The Biden administration’s decision last week to declare the monkeypox epidemic a public health emergency in the US ought to broaden the government’s power to ramp up its response, to change vaccination strategies, and loosen regulations that restrict availability of drugs and tests. But as much as it’s a hoped-for pivot, it’s also an inflection point. The declaration provides a chance to look at what’s been done so far, assess the opportunities that have already passed us by, and ask what’s the smartest thing to do next.

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At this moment, experts perceive the US, along with the rest of the world, as embarking on a giant Choose Your Own Adventure that could have wildly varying results. Reaching the best ending is trickier than it sounds. It requires not just an assessment of what could be created—and, crucially, spent, because doing public health demands funding. It is also a question about what kind of world we want to live in. Is it a society that learned the lessons of the Covid pandemic: about not neglecting preparedness, not reserving the products of research for rich nations, and not consigning some people to run the most risk because of race, geography, or gender? Or is it a society that needs to learn those lessons a second time?

Choice 1: The Boldest Path

Here’s the best possible future: The world learns the lessons of Covid and does everything to stop this next threat.

In that option, “every country, whether they have a case or not, is stepping up to do the things that are necessary for containment: vaccinating populations at risk, making testing widely available, investing in therapeutics,” says William Goedel, an epidemiologist and assistant professor at the Brown University School of Public Health. “This is a different situation than we had with Covid. We have all of the tools from the beginning this time.”

Indeed, unlike Covid, monkeypox was not a disease that arrived without warning. It was first identified decades ago, a rare infection that spread from forest wildlife in the Democratic Republic of the Congo to villagers who hunted the animals. Thomas R. Frieden, a physician and the former director of the Centers for Disease Control and Prevention, heard concerns about it during his tenure in the Obama administration. “I traveled in Africa with CDC staff, and they were worried about monkeypox getting out of control,” he says. “Because they were seeing chains of transmission that weren't stopped, and there wasn't enough money, frankly, to do the research, to partner with African scientists, to better understand it and control it.” In 2018, a cadre of Nigerian scientists published a warning that the virus had changed its behavior, spreading not from animals but person to person.

There’s an opportunity now to learn from these warnings, and from the Covid pandemic as well. In the US, some experts think the best way to bring the present situation under control will be by broad—though not nationwide—deployment of vaccines. Last week, two faculty members and four doctoral students from Brown and the Yale School of Public Health published a preprint (which has not been peer-reviewed) that models how much public-health intervention—testing, contact tracing, and administering vaccines—would be needed to stop monkeypox spreading further in the US. Without vaccines, they found, it would take detecting 40 percent of cases through tests and tracing at least 50 percent of their contacts, goals that are likely unrealistic. But vaccinating at least a third, and up to a half, of the men at highest risk could bring the rate of infection low enough that the epidemic can’t sustain itself.

Models are based on assumptions, and one of the assumptions in this one is that there are approximately 500,000 “high-risk” men who have sex with other men in the US, defined as someone who has more than 100 sexual partners in their lifetime. If that number is correct (the authors acknowledge it may be an underestimate), controlling the epidemic primarily by immunization, with some testing and contact tracing, would require 428,000 doses of vaccine.

An effort that large would go well beyond the “ring vaccination” strategy that the US and other affluent nations have said they want to implement. It would ask people to volunteer to be vaccinated based on their own assessment of their behavior, rather than knowledge of any other person’s infection. Based on men’s eagerness to get vaccinated thus far—in several cities, appointments for the shots have been snapped up as quickly as they were posted—that strategy could be successful, provided the doses are there.

“I think there’s a lot of optimism to be had around monkeypox, particularly in contrast to Covid,” says Alyssa Bilinski, an assistant professor of health policy at Brown University School of Public Health and one of the faculty authors on the preprint. “There's still a lot of reason to believe that this is a virus that public health measures can drastically mitigate, if not completely contain.”

Making this best-case scenario work also requires a few other components. There would have to be enough affordable vaccine doses in every nation to protect anyone who wants or needs the shots. Testing would have to speed up via new assays that detect the virus in blood or saliva, earlier during infection than lesion swab tests can. Public health agencies would need to work with community organizations—for gay and bi men, urban youth, rural and incarcerated men—to make sure education reaches anyone who needs it. Counseling would become a routine part of the regular health care visits that men who have sex with men make in order to stay on HIV prevention therapy. The virus wouldn’t be able to reach its potential victims through those layered protections, and monkeypox would become rare.

