The Washington PostDemocracy Dies in Darkness

The monkeypox outbreak reflects our failure to learn from AIDS activism

AIDS activists wanted to transform health systems to make sure that all people had the care they needed

Perspective by
Dan Royles is an assistant professor of history at Florida International University and the author of "To Make the Wounded Whole: The African American Struggle against HIV/AIDS."
August 12, 2022 at 6:00 a.m. EDT
Health-care and LGBTQ rights activists demonstrate outside the federal building in San Francisco on Aug. 08, 2022, demanding an increase in Monkeypox vaccines and treatments as the outbreak continues to spread. (Justin Sullivan/Getty Images)
8 min

For those LGBTQ people who lived through the worst years of the AIDS epidemic or grew up in its shadow, monkeypox brings a grim sense of deja vu. Once again, an unfamiliar virus is spreading through gay men’s sexual networks, and far too little is being done to stop it. But monkeypox isn’t just a case of history repeating itself. It also shows that, despite remarkable improvements in the prevention and treatment of HIV — the virus that causes AIDS — the vision of health justice that AIDS activists articulated and fought for over the past 40 years remains largely unfulfilled.

Granted, the response to monkeypox shows signs that some doctors, public health officials and political leaders have learned valuable lessons from HIV/AIDS. For example, guidelines on monkeypox from the Centers for Disease and Prevention emphasize “harm reduction,” advising people on how to reduce the risk of transmission during sex. This approach recognizes that abstinence-only messages tend to be ineffective, and harks back to Michael Callen and Richard Berkowitz’s “How to Have Sex in an Epidemic,” which offered gay and bisexual men advice on how to practice a range of sexual activities as safely as possible based on what little information was known about AIDS in 1983.

Public health officials have also shown a genuine desire not to replicate the kind of anti-gay stigma that marred early responses to AIDS. Last week President Biden appointed Demetre Daskalakis, a gay doctor and former assistant health commissioner for HIV prevention in New York City who is well known for offering HIV testing and counseling at the city’s gay sex clubs and bath houses, to be deputy coordinator of the White House Monkeypox Response Team.

Indeed, the U.S. medical system has gotten better at providing care to LGBTQ people, which reflects a greater degree of social acceptance and real political gains in terms of LGBTQ rights and legal protections. That doctors and public health officials have gotten better at talking to and about queer people when it comes to their health is important, and that progress is due in no small part to the work of AIDS activists.

But early AIDS activism was about far more than crafting effective messages about safe sex. AIDS activists also wanted to change health systems to make sure that all people had the care they needed. And monkeypox shows just how much we have failed to deliver on their vision of an equitable health-care system at home and a humanitarian vision of global health abroad.

From almost the time that doctors first identified what would later become known as AIDS among gay men in 1981, activists understood the new disease as part of a larger fight to reform and strengthen the U.S. health-care system. Some saw the opportunity to harness the energy of AIDS groups in the fight for universal health care and rallied around the slogan “health care is a human right.” Others sought to realign national priorities by shifting public spending from the military-industrial complex to medical research and care. From the 1980s through the new millennium, these activists demanded “money for AIDS, not for war.”

This slogan was coined as early as 1983 by queer activists who organized against U.S. interventions in Central America, as the historian Emily Hobson has uncovered. At the time, a growing number of Americans were becoming sick and dying of complications of AIDS while the Reagan administration propped up right-wing regimes throughout the Western Hemisphere. These activists linked the two issues to highlight what they saw as an appalling truth: instead of saving lives at home, the federal government was using its power to destroy lives abroad.

Looking at the numbers underscored their point. By its own account, the Reagan administration spent $1.2 billion on security in Central America and the Caribbean in 1985 alone, although at the time political scientists Joshua Cohen and Joel Rogers estimated the real cost to be almost eight times that figure. Meanwhile, the White House’s proposed federal budget for 1985 allocated just $95 million to funding AIDS research and treatment. In the years that followed, federal spending on public health remained a fraction of spending on national defense, and the difference became even starker after 9/11.

Beginning in the late 1990s, U.S. activists began to organize on behalf of people in the Global South who were seeking access to highly effective treatments for HIV. They did so not because they saw AIDS as a threat to national security, as did U.S. intelligence officials, but because they believed that the United States had a humanitarian obligation to help people who were sick and dying in other parts of the world. If Americans benefited from lifesaving HIV drugs, it was immoral to deny others the same.

U.S. officials were then using trade policy to prevent South Africa and other countries in Africa, Asia and Latin America from producing or obtaining less-expensive generic versions of these treatments. AIDS activists used direct action to force changes to these policies by interrupting Vice President Al Gore’s campaign events and occupying the office of the U.S. Trade Representative.

After George W. Bush became president in 2001, activists continued to pressure the federal government to make HIV drugs available to poorer nations. They took to the streets when Andrew Natsios, the head of the U.S. Agency for International Development, suggested that such treatments would be ineffective in Africa because people there “don’t know what Western time is.”

In the context of both the “war on terror” and the run-up to the invasion of Iraq, AIDS activists continued to demand “money for AIDS, not for war” by pushing for a significant U.S. commitment to fighting AIDS in Africa. Bush chose to fund both.

When Bush committed billions of dollars for fighting AIDS in Africa in the form of the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003, activists considered it a result of years of their own organizing, even if their efforts are often excluded from histories of the program. Since then, the United States has committed over $110 billion to PEPFAR, which has saved an estimated 20 million lives. In contrast, scholars estimate that the war on terror has cost $8 trillion — over 70 times as much — and directly resulted in the deaths of nearly a million people.

From PEPFAR, we might have learned the value of U.S. commitments to global health. Instead, the federal government seems committed to hoarding resources that are badly needed elsewhere in the name of national defense and security.

Take the case of Jynneos, the vaccine now being used to prevent monkeypox, which was developed under the auspices of national security — not health care. After 9/11, amid fears of a future bioterror attack, the U.S. government spent upward of $1 billion on the development of Jynneos as an effective smallpox vaccine. The work was done by Bavarian Nordic, a Danish company.

At one point, the national stockpile held 20 million doses of the vaccine, several times the quantity experts believe is needed to vaccinate every American considered to be at high risk for monkeypox. However, almost all those doses were allowed to expire, perhaps because they were developed for national defense, not public health.

While the United States retained doses of Jynneos, people in Africa were getting sick and dying of monkeypox. Outbreaks in West and Central Africa over the past decades have resulted in thousands of cases — although officials suspect the actual number may be much higher — and at least 75 deaths. This, too, represents a failure to learn from the history of AIDS activism.

Today, the Jynneos vaccine has been in scarce supply in the United States. Dr. Carlos del Rio of Emory University School of Medicine described a Hunger Games approach” to vaccine distribution. In fact, the country may soon face a “vaccine cliff” that will leave a million or more who are at risk unprotected against monkeypox.

Learning from the history of AIDS activism would mean a real investment — of time, money and capacity — in protecting and promoting the health not just of Americans, but also of people around the world, by making sure that all have the care they need.