key: cord-1049396-gge6wzly
authors: Villa, Simone; Jaramillo, Ernesto; Mangioni, Davide; Bandera, Alessandra; Gori, Andrea; Raviglione, Mario Carlo
title: Stigma at the time of the COVID-19 pandemic
date: 2020-08-07
journal: Clin Microbiol Infect
DOI: 10.1016/j.cmi.2020.08.001
sha: cd5af00a2f858ec18686363708562be65196f722
doc_id: 1049396
cord_uid: gge6wzly

nan

Respiratory infectious disease outbreaks marked by significant morbidity and mortality tend to produce serious distress in the general population. Physical distancing is necessary to reduce the chances of transmission of the pathogen. But this practice may engender stigma and discrimination, which can have the counterproductive effect of hindering disease control. People start to hide their symptoms, avoid seeking medical attention and testing until they are seriously ill, and do not collaborate in contact investigation efforts.

Epidemic outbreaks have historically been accompanied by stigma, discrimination, and xenophobia. Tuberculosis, HIV, and leprosy are well known stigmatised infectious diseases. More recently, survivors of the 2013-16 West Africa Ebola outbreak have faced exclusion and unemployment once they returned to their communities. 1 Beginning in late January 2020, when the COVID-19 epidemic was still largely limited to China, verbal and physical attacks against Chinese or people of Asian descent have been documented in many countries. 2 In Italy, for example, numerous racial and violent actions have taken place, including physical violence. in the Vicenza province a young Asian man was beaten and verbally assaulted and a young Asian woman was insulted and accused of spreading COVID-19; 3 in Rome some private stores began to exclude clients of Asian origin barring "all people coming from China" from entering. 2 Similar incidents were reported in countries like France, where there were cases of people refusing to be served by Asian persons in shops and restaurants, and the United States of America, where a single week in March saw around 650 racist acts against Asian Americans. 4

Uses of language by some media, newspapers and political leaders sometimes contribute to fuel stigma. For instance, in January 2020 numerous Italian newspapers used the terms "Chinese virus" and "Chinese syndrome" as if a nationality could be attributed to a virus or a disease. 5 Likewise, in France, provocative and imprudent headlines such as "the Alert Jaune", namely the "Yellow Alert", appeared in Le Courrier Picard.

The President of the United States of America has frequently described COVID-19 as the "Chinese virus". In Italy, some politicians accused Chinese people of poor hygiene and unhealthy cultural practices, including that of eating "live mice". 6 In Rome, a school principal asked all Chinese students to exhibit a formal medical certificate declaring that they were disease-free, if they were to be allowed to attend classes. 2 Some regional governors proposed to exclude children of Chinese descent from class. Counteracting this J o u r n a l P r e -p r o o f language with gestures such as the condemnation of race-based discriminatory behavior by the Italian Prime Minister or the visit of the Italian President to a primary school in Rome where half of the children are of Chinese origin might be insufficient to mitigate the stigma and fear already created. In France, initiatives such as the hashtag #JeNeSuisPasUnVirus (I am not a virus), spread on Twitter after provocative headlines in French newspapers.

Once the pandemic reached Italian territory, stigma was rapidly redirected towards ethnic Italians. 7 The blame went immediately towards people from the north of Italy, the area initially affected by the COVID-19 epidemic, with (fortunately isolated) threats from people from southern Italy of not renting houses to those from the north. Stigmatizing a population can also serve political needs. Some Italian political parties, for example, managed to shift the blame to Germany, stating that the Italian outbreak originated in that country. 8

When COVID-19 became a pandemic affecting more than one hundred countries, stigma and discrimination changed their pattern once again. It is well documented how healthcare workers and ambulance crews in the most affected areas in some Latin-American, African, and European countries became the target of stigma and discrimination. 9 The general public started to see them as the "anointers" -those individual perceived to voluntarily favour the spread of plague in the community during the Middle Ages -and, as a result, deplorable actions have been documented. For instance, in the city of Pisa, Italy, a medical doctor going back home found a notice in which the neighbours asked her to be careful not to touch anything in the common area of the building where she lives. COVID-19 survivors also have had to cope with stigma, especially from neighbours. Given the shortage in testing kits and the overwhelming of laboratories, people who survive could not always be retested as proof of final cure. This led to avoidance and social isolation due to the fear of becoming infected. 10 In contrary, uninfected COVID-19 people may be facing discrimination when applying for jobs in some countries that may implement COVID-19 passport strategies, despite recommendations of the World Health Organization against such a practice. 11 Most countries are struggling to implement an appropriate risk communication strategy to prevent and mitigate COVID-19-related stigma. The role played by stigma and discrimination in favouring the spread of infection has been repeatedly highlighted. 12, 13 Stigma, for instance, can lead ill people to hide their symptoms in the attempt to avoid marginalization. This reactive behaviour facilitates spreading of infectious pathogens especially among those with mild symptoms who avoid seeking medical attention and act J o u r n a l P r e -p r o o f as usual not to raise suspicion on their condition. Besides easing transmission, this behaviour can be conducive to deterioration of clinical conditions and may have psychological consequences. On the other hand, patients with COVID-19 diagnosis frequently suffer from anxiety and depression, mainly as a consequence of hospitalization or home quarantine, or due to the sense of guilt towards family members or acquaintances.

The world cannot bear a parallel pandemic of stigma, which only serves to boost the spread of infectious diseases and worsen people's health conditions and social behaviours. Noteworthy, individuals with COVID-19 may develop poor health-seeking behaviours (e.g. avoiding testing) because, by anticipating and fearing stigma, they may perceive the risk of losing their job and being marginalised in the society. This stress, together with the one caused by hiding symptoms, may further exacerbate conditions linked to biological stress response (i.e., elevated cortisol) leading to immune depression and delay in timely and adequate treatment. 12 Governments, backed by civil societies, have the responsibility to act urgently and make a definite commitment to fight any form of stigmatization, discrimination and xenophobia fuelled by infectious outbreaks. 13 We need to identify and isolate those who exploit the human tragedies of infectious epidemics for their political aims. Interventions to mitigate social stigma should embrace risk communication strategies to fill the knowledge gap in the general population with additional attention to specific, vulnerable segments such as migrants and ethnic minorities, and to prevent the "fake news" from spreading. For instance, medical and scientific societies should encourage health care and public health professionals to develop ad hoc materials to educate patients and the general public. In doing so, public health authorities should seek advice from communication and social media experts especially when developing key messages (e.g., on mask use) and technical guidelines as these can be potentially misunderstood by media and the general public. Technical information should also be paired with comprehensible and clear messages for non-technical recipients.

Ebola virus disease-related stigma among survivors declined in Liberia over an 18-month, post-outbreak period: An observational cohort study

Outbreaks of xenophobia in west as coronavirus spread. The Guardian

As if we were the disease': coronavirus brings prejudice for Italy's Chinese workers. The Guardian

Asian Americans report over 650 racist acts over last week, new data says

Politician apologizes for saying coronavirus caused by Chinese people eating 'live mice'

Italiani untori

You Could Lick the Benches': Life for the First Wave of U

Immunity passports" in the context of COVID-19. Geneva: World Health Organization 2020

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