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What can geography contribute to understanding Monkeypox in the UK?

By Gavin Brown, The University of Sheffield

On 23 July, the World Health Organization [WHO] declared the 2022 Monkeypox outbreak a ‘Public Health Emergency of International Concern’, following the rapid spread of infections in non-endemic countries. The Monkeypox virus was first identified in 1970 and outbreaks are usually confined to West and Central Africa. Since May 2022, more than 16,000 confirmed cases have been reported in 75 countries globally, the majority in Europe.

Unlike its usual epidemiology in Africa, most cases reported since May have been amongst gay, bisexual, and other men who have sex with men (GBMSM). Here, I provide an overview of the current Monkeypox outbreak and the public health response to it, drawing out their geographical aspects, and exploring the contribution geographers can make to understanding what’s going on.

Understanding spatialities of Monkeypox

On 28 July 2022 there were 2546 cases of Monkeypox in the UK, 96% of them in England (compared to 7 known cases between 2018 and 2021). Of the 2436 confirmed cases in England, 73% are currently in London, with significant clusters reported in the South East region (concentrated in Brighton) and the North West (mostly in Manchester). Nationally, around 95% of cases appear to be amongst gay, bisexual, and other men who have sex with men (GBMSM).

Monkeypox is not classified as a sexually transmitted infection, but it is mostly spread through close, skin-to-skin contact, and the current outbreak appears to be spreading through GBMSM’s sexual networks, especially amongst men who enjoy group sex and have multiple sexual partners. Not only is this epidemiology substantially different to what has previously been reported where the virus is endemic, it has also driven new symptoms that have seldom been recorded in African contexts.

In recent weeks, the UK Health Security Agency (UKHSA) has added proctitis (rectal pain, bleeding, and discharge, as well as severe discomfort passing stools) to the list of screening symptoms for Monkeypox. Many of those who have been hospitalized in the UK during this outbreak have been admitted for pain management associated with proctitis. Acknowledging the specific epidemiology of Monkeypox, to ensure public health responses reach those at highest risk, without fuelling stigma and prejudice around gay men’s sexual practices is a serious challenge.

That London, Brighton, and Manchester are the centres of the Monkeypox outbreak in the UK should not be a surprise to many people. Geographers and others have studied the concentration of LGBTQ people and queer spaces in these cities for decades. However, studies of gay migration and mobility highlight that although cities with a concentration of queer venues and specialist services can be a pole of attraction of queer people, relocation to live in those cities is only part of the story. Many more people will visit those places for a pleasure and a break from the routine of their lives than will ever move there. The sexual networks of GBMSM located in those cities are not self-contained but connect with places around the country and beyond.

In the 1990s, geographers of sexuality invested considerable effort in understanding the spatialities of ‘public sex’ venues and environments used by GBMSM. However, this work has been less common recently. This is a mistake, given how the advent of new treatments for HIV and PrEP as a pharmaceutical prophylaxis to prevent HIV infection, as well as smartphone technologies, the rise of certain drugs used to enhance pleasure and disinhibition in sexualized spaces, and other factors have changed GBMSM’s socio-sexual cultures.

There is an urgent need for geographers to understand these changes, and not to restrict our studies to their densest expression in major metropolitan centres, but to consider how they are entangled with other locations too.

Treating Monkeypox

Given that the current Monkeypox outbreak was identified in relation to GBMSM’s sexual networks, since May people with Monkeypox symptoms have been directed to contact their local sexual health clinic for testing and treatment. Sexual health services, which in many places are already under considerable strain, have been given no additional resource to fund this case load.

The strain on sexual health services comes from a perfect storm of recurring funding cuts, a serious shortage of new nurses and doctors training to work in the area, and the retirement of the generation of clinicians who specialised in sexual health in response to the urgency of the HIV pandemic in the 1980s and ‘90s. While it has become commonplace for queer theorists to describe the significant shifts in social attitudes towards homosexuality and the increase in formal legal equalities for many LGBT people as an expression of ‘the sexual politics of neoliberalism’, there is still too little work which has examined the impact of austerity on LGBT people and socio-sexual cultures.

The good news is that there is an effective vaccine (the MVA Smallpox vaccine) which reduces the risks of Monkeypox infection. The bad news is that this vaccine is only produced in one location globally and there are significant supply chain issues. At present, in England, about 80% of available vaccine doses have been reserved for use in London. Given the concentration of cases in the capital, this makes some sense from a public health perspective, as it focuses vaccination in those communities at most immediate risk.

However, as I have already noted, GBMSM’s sexual networks are not neatly contained in place, and vaccines are needed for those GBMSM at highest risk nationally. The supply of vaccines has enabled London sexual health clinics to offer walk-in vaccinations to people deemed at highest risk. That is not currently possible in most other parts of the country, where many local sexual health clinics have only been allocated 20 doses (which must cover frontline sexual health staff as well as known contacts of confirmed Monkeypox cases).

While 20 doses might, just about, be adequate for the sexual health clinics in Telford or Penzance, it is wholly inadequate for cities the size of Leicester or Nottingham. The Government recently announced that it had ordered another 100,000 vaccine doses to be delivered by September. These need to be more effectively distributed nationally. The criteria currently being used for vaccine eligibility are effectively the same as those for accessing PrEP through the NHS (albeit with the proviso that this is not intended to exclude people with HIV who otherwise meet the criteria).

What can geographers contribute?

The current global Monkeypox outbreak poses many questions of interest to geographers and where geographical knowledge can make a useful contribution. Geographers of sexualities already know a lot about the drivers that have created dense concentrations of GBMSM in cities like London and Manchester, we also know something of the ways in which those spaces are always connected to other locations and the patterns of mobility between them. However, intellectual trends within the sub-discipline have also meant that geographers of sexualities have largely failed to keep pace with recent changes in the spatial and cultural dynamics of GBMSM’s socio-sexual networks and practices.

Monkeypox also challenges geographers to collaborate with one another, and there is a case for new collaborations between geographers of sexualities, health geographers, the emerging field of pharmaceutical geographies, and social geographers of austerity. These modes of transdisciplinary thinking are possibly more advanced in a few areas outside Geography, and we could look to queer work at the intersection of critical public health and STS for inspiration, without losing sight of the unique intellectual contribution we can make as geographers.


About the author: Gavin Brown is Visiting Professor in Geography at The University of Sheffield and a trustee of Trade Sexual Health in Leicester.

Suggested Further Reading

Race, K. (2017), The gay science: Intimate experiments with the problem of HIV, London: Routledge.

Hassan, NR, Tucker, A. (2021) “We have to create our own community”: Addressing HIV/AIDS among Men who have Sex with Men (MSM) in the Neuropolis. Transactions of the Institute of British Geographers. https://doi.org/10.1111/tran.12433

Myers, J. (2010), Moving methods: constructing emotionally poignant geographies of HIV in Auckland, New Zealand. Area https://doi.org/10.1111/j.1475-4762.2009.00927.x

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