Pandemics and prejudice

COVID-19 has disrupted life as we once knew it. This pandemic has not only led to an international lockdown, but has also overwhelmed communities across the globe and led to a catastrophic loss of life. The disease has caused tremendous suffering in its own right, but it has not spread alone. Compounded by rising levels of nationalism in many affected countries, the progression of this outbreak has been accompanied by a sense of xenophobia pervading into the political and social responses.

On an international level, world leaders have used the guise of the disease to peddle xenophobic discourse. The US President Donald Trump has persistently referred to SARS-CoV-2, the virus responsible for COVID-19, as the ‘Chinese virus’, declared his belief that the virus originated from a laboratory in Wuhan, and has described the World Health Organization (WHO) as a ‘pipe organ for China’ (Factbase, 2020). In India, Muslims have been targeted as scapegoats for the spread of disease, amid accusations that an Islamic missionary organisation was responsible for the initial outbreak of COVID-19 in the country (Ellis-Petersen & Rahman, 2020).

Such discourses have filtered down to the local level. Incidents have ranged from the exclusive banning of Chinese-born citizens from shops and restaurants, to the decline in trade for local Chinese businesses (Amnesty International, 2020), and even the unprovoked physical assault of Asian-British and Asian-American citizens (Campbell, 2020).

Throughout history it is clear that when disease spreads, xenophobia is rarely left far behind. In the 14th century, Jewish citizens were blamed for the spread of the plague and accused of ‘poisoning’ water supplies (Markel, 1999). In San Francisco, following panic surrounding a local smallpox outbreak, The Chinese Exclusion Act of 1882 was created. This Act not only prevented Chinese immigration, but also forced vaccination of Chinese residents without epidemiological rationale (Parmet, 2007). Even more recently, we saw the spread of Ebola virus lead to a rise in anti-African racism in European communities (Prati & Pietrantoni, 2016).

As demonstrated, outbreaks of infectious disease have a propensity to unveil existing societal prejudices. Some researchers suggest that these responses are driven by fear; infectious disease is seen as a threat and therefore attempts are made to ‘other’ this threat (Reny & Barreto, 2020). These attempts at ‘othering’ are commonly reinforced by a desire to assign blame and responsibility for the disease, in efforts to make sense of such adversity (Nelkin & Gilman, 1988). Combined, this often manifests as xenophobic tendencies at a societal level, such as the blaming of ‘out-groups’ and increased ‘in-group’ protectiveness (Mobayed, 2020). This theory is supported by a study looking at the British media’s response to the 2002 SARS outbreak. This study demonstrates the development of a discourse that suggested British citizens were protected from SARS because they were ‘different’ to the Asian citizens who were initially affected by the outbreak (Washer, 2004). In addition, other researchers suggest that these xenophobic responses have political roots. For example, the West historically saw trade from non-Western parts of the world as a potential source of disease, with ‘foreigners’ becoming associated with ideas of ‘contagiousness’ and ‘infectiousness’ (White, 2020). Unfortunately, these attitudes still persist today – a study from Bulgaria showed that the most frequent words used in articles about migrants are ‘disease’ and ‘threat’ (Gancheva, 2018), and this kind of rhetoric is also perpetuated by world leaders, such as President Trump when he proclaimed that ’tremendous infectious disease is pouring across the border’ in 2015 (Neate & Tuckman, 2015).

Whatever the underlying psychology, it is clear that when society manufactures an identity for a disease, it is never exclusively driven by its biological characteristics. The social aspects of comprehending disease, through various actors at various levels, often mean that our understanding is somewhat rooted in, and constructed by, prejudice and stigma.

These disease identities are not innocuous. Instead, they ‘inform how authorities and the public respond to a particular epidemic’ (Risse, 2012). On an individual level, we know the stigma that results limits the uptake of healthy behaviours (Stangl et al., 2019) and, as Ahuja et al. note in their empirical study published in this issue, the xenophobia that results is in itself bad for people’s well-being. From a broader perspective, the narratives surrounding COVID-19 have dictated the political responses in terms of who they are aimed at protecting and on whose personal liberties they restrict.

