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WP2 Part 1:

Literature Review: Discussion on Stigma, Inequality and Multisectoral

Approach in Epidemic Response

Since the dawn of time, human beings have always had to deal with infectious

diseases, and in the course of human history, scientists have gradually come up with

ways to cope with epidemics. In 1854, John Snow, a British physician, successfully

identified the source of the Cholera outbreak using the London map, which set a

precedent for epidemiology. Fast forward to 2020, which is another year that another

epidemic spread across the globe, modern epidemiologists are facing knottier

problems than Victorian epidemiologists. Understanding the sources of transmission

and transmission patterns is not good enough for outbreak control. Pre-existing

sociological problems like disease-related stigma and inequalities not only impeded

many patient's rights to receive treatment but also created a panic sentiment that these

patients fear to reveal their serostatus. Serostatus is a biological signifier that indicates

whether a person gets infected by the virus, and hiding the serostatus will make

patient tracking even more difficult. However, these problems are far beyond the

boundary of epidemiology, and to address these problems requires multisectoral

collaboration in modern epidemic response. This study brings extensive research from

different academic fields together, such as sociology, psychology, economy, and

political science, to discuss disease-related stigma, inequality, as well as the possible

measures to guide the current COVID-19 response.

The term "stigma" originated from medieval times. Stigma is often tied with

religious activities in the past because religion was prevalent in the medieval world.

Back then, stigma refers to physical, visible symbols on the body made by torture, and
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it often symbolizes negative implications. For centuries, Stigma has been a powerful

source of shame and often manifested in literature. One prominent example is the

book ​The Scarlet Letter​ written by Nathaniel Hawthorne. The protagonist, Hester

Prynne, commits adultery and becomes pregnant. A scarlet letter "A" was

embroidered on her dress as a sign of shame, making her a woeful pariah. The Scarlet

letter is a classic example of how stigmatization was embodied in the past. Stigma has

evolved into a broader meaning as time goes on. Instead of the symbolic meaning

represented by physical signs, stigma is often reflected in prejudice and discrimination

against vulnerable people. In particular, the discrimination direct at infected people

who suffer from the epidemic.

Stigma is a psychological problem in nature. In the article, "Thinking about

AIDS and Stigma: A Psychologist's Perspective," author Gregory Herek analyzes the

AIDS stigma from a social psychological perspective and makes suggestions on how

to respond to these stigmas. The stigmatization of AIDS patients, according to Herek,

comes from their risky behavior that leads them to become infected by diseases. "An

illness is likely to be stigmatized if it is perceived as having been contracted through

voluntary and avoidable behaviors, especially behaviors that evoke social

disapproval."​1​ As a result, many people lack empathy for AIDS patients because they

think AIDS patients are merely paying for their folly. Moreover, the incurable and

lethal nature of AIDS makes many people fearful of the disease. Because of its high

fatality rate, people appear to overestimate the transmission risks and reduce social

interaction with AIDS patients. This type of stigma is what Herek called

“instrumental AIDS stigma”​2​ as it comes from peoples' fear of AIDS. Whereas

1
​Herek, Gregory M. “Thinking about AIDS and Stigma: A Psychologist’s Perspective.” ​The Journal of
Law, Medicine & Ethics​ 30, no. 4 (December 2002)​, ​p.596
2
​Herek, “Thinking about AIDS and Stigma”, 597.
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another type of stigma, "symbolic AIDS stigma,"​3​ targets social groups or lifestyles

perceived to be associated with HIV, which inflicts hardship on frontline medical

workers who willing to help AIDS patients:

“Caregivers and advocates may find that their work is more difficult and

stressful as a result of stigma, or they may be deterred from working with

those with HIV.”​4

The detrimental effect of these stigmas is apparent. These stigmas not only expose

patients to psychological pressure but also make outbreak response much more

difficult. In response to stigma, Herek believes that public education on HIV

transmission helps eliminate stigma to a certain extent. Other anti-stigma measures

like self-disclosure of serostatus, vicarious contact with AIDS patients, and enact laws

to mitigate stigma are also recommended by Herek.

While Herek calls attention to disease-related stigma, sociologists like Cabal,

Somse and Eba demand equality. In the article, "Lessons from HIV to Guide

COVID-19 Responses in the Central African Republic," Somse and Eba draw lessons

from HIV and provide possible solutions for public health response. In addition to

informing the public with scientific evidence, they believe that epidemic response

should uphold human rights.​5​ The presence of inequality impedes vulnerable peoples’

right to receive proper medical treatment. While in another article, "Confronting the

Legal, Social, and Structural Barriers to the HIV Response," author Cabal discusses

how violations of human right and gender inequality hinder the epidemic response.

For example, the government failed to prioritize access to HIV treatment for

3
​Herek, “Thinking about AIDS and Stigma”, 598.
4
​Herek, “Thinking about AIDS and Stigma”, 597.
5
​Somse, Pierre, and Patrick M. Eba. "Lessons from HIV to Guide COVID-19 Responses in the Central
African Republic." Health and Human Rights 22, no. 1 (2020) p. 372
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children​6​, and law enforcement agencies use the possession of condoms as evidence to

arrest sex workers.​7​ Furthermore, Cabal utilizes statistical data to demonstrate

women's vulnerability to AIDS. According to Cabal, there are approximately 7000

young women acquire HIV each week, and transgender women are 49 times more

likely to be living with HIV compared to ordinary people.​8​ Cabal imputes women's

vulnerability to gender inequality and women's low socioeconomic status. She asserts

that human rights issues should be prioritized along with disease prevention,

treatment, and care service. Similarly, Somse and Eba advocate for rights-based

public health responses, which involve "respect of dignity, the prohibition of torture

and degrading treatment, the right to health, and the right to food."​9​ Most importantly,

according to Somse and Eba, "a rights-based approach to health helps ensure that no

one is left behind and that particular attention is paid to the most vulnerable."​10​ To a

certain extent, the amount of care given to vulnerable groups not only reflects the

inclusiveness of society but also beneficial for epidemic response.

