Similar to HIV, the colonial and postcolonial history is fundamental to the biology of this monkeypox outbreak.
In mid June, one of our good friends was sick with monkeypox (MPX) but was unable to get tested. He was in immense pain and couldn’t sleep, but only had proctitis and internal lesions. We wondered whether a test could detect the virus in his saliva, and a friend who was a clinician sent us a research paper. In this paper, one figure showed that it could, whereas another figure showed a lesion-pocked, bloody placenta and explained that the child who’d just been born had died.1
For the second time this decade, a virus is spreading in novel ways around the world. Viruses emerge from animal reservoirs on every continent, including the hantavirus in Southwest desert areas in the United States and the swine flu in 2009.2 However, novel viruses or old viruses that are spreading in new ways are often narrativized, using heartof-darkness imagery that imply these infections are foreign and the human populations they arose in are backward.
We argue that both the current MPX outbreak and the ongoing HIV pandemic proceed from the same flawed premise, in which we can separate the health of Black African individuals in the Democratic Republic of the Congo or Nigeria from the health of the communities we consider closer to home. This flawed premise incorporates an ugly reality, in which we view untreated pustules on Black individuals who live in Africa as unfortunate—but normal or expected—occurrences in that part of the world, even when effective vaccines and treatments exist. However, an outbreak of pus-filled boils on White individuals who live in London or New York City, for example, are a galvanizing tragedy, requiring immediate intervention.
We examine scientific data alongside social and political realities surrounding the emergence of 2 viruses: HIV and MPX. These viruses are fundamentally different: one is an RNA retrovirus that causes lifelong infections and the other is a DNA poxvirus that causes an acute infection. The reasons for their emergence both include a global biomedical infrastructure that doesn’t respond to crises until they belong to White individuals in the Global North. Importantly, continuing these patterns of research and health care resources allocation is a choice that can be undone.
CASE STUDY 1: HIV
HIV is a retrovirus that infects T cells, an essential component of the adaptive immune system. In the Western imagination, HIV emerged in the 1980s and initially impacted homosexual individuals, persons with hemophilia, heroin/ drug users, and Haitians (or known as the 4 Hs).3 Even when HIV had arrived in the United States, its impact was immediately othered. Of course, this pattern of infection would not last. Today, HIV among those with hemophilia is essentially nonexistent; structural factors render HIV still a crisis among queer and Black individuals, especially in the rural South, because of poor health care access.4
However, HIV did not emerge in the United States in the 1980s. It emerged in the region between Cameroon and the Congo and was first transmitted in an urban population under colonial rule in the Belgian Congo. Viral molecular phylogenetics tell this story plainly, one that maps in synergistic ways with the cultural and political story of the Congo. Viral sequencing shows the date HIV arrives in New York City, which was around 1969 from Haiti.5
HIV emerged in the Congo under Belgian rule between the 1920s and 1940s as a virus that largely impacted rural communities until the infrastructure and labor needs put in place by the Belgian lead to wider spread, especially in Kinshasa.6 This viral spread, which certainly included the deaths of many young individuals who were otherwise healthy, was entirely unnoticed by the biomedical infrastructure such as it was under Belgian rule. We may not have had the scientific understanding to isolate a novel retrovirus in the 1940s, as this was at the beginning of modern virology research, but a country with access to health care would notice rising unexpected deaths due to rare cancers and pathogens.
In 1960, the Congo liberates itself from Belgian rule. At independence, the Congo had exactly 0 Congolese doctors, engineers, or lawyers, according to the New York Times.7 Under explicitly racist colonial rule, Belgium forbade the Congolese from getting an education beyond the fifth grade. The extremely stringent exceptions included those adolescents intending to join the priesthood. Again, this is the context in which HIV spreads without detection for so many decades—a nation of 15 million people and no doctors.
A nation cannot build itself with no professional class, so to fill that void, the United Nations developed a program for many French-speaking Haitians to immigrate temporarily to the Congo to help train its first professional class.8 Regardless of the mode of viral transmission, wherever people move, an infectious disease will move as well. It is via this travel to and from Haiti that HIV permanently leaves the African context. HIV then travels from Haiti to New York City around 1969, and from there to the world.5
Similar to HIV, the colonial and postcolonial history is in Europe—largely but not exclusively queer sexual and social networks—has shocked many. Given our expertise in molecular microbiology and our knowledge of colonial history, we were not shocked. We argue that this situation must never be allowed to shock again.
Molecular biological analyses on HIV-positive samples found in various hospitals decades later show us this pattern,5 but the science alone does not explain it. The colonial and postcolonial history is fundamental to the biology of this ongoing pandemic.
