Who’s Most at Risk of Monkeypox as It Spreads

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Monkeypox is currently spreading mostly within the queer community, but experts warn the diseases could expand its reach into other groups where skin-to-skin contact is common, from wrestling teams to spas. Guest host Stephanie Wittels Wachs speaks with Dr. Jay Varma and scientist and queer activist Joseph Osmundson about why cases continue to spread, including a poor rollout of available vaccines, treatment, and testing. They also discuss how to stay protected if you or a loved one is in an at-risk group.

Keep up with Andy on Twitter @ASlavitt.

Follow Dr. Joseph Osmundson and Dr. Jay Varma on Twitter @reluctantlyjoe and @DrJayVarma.

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Jay Varma, Andy Slavitt, Joseph Osmundson, Stephanie Wittels Wachs

Stephanie Wittels Wachs  01:34

Welcome to IN THE BUBBLE. I am not Andy Slavitt. I am Stephanie Wittels Wachs. Today is Friday, July 29th. And I am here today in Andy’s place so he can rest up and be peacefully bored in isolation. We touched base with him today and he promises to be back soon. He says he’s doing okay he’s just pretty exhausted. So we are wishing him a speedy recovery. I had COVID for the first time a few weeks back. It is absolutely no fun. But we are all rooting for you Andy get better soon so you can have your job back. Today we are going to talk about a different virus that I’m sure you’re hearing a ton about these days. Nearly a week ago the who declared monkeypox a global health emergency. And right now the US has reported over 3500 cases of monkeypox, which means we are now the country with the most infections globally. And what’s concerning on top of these numbers is that the public health response to the outbreak here has been relatively slow. So today I am joined by two terrific experts who are going to help us understand what’s going on and what we can do about it. So first Dr. Joseph Osmundson is here. He is a professor of microbiology at NYU and the author of a new book called virology that is fitting. Thank you for being here, Jo.

Joseph Osmundson  02:54

Thank you so much for having me.

Stephanie Wittels Wachs  02:56

And also we have Dr. J. Varma, J is the director of the Cornell center for pandemic prevention and response and previously led New York City’s COVID-19 pandemic response. That is very impressive. Hi, Jay.

Jay Varma  03:10

Thank you for having me.

Stephanie Wittels Wachs  03:12

Absolutely. So let’s start here. Back in April, I remember Andy did a show on monkey pox with Dr. Anne Rimoin. And I remember listening to that conversation and thinking it was concerning, but maybe not immediately dangerous here in the US. That is no longer the case. So how did the monkey pox outbreak move so quickly here? Jay, let’s start with you.

Jay Varma  03:34

Yeah, so I guess just for your listeners to understand, you know, monkey pox is an infection that has historically been thought to only be limited to a certain regions in Africa, mostly central in West Africa, and was historically thought to primarily result from human interaction with some animal, often rodents, but it could be other animals as well. And then an infection would arrive in a person and then they may transmit to their household contacts or to other people in the hospital, through skin to skin contact. What happened in this outbreak is that for reasons that are still trying to be understood, it started to spread very rapidly among gay, bi, and men who have sex with men sexual networks, in many different European cities. So as soon as they got into those sexual networks, you know, these are settings and Joe can talk about this, you know, in more detail, the sociology of this. These are networks that we consider dense social networks, you know, if I know 10 people and all my 10 People also really no 10 people, a disease is going to spread faster than if I’m kind of a loner. And the sexual networks are places in which diseases can transmit faster because a lot of people are in close physical contact with each other. And so it was really in kind of mid-May that I think many of us started to get very alarmed because we know that disease first of all, is unlikely to stay in any one part of the world even if it’s an if Africa which people consider remote even though it’s not. And second of all, once it’s in major European cities. Of course, the connection to the US is much more rapid.

Joseph Osmundson  04:59

Yeah, but what But Jay calls dense social networks I just call a good time. Yeah, you know, I’ve I’m so frustrated by so much of the discourse around this. And almost by the surprise, if you look at the research, you know, I’m trained as a molecular microbiologist. And if you look at the research, going back decades, it’s pretty easy to understand that this was going to be a problem, you know, the globe stops vaccinating for smallpox somewhere around 1980, when the disease is determined to be eradicated by the WHO. And of course, that vaccine protects also against monkey pox. So from 1980 through 2010, you have more and more spillover from animals and more and more subsequent human to human transmission, as the immunity for both smallpox and monkey pox shifts in those countries. Since 2017, there’s been ongoing human to human spread in Nigeria. And you know, as someone who spent time in London, I, of course, know that people of all different sexual orientations go back and forth from Lagos to London all the time, we are living in an increasingly interconnected world. And there are queer people in Nigeria, hello, like this is none of this is a surprise. You know, the real shock is that we let 28 million doses of the Geneious vaccine expire in the American stockpile, without using those doses in the endemic region in Nigeria, and 2017 and 2018 through now, when you have common human to human spread, you know, that’s in our national interest, of course, because that could have potentially prevented this global spread. But I would also like to say that everyone on planet Earth deserves biomedical interventions when they exist, and so hoarding vaccines away from the most affected countries, and the most affected individuals is amoral and ultimately turns out, of course, to harm us all globally.

