The recent shootings in Atlanta highlighted a surge of anti-Asian violence in the United States throughout the pandemic. Disease stigma and racism have together shaped pandemic response and policy for centuries.
And so to better understand this history, on the podcast Social Distance, co-hosts James Hamblin and Maeve Higgins speak with Alexandre White, a sociologist and medical historian at Johns Hopkins University. He shares his views on how a legacy of prejudice tied to disease should lead us to reexamine how we respond when outbreaks occur.
Listen to their conversation here:
Subscribe to Social Distance to receive new episodes as soon as they’re published.
What follows is a transcript of the episode, edited and condensed for clarity:
James Hamblin: How did you get into this line of research?
Alexandre White: I became very interested in the ways in which epidemic moments seem to key off of, or become more severe as a result of, existing social, economic, and political inequalities. I found this most clearly when I was conducting research on HIV/AIDS and tuberculosis infections in South Africa. And I was really struck by the ways in which histories of apartheid and ongoing racial inequities would shape who got sick, who got better, and—ultimately—why. And I became very interested in looking at international epidemic responses and the ways in which economic ideologies, political ideologies, histories, and legacies of colonialism and racism shape international epidemic response.
In the early days of my research, I was exploring an earlier case of racially segregated responses to an epidemic of bubonic plague in Cape Town in 1901. And I was doing this research at the same time we were living through the West African Ebola epidemic. We were seeing highly policed, militarized quarantining of poorer neighborhoods in Monrovia, with violence ensuing. And I was like: There must be something connecting these two phenomena in some way. And as I continued my research, I started to see [that] the way in which we as a globe have responded to the threat of infectious disease spread—the threat of epidemics and pandemics—is to, in so many ways, double down on the rooted and continuing social imbalances as a way of not only ascribing difference to populations but also as a way of providing differential care. And we see the ways in which this has very disparate outcomes in who lives and who dies from epidemic disease.
There’s a wonderful quote by Roderick McGrew from his study on cholera that says: “Epidemics do not create abnormal situations, but rather sharpen existing behavior which ‘betray deeply rooted and continuing social imbalances.’” What I was seeing was an example of what sociologists would call the “social determinants of health.” We could see, especially in the legacies of apartheid, the ways in which racial segregation, unequal access to housing resources, [and] political violence really shape how people live and, unfortunately, also the diseases they get and ultimately how they die. And as we’ve seen in the United States, especially over the last year, racism in a variety of different ways, whether it’s political violence or whether it’s the effects of structural racism leaving you vulnerable to contagion and infectious disease, it quite literally kills.
Hamblin: You mention the social determinants of health. If you’re in a place that’s high-stress, you can’t sleep, can’t eat well, don’t have space, you’re probably going to be in a worse place in this pandemic than otherwise. So there’s been an important need to say that this pandemic is not affecting people equally. How do you highlight that disparity without contributing to notions that this is a disease that is associated with certain populations?
White: That’s a wonderful question. Since the 14th century and perhaps even earlier, the arrival of an epidemic has been grounds for ascribing difference and assigning blame to certain populations—generally marginalized populations—for causing the spread of the disease. And we can look to, for instance, massacres of Jews in Europe and especially the Strasbourg massacre of 1349. The Jewish population of the city was blamed for the spread of plague and ultimately massacred.
Maeve Higgins: And that was because there was already deeply rooted hatred of Jewish people and the plague was used as an excuse.
White: That’s exactly right. And you have to remember that the understanding of disease in the 14th century was very different from what we have now. There wasn’t an understanding of contagion or germ theory. Rather, there was an understanding that this pestilence had arrived and we’re going to blame these particular populations for that spread.
But in the late 19th century, you see similar actions at work, just under new and different understandings of disease. With the acceptance of germ theory and an understanding of the ways in which diseases are capable of traveling, disease becomes really a basis for justifying already latent exclusions—whether they’re internal to a nation or a city or in terms of immigration and global travel. So disease becomes a way of further ascribing difference and otherness in a way that is both biological, cultural, and enduring.
Higgins: You’ve mentioned examples of disease bias from that time period in Africa. What are some cases we saw in the U.S.?
White: I think there are several very disturbing historical cases that resonate today as we see so much anti-Asian discrimination and violence and racism. There were two notable events of bubonic plague occurring on U.S. soil.
