New data emerging from some states and localities closely tracking monkeypox outbreaks show extreme racial disparities that are alarming experts. In Georgia, 82% of people with the disease are Black. In North Carolina, it’s 70%. But in other places that have released detailed demographic data, there are fewer and sometimes no apparent racial or ethnic disparities in monkeypox cases.
In both states, and nationally, almost all cases involve men who have sex with men.
The disparities appear to be further compounded by a lack of vaccine access for people of color. North Carolina’s data show Black men have received 22% of vaccine doses, a number that corresponds to the Black population in the state, but not to the high number of Black men who have been infected. Nationally, white men appear to be getting a far larger share of the vaccine, a factor public health experts say is harming efforts to protect vulnerable populations with less access to health care resources.
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To some experts, the disparities are no surprise, and closely parallel what occurred when the HIV epidemic struck decades ago — and more recently when Covid-19 swept across the country. “We saw it with HIV among marginalized communities in the 1980s just as we saw the tepid response to Covid-19 that disproportionately impacted people of color and those living in poverty,” said Joia Mukherjee, the chief medical officer for Partners in Health. “It’s inexcusable.”
Mukherjee is among those who have criticized the Biden administration for its slow response to a disease that is having an outsized impact on marginalized populations. Others are upset that the media call declaring monkeypox a national emergency earlier this month made no mention of the disease’s disproportionate effect on Black Americans. Oni Blackstock, an HIV and primary care physician in New York, said she was also frustrated that no Black or Latino queer man was chosen to help lead the administration’s monkeypox response.
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“We have learned less than nothing from Covid,” Stella Safo, a primary care physician at Mount Sinai who specializes in HIV treatment and is the founder of Just Equity for Health, told STAT. “We’ve gone backwards.”
The racial disparities appear to be larger in some places than others. In data updated Thursday by the New York City Department of Health and Mental Hygiene, the number of cases in Black men is 25%, roughly the same as the proportion of the population that is Black. Nearly 30% of cases there are among Hispanic men, who make up 28.9% of the population. But Georgia’s 82% case rate far outpaces its Black population, which is about 30%. The 70% case rate in North Carolina is much higher than that state’s Black population, which is 21%.
The disparities in southern states are no surprise to Melanie Thompson, an HIV physician and researcher who has worked in Georgia for three decades and calls disparities “the theme of our public health story in Georgia, and much of the South, whether it be maternal mortality or syphilis or HIV or monkeypox.”
Georgia has the highest rate of newly diagnosed HIV cases among states, she noted, with 73% of those cases occurring among Black men. Such racial inequalities, she said, are higher in states without Medicaid expansion and where uninsured people are disproportionately Black or brown.
In Santa Clara County in California, about 40% of cases are among Latino men, while Latinos make up less than 30% of the population there. Across California, 11.5% of monkeypox cases are in Black men, a figure about twice their population in the state.
National data from the Centers for Disease Control and Prevention as of Aug. 5 show that among cases that have been reported to the agency with available demographic data, 26% are among Black people, who make up nearly 14% of Americans, and 28% are among Hispanic people, who make up nearly 19% of the population. Given that these data are incomplete because not all states are reporting racial and ethnic data, it’s not possible to accurately gauge the extent of the disparities. The total number of monkeypox cases reported in the United States is more than 10,700 as of Thursday afternoon.
Many experts contacted by STAT said that the national data do not yet reflect the full extent of racial disparities because not all states are reporting cases promptly or fully reporting accurate racial and ethnic demographics along with cases. They fear that the disparities seen in Georgia and North Carolina could become the norm as more, and better-quality, data are collected. The CDC has noted a recent increase in cases among Black men and a decrease among white and Hispanic men, an agency spokesperson told STAT.
“We’re seeing the same problems we have with Covid-19, that we have such a fragmented, underfunded, outdated public health data infrastructure that we can only know what’s happening by looking at more of these local jurisdictions,” said Katelyn Jetelina, an epidemiologist in Texas and author of the newsletter Your Local Epidemiologist, who praised North Carolina for the high quality of data it was providing, and for releasing data on vaccine access as well. “I don’t think really any of us in public health are surprised about this data.”
But many are upset. “We should not be struggling to get accurate numbers,” Safo said. “Some states aren’t even reporting data. We don’t even know how bad it is.”
Many physicians and public health experts remain highly concerned that the slow response, education efforts that are not targeted to communities most at risk, and an unequal distribution of the limited supply of monkeypox vaccine will cause great harm to people of color.
In New York, Safo said, white gay men in Chelsea were able to get many doses of the vaccines that were available; Black and Hispanic men received fewer doses. “When you release a resource, people who have privilege are going to access that resource first,” she said, suggesting that when vaccines are distributed in certain neighborhoods of color — Harlem for instance — systems should be put in place so only people who can prove they live in that neighborhood receive the vaccines.
“We’re creating a caste system of who is going to get access to what is needed for monkeypox,” Gregg Gonsalves, a former AIDS activist and epidemiologist at the Yale School of Public Health, told PBS. “What we’re seeing is that the health disparities we’ve seen in Covid, we’ve seen in HIV, are recapitulating themselves with this new virus, monkeypox.”
Public health experts say stigma remains a huge obstacle. Many gay men may not seek testing or vaccination for fear of being outed. It’s important to note, said Safo, that people who contract the disease are more vulnerable partly because of structural inequalities like lack of access to timely health care that would limit the spread of the disease. In some areas, communities of gay men are small and isolated, so the risk of transmission within the group is higher if one person is infected, she said.
Collecting better data is crucial to efforts to contain the outbreak and to get better care and resources to those who need it most, experts say. The second step is targeted outreach. “It’s extremely important (to collect good data) so that we can aim our vaccination and testing in the right direction,” said Carlton Thomas, a San Diego gastroenterologist who is gay and active in LGBTQ+ HIV education and is working with the Black AIDS Institute to improve messaging. “It gives a sense of who we need to protect more.”
Thompson, the HIV researcher in Atlanta, said states should be required to provide full demographic data to the CDC in a timely manner so that resources such as testing, vaccines, and TPOXX treatment could be distributed equitably and to the places it is needed. “Without data,” she said, “we are flying blind about where the epidemic is and where services are going.”