What You Need to Know About the History of Monkeypox

Since it was first identified in a colony of monkeys in Copenhagen in 1958, monkeypox has been largely overlooked by the Western world. An infectious poxvirus that causes fever, chills and rashes, the disease is endemic, or consistently regionally present, in ten African countries. Until recently, however, it was rarely found in Europe and the Americas—a trend that has, historically, led Western public health officials to disregard its spread elsewhere.

“It’s a phenomenon of ‘not in my backyard,’” says Martin Hirsch, editor in chief of the Journal of Infectious Diseases and an immunologist at Harvard University. “There’s not much interest in Western health groups about something that’s only circulating in Africa.”

This May, as news broke of a multicountry monkeypox outbreak, sensationalized headlines and public hysteria (much of it tinged with racism and homophobia) suggested that the disease was poised to kick-start another pandemic. But while there’s cause for concern—at least 2,103 cases have been recorded in 42 countries, and the disease appears to be spreading more rapidly than before—monkeypox is not a novel threat. Western countries that previously paid little attention to the disease can learn much from African scientists who have studied it for decades.

Believed to have been circulating for thousands of years, monkeypox is mired in misconception. Even its name is something of a misnomer: Monkeys (and humans) are just incidental hosts of the disease, which is thought to be found primarily in rodents. While monkeypox is more common in central and western Africa, it’s misleading to describe the virus as “being African,” wrote more than 20 scientists in a recent paper detailing the need for a nondiscriminatory, nonstigmatizing name for the disease. (Monkeypox will soon be renamed to reflect this aim.) In fact, the virus’ continued presence in Africa is largely the result of unequal access to global vaccine stockpiles and health care resources.

“Remember, the first monkeypox was actually found in a laboratory in Denmark, not Africa,” says Oyewale Tomori, a virologist at Redeemer’s University and the former president of the Nigerian Academy of Science.

A cousin of the far deadlier smallpox virus, monkeypox primarily spreads through direct contact with an infected person’s bodily fluids, sores or scabs. Airborne exposure through respiratory droplets is possible but less common and admittedly understudied.

The current outbreak appears to be spreading mainly among men who have sex with other men (MSM)—a trend that has drawn parallels with the HIV/AIDS epidemic, which disproportionately affected the LGBTQ community at its height in the late 1980s and early ’90s. Scientists are not entirely sure why the disease is spreading this way, but early findings suggest it “may have made its way into highly interconnected sexual networks within the MSM community, where it can spread in ways that it cannot in the general population,” per Science magazine.

The story of monkeypox and poxviruses more generally is part of a larger narrative about global health inequities and scientific progressivism, which refers to how science is often portrayed in an irrevocably linear, victorious way that elides the incremental nature of most discoveries. Amid the current outbreak, monkeypox’s long-neglected history renders the disease simultaneously obscure and subject to heightened scrutiny—both to the detriment of public health.

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Monkeypox’s past is inextricable from that of smallpox, which is believed to have first appeared around 10,000 B.C.E. One of humanity’s deadliest diseases, smallpox killed more than 300 million people worldwide in the 20th century alone. From sniffing up dried smallpox scabs to puncturing people with iron needles dipped in smallpox pustules, communities in Africa, India, China, Turkey and other non-Western nations have long sought to prevent the virus’ spread. (These measures, known as inoculation or variolation, involve immunizing a patient by infecting them with a mild form of a virus.) But inoculation only arrived in Europe in the early 18th century, when Lady Mary Wortley Montagu, wife of the British ambassador to the Ottoman Empire, brought the practice back to England after learning about it from Turkish women.

Around that same time, in 1721, a smallpox epidemic in the colony of Massachusetts led Reverend Cotton Mather and physician Zabdiel Boylston to similarly experiment with the procedure. Today, celebrations of the pair’s tenacious efforts tend to erase the contributions of Onesimus, the enslaved man who introduced Mather to inoculation—a practice Onesimus learned in his native West Africa. Otherwise, much about him remains unknown, including his original name and place of birth. As Princeton historian Elise A. Mitchell explains, “The silences surrounding Onesimus are produced at … four moments: His history is obscured in Mather’s records, the archives, our historical narratives and our sense of his historical significance.”

Inoculation’s roots in non-Western cultures made the practice highly contested, condemned as everything from Orientalism to an African conspiracy. In Boston, a local doctor—the only man in the city with a medical degree—decried it as a plot by enslaved Africans to infect their enslavers. The backlash was so intense that someone threw a bomb through the window of Mather’s house, attaching a warning that read, “Cotton Mather, you dog, dam you! I’ll inoculate you with this; with a pox to you.”

