 On 1st July, WHO Regional Director for Europe Dr. Hans-Henry Kluge called for urgent action to prevent the spread of monkeypox in Europe. His call comes in the context of the increasing cases of monkeypox in Europe, which has tripled over the last two weeks. With more than 5,000 cases, the recent monkeypox outbreak in Europe and North America has become a concern for many. As long as monkeypox was confined to Africa, where outbreaks have occurred for years, it raised little concern. But with monkeypox reaching rich countries, it has become an immediate media event, with headlines and TV coverage. What is monkeypox? Monkeypox is actually a misnomer. The disease is not endemic among monkeys, but in rodent populations in central and west Africa. It was wrongly named as the initial case was often infected monkey biting a child and transmitting the disease. The virus is from the orthopox-virus genus, which includes smallpox and cowpox. While the west African variant spreading in Europe and North America has a mortality rate of about 1%, mortality for the central African variant is around 10% or 10 times higher. Monkeypox is no longer a zoonotic infection, meaning it no longer spreads from rodents to humans and then peters out after some cases. It is a human-to-human transmission that is now taking place in many countries, with large numbers infected in the United Kingdom, Germany, Spain and Portugal. What is the trajectory of the spread of the disease? From 1970 onwards sporadic monkeypox outbreaks have occurred in central and west Africa. In the last 10 years, the Democratic Republic of Congo has seen thousands of suspected cases and hundreds of suspected deaths. A significant outbreak occurred in Nigeria in 2017, with over 700 confirmed and suspected monkeypox cases. Genomic studies show the virus probably circulated in east and north Africa from 2018 onwards. Even in Europe, it has probably been in community circulation for some time. Initially, cases would have been mistaken for a skin condition or allergies and not recognized as monkeypox. Why has monkeypox appeared now? One major reason for its increased spread now is the discontinuation of smallpox vaccination, once it was eradicated. The smallpox vaccine gives production against monkeypox. As younger people are no longer vaccinated, the fraction of people who have no immunity against monkeypox has increased and this makes them susceptible. The only ones who still have immunity are people in the age group of 45 and above. Once the virus spread from sparsely populated regions to more densely populated urban settings, the current rapid spread was an event waiting to happen. Currently, the transmission speed may appear more rapid but that may be because monkeypox is getting recognized more quickly, also because public awareness has increased. How does the virus spread? In the recent cases of monkeypox, the infection seems to have spread among gay men. Experts have already explained that this is not a sexually transmitted disease and spreads through contact. It has spread among gay men because they tend to be closed groups and sex obviously provides close contact. The problem for health officials is how to warn high-risk groups without stigmatizing them as happened with AIDS. During the initial period of spread of AIDS, it was regarded as a disease of the gay population. This led to public health systems ignoring the problem and its subsequent much wider spread. The current outbreak results from not addressing monkeypox in Africa when it was sporadic and could have easily been contained. Why does the global health system wake up only when the rich countries are affected? The West, according to health experts, believe that antibiotics and vaccines had won them victory against the threat of infectious diseases. The western countries also believe infectious diseases are only a problem of the poor countries and all they have to do is restrict the entry of people from those countries. So it was of little concern to the rich that infectious diseases endemic in poor countries killed millions every year. Belief in victory over infectious diseases led to collective amnesia in the west about a host of diseases that still plague the world. Their other mistake was believing microbes do not evolve and our defences against them will hold for a long time. But diseases have a way of striking back. The AIDS epidemic was the first obvious breach. The COVID-19 epidemic proved we are always only one mutation away from a new infectious disease. The West's belief that it could keep infectious diseases outside its borders is what led to its unpreparedness for the COVID-19 pandemic. This is repeated for monkeypox. What is the way out of this crisis? Unless patients are immunocompromised or have comorbidities, monkeypox is not life-threatening. An antiviral drug, tycoviromat, authorized for use against smallpox is also effective against monkeypox. It is a small molecule drug so easy to manufacture and scale up production if required, provided high-cost intellectual property rights do not cause an AIDS-like disaster again. Many countries have a stock of smallpox vaccines and can be rapidly deployed to vaccinate people who have come in contact with a possibly monkeypox case. Old-fashioned epidemic control measures, tests, isolate and vaccinate, all who have come in contact with the patient should control this epidemic. Why were such measures not taken for Africa then? African health experts say that though countries have pledged 31 million doses of smallpox vaccines to the WHO for emergencies, no vaccine has been made available to Africa to address monkeypox. This needs to be addressed urgently and ramping up testing and antiviral use at prices people can afford. If we do not, we will see a repeat of the COVID-19 vaccine apartheid and a replay of Africa's high-cost patent and antiviral AIDS drugs disaster. What we really need to ask is not so much a direct concern about this virus but the lessons drawn from COVID-19 monkeypox influenza and related viruses, which is do we globally have public health systems funded by communities and states rather than by profit-making companies which reach remote communities, which reliably monitor with good technological backup for a variety of viral diseases, does information get collated, analyzed and put into public health policies by developing vaccines, by developing networks and by enhancing our public healthcare capacities for delivery to the poorest, most disempowered of communities. That still remains the monkeypox question.