Rishabh Kumar woke up in his California bedroom in a cold sweat. In the space of three weeks, the 37-year-old finance executive had lost his mother, best friend, brother-in-law and two cousins. They all died of Covid back home in India in April and May last year. The experience left him shattered and experiencing nightmares that continue to this day. On this particular night last month, it was not thoughts of Covid tormenting him, but monkeypox, which had just been declared a health emergency in the US. Like many Indians at home and abroad, Kumar was worried for his country and the rest of his family. At the root of Kumar’s concerns were frustration and anger over India’s missteps during the Delta wave in 2021, when the country’s crematoriums and graveyards were full of bodies and smoke from funeral pyres. India has the largest vaccine manufacturing capability in the world, yet a failure to order and produce enough Covid doses in time led to shortages and a slow rollout. His mother had had a single vaccine shot before she tested positive – the others he grieves for had none. Now, as monkeypox cases climb steadily around the world, India’s government has been relatively prepared, say public health experts. Researchers at the National Institute of Virology in the western city of Pune isolated the monkeypox virus in July. And the Indian Council for Medical Research (ICMR), the government’s network of biomedical labs, has offered the isolated virus to private firms for the development of indigenous vaccines. But experts want India to do more. So far, only 12 monkeypox cases have been reported in the country, with one death. That’s a tiny fraction of the 61,000 known cases worldwide. Yet Covid has taught us that that could change. India’s vaccine preparedness matters not just for its population, but for the other developing nations dependent on its shots. “It doesn’t matter that India has only a few cases at the moment – the world needs India to step up when it comes to vaccine production,” says Ishwar Gilada, an infectious diseases specialist who set up India’s first Aids and HIV clinic in 1985. Globally, monkeypox has killed fewer than two dozen people this year, according to the World Health Organization, and research suggests that the mortality rate is significantly lower than from Covid. Monkeypox spreads primarily through prolonged, direct contact with a patient, rather than through respiratory droplets or aerosols. Still, this is the first time the virus has spread widely to countries with no history of monkeypox: 104 nations have reported cases. And the global scramble for vaccines that marked the Covid pandemic has started with monkeypox, presenting a challenge for public health initiatives seeking funding, such as the Global Fund, which met on 21 September for its seventh replenishment conference. Only one vaccine, for smallpox – Jynneos, produced by Danish firm Bavarian Nordic – has so far been approved by the US Food and Drug Administration for use against monkeypox. Wealthy nations such as the US, UK and Australia, joined the queue for doses early but are already facing shortages. As with Covid, poorer countries risk falling far behind in accessing the vaccines. India is yet to order any. “Even if the government ordered vaccines today, the pile-up of demand is such that we aren’t going to get doses for many, many months,” says Gagandeep Kang, a virologist at the Christian Medical College, Vellore, and the first Indian woman elected as a Fellow of the Royal Society of London. India’s efforts to develop indigenous vaccines for monkeypox could help it limit its dependence on Jynneos eventually, but that, too, will take time. “This isn’t going to yield vaccines soon either,” says Kang. If the spread of monkeypox can be contained, mass vaccinations may not be needed, and some researchers suggest that a vaccine may not be needed at all – at least for now. T Jacob John, a paediatrician and virologist who was one of the founders of India’s successful polio vaccination programme, says: “If we could do well without a vaccine for HIV/Aids, we can manage here too.” However, in some ways monkeypox presents a challenge more complex than HIV, says Gilada. “There’s a double social stigma, especially in a conservative country like India.” It is a sexually transmitted disease – a vast majority of cases involve men who have sex with men. “I wouldn’t be surprised if the cases we’re seeing reported are just a tiny fraction of the actual number,” he says. While India waits for a homemade vaccine and for demand for Jynneos to ease up, its vast pharmaceutical industry should focus on developing antiviral treatments for monkeypox, Kang says. Yet Covid brutally exposed a challenge that the government is still to address. “India does not fund research in sufficient amounts,” says John, meaning the private sector is left to take the risks. Even though the ICMR has invited private firms to join efforts to develop vaccines, it has not issued any research grants to incentivise their science. However, the way monkeypox is spread is a silver lining for India, says Gilada. Once a vaccine or antiviral is available, the country’s vast Aids-control network – consisting of 1,160 centres dedicated to treating sexually transmitted infections – could offer rapid frontline services. “We should be able to prioritise those who are most vulnerable, in settings where they already feel somewhat comfortable,” says Gilada. For those traumatised by the unnecessary human losses of the Covid pandemic, the way India responds to monkeypox will be closely scrutinised. Back in San Jose, California, Kumar said it would be “unpardonable” if the Indian government were to repeat its Covid mistakes. “I hope they have learned their lessons,” he says. “I can’t deal with these nightmares any more.”