CASE STUDY 2: MPX
MPX is an Orthopoxvirus, similar to smallpox, that causes a painful rash. Its animal reservoir is not monkeys but various rodent species in the previously endemic regions of Central and West Africa, including the Congo. Spillover in these regions is common, but human-to-human transmission has remained low for decades.9
In the Western imagination, MPX emerged as a serious problem sometime in mid-2022. Even then, as cases rose in US cities in early summer, many still wondered whether MPX was something we needed to worry about. The “we” in that sentence meaning ordinary US citizens. MPX was identified in 1958, and its human infection characterized in 1970 in the Congo (then Zaire).10 According to our imperfect epidemiology, it killed mostly children in the Congo and spread to Nigeria throughout the 1970s.10 In 2003, there was an outbreak in the United States, affecting at least 47 patients.11
Yet most deaths have occurred in Africa, where since 2017, Nigeria has faced another outbreak that includes consistent human-to-human spread for the first time on record.12 Because of the similarity between MPX and smallpox, effective vaccines existed even before MPX was discovered in humans in 1970. However, once smallpox was eradicated in 1980, vaccination ceased worldwide, even where it helped limit MPX spread.13
Similar to HIV, the colonial and postcolonial history is fundamental to the biology of this MPX outbreak. When the first human MPX case was discovered in 1970, the Congo’s national health infrastructure was barely 10 years old. At the time, a US-supported dictatorship ruled and steered the national economy into the ground over the next 26 years. By the mid-1990s, dysfunctional medical infrastructures left millions without realistic options for treatment during illness.
At the same time, travel between Congo (the colonized country) and Belgium (the former colonial power) has been common for decades. The same goes for travel between Nigeria and the United Kingdom. Hundreds of thousands of Congolese and Nigerians live in Belgium, France, and the United Kingdom, and multiple commercial flights serve this colonized-colonizer corridor every day, through which people regularly visit family, vacation, and conduct business. Under these circumstances—absent targeted research and intervention—widespread transmission of MPX into Europe was only a matter of time.
Despite these obvious connections, the research and categorization of MPX was relegated to “neglected” tropical diseases, which receive less research funding. Fifty-two years after its discovery in humans, we still don’t know basic information about MPX’s epidemiology, diagnostics, and virology. Is the virus systemic (eg, in saliva and blood) or just on skin lesions? Is the virus found in semen or vaginal fluids? What is the actual seroprevalence of the virus in various regions? How long does the virus live on surfaces, and what types of cleaning supplies are needed to remove it? The answer to these questions is simple: We don’t know.
A Nigerian doctor noticed the change in transmission through sexual encounters in 2017, and he “tried to warn health officials and scientists repeatedly,” he later told reporters from NPR.14 All the while, the US federal government let 20 million doses of its vaccine expire in a warehouse15; none of those doses were considered for use in the endemic region. It’s unclear whether this could have stopped enough transmission to prevent our current global catastrophe, but it’s possible. At present, Nigeria has no countermeasures to the virus, including vaccines and antiviral treatment.16 Nigerian queer activists remind us that queer individuals exist in every country, even where queerness is outlawed.17
The emergence of MPX into new social and sexual networks in Europe—largely but not exclusively queer sexual and social networks—has shocked many. Given our expertise in molecular microbiology and our knowledge of colonial history, we were not shocked. We argue that this situation must never be allowed to shock again.
Viruses emerge everywhere. The pattern of viral emergence in Africa and the spread among queer social and sexual networks is not biological. This pattern is because of centuries of systemic disregard for urgency in stemming all viral spread everywhere. Both HIV and MPX spread in queer sexual networks after their emergence in the Global North. That US society marginalized all 4 of the Hs we described above, which played a clear role in the slow US response to HIV.
The US government has been reluctant to respond to MPX, even as cases in queer individuals rose precipitously, deciding to activate only a small portion of MPX vaccines in response to this actual threat out of fear for a theoretical smallpox bioterrorism event.18 The World Health Organization panel recommended against labeling MPX a public health emergency because the virus was “only” spreading in men who have sex with men (MSM).19 Ignoring the suffering of a marginalized community dehumanizes them and normalizes their pain.
As HIV taught us, these viruses will ultimately impact everyone. We continue to envision health threats to Africa as marginally related to health threats in the rest of the world. This belief proceeds from the notion that African lives are marginally related to Western lives. This belief is neither logical, humane, nor scientific.20
We argue that the lens of who is considered like or among “us” must change. Not only does narrowing that lens lead to our own peril because our social and sexual networks are interconnected, but it is also inhumane to imagine that individuals in certain parts of the world populated by people of color may suffer from preventable illnesses, whereas the West, which is populated by a White majority, ought not.
We propose the first step toward change: As scientists begin to advocate for more research on MPX and more access to vaccines, they should explicitly include the endemic regions in that advocacy. Research capacity in all regions of the world, including African countries, is essential for self-determination and global public health. This is the first step toward shifting the imagined “us” in science and health policy to the “us” that exists in objective reality.
