How Do We Balance Tensions Between COVID-19 Public Health Responses and Stigma Mitigation? Learning from HIV Research
Identifieur interne : 000036 ( Pmc/Corpus ); précédent : 000035; suivant : 000037How Do We Balance Tensions Between COVID-19 Public Health Responses and Stigma Mitigation? Learning from HIV Research
Auteurs : Carmen H. Logie ; Janet M. TuranSource :
- AIDS and Behavior [ 1090-7165 ] ; 2020.
Url:
DOI: 10.1007/s10461-020-02856-8
PubMed: NONE
PubMed Central: 7137404
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">How Do We Balance Tensions Between COVID-19 Public Health Responses and Stigma Mitigation? Learning from HIV Research</title><author><name sortKey="Logie, Carmen H" sort="Logie, Carmen H" uniqKey="Logie C" first="Carmen H." last="Logie">Carmen H. Logie</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.17063.33</institution-id><institution-id institution-id-type="ISNI">0000 0001 2157 2938</institution-id><institution>Factor-Inwentash Faculty of Social Work,</institution><institution>University of Toronto,</institution></institution-wrap>246 Bloor Street West, Toronto, ON M5S 1V4 Canada</nlm:aff></affiliation><affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="GRID">grid.417199.3</institution-id><institution-id institution-id-type="ISNI">0000 0004 0474 0188</institution-id><institution>Women’s College Research Institute, Women’s College Hospital,</institution></institution-wrap>Toronto, Canada</nlm:aff></affiliation></author><author><name sortKey="Turan, Janet M" sort="Turan, Janet M" uniqKey="Turan J" first="Janet M." last="Turan">Janet M. Turan</name><affiliation><nlm:aff id="Aff3"><institution-wrap><institution-id institution-id-type="GRID">grid.265892.2</institution-id><institution-id institution-id-type="ISNI">0000000106344187</institution-id><institution>Department of Health Care Organization and Policy, School of Public Health,</institution><institution>University of Alabama at Birmingham,</institution></institution-wrap>Birmingham, USA</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmc">7137404</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7137404</idno><idno type="RBID">PMC:7137404</idno><idno type="doi">10.1007/s10461-020-02856-8</idno><idno type="pmid">NONE</idno><date when="2020">2020</date><idno type="wicri:Area/Pmc/Corpus">000036</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000036</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">How Do We Balance Tensions Between COVID-19 Public Health Responses and Stigma Mitigation? Learning from HIV Research</title><author><name sortKey="Logie, Carmen H" sort="Logie, Carmen H" uniqKey="Logie C" first="Carmen H." last="Logie">Carmen H. Logie</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="GRID">grid.17063.33</institution-id><institution-id institution-id-type="ISNI">0000 0001 2157 2938</institution-id><institution>Factor-Inwentash Faculty of Social Work,</institution><institution>University of Toronto,</institution></institution-wrap>246 Bloor Street West, Toronto, ON M5S 1V4 Canada</nlm:aff></affiliation><affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="GRID">grid.417199.3</institution-id><institution-id institution-id-type="ISNI">0000 0004 0474 0188</institution-id><institution>Women’s College Research Institute, Women’s College Hospital,</institution></institution-wrap>Toronto, Canada</nlm:aff></affiliation></author><author><name sortKey="Turan, Janet M" sort="Turan, Janet M" uniqKey="Turan J" first="Janet M." last="Turan">Janet M. Turan</name><affiliation><nlm:aff id="Aff3"><institution-wrap><institution-id institution-id-type="GRID">grid.265892.2</institution-id><institution-id institution-id-type="ISNI">0000000106344187</institution-id><institution>Department of Health Care Organization and Policy, School of Public Health,</institution><institution>University of Alabama at Birmingham,</institution></institution-wrap>Birmingham, USA</nlm:aff></affiliation></author></analytic><series><title level="j">AIDS and Behavior</title><idno type="ISSN">1090-7165</idno><idno type="eISSN">1573-3254</idno><imprint><date when="2020">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Sontag, S" uniqKey="Sontag S">S Sontag</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Stangl, Al" 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<front><journal-meta><journal-id journal-id-type="nlm-ta">AIDS Behav</journal-id><journal-id journal-id-type="iso-abbrev">AIDS Behav</journal-id><journal-title-group><journal-title>AIDS and Behavior</journal-title></journal-title-group><issn pub-type="ppub">1090-7165</issn><issn