Stephanie Wittels Wachs  06:53

You are such an overachiever, because we are going to get so deep into vaccines in a minute here. But for now,  before we get to those, can we talk about this, this risk group for a second? So men who have sex with men are at highest risk right now. But anyone can get it? I mean, I have a four year old going back to school next week, germ factory daycare. You know, is this something that I should add to my list of worries is this, you know, specific to this group? Can you talk about that a little bit, Jo?

Joseph Osmundson  07:25

You know, I think, you know, the vast majority of cases have been confined to the sexual networks of men who have sex with men. That doesn’t mean that it won’t reach outside of those communities that it already has. But it also doesn’t mean that you know, you’re talking about a toilet and a school is going to give hundreds and hundreds of cases, we don’t see that in the epidemiology in western Central Africa. And we don’t see that about around household transmission. Outside of the endemic region, I’m much more worried about places where MDR MRSA, an outbreak in 2008 that started in gay men, which again, is a skin infection that involves close skin to skin contact. Subsequent to the initial outbreak and gay men, there were huge outbreaks in wrestling teams, and it actually led to a death of a young wrestler, right? So I’m thinking much more about other places where there’s intense, long term skin to skin contact football teams, wrestling teams or sharing of clothes. I’m you know, I was a band nerd growing up, I’m thinking about the person handling all those band uniforms, right? Like touching hundreds clothes from hundreds of people. It’s much more about those high risk sites. And then, you know, I’m writing a piece with my friend Saskia, right now about getting ahead of that, moving the messaging away from just gay men and our sexual networks, to touch, to physical interaction between bodies and clothes.

Stephanie Wittels Wachs  08:48

Yeah, I just had a flashback to my theater days in high school and how absolutely filthy those costumes were. And yes, yes, really took me to a place there. Thank you for that memories.

Joseph Osmundson  09:00

Like trauma, like my band nerd and your theater nerd. It’s like, monkey pox is just pulling it out of us. It’ll never leave us alone.

Stephanie Wittels Wachs  09:07

Yeah. Jay, anything to add to that?

Jay Varma  09:09

Yeah. I mean, I think this has been one of these tragic thing that gets tortured by social media, right? Just because something is possible, doesn’t mean it’s equally likely. And you know, I think what many of us who have been sounding the alarm about this or saying is that diseases don’t stay in a social network just because of geography or because of behavior, right? They will always bridge to other places. People travel, people have partners that are outside their sexual networks, they have household contacts. So we’re really trying to say is that there needs to be this sort of Full Frontal push on limiting transmission within the network. It’s defined in right now because right now it’s fairly tightly linked to that, you know, there’s going to be sporadic cases here. But if we don’t get this under control, which is the problem we’re facing right now, these other modes of transmission then do become more common. You could see the outbreak in the wrestling team or other places as well. So, so that’s what we’re really trying to get ahead of. And it’s a lesson that we’ve all learned from infectious diseases that you can fall very, as soon as you fall behind on an infectious disease outbreak you are, you know, even further behind than you want to be because it just takes that much longer and that much more money to catch up.

Joseph Osmundson  10:13

And I just want to add, before we move on very quickly, that like, there are patterns of viral spread in America. And we know where they go, right? Is the story of HIV in the last two decades, HIV new infections are coming up every year. And they’re largely coming up in the rural south in places where people are away from health care. So just what Jay said, if we don’t get ahead of this and contain it as much as we can, and then networks is spreading and now it is more and more likely to get into these networks where people constantly are suffering worse from health care outcomes and viruses specifically, and where we very difficult to contain the spread of the virus because people are so far removed from access to health care.

Stephanie Wittels Wachs  10:57

Yeah, that makes a ton of sense. Let’s take a quick break. We’re gonna come back and talk about why testing and treating monkeypox is still not where it should be. I’d like to talk about treatment and testing. So let’s start with testing. Joe, I know you’ve written that you’re in touch with friends, people in your social networks in New York where there’s a significant outbreak right now. What are you hearing about access to testing? And what is testing like right now?