What is popularly known about the history of smallpox generally begins and ends with Edward Jenner, an English surgeon who performed the world’s first vaccination in 1796. Powel H. Kazanjian, an infectious diseases physician and historian at the University of Michigan, says that Jenner is at the forefront of this history because he feeds neatly into the story of Western medicine’s authority.

In all likelihood, the commonly cited tale about Jenner’s discovery of vaccination is flat-out wrong. Popular lore suggests that Jenner saw the “rosy, unblemished complexion” of a local milkmaid and theorized that infection by cowpox would offer protection against smallpox. But this “Myth of the Milkmaid,” in the words of pathology expert Arthur W. Boylston, neglects the work of country doctor John Fewster, who discovered the protective nature of cowpox in the 1760s, decades before Jenner. Boylston argues that Jenner’s biographer invented the milkmaid story to safeguard his subject’s reputation and allow a more triumphalist narrative to take root, rather than one based on gradual scientific progress.

What was truly heroic, according to Hirsch, was the smallpox eradication effort, which he describes as “one of the great hallmarks of Western medicine.” While the aim had long been discussed, only in 1959 did it become an explicit goal of the World Health Organization (WHO). The year prior, Viktor Zhdanov of the Soviet Union presented a theoretical foundation for eradicating smallpox at a Minneapolis meeting of the World Health Assembly. In an attempt to rally support, Zhdanov quoted a letter from President Thomas Jefferson to Jenner: “It is owing to your discovery … that in the future the peoples of the world will learn about this disgusting smallpox disease only from ancient traditions.”

At the time, the WHO’s director-general estimated that eradicating smallpox from endemic regions would require vaccination of 80 percent of the population and cost nearly $100 million. But lack of funding, vaccine donations and personnel stalled the program for several years. India, for instance, had to halt its ambitious eradication effort when emergency appeals for vaccines went unheeded.

In 1967, the WHO reignited the initiative under the moniker the Intensified Smallpox Eradication Programme (SEP). A confluence of factors sparked the fresh interest, including the appointment of WHO leaders who were bullish about the project, technological developments that enabled mass vaccination (such as the jet injector and bifurcated needle), and greater commitments of support from the United States. The organization’s strategy eventually moved away from mass vaccination to identifying new cases, isolating the infected and vaccinating all potential close contacts. Ten years later, the last endemic smallpox case was recorded in Somalia; in 1980, the WHO declared smallpox eradicated.

But this milestone came at a significant cost. Then a United Nations medical officer, American epidemiologist Lawrence Brilliant described the extreme lengths of public health officials’ surveillance and containment strategy in his 1985 book, The Management of Smallpox in India. As Brilliant wrote, Operation Smallpox Zero began in 1975 with village-to-village searches that soon escalated into house-to-house and room-to-room searches. Patients with a rash and fever were found guilty of having smallpox until proven innocent, and informants received cash rewards for identifying those infected. Guards were posted to contain isolated individuals, and teams on motorbikes and Jeeps combed through all villages within a ten-mile radius of known (or suspected) smallpox cases. Everyone in a one-mile radius was given the vaccine, regardless of whether they had already been vaccinated.

Paul Greenough, a historian at the University of Iowa, argues that the last steps of the vaccination campaign in South Asia were rooted in intimidation, coercion and resistance. Expatriate epidemiologists, many of them from the U.S., descended onto India and Bangladesh. Given fuel, transportation and cash not typically afforded to local health officials, these epidemiologists were officially considered advisors but operated with impunity. Their singular focus on smallpox, to the exclusion of all other concerns, made their eradication efforts ring hollow with the locals. In one case study described by Greenough, a starving Bangladeshi woman refused the vaccine until she was given food. As senior WHO epidemiologist Stanley Music recounted, “She said that if I didn’t care whether or not she died of starvation, why should I care if she got smallpox!” She was vaccinated without her consent.

In an unpublished dissertation, Music offered more details on the program’s relentless approach:

The initial stage in the evolution of a coherent containment policy was marked by an almost military-style attack on infected villages. … In the hit-and-run excitement of such a campaign, women and children were often pulled out from under beds, from behind doors, from within latrines, etc. People were chased and, when caught, vaccinated.

With the SEP hanging in the balance in South Asia, the ends, officials concluded, justified the means.

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Smallpox vaccines provide some protection against the closely related monkeypox virus. Since the 1970s, though, many countries have stopped vaccinating against the now-eradicated disease.

