Mpox Declares to Africa that Global Health is in Fact, Not Global

By guest contributor Nadia A. Sam-Agudu, MD, CTropMed., University of Minnesota, USA; Institute of Human Virology Nigeria; and University of Cape Coast, Ghana.

On August 13, 2024, the Africa Centers for Disease Control and Prevention (Africa CDC) made an official declaration on mpox, designating it a “public health emergency of continental security (PHECS)”. This is the first ever such declaration for the African continent. The following day, August 14, the World Health Organization (WHO) declared mpox a public health emergency of international concern (PHEIC), following the first one for mpox on July 23, 2022.

Before the recent announcement, the WHO had declared seven PHEICs between 2009 and 2022, for swine flu, polio, twice for Ebola, Zika, COVID-19, and mpox. The August 14 declaration now makes eight PHEICs in 15 years, with mpox joining Ebola as diseases with two PHEIC declarations.  The 2022 mpox pandemic was driven by a Clade IIb mpox virus (MPXV) strain so far reported from 117 countries. Mpox transmission was significantly reduced after rapid deployment of diagnostics, vaccines and treatments, largely in highly affected global North countries, The WHO declared the 2022 mpox pandemic over on May 10, 2023, with the response hailed as a public health success story.

Only, it wasn’t. Not for the African region, which been seeing rising numbers of mpox cases. For example, for June 2024, the WHO reported a 22% rise in the monthly number of reported mpox cases in the African region, compared to a 19 to 50% reduction in all other regions. Take the Democratic Republic of the Congo (DRC), which has been experiencing Clade I mpox outbreaks since 1970 and continued to do so during and after the 2022 global outbreak. A large local outbreak linked to sexual transmission was reported in March 2023. This was followed by separate outbreaks across the country, including areas reporting mpox for the first time, such as the Kamituga Health Zone in eastern DRC. MPXV isolated from samples collected in this area between September 2023 and February 2024 was identified as a novel Clade 1 MPXV strain (called Clade 1b) distinct from the original circulating Clade I (now Clade Ia).   Mutations in Clade 1b have been linked to sustained human-to-human transmission and have implications for outbreak control.   In addition to the DRC outbreaks, other countries across Africa have reported (re)-emerging mpox disease in 2024. These include four new countries in Eastern Africa (Burundi, Kenya, Rwanda, and Uganda reporting Clade 1 cases related to the DRC outbreaks; with Côte d’Ivoire and South Africa reporting Clade II MPXV.

Sustained and worsening mpox transmission in Africa is a total and tragic failure of the global response. Once again, the “health for all” principles of global health are denied to people in the global South, in this case, African people. We have seen this happen with HIV, TB, malaria, and COVID-19, and we are watching it happen with mpox. In their actions and inaction, resource-rich Global North governments and institutions have demonstrated a lack of value for global South lives. In 2024, we are still discussing the expansion of a TRIPS (Trade-related Aspects of Intellectual Property Rights) waiver for COVID-19, which emerged in 2019.

Global health action is an exhausting cycle of advocacy and activism met with crumbs and condescension from the powers that be. Case in point: on August 14, the day after the Africa CDC PHECS declaration, the European Commission’s Health Emergency Preparedness and Response Authority (HERA) announced it will donate “over 215,000 doses” of the MVA-BN mpox vaccine to the Africa CDC. For a two-dose vaccine, HERA’s MVA-BN donation will only fully vaccinate about 108,000 African people. That is woefully inadequate for DRC alone, much less several other affected African countries. Furthermore, MVA-BN is indicated for adults 18 years and older, which excludes African children, which is significant, because mpox in Africa is a substantially pediatric disease: 67% of suspected cases and 78% of suspected deaths in the 2023/2024 DRC outbreak have been among children aged ≤15 years. Criticism should also be directed to African governments for inadequate investments in health infrastructure, wasteful spending, and overdependence on foreign aid.

Limited resources notwithstanding, Africa’s mpox response after two PHEICS and a PHECS should be characterized by African leadership in equitable partnership with invested partners. The Africa-led Mpox Research Consortium (MpoxReC) was established in recognition of the long-standing unmet need for sustainable local diagnostic tools, infrastructure and research capacity in mpox-endemic African countries. MpoxReC has an initial focus on six countries: Cameroon, the Central African Republic, DRC, Ghana, Nigeria and the Republic of Congo. Several MpoxReC members are involved in Africa CDC’s Emergency Consultative Group and WHO’s Emergency Committee on mpox. It is important to have competent African leadership in decision-making, including for research priorities, public health measures, resource allocation, and community engagement in the mpox response, and with representation from decision-makers such as women, youth, affected patients and at-risk community members, ethicists, social scientists, and government officials.

(Re)-emerging mpox transmission in Africa is a demonstration of the lack of “global” in global health, and after several outbreaks, two PHEICs, and a PHECS, the mpox response in Africa should be done differently: equitably, sustainably, and consistent with the principles of global health.

About the author:

Dr. Nadia Adjoa Sam-Agudu is a clinician-scientist and implementation researcher in pediatric infectious diseases with a focus on HIV, TB, COVID-19 and mpox. She is a Professor of Pediatrics and Director of the Global Pediatrics Program at the University of Minnesota Medical School, USA. However, most of her work is in Nigeria in affiliation with the Institute of Human Virology Nigeria. She also conducts research in Ghana, as a faculty of the University of Cape Coast School of Medical Sciences.

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