Joseph Osmundson  14:11

Yeah, you know, when we face an infectious disease, and in this way, we’re quite lucky with this virus because there are known tests, FDA approved treatments that are likely to work and vaccines that are FDA approved as well. But access has been a real issue and of the three pillars the testing treatment and vaccines. Testing is really the only place where we’ve seen any movement, testing is appreciably better than it was three weeks ago. But it came too late to colleagues […] and I wrote in the New York Times in May, arguing that we were clearly missing cases because most of our cases were not linked to one another nor to travel. That’s a signal that you’re missing cases. And anytime where you’re in an infectious disease response where you You’re missing the majority of cases and you have a test; it is time to get ahead and to scale with every possibility, the access to that test. And what we saw is until mid-July, it was, you know, The Hunger Games that we talked about for getting vaccines, it was the same issue for testing, people were being presumed positive by departments of health without being able to access the diagnostic test, which is a simple PCR test. It’s not complicated molecular biology, colleagues or friends in San Francisco, were reporting a seven to 10 day test turnaround time, because the labs were so overwhelmed. I mean, epidemiological we don’t even know right now, if the cases that we’re counting are reflecting new spread, or catching up on the size of the epidemic as it was before, or most likely, both. But it’s impossible to really understand even what’s happening now, even though our testing capacity is significantly better.

Stephanie Wittels Wachs  15:58

And Jay, what kind of treatment is available right now and how is it being distributed?

Jay Varma  16:03

So there are really only kind of two recommended approaches that can help you with the disease itself, there’s quite a number of ways to help care for people with monkeypox, you know, because it’s been very uncomfortable disease. But let’s talk about treatment. So the first is if somebody’s been exposed to monkey pox, and they’re identified quickly enough. And I’ll just point out the fact that that is basically a fictional scenario at this point, that doesn’t happen anywhere in the US people are not being identified quickly enough that you can identify who they expose. But in the dream scenario, where testing is widespread cases are being caught very early, you’re able to do an investigation and find that either context on, you can offer a vaccines. And the advantage of a vaccine is that when applicable early enough, because this disease has a relatively longer incubation period, it can either stop you from developing the disease or give you a lower severity of disease. So that’s one opportunity is to offer vaccination to people who are exposed and a very high risk of getting infected. The second form of treatment is a drug called Tecovirimat, which is Joe and I have written about in an essay and thankfully, a lot of work by many different people across the spectrum from community activists to medical professionals, to scientists have pushed in this is a drug, interestingly enough that, you know, the US, is basically sitting on a pot of gold here, the US because of the interest in in in, we’re in the worry about smallpox during the Bush administration, there was an all of government approach involving the National Institutes of Health, the CDC Department of Defense Research units, to basically say, is there a drug we can develop to treat this disease that was previously thought to be incurable. And through that tremendous amount of investment over a 20 year period, the US developed a drug tested it proved it could work in animal models, including an animal model of monkey pox in monkeys themselves, or non-human primates, we call them and showed safety and hundreds of them of adults, but then kind of sat on that drug. And so this is something that we’ve been concerned about. And there are some important regulatory concerns about why CDC was slow to release it. But thankfully, now, if you get diagnosed with monkey pox, and you have a doctor who knows about the availability of this treatment, which is an issue, they’re able to call a hotline through CDC and get the drug shipped directly to a patient’s home. And again, I’ll just qualify by saying, we don’t know with 100% certainty about the effectiveness and the risks of this. But we have a very good reasons to believe based on both, you know, people have been treated so far as well as the animal models that is likely to be affected. And during an outbreak like this, where the consequences of untreated spread the burden of having to stay isolated for four weeks is so great. You know, Joe and I […] out to this, you know, I’ve really felt that there’s a real humanitarian imperative to do two things at the same time, get the drug to people. And number two also collect good data about how well it works.

Joseph Osmundson  18:48

Yeah, you know, there is just, I get to be the emotional side of this because I have friends who are suffering. You know, I saw Twitter today of an individual with monkey pox who had quarter sized lesions all over his mouth and face. This is obviously a very severe case. Not every case is like that. But I have a friend right now, a very close friend of mine, and I’ve been advocating for over a week, and he has lesions in location, let me just say lesions in locations that indicate that he should be treated and he has still not received the drug. You are asking people to sit alone in their apartments for four to six weeks in immense pain, as the biomedical intervention sit, that investment into making Biomedicine just sits in the freezer and on the shelf. It’s unconscionable.

Stephanie Wittels Wachs  19:39

It seems unconscionable and I guess my question is why? Why is it sitting on the shelf? You know, why can’t people get the drug? What is the barrier? Is it all marginalized communities stigma, what is the root of why we can’t access these treatments?

Joseph Osmundson  19:56

Jay, do you want to take that one first?