The first case of human monkeypox was identified in a 9-month-old boy in the Democratic Republic of Congo in 1970. The WHO subsequently reported 54 cases between 1970 and 1979 and 338 cases between 1981 and 1986; given high smallpox immunization rates during this period, the increase was probably the result of increased surveillance and case identification.

Over the past 30 years, amid waning smallpox vaccine coverage, Africa has reported dozens of monkeypox outbreaks and an untold number of cases, at least in the tens of thousands. In the U.S., however, these events “didn’t really raise any alarm,” says Hirsch.

A 2003 outbreak of monkeypox in the U.S. proved to be a different story. Three-year-old Schyan Kautzer was the first person infected in the country. Red welts flared all over her body after she was bitten by one of her two pet prairie dogs. As Kautzer’s mother told the Washington Post, “The bite on her finger just kept getting bigger and bigger. All she did was sleep or cry. She couldn’t eat anything. Her glands swelled up so much on her neck you could see them popping out.” One of the family’s prairie dogs died, but they kept the second, named Chuckles, after he made a full recovery.

In total, the Centers for Disease Control (CDC) recorded 71 monkeypox cases during the outbreak. Most of the patients had been around prairie dogs, with human-to-human transmission not suspected as a source of infection. The culprits behind the outbreak were likely Gambian giant pouched rats that had been imported from Ghana and housed next to a shipment of prairie dogs. After the CDC banned the importation of African rodents into the U.S., the outbreak was quickly controlled—and forgotten.

While Western countries have largely avoided other monkeypox outbreaks, African countries haven’t been so fortunate. Between November 2005 and November 2007, a study found that monkeypox cases in Congo spiked 20-fold compared with the 1980s. In Nigeria, a severe 2017 outbreak occurred almost 40 years after the country’s last reported case. Again, the response outside Africa was minimal. “Why should the West care?” Tomori asks.

Monkeypox is the latest example of a disease being neglected by countries not yet affected. Similar responses—or lack thereof—took place with Ebola, Zika and countless other infectious diseases. “That’s the troubling, disconcerting thing,” says Kazanjian. “We only care about people in our own land.”

He adds, “Once the victim changes, concern about the disease heightens.”

Indeed, reminiscent of Covid-19 vaccine hoarding, Western countries have been buying up smallpox vaccines from biotech company Bavarian Nordic, which recently entered into a series of lucrative deals with multiple undisclosed nations. Last week, the WHO announced plans to share some of the 31 million smallpox vaccines in its stockpile, sparking speculation that the agency will end up “distributing scarce vaccine doses to rich countries that can otherwise afford them,” per the Associated Press (AP).

In Africa, where case counts are currently three times higher than usual, conservative treatments remain the norm, with vaccines and antivirals unavailable in much of the continent. This year, officials have reported more than 1,400 cases and 66 deaths in Cameroon, Central African Republic, Congo and Nigeria, according to the Africa Centers for Disease Control and Prevention. But public health officials have “no clear path for how poorer countries [like these ones] will be able to get vaccines,” Brook Baker, a law expert at Northeastern University who studies access to medicine, tells the AP.

As Baker predicts, “Rich countries will protect themselves while people in the global south die.”

Media coverage of the outbreak has reflected Western bias, too. Many news reports featured images of Black monkeypox patients, making them the face of an outbreak that’s in the headlines because it has spread to Europe and the U.S. “This is your pox, not ours,” Tomori says. “Why are you putting the figure of a person who is not from Europe?” The racialized images have, in turn, elicited fear among Western audiences and perpetuated a narrative of an “African” disease and an epidemic-ridden continent. “This wild thing from Africa,” Tomori scoffs. “Newspapers sell better when you have some exotic story to put out there.”

The history of poxviruses has long been characterized by a certain myopia, with the early work of African, Indian, Chinese and Turkish civilizations; Onesimus’ contributions to Boston’s inoculation campaign; and vaccine coercion by the SEP all overlooked. Monkeypox is the latest casualty of this myopia, historically neglected and dismissed.

The stakes are high. Beyond its racist and homophobic overtones, the global monkeypox response has been fraught with other problems, including significant underreporting, testing bottlenecks and CDC-WHO feuding. Experts are also concerned that monkeypox could “take up permanent residence in wildlife outside of Africa,” making outbreaks more frequent and potentially creating new variants, per Science magazine.

“The world is a small place,” Tomori says. “This is not an African thing; it could happen anywhere.”

Simar Bajaj | | READ MORE

Simar Bajaj is a student at Harvard University studying the history of science and a research fellow at Massachusetts General Hospital and Stanford University School of Medicine. He has previously written for the Washington Post, Guardian, TIME Magazine, and New England Journal of Medicine.