“Spanish Flu”: When Infectious Disease Names Blur Origins and Stigmatize Those Infected

Abstract

Despite not originating in Spain, the 1918 influenza pandemic is commonly known as the “Spanish flu”—a name that reflects a tendency in public health history to associate new infectious diseases with foreign nationals and foreign countries. Intentional or not, an effect of this naming convention is to communicate a causal relationship between foreign populations and the spread of infectious disease, potentially promoting irrational fear and stigma.

I address two relevant issues to help contextualize these naming practices. First is whether, in an age of global hyperinterconnectedness, fear of the other is truly irrational or has a rational basis. The empirical literature assessing whether restricting global airline travel can mitigate the global spread of modern epidemics suggests that the role of travel may be overemphasized. Second is the persistence of xenophobic responses to infectious disease in the face of contrary evidence. To help explain this, I turn to the health communication literature.

Scholars argue that promoting an association between foreigners and a particular epidemic can be a rhetorical strategy for either promoting fear or, alternatively, imparting a sense of safety to the public.

In 2015, the World Health Organization (WHO) published best practices recommendations for the naming of infectious diseases. WHO discouraged scientists and public officials from naming infectious diseases in ways that reference specific people, places, animals, or occupations or using “terms that incite undue fear.”¹ Their guidelines were intended to be a corrective to the centuries-old trend in public health practice of naming epidemics in association with “the other,” for example, “gay-related immune deficiency,” “Mexican swine flu,” and the subject of this special issue, “Spanish flu.” One effect of these naming practices is, whether intentional or not, to communicate to the broader public a causal relationship in how the disease is transmitted.²

These potentially stigmatizing perceptions can have more than just psychological effects: they can inform how authorities and the public respond to a particular epidemic. This was especially evident during the 2009 influenza outbreak, which was commonly referred to as “Mexican swine flu.” Although it was not transmitted by pigs, the erroneous perception that it was prompted some countries to slaughter livestock and ban the importation of pork products.³

The 2009 swine flu epidemic is an example of assigning a name to a disease on the basis of its perceived transmission pathway. In other cases, scientists assign names to a disease on the basis of their place of discovery—such as Ebola, which was first identified near the Ebola River in what is now the Democratic Republic of Congo.⁴ More common, however, is the practice of naming diseases in association with foreign nationals or foreign countries. For example, although the disease did not originate in Spain, scholars argue that the “Spanish flu” moniker is the result of an early news service cable describing a “strange new form of disease” in Madrid.⁵ These associations typically stem from the perceived origin of the epidemic, accurate or not.

WHO notes that the age of social media has made it especially urgent for officials to generate and disseminate accurate and nonstigmatizing epidemic names to the public without delay as soon as they are identified. However, history suggests that naming is a problem that plagues infectious disease history. To that point, all four of the epidemics that killed more than 1 000 000 people during the 20th century featured colloquial names that referenced a foreign group or stigmatized minority. In order of least to most deadly, they are Hong Kong flu (1968–1969; 1 000 000 estimated dead); Asian flu (1957–1958; 2 000 000 estimated dead); the Spanish flu (1918–1920; at least 50 million estimated dead); and AIDS, originally termed “gay-related immune deficiency” (1981–present; 30 million estimated dead). But even epidemics that are far less deadly often feature such names, such as the Mexican swine flu epidemic of 2009.

I address two relevant questions to help contextualize these naming practices. First, in an age of global hyperinterconnectedness, is fear of the other truly irrational, or does it have a rational basis? Second, why do xenophobic responses to infectious disease persist in the face of contrary evidence?

INCREASED AIRLINE TRAVEL AND GLOBAL EPIDEMICS

Although scholars acknowledge that global travel can play a role in infectious disease, the extent to which it contributes to globalizing pandemics is unclear. Obviously, infectious disease agents have successfully traversed the globe for centuries—far in advance of the rise of commercial aviation. Clearly, the 14th- and 15th-century outbreak of the bubonic plague did not depend on everyday citizens regularly traveling across the globe. Instead, experts argue, the spread of medieval black death followed global trade patterns.⁶

The limited effectiveness of efforts to curtail epidemics by clamping down on global travel suggests that we should be cautious about assigning too much significance to migration and travel. One recent study, for example, found that travel bans issued in the wake of the 2014 Ebola outbreaks in West Africa did not prevent the disease from reaching new countries; they did, however, delay its spread by a few weeks.⁷ A similar study evaluating the effectiveness of travel bans in the wake of the 2009 influenza outbreak found that they failed to contain the disease; the authors argue that the resulting 40% decline in all air traffic to Mexico (the country with which the outbreak was associated) was too small to curtail the disease’s spread. The authors estimate that stricter travel bans would have also failed to contain the disease—although they may have delayed its spread by up to two weeks.⁸ Other studies analyzing the global spread of influenza reached similar conclusions, leading scholars to conclude that local interventions to reduce the transmission of the disease were likely to be far more effective than air travel restrictions.^9,10