Jay Varma  19:58

Yeah, let me answer it because I can put my government bureaucracy hat on because I was with, I worked for CDC for 20 years and know exactly what it’s like to be on the inside during these emergencies. That’s what I did for 20 years. So if I’m sitting in in Health and Human Services right now, what I’m saying is, number one, this drug was developed through a special FDA regulatory pathway that was meant for diseases that cannot be studied under normal circumstances because Smallpox is eradicated. You can’t randomize one group to get the treatment for smallpox and the other not because the disease isn’t there. So the FDA has a special exemption pathway four we call medical countermeasures, things that are bioterrorism, that’s where you can do studies in animals. And then you can then do safety studies in humans. So just safety to say, if I give it to healthy humans, are they going to be okay? And then use that as your pathway. So FDA is argument is like, look, we only approve this for smallpox because of this special pathway. Monkey pox, in contrast, is a disease that occurs in humans. Now you’re seeing it all over, you could do a clinical trial and get it evaluated that way. So that’s one concern. The second is with CDC, and then what’s called Asper. This is the Secretary for Preparedness and Response which oversees the stockpile. What they say is, well, look, you know, FDA has technically approved this drug. And so in the real world, FDA has a specific restrictions, it goes back to the origins of FDA, FDA is not supposed to what’s called regulate the practice of medicine. So FDA can only say it’s approved for this treatment. But if you’re a doctor out there, and the drugs on the market, go ahead and use it for everyone. It’s called off label use. So that exists for everything. Aspirin is used for a million different reasons other than why it was originally approved, for example. So from CDC and Aspers perspective, they’re saying, but look, we don’t want to go beyond FDA, and recommend off label use. Because we’re a government agency, and there’s liability issues. We don’t want to go ahead and say you can prescribe this just on your own. So what CDC did, it says, well, we’ll develop a research protocol called an investigational new drug. And so we’re going to research the benefit of this drug for monkeypox. So to get this drug, as a doctor, you need to enroll your patient in this study and do all of the steps if anybody’s ever been part of a study, you got to do an ethical consent form, you have to have a review board at your institution approve it, you need to know about this, you fill out a bunch of paperwork, you take a bunch of photos, and then the patient finally gets a drug. So that’s the way it was at the beginning of this and through a lot of activism, the only thing that’s really changed has been that CDC has basically come up with a shorter list of forms, fewer forms that are needed, and also said that a doctor can order the medicine even before the patient has been officially enrolled in the study, to expedite the process. But that’s the government argument is that FDA says we approve this for one purpose. You can’t use it for another unless you do a study CDC and as per se, we’re government agencies, we don’t want to go against our federal government agency and recommend off label use.

Joseph Osmundson  22:55

It’s like so important to understand the bureaucratic steps. I would like to add that the reason that this drug hasn’t been tested in proper clinical trial is biomedical racism, because monkeypox exists on this planet. And we could have done a clinical trial in the endemic region. And it would have been actually useful to understand how it works in that context for the use of for smallpox additionally, and it’s not a super expensive drugs drug to make small molecule synthesis is not like making a vaccine, we could have been using this drug in the endemic region. And there’s reasons that we’re not and those reasons are largely post colonialism and the fact that we allow Black suffering in certain parts of the world. So you know, this is a virus has been described in humans since 1970. We don’t know if it’s in semen. We don’t know if it’s in vaginal fluids. We don’t we know that there’s DNA, but we don’t know whether there’s virus and saliva, would we allow that for a virus that were anywhere else on this planet? We would not. Right? So I want to be very clear about that. You know, with all of these regulatory bureaucratic hurdles, we’ve been really going back and forth in the activist community, the science activist community, by wondering if it’s sort of bureaucratic ineptitude. The inability to recognize that we have an emergency, or homophobia or some mix of the three, you know, the feds are very defensive that they’re not homophobic. It’s a lot of people who’ve worked on HIV for a very long time. Usually, you know, that’s kind of the infectious disease model. So, you know, they like to feel that they have a great relationship with the queer community. And yet, there’s just some urgency that is missing somewhere, you know, quick quiz for the for the room. The IND is not technically a clinical trial. There’s only I believe; two clinical trials open right now who can enroll in the clinical trials at the moment.

Jay Varma  24:38

I’m not even sure I know the answer to that.

Stephanie Wittels Wachs  24:41

I clearly don’t either.

Joseph Osmundson  24:43

It’s only people in the US military. Right?

Jay Varma  24:46

Which is interesting. I mean, that’s usually where a lot of these drugs end up getting developed because they want to protect soldiers was actually in some ways okay, in the sense that like, it’s a, you know, a benevolent self-interesting like, if you have no choice now, trust me. I agree. Joe, this needs to be done as a global good, but the sort of middle pathways, okay, let’s just look at it in terms of self-interest, right? And what’s really strange here is that even with benevolence sort of self-interest, it’s still wasn’t evaluated as quickly as it should have been.