pub-type="epub">1573-3254</issn><publisher><publisher-name>Springer US</publisher-name><publisher-loc>New York</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmc">7137404</article-id><article-id pub-id-type="publisher-id">2856</article-id><article-id pub-id-type="doi">10.1007/s10461-020-02856-8</article-id><article-categories><subj-group subj-group-type="heading"><subject>Notes From The Field</subject></subj-group></article-categories><title-group><article-title>How Do We Balance Tensions Between COVID-19 Public Health Responses and Stigma Mitigation? Learning from HIV Research</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Logie</surname><given-names>Carmen H.</given-names></name><address><email>carmen.logie@utoronto.ca</email></address><xref ref-type="aff" rid="Aff1">1</xref><xref ref-type="aff" rid="Aff2">2</xref></contrib><contrib contrib-type="author"><name><surname>Turan</surname><given-names>Janet M.</given-names></name><xref ref-type="aff" rid="Aff3">3</xref></contrib><aff id="Aff1"><label>1</label><institution-wrap><institution-id institution-id-type="GRID">grid.17063.33</institution-id><institution-id institution-id-type="ISNI">0000 0001 2157 2938</institution-id><institution>Factor-Inwentash Faculty of Social Work,</institution><institution>University of Toronto,</institution></institution-wrap>246 Bloor Street West, Toronto, ON M5S 1V4 Canada</aff><aff id="Aff2"><label>2</label><institution-wrap><institution-id institution-id-type="GRID">grid.417199.3</institution-id><institution-id institution-id-type="ISNI">0000 0004 0474 0188</institution-id><institution>Women’s College Research Institute, Women’s College Hospital,</institution></institution-wrap>Toronto, Canada</aff><aff id="Aff3"><label>3</label><institution-wrap><institution-id institution-id-type="GRID">grid.265892.2</institution-id><institution-id institution-id-type="ISNI">0000000106344187</institution-id><institution>Department of Health Care Organization and Policy, School of Public Health,</institution><institution>University of Alabama at Birmingham,</institution></institution-wrap>Birmingham, USA</aff></contrib-group><pub-date pub-type="epub"><day>7</day><month>4</month><year>2020</year></pub-date><fpage>1</fpage><lpage>4</lpage><permissions><copyright-statement>© Springer Science+Business Media, LLC, part of Springer Nature 2020</copyright-statement><license><license-p>This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.</license-p></license></permissions></article-meta></front><body><p id="Par1"><disp-quote><p id="Par2">We are not being invaded. The body is not a battlefield. The ill are neither unavoidable casualties nor the enemy. We—medicine, society—are not authorized to fight back by any means whatever. – Sontag (1 p. 180)</p></disp-quote></p><p id="Par3">Sontag’s quotation above from ‘AIDS and its metaphors’ [<xref ref-type="bibr" rid="CR1">1</xref>] reminds us to expose, and disengage from, constructions of illness that propagate fear. We are called to address the fear of COVID-19 by correcting misinformation [<xref ref-type="bibr" rid="CR2">2</xref>, <xref ref-type="bibr" rid="CR3">3</xref>]. While misinformation is indeed a driver of fear and stigma, other underlying facilitators produce stigma [<xref ref-type="bibr" rid="CR4">4</xref>, <xref ref-type="bibr" rid="CR5">5</xref>] and need to be considered in stigma mitigation. HIV research and an understanding of the historical construction of illness can be leveraged to mitigate COVID-19 stigma. COVID-19 public health responses—essential for prevention and containment [<xref ref-type="bibr" rid="CR6">6</xref>, <xref ref-type="bibr" rid="CR7">7</xref>]—also have the potential to exacerbate stigma [<xref ref-type="bibr" rid="CR8">8</xref>]. We outline four tensions between COVID-19 containment and stigma mitigation, and offer possible ways forward.</p><sec id="Sec2"><title>How We Approach Illness Matters</title><p id="Par4">There is a long history of othering in conceptualizing illness, whereby the sick are separated from the healthy [<xref ref-type="bibr" rid="CR9">9</xref>]. Responses to illnesses are shaped by their unpredictability and perceived contagion [<xref ref-type="bibr" rid="CR10">10</xref>]. Illnesses have been constructed as both evil predators and personal responsibilities, contributing to social rejection [<xref ref-type="bibr" rid="CR1">1</xref>, <xref ref-type="bibr" rid="CR10">10</xref>]. Jones [<xref ref-type="bibr" rid="CR11">11</xref>] described historical examples of how responses to epidemics unfold. At first there may be a lack of recognition of the seriousness of the problem, followed by public responses that are grounded in moralistic and mechanistic interpretations. This could be followed by government actions, such as quarantine, that can exacerbate power imbalances between civilians and the state. Who and what is respected in a society become clear in an epidemic [<xref ref-type="bibr" rid="CR11">11</xref>].