Infectious Disease Rhetoric & Stigma: Evolution over Time

The impact of infectious diseases extends far beyond the symptoms experienced, hospitalizations observed, number of lives lost, and jobs left uncertain due to associated economic upheaval. Across distinct health systems and even cultures, particular social consequences and stigmas seem to be associated with infectious disease outbreaks both large and small. So topical has this become that pandemics are gradually becoming known as social problems, burdening not only the health care system and its subsidiaries, but also taking a toll on individual mental health and the sense of safety, security, and comfort. The existence of this social problem is exemplified in pandemics of past and present. During the HIV/AIDS epidemic, victim blaming and fear ran rampant throughout the 1980s and early 90s (1, 2); while stigma still surrounds communities with regards to this epidemic far into the 21st Century, overt expressions of stigma were seen to decline through the 90s, with its most extreme forms supposedly reaching very low levels by the late 90s and early 2000s. Similar stigmas have been seen to permeate society over the course of the COVID-19 pandemic, with racist words and actions being directed to members of the Asian community. Only recently have these discriminatory sentiments become less prevalent in day to day interactions and media coverage (1, 2), but members of these communities continue to live in fear. 

Extensive research exists with regards to tracking stereotypical attitudes and trends in stigma over the course of infectious disease outbreaks. More recently, the use of online social networks has become a popular avenue by which to analyze stigma and related contributing attitudes. Analysis of forums such as Weibo and Twitter have allowed for a comprehensive understanding of an individual’s psychology in a manner that is distinctly non-invasive. Through data extraction, stigmatizing points could be identified and stigmatizing attitudes determined, allowing for tracking over the course of the pandemic in Wuhan, China.

What also should be a point of focus is the targeted language that centers upon particular groups in society. This can be traced back to the HIV epidemic of the late 20th Century, when language describing outbreaks largely attributed the blame to men who have sex with men (MSM), and can also be found amidst the pandemic that defines the early 21st Century, with examples of SARS-CoV-2 being dubbed the ‘Wuhan-virus’ or ‘China virus’. It is unclear how or whether public health messaging has become less targeted than that which was seen in pandemics of years past. 

Public health messaging is an influential countervailing force. It has the power to shape perceptions and understanding of epidemics and pandemics. Health communication is inherently important for the role it plays in mediating the achievement of public health objectives and driving behavioral changes at the population-level. It would be invaluable to see how the language and rhetoric inherent to this messaging has changed over the course of history, both across different epidemics and within the course of individual ones. An analysis of how the discourse surrounding pandemics has changed demonstrates that while the early stages of outbreaks rather consistently target particular groups, the communication prevailing in outbreaks of today is markedly more inclusive that those of outbreaks past. 

Targeted, Stigmatizing Language Typifies Early Outbreak-related Discourse 

During infectious-disease outbreaks, initial public-health messages appear to center upon particular groups – those that are the origin or the victim. During the rise of polio, which had been predominantly linked with “filth” (such as rat infestation), the related illness and disease became inextricably linked with disenfranchised populations. Language surrounding the outbreak suggested that abject living conditions, such as poverty and overcrowding were the source of the epidemic disease. With the vast majority of cases being in children aged four or younger, the term “infantile paralysis” was widely thrown around. Just two years after polio’s eradication, cases of HIV began to be reported amongst gay men, and shortly thereafter, terms such as “Gay Men’s Pneumonia” and “Gay-Related-Immuune Deficiency” began to be thrown around. From a public health standpoint, the growing epidemic came to be known as a “gay” or “drug user” problem (3). Fast-forward to the COVID-19 pandemic, and similar patterns emerge. Rather immediately, there were references to the “Wuhan virus” or the “Chinese virus”.

Over the Course of Individual Outbreaks, Language Evolves

Marked shifts can be seen regards to the nature of language across outbreaks, epidemics, and pandemics. Over time, the language used to describe polio became less tied to immigrant families and filth in racist and classist ways, but instead, began to convey the message that the virus was indiscriminate. In the case of the HIV epidemic, descriptions of the illness became universalized. By the late 1980s, language came to acknowledge that the issue was not one just confronting the gay community and drug users, but all of society. Specifically, there was a noticeable transition from message-associated fear and victim-blaming to messaging that centered upon highlighting the importance of prevention, testing, and treatment at the more general population level (4). In literature exploring discourse during the COVID-19 pandemic, an approach that centered upon personal responsibility consistently emerged. Messages like “we’re all in this together” emphasize the fact that we all are at risk of infection by SARS-CoV-2 (some more serious than others). As well, described public health mandates, from mandatory masks to strong recommendations regarding vaccinations, seem relatively consistent with the trend of not singling out particular individuals or communities. 

