As she left Massachusetts General Hospital after a shift spent caring for her patients, anesthesia resident Lucy Li was accosted by a stranger. He shouted racial slurs as he followed her, demanding to know, “Why are you Chinese people killing everyone?”1 The persistent association of the COVID-19 pandemic with its origin in Wuhan, China has spawned bigotry and even hate crimes against Asian Americans, who have been excluded from restaurants, ostracized, seen their businesses suffer, and endured verbal and physical harassment.2, 3 Blaming the rise and spread of epidemic diseases on people who are deemed “different”—whether in terms of their race, ethnicity, gender, class, or behavior—is a lamentably long-practiced impulse. This short-sighted reaction fosters unproductive stigma and sabotages public health responses to these diseases, resulting in increased morbidity and mortality for entire populations. Leaders, medical and political, have both exacerbated and mitigated this response throughout history, with predictable consequences for society.

Epidemics incite fear and uncertainty, sickness and death, and massive disruptions to daily life. Those affected will search for explanations and frequently for someone to blame. Discriminatory responses are not inevitable; however, at crucial moments, many historical actors have located scapegoats among minority or otherwise vulnerable populations perceived as outsiders. Many are familiar with the conspiracist thinking that saw numerous medieval Europeans attribute plague to Jews poisoning wells, an explanation that led to the massacre of thousands. Yet the arrival of this dreaded disease to American shores, with an outbreak in San Francisco in 1899, made it clear that such scapegoating was neither a specifically medieval nor a European response. Although investigators in the new field of microbiology narrowed plague’s etiology to a bacillus transmitted through a chain of rats, fleas, and humans, this advance in knowledge did little to unsettle the ensuing xenophobia. Age-old fears of dirty, diseased foreigners quickly re-emerged, with Chinese Americans taking the blame. Not only did these citizens appear different, but they also lived in segregated geographic areas and held jobs deemed unhygienic and undesirable, like building railroads and running laundries.

Public health officials were quick to quarantine Chinatown while leaving the rest of the city largely unrestricted. Other measures, such as insisting on autopsies of suspicious deaths, requiring vaccinations, and forced relocations, were selectively implemented among Asian American communities. This racist application of public health law unsurprisingly led Chinese Americans to mistrust both the government and the medical profession and prompted some to conceal cases of plague, limiting the ability of doctors to diagnose and treat patients in those communities. In this instance, racial discrimination directly negated public health measures and increased morbidity and mortality.4

Epidemic fears have also seen individuals blamed for the spread of infectious diseases. Perhaps most famously, the popular press labeled Irish-American cook Mary Mallon “Typhoid Mary,” portraying her as a willfully ignorant woman who intentionally spread typhoid by refusing to follow strict public health orders. An asymptomatic carrier at a time when that concept was poorly understood, Mallon struggled to comprehend how she could possibly cause a disease from which she did not suffer. Working as a household cook to support herself, she was linked to outbreaks of typhoid throughout New York and Maine. Rather than convincing Mallon of the nature of her infectiveness, the New York City Health Department became determined to curtail her cooking. Unconvinced, defiant, and desperate to make a living, Mallon continued preparing food and spreading typhoid. As a result, public health authorities forcibly confined her on North Brother Island in the East River in 1915 for the last 23 years of her life.5 Mallon’s story and her resulting nickname—still used today as shorthand for a disease vector—demonstrate the dangers of pinning fears of epidemic diseases upon a single individual. Moreover, Mallon’s immigrant status likely played a role in the Health Department’s antagonistic stance toward her, while popular press coverage emphasizing her headstrong, unfeminine nature and lower-class occupation shaped public opinion. While Mallon’s banishment may have curtailed a few cases, ultimately public health efforts championing clean water, sanitation, and behavioral changes controlled typhoid definitively.

The urge to find a single individual responsible reappeared prominently during the early AIDS epidemic, with the posthumous castigation of French-Canadian flight attendant Gaétan Dugas as the first ever “Patient Zero.” Dugas’ exotic ethnicity rendered him memorable to his sexual contacts, allowing his name to stand out in later contact-tracing interviews investigating the possibility that AIDS was caused by a sexually transmissible agent. His homosexual behavior, selectively described in the sensationalized writing of journalist Randy Shilts, later made him an easy target for people looking to place blame for the new syndrome. Despite the epidemiological impossibility that Dugas had actually been the first North American to contract HIV or the primary vector for the virus around the continent, social anxieties around the disease and the comparative ease of blaming a person rather than a complex system combined to condemn Dugas, like Mallon, to notoriety.6 That Dugas was a relatively privileged white man also highlights how perceived differences of behavior, not simply those of race or class, could serve as a basis for scapegoating. As a gay man, Dugas belonged to the infamous “4-H” cohort—homosexuals, heroin users, hemophiliacs, and Haitians. Both the press and public health authorities linked these “risk groups” with AIDS, a syndrome initially designated GRID, or gay-related immune deficiency. Such labelling made members of already vulnerable groups into targets for increased discrimination, social ostracization, and hate crimes. Another correlate of this narrow focus upon risk groups, rather than risk behavior, was the neglect of heterosexual transmission as an important nidus of disease and long delays in recognizing the differential manifestations of HIV infection among women.7

Blaming members of marginalized groups for epidemic diseases is a well-worn practice that has unfortunately, yet unsurprisingly, returned during the COVID-19 pandemic. The challenge—even today—of understanding how a microscopic virus can cause such widespread devastation can lead those with little recourse to lash out. This is especially true if leaders in positions of power fail to take steps to anticipate and mitigate such tendencies or worse, exacerbate them as President Trump has done through derogatory names like the “China virus” and more recent “kung flu” appellation. Rather than reverting to old patterns of blame, public health and public policy approaches to COVID-19 must attend to the needs of our entire society, as neglecting to do so will negatively impact the health of our population.