</p><p id="Par5">Social reactions to ‘plagues’ reveal the perception that the illness originates elsewhere [<xref ref-type="bibr" rid="CR1">1</xref>, <xref ref-type="bibr" rid="CR10">10</xref>, <xref ref-type="bibr" rid="CR11">11</xref>]. Blaming a foreign other for epidemics is commonplace throughout history. Sontag described “a link between imagining disease and imagining foreignness…illness is a species of invasion” (1 p. 48). Military metaphors—including such terms as targets and fighting—frame illnesses as society’s invasive, wicked infiltrators that spur paranoia and command social order, and in turn can exacerbate pre-existing social inequities [<xref ref-type="bibr" rid="CR1">1</xref>, <xref ref-type="bibr" rid="CR10">10</xref>, <xref ref-type="bibr" rid="CR12">12</xref>]. Medical education constructs the body as a battlefield that requires us to strengthen our defense system [<xref ref-type="bibr" rid="CR12">12</xref>].</p></sec><sec id="Sec3"><title>Tensions Between Stigma Mitigation and COVID-19 Public Health Responses</title><p id="Par6">Historical and current approaches to illness—including HIV—can inform COVID-19 stigma reduction. Tensions between stigma mitigation and COVID-19 containment emerge regarding: physical distancing, travel restrictions, misinformation, and engaging affected communities.</p><p id="Par7">First, othering can result in social distancing through reduced interaction with stigmatized persons [<xref ref-type="bibr" rid="CR13">13</xref>]. Yet to slow the spread of COVID-19, it is necessary to practice public health recommended physical distancing—avoiding close contact and maintaining 1 m distance from others [<xref ref-type="bibr" rid="CR7">7</xref>]. While an integral component of containment [<xref ref-type="bibr" rid="CR6">6</xref>, <xref ref-type="bibr" rid="CR7">7</xref>], how can we ensure that physical distancing does not exacerbate othering, avoidance, and mistreatment toward persons associated with COVID-19? Stigma-reduction messaging can carefully reflect the evolving patterns of COVID-19 risk to foster empathy while simultaneously transforming physical distancing into a normal and sustained practice until the pandemic is over. While there are no direct parallels to HIV with physical distancing, HIV has long contended with the tension between negotiating intimacy and physical connection in a pandemic. The 1983 publication “How to have sex in an epidemic: One approach” explored care, love, and intimacy as reasons for safer sex motivation [<xref ref-type="bibr" rid="CR14">14</xref>]. Pleasure (not only fear of HIV infection) is key to engaging in HIV preventive practices [<xref ref-type="bibr" rid="CR15">15</xref>, <xref ref-type="bibr" rid="CR16">16</xref>]. Similarly, UNAIDS [<xref ref-type="bibr" rid="CR8">8</xref>] and WHO [<xref ref-type="bibr" rid="CR3">3</xref>] suggest that building connections via kindness and caring (rather than simply fear of COVID-19 infection) can motivate uptake of non-stigmatizing physical distancing.</p><p id="Par8">COVID-19 travel bans, lockdowns, and movement restrictions are being implemented across dozens of countries. Movement bans and quarantines are often legally enforced, for instance by military and municipal police. These approaches help with COVID-19 containment and allow greater responsiveness to overstretched health systems. Yet COVID-19 travel restrictions may also facilitate stigma and xenophobia by reproducing the social construction of illness as a foreign invasion, in turn reinforcing social hierarchies and power inequities [<xref ref-type="bibr" rid="CR1">1</xref>, <xref ref-type="bibr" rid="CR10">10</xref>] —at times through authoritarian means [<xref ref-type="bibr" rid="CR11">11</xref>]. Enforcement of travel bans, movement restrictions, and quarantines may disproportionately affect already stigmatized persons, including homeless persons [<xref ref-type="bibr" rid="CR17">17</xref>], persons who are incarcerated [<xref ref-type="bibr" rid="CR18">18</xref>], migrants and refugees [<xref ref-type="bibr" rid="CR19">19</xref>], undocumented immigrants [<xref ref-type="bibr" rid="CR20">20</xref>], and racial minorities [<xref