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)
Sontag’s quotation above from ‘AIDS and its metaphors’ [1] 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 [2, 3]. While misinformation is
indeed a driver of fear and stigma, other underlying facilitators produce stigma [4,
5] 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 [6, 7]—also
have the potential to exacerbate stigma [8]. We outline four tensions between COVID-19
containment and stigma mitigation, and offer possible ways forward.
How We Approach Illness Matters
There is a long history of othering in conceptualizing illness, whereby the sick are
separated from the healthy [9]. Responses to illnesses are shaped by their unpredictability
and perceived contagion [10]. Illnesses have been constructed as both evil predators
and personal responsibilities, contributing to social rejection [1, 10]. Jones [11]
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 [11].
Social reactions to ‘plagues’ reveal the perception that the illness originates elsewhere
[1, 10, 11]. 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 [1, 10, 12]. Medical education constructs the body as a battlefield that
requires us to strengthen our defense system [12].
Tensions Between Stigma Mitigation and COVID-19 Public Health Responses
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.
First, othering can result in social distancing through reduced interaction with stigmatized
persons [13]. 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 [7]. While an integral component of containment [6, 7], 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 [14]. Pleasure
(not only fear of HIV infection) is key to engaging in HIV preventive practices [15,
16]. Similarly, UNAIDS [8] and WHO [3] suggest that building connections via kindness
and caring (rather than simply fear of COVID-19 infection) can motivate uptake of
non-stigmatizing physical distancing.
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 [1, 10] —at times through authoritarian means [11]. Enforcement of travel
bans, movement restrictions, and quarantines may disproportionately affect already
stigmatized persons, including homeless persons [17], persons who are incarcerated
[18], migrants and refugees [19], undocumented immigrants [20], and racial minorities
[8]. There are global media reports of arrests for COVID-19 transmission [21–25].
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 [26]. HIV transmission has been criminalized [27]
in 72 countries [28]: such policies are not evidence-based and harm the health and
human rights of people with HIV [29, 30]. 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 [31–34]. As an alternative approach, COVID-19
travel bans and quarantine could include anti-stigma and anti-xenophobia public messaging
and training of legal authorities [4, 35]. 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 [8].
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 [4], 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 [36]. Interventions should address
both drivers (knowledge, misinformation) and facilitators (health policies, institutional
practices) [37]. We know from an extensive body of HIV-related stigma research that
multiple stigma dimensions can negatively impact health practices and outcomes [5].
COVID-19 stigma mitigation can therefore consider enacted stigma—acts of discrimination
and mistreatment, felt-normative stigma—demeaning community norms and values, internalized
stigma—the ways that persons accept negative perspectives toward a group(s) they may
belong to, and anticipated stigma—concerns that one will experience future discrimination
and bias [5]. We have seen international financing for HIV decline [38], 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 [39]. We need to act now to harness political investment in challenging the
social inequities that exacerbate COVID-19′s impact on marginalized communities—such
as refugees [19] and undocumented immigrants [20]—rather than waiting for the pandemic
to subside when there may be a decreased sense of commitment, urgency, and momentum.
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
[4, 5, 40] 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 [41], 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 [42], abortion
[43], and reduced uptake of HIV services [44]. Social disparities are associated with
health disparities. Persons experiencing stigma, such as people newly diagnosed with
HIV [45] and LGBT persons [46], are disproportionately impacted by depression. Although
research is nascent, the stress from COVID-19 stigma may have analogous mental health
impacts [47, 48], including on healthcare providers [49, 50]. 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 [51]. 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).
We need more than information to reduce COVID-19 stigma—multi-level strategies can
address underlying stigma drivers and facilitators [4]. Public health actors can challenge
military metaphors and other stigmatizing language in public health messaging and
media [1, 10, 12]. Applying an intersectional lens [4, 40] 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.