China was once mocked by Westerners as the “Sick Man of Asia.” That caricature provided motivation for a long campaign of national rejuvenation. Now the tables are turned after China’s handling of the coronavirus pandemic proved more effective than that of the United States and other Western nations.
Like a lot of other people, I’ve had to adjust to working from home during the COVID-19 pandemic. My medical-historian colleagues and I, however, have been kept busy by high demand for putting this crisis in historical perspective. As soon as the American Association of the History of Medicine agreed to cancel its May 2020 annual conference, members began to organize a virtual meeting to respond to the coronavirus crisis. The resulting two-day webinar on the theme “Creating a Usable Past: Epidemic History, COVID-19, and the Future of Health” sought to mine history for critical insights about our pandemic present.
During the closing discussion on “Pandemic Legacies and the Future of Health,” Ruth Rogaski, a historian of China, provided a valuable perspective. The current pandemic could not be understood without integrating the historical legacies of East Asia’s past epidemics into the analysis, she argued. Not only did epidemics accompany foreign invasions of China starting with the Opium Wars (1839–60), but experiences with epidemics also fundamentally shaped all modern Asian nation-states.
Over the transition from the late nineteenth to the early twentieth century, the Qing dynasty (1644–1911) proved incapable of defending itself from either foreign incursions or epidemic diseases. European observers and Chinese reformers alike began to cast China as the “Sick Man of Asia” or the “Sick Man of the Far East.” They borrowed the image from the earlier trope of the “Sick Man of Europe,” allegedly inspired by Tsar Nicholas I when he referred to the Ottoman Empire, just before the Crimean War (1853–56), as “a sick man on our hands, a man gravely ill.”
Of course, the “Sick Man” label was not only slapped on Turkey and China; even a rising new power, the United States, was not immune. In 1860, the New York Times published “Sick Man of America,” an editorial focused on the US government’s failure to solve the “great Mexican question” at the end of Mexico’s War of Reform (1857–60). For the most part, though, the term was used in an Orientalist way to denigrate Eastern empires (see Figure 1). But the provocative suggestion that the United States was itself a “sick man” would turn out to be prescient 160 years later.
East–West Role Reversal
Among all these variations on the theme, the racist “Sick Man of Asia” trope may have been the one that had the greatest long-term impact on the nation that it mocked. For most of the twentieth century, the label haunted Chinese rulers and people alike. Now, however, as the public health consequences of America’s structural racism and lack of universal health coverage have been revealed by COVID-19, on top of working-class “deaths of despair,” the roles have been completely reversed. How did this happen?
The recent experiences of China, Taiwan, Singapore, and Vietnam in dealing with the SARS epidemic (caused by the coronavirus now called SARS-CoV-1) in 2002–3 and South Korea’s experience with MERS in 2015 certainly provided lessons that helped them respond more effectively to the present SARS-CoV-2 (the virus that causes COVID-19) pandemic. But a longer-term perspective shows that East Asian nations much earlier were forced to strengthen their state, medical, and public health infrastructures in order to survive the invasions, wars, epidemics, and national humiliations of the twentieth century. Paying attention to such historical legacies clarifies the geopolitical context of these countries’ collective success in controlling COVID-19, despite distinctly different languages, cultures, national histories, and health care systems.
Using illness as a metaphor allows one to make a diagnosis that can then be acted upon.
That context was well explored by Andrew Salmon in a two-part May 15–16 report for the Asia Times titled, “Why East Beat West on COVID-19.” Salmon sought to explain how “East Asia has handled and contained the pandemic far better than the West on nearly all metrics.” Here, East meant China, Japan, South Korea, Taiwan, and Vietnam; West meant the European Union and the United States.
The first part of the report examined differences in culture and communalism, attitudes toward authority, rights to privacy, and divergences in recent historical and epidemic experience that may have contributed to the more effective COVID-19 response by East Asian nation-states, whether authoritarian (China, Singapore, Vietnam) or democratic (Japan, South Korea, Taiwan). The second part compared leadership, policy responses, vaccination policies, travel and geographic integration, manufacturing capacity, viral variations, genetic vulnerabilities related to race, and differences in weather and climate. Finally, it cited a pervasive Western sense of cultural superiority that contributes to arrogance toward Eastern models and ignorance of both East Asian history and the region’s modern health care systems.
The author neglected, however, to take account of national policies across East Asia that to varying degrees integrate traditional medical therapies with modern biomedicine. In Europe and the United States, these approaches are generally separated into incommensurable spheres. Western press coverage of the Chinese government’s top-down support for integrating Chinese medicine with biomedicine to treat COVID-19 patients has largely been disparaging. Salmon’s report altogether ignored such integrated medical decision-making in hospitals across China as well as in clinics of Korean medicine and Japanese Kampo across East Asia.
Just over a month later, most reasonable US analysts agreed with Salmon’s assessments as COVID-19 case numbers began sharply rising again across the country. On June 23, the director of the federal Centers for Disease Control and Prevention (CDC), Dr. Robert Redfield, testified before a congressional committee: “We have all done the best that we can do to tackle this virus and the reality is that it’s brought this nation to its knees.” By June 30, the European Union blocked travel from the United States as well as Brazil and Russia, while allowing the resumption of flights from countries that had more effectively responded to COVID-19.
As I finish writing this essay, the Republican-run states that ended shutdowns earlier than the CDC guidelines recommended are now leading the nationwide US surge in COVID-19 infections. No state has been able to build the four-step public-health infrastructure necessary to render the epidemic sufficiently visible to implement effective control measures: 1) widely test, 2) isolate the infected, 3) trace all their contacts, and 4) selectively quarantine all contacts for 14 days.