ref-type="bibr" rid="CR8">8</xref>]. There are global media reports of arrests for COVID-19 transmission [<xref ref-type="bibr" rid="CR21">21</xref>–<xref ref-type="bibr" rid="CR25">25</xref>]. Travel bans also exist for HIV: 48 countries currently maintain travel restrictions for people with HIV, reflecting the pervasiveness and persistence of social control measures that perpetuate stigma [<xref ref-type="bibr" rid="CR26">26</xref>]. HIV transmission has been criminalized [<xref ref-type="bibr" rid="CR27">27</xref>] in 72 countries [<xref ref-type="bibr" rid="CR28">28</xref>]: such policies are not evidence-based and harm the health and human rights of people with HIV [<xref ref-type="bibr" rid="CR29">29</xref>, <xref ref-type="bibr" rid="CR30">30</xref>]. Lesbian, gay, bisexual and transgender (LGBT) persons, sex workers, and people who use drugs, experience criminalization that reduces access to employment, housing, and healthcare, and exacerbates risks for violence and practices that elevate HIV exposure [<xref ref-type="bibr" rid="CR31">31</xref>–<xref ref-type="bibr" rid="CR34">34</xref>]. As an alternative approach, COVID-19 travel bans and quarantine could include anti-stigma and anti-xenophobia public messaging and training of legal authorities [<xref ref-type="bibr" rid="CR4">4</xref>, <xref ref-type="bibr" rid="CR35">35</xref>]. Furthermore, UNAIDS recommends that in lieu of criminalization for breaching COVID-19 public health policies, approaches should focus on empowering and strengthening communities to support persons to protect their own and one other’s health [<xref ref-type="bibr" rid="CR8">8</xref>].</p><p id="Par9">Third, it is necessary to address misinformation and lack of awareness regarding COVID-19—but not sufficient. Stigma mitigation also needs to tackle facilitators such as social inequities [<xref ref-type="bibr" rid="CR4">4</xref>], including racism and xenophobia. Public health strategies that improve access to COVID-19 testing and employment sick leave benefits have the potential to reduce stigma. Yet addressing underlying social inequities and healthcare access require long-term investment in transforming values, laws, and policies. The tension therefore emerges between the immediate—and faster—work of providing information in the midst of the COVID-19 pandemic and the need for long-term investment in reducing social inequities. Stigma-reduction strategies for HIV and other health issues have largely targeted intrapersonal and interpersonal dimensions, far fewer have addressed structural factors such as legal issues, policies, and rights [<xref ref-type="bibr" rid="CR36">36</xref>]. Interventions should address both drivers (knowledge, misinformation) and facilitators (health policies, institutional practices) [<xref ref-type="bibr" rid="CR37">37</xref>]. We know from an extensive body of HIV-related stigma research that multiple stigma dimensions can negatively impact health practices and outcomes [<xref ref-type="bibr" rid="CR5">5</xref>]. COVID-19 stigma mitigation can therefore consider <italic>enacted stigma—</italic>acts of discrimination and mistreatment, <italic>felt-normative stigma—</italic>demeaning community norms and values, <italic>internalized stigma—</italic>the ways that persons accept negative perspectives toward a group(s) they may belong to, and <italic>anticipated stigma—</italic>concerns that one will experience future discrimination and bias [<xref ref-type="bibr" rid="CR5">5</xref>]. We have seen international financing for HIV decline [<xref ref-type="bibr" rid="CR38">38</xref>], threatening the global ambition to end the pandemic. This is not unique to HIV: the United Nations Population Fund also reported significant funding shortfalls for humanitarian relief in 2019 [<xref ref-type="bibr" rid="CR39">39</xref>]. We need to act <italic>now</italic> to harness political investment in challenging the social inequities that exacerbate COVID-19′s impact on marginalized communities—such as refugees [<xref ref-type="bibr" rid="CR19">19</xref>] and undocumented immigrants [<xref ref-type="bibr" rid="CR20">20</xref>]—rather than waiting for the pandemic to subside when there may be a decreased sense of commitment, urgency, and momentum.