ࡱ> & (              ! " # $ % N P c a  `  bjbjss   TTTTTTT8!!!!d%8 -H%RRRS1VG^a$hb)TqU@1Vqq)TTRSmβE E E qOTRTSE qE E <OTTϑRx- #u!Clן,0^'^ϑϑ` ^T/cb+^FE  L8D,ccc));  cccqqqq888d$888888TTTTTT Stigma and epidemics References 010506 ======= Stigma in the lives of adolescents with epilepsy: a review of the literature Jessica S. MacLeod and Joan K. Austin (2003), Epilepsy and Behaviour, 4, 2:112-117 Abstract The World Health Organization, the Centers for Disease Control and Prevention, and the Epilepsy Foundation have recently focused attention on problems experienced by people with epilepsy as a result of stigma. Stigma is associated with poor psychosocial health outcomes in people with epilepsy, and its effects may be strongly felt by adolescents who are already dealing with the challenges of developing self-identity and self-esteem. This review synthesizes the empirical literature on stigma in the lives of adolescents with epilepsy. Beginning research indicates that stigma is related to quality of life in adolescents with epilepsy, although existing measures may not yet fully capture how this stigma is experienced. For example, instead of reporting stigma actually experienced, adolescents report limiting disclosure of their illness, perhaps because they anticipate being stigmatized in a peer social environment that fosters misconceptions about people with epilepsy. Recommendations for future research are discussed. Das V. Stigma, contagion, defect: issues in the anthropology of public health. Stigma and Global Health: Developing a Research Agenda; 2001 September 57; Bethesda, Maryland. Available from: http://www.stigmaconference.nih.gov/ Stigma, Contagion, Defect: Issues in the Anthropology of Public Health Veena Das, Ph.D. John Hopkins University The concept of stigma gained currency in social science research first through the work of Erving Goffman HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn1" \o "" . Much of this research has been framed by his interests in questions of micro-social processes within which the self is created and maintained. Goffman applied the term (negative) stigma to any condition, attribute, trait, or behavior that symbolically marked off the bearer as culturally unacceptable or inferior, with consequent feelings of shame, guilt and disgrace. He distinguished between three types of stigma associated with abomination of the body, blemish of individual character, and with membership of a despised social group. The common element among these three types was the notion of a spoilt identity and its management through stances such as concealment, defiance or irony. In considering this concept and its relevance for issues in public health, I shall ask whether we need to place this concept within a family of concepts e.g. that of contagion, defect, and disability, in order to give it a greater cross-cultural relevance. Stigma manifests itself most clearly in what is at stake in face-to-face relations yet the programs and policies of larger social actors such as the state and global institutions are implicated in both, the production and amelioration of this condition. Let me start with the way that notions of stigma come to be linked with other related concepts such as that of contagion and defect within what Arthur Kleinman calls local moral worlds, and in the policies and programs of larger social actors HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn2" \o "" . Stigmatized subjects and the connections between body-selves Although Goffman was sensitive to the differences between the three types of stigma that he identified, the unifying concept of a spoilt identity and its management, loaded his analysis towards a highly individualistic rendering of the subject the individual appears in his analysis as the sole bearer of value. Since agency is conceived in the form of resistance to collective representations, the concept of culture comes to rest on the notion of shared values and representations with rather less attention to the nuances through which culture is in fact embodied or actualized in individual lives. This leads to a neglect of forms of collective action on the one hand, and of contests over values within the rubric of everyday life, on the other. Elsewhere I have argued that whereas the language of normality assumes a sharp hiatus between norm and its transgression, we can find a hyphenated relation between these in the blurred contours of everyday life HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn3" \o "" . I suggested further that the notion of domestic citizenship may be useful to capture this nuanced relation of norm and transgression and to see how families may mediate between the collective level of social response to conditions of stigmatized disability and the individual life trajectories HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn4" \o "" . Recent ethnography offers interesting examples of how the immediate community within which the domestic is embedded (be it kinship or neighborhood) becomes the world within which family often has to confront the opprobrium of stigma, making it difficult to postulate a seamless continuity between family and kinship or community in the case of stigmatizing illness. This, in turn, yields startling revelations about stigma associated with disease, disability and impairment as located not in (or only in) individual bodies but rather as off the body of the individual within a network of family and kin relationships. It is useful in this context to consider the different types of stigma in relation to the configuration of domesticity - rather than individual agency as the focus of attention we could see how the individual comes to be embedded within the domestic or excluded from it and its implications for policies on public health. Stigma, Aesthetics, and the Importance of Face An examination of the genealogy of the ideas of defect shows how defective and stigmatized subjects were historically produced on the intersections of various kinds of norms especially those of femininity and normalcy. For instance, Campbell HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn5" \o ""  has argued that that contingent discursive inscriptions of defect could imperil the life projects of female subjects even in the absence of any functional disability or impairment of the senses simply because of the way that diseases were seen to mark the individual female subject. She gives the example of eighteenth century European women whose small pox scarred faces were rendered as damaged and who were then assimilated to other stigmatized and damaged subjects HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn6" \o "" . A recent study by Weiss of new born infants in Israel who were abandoned by parents because they were appearance-impaired though they did not suffer from any functional disabilities, points to the conditional character of parental acceptance of stigmatized subjects HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn7" \o "" . Her analysis shows that parents felt that their social lives would be thrown into peril for which they blamed their impaired infants even when persuaded by social workers to bring such infants home for short periods of time, they ended up hiding them in dark corners of the house because they wanted to protect their other children from contact with an impaired sibling. What is remarkable in Weisss account is not that parents expressed despair or even hostility, but that all other emotions such as hope, sorrow, or regret were censored out of their narratives. Thus the tyranny of norms of appearance that stigmatized facial defects seems to have thrown these infants out of domestic citizenship into the domain of the state as the only sphere in which their rights, including rights to life, could be defended. In an earlier study Arthur Kleinman discussed the narratives of six patients suffering from various kinds of stigmatized diseases or disfigurement, five of these patients were treated in his psychiatric clinic in Cambridge HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn8" \o "" . The stories of these patients range from the severe constraints on life experienced by a man with a facial disfigurement despite support from his family, to life lived in complete isolation by a man who suffered brain injury that led to a critical diminishing of his cognitive capabilities followed by a divorce and separation from his family. Kleinmans main concern was to show the intersubjective nature of experience in chronic illness - it is remarkable that even in the clinical setting of individualized therapy, he is able to show the ghosts of family dramas in the individual narratives of his patients. But because of the context in which therapy was offered we do not get a sense of the politics of family and community within which such dramas took place. What, for instance, would account for the complete severing of the relationships in the latter case? The power of his description shows that for the patient, the suffering of the disease was indistinguishable from the suffering of social isolation and stigma. If we had access to the other members of the family we may have also learnt how they lived with the memory of this ruptured relationship. The stories of such betrayals of persons with stigmatized conditions need to read along with other stories in which parents and caregivers negotiate norms, form associational communities to learn and provide support and act in the public domain to influence state policy and science HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn9" \o ""  In these cases the family appears to form a protective envelope around the child and caregivers repeatedly contest the collective representations that would assimilate such children to stigmatized subjects. It is especially interesting to see the new developments around what Paul Rabinow calls bio-sociality, i.e. the forming of associational communities around biological conditions to influence state policy and science HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn10" \o "" . Yet the capacity of a group to use social capital for dealing with adverse biological conditions is strongly dependent on other social conditions such as education a public good, but not equally available to those who occupy a lower position in the socio-economic hierarchy. So what are the other ways in which family and community might become supportive rather than hostile to its vulnerable members? In some of my own work on this subject, I have argued that while the attention to associational communities calls upon the individual as the subject of a liberal political regime, there is another sphere of sociality relating to the politics of domesticity, which operates outside this domain HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn11" \o "" . In the domains of family and kinship stigmatized conditions are seen as a matter of connected body-selves hence they give rise to a different kind of politics from the politics of associational communities. Rather than a confrontation between state and community, here we find the family pitted against the kinship group which tries to put pressure on it so as to contain the stigma to the individual body rather than allowing it to spread to the whole kinship group. Various strategies are then put into place through rumor and gossip for separating the stigmatized individual, confining him or her to a limited sociality, or giving only limited recognition when included in the collective life of the group. While in such cases families may not have the biocapital to engage with state and science in the way described by Ginsburg, Rapp and Rabinow, they do need to use other resources of the state to confront and defeat the social pressures generated by local communities. I have elsewhere given the example of a Hindu Punjabi family who risked their social capital in order to find a sexual and reproductive future for their daughter stigmatized by a facial disfigurement by aligning themselves to the state and claiming the rights promised in such legislative actions as the Civil Marriage Act  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn12" \o "" . I am therefore wary of assuming a sharp separation between face to face communities as repositories of the moral and the state as a source of rational policy, for it seems to me that it is not in individual institutions (e.g. family and community or the state and bureaucracy) but in their alignment that resources to address problems of social exclusion resulting from stigmatized conditions may be found. As we saw earlier, we cannot treat the domain of family as that of unconditional parental acceptance but nor can we treat the state as uncontaminated by social norms regarding stigma. Rather it is in the way that new patterns of sociality around biological conditions emerge through an alignment of domesticity with the state that we can find salutary examples of the way in which the social exclusion resulting from stigmatized conditions has been contested. Body, danger and shame While illness narratives of persons with disability generally deal with the feelings of damage and low self-esteem as a result of the loss of the autonomy of the body, there is a far greater weight placed on the feelings of guilt and shame in the case of stigmatized conditions. Consequently a big question that looms in the narratives of stigmatized illnesses is the question of innocence. Writing on his experience of disability, Robert Murphy wrote, Disability is not simply a physical affair for us; it is our ontology a condition of our being HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn13" \o "" . Borrowing the metaphor of the primal scene from Freud, he argued that any confrontation of people in which there is some great flaw leads to feelings of guilt and shame. This, for him, was related not only to the social opprobrium of the others, but also to the subjective feelings that the body impairment is a punishment for repressed, elusive and forbidden desires. Thus stigma became for him, not a byproduct of disability, but its very substance. On the level of social relationships the disabled person presents a counterpoint to normality Murphys bitter lament was that the very humanity of the disabled person is made questionable. It seems to me that Murphys acute analysis captures the important point that the changed body image in stigmatized conditions seems to trigger broader fears of violation of sexual norms and hence dangers to a moral universe. Some support for this can be found in Hanne Bruins analysis of the discursive formations around the condition of leprosy in Tamilnadu in India where she found that the major part of the stigma of leprosy arises because of a fear that the stricken person has violated sexual norms such as that of incest or the sexual and reproductive norms of caste hierarchy HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn14" \o "" . It is important to note though that stigma seems to be associated not with the disease as such but with the bodily deformities that come after the patch stage if the disease remains untreated. The person afflicted with leprosy, however, has to start reading the disease right from the onset of first symptoms -noticing changes in the body and devising strategies of concealment. Patients have described their fears that if their disease were to become known they would be cast out of the moral community because of the presumption that the deformity of the body was a punishment for infringement of sexual taboos. The entire discourse of anxiety that surrounds the stigma of deformed bodies thus is about reduction of sociality, exclusion from moral community as well as subjective feelings of guilt and shame. Being cast out of the social community coupled with a diminished sense of worth reduces the capability of the afflicted person to seek help even when this is in objective terms, easily available. It is in this context that we can see the great anxiety reported in the case of stigmatized diseases with questions of innocence. In a study of leprosy patients in Delhi and in Kanpur Dehat in Uttar Pradesh, Surabhi Tandon reports that patients worry enormously about what kind of moral taboo they could have violated HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn15" \o "" . She found that the predominant claim on the part of patients was that their illness was not a result of any moral fault and that if the illness was indeed a punishment, then it could only have been because they had inadvertently