While most East Asian states have fully integrated these four steps into their health care infrastructures, US states remain blind, unable to see their mutual enemy. Even more alarming, the cynical Trump regime considers everything that makes the pandemic visible to experts and the public alike—from testing and masking to shelter-in-place orders—contrary to its political interests.
Exacerbated by myriad failures of federal-level leadership, the United States now leads the world with more than 3.9 million positive cases. Epidemiologists advise that we should multiply this figure by ten to arrive at a rough estimate of total infections, given the limited reach of testing and the related inability to follow through on the next three essential steps of isolating, tracing, and selective quarantining. This means that about 39 million have likely been exposed to COVID-19—just over 10 percent of the country’s total population of roughly 330 million.
The current accounting of more than 136,000 COVID-19 deaths in the United States is about to surpass the twentieth-century US fatalities of World War I (53,402), the Vietnam War (58,220), and the Korean War (36,574) combined. Still worse, we could be heading toward the estimated 600,000 American lives lost after World War I, when the 1918 influenza pandemic spread across the country.
Historically reconstructed global estimates of influenza deaths from 1918 to 1920 range much higher. The already hard-to-fathom conservative estimate of 50 million, some scholars argue, may be more accurately doubled to 100 million. State and medical infrastructures were pushed beyond their capacity to care for the sick, much less to fully account for the dead. Postwar fatigue, as well as historians largely focused on Anglo-American and European rather than global consequences of the influenza pandemic, together contributed to historical amnesia regarding its massive toll, until Laura Spinney’s long overdue reckoning in her 2017 book Pale Rider: The Spanish Flu of 1918 and How It Changed the World.
Powerful Discourses of Weakness
While the West has struggled, China and the other East Asian nations overall have controlled the COVID-19 pandemic within their borders. Although the multiple and divergent reasons for East Asia’s overall success and European and American failures will take at least the next decade to work out, anyone paying attention can clearly see that the tables have turned. China’s old reputation as the “Sick Man of Asia” has indisputably shifted to the United States. “Sick Uncle Sam” is now the new focus of the world’s concern over a clearly declining superpower.
That’s not necessarily a bad thing. The power of the “sick man” label is that using illness as a metaphor allows one to make a diagnosis that can then be acted upon. And the staying power of the “Uncle Sam” moniker relies on metonymy, using the name of one thing to represent something related—such as “the press” for journalists. It often lends human scale, through personification, to an otherwise unwieldy institution.
Uncle Sam, as a metonym for the US government, also draws power from history and myth. In September 1861, the US Congress formally recognized Sam Wilson, a meat-packer from Troy, New York, as the model for America’s national symbol. The story was that Wilson, during the War of 1812, had supplied “US”-stamped, beef-filled barrels that Army soldiers called “Uncle Sam’s grub.” This proved apocryphal, but Uncle Sam nonetheless has been a fixture ever since in the national imagination.
Twenty-five years after Uncle Sam’s supposed war exploits, artist Edward Williams Clay engraved a lithograph of “Uncle Sam Sick with La Grippe” (see Figure 2). In this political satire, Clay used the “grippe” (influenza) as a metaphor for the severe recession of 1837. Sick Uncle Sam sits splayed in a chair, holding a sheet of paper listing the millions of dollars lost by US banks. Standing from left to right, President Andrew Jackson blames overeating (economic overexpansion), Jackson’s ally Senator Thomas Hart Benton prescribes “mint drops” (coinage), and Jackson’s vice president and successor Martin Van Buren (feminized as elderly “Aunt Matty”) diagnoses “over-issues” of paper money.
The Sick Uncle Sam trope is as effective today as it was back then for diagnosing what ails the US government. It has recently resurfaced in the title of an article about Washington gridlock, “Uncle Sam Is Very Sick: Here’s What Can Be Done,” which appeared in June 2019 in an online magazine, The Bulwark, and in The Economist’s assessment from mid-March, “Uncle Sam v the Coronavirus.” Anticipating these examples by several years was foreign policy analyst John Feffer’s commentary, “The Sick Man of North America.”
The “sick man” trope, whether applied to Europe, Asia, North America, or even Africa, also does geographic work by drawing national distinctions within the handful of metageographical concepts that divide up the world’s major landmasses into regions. It wields its power by clarifying a diagnosis of illness within that regional body politic.
Thus, the “Sick Man of Asia” trope pejoratively positioned China as inferior to its East Asian neighbors as well as its European counterparts. Yet among Chinese reformers, it also constituted a broader “discourse of weakness,” one that Iwo Amelung, a historian of modern Chinese science, has argued included the concepts of “national salvation” and “saving the country by science.” Closely linked to social Darwinist interpretations of the rise and fall of nations, these discourses of weakness motivated the Chinese government to pursue the long-term aim of not only regaining national strength, but also rising above all others on the global stage.
Now that Uncle Sam has been rendered an invalid by the misrule of Trump, the virus-spreading Novel Corona King (see Figure 3), the humiliating labels “Sick Uncle Sam” and “Sick Man of North America” could not be more apt. They are also as potentially transformative for the United States as the “Sick Man of Asia” slur was for China. A regime change would be needed, however, for Uncle Sam to acknowledge being sick, diagnose his illnesses and comorbidities, and effectively mobilize the wider range of treatments available from East Asian experiences, models, and even medicines, all of which he currently scorns.