Stigmatization of Newly Emerging Infectious Diseases: AIDS and SARS

Both the fear of people who are different and the fear of disease can lead to social stigmatization.1 Occasionally these fears co-occur, resulting in severe stigmatization of strangers with diseases. Such stigmatization can increase the adverse consequences of a disease in multiple ways. First, stigmatization can substantially increase the suffering of persons with the disease. Second, persons with or at risk for the disease may avoid seeking health care, making it much harder for public health authorities to control the disease. Third, professionals and volunteers working in the field may also become stigmatized, leading to higher rates of stress and burnout.2 Finally, stigmatization may generate considerable economic losses if people avoid groups or geographic areas associated with the disease. Many diseases have been stigmatized throughout history. For example, persons with the plague were stigmatized during the Middle Ages, and sexually transmitted diseases have been stigmatized throughout the last several centuries.3,4 Acquired immunodeficiency syndrome (AIDS) has been one of the most feared and stigmatized diseases of the last 20 years. There is abundant evidence that the stigmatization of AIDS has been detrimental to the health of those with AIDS and has played a role in limiting public health and medical efforts to control the disease.5,6 For example, early stigmatization of AIDS as a disease of homosexual men contributed to low levels of funding for AIDS research in the1980s.3,4,7 Over the last several years, severe acute respiratory syndrome (SARS) has emerged as a new feared disease associated with strangers (Asians, particularly Chinese) and has generated considerable stigmatization.8,9 Reduced travel to SARS-affected areas clearly led to large economic losses for those areas,10,11 but there has been relatively little systematic research on fear of SARS or stigmatization of persons with or at risk for the disease.12 In one study of medical access patterns in Taiwan, Chang and colleagues found that “fear of SARS” led to substantial reductions in seeking medical care: a 23.9% reduction for ambulatory care, a 35.2% reduction for inpatient care, and a 16.7% reduction for dental care.13 Presumably, people avoided seeking medical care out of fear of becoming infected with SARS in these medical settings. Studying the stigmatization of SARS may provide us with insight into the stigma associated with emerging infectious diseases and the potential consequences of such stigmatization. A potentially useful model for considering stigmatization of SARS and other newly emerging infectious diseases may be found in the work of Pryor et al.14 They suggest a 2-factor theory of HIV- related stigma: (1) an immediate affective reaction, based on multiple negative qualities associated with the disease (e.g., death, promiscuity, drug use, homosexuality), possibly followed by (2) a cognitive rule-based system that ameliorates stigmatization “if perceivers have enough time, motivation, and cognitive resources.”14(p1189) Within this formulation, availability of additional information about the disease should lead to a reduction in stigmatization. This prediction is consistent with the activities of many public health authorities who hope to reduce stigmatization through increased public education on diseases such as AIDS. We compared stigmatizing attitudes toward AIDS and SARS in a representative sample of persons living in the New York City (NYC) metropolitan area and examined factors associated with these attitudes.