broken a social norm. However, Tandon also shows that intricate patterns of domestic and village politics entered the decisions of patients on whether they could continue to live within the same moral community or whether it was necessary for them to move out and to form new communities. However, it was the visible changes of the body and the stereotypes about patients having no fingers and toes, open wounds, fallen nose bridges, etc. that were read as evidence of the moral transgressions rather than the disease itself. With greater awareness about the role of multidrug therapy in curing leprosy and reconstructive surgery, even in areas with endemic leprosy such as Kanpur Dehat, the aspect of stigma became much less pronounced in the discussions with patients and their caregivers HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn16" \o "" . This should warn us against tendencies to reify culture, to assume that there are a set of unchanging values that inform local worlds - for medical technology can make a decisive difference in how a disease is culturally perceived. In the case of Kanpur Dehat a large number of patients were recruited for a clinical trial of an immuno-therapeutic and prophylactic vaccine and interestingly this helped to bring the disease into the open. Villagers reported that the easy mannerism of the doctors and social workers in the field when they touched or interacted with known leprosy patients did more to allay fears about the disease than any verbal messages. This is an interesting case demonstrating that it is the style of care as much as its content that makes people read the disease in a different way. The fear of contagion The notion of stigma and contagion are theoretically distinct concepts the first refers to the experience of being marked on the body by a condition that sets one apart and the second to the potential for a condition to be transmitted from one person to another but in the everyday life of communities these two concepts tend to slide in each other. Even in the case of a disability such as quadriplegia resulting from a neurological disorder, Murphy noted that social encounters were fraught with danger because people acted like it is catching. Murphy experienced it as a contamination of identity. As I have stated earlier, though, the stigma of disability, impairment and body disfigurement is not treated as an individual affair in societies that place less importance on the individual as a locus of value instead it is treated as a matter of connected body-selves. This does not mean that we can neatly divide societies into individual-centered societies and socio-centric societies as some have suggested. Rather it is a matter of seeing how stigmatized diseases lead to the drawing of boundaries within the domestic and its immediate environment of kinship and village or neighborhood community. The case of tuberculosis presents an important example of the way that notions of stigma and contagion slide into each other in the villages and urban neighborhoods in low-income countries. This, I argue, has implications for the way that the biological course of the illness comes to be related to its social course. Susan Sontags analysis of illness as metaphor shows us the romantic notions regarding the character of TB patients in nineteenth century Europe and the ambivalence with which such patients were viewed HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn17" \o "" . While elite discourses on tuberculosis in the South Asian subcontinent might have been influenced by such notions of the relation between tuberculosis, melancholia and artistic creativity (especially in literature and film), in the everyday life of communities the stigma of tuberculosis exposes the patient to dire risks from the way that the biomedical system(s) and the institutions of the state treat those who have suffered from the disease. In a critical analysis of the biomedical discourse on tuberculosis, Paul Farmer has shown that there is predominant tendency to attribute failure of compliance to the beliefs of the patients and the stigma attaching to the disease. HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn18" \o ""  Farmer presents a survey of the literature to show that the agency of the patient is highly exaggerated in this discourse patients often fail to comply because there are inadequate supplies of medicines in treatment centers, or because of severe constraints on their time and money. Yet the biomedical discourse creates a geography of blame in which their failure to comply is attributed to their beliefs about tuberculosis. Do the institutions of the state and science themselves contribute to this stigmatization of the disease? In an ongoing study of health practices of families in low-income neighborhoods in Delhi, we found that while tuberculosis undoubtedly created new boundaries within kinship and community, there were other major deprivations patients faced from the institutions of the state HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn19" \o "" . This was because of the way that notions of stigma and contagion were collapsed into each other in local administrative and social practices. Thus, for instance, some children who had to drop out of government schools because of tuberculosis in one year were refused admission in the next year even after they were cured, on the grounds that they could spread the disease. At least in part because of the way that people who had suffered from tuberculosis were treated in the community and in the DOT centers, they themselves experienced recurrent fears that the disease would never be fully cured and tended to attribute any subsequent symptoms of weakness, sadness, fevers, unspecified pains to the fact that they once had tuberculosis HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn20" \o "" . In an overall environment of poor regulation of pharmacies, some of our respondents reported taking TB medication whenever they had cough or fever as a prophylactic because they were scared that the disease may recur and that they may be blamed for this. The collapsing of the categories of stigma and contagion points to the fact that the social course of the disease may extend beyond its biological course so that each notion reinforces the other. Stigma is seen as contagious and conversely a disease that is contagious may be seen as marking a person with stigma. It also raises the question of how science and state might contribute to the perception of a disease as stigmatizing and how that is related to existing fault lines of race, ethnicity and gender discrimination. Stigma, silence, and the geography of blame A major concern in relation to stigmatized disease is that the social marks of inferiority or blemish may lead patients and their caretakers to conceal their disease. This has serious consequences for both the health of the individual and the containment of infectious diseases for the population. It was mentioned earlier that bearers of stigmatized diseases are seen as a great danger to the community because of the assumptions that they have somehow violated the moral taboos, especially those on sexuality. This leads to feelings of guilt and shame. Obviously then diseases that directly relate to sexually tabooed behavior bring questions of guilt and shame much more to the surface. However it is not only individuals who are targeted as the bearers of stigma and blame in the case of sexually transmitted diseases but there is also a political geography of blame that comes to arrange the world in terms of guilt and innocence. The case of sexually transmitted diseases such as syphilis and AIDS provides telling examples of the way in which stigma of various kinds comes to be configured together in informing the public discourse on stigmatized diseases. The first decade of the twentieth century was a period of intense concern with sexually transmitted diseases and the appearance of the social hygiene movement in North America. It is interesting to observe that not only in popular discourse but also in the biomedical system, a distinction was made between venereal insontium, i.e., the venereal disease of the innocent versus the venereal disease of those who were held guilty because of sexual misconduct. Allen Brandt argues that this distinction had the effect of dividing victims into those who were deserving of medical support and sympathy and others who were not, because they were guilty of sexually promiscuous behavior HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn21" \o "" . It is not surprising to see that the latter category slides into stereotypes fuelling a fear of new immigrants, urban populations and blacks. Brandt shows that the assumption of guilt led to the most pernicious violation of the civil rights of groups identified as guilty sources of this disease. It is uncanny to see that the end of the century saw very similar processes in relation to the discursive formations that developed around AIDS. In the initial years of the North American epidemic AIDS was widely termed as the gay plague the discourse on the disease was hooked into the cultural concerns with sexual morality and especially with homophobia. Because of the rich cultural response by the gay community, at least in important urban centers in North America, the taboo on silence was broken. Yet the very power of this cultural critique of homophobia may have served to draw attention away from other forms of discrimination that the anxiety on AIDS brought to the fore. Susan Sontag claimed in 1988 that in North America AIDS evoked less pointed racist reactions than in Europe or Soviet Union where the African origin of the disease was much more stressed HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn22" \o "" . In his influential work on Aids and accusation Paul Farmer pointed out that as early as 1981, members of the Haitian community denounced the racism inherent in the stigmatization of Haitians qua Haitians as AIDS-carriers HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn23" \o "" . Through a careful analysis of the popular media and scientific representations in this period, Farmer shows how the discourse on AIDS was tied to questions of immigration with a strong denial of the evidence that many of the Haitians who were reported to have brought in HIV infection into the country were likely to have contracted it after their arrival here. Just as in the case of syphilis earlier, there was stigmatization of high risk, marginal groups so that in many public pronouncements there were powerful assumptions about culpability and guilt of these populations. Questions of guilt and innocence seem to haunt other instances in which the question of HIV infection has been addressed. In a little appreciated corner of the epidemic there has been a controversy regarding those patients with hemophilia who were infected with contaminated blood. As early as 1983, an article in New York Times Magazine referred to the disease as if it were more poignant when it attacked nonhomosexuals then when it attacked homosexuals. In recent hearings on patients infected by contaminated blood products, the collective narrative tried to carve out a space of innocence from which patients could separate their own affliction from those whose AIDS was blamed in the popular culture on personal behavior such as unsafe sex, or IV drug use HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn24" \o "" . The very process of fighting stigma in such cases reaffirms the way in which personal affliction is made to fold into the stigma of belonging to marginal groups. There are other contexts in which ideas of innocence and their counterpoint notions of blame- have been used to open up other kinds of suspect moral spaces. Thus for instance, just as there is a discourse of the geographical origin of AIDS in North America and Europe that is hooked into discursive formations on race and racism, so there is a discourse in non-Western countries that reverses this geography of blame. For instance in the popular representations of AIDS in India and several other non-Western countries, the epidemic was attributed to the moral degeneration and the lax sexual morality of the West. This allowed even Government representatives and scientists to claim in the early nineties that AIDS would never be a problem in India because Indians were protected by a rigid and puritan sexual morality. Even when the problem was grudgingly acknowledged in the late nineties, popular conceptions of AIDS continued to link it with either marginal groups such as sex workers or with westernized women from the feminist movement despite mounting evidence of the high rate of infections among monogamously married women whose plight till recently was completely ignored. Scholars concerned with public health discourse and critical epidemiology have repeatedly pointed out that notions such as patients beliefs have often led policy makers and biomedical practitioners to blame the patient for failure to comply with medical regimes. I hope this analysis shows the intricate connections between the public and the private domains in addressing problems of stigma. While the importance of stigma and the consequent social exclusions in local moral worlds is very important to document, it is equally important to realize that threats of new diseases create anxieties that can be expressed through a political geography of blame not only in the popular discourse but also in the scientific discourse. The role of the state Fears of contagion and stigma have often led to denial of basic rights. We can document this by the well-known cases of sexually transmitted diseases. An important example of how prejudices produced by stigma can function in state sponsored terror is provided by the example of leprosy patients who were sought to be compulsorily segregated despite scientific recommendations to the contrary during the colonial period in India. This case is useful to demonstrate the relation between contagion and state formation though it also points out that colonial states did not exercise draconian powers simply as a matter of course. Take the debate on incarceration of leprosy patients in India in 1890 when a Commission was appointed to investigate the disease of leprosy in India. The members of the Commission included eminent medial scientists nominated by the Royal Society for Surgeons and the Royal Society for Physicians. The Commission, after completing its investigations concluded that leprosy was a disease sui generis and that it was not a form of syphilis or tuberculosis despite ateological analogies with the latter. It said that the extent to which leprosy was contagious was exceedingly small and hence no imperial law need be passed to implement compulsory segregation. It stated No legislation is called for on the lines of either segregation or interdiction of marriage with lepers. The Commission did recommend that lepers should be prohibited from practice of professions that involved handling of food or drink or from providing services as barbers or washer men but they thought that segregation should be on a voluntary basis. Accordingly they recommended that municipal bye laws would be enough to handle the necessary state provisions that were needed in this case undue force in the form of compulsory segregation, they thought, would be unjust and would cause untold misery. The Executive Committee of the National Leprosy Fund rejected the recommendations of the Commission in 1892. The Executive Committee found that the scientific evidence regarding most cases of leprosy having occurred de novo was not conclusive. Hence it emphasized the importance of maintaining colonies for compulsory segregation of lepers and also required that if leprous patient be retained at their homes at the express wishes of their friends then separate lodgments would have to be provided. It further stated, For carrying out the above, in addition to funds, legislative authority is needed to take up the vagrant sick, to remove the sorely diseased who is insufficiently guarded at home, and at times to enforce continued isolation of the infected until medical sanction of liberty be granted. This case shows that it was not scientific evidence available in that period but notions of stigma that informed colonial policy, though these concerns were hidden under the overall concern with public health and public order. The state turned out to be a major actor in the production of stigmatized subjects- far from a rational state correcting the credulous