What are the social effects of infectious disease?
The social effects of infectious disease can range from stigmatization to civil unrest and political upheaval. Identifying the source and mode of transmission often involves focusing on people in lower socioeconomic groups, who typically live in overcrowded conditions. Infectious disease control can lead to isolation, discrimination, and violence against those groups and persons who are believed responsible for an outbreak.
Poor regions of the world often have inadequate health care, nutrition, and sanitation, which makes these areas ideal reservoirs for infectious disease. Furthermore, local hygienic practices, cultural traditions, and social behaviors can help perpetuate the transmission of disease.
In the fourteenth century, quarantine was developed to contain the Black Death, and outbreak of bubonic plague caused by the bacterium Yersinia pestis. Although the germ theory of disease and modes of disease transmission were unknown, it was commonly accepted that the disease was somehow transported by travelers and goods arriving from plague-infected areas. This understanding led to the establishment of a forty-day isolation period (a quarantine) to identify infected persons, but this did little to stop the spread of plague throughout Europe.
Quarantine was again used around the beginning of the twentieth century in San Francisco to isolate Chinese immigrants believed to be spreading Y. pestis. San Francisco was the primary port for incoming Asian immigrants and for exotic goods from the Far East. Fleas harboring the bacteria were carried by rats aboard the arriving ships. Based on an unconfirmed diagnosis of plague in a Chinese immigrant, the San Francisco health department quarantined the entire Chinese quarter of the city to satisfy an increasingly fearful and demanding public. Residents of Chinatown were forbidden to leave the area, and the health department began an invasive house-to-house inspection to find any others infected with plague. Chinese community leaders objected to this drastic treatment, but many citizens of San Francisco were calling for more stringent measures. The quarantine was soon lifted because of continuing protests by the Chinese community.
Sporadic deaths from plague continued in Chinatown for the next three months, and the health department began a massive disinfectant campaign. The disease control effort was assumed by the surgeon general of the United States, who reinstated the quarantine and disinfectant programs, prevented Asians from leaving San Francisco, and instituted an inoculation program with an unproven vaccine. The program also led to the burning of personal possessions.
A proposition was then made to move Asian immigrants to a detention camp outside the city. Isolated incidents of violence then erupted in Chinatown, not only against the health department but also against those Chinese people who were cooperating with the health authorities. Chinatown was then enclosed with wooden fences and barbed wire. The quarantine was eventually lifted by a court order. This extreme quarantine response caused more social damage than disease control: In the years 1900 to 1904, there were only 121 reported cases of plague.
Quarantine was also used, to a much more productive end, to contain severe acute respiratory syndrome (SARS) during the outbreak of early 2003. Quarantine has also been considered as an option to contain multi-drug-resistant (MDR) and extremely drug-resistant (XDR) tuberculosis. Under this option, passengers on an airliner carrying a person identified as having one of these strains of tuberculosis would be quarantined. Persons who came into contact with the infected passenger would be tested. In the United States, a person who refuses treatment for tuberculosis can be detained until he or she agrees to treatment.
In the event of an outbreak, identifying the disease source and the success of disease control can depend on how the affected populations are perceived by society at large. The stigma associated with infectious diseases, principally sexually transmitted diseases (STDs), makes it difficult to identify infected persons and their contacts to ensure they receive proper treatment. In some societies, STDs are synonymous with deviant sexual behaviors and a lack of morals. Other diseases, such as typhus and tuberculosis, have historically been associated with certain ethnic groups, thus exacerbating prejudice against these groups. Diseases caused by inadequate and improper sanitation are common in poor neighborhoods, leading to further prejudice against the poor.
Human immunodeficiency virus (HIV) infection is a highly stigmatized infectious disease because it is transmitted primarily through intravenous drug use and sexual activity; HIV, and the disease it causes, acquired immunodeficiency syndrome (AIDS), also is stigmatized because of its early (and still prominent) association with homosexuality. Many people refuse to be tested because of the ramifications of testing positive for HIV infection. In some developing countries, being HIV-positive leads to social isolation and even physical violence for infected persons and their families. As a result, HIV/AIDS prevention programs often remain underfunded or are nonexistent, and people continue to be at risk for HIV infection because of the stigma attached to the disease.