Joseph Osmundson  25:14

And now there’s no reason for this, right? We have hundreds, we have 1000s of cases now in the gay community, and our sexual networks. And so why not do clinical trials where the cases are, why not allow people, you know, the gay community, or at least some parts of us love science, because, you know, we see biomedical, the biomedical tools that help us prevent and treat HIV that keep people alive and keep people zero negative. There’ll be a ton of people who would want to enroll in a proper randomized clinical trial, and, you know, get all of the support and the care that that trial would entail and make the best science, but we’re not we’re actually not allowed to enroll. Because we’re not in the military. So you know, there’s just, when we sit and look at the lay of the land, as people who have been thinking about working on clinical trial, you know, it’s very tricky. How do you ethically do a clinical trial for an HIV vaccine, right? But you have people who have been working on that for decades, you have a whole infrastructure built up to do that type of work with engagement with communities with infectious disease doctors who have been thinking about these issues for forever. And still, with all of this infrastructure, with the queer community, ourselves, having experts in science and epidemiology and infectious disease, this is still the lay of the land sort of two and a half months into an emergency. And it’s just a little bit perplexing.

Stephanie Wittels Wachs  26:26

Yeah, that’s a tremendous amount of inequity and bureaucracy wrapped into a nice, neat little bow. And by nice, neat, I mean, it’s not, it’s very messy, and unfortunate. So there’s also a smallpox vaccine used to fight monkey pox that’s supposed to be available. You mentioned this earlier, Joe, but you said that people aren’t able to get it. So who is able to access that right now?

Joseph Osmundson  26:50

of folks with lots of free time and a fast internet connection. You know, it is, we’ve been perplexed by this as well. You know, you know, you had cases popping up that weren’t epidemiologically linked, there was obviously huge demand in the gay community and our larger network for vaccine prior to pride, you know, that pride is going to be an event with lots of skin to skin contact both of a sexual and non-sexual nature, that’s exactly the type of large events skin to skin contact, where we know that this is a very high risk for spread of this virus. We know that the virus may be, you know, mildly symptomatic, and people, there’s not a ton of awareness, people may not know they have it and know to stay home. And someone might go to a large pride party with 1500 people there and touch a lot of them. So, you know, we were a bit perplexed why, why there was an urgency to get vaccine here. And we kept getting different numbers when we were talking to our federal partners about how many doses of vaccine they had, and what the final number was, was somewhere around 76,000-78,000 doses that they had on the ground in the states that could go out to cities. And it did go out to cities that were all snapped up by the most privilege in our community and literal seconds on the internet, you know, sort of like a Kim K breaking the internet, except every time. And we just found out by reporting in the New York Times an incredible investigative report showed that there were actually 300,000 doses sitting in a freezer in Denmark, that could have been flown in May. And they were the federal government made an active decision not to fly those doses here. They made the choice not to fly them to New York and other cities where there was pride events in June, because they were worried about a theoretical smallpox bioterrorism event. So they were failing to respond to an actual emergency by worrying about a theoretical emergency. You know, as my friend who wanted to get vaccine and didn’t and now has monkeypox since isolating for the 15th day in his apartment.

Jay Varma  28:57

I just want to add in here, you know, I mean, in addition to the I mean, I think there’s this really horrible cycle that happens, you know, when you underestimated threat, as was done here, and then we can discuss the origins of that it could be because this is viewed as an African diseases because it’s limited to queer populations. And you know, they’re not something we need to worry about, for whatever reason, there is an under delayed response. And then the absence of testing feeds that neglect. Because, you know, people say, well, we don’t really see that many cases. Therefore, just like, I thought, this isn’t a real problem. And because of that, you end up with these progressive delays, where people are like, oh, let’s only order some vaccine because we don’t want to ruin this whole stockpile, because it’s not that big of a threat. And so, you know, and I think people have learned this during COVID. Right, everybody got kind of a graduate degree in how you do public health surveillance. And it really starts with testing. Testing is diagnosis is your entry point, to getting treated, it’s your entry point to do in contact investigations and figure out who needs to get vaccines and it’s the entry point to caring, right? Like people only care when they see numbers. They don’t trust the voices of community members saying, yey, I’m suffering, they trust it when CDC says get puts a number that has a bunch of zeros after it. And so I just want to emphasize that that’s one of the areas that I’ve been really enjoying, as we’ve all been very distressed about is that getting testing out into the field, and by the field, I mean, to bars to play parties to other places, is so critical, because the more we know, well, one, it might reassure us, I don’t think it will, but in theory could reassure you. But in reality, what I think many of us suspect is going to scare us, and that’ll accelerate the response.

Joseph Osmundson  30:30

Yeah, and this is not just a US problem. Just to add very quickly, in the WHO debate over whether to declare this a public health emergency of international concern. The committee actually voted against saying specifically, oh, this is only affecting men who have sex with men right now. As though our suffering is not an emergency. And of course, you know, some of our African partners are incredibly angry about the WHO’s declaration because they said what is not an emergency when it’s spreading human to human in Loggos are suffering doesn’t matter. So you see these patterns of being able to sort of downplay the importance of an epidemic because it’s quote only in certain communities as once again infectious diseases haven’t taught us by now that no community is a bubble that no one is an island infectious diseases actually show us how interconnected we all are.