public - its own policies were likely to have contributed to the legitimization of the stigma surrounding leprosy and to criminalize the patients through draconian laws. The role of the state in establishing a connection between stigmatized disease and criminality is further attested in the case of mental illness. The emergence of new technologies of power in eighteenth century Europe through which the state tried to control its unruly population has been the great theme of Michelle Foucaults rendering of disciplinary power. Foucaults inattention to the colonies leaves considerable scope to add greater complexity to the issue of disciplinary power. Earliest asylums for the insane were established in India between in 1787 and then 1795 to incarcerate European soldiers showing signs of insanity. In the period between 1856 and the end of the nineteenth century, asylums were established for Indians. As in the colonies of Africa, where these came to be established in the beginning of the twentieth century, asylums functioned as adjuncts to the penal systems. In a recent analysis based upon archival records James Mills HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn25" \o ""  has shown that though the number of those incarcerated in the asylums in India was not large in itself, the discursive formations around madness were part and parcel of the wider politics of the colonization of bodies in which the capacity to perform approved labor was established as an important sign of normality. Thus insanity and criminality had a great deal to do with refusal to perform forms of labor that were approved by the state. While it is clear that labor did not structure asylum regimes in India in the same way as the prison, yet irregular, peripatetic, and unproductive occupations were likely to come under one or the other form of disciplining by the state. Thus prisoners who refused to perform productive labor were frequently transferred to asylums where their perceived aversion to labor was counted in support of the diagnosis of insanity. Mills observes that readiness to resume labor was seen as evidence of recovery and that the discourse of madness easily slides into the perceived faults of the Indians as a group and the asylum regime, like colonialism itself, as a project for reforming the Indians. In this context it is important to consider not only the institutions but also the systems of knowledge through which such slippage between individual affliction and group stigma was sustained. Jock McCulloch has analyzed the colonial archives on asylums in Africa and the literature on ethno psychiatry to show how discussion on causes of insanity among African patients inevitably led to the stigmatization of the whole culture HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn26" \o "" . He quotes extensively from respectable journals in this period to show how in evaluating African patients there was a strong tendency to stigmatize African culture that was held responsible for creating a climate of fear because of widespread belief in witchcraft. Africans were further accused of having lack of individuality, of rigid adherence to rules and absence of responsibility, which led them to be sexually promiscuous and socially unreliable. Ethno psychiatry played a role in stigmatizing independence movements in Africa. Thus the scientific discourse on stigmatizing illnesses followed the fault lines of race and ethnicity. It is quite likely that the state thus played an important role in legitimizing social exclusion of the insane though as McCulloch himself notes, hospitals and asylums were likely to be used only for those who already fell into the category of social refuse. Unfortunately it would be far too easy to assume that postcolonial societies have been able to overcome this pernicious equation between stigma, crime and guilt. It was as late as 1987 that the Indian Lunacy Act, which had little concern with the welfare of the mentally ill, was changed to the Mental Health Act in India after considerable pressure from the mental health community. The National Commission of Human rights in India, since 1996, has been pressing the various state governments to take steps for the amelioration of the condition of mentally ill patients who are languishing in prisons. The conditions in private institutions for the confinement of the mentally ill in small towns continues to be dismal though there is some reported improvement in the government run institutions after strictures from the Supreme Court in early nineties. As recently as last month (i.e. August 2001), 25 mentally ill patients were burnt to death in a fire in an asylum in a small town in Tamilnadu where enquiries confirmed that there were fifteen private asylums in the city and that it was normal practice in these to keep the inmates tied. Even in a country as affluent as the United States, the Justice Department has stated that one-fifth of the estimated 191,000 inmates of prisons who were identified as mentally ill were not receiving any treatment. State and Science As we saw in the case of AIDS activism, the homophobia in popular discourse as well as in the institutional practices of state and science was challenged in the responses by AIDS activists. Their challenge also brought out the way in which notions of stigma inform policy and programs of the state. It is salutary to realize that the community discourse on stigma is not isolated from the discourses of the state. In the previously colonized countries such as India, the discourse on stigma bore the marks of colonial legislation. Thus the Vagrant Lepers Act, the Lunacy Act, the Contagious Diseases Act, the Cantonment Act, were all designed to protect public spaces from the presence of stigmatized bodies. The Vagrant Lepers Act still forbids begging by lepers the language used is not neutral and points to the way in which patients suffering from Hansens disease were often abandoned and had to fend for themselves by begging and were criminalized for this. In general, the legislation has lagged behind scientific breakthroughs. For instance though the prevalence rate of leprosy in India declined from 50.2 per 10000 in 1994 to 6.2 per ten thousand in 1996, yet changes in legislation on various debilitating conditions for such patients has been very slow. This is true for many other countries. In the case of Japan, the Kumamoto District Court recently ordered the government to pay 1.82 billion yen in compensation to 127 Hansen's disease patients for violating their personal rights by segregating them under the 1953 Leprosy Prevention Law. The court said the former Health and Welfare Ministry was negligent for failing to alter its isolation policy. This could have been done by 1960, when it had been confirmed that the disease was curable The legislature was also held responsible for failing to amend relevant laws, including scrapping the Leprosy Prevention Law. The government policy of isolating Hansen's disease patients in sanatoriums ended in 1996 when the Leprosy Prevention Law, which the Kumamoto court deemed unconstitutional, was abolished. (As reported in Mainichi Shimbun, 2001) HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftn27" \o "" . The above instances are important for devising strategies to deal with the stigma While such stigmatized groups as patients with Hansens disease, prostitutes and other high risk marginal groups, ethnic minorities, new immigrants may not have the biocapital to fashion a cultural response to stigma in the manner of gay activists, the removal of pernicious laws and administrative practices would be an important step in low income countries to deal with such issues. Concluding summary In conclusion I would like to draw attention to the following salient points with regard to notions of stigma, and its relevance for public health interventions. While much of the literature in the West emphasizes the stigma as production of spoilt identity and its management, in other parts of the world stigma along with its related concepts of contagion and defect are seen as problems of connected body-selves. The moral anxiety around stigma arises from its connection with taboo  deformed body selves are especially seen as marks of violation of sexual and reproductive taboos. Discourses on stigma are deeply implicated in the fault lines of racism, sexism and other forms of discrimination, but it is important to treat culture not as a set of shared, unchanging beliefs but as framed by contests and adjustments. The notion of domestic citizenship provides an entry into thinking of the ways in which culture is mediated and recrafted by contested engagements in the sphere of domesticity. A major way of contesting stigma in recent years has been through formation of associational communities  not all forms of stigma though may be addressed in this manner since this depends crucially upon social capital and  bio-capital . In many previously colonized countries state legislations have lagged behind scientific knowledge in changing forms of legislation that was enacted in colonial contexts and was designed to protect colonial interests rather than the interests of the patients. Since the institutions of the state are equally implicated in production of stigmatized subjects, judicial activism towards reform of pernicious laws especially with regard to sexually transmitted diseases and mental illness would be an important resource for marginalized groups to deal with stigmatized conditions.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref1" \o "" Erving Goffman, Stigma: Notes on the management of spoilt identity. Englewood cliffs, N.J.: Prentice Hall, 1963.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref2" \o "" Kleinmans notion of `local moral worlds is complex but it essentially signals the importance of how we come to invest in relations. Thus traditions and customs are neither a matter of following pure habits, nor indeed of constant self-interrogation about how we make meaning of culture. Rather it is Kleinmans thought that the making of moral beings depends upon the way we place ourselves within local worlds and relationships. Local then does not have an exclusively spatial reference it relates rather to quality of relationships. Kleinman also speaks of the tension between the moral, shaped in local worlds and the ethical as allegiance to abstract principles. As I understand him, ethical principles become grounded only when they become entangled in the discourse of local worlds. See Arthur Kleinman, Moral experience and ethical reflection: Can ethnography reconcile them? A quandary for the The New Bioethics Daedalus, 1999, 128 (4): 69-99. I see this complex engagement with the moral in Kleinmans work as related to Wittgensteins basic insight about rules as always entangled in customs and habits. See Veena Das, Wittgenstein and anthropology, Ann. Rev. Anthrop., 1998, 27:17 95.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref3" \o "" See Veena Das, The act of witnessing: Violence, poisonous knowledge and subjectivity. In Violence and subjectivity, ed. Veena Das, Arthur Kleinman et al, Berkeley: University of California Press, 2000: 205-226.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref4" \o "" See Veena Das and Renu Addlakha, Disability and domestic citizenship: Voice, gender, and the making of the subject. Public Culture, 2001, 13 (3): 511-531  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref5" \o "" Jill Campbell, Lady Mary Wortley Montageu and the "glass reversd of female old age. In Defects: Engendering the modern body, edited by Helen Deutch and Felicity Nussbaum. Ann Arbor: University of Michigan Press.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref6" \o "" We need to be wary of cross-cultural generalizations here. Historical scholarship suggests that in India, at least after the seventeenth century, small pox came to be seen as a visitation from the goddess Sitala and the victim defined as sacred and taboo rather than a bearer of negative stigma. Though the suffering of the disease was not minimized in the culture as evidenced by the various rituals to propitiate the goddess so that she did not possess anyone, the typical association of stigma with guilt and shame was not part of the experience of the disease. See Ralph W. Nicholas, the goddess Sitala and the epidemic smallpox in Bengal. Journal of Asian studies, 1981, (1): 21-44.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref7" \o "" Meira Weiss, Ethical reflections: taking a walk on the wild side. In Small wars: the cultural politics of childhood, Ed, by Nancy Scheper Hughes and Carolyn Sargent. Berkeley: University of California Press, 1998.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref8" \o "" Arthur Kleinman, The illness narratives: Suffering, healing and the human condition. New York: Basic Books, 1988.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref9" \o "" See especially, Rayna Rapp, Testing women, testing the fetus: the social impact of amniocentesis in America. New York: Routledge, 1999. Rayna Rapp and Faye Ginsburg, Enabling disability: Rewriting kinship, reimagining citizenship. Public Culture, 2001. 13 (3).  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref10" \o "" Paul Rabinow, Making PCR: A story of biotechnology. Chicago, University of Chicago Press, 1996.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref11" \o "" See Veena Das, Violence and the work of time. In Signifying identities, ed. Anthony Cohen, London: Routledge, 2000 and Veena Das, The act of witnessing: Violence, poisonous knowledge and subjectivity. In Violence and subjectivity, ed. Veena Das, Arthur Kleinman et al, Berkeley: University of California Press, 2000.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref12" \o "" See Veena Das and Renu Addlakha, Disability and domestic citizenship: Voice, gender, and the making of the subject. Public Culture, 2001, 13 (3): 511-531.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref13" \o "" Robert Murphy, The body silent. New York: Henry Holt, 1987.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref14" \o "" Hanne M de Bruin, Leprosy in South India: Stigma and strategies of coping, Pondy papers in social sciences. Pondicherry: French Institute, 1996.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref15" \o "" Surabhi Tandon, Social and individual aspects of chronic illness: A case study of leprosy, Unpublished Ph.D. dissertation of the University of Delhi, 1999.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref16" \o "" See Surabhi Tandon and Mukul Kumar, Ethnography of a vaccine trial: the trajectories of documents and objects. Economic and Political Weekly (special issue on Social science and immunization), February 2000.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref17" \o "" Susan Sontag, Illness as metaphor, New York: Vintage, 1978.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref18" \o "" Paul Farmer, Infections and inequalities, Berkeley: University of California, 1999.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref19" \o ""  This is longitudinal study of health seeking behavior among 300 households in seven neighborhoods in Delhi directed by R.K. Das and myself.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref20" \o "" I owe this point to Laura Pincus who has interviewed a number of young women in a low-income locality in Delhi who were cured by biomedical standards but continued to feel that their illness would never be cured. TB patients in our sample in Delhi express same or similar fears.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref21" \o "" Allen M Brandt, From social history to social policy. In Aids: The Burdens of History, ed. Elizabeth Fee and Daniel M Fox. Berkeley: University of California Press, 1988: 147-172.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref22" \o "" Susan Sontag, AIDS and its metaphors. New York: Farrar, Strauss, and Giroux, 1988.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref23" \o "" Paul Farmer, AIDS and accusation: Haiti and the geography of blame. Berkeley: University of California Press, 1992.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref24" \o "" For an incisive analysis of this case, see Arthur Kleinman, The violences of everyday life: the multiple forms and dynamics of social violence. In Violence and Subjectivity, op.cit.226-242  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref25" \o "" James H. Mills, Madness, Cannabis and Colonialism London: St. Martin's Press, 2000. Also see James H Mills, Reforming the Indian: Treatment regimes in the lunatic asylum in British India, 1857-1880. Indian Economic and Social History Review, 1999 (36).  