures in history in the last seven years.

3. They seem relatively ignored or dismissed. The biggest risks may not be pre-built into models, or the assumptions used may not match what will actually happen. (I’d like to see companies’ 2019-era projections for office attendance during a pandemic.) It takes some time to adjust and account for emergent risks. Many poorly performing individual mortgage securities in 2006 and 2007 were largely ignored, buried under mounds of models that predicted better outcomes for large bundles of those same securities.

And monkeypox was previously thought to be a self-limiting, benign disease that tended to burn out after a few links in the human-to-human transmission chain. It has changed, but it takes a while—too long—for people’s models to catch up with those unanticipated changes. That’s precious response time lost.

There are many other examples in history. By August 2001, a “stream of warnings” was flowing in to intelligence agencies (both unusual and relatively widespread chatter). It was identified and flagged up the chain. But that risk was ultimately dismissed, and we lost a potential opportunity to mitigate the 9/11 attacks. 

Even if anomalies can be identified sooner, what then?

In risk management, in the window before an incident may occur, overreaction is likely better than under-reaction. That doesn’t mean going down the Minority Report path, which creates even greater risks to human life and liberty in the name of security. That would be a terrible idea. But within the realm of reasonable precautions, overreacting is the best way to stop an unfolding crisis in its early stages.

Taking a long-term perspective, it’s easier to take stronger steps at the outset and then relax that stance over time. And it’s much harder to take a relaxed stance at the outset and then try to catch up when a problem is much larger.

Unfortunately, incentives often favor short-term perspectives over long-term ones. In the short term, taking a strong stance can feel incredibly difficult, even silly, possibly demotion-worthy, while taking a relaxed stance may feel logical and reasonable. After all, everything looks fine out there in the world, if you don’t squint too hard. And if you take strong action and solve a problem, and everything still looks fine…. you’ll look like someone who overreacted.

But a public health axiom puts it differently. As Dr. Sanjay Gupta wrote in a recent CNN essay: “if you think you are overreacting, you are probably reacting just the right amount.” Proactive success often looks like overreaction: that’s the inherent nature of risk management victory. And that’s why risk management requires persistence, humility—and bravery. Each individual’s incentives are to minimize risks to their career. But collectively, that risk aversion can allow real systemic risk to balloon, until it’s far larger and more difficult to mitigate.

What’s the takeaway?

Keep these three key principles in mind for spotting important anomalies: Unusual. Widespread in small numbers. Largely ignored or dismissed.

By recognizing these situations quickly, observing just long enough to confirm what you think you’re seeing, and then responding at a moment when you may appear to be overreacting, you greatly increase your chances of risk management victory.

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Extra, Extra!

Three links from the depths of my bookmark archives; tangential extras for curious readers: 

1. Heat map shows clear trend in global temperature change - by the Climate Council - crystal-clear infographic of the warming trend over time, and the earlier points when we could have identified that trend.

2. Meet the man who sold his fate to investors at $1 a share - by Joshua Davis in Wired - post-modern performance art, disturbing but also interesting since this person did this by choice.

3. Global Warming Science - by Kerry Emanuel, Dan Cziczo, and David McGee at MIT via edX - archived, but you can still watch the course videos and answer self-assessment questions.