by Eric Boa
Crab-eating or long-tailed macaque (Macaca fascicularis) at the Angkor Wat temple complex, Cambodia. Monkeypox was first observed in such monkeys, used for lab experiments, in 1958. But it may have existed in the wild for 3000 years. Credit: Emőke Dénes
Just when we thought it was safe to go out, along comes another disease. Is monkeypox the next pandemic? A cold look at the facts might help to answer that, courtesy of official UK data and the World Health Organisation (WHO). At the time of writing (10 June) there are around 300 confirmed cases of monkeypox in the UK, the bulk from England. The WHO notes 27 countries with confirmed cases, with Spain and Portugal also badly affected –if you count 156 and 138 cases respectively to be a cause for concern. Still, 27 countries doesn’t sound so good.
The WHO records 780 confirmed cases worldwide, excluding those seven countries in Africa where monkeypox is an established or endemic disease. Africa has had only 44 confirmed cases recorded by the WHO in the last six months. That may sound reassuring, until you realise that there are 1408 suspected cases. Why the uncertainty? Weak diagnostic capacity and health services are some of the obvious reasons. Let’s assume all suspected cases are monkeypox and that more people are probably infected in the endemic countries. We still don’t know exactly how many, but with a combined population of 350 million people in these countries monkeypox appears to be a minor problem.
What about disease outcomes? I head off to a mega-source of medical information, the USA’s Centers for Disease Control and Prevention (CDC). Their reputation took a bit of a battering over COVID-19 – slow to react, weak responses - yet this is a formidable organisation and still highly respected (so much so that China has its own CDC). Back to the monkeypox outcomes in humans: milder than smallpox; fever, headache, chills, exhaustion and so on. The ensuing rash is probably the worst part, but I’m reassured to learn that the oozing scabs that form eventually fall off. And smallpox vaccines are known to be effective against the disease.
Clearly the disease has unpleasant symptoms, but does monkeypox kill? The CDC website notes that “in Africa [it] has been shown to cause death in as many as 1 in 10 persons”. No deaths from monkeypox have been recorded in the 27 countries with new cases, predominantly in Europe. The information gathered from the recent outbreak are still indicative of the low risk to healthy and well-nurtured populations in countries with good diagnostic and healthcare services. Persons weakened by poor nutrition and already suffering from other conditions, such as malaria, tuberculosis and widespread gut problems are more likely to succumb to a new infection. Add monkeypox to the mix and it’s not surprising that people die in Nigeria or the Democratic Republic of the Congo.
If only our assessments of human health risks could be so objective. Making a rational assessment of a human health risk is never going to be straightforward. Our fears and worries, coupled with incomplete information and the power of anecdotal knowledge, will always cloud our judgements. Although we already have plenty of data about monkeypox, there are still many uncertainties. And more cause for anxiety. No one knows why the disease has spread so widely and so rapidly. Could monkeypox be more serious than it appears to date? The widely held opinion is that this is as unlikely as the current UK Prime Minister resigning voluntarily. Monkeypox is a pandemic, but it’s not the next COVID-19.
Still not convinced? Consider what Bertolt Brecht wrote in a play about Galileo, a pioneering scientist who used observation and discernible facts to propose theories. Galileo says in the play that “the job of science is not to open the doors to infinite wisdom, but to set a limit to infinite error”. Put another way, there is an inherent degree of uncertainty about how things work, one that science seeks to define in seeking wider truths. Which is what I’ve tried to do when looking at monkeypox.
Reality and perception are notoriously difficult to separate in any consideration of human health. “My uncle smoked 80 cigarettes a day and he never got lung cancer.” Lucky man, but sadly not a reliable indicator of the indisputable perils of smoking. Fear hangs like a fog over our ability to assess health risk. Medical terminology and jargon can confuse. Pandemic, endemic and epidemic all sound worrying. Remove three letters from the first and you get panic. Make of that what you will, but there is no doubt that our COVID experiences have sensitized us to the threat from new diseases, raising new fears and fuelling worries about monkeypox.
One of the positive consequences of COVID, reinforced by monkeypox, is that more money will be poured into research, particularly on vaccines. These are as near a silver bullet as you could wish for, yet there’s an equal if not stronger need to improve surveillance, monitoring and basic healthcare. Whether this will provide permanent strengthening of primary health services, an invaluable source of data on new and emerging diseases, is another matter. Improvements to clinics and better access to general practitioners are difficult to sustain in the richest of countries.
I’m interested in monkeypox because the reaction to a new pandemic in humans mirrors my professional experience in dealing with plant pests and diseases. Yes, they also have pandemics, though you’ll rarely read about them. I’d like to think that the concern about human pandemics has raised awareness of threats to plants, but I’m not so sure. In 2020 I helped to establish a small scheme for my fellow plant health colleagues to write about plant pandemics. Funded by the British Society of Plant Pathology, we’re now on our second round. The first round considered Ug99, pine wilt nematode, greening disease of citrus and ash dieback*.
If you live in the UK, you’ll probably have heard of ash dieback, a fungal disease which is expected to kill up to 95% of Britain’s ash trees, but I suspect the other ones will have passed you by. That’s a shame, because the economic and social consequences of these other diseases are huge. Greening disease has had a devastating effect on the citrus industry in Florida, where farmers are struggling to cope. It has caused billions of dollars of losses. The pine wilt nematode, native to the USA and Canada, has killed millions of pine trees in Japan, eastern Asia and, more recently, Portugal and Spain. Ug99 is another fungal disease, a variety of wheat stem rust, first observed in Uganda, that has spread as far as Iran and remains a constant threat to key wheat producers in Pakistan, India and beyond.
Ug99 (Puccinia graminis.f.sp.tritici) in Kenya: a new variant of stem rust on wheat
There are key lessons to be learnt from all pandemics, whether they affect humans, animals or plants. All can be tackled in a similar fashion. Gather information, establish its reliability, be alert, respond quickly and, dare I say it, don’t panic. Accept uncertainty and learn to live with it; there is fundamental unknowability of what goes on around us. Pandemics, epidemics and endemic diseases are a fact of life. Maintain diagnostic services and fund research. Have a plan for tackling a new or emerging disease before it happens, which the UK government had in fact done, but then appeared to forget.
In 2006 the UK government funded a major study of infectious diseases, which “prepared for the future” and produced a “vision of future detection, identification and monitoring systems”. It was part of the Foresight programme, funded through the Office of Science and Innovation. Those were the days.
Neglecting the basics will return to haunt you.
* You can read more about plant pandemics at: https://www.bspp.org.uk/category/Plant-Pandemic-Studies/