When a disease goes pandemic, we need to fight more than just the spread

COVID-19, or coronavirus, is now at the point that epidemiologists believe it can’t be contained to China.

From an epidemiological standpoint, that means that now, instead of having one focal point to which all cases of the disease can be traced, we will have any number of focal points. This is what it means for a disease to become a pandemic – it has multiple points from which it can spread. But when we hear the term pandemic, we think of people falling sick all around us as society crumbles. And while at this point, we may not be able to prevent the disease from getting to that level of virulence, we can stop ourselves from panicking about that doomsday scenario. Because when a pandemic worms its way into our collective consciousness, fighting the disease is no longer just about fighting the virus, but also about fighting the social anxieties that surround it.

COVID-19 has already inspired some racist behavior, particularly on college campuses, where Asian students are singled out as possible disease carriers for no good reason. This kind of scapegoating becomes as much a problem as the disease itself. Although it does not directly lead to a worse outcome for the spread of the disease – it can, if people ignore the actual disease vectors in favor of their scapegoat – it creates a situation of mass anxiety that becomes an equally difficult social health issue. The best solution to both the spread of the disease itself and the development of social panic around the disease is to remain calm and follow best hygiene practices. But it can be difficult to implement that kind of behavior because it often goes against our immediate impulses.

COVID-19 has an oddly apt parallel in premodern plague, particularly the pandemic event known as the Black Death. And I bring up this comparison not to inspire fear, but to highlight how important it is to think about the impact of the disease as more than its potential death toll. Because the Black Death didn’t happen as one rapid outbreak, but as a seasonal disease that swept Eurasia yearly for over a decade. Our modern ideas about disease containment began with the Black Death – famously, the concept of quarantine comes from the fourteen day (quarenta) period that merchant ships trying to enter Venice were forced to wait to make sure those onboard were disease-free. The reason it was necessary to implement this kind of system was because, like COVID-19, the plague had a two-week gestation period, during which an infected individual would not exhibit symptoms. A further biomedical similarity to plague is the fact that the most virulent spread of both diseases is in its pneumonic, or respiratory, presentation. What made the Black Death a pandemic in Europe, where it was traditionally too cold for the disease to spread, was the less contagious presentation, bubonic plague, remaining in the body for longer than a few days, at which point it entered the soft tissue of the lungs and could became airborne. Because Europeans spent most of the winter indoors, this pneumonic presentation of the disease could easily spread, as people were in close proximity in a relatively warm and moist environment. This is the same reason that there is a cold and flu season – even though it is too cold outside for the disease itself to survive, humans are able to carry it within their bodies indoors and communicate it from one to another that way. For COVID-19, this type of spread means that we shouldn’t rely on large-scale travel bans to stop the spread of the disease, because once enough people in an area become carriers, communication of the disease will happen on a much more individual level.

It’s for this reason that medieval peoples envisioned contagious disease not as a tiny organism inside a sick person’s body, but as a cloud, a miasma, that settled onto a city. Because once a disease becomes endemic to a place, we can’t track its movement from one person to another except in retrospect. To fight this uncertainty, medieval Islam developed a legalistic approach to regulations around the plague. The plague was a significant topic for Islamic legal scholars during the time of the Black Death because the religion itself had come up in the time of the previous pandemic, 700 years before. Despite the tremendous gap in time, stories about that first plague pandemic, often called the Justinianic plague because it started during the reign of the Roman Emperor Justinian, were preserved in the core texts of Islam, the Qur’an and Hadith (stories about the Prophet and his companions), as well as in records of the spread of the disease that constituted their own literary genre. For legal scholars in the 14th century, the concern with the Black Death was not so much in dying from or spreading the disease, but in the tremendous panic that would ensue when people heard about the disease and the irrational behavior it encouraged. Ibn Qayyim al-Jawziyya, one legal scholar who wrote about the plague and the concept of contagion extensively in his a-Tibb an-Nabawi, imagined that there were two sides to every disease: the body and the heart. The disease of the body was the miasma entering the blood or the lymphatic system or soft tissues and upsetting the natural order of things, and it could be spread by various kinds of physical contact. The disease of the heart, on the other hand, was how the disease affected a person’s emotional response. And this, Ibn Qayyim argued, could not spread the disease of the body. It was important for him to convey that it was pure superstition to believe that a person could get sick merely by proximity to someone who was in some way associated with a disease, such as by being shunned by society or otherwise known to be unlucky. He recognized the inclination to scapegoat and wanted to explain to people why it was the wrong approach. Ibn Qayyim saw people around him panicking and implored them to approach the disease rationally, to see that the disease in their minds was worse than the disease that had not actually reached their bodies.