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref26" \o "" Jock McCulloch, Colonial psychiatry and the African mind. London: Cambridge University Press, 1995.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" \l "_ftnref27" \o "" One can multiply examples of the ham handed approach to legislation in the case of new stigmatizing diseases such as AIDS. In India both legislation and adjudicatory practices of lower courts have passed through phases in which AIDS patients were sought to be imprisoned, foreign students had to submit to compulsory testing and courts have been hesitant to endorse the rights of patients with HIV infection to be treated. The situation has changed slowly mainly due to the work of various organizations such as the Lawyers Collective and the Naz Foundation. The first AIDS case in India that entered the courts was the case of Dominic DSouza who was incarcerated in a TB sanatorium under the (now repealed) Goa Public Health Amendment Act, 1986. Lawyers Collective successfully represented a person known as MX in the literature who was a public sector employee and who lost his job when he was found to be HIV positive in the course of a routine health examination. He was reinstated by the Bombay High Court. In general AIDS activists have concentrated their fight for repeal of Section 377 that penalizes intercourse between consenting men as against the order of nature. Such laws are often used by police to harass and intimidate homosexuals and those testing positive. I am grateful to Lester Coutinho for a discussion on this point. Updated August 2002  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/darkblue.gif" \* MERGEFORMATINET Message from the Conference organizers The Conference was held September 5-7, 2001. The complete Conference video is available for viewing (see below). Please check this website for continuing updates about stigma and global health research. Thank you for your interest.  HYPERLINK "http://www.nih.gov/news/NIH-Record/02_19_2002/story02.htm"  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/new.gif" \* MERGEFORMATINET Request for Applications (RFA)  HYPERLINK "http://www.nih.gov/news/NIH-Record/02_19_2002/story02.htm"  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/darkblue.gif" \* MERGEFORMATINET  HYPERLINK "http://grants.nih.gov/grants/guide/rfa-files/RFA-TW-03-001.html" Stigma and Global Health Research Program RFA Release Date: June 20, 2002 NIH RFA: TW-03-001 Letter of Intent Deadline: October 14, 2002 Application Deadline: November 14, 2002  HYPERLINK "http://www.nih.gov/news/NIH-Record/02_19_2002/story02.htm"  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/new.gif" \* MERGEFORMATINET News Release  HYPERLINK "http://www.nih.gov/news/NIH-Record/02_19_2002/story02.htm"  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/darkblue.gif" \* MERGEFORMATINET  HYPERLINK "http://www.nih.gov/news/pr/aug2002/fic-28.htm" August 28, 2002: Fogarty International Center Announces New Research Program in Stigma and Global Health  HYPERLINK "http://www.nih.gov/fic/programs/stigma.html" For more information about the Stigma and Global Health Research Program, please visit the Fogarty International Center website at http://www.nih.gov/fic/programs/stigma.html. Conference VideoCast Click the following links to view the Conference VideoCast. This is a work of the United States Government. No copyright exists on this material. It may be disseminated freely.  HYPERLINK "http://videocast.nih.gov/ram/stigma090501.ram" Day 1: Wednesday, September 5 (click here)  HYPERLINK "http://videocast.nih.gov/ram/stigma090601.ram" Day 2: Thursday, September 6 (click here)  HYPERLINK "http://videocast.nih.gov/ram/stigma090701.ram" Day 3: Friday, September 7 (click here) VideoCasts can be viewed using RealPlayer. If you do not have this software, you may download and install the latest free version, called RealPlayer Basic, from  HYPERLINK "http://www.real.com/player/" http://www.real.com/player.  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/images/t-description.gif" \* MERGEFORMATINET  Posted May 2001 In partnership with other National Institutes of Health (NIH) Institutes and Centers, U.S. agencies, and domestic and international organizations, the Fogarty International Center (FIC) announces a major international conference: "Stigma and Global Health: Developing a Research Agenda." Focusing on stigma as it relates to public health, this conference will examine the causes and consequences of stigma, both in the developing world and the United States. Together, participants and speakers will seek to identify the gaps in disease-associated stigma research. According to "The Global Burden of Disease Report" (WHO, World Bank, and Harvard School of Public Health), the disease burden for HIV, major depression, and self-inflicted injuries will increase dramatically by the year 2020. Given these increases, the accompanying stigma due to these and other diseases will likely increase. Individuals with stigmatizing diseases are less likely to seek medical attention, causing higher morbidity and mortality among these "silently sick" populations, and communicable diseases such as HIV/AIDS spread more easily through populations with untreated individuals. Social stigma, therefore, is a global health concern. The first full day of the conference (September 6) will be devoted to discussions examining alcohol and drug abuse, epilepsy, schizophrenia, HIV/AIDS, sexual and physical abuse, and other conditions. Subsequent presentations will focus on cross-cutting socio-cultural issues, including policy, gender, population genetics, and media. The final day of the conference will be comprised primarily of breakout sessions, divided according to the disorders reviewed on the previous day. Breakout sessions will examine methodological strategies and barriers to stigma research in cross-cultural settings. Updated August 2002  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/darkblue.gif" \* MERGEFORMATINET Message from the Conference organizers The Conference was held September 5-7, 2001. The complete Conference video is available for viewing (see below). Please check this website for continuing updates about stigma and global health research. Thank you for your interest.  HYPERLINK "http://www.nih.gov/news/NIH-Record/02_19_2002/story02.htm"  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/new.gif" \* MERGEFORMATINET Request for Applications (RFA)  HYPERLINK "http://www.nih.gov/news/NIH-Record/02_19_2002/story02.htm"  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/darkblue.gif" \* MERGEFORMATINET  HYPERLINK "http://grants.nih.gov/grants/guide/rfa-files/RFA-TW-03-001.html" Stigma and Global Health Research Program RFA Release Date: June 20, 2002 NIH RFA: TW-03-001 Letter of Intent Deadline: October 14, 2002 Application Deadline: November 14, 2002  HYPERLINK "http://www.nih.gov/news/NIH-Record/02_19_2002/story02.htm"  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/new.gif" \* MERGEFORMATINET News Release  HYPERLINK "http://www.nih.gov/news/NIH-Record/02_19_2002/story02.htm"  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/darkblue.gif" \* MERGEFORMATINET  HYPERLINK "http://www.nih.gov/news/pr/aug2002/fic-28.htm" August 28, 2002: Fogarty International Center Announces New Research Program in Stigma and Global Health  HYPERLINK "http://www.nih.gov/fic/programs/stigma.html" For more information about the Stigma and Global Health Research Program, please visit the Fogarty International Center website at http://www.nih.gov/fic/programs/stigma.html. Conference VideoCast Click the following links to view the Conference VideoCast. This is a work of the United States Government. No copyright exists on this material. It may be disseminated freely.  HYPERLINK "http://videocast.nih.gov/ram/stigma090501.ram" Day 1: Wednesday, September 5 (click here)  HYPERLINK "http://videocast.nih.gov/ram/stigma090601.ram" Day 2: Thursday, September 6 (click here)  HYPERLINK "http://videocast.nih.gov/ram/stigma090701.ram" Day 3: Friday, September 7 (click here) VideoCasts can be viewed using RealPlayer. If you do not have this software, you may download and install the latest free version, called RealPlayer Basic, from  HYPERLINK "http://www.real.com/player/" http://www.real.com/player.  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/images/t-description.gif" \* MERGEFORMATINET  Posted May 2001 In partnership with other National Institutes of Health (NIH) Institutes and Centers, U.S. agencies, and domestic and international organizations, the Fogarty International Center (FIC) announces a major international conference: "Stigma and Global Health: Developing a Research Agenda." Focusing on stigma as it relates to public health, this conference will examine the causes and consequences of stigma, both in the developing world and the United States. Together, participants and speakers will seek to identify the gaps in disease-associated stigma research. According to "The Global Burden of Disease Report" (WHO, World Bank, and Harvard School of Public Health), the disease burden for HIV, major depression, and self-inflicted injuries will increase dramatically by the year 2020. Given these increases, the accompanying stigma due to these and other diseases will likely increase. Individuals with stigmatizing diseases are less likely to seek medical attention, causing higher morbidity and mortality among these "silently sick" populations, and communicable diseases such as HIV/AIDS spread more easily through populations with untreated individuals. Social stigma, therefore, is a global health concern. The first full day of the conference (September 6) will be devoted to discussions examining alcohol and drug abuse, epilepsy, schizophrenia, HIV/AIDS, sexual and physical abuse, and other conditions. Subsequent presentations will focus on cross-cutting socio-cultural issues, including policy, gender, population genetics, and media. The final day of the conference will be comprised primarily of breakout sessions, divided according to the disorders reviewed on the previous day. Breakout sessions will examine methodological strategies and barriers to stigma research in cross-cultural settings. Background papers: The following Background Papers were presented by their authors during the Conference.  HYPERLINK "http://"  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/darkblue.gif" \* MERGEFORMATINET  HYPERLINK "http://www.stigmaconference.nih.gov/FinalDasPaper.htm" History of Stigma - Stigma, Contagion, Defect: Issues in the Anthropology of Public Health (click title to view paper)  HYPERLINK "http://www.stigmaconference.nih.gov/abstracts/DasAbstract.htm" Abstract (click here to view the abstract of this paper)  Author:  HYPERLINK "http://www.stigmaconference.nih.gov/bios/Das.htm" Veena Das, Ph.D., Johns Hopkins University (click here to view a short biography of this author)  HYPERLINK "http://"  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/darkblue.gif" \* MERGEFORMATINET  HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" Stigma, Race, and Disease in 20th Century America - An Historical Overview (click here to view paper)  HYPERLINK "http://www.stigmaconference.nih.gov/abstracts/WailooAbstract.htm" Stigma, Race, and Disease in 20th Century America (click here to view the abstract of this paper) Author:  HYPERLINK "http://www.stigmaconference.nih.gov/bios/Wailoo.htm" Keith Wailoo, Ph.D., Rutgers University (click here to view a short biography of this author)  HYPERLINK "http://"  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/darkblue.gif" \* MERGEFORMATINET  HYPERLINK "http://www.stigmaconference.nih.gov/ReingoldPaper.htm" The Study of Potentially Stigmatizing Conditions: an Epidemiologic Perspective (click title to view this paper)  Author:  HYPERLINK "http://www.stigmaconference.nih.gov/bios/Reingold.htm" Arthur Reingold, M.D., University of California at Berkeley (click here to view a short biography of this author)  HYPERLINK "http://"  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/darkblue.gif" \* MERGEFORMATINET  HYPERLINK "http://www.stigmaconference.nih.gov/FinalLinkPaper.html" On Stigma and its Public Health Implications (click title to view this paper)  HYPERLINK "http://www.stigmaconference.nih.gov/abstracts/LinkAbstract.htm" Abstract (click here to view the abstract of this paper)  Author:  HYPERLINK "http://www.stigmaconference.nih.gov/bios/Link.htm" Bruce Link, Ph.D., Columbia University (click here to view a short biography of this author)  HYPERLINK "http://"  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/darkblue.gif" \* MERGEFORMATINET  HYPERLINK "http://www.stigmaconference.nih.gov/FinalWeissPaper.htm" Stigma Interventions and Research for International Health (click title to view this paper)  HYPERLINK "http://www.stigmaconference.nih.gov/abstracts/WeissAbstract.htm" Abstract (click here to view the abstract of this paper) Author:  HYPERLINK "http://www.stigmaconference.nih.gov/bios/MWeiss.htm" Mitchell Weiss, M.D., Ph.D., Swiss Tropical Institute, Switzerland If you have any questions about the Conference, please contact: Kathleen Michels, Ph.D. Program Director Fogarty International Center ( HYPERLINK "http://www.nih.gov/fic" www.nih.gov/fic) National Institutes of Health E-mail:  HYPERLINK "mailto:stigmaconference@nih.gov" stigmaconference@nih.gov Telephone: 301-496-1653 Fax: 301-402-0779 Stigma, Race, and Disease in 20th Century America: An Historical Overview Keith Wailoo, Ph.D. Professor Department of History Institute for Health, Health Care Policy, and Aging Research Rutgers, the State University of New Jersey New Brunswick, New Jersey The topic of the history of stigma, race, and disease is, of course, an expansive one even if one confines the discussion to the 20th century United States. In my own field of the history and sociology of medicine, the starting point for any such discussion of stigma must be Erving Goffmans classic 1963 book, Stigma: Notes on the Management of Spoiled Identity. HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_edn1" \o ""  In the work, Goffman sought to analyze three types of stigma. The first he called stigma deriving from physical deformities (and we might add to, physical infirmity). Second, he suggested that stigma was often associated with perceived blemishes of individual character which could include anything from mental disorder and homosexuality to radical political behavior. Third, Goffman designated the tribal stigma of race, nation, and religion which are transmitted through lineages and possessed equally in all members of a family. HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_edn2" \o ""  Thus, group membership and group identity could be (in themselves) significant sources of stigma. In all three kinds of stigma, Goffman wrote, an individual who might have been received easily in ordinary social intercourse possesses a trait that can obtrude itself upon attention and turn those of us whom he meets away from him He possesses a stigma, an undesired differentness from what we had anticipated This image of undesired differentness, could and often did have extensive negative implications for the person to identified. Because of our assumption of this persons lower status, noted Goffman, we exercise varieties of discrimination, through which we effectively, if often unthinkingly, reduce his life chances We construct a stigma-theory, an ideology to explain his inferiority and account for the danger he represents We use specific terms and we tend to impute a wide range of imperfections on the basis of the original one HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_edn3" \o ""  Goffmans work in 1963 was one among many that began to open the eyes of social scientists to this complex social process of stigma and discrimination. It was a process, of course, that was quite clearly visible to any Americans familiar with then current debates about racial segregation in the South, voting rights, and civil rights. Goffmans writings on stigma seemed particularly relevant in the 1960s and into the 1970s and subsequent decades as American society confronted other challenges womens rights, gay and lesbian rights, the rights of the mentally ill. As Goffman knew well, the process by which identities became spoiled was relevant not only to questions of social discrimination and social relations, but also to questions of public health and health care. The following pages build upon Goffmans basic observations, turn our attention to questions of race, disease, and health. My essay offers a brief analysis of the historical process by which stigma has become associated with particular disorders, and of the process by which these associations have been loosened. More specifically, if focuses on the case of people of African descent in the United States, in order to explore the problem of double stigmatization (tribal stigma and stigma stemming from disease or deformity) particular impact of race relations in stigma formation. I will focus on particular disorders and on the dissemination of images of disease and group identity, in order to arrive at some basic lessons about the interplay of stigma and race and disease in American society. Any discussion of stigma and disease in particular groups must begin, of course, with a discussion of the group and group identity. Only 12 years before Goffmans writings, in 1951 an historian of health care in the South published a book entitled Health of Slaves on Southern Plantations. HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_edn4" \o ""  The picture inset of the book presented an image, a kind of stereotype of race and nineteenth century health care.  