The Same Problem on Repeat

To be an American is to live under a regime of profound inequalities, which result from the same concentrations of wealth that make the country an international power. Health care is one of the points at which those inequalities converge most catastrophically. As the journalist Steven Thrasher writes in his recent book The Viral Underclass, “viruses show us where the cracks in our society are.”

The three viruses that to my mind are now at the center of American life have different histories and consequences, but HIV, Covid-19, and monkeypox share a tragic fact: their prevention and treatment are neither equally nor effectively distributed to everyone who needs them. For HIV prevention, we now have PrEP; to mitigate Covid, we have vaccines with boosters, testing, and masks. Since the FDA issued an emergency use authorization for it earlier this month, the JYNNEOS vaccine can be used alongside the vaccine ACAM200 against monkeypox. Yet the US lacks a functional health care system to help people access medications that already exist.

The first PrEP (pre-exposure prophylaxis) drug was approved for preventive use a decade ago and has an almost perfect rate of effectiveness at keeping people who are exposed to the virus from becoming infected by it. But infection rates show striking disparities in access to the drugs. The CDC’s latest report on PrEP indicates that rates of new HIV infections in the US among Black people “are over eight times as high—and among Hispanic/Latino people almost four times as high—as that of rates of new HIV infections among white people,” who comprise 65 percent of PrEP users. Because of who currently has HIV in the US, the report continues, “Black and Hispanic/Latino people account for the majority of people for whom PrEP is recommended,” but only 9 percent of the nearly 469,000 Black people and 16 percent of the nearly 313,000 Latinx people who could benefit from the drug received a prescription in 2020.

Twenty-three percent of people with HIV in the United States are women. Yet a recent report in Reproductive Health showed that “although PrEP is a safe and effective medication for women,” its use “remains exceedingly low among cisgender women at risk of HIV in the US,” who are less likely than queer men either to be offered PrEP by physicians or to hear about it from each other. Being “prepared,” as PrEP’s name suggests, also means acknowledging in advance that you plan to have sex with someone you may not know, or may not know well—an admission that cultural double standards make it especially hard for some women to admit.

But domestic inequalities in PrEP access pale in comparison to global deficiencies in Covid vaccine distribution. Due to the greed of pharmaceutical companies and the resource stockpiling of wealthy nations, poor countries around the world have gone without adequate testing and vaccines. Last year the World Health Organization set a goal to inoculate 70 percent of the global population by mid-2022, but as of June just 37 percent of health care workers and 16 percent of the general population in low-income countries had received their first complete course of the vaccine. In an open letter to the World Trade Organization (WTO) that month, E. Tendayi Achiume, the UN Special Rapporteur on contemporary forms of racism, argued that such disparities amounted to “vaccine apartheid.” Only in June did the WTO issue patent waivers on Covid-19 vaccines so that they could be manufactured outside of the US and Europe.

The government response to monkeypox, a disease for which there is both a preventive two-shot vaccine and treatment for the infected, has been marked by a similar structural inability to get drugs to the people who need them. In August the CDC reported that 94 percent of cases were spread by sexual contact between men. The racial breakdown of cases—of the 88 percent of infected people for whom data was available, 41 percent were white, 28 percent were Latinx, and 26 percent were Black—shows that monkeypox infection rates among men of color who have sex with men are proportionally much higher than the presence of those men in the general population. And whereas the number of cases among white and Latinx people diminished as those patients were vaccinated between May and July, infections among Black patients increased over the same period by 12 percent.

In all three cases, the reason for these shockingly unfair conditions should be obvious to anyone who has ever needed medical services in the US. Getting quality health care here requires money, time, access, and savvy—resources that in this country are cruelly maldistributed along lines of class, gender, and race. Americans who can afford a private doctor have continuous, long-term health care relationships. An equitable system would ensure that every person has a provider who knows them and privately helps them make decisions about prevention and treatment at the highest standard of care.

The monkeypox outbreak has revealed not only racial inequities within the health care aimed at gay communities but also the inability of the public health system as a whole to recognize the specific needs of men who have sex with men. Despite both the fears and the hopes (depending on who you are) in recent decades that queer men are assimilating into heterosexual expectations about relationships and sexual practice—and despite the disappearance of public spaces for gay male sex like bathhouses or sex clubs and the gentrification of urban cruising areas like piers—some gay men continue to want, and insist on preserving, a sexual culture that involves communal experience. But these practices are still largely hidden and subcultural because of the stigma and homophobia they too often inspire. Asking people to stand on line, publicly, in the streets of their own neighborhoods to get vaccines for a virus widely associated with homosexuality is not good public health policy.

As long as our health system continues to be characterized by the unequal distribution of care, information, treatment, and prevention, our government’s response to new emergencies like the monkeypox outbreak will continue to favor rich, white men at home and wealthy countries around the world. If we want to defeat these already treatable and preventable illnesses, we need one global health care system in which every person can get the care we all deserve. Without that, the research and development of new drugs will keep generating profit for private industries and viruses will keep causing unnecessary suffering.