Jay Varma  31:20

Now you put the bubble in there, good job.

Stephanie Wittels Wachs  31:25

You’re hired. You get the job, Andy’s you know, he’s gone now and you can step into village let’s take another quick break. And when we come back, we’ll talk about what you should do if you’re concerned you have or could get monkeypox.

Stephanie Wittels Wachs  32:21

So, I’d actually love to this is a good moment to segue and circle back to what we were talking about earlier. This messaging here some people say that the messaging and outreach on monkeypox wrongly makes it sound like it’s a gay man’s disease when really anyone can get it. We talked about this earlier. Others say the opposite, that the messaging is not targeted enough to those currently contracting it through sex. Where do you land on that? I feel like you’ve been very clear, but I want to just ask, should the messaging focus on the queer community or at the risks for general spread?

Joseph Osmundson  34:08

I mean, I can I can, you know, this is a very sensitive topic, the debate I’m staying completely out of the debate over whether this is an STI or not by whoever’s definition which is raging on Twitter, no thanks, don’t need it. Don’t need those mentions in my phone. There has been huge amount of urgency in the queer community, anyone who’s saying that we’re not getting the message out. That may have been true in May and June. But at this point, so many of us know people who have been ill that it’s sort of a three alarm fire in our community. And you see that by how many people are trying to get vaccinated, trying to do everything they can to keep themselves and the community safe. I what I ask for is that queer people who have been doing work around sexual and public health for decades, are given the ability and empowered to reach out to our communities that CBOs community based organizations that work on the ground, particularly in places where people might be outside of other socially queer social networks, you know, in only Spanish speakers in New York, for example, well, there are CBOs that work specifically with only Spanish speakers in New York City, that work with a lot of queer folks in that community and they need money, they just need they are, they are strapped already. And this is another thing on their backs, and they need money to take care of it. And you know, all of Jay’s work on sexual health clinics, you know, sexual health clinics have patients, you know, and the patients that go to sexual health clinics are the prime folks who need vaccines, and who may need tests and treatments. And so we need to think about how to reach beyond that. But we need to use the trusted existing platforms to do so. And then as I previously mentioned, also think about who else might be high risk groups, you know, sex workers, gay or straight, massage parlors, spas, you know, any place where there’s a lot of skin contact, or a lot of skin to surface contact, right, and just have that on our radar, get proactive and messaging to those places.

Jay Varma  36:13

Yeah, I mean, I sort of add just a little bit to augment, you know, basically, with three points really quickly. One is, you know, to get to this issue, that one of the things I’ve learned in my public health career working on a lot of sexual health issues, and you know, whether it’s STDs and other HIV, hepatitis, viral hepatitis, you’re not going to be able to control you know, what the bad actors are going to do, you know, people are gonna be homophobic would no matter what words you say. So you have to keep the needs of your community and, you know, the community are serving upfront first and kind of deal with the slings and arrows that come obviously, the messaging has to be targeted, but so. So I think it’s very important to really name and identify the group at risk and the behaviors that are at risk, and give people the information to reduce their harm.

Joseph Osmundson  36:52

And we got to say, look, sex is awesome. Gay sex is awesome. Asking people not to have sex is a long term failed public health strategy. You know, Jay, in an email thread that we were in this week, says said it actually better than I think anyone else in Jay, you can correct me if I use the wrong language, but you said something like infectious disease, doctors need to see sex as a healthy human behavior, and that their role is to help people have sex without infectious disease burden. And, you know, we are in a country right now, where queer identity and gay and queer sex is being attacked, we’re being called groomers for having consensual adult interactions with one another. So it is a very difficult time to message around this, this is gonna be all over the news now, right? And it is a horrific skin infection being spread, in large part by gay, sex, and our sexual activities and networks, we have to be very strong in saying we will not accept messaging that stigmatizes our sexual behavior. We won’t do it. And we have to be very careful even internally about our language. I’m sorry, gay sex is not driving this epidemic. This epidemic is being driven by a lack of access to resources globally, that could prevent spread. People want to get vaccinated, and they can’t get vaccinated, asking people not to have sex for weeks and months on end is going to fail, we know that it’s going to fail. And so we have to focus on where the problems are and where the interventions can be.

Stephanie Wittels Wachs  38:27

So, this is a great time to bring this up, because the chief of the World Health Organization said this week that queer men should limit their sexual partners to lower the risk of infection and reduce the spread. So, with what you just said, do you agree with that medical recommendation, I’d love to hear from both of you.