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/FinalWailooPaper_files/image002.jpg" \* MERGEFORMATINET  It was an image of the forces defining the identity of all Americans, and of African Americans. The picture was that of a modest home in the country, with views of the surrounding landscape. On the viewers left at the front door of the home, one saw the physician leaving his horse and buggy approaching the house. Beneath the doctor, one saw images of the particular tools of his trade calomel (mercury compound widely used in allopathic medicine). His was the world of complex chemical derivatives used in therapy. And more important, as suggested by the surrounding landscape at the front of the house, the doctors world was the world of cleared land, limited vegetation, and sunlight. At the back door, one saw the other world of health care, symbolized by the black woman on foot. Beneath her were images representing her practices and beliefs chickens head, frog and snake parts, and roots and herbs of undetermined varieties. Looking at the surrounding terrain at the back of the home, the viewer would see a world of dense vegetation, of darkness and shadows, and of nefarious, barely discernible figures in the background dancing mystically around fire. Such images highlight the features associated in the popular mind with African-American group identity, a characteristic transmitted through lineages and presumably shared by all members of the group a stereotype that often came into play when issues of stigma and physical maladies emerged. How did particular diseases inform these images of group identity, and contribute to the creation of stigma? Each disease in each time would tell its own story. In this paper I focus on only a few disorders in order to illustrate this interaction of disease, race, and stigma. Let us first consider hookworm in the early 20th century (a disorder prevalent in the American South, and a disease designated as the germ of laziness because of the anemia and lethargy associated with hookworm infection); and a disease that, some believed, has special relation to the American Negro. Tuberculosis, a major cause of mortality and morbidity in nineteenth and early twentieth century America, (and still today in the developing world), and one among several infectious diseases for which one southern physician could write in 1932, that in the safeguarding of the health of the Negro [was not a] fight against disease, but against physical, mental, and moral inferiority, against ignorance and superstition, against poverty and filth. HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_edn5" \o ""  In many of such diseases, as I have noted elsewhere, one image dominated it was the image of the carriers (a portrait of a social menace whose collective superstitions, ignorance, and carefree demeanor stood as a stubborn affront to modern notions of hygiene and advancing scientific understanding [a people best understood as] a disease vector We see this image clearly exemplified in an image in a 1914 Atlanta Constitution newspaper, republished recently in Tera Hunters history of black women in the South. HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_edn6" \o ""  In the context of an economy where black people worked as cooks, gardeners, domestic servants, and caregivers in white homes, this image of the black woman as disease vector highlighted a particularly prevalent, pervasive, and long-lasting anxiety (one that, I should say, continues to exist in contemporary global health discussions today).  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/FinalWailooPaper_files/image004.jpg" \* MERGEFORMATINET  The black woman is pictured flying alongside the mosquitoes, the flies, and other disease vectors in a cloud of dust, leaving her filthy habitat that waves the flag of contagious disease. She evades many different kinds of public health surveillance, flying directly over the barriers that have been erected by modern medical sciences to protect this average white home. The barricades of sanitary precaution, screen, pure water, garbage cans, and good sewage, are not enough to protect the denizens of the home. In the context where bacteriology was only a few decades old and being widely disseminated in popular consciousness, and in a context where Typhoid Mary, the asymptomatic carrier, had become a household name, such images resonated with popular thinking, and fears of these human disease vectors seemed to be strongly rooted in the best scientific evidence of the time. The legitimacy of new scientific concepts such as disease carriers was becoming well established in public health and bacteriology, fields which were unquestionably the ascendant sciences of the time (akin to the rising status of genetics today). Thus, one important feature of stigma in public health was associated with both scientific and social ideas about the carrier of disease. The image of the black (and also ethnic or immigrant) person as disease vector was constantly reinforced by the writings of scientific authorities. HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_edn7" \o ""  In his 1911 article on Hookworm in its relation to the negro, for example, pioneering hookworm researcher Charles Wardell Stiles noted that the incidence of the disease possibly indicates that the negro has brought [it] with him from Africa and because of his soil pollution has spread it broadcast through the south, thereby killing thousands and causing serious disease among tens of thousands of others. Whether this line of thought be considered justified of not, Stiles continued, we must frankly face the fact that the negro because of his unsanitary habit of polluting the soil is a menace to others. HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_edn8" \o ""  Here was the expansion that Goffman had commented upon that is, the expansion of the vector notion to define and stigmatize Negro character itself. Such images of disease are not uniform. Other Other maladies presented a very different public face highlighting very different features of race and region in America.  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/FinalWailooPaper_files/image006.jpg" \* MERGEFORMATINET  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/FinalWailooPaper_files/image008.jpg" \* MERGEFORMATINET  Cancer in the 1920s, 30s, and 40s, was a widely feared disorder (widely perceived as a death sentence and it was a disease which few sufferers or families would speak about publicly or privately. 1926, Danger Signals of Cancer 1927, Cancer: A Womans Problem But there are several interesting contrast between images of hookworm and tuberculosis, on one hand, and cancer, on the other. First, cancer was widely portrayed as a disease of well-to-do women and social leaders (as these images suggested). It was widely characterized as a disease of civilization and a disease originating in refined living and lifestyles; the disease was unknown, experts said, among so-called savage and primitive cultures. Second, the popular and professional literature of the time worked aggressively to undo the association of cancer and death, by filling the silence.  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/FinalWailooPaper_files/image011.jpg" \* MERGEFORMATINET  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/FinalWailooPaper_files/image012.jpg" \* MERGEFORMATINET  1938, Im Not Afraid of Cancer 1942, You Can Tell the Doctor The message one encounters in the early 20th century media was one preaching courage instead of fear, encouraging early action, and promoting watchful attention (particularly to audiences of middle-class white women) to the danger signals of the disease, and open discussion with the doctor albeit in the shadows. These images were part of broader, concerted, efforts orchestrated by the American Society for the Control of Cancer, the predecessor of the American Cancer Society, to raise cancer awareness. And these images of hope were embraced by physicians, and by many of the women to whom the message was directed. As cancer became an even more widely discussed disease in the 1950s, the understanding of the individuals disease experience became gradually more developed. The story is a complex one, but for the purposes of this essay it is necessary to say only that the cancer patient became widely portrayed as a complex individual within, generally speaking, high-class social groups, inspiring hope, reflecting the battle against fear. There are many analogies and dysanalogies, but the main point Id like to make here is that disease (even diseases widely regarded as shameful as cancer was) need not necessarily reinforce individual or group stigma. Indeed, even though cancer was regarded by some as a familial disease, and therefore evidence of familial taint, a reader of popular or professional journals of the time rarely encounters images of cancer patients carrying within them hidden dangers as they moved about in society. As Goffman wrote, assumptions about stigmatized identity often informed broader discriminatory social policies. Consider, for example, this image from the World War II era a cartoon illustrating the American Red Crosss practice of racial segregation of blood plasma. The war had spurred numerous technical innovations from the scaled-up production of penicillin to the use of blood plasma transfusions on the front. At home, the changing social relations of the war had drawn women and ethnic minorities into new roles in wartime industries, and called for all Americans to sacrifice at home for the effort abroad. The war against Nazism and Aryan racial ideology had also led to broad scrutiny of racial ideologies and assumptions about blood, stigma, and group identity at home. In this context, some critics began to look closely at the ways in which spoiled identities were in fact created and manufactured, and at the sweeping impact of racial ideologies in American society. In 1942, a cartoon appeared which can be read as one of many commentaries on this process of stigma formation.  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/FinalWailooPaper_files/image014.jpg" \* MERGEFORMATINET  EEntitled An American Tragedy, the cartoon appeared in a New York City African-American newspaper and sought to put aside narrow conceptions of race while promoting a focus on the larger group the nation as the unifying whole. The first caption shows a white soldier crawling up to a ARC attendant who tells him, you might as well wait here, bud we aint got nothin but negro blood left. The second captions portrays the dilemma of science the scientist scratches his head because the labels have fallen off the bottles (negro blood and white blood). What a dilemma, he says, now how can we tell the white from the negro plasma?  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/FinalWailooPaper_files/image016.jpg" \* MERGEFORMATINET  The third caption shows the white soldiers (and note that the images suggest that this system of blood segregation works against the white soldiers, not the black soldiers) commenting on the situation looks like the colored lads is the only ones thats got round trip tickets to the horspital today guess they only got colored blood.) In the final caption, a wounded, seemingly patriotic and heroic, black soldier is pictured lying on a hospital bed looking up to his white physician. If I need a transfusion, he says, gimme anybodys blood, so long as I get back to the front. Such images from popular culture can be seen as efforts to look closely at the workings of stigma in society how assumptions about group inferiority (and the unseen and dangerous entities hidden in negro blood) were played out in terms of public health policy. The post WWII decades would witness a dramatic transformation in disease itself in America. For one, there was a growing focus on increasing morbidity from polio, increasing mortality from cancer as a disease of aging, and the rise of previously obscure diseases now made visible by new diagnostic tools and by the decline of older acute infectious diseases. Polio, it seemed, defined many of the conventional associations of race, pollution, filth, and disease. In Memphis, Tennessee, for example, one public health official noted that although the incidence of polio in post war America has reached unprecedented levels, the negro attack rate has been consistently lower than for whites and theorized that negroes living in less favorable sanitary surroundings and in more overcrowded houses acquire the disease at an earlier age [when it manifests] as a subclinical infection that is not recognized and that is mild in its effects. Thus, in this theory, filth acted as its own preventive agent. Additionally, in the 1950s the rising mortality rates from cancer and its differentiation into several diseases would begin to open yet other lines of race characterization and stigma, prompting further revisions of truisms from the past. According to a 1950 Congressional Report, for example, non-whites were not as commonly believed immune from cancer. Rather, new evidence suggested that while skin cancer and breast cancer were indeed more prevalent among whites, other cancerous disorders such as cervical cancer appeared to be quite prevalent among non-white Americans. Indeed, the African-American women of the South seemed to have a particularly high incidence of cervical cancer.  