One was in Honolulu, which was at the time part of the American colony of Hawaii. There was great concern, in that case, of Hawaii being seen fundamentally as an Asiatic colony because of this stigma around the spread of infectious disease coming from the Asian continent. And what resulted was an incredibly violent, racist, and xenophobic quarantine of the city’s Chinatown, whereby Chinese homes and businesses were segregated away from the rest of the city. People were unable to travel in and out.
But at the same time, the region around this Chinatown, and even within, was gerrymandered such that [for] American and white-owned businesses and homes, you could travel without encumbrance. The public-health authority of the city attempted to burn down and sanitize plague-infected homes, and ultimately these fires got out of control and engulfed much of the Chinatown in flames, obviously leaving many homeless, without employment, without a job, without a place of work.
Higgins: On top of a plague.
White: Indeed. And we saw similar racially segregated quarantines occur in San Francisco’s Chinatown from 1900 to 1904 as they were battling the plague. And those quarantines also played out in rather similar and oppressive ways.
Higgins: Back in April of last year, you wrote: “As we witness spates of xenophobic violence, Sinophobia and other anti-Asian sentiment, it is important for us to notice whose perspective dominates responses to epidemics.” What have you been thinking about as we’ve seen this anti-Asian harassment and violence escalating?
White: I’ve been both incredibly saddened by this and also frustrated. This history of anti-Asian racism runs very much through histories of epidemics, of immigration, of colonialism that the United States often doesn’t discuss. What this ignores is the long history of structurally racist action against Asian populations broadly. And this goes back to the latter half of the 19th century, reaching a sort of apex with two major federal acts that would control immigration from Asia to the United States.
The first was the Page Act of 1875, which banned the immigration of Chinese women, and which was justified on the basis that Chinese women were perceived to be immoral or guilty of sexual misdeeds. And this conflation of sexual and moral perversity was linked fundamentally with a medical justification that somehow the venereal diseases that Chinese women might bring and spread as sex workers were somehow more virulent than those brought by either other European migrants or that existed in the United States. So there was this grim and horrific conflation of gender, sexuality, race, and the foreignness and concern for the diseases that were more threatening because they were fundamentally arriving from Asia.
Higgins: And we saw an apparent attack specifically on Asian women working in massage parlors over 100 years later.
White: The other major coercive, racist, and anti-Chinese act that emerged in the late 19th century is the Chinese Exclusion Act, which banned the immigration of Chinese men as well, doubling down on the Page Act. This was once again justified by beliefs of the threat of contagion arising from Asia and somehow poisoning the moral and epidemiological space of the United States.
And it’s really important to note that these acts were not solely effective against Chinese or broadly Asian populations, but the sheer fact that these acts were passed really allowed for the slews of racist and xenophobic immigration acts that we saw in the 20th century and 21st century against South American and Central American populations. Even former President [Donald] Trump’s Muslim ban is rooted in this legacy that really emerges out of a very specific, racially targeted form of exclusion in the Chinese Exclusion Act. And this is something that Erika Lee and many others have written about in great detail, and I think is really important to keep in mind, especially when we attempt to understand the complexities of the violence that we’ve seen in recent weeks and the violence we’ve seen broadly across 2020.
A troubling aspect in [how] the United States responded to COVID-19—and I would include the United Kingdom in this response as well—is that for the 19th century and 20th century, so much of Western beliefs of fundamental superiority of civilization and justifications for colonialism emerged out of this mythology of the West being the most sanitary, the most hygienic space, and being the most hygienic civilization on the planet.
Rudyard Kipling’s infamous poem The White Man’s Burden, for instance, was written about American colonial actions in the Philippines, where he writes: “Take up the White Man’s burden— / The savage wars of peace— / Fill full the mouth of Famine, / And bid the sickness cease.” It was very much his belief that Western civilization, and explicitly American civilization, was the most hygienic, the most sanitary, and that the rest of the world was responsible for the diseases that could pollute that civilization.
And we see that same rhetoric coming up today. But we also see that myth falling apart as we recognize that the U.S. COVID-19 response up to vaccination delivery has been one of the worst—one of the most unequal and most deadly in the world.
Hamblin: I have a particular interest in the history of hygiene. That myth that you talk about of the Western world being uniquely hygienic—it’s actually the inverse of that. Christian countries were late to and sometimes actively discouraged things like baths because they were lewd and you had to be naked. When Marco Polo traveled, he was taken by hygiene standards elsewhere that were much higher than in Europe. And Europe certainly had its share of plagues and infectious disease. So that was always a baseless idea, right?
