What is the politics and economics of mpox

When it arrived finally in Kinshasa on September 5, one could only wonder at the time and effort it took for a small consignment of vaccines from Europe to reach the Democratic Republic of Congo (DRC), the epicentre of the mpox (earlier called monkeypox) outbreak in Africa.

The picture of the container of desperately needed vaccines — 100,000 doses donated by the EU — unloaded on a trolley at the airport was reflective of the global politics, economics and bureaucratic heaviness that dictate how an epidemic in a poor country is handled.

Two days later, as this column was being written, another 200,000 doses sent by the EU arrived in the DRC capital and a few other African countries where mpox cases are spiking. Yet, together, the donation is just a fraction of what is needed to combat the epidemic, which has so far hit a dozen countries on the continent.

In the eight months of 2024, over 18,000 cases of mpox have been reported in DRC alone, which has recorded 629 deaths, the majority of them children.

As before, and most recently with the COVID-19 pandemic, Africa is desperately short of vaccines, not to mention testing kits and therapies to help fight a disease, which is a throwback to the times when smallpox was the deadliest scourge in the world. DRC needs 3.5 million doses to stop the spread of the disease, while other African states need 10 million doses.

Vaccine though is the best tool to control the epidemic and what works is the smallpox vaccine; who has any shots to spare? Most countries have little or no smallpox vaccine stocks at all after the World Health Organization (WHO) declared the world free of smallpox in the 1980s.

We are told that only two companies worldwide produce mpox vaccines — the Danish Bavarian Nordic (JYNNEOS) and Japan’s KM Biologics, which makes LC16, the only vaccine that can be administered to children but is yet to be commercialised.

Another company, Emergent BioSolutions of the United States makes the older smallpox vaccine which is primarily used by the US for stockpiling. All of this makes the shots expensive—one report said Bavarian Nordic charges $110 per dose — and creates a supply shortage.

The dark truth is that the US does have a huge stockpile of smallpox vaccines, only it is meant for use in case of biological warfare! It is said to have over 100 million doses of the older ACAM2000 vaccine in its Strategic National Stockpile apart from second-generation smallpox vaccine stocks, which were added in recent times. These vaccines are regularly replaced when they expire.

In July 2022, at the onset of the mpox disease in the US, the Centers for Disease Control and Prevention (CDC) said it had ordered an additional 2.5 million doses of JYNNEOS vaccine, which add up to a comfortable 7 million doses by mid-2023.

The US Food and Drug Administration explains that the availability of second-generation vaccines in the Strategic Stockpile was necessary to enhance the emergency preparedness of the US against the use of smallpox as a dangerous biological weapon.

That is why there was no shortage of vaccine to go around in the US, or in Europe for that matter, when mpox reemerged in these countries. And yet, despite such a comfortable reserve, the Washington has announced a donation of just 50,000 vaccine doses to Africa, most of it going to Nigeria, possibly for strategic reasons.

Japan, on the other hand, has said it will donate 2 million to 3 million doses of LC16 though it has yet to provide a timeline. While vaccine inequity has been a constant, the response of WHO to the outbreak of mpox in the developed world, starting May 2022, and in Africa, is rather curious to say the least.

In the case of the former, WHO Director-General Tedros Adhanom Ghebreyesus declared the situation a public health emergency of international concern (PHEIC) within a couple of months, although WHO’s own emergency committee failed at two meetings to approve such a declaration. The decision was taken by Ghebreyesus.

This year, even after observing the spike in cases in DRC and nearby countries, WHO dragged its feet on declaring a PHEIC. It was only a day after the Africa CDC (Centres for Disease Control and Prevention) issued an emergency declaration that WHO finally did so on August 14 — a year after DRC declared a health emergency in the county.

WHO decides on PHEIC under the International Health Regulations that are set by the apex health organisation itself and it is difficult to understand why the director-general took so long to issue this decision. The PHEIC declaration is vital to galvanise action worldwide.

The reason why vaccine consignments did not arrive earlier is because donor countries and agencies wait for WHO’s assessment of the gravity of the situation even if public health campaigners have been warning of a runaway crisis. In fact, it was 15 days after the declaration that United Nations Children’s Fund (UNICEF) issued an emergency tender for procuring vaccines, emphasising that Africa CDC had also categorised the mpox spread as a public health emergency.

The UNICEF tender is aimed at helping the hardest-hit countries secure supplies through conditional supply agreements with vaccine manufacturers. But this is contingent on countries and partners having secured financing, confirmed demand and readiness, and the necessary regulatory framework for accepting the vaccines. A snag here is that WHO is yet to complete its review of information submitted by manufacturers for emergency use listing.

But some lessons have been learnt. Africa is learning that it has to be at the forefront of the campaign and not leave it to global health organisations to take critical decisions.

A clear signal of this development is the key role that Africa CDC is playing. In every initiative, it is an active partner and is laying out a joint response plan to contain the spread of mpox. Running from September to February 2025, the six-month plan with a budget of around $600 million envisages a major chunk being spent on getting 29 African nations ready to tackle the scourge. 

As WHO’s regional boss noted, the joint action marks a milestone as the two agencies act swiftly and effectively to mobilise resources and capacities in a region that has for too long come across as helpless and incompetent in dealing with health catastrophes. It is a big sign of change — and hope — for some of the least developed nations. DRC in particular needs a big helping.

This was first published in the 15-30 September, 2024 Print edition of Down To Earth