Travel bans can have spillover effects that negatively affect the economy and infectious disease control efforts. For example, in analyzing the response to the Ebola outbreak of 2015, one legal expert noted, “Travel bans and flight suspensions harmed fragile economies and hampered the flow of trade and aid.”^11(p1903)

There is an ongoing debate over the value of delaying the global spread of an epidemic by weeks; some scholars argue that delaying the global spread of an epidemic by even a few weeks could provide governments and health agencies with precious time to implement disease control interventions.¹² Nonetheless, the literature on air travel restrictions strongly suggests that travel may be overemphasized as a driver of global epidemics; in a globalized society, there are many plausible routes along which epidemics can spread.

XENOPHOBIA AS RHETORICAL STRATEGY

Ever since we settled down in cities and communities, we have been open to the possibility of communicable disease. And, in our folk history, most of this arises in the East, a treacherous result of trade and modernity. The Black Death is supposed to have originated variously in the Gobi desert, in Manchuria, or (best of all) “in the depths of Asia,” reaching Dorset in August 1348. The cholera pandemic that swept across England in 1832 was supposed to have entered on a ship from Hamburg, but to have started in Bengal. Latterly Africa has been fixed upon as an alternative starting place for terrible diseases. Teeming Asia or the Heart of Darkness—take your pick of which most frightens you.^13(p2568)

Perhaps ironically, casting an epidemic as foreign can have potentially diametrically opposed effects: it can be a rhetorical strategy for promoting fear or for reassuring the public of safety. The observation in the quotation—excerpted from an editorial in a British newspaper—articulates the former possibility: that diseases named after places perceived by the public to be exotic or unknown can inflame the body politic. However, to the latter point, scholarly analysis of British newspaper coverage of the severe acute respiratory syndrome in East Asia that sparked the editorial finds that newspapers often went to great lengths to reassure their British readers that they were safe; media outlets and officials communicated containment to the public by claiming that their differences from Asians would protect the British populace.¹⁴

Health communication scholars have observed that media coverage of an emerging infectious disease will quickly shift from the strategy of promoting fear to the strategy of emphasizing safety. Early coverage typically emphasizes the threat of contagion, whereas subsequent reporting aims to reassure the public that the threat will be contained.¹⁵ One strategy for reassuring readers of an epidemic’s containment is to associate the epidemic with foreigners or a foreign country.

These scholars help to reframe the issue of naming as not a banal scientific fact but, instead, a social production that reflects complex social realities and politics. That there is no epidemic colloquially known as “American flu” or “European flu” in recorded history is perhaps telling. One could interpret this absence as merely the coincidental result of epidemiological patterns in the spread of disease. But one could also argue that it reflects global inequalities that allow powerful countries in the Global North to assign responsibility for disease and epidemics to foreigners and foreign countries, rather than to themselves.

CONCLUSIONS

Xenophobic reactions to disease are not limited to outbreaks specifically named after a foreign country or stigmatized group. The history of infectious disease control is rife with examples of heavy-handed responses to epidemics that are assigned perfectly neutral names but that nonetheless inspired intrusive measures against foreigners. For example, authorities quarantined San Francisco’s Chinatown while explicitly exempting non-Asian businesses during a plague outbreak in 1900¹⁶; in the wake of cholera and typhus outbreaks in 1892, New York City officials selectively quarantined Jewish immigrants, whereas Italians arriving on the same boat were detained for only a brief time.¹⁷ Although stigmatizing names can exacerbate public anxiety, they are but one example of the deeply entrenched xenophobia in public health history.

Xenophobia has taken many forms throughout history and, broadly speaking, reflects a common (and perhaps human) impulse to assign social meaning and responsibility to disease. Those efforts are necessarily flawed, as they try to make sense of infectious disease agents that are not tethered to our social reality (disease does not discriminate; people do). Public health has a responsibility to check the tendencies of a prejudicial public—to resist efforts to fan the flames of stigma and discrimination—by rapidly disseminating scientifically accurate information. Considering that a name is often the first way the public encounters a new disease or epidemic, it is especially important that officials take care to get that piece right. First impressions matter.

The 2009 influenza outbreak provides one additional lesson for public health: health communication must be neutral and accurate, yes, but it must also be comprehensible to average Americans. The strain of influenza circulating in 2009 was often referred to as “swine flu” or “Mexican flu” (or a combination of the two). Although health officials initially employed similar language in communicating with the public, they began to rethink those efforts as Egypt slaughtered pigs and the pork industry began to protest.¹⁸ Officials and medical scientists changed tack and proposed overly convoluted alternatives, such as “swine-origin influenza A (H1N1) virus,” S-OIV for short—a suggestion that (unsurprisingly) failed to transform the media landscape.¹⁹ Although public health’s communication attempts were perhaps more scientifically accurate, their incomprehensibility rendered them a failure.