Leren Landman

On Saturday, July 23, World Health Organization Director General Tedros Adhanom Ghebreyesus declared the spread of monkeypox to be a public health emergency of international concern (PHEIC), the organization’s loudest alarm bell signifying an emerging outbreak. 

Since early May, more than 15,000 cases of monkeypox have been identified across more than 60 countries. Disease caused by the monkeypox virus typically involves a few days of fever and lymph node swelling followed by a rash, which can leave scars. Most cases in the current outbreak have resolved without hospitalization or the need for medication. As of July 7, there have been three deaths, all of them in Africa.

When the WHO first convened a committee in late June to determine whether monkeypox was a PHEIC. As cases have continued to rise worldwide, the committee reconvened on July 21 — and this time, the outcome was different.

“We have an outbreak that has spread around the world rapidly through new modes of transmission, about which we understand too little and which meets the criteria in international health regulations,” Tedros said when announcing the emergency.

Tedros made the declaration despite the the WHO’s emergency committee for monkeypox, which did not come to an unanimous consensus on whether to declare an emergency. “There are uncertainties on all sides,” said Michael Ryan, executive director of the WHO’s health emergencies program, explaining Tedros’s reasoning in deciding to declare a PHEIC. “He sees a window of opportunity to to bring this disease under control,” said Ryan. The committee offers a recommendation, but ultimately it was Tedros’s decision. 

The last time the WHO declared an international emergency was in early 2020, for Covid-19. While the disease caused by the currently spreading monkeypox virus is much less severe than Covid-19 and spreads far less easily, there are good reasons for the WHO to declare an emergency.

For starters, said Ana B. Amaya, an expert in global health governance at Pace University in New York, this monkeypox outbreak is just very different from past outbreaks of the disease. The vast majority of the latest cases have been identified among gay and bisexual men, and sexual contact with multiple sexual partners has emerged as an important risk factor. Scientists are now trying to determine if the virus spreads through sexual fluids like semen and vaginal fluid in addition to the ways it’s already known to spread: via skin-to-skin contact and, to a lesser degree, by respiratory transmission. 

Prior to the current outbreak, monkeypox often spread throughout households via close contact and, possibly, shared items like utensils and linens. In the past few weeks, isolatedreports of infections in children, who are thought to be at higher risk for severe outcomes of monkeypox infection, reinforce the worry that without containment, outbreaks often spread beyond the populations where they start.

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How bad could the monkeypox outbreak get? 

The prospect that the virus might be spreading in ways not seen before raises the concern that it will surprise us in other ways — for example, by causing severe disease if it reaches certain populations it has not yet reached, like large groups of immunocompromised people, said Amaya. “All of that is really alarming. And that’s why it’s very important for us to have a coordinated response that starts from the WHO level,” she said in a late-June interview, before the WHO’s first meeting to discuss issuing an emergency declaration.

But beyond that, this kind of declaration encourages countries to coordinate to stop the virus’s spread in a few different ways. Here’s how that works.

A public health emergency is not the same thing as a pandemic

To be resoundingly clear: The WHO did not declare monkeypox to be a new pandemic. There’s a difference between a pandemic and a PHEIC.

A pandemic is squishily defined as “an epidemic occurring over a very wide area, crossing international boundaries, and usually affecting a large number of people,” according to A Dictionary of Epidemiology. Public health experts use the phrase “pandemic” to emphasize the global reach of an outbreak. They seem to agree that calling something a pandemic means it demands a coordinated international response — and potentially, that it’s too big to contain.

On the other hand, a PHEIC is a more carefully defined term. It describes a situation that has not necessarily grown out of control, but has the potential to do so. 

According to the WHO’s International Health Regulations, an outbreak qualifies as a PHEIC if 1) it’s unusual or unexpected, 2) has potential for international spread, and 3) requires an immediate international response. 

The WHO has only declared six PHEICs to date, including Ebola, Zika, and Covid-19. 

The monkeypox outbreak easily meets the first two criteria for an emergency: the virus’s spread outside West and Central Africa and among sexual networks are both unusual patterns, and the virus has already spread internationally, with cases now present in about 60 countries. And given that spread, containing monkeypox will clearly require an international response.

Why did the WHO wait to declare an emergency?

Some experts think this outbreak easily met the PHEIC criteria when the WHO first addressed the question about a month ago. Why didn’t it declare an emergency then?