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/FinalWailooPaper_files/image018.jpg" \* MERGEFORMATINET  And so, i f the story of polio was undermining previous patterns of racial stereotyping, the rising incidence and social profile of cervical cancer in the 1950s would lead to new generalizations about racial identity, disease, and group behavior. New truisms would emerge and flourish in the 1960s. Writing in the early 1960s, for example, o ne British researcher linked the rise of cervical cancer among black women to individual choices and sexual behaviors. The different incidence of carcinoma of the cervix in Negroes could be explained, Lewis stated, by differences (first) in the age of first coitus, (second) the age of marriage, and (third) by the frequency of coitus with uncircumcised partners. Thus, as polio challenged the stigma associated with group identity and disease, cervical cancer opened new lines of thinking about group identity and disease. Stigma operated differently in each disease realm and in different groups. As Lewis continued, the higher rate of carcinoma of the cervix is found in those women who first have coitus at an early age, who marry early and remarry frequently and whose men are uncircumcised. So, although there was (in the 1950s and 1960s) increasingly openness about the cancer experience, and increasing hope about surviving cancer, there was also increasing scrutiny of the morality and behavioral choices that individuals of particular groups had made, and of the ways in which these choices brought the burden of disease directly upon themselves. New social trends in the 1960s, however, were changing the dynamics of stigma formation once again. In 1963, Goffman noted that the members of a particular stigma category will have a tendency to come together into small social groups whose members all derive from the category. HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_edn9" \o ""  He could not foresee at the time that, in these groups, the blemishes of individual character and tribal stigmas of lineage could themselves become symbols of pride, resistance, and even engender social movements of the marginal versus the mainstream. In the 1960s and 1970s, a variety of patients groups (the elderly battling for Medicare legislation, terminal patients battling for hospice care, women, and the institutionalized mentally ill, to name only a few) gained stronger voices. Their unique perspectives now stemmed, these groups often insisted, precisely from the very stigmatized experiences or identities that had been deemed problematic. The story of disease and activism in the 1960s and 1970s is far too complex and multi-faceted to rehearse again here. The social changes of the era, however, radically transformed the social significance of disease; and these social changes also altered the relationship of stigma to issues of health and race. Consider, for example, the final example of the story of sickle cell anemia in 1960s and 1970s American society. It was in the context on these decades of racial tension over civil rights in America that sickle cell anemia gained national political significance as a disease symbolized by recurrent pain and suffering of African-Americans, a disease that had long been ignored by mainstream America, and was finally getting (like black Americans generally) the attention it deserved. HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_edn10" \o ""  One can see clearly in the discourse of the era the ways in which the disease experience was being put to new social and political uses in the 1970s. Where some might see the disease as a taint or stigmatizing mark, others now portrayed the malady as a particularly poignant symbol of the African-American experience. In the context of the 1960s and 1970s, such a disease experience (and particularly the recurrent painful episodes or crises) became a positive symbol of an entire group experience with the health care system, with biomedical research, and with mainstream society itself. Additionally, new movies and television programs could be made to portray the experience of the disorder, as an example of a larger group experience. HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_edn11" \o ""  This high profile, however, also fed into a new kind of stigma generated by the increasing attention and the public health response to sickle cell disease. In national hearings before the U.S. House and Senate, for example, elected officials debated the question of testing for sickle cell trait and counseling carriers. These carriers of hereditary defect represented a new type of concern in America, and the question before politicians and society was how carriers of defective genetic material and hidden taints should be counseled on matters of reproduction. Should they be encouraged not to have children? Should they simply be warned about the chances of producing diseased offspring? While some states debated mandatory heterozygote testing of particular populations, some experts (such Nobel Prize laureate Linus Pauling, who had himself been associated with discovering the molecular basis of sickling) helped to feed controversy about testing carriers by suggesting in the pages of the UCLA Law Review, somewhat bizarrely: I have suggested that there should be tatooed on the forehead of every young person a symbol showing possession of the sickle-cell gene or whatever similar gene If this were done, two young people carrying the same seriously defective gene in single dose would recognize this situation at first sight, and would refrain from falling in love with one another. HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_edn12" \o ""  New forms of stigma emerged, then, in the very attempts of scientists, public health officials, and politicians to address the problem of suffering and disease in the African-American community for these discussions about monitoring and counseling and stigmatizing the carrier seemed to conflict with attempts to undermine group stigma in society. These were complex and controversial years indeed, for in the early 1970s many issues seemed to revolve around the health care and group stigma in African-Americans. The year 1972 alone saw the first national revelations about the Tuskegee Study of untreated syphilis in African-American men in Macon County, Alabama, as well as the passage of national sickle cell legislation, and also lingering controversies about the assertions of William Shockley and Arthur Jensen assertions about IQ and racial inferiority. With increasing attention to sickle cell trait carriers came new practices the U.S. Air Force decision to ban carriers from high altitude missions, and E.I. DuPont companys purported practice of using the sickle cell trait as a screening and selecting test to fit employees to job (on the assumption that carrier status made them susceptible to ill health under adverse circumstances).  INCLUDEPICTURE "http://www.stigmaconference.nih.gov/FinalWailooPaper_files/image020.jpg" \* MERGEFORMATINET  What general conclusions on the history of race, disease, and stigma in America might be warranted from such a cursory overview of a handful of diseases from hookworm and tuberculosis, to polio, cancer, and sickle cell disease? First, Ive attempted to sketch (using these few examples) a picture of the complex ways in which stigma works in society and the ways in which the social context, the particular diseases, the politics of group identity, and the sciences themselves (from bacteriology in the early 20th century to genetics at the end of the century), feed into the process of stigmatizing individuals doing so by designating hidden invisible taints, and thereby reinforcing broader prejudices and policies. Secondly, this overview suggests a particular research agenda. If part of the goal of this gathering of scholars is to identify areas for further research, I would suggest increasing attention to the historical and sociological processes by which stigmatized categories are formed and deconstructed. This would be a useful undertaking in the effort to understand stigma and global health today in America and in the developing world. Endnotes  HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_ednref1" \o "" Erving Goffman, Stigma: Notes on the Management of Spoiled Identity (New York: Simon and Schuster, 1963)  HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_ednref2" \o ""  Goffman, p. 4-5.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_ednref3" \o ""  Goffman, p. 5.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_ednref4" \o "" William Postell, Health of Slaves on Southern Plantations (Baton Rouge: Louisiana State University Press, 1951)  HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_ednref5" \o "" Keith Wailoo, Dying in the City of the Blues: Sickle Cell Anemia and the Politics of Race and Health (Chapel Hill: University of North Carolina Press, 2001), p. 56.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_ednref6" \o ""  Tera Hunter, To Joy My Freedom: Southern Black Womens Lives and Labors after the Civil War (Cambridge, MA: Harvard University Press, 1997), photograph appears in section after p. 144.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_ednref7" \o ""  See for example, Alan Kraut, Silent Travelers: Germs, Genes, and the Immigrant Menace (New York: Basic Books, 1994); Nayan Shah, Contagious Divides: Epidemics and Race in San Franciscos Chinatown (Berkeley: University of California Press, 2001)  HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_ednref8" \o ""  Charles Wardell Stiles, Hookwork in Relation to the American Negro, Southern Medical Journal 2 (1909): 1125-26.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_ednref9" \o ""  Goffman, p. 23.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_ednref10" \o ""  Keith Wailoo, Dying in the City of the Blues, p. 183.  HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_ednref11" \o ""  Keith Wailoo, Dying in the City of the Blues  HYPERLINK "http://www.stigmaconference.nih.gov/FinalWailooPaper.htm" \l "_ednref12" \o ""  Linus Pauling, Reflections on a New Biology: Foreword, UCLA Law Review 15 (1968): 269. For a more detailed discussion, see Wailoo, Dying in the City of the Blues. The Study of Potentially Stigmatizing Conditions: an Epidemiologic Perspective Arthur L. Reingold, M.D. University of California at Berkeley Suneeta Krishnan. M.S., Ph.D. Introduction That various medical conditions or diseases and behaviors are stigmatizing within human society is attested to by numerous early written works, including the Bible. In the Old Testament, a skin disease commonly believed to have been leprosy is clearly portrayed as a divine punishment for moral lapses and as a cause for removal from society and social isolation. Some conditions, such as leprosy, appear to have been severely stigmatizing in virtually every known culture and time period for which evidence exists. Other conditions and behaviors, however, such as mental retardation and abuse of women, have almost certainly been met by widely varying degrees of approbation or acceptance in different cultures and at different times in the history of or by different strata of the same culture. Many different types of behaviors, conditions, and diseases may be stigmatizing. In an effort to organize such behaviors and conditions into logical and distinct groups, we have divided them into behaviors; structural abnormalities; functional abnormalities; and contagious diseases. (See table 1). These groupings are not, however, mutually exclusive. That is, a disease like leprosy, in addition to raising concern about contagion, produces structural and functional abnormalities through damage of the tissues of the face and extremities. Similarly, individuals born with both cleft palate and cleft lip can have abnormalities of speech in addition to the readily apparent structural anomaly of the face. Furthermore, some conditions that have been associated with stigma at various times and in various places, such as cancer, do not fit readily into any of these groups. In this article, we have assembled the information available about the current (or, based on historical information, the likely current) global prevalence of only selected conditions and behaviors associated with varying levels of stigma, choosing conditions from each of the groupings. We have selected the following conditions to review here: alcohol and drug use, and spouse and child abuse (behaviors); cleft lip and palate (structural abnormalities); mental retardation, schizophrenia, and epilepsy (functional abnormalities); and HIV/AIDS (contagious diseases). In selecting and summarizing these data from various published and unpublished sources, our focus has been on gathering information that can be used to help estimate the number of individuals with such conditions and, hence, the approximate magnitude of the problem of social stigma attached to selected medical conditions and behaviors worldwide. However, we have not attempted to gather the information needed to describe the extent to which the various conditions under review are, in fact, stigmatizing in various cultures and geographic settings. This information, which is equally necessary in order to estimate the global burden of such stigma, is more properly assembled and assessed by anthropologists and other social scientists who are expert in measuring stigma within a cultural framework. The conditions we review here are all either multi-factorial in origin (e.g. mental retardation and cleft lip/cleft palate) or conditions for which there is a single causal agent (e.g. AIDS), but for which multiple (and often differing) behaviors, exposures, and other risk factors may play an important role in determining the prevalence of the condition and who is affected in a given part of the world. However, a systematic review of the risk factors for and/or possible causes of the conditions being considered is beyond the scope of this review. When appropriate, we do discuss briefly what is known about the factors that contribute to the risk of having or acquiring a given condition, primarily to focus attention on why the prevalence of the condition may vary geographically, culturally, or temporally. Information concerning what is known about the causes and risk factors for a condition may also be useful in predicting the likely impact of prevention or intervention efforts on the prevalence of a condition in the future. Choice of Measures for Estimating the Burden of Disease In this article, we primarily review and discuss the prevalence (i.e. what proportion of a given population has a condition at a given point in time or during a given time period) rather than the incidence (i.e. the rate at which new cases of the condition occur in a population during a specified time interval) of a given condition. In conducting analytic epidemiologic studies intended to elucidate the cause(s) of or contributing factors for a given condition, it is almost always preferable to calculate incidence rates rather than prevalence rates. However, in this review we are more concerned with estimating the proportion of the population or the number of individuals who are or who may be at risk of being stigmatized as a result of having the condition, a purpose for which the prevalence is a more useful indicator. However, for some conditions (e.g. HIV infection/AIDS), predictions about the likely future prevalence depend greatly on the incidence. Therefore, when appropriate, we also review what is known about the incidence of a given condition. Epidemiologic Approaches to Estimating the Burden of Disease When attempting to estimate the prevalence or incidence of a given condition in a population, epidemiologists generally rely on one or more of the following five approaches: 1) passive surveillance 2) active surveillance/registries 3) surveys/cross-sectional studies 4) special studies involving closely monitored cohorts 5) use of administrative data bases assembled for other purposes Each of these approaches can provide useful data about selected conditions and diseases under the proper conditions, but each has its limitations. The advantages and limitations of each of these approaches are discussed in general terms here, to set the stage for a more detailed discussion of the accuracy of the data available for and to possible future approaches to studying the specific conditions under review. Passive surveillance, which typically involves having health care providers report occurrences of disease or disability to a local government health agency and subsequent reporting by that agency to national and/or international agencies, is commonly used around the world for a variety of infectious diseases. In some countries, such as the United States, there is also passive surveillance for selected non-infectious diseases (e.g. epilepsy and certain occupational or environmental illnesses considered "sentinel health events"). However, even when there are legal sanctions for failing to report and even in wealthy countries, passive surveillance systems generally capture only a subset of the occurrences of the disease being monitored. While the sensitivity (the proportion of all cases that are reported) of such systems may be high in wealthy countries for rare and serious diseases of obvious public health significance (e.g. botulism or plague), the sensitivity is much lower for more common diseases (e.g. sexually transmitted infections); those cases that are reported are often not representative of those that aren't; and reporting may not occur at all in poor countries. Furthermore, in addition to the fact that cases may go uncounted because they are not diagnosed or not reported, there may be political, economic, cultural, and social reasons why stigmatizing diseases such as AIDS or diseases whose occurrence can affect trade and tourism (e.g. cholera and plague) go unacknowledged. Thus, data from passive surveillance systems are generally not available for many of the conditions under review and are unreliable for others. Active surveillance systems or registries differ from passive surveillance systems primarily by having more resources available and having well-trained staff whose job it is to go out and find the cases of the condition under study and collect all needed data in a complete and consistent manner. Such systems, while