As mpox continues to spread within the Democratic Republic of Congo and neighbouring countries, concern is growing over how best to respond to this second mpox Public Health Emergency of International Concern (PHEIC). In this PHEIC, Clade 1b cases in non-endemic contexts are increasingly linked to sexual contact within densely populated areas. We know that it is incredibly important to treat the issue of disease transmission linked to sex with care and sensitivity. Learning from activism during the HIV epidemic has taught us the importance of engaging in sensitive and rights-based prevention and care.
Care should not exacerbate stigma against an at-risk population. Critically, these anomalies in the second mpox PHEIC demonstrate once again that one disease can manifest differently in different local contexts. What does this heterogeneity mean for response? Our research in Nigeria during the first PHEIC point to the vital importance of involving the perspectives of affected communities and avoiding approaches that can exacerbate shame, blame, or discrimination.
Mpox, stigma and inclusion
Experiences of men who have sex with men (MSM) in Nigeria highlighted the impact that global narratives can have on people’s local experiences of mpox as the global outbreak generated fear and misinformation locally. Globally, the 2022-23 mpox outbreak which largely affected communities of gay, bisexual, and other men who have sex with men (GBMSM) in Europe and North America, contrasted with previous mpox outbreaks and what we saw in Nigeria during the first PHEIC, where cases were heterogeneous. Mpox was spreading amongst children, older and younger men and women, with very little commonalities amongst cases.
Before our research, very little was known about the mpox experiences of GBMSM in Nigeria where the law and social norms are largely homophobic. First, we found that GBMSM and their healthcare providers had low knowledge of mpox. Those who had symptoms of mpox sought care from key population-friendly sexual and reproductive health service facilities (e.g., ‘one stop shops’) which they have come to trust. GBMSM who contracted mpox believed that they likely were infected during sexual intercourse, but our broader study indicated non-sexual spread across sexual identity lines.
On the other hand, we know that same-sex transmission may have been underreported in Nigeria because of the legal implication of identifying as gay or bisexual. If and when they were referred to public health facilities that are meant to be better equipped to treat mpox patients, GBMSM would prefer not to visit these facilities, and those who did complained of stigma. Some of them resorted to self-treatment with antibiotics and herbal remedies, but generally found their experience with mpox stressful because of their limited social support and stigma.
Nigeria’s homophobic legal and social environment limits or even prevents policymakers and programme implementers from partnering with and centring the GBMSM community in its national response. Because of this, Nigeria requires a different disease framing and context-specific response that will not worsen the condition of GBMSM while trying to centre and partner with them.
This points to ethical issues of inclusion. How can we work with communities that may be at higher risk but also face stigma due to mpox transmission linked to sexual contact? We note the need for improved surveillance and engagement with ‘one stop shops’ that are experts in sensitive care, to deepen understanding of mpox care seeking among GBMSM in Nigeria.
Mpox and health equity
Whilst many high-income countries had access to mpox vaccines and supportive therapies, mpox patients in Nigeria often managed symptoms at home. With the country’s healthcare situation, care seeking practices particularly among low-income urban informal settlement populations are diverse, presenting challenges to both case identification and management during an outbreak.
Mpox was perceived to be a mild disease which had implications on the study population’s behavioural practices affecting diagnosis and management. Generally, there was a low level of awareness and knowledge about mpox.
Our study revealed complex conditions which shaped how informal settlement residents perceive, and therefore access, different kinds of health care. For instance, the low patronage of formal healthcare facilities, notably local primary healthcare clinics, was shaped by mistrust, perceived disease severity, proximity, finances and cultural beliefs about herbal medications compared to western biomedical medication and treatment.
In contrast with the public health emergency globally, the mpox outbreak was seen amongst some urban poor in Nigeria as more routine, as a norm which manifests seasonally (dry season and heat period) during the year. Findings from our study highlight heterogeneous experiences of epidemic diseases and how this can inform future global health security priorities.
Pressures on the health workforce
Our research revealed how frontline health workers must navigate multiple, often competing, priorities when responding to an outbreak. We are seeing this in Uganda today, where the country faces overlapping outbreaks of mpox and Ebola virus (Sudan strain). In Nigeria, frontline health workers engaged in various forms of ‘repair’ to make sure that outbreak response could function alongside their existing scope of work to detect, confirm, and track other potential cases of disease. Importantly, these vital health workers are forced to make difficult choices about prioritisation when new outbreaks like mpox are declared. These moments of ‘crisis’ highlight gaps in the primary health system and the need for long-term health system strengthening and sustainability.
More work to address mpox and discrimination
Our research in Nigeria during the first mpox PHEIC points to several critical considerations for responses that understand and incorporate the perspectives and experiences of affected communities. Nigeria has long-standing capacities in virology and rapidly increasing capacities in epidemiology and public health surveillance. Much of the response has been designed and led by Nigerian institutions, notably the Nigeria Centre for Disease Control and Prevention. It is important to learn from Nigeria’s response. We are building on this learning in our work through the Social Science in Humanitarian Action Platform during the second PHEIC and in deeply worrying circumstances in the Democratic Republic of the Congo where many areas are seeing sustained transmission and the escalating violence in the eastern part of the country poses additional challenges for the mpox response.