This pandemic has not only incited xenophobic rhetoric, but has also unveiled deeper systemic xenophobic structures, which both play into, and arise from, these narratives. Early evidence suggests that the risk of acquiring and dying from COVID-19 are greatly increased for BAME (Black, Asian and Minority Ethnic) groups compared to White ethnic groups. This difference exists even when differing age, sex and co-morbidity profiles are taken into account. Untangling the various factors that may contribute is difficult, but a key element appears to be that BAME groups are often over-represented in the most socio-economically deprived communities. (Fenton, 2020; Razaq et al., 2020) There is a plethora of evidence that lower socio-economic status is associated with worse health outcomes (Marmot et al., 2020) and, in times of infectious disease outbreaks, these inequalities tend to be exacerbated in the context of more overcrowded households, poorer access to healthcare and greater occupational risk for these communities (Quinn and Kumar, 2014). It is noted, however, that even when socio-economic deprivation is controlled for, the increased mortality risk for BAME groups from COVID-19 remains. As well as socio-economic deprivation, it seems likely that more direct racial discrimination is leading to altered health-seeking behaviours that are directly contributing to this increased risk of mortality. (Fenton, 2020) The evidence at this stage seems to support the idea that the virus itself does not discriminate – but our society that does (Younge, 2020).

Devakumar et al. (2020) stated in The Lancet that ‘health protection relies . . . on social inclusion, justice, and solidarity . . . division and fear of others will lead to worse outcomes for all’. So, how can we ensure our response to outbreaks and narratives surrounding disease are not entrenched in xenophobia? In the first instance, the WHO is clear when it says that states must take tangible steps in ensuring that they are preventing and addressing stigma during this pandemic. This begins with guidance such as avoiding the use of geographical terms to name viruses, thus discouraging racially charged beliefs about the disease that may ensue. WHO (2020a) also stipulates that we should avoid promoting visual narratives that encourage xenophobic perspectives, such as disproportionately using images that imply an association between the disease and a particular group of people. Furthermore, as the US Centers for Disease Control and Prevention (CDC) recommends, we should make sure to share accurate information about the disease, speak out against negative behaviours, practise caution with regard to the narratives we are promoting and work to ensure the engagement and amplification of stigmatised groups (US CDC, 2020).

This advice applies to organisations and individuals at the international level as much as it does for actors at the community level. Authority figures should act as role models in displaying positive actions that can be emulated downstream (Reny & Barreto, 2020). To be clear, leaders and influencers in politics and the media should provide strong messaging that emphasises that xenophobic actions and behaviour are unacceptable. Moreover, they must promote narratives that stress the need for social cohesion and our combined progress towards a shared goal. The evidence shows that unequivocal messaging, clear in its condemnation of xenophobia, is vital in non-stigmatising responses and behaviours (Lunn et al., 2020). The director general of WHO, Dr Tedros, recently stated, ‘stigma . . . is more dangerous than the virus itself’ (WHO, 2020c). Other world leaders should take note of such messages, and be as clear as Dr Tedros when he says ‘now is a time for solidarity, not stigma’ (WHO, 2020b). Moreover, from these narratives should follow responses themselves which, at their core, are embedded in principles of equality and non-discrimination. This is both a moral duty and, under international human rights law, a legal duty (Amnesty International, 2020).

During these times, to move forward with achieving equitable responses to outbreaks of infectious disease such as COVID-19, we must do so in unity. This virus, like all infectious agents, does not respect borders. In a globalised world, this is a global outbreak, requiring a globally cohesive response. That response should be united, not only in its message that stigma and prejudice are unacceptable, but also in the actions that follow. Those actions must be guided by an understanding of the deep, structural, historically embedded biases that exist against many of the groups most affected. It is only through listening to these communities and amplifying the lived experiences of these biases, accepting and appreciating many of the uncomfortable truths that accompany them, that we can ensure future responses to outbreaks such as COVID-19 are built on understanding instead of ignorance, resulting in equity instead of discrimination.