expensive, typically produce very high quality data. The existence in numerous locations around the world of birth defects registries that are using consistent case definitions and case detection methods makes it possible to estimate quite accurately the prevalence of conditions such as cleft lip and palate. Surveys and cross-sectional studies, in which the prevalence of a given condition at a given point in time (or during a given period of time) is estimated, can be very useful sources of data concerning conditions that persist over time and are detectable through interview, physical examination, or a laboratory test. Historically, such surveys have been used to gather data about diverse conditions such as blindness and polio-induced lameness, and much of what we now know about the prevalence of mental retardation, epilepsy, HIV infection, alcohol abuse, and spouse and child abuse comes from such surveys. However, such surveys tend to be expensive and time-consuming, particularly if truly representative samples of large populations are to be studied. Also, if the prevalence of the condition under study is not stable over time, such surveys may need to be repeated with some frequency. Highly accurate estimates of the incidence or prevalence of various conditions (e.g. HIV infection) can also come from epidemiologic studies of selected populations assembled for research purposes and followed over time (i.e. cohorts). While such studies produce very accurate information about the incidence of the condition within the cohort, cohorts can be very expensive to assemble and follow over time, particularly if they need to be large. Also, individuals agreeing to participate in such studies, like individuals agreeing to participate in surveys, may not be representative of the broader population (see below). Finally, administrative data bases gathered for other purposes (e.g. provision of services or billing) or medical records from health care providers (e.g. health maintenance organizations, insurers, national health systems, etc.) can also be used to estimate the number of affected individuals or, when a denominator (i.e. the population at risk) is known, the prevalence of a condition such as mental retardation or schizophrenia. However, such data bases are often inaccurate or incomplete, and the proportion of affected individuals captured in such data bases may vary by severity of the condition; changes in the treatment or management of the condition; referral patterns; and other factors, all of which may vary substantially over time or by geographic region. Case Definitions In order to estimate the prevalence or incidence of a given condition, it is necessary to establish a case definition or criteria for classifying individuals. In order to make meaningful comparisons of the prevalence or incidence of a condition between different geographic regions, cultures, or time periods, it is important to assure that consistent case definitions are used (see below). For some conditions, particularly dichotomous conditions (e.g. cleft lip and/or palate or HIV infection), it is relatively straightforward to establish and use a case definition or criteria to classify individuals as affected or not. For other conditions, however, such as mental retardation, alcohol abuse, and spouse and child abuse, numerous case definitions are possible and can give rise to vastly different estimates of the number or proportion of individuals affected. For such conditions, particularly those ascertained entirely through interview or questionnaire, it can be particularly challenging to establish, test, and assure the use of consistent classification criteria across multiple cultures, geographic regions, languages, and time periods. Challenges Related to Accurate Measurement In addition to the problems that can arise from using inconsistent sources of data or case definitions, the accuracy of the information concerning the frequency of a given condition in a population can be affected by selection bias, information bias, and problems associated with measuring prevalence rather than incidence. Selection Bias Selection bias occurs when the individuals selected for inclusion and agreeing to participate in a study differ systematically from the broader population about which one would like to draw conclusions. High quality, population-based birth defects registries should produce measures of the prevalence of conditions like cleft lip and/or palate that are free or virtually free of selection bias. On the other hand, the validity of the estimates of the prevalence of conditions like HIV infection; alcohol and other drug use; spouse and child abuse; and mental retardation and schizophrenia can be seriously jeopardized when surveys target and/or capture non-representative samples of the population under study. Furthermore, the approaches to sampling a population that yield the most accurate estimates of the prevalence of a condition (i.e. sampling schemes that approximate simple random sampling) are invariably the most expensive and most difficult to implement. Equally important, the willingness of individuals to participate in surveys or studies may vary substantially depending on whether they do or don't have the condition under study, particularly when the condition is stigmatizing or even illegal (e.g. illicit drug use). Information Bias Information bias occurs when there are systematic errors in the accuracy of the data collected concerning the exposure(s) or outcome(s) under study. As a result, individuals being studied may be mis-classified as to whether they do or don't have a particular condition. While such errors can occur as a result of imperfect laboratory tests (e.g. for HIV infection), medical records, or clinical case definitions (e.g. for mental retardation), they are of particular concern when studies rely on individuals to provide accurate information about their behaviors, especially behaviors that are stigmatized or illegal. Thus, individuals may not acknowledge illicit drug use, spouse/child abuse, or even alcohol/tobacco use because of fear, denial, or wanting to provide socially desirable answers. While this problem can be reduced through a variety of means (e.g. collecting information from respondents in a private setting; asking questions about specific behaviors in a non-judgmental fashion; assuring the confidentiality of responses), it can rarely, if ever, be eliminated. Examination of Prevalence vs. Incidence As noted above, this review focuses largely on the prevalence of various conditions because we are interested in estimating the numbers of individuals at risk of being stigmatized by a given disease or condition. However, for some conditions, such as child and spouse abuse, surveys or studies that estimate what proportion of respondents have abused a child or a spouse or been abused by a spouse or parent will systematically miss the most severe instances of such abuse - those instances in which a child or spouse died as a result of the injuries received. When recognized as such, these episodes potentially can be studied through police or other legal records, but it is likely that many such deaths are never recognized or acknowledged to have been the result of abuse. Comparisons and Compilations of Rates Collection of data concerning the prevalence of potentially stigmatizing conditions in diverse geographic locations and cultures permits comparisons of the prevalence rates in different areas and compilation of the overall number of affected individuals. Such information can help in planning the delivery of curative services (e.g. surgery to correct facial anomalies); programs to reduce the incidence or prevalence of a condition (e.g. drug treatment programs); and programs to reduce stigma. Furthermore, such data can be used to establish baseline rates of these conditions, which can be invaluable when the impact of various interventions or prevention strategies is going to be assessed. However, as alluded to above, estimating the prevalence of a medical condition or behavior in a given population, as well as compiling and comparing the estimated prevalences from various populations (or time periods) are beset by a number of difficulties, some of which may be peculiar to a given condition or behavior and others of which are more general in nature. Thus, passive surveillance systems in which cases of a given illness (e.g. AIDS) are to be reported by health care providers almost invariably produce underestimations of the numbers and rates of cases in the population under study, due to misdiagnosis and failure to report. Active surveillance systems or registries, for which specifically trained and dedicated staff gather data using standardized case definitions and have legally-mandated access to medical records (e.g. birth defects monitoring programs), typically produce very high quality information and virtually complete case ascertainment. Population-based surveys, while expensive and cumbersome, and therefore often of limited size or scope, can also produce high quality data about the prevalence of a condition or behavior (e.g. mental retardation, alcohol or drug abuse, and spouse or child abuse), although fatalities may go uncounted, and conditions about which there is a feeling of shame or guilt are likely to be under-reported. In this review, we rely as much as possible on active surveillance programs, disease registries, and population-based surveys for data concerning the prevalence (or incidence) of the conditions being discussed. However, comparing or compiling results from different geographic areas, cultures, or time periods can produce meaningful results only if comparable case definitions, case finding methods, and approaches to data collection have been employed. Therefore, when appropriate, we also discuss the comparability (or lack thereof) of these key aspects of the studies being reviewed. Future Directions for Research The conditions under review here can be divided into three groups with regard to the types of research needed in the future to define more accurately the global burden of disease and the numbers of individuals at risk of being stigmatized. 1. Conditions for which current approaches to estimating the number of affected individuals are adequate methodologically, but could be applied more broadly. For some conditions, including cleft lip and palate and HIV infection, currently available approaches to estimating the prevalence are well-established and can give reasonably accurate estimates of the number of currently affected individuals when applied in a given country or region. For these conditions, more resources would, if available, make it possible to apply these approaches to larger and more diverse populations, producing commensurate increases in the accuracy or certainty of the estimates of the number of individuals affected globally. Additional research could, however, address whether there simpler, less expensive approaches to estimating prevalence that produce data of comparable accuracy. 2. Conditions for which current approaches to estimating the number of affected individuals have been shown to work in some settings, but their applicability and feasibility in diverse cultural settings is uncertain. For some conditions, such as alcohol use, schizophrenia, epilepsy and mental retardation, approaches to estimating prevalence (largely based on surveys) have been developed and used in selected settings. However, the applicability and feasibility of these approaches in diverse cultural settings has not been adequately tested. For these conditions, additional research is needed to refine, standardize, and validate various aspects of these approaches (e.g. case detection methods and case definitions) to ensure that they can be applied in a consistent manner and can produce comparable results in diverse settings and cultures, particularly when the surveys have to be conducted by non-medically trained individuals. 3. Conditions for which current approaches to estimating the number of affected individuals are or may be inadequate and better approaches may be needed. For some conditions, including use of illicit drugs and the more severe forms of spouse and child abuse, current approaches to estimating the number of affected individuals are or are likely to be inadequate, in large part because the conditions or behaviors under study are illegal and subject to punishment or because they are highly stigmatized and likely to the source of substantial feelings of shame and guilt. For these conditions, current estimates of the numbers of affected individuals must be considered minimum estimates, and future research needs to focus on new or improved approaches to data collection that reduce or eliminate selection and information bias. Table 1. Classification Scheme for Possibly Stigmatizing Conditions BehaviorsStructural AbnormalitiesFunctional AbnormalitiesContagious DiseasesOtherDrug Use (alcohol, tobacco, illicit drugs) Homosexuality Spouse and Child AbuseFacial Anomalies (e.g. caused by cleft lip, burns, infection) Skeletal Anomalies (e.g. severe kyphoscoliosis) Abnormalities of Skin Pigmentation (e.g. albinism, vitiligo) Abnormalities of Body Size (e.g. obesity, dwarfism)Physical: Motor (e.g. gait disturbances, hemiplegia) Speech (e.g. stutter, Tourette's syndrome) Vision (blindness) Hearing (deafness) Mental: Mental Retardation Schizophrenia Other: EpilepsyLeprosy HIV/AIDS Tuberculosis Sexually-transmitted diseasesCancer On Stigma and Its Public Health Implications Bruce G. Link Columbia University and New York State Psychiatric Institute Jo C. Phelan Columbia University Introduction The publication of Erving Goffman's seminal Stigma: Notes on the Management of Spoiled Identity in 1963 generated a profusion of research on the nature, sources and consequences of stigma. Numerous elaborations of Goffmans ideas, conceptual refinements, and repeated demonstrations of the consequences of stigma for stigmatized individuals have been put forward. The stigma concept has been applied to a very broad array of circumstances ranging from urinary incontinence (Sheldon and Caldwell 1994) to exotic dancing (Lewis 1998), being in debt (Davis 1998) and being a mother who is lesbian (Causey and Duran-Aydintug 1997). Amidst this profusion of research, we return to the idea of stigma to reconsider its conceptualization, to explore how and why it has pervasive and persistent effects on peoples lives and to ask how and why it is connected to the health of the public. After considering these issues, we turn to ideas about what we need to know and what we need to do to address stigma and its consequences. Conceptualizing Stigma There is a great deal of variability in approaches to defining stigma (Stafford and Scott 1986). Many investigators provide no explicit definition and seem to refer to something like the dictionary definition ("a mark of disgrace") or to some related factor like stereotyping or rejection (e.g. a social distance scale). When stigma is explicitly defined, it is often in terms of Goffman's description of stigma as an "attribute that is deeply discrediting" and that reduces the bearer "from a whole and usual person to a tainted, discounted one" (Goffman 1963, p. 3). Other investigators have elaborated Goffmans definition or offered alternatives, and these have varied considerably. For example, Stafford and Scott (Stafford and Scott 1986, p. 80) define stigma as "a characteristic of persons that is contrary to a norm of a social unit" where a "norm" is defined as a "shared belief that a person ought to behave in a certain way at a certain time" (p. 81). Crocker et al. (1998, p. 505) suggest that "stigmatized individuals possess (or are believed to possess) some attribute, or characteristic, that conveys a social identity that is devalued in a particular social context." An especially influential definition is that of Jones et al. (1984) who use Goffman's (1963, p.4) observation that stigma can be seen as a relationship between an "attribute and a stereotype" to produce a definition of stigma as a "mark" (attribute) that links a person to undesirable characteristics (stereotypes). Despite their variability, most definitions of stigma share features that have been criticized for the narrow and biased vision they allow. Two critical challenges can be identified. First, many social scientists who study stigma do not themselves belong to stigmatized groups, and their theories are consequently uninformed by the lived experience of the people they study (Kleinman et al. 1995; Schneider 1988). For