Joseph Osmundson  38:47

We released a document and we being me and two colleagues of mine, who are both MPH public health professionals, asking yes, for our community, until vaccine is more widespread, to consider risk reduction, until we get a better biomedical response. You know, if we say canceled sex parties, closed saunas, it’s just not going to happen. But if we give people options, you know, I might have coined the term anal autumn, the best thing I’ve ever written in my entire life, if we say, hey, wait till September, October, have an anal autumn pumpkin spice latte, you know, think about using condoms, limiting your number of high risk events and sex partners. But you know, you got to give people something to say this is temporary and options to still enjoy themselves.

Jay Varma  39:37

Yeah, I would just add to what Joe says is, you know, I think the problem and I’ll just speak to this as a, you know, physician in my trip. We’re not trained to think of sex as both a health enhancing and joy enhancing activity. And, you know, this gets down to, you know, socialization at early age where sex ed is not about pleasure, it’s about risk. And in your medical world, it’s all about risk. In reproductive health, and it’s not about pleasure and joy and health benefits and true documented health benefits that come from and vibrant sex life. So if you approach it from that perspective, and you acknowledge that and you can just say then, so here are the options you have for you, if you are concerned about your risk, you know, this is a time to use condoms, maybe you’ve been reluctant to because you’re on and you think you’re invulnerable. Now’s the time to go back to that for an alarm or whatever it is. So there’s a way to message this in the right way. And I think that’s really what it comes down to, I think, you know, people are smart, they, you know, we often, you know, think that people aren’t going to get the message. Well, if we say the message in a way that resonates with them, they’re gonna make rational choices.

Stephanie Wittels Wachs  40:43

Great. Jay, we talked earlier about how the US response to monkey pox was delayed. And it seems like public health officials didn’t realize how explosive it would be. So what do they need to do now to contain it?

Jay Varma  40:55

So number one is, as I keep pointing out, we need to know how many people are infected. And we need to know how readily it spreads and what way it spreads. And the best way to do that is by widespread testing, one of the barriers we have right now that that I’ve been trying to hammer out is the fact that current testing procedures are based on swabbing a skin swab. But we also know that you can detect this virus in saliva, in the throat, and then possibly in other body fluids as well. And that’s what we in the public health community have long used for STD and HIV testing is go to bath houses, go to venues where you know, lots of gay men intersection networks, you’re hanging out and do screening on site. So that’s something we can do now, by accelerating testing to get a much better understanding of who’s at risk and how disease presents. That’s number one. Number two is, you know, really accelerating the availability of vaccination. And this just means doing everything possible. And again, all of these regulatory hurdles are real. I mean, we can’t pretend the government can always violate the law or violate contracts. But if you care enough, you haven’t worked enough in government, there are always ways to interpret the contract or interpret the law to the benefit of patients. And so it’s really about that urgency of getting the vaccines out there. What I’m worried about, and I’ll highlight why go back to testing is that no matter what vaccine you have, it’s very rare to get up higher than say 50, or 60% uptake just by voluntariness. A lot of people are squeamish, they don’t trust vaccines for lots of reasons. So you need to have other layers of protection, like we’ve talked during COVID and testing and all that is another one. The next component obviously is access to this drug, you know, if we learned that, in fact, it is, as we suspected, is very effective at reducing the duration of infection. That’s gonna help public health and it may be useful also in people who’ve been exposed. So we need to have those studies and all that activism in place. The next piece that I would highlight is, I think, really one of our big barriers is going to be I suspect, and Jo and others may disagree, I have sort of an optimism that the sort of supply issues are gonna get solved, not as fast as it shouldn’t make itself. But the next bottleneck is what we’re seeing right now, which is our state and local health departments are either understaffed and can’t hire enough staff. So sexual health clinics are closed, including in New York City, which has had these sort of Premier sexual health clinics for a decade. Of those places that the staff that are there, they’re beleaguered and overworked. So there needs to be funding through the ability to hire new contracted staff or do something and I’m really worried about the political divides in this country and not getting it to where it needs to be. And then the last, of course, is the community activism engagement, because none of these steps work, if they aren’t addressing the needs of the communities themselves.

Stephanie Wittels Wachs  43:32

Yeah, so I think we could talk forever and ever about anal autumn but I will actually try to wrap this up here. So before we end, Jay and Joe, what advice would you give someone if they think they have monkey pox and don’t know what to do? What would you tell someone who was worried out there and needs to know what the next step should be for themselves? Or a loved one?

