There's something else at play. We just don't know what it is.
Monkeypox cases surged to 3,500 across 50 countries in just two months, yet WHO stopped short of declaring the highest alert level (PHEIC) on June 25. Health experts argue the outbreak meets all three PHEIC criteria—extraordinary nature, significant international spread risk, and need for coordinated response—raising questions about the decision's rationale.
- 3,500+ cases across 50+ countries in two months (May 6–late June 2022)
- WHO declined PHEIC declaration on June 25 despite committee acknowledging outbreak as emergency
- 99% of UK cases occurred in men; Germany reporting ~50 new infections daily
- Spain received 5,300 vaccine doses; U.S. began distributing tens of thousands nationwide
The WHO declined to declare monkeypox a public health emergency despite 3,500+ cases in 50 countries in two months, drawing criticism from global health experts who question the decision's consistency with established criteria.
By late June, the World Health Organization faced a decision that would define its credibility in the eyes of global health experts. Two months had passed since the first monkeypox cases appeared in the United Kingdom on May 6th. In that span, the virus had spread to more than fifty countries, infecting over 3,500 people and spawning multiple genetic variants. Yet on June 25th, after two days of deliberation by its emergency committee, the WHO announced it would not declare monkeypox a Public Health Emergency of International Concern—the organization's highest alert level. The decision stunned many in the field.
The timing stung particularly hard given recent history. The WHO had delayed its pandemic declaration for COVID-19, a hesitation that haunted the organization for years. Now, with monkeypox spreading rapidly across continents, the same institution was again choosing restraint. WHO Director-General Tedros Adhanom Ghebreyesus acknowledged the committee's "growing concern" about international spread and noted that the outbreak's "rapid and continuous propagation to new countries and regions" posed particular risk to vulnerable populations—immunocompromised people, pregnant women, children. Yet he stopped short of the formal emergency designation.
The committee's own language suggested internal conflict. Members unanimously recognized the outbreak as an emergency requiring an "intense" response. They flagged significant gaps in available data and acknowledged numerous unknowns about the virus's behavior. They advised close monitoring and promised to revisit the decision within weeks if circumstances changed. But they did not cross the threshold into a formal PHEIC declaration.
Global health experts questioned the logic. A PHEIC, by definition, applies to outbreaks that are extraordinary, pose significant risk of international spread, and require coordinated global response. Clare Wenham, a health policy professor at the London School of Economics, observed that the WHO's own report appeared to document all three criteria being met. "It seems the criteria were satisfied, but it still hasn't been declared," she said. "There's something else at play. We just don't know what it is." Paul Hunter, a professor of medicine at the University of East Anglia, suggested possible explanations: transmission rates might be declining in non-endemic countries; declaring a PHEIC could stigmatize affected groups and violate human rights; or understanding of the virus's public health risk remained too incomplete.
Alexandra Phelan, a global health lawyer at Georgetown University, raised a more uncomfortable possibility. The virus had circulated in African countries for decades with minimal international attention. Only when it reached Europe and wealthy nations did it trigger global concern and media coverage. "It's unjust and unethical to determine that an event is only extraordinary if it's now happening in high-income countries," Phelan told Science magazine. The decision, she suggested, exposed uncomfortable questions about whose health emergencies the world treats as truly urgent.
Meanwhile, the virus continued its work. In the United Kingdom, which accounted for roughly one-third of global cases, 99 percent of infections occurred in men, predominantly within networks of men who have sex with men. Some clusters traced back to single "superspreader" events that had seeded rapid transmission. A Portuguese research team publishing in Nature Medicine found the virus had accumulated more mutations than expected—a possible explanation for why it was establishing itself in new countries after previously fading away. Germany was experiencing the fastest sustained growth in Europe, reporting nearly fifty new infections daily. In England alone, cases had jumped from 873 to 1,035 in just two days by late June.
A PHEIC declaration would legally obligate WHO member states to follow the organization's health recommendations. Currently, only polio and COVID-19 held that status. Gordon Dougan, director of infectious diseases at the Wellcome Trust, noted that governments need not wait for an official declaration to act. "When cases are identified, rapid public health responses will be crucial—better disease surveillance, contact tracing, self-isolation," he said. But as transmission continued, all countries needed to intensify preparations and support those with limited capacity. Hunter predicted the picture would shift within two weeks. "I suspect we'll see the epidemic outside Africa continue growing and possibly accelerating, and a PHEIC will likely be declared sometime in the coming weeks," he said.
Europe was already moving. Spain, which had recorded the second-highest case count globally after the UK, received its first 5,300 doses of the Imvanex vaccine on June 28th, followed by Belgium, Germany, and Portugal. The United States announced it would distribute tens of thousands of vaccine doses to clinics nationwide. The machinery of response was grinding forward, even as the WHO's formal designation remained withheld—a gap between what experts saw happening and what the organization was willing to officially name.
Citações Notáveis
It seems the criteria were satisfied, but it still hasn't been declared. There's something else at play. We just don't know what it is.— Clare Wenham, health policy professor, London School of Economics
It's unjust and unethical to determine that an event is only extraordinary if it's now happening in high-income countries.— Alexandra Phelan, global health lawyer, Georgetown University
A Conversa do Hearth Outra perspectiva sobre a história
Why would the WHO hold back on declaring an emergency when the numbers seem to clearly justify it?
The committee's own report suggests they saw the criteria being met. But declaring a PHEIC carries weight—it obligates member states to follow recommendations, it shapes how the world perceives a threat. There may have been concern about stigmatizing the affected communities, or uncertainty about whether transmission was actually accelerating or stabilizing.
But didn't the WHO learn from COVID-19 that hesitation can be costly?
You'd think so. The delay on COVID haunted them for years. Yet here they were again, choosing caution. Some experts wondered if the hesitation reflected something else entirely—whether a virus circulating in Africa for decades suddenly seemed urgent only once it reached wealthy European nations.
That's a serious accusation. Do you think that's what happened?
I think it's a fair question to ask. The virus had been in African countries for a long time with little international fanfare. The moment it spread to London, Berlin, Madrid—suddenly it was a global concern. That pattern is worth examining.
So what changed? Why did the virus suddenly spread so effectively in Europe?
That's the mystery. Researchers found unexpected mutations. There were superspreader events—single gatherings that seeded rapid transmission. The virus may have been circulating undetected for longer than anyone realized. But the honest answer is we didn't fully understand it yet.
Did the WHO's caution actually matter? Were countries acting anyway?
Yes. Spain, Belgium, Germany were already receiving vaccine doses. The U.S. was distributing thousands of doses. The response was happening on the ground regardless of whether the WHO formally called it an emergency. But the declaration would have made it official, would have legally bound member states to coordinate.
What did experts predict would happen next?
They expected the declaration would come within weeks. The virus was still spreading, particularly in Germany. The data gaps would fill in. And when they did, the WHO would likely have to reverse course and declare what it had initially withheld.