Although sociologists and psychologists seek to address social issues like

stigma and inequality, expertise from other academic fields is nonetheless vital for

guiding epidemic response. The coronavirus outbreak has resulted in unprecedented

unemployment and a pandemic-induced recession. In the article, "Epidemiology's

Time of Need: COVID-19 Calls for Epidemic-Related Economics," author Murray

enumerates several examples of how economists use their expertise to guide epidemic

response. For instance, economists can “envision a vibrant remote economy”​11​, in

6
​Cabal, Luisa, and Patrick Eba. "Learning from the Past: Confronting Legal, Social, and Structural
Barriers to the HIV Response." Health and Human Rights 19, no. 2 (2017) p. 114
7
​Cabal, and Eba, “Learning from the Past”, 114.
8
​Cabal, and Eba, “Learning from the Past”, 114.
9
​Somse, and Eba, "Lessons from HIV to Guide COVID-19”, 372.
10
​Somse, and Eba, "Lessons from HIV to Guide COVID-19”, 372.
11
Murray, Eleanor J. "Epidemiology's Time of Need: COVID-19 Calls for Epidemic-Related
Economics." The Journal of Economic Perspectives 34, no. 4 (2020) p.115
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which people can work from home without losing their jobs in the epidemic.

Moreover, economists can build quick response capacity into the economy and detect

​ Murray also
early warning signals of pandemic spread in economic networks. 12​

encourages collaboration between economists and epidemiologists so that they can

​ Although
evaluate policy impact and deploy research resources more rapidly. 13​

economics seems irrelevant to the epidemic response, Murray has shown us how

economists can participate in the epidemic response and reinvigorate the

post-pandemic economy.

Another key aspect of the epidemic response is the governmental response

because it enacts public health policies and updates real-time information on the

epidemic. As Somse and Eba noted in their article, the epidemic response requires to

"mobilize leadership at the highest level."​14​ Heads of state have the responsibility "to

bring all departments and institutions into the response, to activate crisis mechanisms

and resources, and to convey the urgency of the situation."​15​ On the other hand,

Porumbescu advocates transparency in local government. According to Porumbescu,

"meaningful pandemic planning requires a dynamic exchange of information between

various segments of the population and the local government responsible for their

safety."​16​ Porumbescu analyzes the studies on past influenza pandemic and concludes

that “many municipal governments in the U.S. eschew greater transparency and limit

​ Recent news has shown us that these problems still

opportunities for public input”. 17​

existed in the context of the COVID-19 pandemic. California Governor Gavin

Newson broke the rules of social distancing by attending parties, while CDC dropped

12
​Murray, "Epidemiology's Time of Need”, 116.
13
​Murray, "Epidemiology's Time of Need”, 117.
14
​Somse, and Eba, "Lessons from HIV to Guide COVID-19”, 373.
15
​Somse, and Eba, "Lessons from HIV to Guide COVID-19”, 373.
16
Porumbescu, Gregory A. "Using Transparency to Enhance Responsiveness and Trust in Local
Government: Can It Work?" State & Local Government Review 47, no. 3 (2015) p.208.
17
​Porumbescu, “Using Transparency”, 208.
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the coronavirus testing numbers from their website in March. Governmental

involvement and transparency on information are crucial to epidemic response, and

measures to address these problems are urgently needed.

The modern epidemic response is not merely the duty of epidemiologists.

Instead, the epidemic response requires interdisciplinary studies and multisectoral

collaboration.While psychologists seek to eliminate the disease-related stigma,

sociologists advocate for equality to ensure nobody is left behind. On the other hand,

economists help reinvigorate the post-pandemic economy, and transparency in

government makes information more accessible to the public. The whole society,

from individuals to the government, can engage actively in the epidemic response, as

any action we take makes a huge difference.

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WP2 Part 2: Contribution

Stigma is one of the topics I discuss in my literature review, and most

examples in my literature review about stigma relate to the HIV pandemic. As Herek

mentioned in his article, stigma partly comes from people's fear of disease. From my

observation, COVID stigmas do exist in the current pandemic. However, most people

didn't really worry about the coronavirus at the beginning of this outbreak. Instead,

most people treated COVID-19 as seasonal flu. Therefore, the COVID stigma never

comes from fear of the disease but rather the resentment toward a specific group,

which is another type of stigma that Herek classified as "symbolic stigma."

Ironically, COVID stigma was spread from social media and even some government

officials. For example, President Trump often refers to COVID-19 as the "China

Virus,” and hashtags like “#ChinaVirus” and “#WuhanVirus” were frequently used

on social media like Twitter. As a result, Asian-Americans and Asians have

encountered a spike in xenophobic attacks and discrimination. Stigma is not only

detrimental to the epidemic response but also intensified racial conflict. I believe that

mutual respect is the key to mitigate stigma. Coronavirus is our common enemy, and

discrimination against other people never helps in epidemic response.