Jay Varma  43:54

Yeah, I mean, if somebody so a lot of this, unfortunately, excuse me, depending on geography, right. And so, I’m gonna say something that I normally as a doctor don’t like to have to say, but I feel like I have to, you’re gonna have to be your own advocate. If you’re a somebody out there most likely a man or trans woman you know, who has a, you know, bump on your penis, or lump in your groin pain in your butt, you have to be a pain in the butt, you’re gonna have to expect the fact that if you go to a primary care doctor, if you have one, you feel lucky to have an or an urgent care center. If you don’t have one in  […], there’s a very high likelihood that your provider is not going to be thinking about this and he’s going to dismiss it as acne or an ingrown hair. I’m going to test you for gonorrhea and give you an Xbox. So be and I’d say that just from the experiences that we’ve seen, and knowing how little provider awareness and educate out there. So try to get online, educate yourself at the CDC website through the community groups that are out there, and then be an advocate. And if a provider says no, I don’t think you need to get tested. Try to find a way to reach out and find other people to get there because that’s important. And then the second thing is just in your own personal risk is, is keep those lesions covered. And by lesions were fine any skin, keep them as covered as you can. So if you have roommates, you have other sex partners, you know, keep them covered until you know for sure what you have. And the third is to the best that you can tell your partners and partners that you know, you know, some people obviously have partners, they don’t know the names or can’t guide them, message them. And that’s a very hard thing to do. Nobody wants to say, I may be the source of infection in you. But right now caring for the community is important. So I think those are the three messages that I would give.

Joseph Osmundson  45:29

Yeah, I have a lot of friends reaching out to me, friends, community members. So my only additional message, just, you know, we know also from the literature, that there’s a huge mental health burden from this infection. You know, you’re talking about really painful skin lesions, you’re talking about physical isolation for well over two weeks, usually, this will end. This is not a chronic infection. This virus is not like HIV in that it doesn’t become a part of you, you will get through to the other side, and you have a community of people who are working very hard on your behalf. And you have to work very hard on your own behalf on how you’re feeling you have a virus, you have an infection, that does not change who you are, it is not your fault. It is the fault of the lack of resources that were presented to you. And it’s your job to rest to heal, and you will move forward with the best mother […] and monkeypox antibodies on the planet as the safe the likely the safe a sex partner, sexy post monkeypox queen, but we really need to be aware of people’s financial needs, emotional needs and mental health needs. As we’re asking, you know, we see what COVID. Can people isolate for 5 or 10 days, it’s really freakin hard. And here we’re talking about 21 days, over a month. So really focusing on the whole person, not just the infection and the pain, but the whole person who is a person who’s dealing with something scary and new, and really is going to need community and emotional support.

Stephanie Wittels Wachs  47:08

That is such a beautiful note to end on. I really appreciate that, that humanity piece cannot be overlooked. And coming out of COVID. I think I hope we are taking the mental health piece a little more seriously than we have in the past. But I really appreciate you saying that anything else we didn’t get to before we wrap up?

Jay Varma  47:29

No, I just want to thank you for raising this issue because it is really important. And again, I would just I think we don’t want to unduly alarm Americans that you know, this is not going to be like COVID It’s not going to result in cities closing down and people having to wear masks and your kids being home from school forever. But everything we know about viruses is that when you have an old virus and a new population, you learn new things, and it’s never good. So one of the many reasons we need to get a handle on this is that things could get worse for the people that do get infected beyond even the suffering that Joe has described so eloquently. And so that’s the reason to care about it is even if it’s not affecting you directly, it’s going to harm people you know and love and it could harm you right now. But for most Americans, your risk is relatively low.

Stephanie Wittels Wachs  48:14

Amazing. I can’t imagine a more delightful conversation about monkeypox then I want you to today Thank you so much. This was wonderful. I appreciate your time. And I appreciate you bearing with me today. The fake Andy Slavitt.

Joseph Osmundson  48:30

It was my pleasure.

Jay Varma  48:30

Great. Thank you for having us.

Stephanie Wittels Wachs  48:45

Thanks so much to all of you for tuning in today. I promise that Monday Andy will be back with more of his interview with Dr. Eric Topol. They will talk about the next steps in fighting COVID and one solution Dr. Topol says could be a game changer. So you do not want to miss that. Plus with the Fed rate hike this week, Andy is back on Wednesday to talk about inflation. And what this rate hike means for your pocketbook. But don’t worry, this podcast is still free. Thanks for listening to IN THE BUBBLE

Andy Slavitt  49:21

Thanks for listening to IN THE BUBBLE. We’re a production of Lemonada Media. Kathryn Barnes, Jackie Harris and Kyle Shiely produced our show, and they’re great. Our mix is by Noah Smith and James Barber, and they’re great, too. Steve Nelson is the vice president of the weekly content, and he’s okay, too. And of course, the ultimate bosses, Jessica Cordova Kramer and Stephanie Wittels Wachs, they executive produced the show, we love them dearly. Our theme was composed by Dan Molad and Oliver Hill, with additional music by Ivan Kuraev. You can find out more about our show on social media at @LemonadaMedia where you’ll also get the transcript of the show. And you can find me at @ASlavitt on Twitter. If you like what you heard today, why don’t you tell your friends to listen as well, and get them to write a review. Thanks so much, talk to you next time.

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