Choice 2: The Mushy Middle

There’s a second-best path, and it’s the uncertain ground that the US and other industrialized nations now find themselves stumbling through.

This maintains the status quo: distributing vaccines, but not to everyone who wants one. Deploying tests, but not rapidly, because the current assay can’t be used until an infected person develops the characteristic pustules. Dispensing drugs, but only after asking prescribers to vault bureaucratic hurdles imposed by the only available treatment being held in a federal stockpile.

It is a path in which we have some vaccines, but their distribution is stymied by a manufacturing bottleneck. The Biden administration on Tuesday disclosed details of its strategy to make more vaccines available by splitting doses into fifths. The plan is controversial among some researchers—it would change the way the shot is administered in order to make the smaller dose protective, and it has not been studied for effectiveness—but if successful, it could solve the problem of vaccine supply in the US.

Still, that path is made messier by doing nothing for the countries in West and Central Africa, where monkeypox was first identified decades ago and has been spreading since 2017. Vaccines are not arriving there; Western nations, including the US, have snapped up the limited supply. Nigeria is believed to have been the source of the current international outbreak, via a long chain of transmission that wound through several European countries before arriving in the US. Unless that epidemic can be addressed, monkeypox won’t successfully be controlled there, or anywhere. “If the global equity issues are not attended to, if vaccines and therapeutics don’t make their way to Nigeria and the Democratic Republic of the Congo, then that has implications for random importations back out to other places,” Goedel says.

On this middle path, monkeypox continues to spread in low-income countries that cannot afford to buy vaccines or set up the infrastructure for testing. It is periodically reimported to rich countries, whose populations may or may not be protected, depending on how widespread their vaccination programs have been. It remains a persistent threat to men who have sex with other men, particularly in places where cultural pressure to seem straight, or structural racism, or simple poverty, make it difficult to obtain health care that is sensitive to sexual identity. Maddeningly, the rest of the world is OK with that.

Choice 3: The Dead End

Then there’s the worst case: We don’t control monkeypox. In this imagined future, monkeypox slips through the imperfect containment created by insufficient vaccine supplies, leaking from the social networks of men who have sex with other men, through other sexual partners and members of households, and into the rest of society—particularly people with vulnerable immune systems, including older folks, pregnant people, and kids.

“The epidemiologic worst case is that there is sustained, efficient human-to-human transmission outside of sex,” says Jay Varma, a physician and director of the Cornell Center for Pandemic Prevention and Response at Weill Cornell Medicine in New York City. “And then it will spread like chickenpox does, in schools and daycare centers. And we’ll be faced with a vaccine that has never been tested in children.”

This is the path the US will choose if it declines to share national stocks of vaccines and doesn’t exert influence on patent exclusivity so that other countries also can manufacture them. On this path, the federal government doesn’t pressure the Food and Drug Administration to move quickly to test that new fractional-dose regimen, and doesn’t ask gay community organizations to participate in adaptively designed clinical trials that would help deploy the regimen more quickly. It also doesn’t coax drug and device manufacturers into developing inexpensive point-of-care tests that can further shorten time to diagnosis.

The epidemiologist Mary Bassett, director of the François-Xavier Bagnoud Center for Health and Human Rights at Harvard University and currently the health commissioner for New York state—which declared a public health emergency before the White House did—is famous among public health people for declaring that epidemics follow fissures in society. That was true for Covid: The illness, disability, and death it cast across the country fell hardest on people of color, people in poor neighborhoods, people without the political access to advocate for themselves. The dismaying reality of the monkeypox epidemic is that it could carve those fissures even deeper, inflicting the most cost on those least able to bear it.

In the economic and political chaos imposed by Covid, the inability to organize an effective response might have been inevitable. Encountering the same problems a second time ought not to be. “If there's one bottom line lesson here,” Frieden says, “it is—as if we needed another reminder—we really are connected. A weak link anywhere is a threat everywhere.”