Social stigma has also led to compliance with public health campaigns to control communicable diseases. In the twentieth century, programs to stop the spread of STDs and programs encouraging vaccinations argued that failure to take measures to stop the transmission of infectious diseases was essentially a display of ignorance. The disgrace of having an STD or the stigma of having an unvaccinated child were used to pressure people into compliance with health programs.
Misconceptions surrounding the source of disease can lead to the disenfranchisement of entire ethnic communities. In the 1980’s and 1990’s, during the early years of the HIV/AIDS epidemic, Haitians around the world were commonly blamed for this disease. Epidemiologists searching for the origin of the virus focused on Haiti because of its reputation as a popular vacation spot for gay men and because of Haitian vodou rituals involving blood. Health officials considered intravenous drug users, gay men, and Haitians to be “high-risk” persons. Haitian immigrants in the United States were treated with prejudice and fear and, ultimately, became almost synonymous with HIV/AIDS. Even after being “declassified” as high risk in 1983, they were prohibited by the U.S. Food and Drug Administration (FDA) from donating blood.
The consequences of this distinction were predictable. Reports surfaced of Haitian children being ostracized and even beaten by their classmates. Businesses in Florida were urged not to employ Haitians because their presence would discourage tourists. Pro-Haitian immigrant groups organized protests in Miami and New York City. A small protest outside the FDA office in Miami, a much larger protest in New York City, and several other marches led to the FDA reconsidering and then rescinding its ban on blood donations by Haitian immigrants. However, the association between Haitians and HIV/AIDS was already established, and it persisted for many years.
During the SARS outbreak in early 2003, people in New York’s Chinatown were stigmatized. Tourists were encouraged to avoid the area even though not one case of SARS had been reported in that part of the city. There was an influx of Chinese immigrants to New York’s Chinatown in the 1990’s, leading to the perception that people living in Chinatown had close relationships with mainland China. In addition, the media had so absolutely linked the SARS outbreak with Asians, and Chinese people in particular, that e-mails began to circulate almost immediately warning people to stay out of Chinatown to avoid being infected. Community groups in Chinatown issued press releases to try to counter these rumors and fears, but businesses still reported losses of 30 to 70 percent. The stigmatization was based on perceptions of the origins of SARS and on fear because the seriousness of the epidemic and the means of transmission were unclear.
The identification of infectious diseases with certain ethnic groups or regions has led to social unrest and violent responses. In 1917, a violent two-day riot erupted in El Paso, Texas, in response to a quarantine imposed to contain typhus. The disease was believed to be spread by Mexican day laborers, who crossed the border into Texas each day to work. The quarantine applied to Mexicans crossing the border; each day they had to undergo physical examinations, disinfection of their belongings, and disinfecting baths in a mixture of kerosene, vinegar, and gasoline.
The protest, which began when a group of Mexican women attempted to cross the border to work, escalated into a riot. Hundreds of U.S. soldiers were mobilized to the border. Persons who wanted to cross into Texas to work submitted to the examinations. After several months, the disinfection procedures were required weekly only. U.S. health authorities performed nearly 900,000 examinations of Mexicans entering the United States in a five-month period in 1917. Only three cases of typhus were reported in El Paso during that period.
In Africa, the HIV/AIDS epidemic and the smaller hemorrhagic fever outbreaks provide examples of how diseases can cause social and political instability. When the first outbreaks of Ebola hemorrhagic fever occurred in Gabon, Africa, in 1995, international health care workers sent to address the outbreak did so in a culturally insensitive manner, disregarding the local customs and traditions. Sick and deceased persons were kept in tents or body bags. Although this was done for protection against further infection, local residents feared that something appalling was being done to their sick relatives and to their relatives’ bodies after death. The autocratic manner in which the disease was managed created hostility and suspicion toward the health care workers. When another outbreak occurred in 2001, health care workers encountered armed villagers opposed to their presence. In contrast, President Robert Mugabe of Zimbabwe attempted to buttress support for his government and preserve social stability in 2008 by proclaiming that he had stopped a cholera epidemic.