1. Pittman PR, Martin JW, Kingebeni PM, et al. Clinical characterization of human monkeypox infections in the Democratic Republic of the Congo. medRxiv. doi:10.1101/2022.05.26.22273379
2. Nelson MI, Vincent AL. Reverse zoonosis of influenza to swine: new perspectives on the human-animal interface. Trends Microbiol.2015;23(3):142-153. doi:10.1016/j.tim.2014.12.002
3. Farmer P. AIDS and Accusation: Haiti and the Geography of Blame. University of California Press; 2006.
4. Payne-Foster P, Bradley ELP, Aduloju-Ajijola N, et al. Testing our FAITHH: HIV stigma and knowledge after a faith-based HIV stigma reduction intervention in the rural South. AIDS Care.2018;30(2):232-239. doi:10.1080/09540121.2017.1371664
5. Worobey M, Watts TD, McKay RA, et al. 1970s and ‘Patient 0’ HIV-1 genomes illuminate early HIV/AIDS history in North America. Nature. 2016;539(7627):98-101. doi:10.1038/nature19827
6. Rodgers MA, Wilkinson E, Vallari A, et al. Sensitive next-generation sequencing method reveals deep genetic diversity of HIV-1 in the Democratic Republic of the Congo. J Virol.2017;91(6):e01841-16. doi:10.1128/JVI.01841-16
7. Gilroy H. Lumumba assails colonialism as Congo is freed. New York Times. July 1, 1960. Accessed August 15, 2022. https://archive.nytimes.com/www.nytimes.com/library/world/africa/600701lumumba.html
8. Jackson RO. The failure of categories: Haitians in the United Nations Organization in the Congo, 1960-64. J Haitian Stud.2014;20(1):34-64. doi:10.1353/jhs.2014.0001
9. Beer EM, Rao VB. A systematic review of the epidemiology of human monkeypox outbreaks and implications for outbreak strategy. PLoS Negl Trop Dis.2019;13(10):e0007791. doi:10.1371/journal.pntd.0007791
10. Breman JG, Kalisa-Ruti, Steniowski MV, Zanotto E, Gromyko AI, Arita I. Human monkeypox, 1970-79. Bull World Health Organ.1980;58(2):165-182.
11. Reynolds MG, Davidson WB, Curns AT, et al. Spectrum of infection and risk factors for human monkeypox, United States, 2003. Emerg Infect Dis.2007;13(9):1332-1339. doi:10.3201/eid1309.070175
12. Yinka-Ogunleye A, Aruna O, Ogoina D, et al. Reemergence of human monkeypox in Nigeria, 2017. Emerg Infect Dis.2018;24(6):1149-1151. doi:10.3201/eid2406.180017
13. Rimoin AW, Mulembakani PM, Johnston SC, et al. Major increase in human monkeypox incidence 30 years after smallpox vaccination campaigns cease in the Democratic Republic of Congo. Proc Natl Acad Sci USA.2010;107(37):16262-16267. doi:10.1073/pnas.1005769107
14. Doucleff M. He discovered the origin of the monkeypox outbreak — and tried to warn the world. NPR. July 29, 2022. Accessed August 15, 2022. https://www.npr.org/sections/goatsandsoda/2022/07/28/1114183886/a-doctor-in-nigeria-tried-to-warn-the-world-that-monkeypox-had-become-a-global-t
15. Kimball S. The CDC is sending monkeypox vaccines to people at high risk in a race to prevent the spread. CNBC. June 4, 2022. Accessed August 15, 2022. https://www.cnbc.com/2022/06/04/the-cdc-is-sending-monkeypox-vaccines-to-people-at-high-risk-in-a-race-to-prevent-the-spread.html
16. New York City Pandemic Response Institute. The 2022 Monkeypox Outbreak: Insights from around the World. YouTube. July 12, 2022. Accessed August 15, 2022. https://www.youtube.com/watch?v=9fixs_KpH7U
17. Blaise M. Queer Nigerians are being beaten by SARS — I’m trying to end that. Out.October 13, 2020. Accessed August 15, 2022. https://www.out.com/news/2020/10/13/endsars-queer-nigeria-homophobic-abuse-viral-matthew-blaise
18. Joseph Goldstein, Otterman S. As monkeypox spread in New York, 300,000 vaccine doses sat in Denmark. New York Times. July 25, 2022. Accessed August 15, 2022. https://www.nytimes.com/2022/07/25/nyregion/nyc-monkeypox-vaccine-doses-denmark.html
19. Second meeting of the International Health Regulations (2005) (IHR) Emergency Committee regarding the multi-country outbreak of monkeypox. World Health Organization. July 23, 2022. Accessed August 15, 2022. https://www.who.int/news/item/23-07-2022-second-meeting-of-the-international-health-regulations-(2005)-(ihr)-emergency-committee-regarding-the-multi-country-outbreak-of-monkeypox
20. Prescod-Weinstein, C. Making Black women scientists under White empiricism: the racialization of epistemology in physics. Signs: Journal of Women in Culture and Society. 2020;45(2):421-447. doi:10.1086/704991