Ibn Qayyim turned to the Qur’an and Hadith for support. He wanted the general public to remember that it was a place that had a contagious disease and not a person. So, as the Prophet had said, you should not enter a place with the plague, but neither should you leave a place once the plague is there. Once you are inside a place with the plague, your ability as an individual to stop its spread is incredibly minimal. Although our approach to medicine has undergone a paradigm shift as well as several technological revolutions since the 14th century, this aspect is still true. As modern peoples, and especially as Americans, we tend to approach problems individualistically. We believe that individual actions can inspire large-scale change. But it is only in aggregate that our actions can make a real impact. So one person moving away from a disease epicenter might see themselves escaping it, when in reality they might be one of dozens of people doing so, thereby making it more likely that the place they are escaping to will also catch the disease.

As we scramble to coordinate a response to COVID-19, we would do well to remember Ibn Qayyim’s argument. It is the place, not the people, that has the disease, and our actions as individuals only matter when aggregated with the whole. That means that we should no make exceptions for ourselves to do dangerous things, like leaving an infected area because we don’t feel sick. But it also means that we need to continue to approach this disease rationally. Recently, the New York Times published an op-ed by Yi-Zheng Lian in which he argued that COVID-19’s elevation to epidemic status was due to “two fundamentally Chinese cultural practices” – not that the Chinese government had suppressed information about the disease to the detriment of global health, but that China as a culture was to blame for the disease existing and spreading as it has. This is the essence of Ibn Qayyim’s understanding of contagion of the heart – that because of how a person or group of people is, they are more likely to spread disease. And this is exactly why he warned against believing such an idea. There are so many historical problems with Lian’s argument – the fact that culture does not maintain for thousands of years, or that fringe practices are not the root cause of major disease events [sidenote: Lian blames the Chinese market in exotic animal meat for exposing people to the disease. While this might be true, it likely did not create an epidemic. See, as a model of this, the original jump of HIV from other primates to humans, which was kept to local communities until economic shifts in Africa in the ’70s exposed those local outbreaks to the global community unmitigated.]- but the most important reason to ignore his claims is that his argument is unhelpful. By publishing this op-ed in English, in a major American publication, that is read primarily by educated English-speakers in major urban areas, Lian’s argument only serves to incite fear and distrust of China as a country, as a place that is a problem or a threat to America. That belief does nothing to critically examine the government that suppressed information about the disease or the systems it had in place to respond, nor does it help contain the disease now that it is developing new epicenters in other countries, or to educate the general public about how to keep themselves and their communities safe. It simply points a finger at a scapegoat, a convenient scapegoat that is already the source of plenty of American anxiety.

Epidemics are scary, and their danger is real. But so too is the danger caused by our social anxieties around epidemics. We look to the past in times like this, when we are faced with problems that have always challenged human societies, to find the wisdom of the people who already lived through it. When the Black Death was a yearly danger for people across Eurasia, the wise among them did not say to blame the most problematic culture – they said to remember that the disease was in the body, not the mind, and to follow best practices for containment. I echo those words now in the hope that we can keep them with us throughout this trial.