Increased Guidance by an Equity-centered, Person-focussed Approach

Especially in relation to HIV-related discourse, over time, there has been an observable increased emphasis on working to avoid categorizing individuals using language that reduces, and instead harnessing categorizing language that empowers (5). Various articles provide tangible examples of language that ought to be incorporated and avoided, and how each respectively contributes to the lessening or strengthening of stigma for patients living with or at risk of HIV. Similar reasoning is observed in an article focussing on guidelines that can be adopted as a National Action plan for individuals living with HIV, which demonstrates the need for a health equity-driven approach with regards to strategies (6). Present research also points towards how messages have become significantly more equity-centered and mindful of stereotypes (7) and have become distinguishable from historical messages during infectious disease outbreaks (which noticeably can be characterized by the vast promotion of us vs. them mentalities).

Pandemics Start with Various Communicative-related Hallmarks

It is evident that early-stage discourse is one which targets and singles out identifiable groups and communities, whether it be those who are disproportionately affected (as seen during the HIV epidemic) or those from the believed place of origin (as seen during the recent COVID-19 pandemic). This element is one which can be found in infectious disease outbreaks of past and present, and perhaps serves to point towards an inevitable part of infectious disease outbreak which is unavoidable, given the inherent human tendency to rapidly assess problems and make attributions. 

There are Clear, Objective-driven Temporal Shifts in Infectious-Disease Communication

The temporal element of infectious-disease public health discourse is rather noticeable. It exists within the course of individual outbreaks themselves, with a clear progression from the aforementioned targeting language to universalized messages. There is movement away from singling out specific groups, in a way that every individual is made to feel impacted and touched by the given pathogen. Reasons for this, though unexplored, could be related to the filling of knowledge gaps (wherein more information is gained regarding the nature of infectious diseases which mean that premature and arbitrary labels may be dropped) or the desire to justify large-scale public health policies and interventions (in which case, language which is more inclusive and universalized, as opposed to targeted towards specific communities, would be less likely to fall on deaf ears) (8, 9). 

Guides pertaining to equity-centered, non-targeting and digitizing language usage during infectious disease outbreaks from decades past were rather limited. Rather, guidance pertaining to the importance of incorporating person-centered approaches that put people first (as opposed to their illness or disease) in descriptions and strive for the promotion of universality were more common to the present decade. This points towards the desire of putting into action societal goals of equitable and inclusive language into communication so as to move on from the stigmatizing mistakes of language of the past (10, 11). 

Public-Health-related Infectious Disease Discourse is not Binary

Public health related discourse is much more complex and dimensional than can be described, not necessarily evolving in a uniform manner, but instead being susceptible to the intricacies of the public health organizations by whom they are formulated and the unique nature of the infectious diseases that they are about and describe. It is subject to the whims of political structures and cultural values. This is exemplified by the COVID-19 pandemic, where racially-targeted language and discourse largely permeated the West.  

The consideration of global infectious disease outbreaks in a temporal manner demonstrates how the language conveyed and utilized during these outbreaks has changed over time, not only over the course of the events themselves, but also as we have progressed as a civilization across the decades. While outbreaks are still marred by targeted rhetoric that perpetuates stigma at the early stages, deliberate efforts have been made to incorporate inclusive language that is mindful of the circumstances and experiences of our society’s most marginalized. As a society, we all have an obligation to contribute to these deliberate efforts, especially if want all communities to be immune from unfair targeting, discrimination, and prejudices during times when we should be coming together.

References

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2. Herek GM, Capitanio JP, Widaman KF. HIV-related stigma and knowledge in the United States: prevalence and trends, 1991-1999. Am J Public Health. 2002 Mar;92(3):371-7. doi: 10.2105/ajph.92.3.371.
3. Crowe, J.H. Contagion, Quarantine and Constitutive Rhetoric: Embodiment, Identity and the “Potential Victim” of Infectious Disease. J Med Humanit 43, 421–441 (2022). doi: 10.1007/s10912-022-09732-7
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5. Watson S, Namibia A, Lynn V. The language of HIV: a guide for nurses. HIV Nursing. 2019; 19(2):1-4
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7. Calanan RM, Bonds ME, Bedrosian SR, Laird SK, Satter D, Penman-Aguilar A. CDC’s Guiding Principles to Promote an Equity-Centered Approach to Public Health Communication. Prev Chronic Dis. 2023;20:230061. doi: 10.5888/pcd20.230061
8. Porat T, Nyrup R, Calvo RA, Paudyal P, Ford E. Public Health and Risk Communication During COVID-19-Enhancing Psychological Needs to Promote Sustainable Behavior Change. Front Public Health. 2020 Oct 27;8:573397. doi: 10.3389/fpubh.2020.573397.
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11. Mamuji AA, Lee C, Rozdilsky J, D’Souza J, Chu T. Anti-Chinese stigma in the Greater Toronto Area during COVID-19: Aiming the spotlight towards community capacity. Social Sciences & Humanities Open. 2021; 4(1). doi: 10.1016/j.ssaho.2021.100232.