</p><p id="Par10">Fourth, we need to engage persons most affected by COVID-19 in developing stigma mitigation strategies, yet they may experience social and health disparities that present barriers to research participation. Lived experiences of COVID-19 and other intersecting stigmas [<xref ref-type="bibr" rid="CR4">4</xref>, <xref ref-type="bibr" rid="CR5">5</xref>, <xref ref-type="bibr" rid="CR40">40</xref>] can inform contextually specific and stigma-informed public health approaches. For instance, gendered roles as family caregivers and front-line healthcare workers may elevate women’s exposure to COVID-19 [<xref ref-type="bibr" rid="CR41">41</xref>], requiring a gender-based analysis of social and health impacts of public health measures such as quarantine. Past pandemics such as Ebola reduced women’s access to maternal and child health services [<xref ref-type="bibr" rid="CR42">42</xref>], abortion [<xref ref-type="bibr" rid="CR43">43</xref>], and reduced uptake of HIV services [<xref ref-type="bibr" rid="CR44">44</xref>]. Social disparities are associated with health disparities. Persons experiencing stigma, such as people newly diagnosed with HIV [<xref ref-type="bibr" rid="CR45">45</xref>] and LGBT persons [<xref ref-type="bibr" rid="CR46">46</xref>], are disproportionately impacted by depression. Although research is nascent, the stress from COVID-19 stigma may have analogous mental health impacts [<xref ref-type="bibr" rid="CR47">47</xref>, <xref ref-type="bibr" rid="CR48">48</xref>], including on healthcare providers [<xref ref-type="bibr" rid="CR49">49</xref>, <xref ref-type="bibr" rid="CR50">50</xref>]. Strategies therefore need to factor in multiple health conditions and social identities to understand and reduce COVID-19 stigma. A syndemics approach could be useful in mapping the ways that social inequities contribute to the production of multiple interacting health issues, including COVID-19 [<xref ref-type="bibr" rid="CR51">51</xref>]. Creative, web-based, and community-engaged strategies can aim to reduce participation barriers to involve persons most impacted by COVID-19 stigma in research and program development (e.g., addressing access barriers posed by COVID-19 caregiving and/or healthcare provider roles, quarantine, mental health challenges).</p><p id="Par11">We need more than information to reduce COVID-19 stigma—multi-level strategies can address underlying stigma drivers and facilitators [<xref ref-type="bibr" rid="CR4">4</xref>]. Public health actors can challenge military metaphors and other stigmatizing language in public health messaging and media [<xref ref-type="bibr" rid="CR1">1</xref>, <xref ref-type="bibr" rid="CR10">10</xref>, <xref ref-type="bibr" rid="CR12">12</xref>]. Applying an intersectional lens [<xref ref-type="bibr" rid="CR4">4</xref>, <xref ref-type="bibr" rid="CR40">40</xref>] can improve understanding of the ways that COVID-19 stigma intersects with gender, race, immigration status, housing security, and health status, among other identities. Balancing tensions between stigma mitigation and COVID-19 prevention and containment can inform immediate and long-term strategies to build empathy and social justice in current and future pandemics.</p></sec></body><back><fn-group><fn><p><bold>Publisher's Note</bold></p><p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p></fn></fn-group><ack><title>Acknowledgements</title><p>CHL was supported during the writing of this manuscript by a residency at the Brocher Foundation and an Eccles Fellowship at the British Library. She also receives support for her program of research from Canada Research Chairs, Canada Foundation for Innovation, and the Ontario Ministry of Research and Innovation. JMT's contribution to this research was supported by the University of Alabama at Birmingham (UAB) Center for AIDS Research CFAR and an NIH funded program (P30 AI027767) that was made possible by the following institutes: NIAID,NCI, NICHD, NHLBI, NIDA, NIA, NIDDK, NIGMS, and OAR. Funders played no role in writing this manuscript.</p></ack><notes><title>Compliance with Ethical Standards</title><notes notes-type="COI-statement"><title>Conflict of interest</title><p id="Par12">The authors have no conflicts of interest to declare.</p></notes></notes><ref-list id="Bib1"><title>References</title><ref id="CR1"><label>1.</label><element-citation publication-type="book"><person-group person-group-type="author"><name><surname>Sontag</surname><given-names>S</given-names></name></person-group><source>AIDS and its metaphors</source><year>1989</year><publisher-loc>New York</publisher-loc><publisher-name>Farrar, Straus and Giroux</publisher-name></element-citation></ref><ref id="CR2"><label>2.</label><mixed-citation publication-type="other">World Health Organization. WHO Director-General’s opening remarks at the media briefing on COVID-19—5 March 2020 [Internet]. 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