Methods employed to control or eradicate infectious diseases often conflict with basic human rights. During an outbreak, a point is reached where it must be considered whether the rights of a minority of diseased persons outweigh the need to protect the public. Quarantine, mandatory vaccination, and the treatment and reporting of infected persons, while somewhat effective in controlling disease, also are restrictive and invasive.
Quarantine has been used throughout history to contain communicable diseases, especially those diseases for which the mode of transmission has not been clearly defined. Quarantine is a reasonable measure when substantial proof exists that isolation will be effective in controlling the disease and maintaining public health. Without these assurances, quarantine can have dire social consequences; it also can lead to the exposure of uninfected quarantined persons to the disease. Any quarantine order must be enforced fairly and without singling out any ethnic, racial, or socioeconomic group.
Mandatory vaccinations, like those promoted by the World Health Organization’s (WHO) smallpox and polio eradication campaigns, are considered by some to be violations of the rights of persons to determine their own medical care. Again, the issue here is the right of an individual to refuse a possibly harmful vaccination versus the potential to rid the world of a deadly disease. In the 1950’s and 1960’s, the WHO smallpox eradication campaign in India occasionally involved the military vaccinating people by force.
Similar mandatory vaccination campaigns in Africa led to suspicion among vaccine recipients and community leaders. Cultural and political issues were raised in 2003 regarding the oral polio vaccine. The Nigerian state of Kano suspended oral polio vaccinations for eight months in 2003 and 2004 because of rumors that the vaccines contained traces of HIV and female hormones. The rumors were allegedly started by local Islamic clerics who claimed the vaccines were designed to infect Muslim children with HIV and to sterilize them. Because of this suspension of the vaccination program, Nigeria accounted for 145 of the 201 reported polio cases in Africa in 2004 before resuming the program.
Other types of mandatory actions must also balance a person’s right to refuse treatment with the potential to spread the disease to others. Tuberculosis is highly contagious and is quickly reemerging in areas where it has previously been controlled. In most instances tuberculosis is easily cured by an inexpensive course of therapy, but in many cases infected persons do not complete the entire treatment. This has led to the development of MDR and XDR tuberculosis that are highly resistant to the standard drug therapies. To help prevent the spread of tuberculosis and the development of these drug-resistant strains, it is now standard procedure worldwide to treat persons under the DOTS (directly observed treatment, short-course) program. The DOTS approach to stopping the spread of tuberculosis, while not coercive, is a highly monitored program sponsored by WHO to provide standardized treatment, to provide supervision to ensure persons are taking their medications, and to provide patient support. Since its inception in 1995, approximately thirty-six million persons have been treated under this supervised program and by 2007 the treatment success rate was 86 percent. While not compulsory, the support and supervision by health care professionals to complete treatment may result in more treatment compliance than would an actual mandate.
A person’s right to privacy may also be compromised in the event of an infectious disease outbreak. In some cases, health care workers are required to report infectious diseases to the health authorities to control a potential outbreak and to protect the public. In other cases, third-party notification of anyone the infected person may have come in contact with might be required. This could violate the right to privacy of the infected person; however, it also is necessary to protect those who may have been exposed and to prevent further spread of the disease.
In addition to the medical and economic impact of infectious diseases, the social impact can be devastating. It has been repeatedly demonstrated how association of a disease with a particular ethnic, racial, or other minority group can stigmatize an entire community. People can be ostracized and treated with disgust, misjudgment, and even violence based on perceptions regarding how they acquired the disease. An infected person’s fear of self-identifying can disrupt disease eradication programs and endanger others who are not infected. In extreme circumstances, epidemics can disrupt disease control programs, cultivate distrust in the health authorities, and result in civil unrest and social instability.
The difficulty of managing infectious disease comes down to this: how to balance programs and medications that will benefit the health of millions with the rights and choices of individual persons. Mandating treatments or vaccinations is a definite infringement on individual human rights. However, doing so protects the rights of others to retain their freedom of movement without being unknowingly exposed to communicable diseases.
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