A debate over how best to warn New Yorkers about monkeypox is roiling the New York City Department of Health.
At the center of the dispute is a fundamental disagreement about public messaging, with some health officials saying the city should be encouraging gay men to reduce their number of sexual partners while monkeypox spreads, while others argue that message would backfire.
The internal turmoil peaked when the health department issued an advisory last week suggesting that having sex while infected with monkeypox could be made safer if people avoided kissing and covered their sores. Several officials at the agency were outraged, saying the agency was giving misleading and even dangerous health advice, according to several epidemiologists within the agency and a review of internal emails.
The advice on safer sex was not medically sound, said Dr. Don Weiss, the director of surveillance for the department’s Bureau of Communicable Diseases, in an interview. He believes the department should advise those at risk of monkeypox to temporarily reduce their number of partners, saying, “We’re not telling people what they have to do to be safe.”
His concerns are shared by some of his colleagues, emails and interviews show, indicating growing frustration and pessimism within the ranks of the health department as the window for bringing under control New York City’s monkeypox epidemic — the largest such outbreak in the United States — quickly closes.
Monkeypox has been spreading globally since early May. Cases in New York City, where nearly all monkeypox patients are gay men, have nearly tripled in the last week: There were 618 documented cases of monkeypox in the city as of Monday, though Dr. Weiss said that the true number of infections was far higher, because testing has been limited.
The strategy favored by Dr. Weiss, who has long played a frontline role in the department’s response to disease outbreaks, has received little traction within the department.
“For decades, the L.G.B.T.Q.+ community has had their sex lives dissected, prescribed, and proscribed in myriad ways, mostly by heterosexual and cis people,” the health department said in a statement.
The city’s response to monkeypox is grounded in the science and history of “how poorly abstinence-only guidance has historically performed,” the statement said, “with this disgraceful legacy in mind.”
The spread of monkeypox has reignited an ongoing debate within public health over how best or even to what degree public health officials should tell people to change their sexual behavior in times of outbreak.
What to Know About the Monkeypox Virus
What is monkeypox? Monkeypox is a virus endemic in parts of Central and West Africa. It is similar to smallpox, but less severe. It was discovered in 1958, after outbreaks occurred in monkeys kept for research, according to the Centers for Disease Control and Prevention.
What are the symptoms? Monkeypox creates a rash that starts with flat red marks that become raised and filled with pus. Infected people may also have a fever and body aches. Symptoms typically appear in six to 13 days but can take as long as three weeks after exposure to show, and can last for two to four weeks. Health officials say smallpox vaccines and other treatments can be used to control an outbreak.
How infectious is it? The virus spreads mainly through body fluids, skin contact and respiratory droplets, though some experts suggest that it could occasionally be airborne. Typically it does not lead to major outbreaks, though it has spread in unusual ways this year, and among populations that have not been vulnerable in the past.
Should I be worried? The likelihood of the virus being spread during sexual contact is high, but the risk of transmission in other ways is low. Most people have mild symptoms and recover within weeks, but the virus can be fatal in a small percentage of cases. Experts say that monkeypox is unlikely to create a pandemic scenario similar to that of the coronavirus.
What’s the situation in the United States? Experts say that the rapid spread of monkeypox across the country and the government’s sluggish response raise questions about the nation’s preparedness for pandemic threats. Tests will not be readily available until later this month and vaccines will be in short supply for months. Official case counts, now in the hundreds, are likely a gross underestimate.
It’s a debate familiar from the earlier years of H.I.V./AIDS, when terror and stigma ran high. The stakes are far lower with monkeypox, given that no one in the United States has yet died from the disease, treatments and vaccines exist, and the illness appears to pass relatively quickly. Still, some epidemiologists say an aggressive response now — while transmission is predominantly limited to gay and bisexual men — could prevent the virus from becoming endemic in New York or reaching a broader swath of the population.
Some public health experts say that many gay men are likely to push back against any advice that could be seen as discouraging or stigmatizing gay sex. They say that such advice shifts blame onto them for the outbreak and could lead the intended audience to view public health authorities with distrust.
“Telling people not to have sex or not to have multiple sex partners or not to have anonymous sex is just a no-go, and it’s not going to work,” said a longtime AIDS activist, Charles King, who is chief executive of Housing Works, which provides housing and social services to the homeless and those affected by H.I.V.
“People are still going to have sex and they’re going to have it even if it comes with great risk,” he said.
But there may be a middle ground, some experts said, noting that urging people to temporarily reduce their number of sexual partners or avoid sex parties where they might have multiple partners is not the same as a message of abstinence or monogamy.
“Name the risk factors and behaviors and give people options,” said Dr. Dustin Duncan, a epidemiologist of infectious diseases among sexual and gender minority groups at Columbia University.
He offered an example: telling people they could reduce their risk of getting monkeypox by “having one consistent casual partner as opposed to multiple people” seemed a reasonable message at the moment, he said.
Dr. Weiss said that asking people to change their sexual behavior — even if just for a month or so — was the most potent weapon health officials had right now to reduce monkeypox cases. Vaccine supply is limited and had been initially doled out via hard-to-get appointments during daytime hours at a few clinics, though mass vaccination sites have opened in recent days.
But Dr. Weiss said his recommendations have been largely ignored by the department’s senior leadership, who seem “paralyzed by fear of stigmatizing this disease,” he wrote in an email to colleagues this June.
“If we had an outbreak associated with bowling, would we not warn people to stop bowling?” he wrote.
So far, the health department has been reluctant to publicly encourage people to change their sexual behavior, unless they are actively infected with monkeypox. That mirrors the broader messaging about the outbreak by the federal government.
The department’s advice, posted on its website, does note that “Having sex or other intimate contact with multiple or anonymous people (such as those met through social media, dating apps, or at parties) can increase your risk of exposures.”
At an online “town hall” event last week about monkeypox, the city’s health commissioner, Dr. Ashwin Vasan, said the department’s goal is to be “sex positive.”
“We want to in no way stigmatize sex at all,” Dr. Vasan said. “We want to be very clear there are certain activities and one of them is intimate sexual contact that places you at higher risk in certain settings.”
Dr. Weiss, who has held the same job for 22 years, investigating and responding to new outbreaks for the Bureau of Communicable Diseases, said he felt obliged to speak out publicly because he felt the department’s public statements were at times irresponsible. He pointed to the news release issued on Friday containing several prevention tips for “those who choose to have sex while sick.”
It stated that covering up monkeypox sores with clothes or bandages while having sex “may help reduce — but not eliminate” the risk of transmission. The release also said “for those who choose to have sex while sick, it is best to avoid kissing and other face-to-face contact.”
Dr. Weiss said it was “ludicrous” to suggest these steps would meaningfully reduce the risk.
The Health Department’s guidance to the public has often highlighted nonsexual routes of potential transmission, such as hugging or contact with bedding. While those are certainly possible routes of transmission, the result — Dr. Weiss said — was to make people overly concerned about casual physical contact and not sufficiently aware that most monkeypox infections in New York appeared to be transmitted through sex.
Dr. Weiss said he has supervised a team of epidemiologists who reviewed many of the city’s monkeypox cases. In most, patients have had lesions on the penis, anus or in the rectum, suggesting, he said, that the disease is spreading mainly through sexual contact.
He also said that reports of asymptomatic spread and the presence of the virus in semen should have resulted in the department’s recasting their public advice.
“I know I sound like a Bible-thumping preacher,” Dr. Weiss wrote recently to a group of epidemiologists in a Department of Health email chain.
But, he has argued, “If we don’t act soon, it may be the point of no return.”
Sharon Ottermancontributed reporting.