White: Absolutely. And it’s [an] idea that really emerges in the aftermath of 19th-century European colonization of the rest of the world. When we look at the history of international infectious-disease control, that emerges really in the 19th century out of what were called the International Sanitary Conferences, which was a set of conferences that began in  and continued into the 20th century, that focused on creating the first international infectious-disease controls for regulating the spread of infectious disease among people.
But the focus of these controls were not health for all or some sort of humanitarian principle. Rather, it was: How do we allow for the maximum speed and pace of trade and traffic with also the maximum control of infectious disease? It was really about minimizing the effect on trade and traffic while also controlling infectious disease. And unsurprisingly, especially as these conferences were driven by European imperial powers—the particular concern over disease traveling from colonial sites, especially in Africa, the Indian Ocean, and then ultimately also in South and Southeast Asia—the focus became on how to maintain lucrative sea lanes and shipping without spreading diseases that were becoming very dangerous in the eyes of Europe, like cholera, plague, and yellow fever.
So this myth emerges. And it’s a mythmaking process that I think is actually central to Europe and the West coming to envision itself as an entity apart from the rest of the world. And in my work, I call this “epidemic Orientalism.” We see the ways in which the need to maintain trade, colonial, and resource exploitation becomes bound up with controlling particular bodies and people who were seen to be in opposition to a sanitary global trade regime. And this is where you get a lot of the racist and xenophobic ideologies we’ve talked about already, and ideas that we see still in the present when we associate diseases with certain parts of the world, essentially slurring the names for an epidemic like COVID-19 in a variety of ways that ascribe blame to certain countries or certain areas.
Hamblin: Right. That draws out this interesting distinction: There’s a lot of scapegoating and blaming of immigrants during these heightened times of infectious-disease spread. But the actual issue is just travel. If there is an outbreak in a particular place that you need to contain, you can ban travel to and from that area. Sometimes that’s a legitimate and necessary public-health measure. But why would you ever specifically say that it has something to do with immigration and yet people can travel to these places?
White: Framing of threat through disease allows for the pathologization of peoples and cultural practices as somehow distinct and different from one’s own. So it’s a way of creating difference. If an epidemic is occurring in a certain region, there are certainly justifications for containing that epidemic, controlling it, and mitigating its spread. I think it’s when you start applying differential systems of control.
For instance, in the 19th century, the diseases spreading from Europe were not regulated or controlled in these International Sanitary Conventions, [which] essentially allowed disease to spread from Europe to the rest of the world, but policed diseases traveling from elsewhere, namely colonial sites to European metropoles, which created a fundamentally differential system of travel regulations rooted in disparities and in systems of oppression.
Hamblin: Connecting the idea of a place or group of people to a pathogen has occurred throughout history. In 1919, people referred to the Spanish flu despite it seeming to have originated in the U.S. Donald Trump used the phrase “China virus” a long time into the pandemic when that was not at all an appropriate term. Now we are seeing things like “U.K. variant” or “variant that originated in the U.K.,” or South Africa or Brazil. Is there a more sophisticated nomenclature that would avoid inappropriate conflation of a certain group of people or a place with a pathogen?
White: We could go with the scientific variant names. The U.K. variant is known as B.1.1.7.
Hamblin: Though that is hard to do in popular media, especially now that there’s [at least] five variants of concern here in the U.S. and they all jumble up and sound the same.
White: I think there’s a slightly more philosophical question related to this, which is: Obviously, epidemics may begin in a certain place, but to what extent do origins actually matter? Especially when we’ve seen the epicenter of this pandemic move from China to Italy to take up home for a very long time in the United States. How do we equate geography and threat when epidemic epicenters do tend to move and shift? And this is something that the WHO has challenged—the naming of diseases for their point of origin.
Several diseases have been renamed to reduce that stigma. One of the reasons COVID-19 is COVID-19 and SARS-CoV-2 is [because those names are] completely devoid of any geographic signifiers. The one disease that I think really sticks in the minds of people today is still Ebola virus disease, which is named after the Ebola River. So what we’re seeing—and I think the variants are bringing up this conversation again—is while it’s important to understand and control the disease within a specific geography, the conflation of a place as somehow the cause of the emergence or spread of the disease is where we run into very real challenges, where culturally specific, racially specific, nationally specific stereotypes and anxieties start to emerge. And that’s really what we fundamentally need to combat against because it leads to very, very bad public-health policy. And it also leads obviously to very significant resentments, which simmer over and lead to oppression in so many different ways.