example, with regard to the experience of disability, Schneider (1988) asserts that "most able-bodied experts" give priority "to their scientific theories and research techniques rather than to the words and perceptions of the people they study." The result is a misunderstanding of the experience of people who are stigmatized and the perpetuation of unsubstantiated assumptions. Writing about disability, Fine and Asch (1988) identify five assumptions: 1) that disability is located solely in biology, 2) that the problems of the disabled are due to disability-produced impairment, 3) that the disabled person is a "victim," 4) that disability is central to the disabled persons self-concept, self-definition, social comparisons and reference groups, and 5) that having a disability is synonymous with needing help and social support. The second main element of the critique is that stigma has been studied from a decidedly individualistic perspective. For example, Oliver (1992) notes that stigma research has focused largely on the perceptions of individuals and the consequences of those perceptions for micro-level interactions. According to Oliver (1992), it is rare for stigma research to examine the sources and consequences of pervasive, socially shaped exclusion from social and economic life. In another vein, Fine and Asch (1988) point out that, although Goffman (1963, p.3) advised that we needed "a language of relationships, not attributes," subsequent practice has often transformed stigmas or marks into attributes of persons. The stigma or mark is something in the person rather than a designation or label that others affix to the person. Consider how the term "stigma" directs our attention differently than a term like "discrimination." Whereas "discrimination" focuses attention on the producers of rejection and exclusion -- those who do the discriminating, "stigma" directs attention to the people who are the recipients of these behaviors (Sayce 1998). Thus the terms we use may lead to "different understandings of where responsibility lies for the 'problem' and consequently to "different prescriptions for action" (Sayce 1998). We propose a conceptualization of stigma that locates its meaning in the relation between several concepts. The relational nature of this conceptualization expands on Goffman's observation that stigma can be seen as the relationship between an "attribute and a stereotype," provides a framework that integrates many of the diverse definitions of stigma that have been previously offered, and responds to some of the valuable criticisms and challenges to the study of stigma that we have just described. We first state our conceptualization briefly and then elaborate its components. In our conceptualization, stigma exists when the following interrelated components converge. In the first component, people identify and label human differences. In the second, dominant cultural beliefs link labeled individuals to undesirable characteristics -- to negative stereotypes. In the third, labeled persons are placed in distinct categories, separating "us" from "them." In the fourth, labeled persons experience status loss and discrimination that lead to unequal outcomes. Finally, stigmatization is wholly contingent on access to social, economic and political power that allows the identification of differentness, the construction of stereotypes, the separation of labeled persons into distinct categories and the full execution of disapproval, rejection, exclusion and discrimination. Thus we apply the term stigma when elements of labeling, stereotyping, separation, status loss and discrimination co-occur in a power situation that allows them to unfold. We now turn to a more detailed examination of each of these components of stigma. Component #1 B Distinguishing and Labeling Differences The vast majority of human differences are ignored and therefore socially irrelevant. Some, such as the size of ones feet, the color of ones car or the month of ones birth, are routinely overlooked. Others, such as eye color or right vs. left handedness are relevant in relatively few situations and are therefore typically inconsequential in the large scheme of things. But other differences, such as one's skin color, IQ, sexual preferences or gender are highly salient in the United States at this time. The point is that there is a social selection of which human differences are considered relevant and consequential and which are not. The importance and even the existence of this process is often overlooked, because once differences have been identified and labeled, they are typically taken for granted as being just the way things are B there are black people and white people, deaf people and hearing people, people who are handicapped and people who are not. In order to highlight just how social this social selection of human differences is, however, consider the substantial simplification that is required to create such groups. One example is the rarely questioned assignment of individuals to categories of "black" or "white" when there is no clear demarcation between these categories and enormous variability within categories on any criteria one can think of, even attributes like skin color, parentage, or facial characteristics that are considered the defining characteristics of the categories (Fullilove 1998). The same is true for other categorizations like gay or straight, blind or sighted, handicapped or not. When we turn attention to medical conditions, we note that they vary dramatically in the extent to which they or their attributes are selected for social salience. Hypertension, bone fractures, and melanoma are not nearly as socially relevant as are incontinence, AIDS and schizophrenia. Again the importance and social relevance of the latter characteristics are frequently taken for granted, and we would consequently find it very easy to enumerate the reasons that people consider these to be important human categories. Still, the selection for social salience is a social accomplishment that must be an important part of any thorough study of the stigma associated with different diseases. Component #2 B Linking Human Differences with Negative Attributes The second component of stigma occurs when human differences become associated with undesirable attributes. This aspect of stigma, highlighted by Goffman (1963), has been a central part of the conceptualization of stigma. In our terms, this aspect of stigma involves a label and a stereotype -- the label links a person to a set of undesirable characteristics that form the stereotype. This component is exemplified in a vignette experiment conducted by Link et al. (1987). The investigators experimentally manipulated labeling, tagging a random half of the vignettes former mental patients and the other half former back-pain patients. They also measured the extent to which respondents believed that mental patients in general were dangerous. When the vignette described a former back-pain patient, beliefs about the dangerousness of people with mental illness played no part in social distancing responses. However, when the vignette described a former mental patient, these beliefs were potent predictors of rejecting responses: respondents who believed mental patients were dangerous reacted negatively to the person described in the vignette as a former mental patient. For many people, apparently, the "mental patient" label linked the described person to stereotyped beliefs about the dangerousness of people with mental illness, which in turn led them to indicate a desire for social distance from the person. Component #3 B Separating "Us" from "Them" The third component of stigma occurs when social labels connote a separation of us from them (Morone 1997; Devine, Plant, and Harrison 1999). United States history and politics offer many examples of established old order Americans defining Native American people, African American slaves, and successive waves of immigrants as the "them" who were very different from "us." Few groups were wholly spared. For example, Morone (1997) quotes Benjamin Franklins observations on Dutch immigrants ("them") and English colonists ("us"). "Already the English begin to quit particular neighborhoods, surrounded by the Dutch, being made uneasy by the disagreeableness of dissonant manners... Besides, the Dutch under-live, and are thereby enabled to under-work and under-sell the English who are thereby extremely incommoded and consequently disgusted (Franklin 1752). The separation of "us" and "them" is closely linked to other components of the stigma process. For example, the association of labels with undesirable attributes (Component #2) provides the rationale for viewing the negatively labeled persons as fundamentally different from those who dont share the label B different kinds of people. In the extreme, the stigmatized group is thought to be so different from "us" as to be not really human, and all manner of horrific treatment of "them" becomes possible. The separation of "us" from "them" is sometimes apparent in the very nature of the labels conferred. Incumbents are thought to "be" the thing they are labeled (Estroff 1989). For example, we would say that a person has cancer, heart disease or the flu, but people often say that a person is a schizophrenic or an epileptic. Someone who suffers from heart disease is one of us, a person who just happens to be beset by a serious illness, whereas a schizophrenic is a different kind of person - one of them. Component #4 -- Status Loss and Discrimination In this component of the stigma process, the labeled person experiences status loss and discrimination. Most definitions of stigma do not include this component, but as we shall see, the term stigma cannot hold the meaning we commonly assign to it when this aspect is left out. In our reasoning, when people are labeled, set apart and linked to undesirable characteristics, a rationale is constructed for devaluing, rejecting, and excluding them. Thus people are stigmatized when the fact that they are labeled, set apart and linked to undesirable characteristics leads them to experience status loss and discrimination. Component #5 B The Dependence of Stigma on Power It takes power to stigmatize. The role of power is often overlooked, because social, economic and political power differences may be so taken for granted as to seem unproblematic. When we think of mental illness, obesity, deafness, and having one leg instead of two, we tend to focus on the attributes associated with these conditions rather than on power differences between people with and without the conditions. But power, even in these circumstances, is essential to the social production of stigma. The essential role of power can be illustrated by considering the ability of low-power groups to stigmatize others. Although members of low-power groups may engage in components of the stigma process, such as labeling and stereotyping, lack of power limits their ability to fully stigmatize members of a higher-power group. For example, patients in a treatment program for serious mental illness are likely to identify and label human differences in psychiatric staff. They may label certain clinicians as "pill pushers" and link the label "pill pusher" to negative characteristics such as being "cold," "paternalistic," and "arrogant." They may categorize "them" -- the pill pushers -- as distinct from "us." Finally, they might treat "pill pushers" differently in accordance with these negative views by avoiding them, undermining their treatment plans, exchanging derogatory comments and jokes about them, and so on. Thus the patients might engage in every component of stigma we have identified. Nevertheless, we would not consider the psychiatrists targeted for this treatment to be a stigmatized group. The patients lack the social, cultural, economic and political power needed to translate their negative cognitions and behaviors into any significant consequences for the staff. Similar scenarios could be described for all sorts of circumstances in which relatively powerless groups create labels and stereotypes about more powerful groups and treat members of the more powerful group in accordance with those stereotypes but without serious consequences for the powerful group. Without reference to power, stigma would become a very different and much broader concept that might be applied to lawyers, politicians, Wall Street traders and white people. Stigma depends on power. To understand whether stigma is occurring, then, it is critical to ask the following set of questions: Do the potential stigmatizers have the power to insure that the human difference they recognize and label is broadly identified in the culture? Do they have the power to insure that the culture recognizes and deeply accepts the stereotypes they connect to the labeled differences? Do they have the power to separate us from them and to have the designation stick? And do they control access to major life-domains like educational institutions, jobs, housing and health care so as to attach real consequences to the distinctions they draw? To the extent that the answers to these questions are yes, we can expect stigma to result. To the extent that the answers are no, although many cognitive and behavioral components of stigma might be in place, what we generally mean by stigma would not exist. Mechanisms Producing Stigma-related Discrimination Direct Discrimination This standard way of conceptualizing the connection between labeling/stereotyping and discrimination points to direct discriminatory behavior on the part of the person who holds the stereotyped beliefs. In this approach, the importance of attitudes and beliefs are thought to lie in whether person As labeling and stereotyping of person B leads person A to engage in some obvious forms of overt discrimination directed at person B, such as rejecting a job application, refusing to rent an apartment and so on. There are several studies that when taken together offer compelling evidence that this form of discrimination occurs with some regularity in the lives of people who are stigmatized. In an experiment, Page (1977) demonstrated clear-cut discrimination in landlords reports of apartment availability by varying whether a prospective tenant indicated that he/she was calling as a patient from a psychiatric hospital or from another setting. There is also evidence from non-experimental studies of real-world circumstances in which people with mental illnesses receive less than adequate treatment following a myocardial infarction. Druss and colleagues (2000) demonstrate that, like women and ethnic minorities, people with schizophrenia are less likely to receive state-of-the-art procedures such as angioplasty or coronary artery bypass graft following myocardial infarction than are people who have similar physical conditions but do not have schizophrenia. Finally, Wahl (1999) asked a large sample of consumers of mental health services about experiences of rejection and found that sizeable minorities reported being denied educational opportunities, jobs, apartments and health insurance. Thus reports from investigator constructed experiments, from quasi-experiments conducted in real world settings and from surveys of consumers converge to indicate that direct discrimination occurs with unacceptable regularity in the lives of people with mental illnesses. But direct discrimination is not the only way in which discrimination can occur. Structural Discrimination This form of discrimination sensitizes us to the fact that many disadvantages can result outside of a model in which one person consciously does something bad to another (direct discrimination). In the United States, structural discrimination is clearly evident with regard to differences in life chances between African Americans and whites (Hamilton and Carmichael 1967). For example, employers (more often white) rely on the personal recommendations of colleagues or acquaintances (more often white and more likely to know and recommend white job candidates) for hiring decisions. In instances like these, there is no direct denial of a job to an individual African American because of his or her race, and the employer offering a job in such an instance need not hold racist beliefs. Yet, discrimination has clearly occurred. Does this kind of discrimination affect other stigmatized groups as well? Consider some possible examples of structural discrimination against people with schizophrenia. Suppose that, because it is a stigmatized illness, less funding is dedicated to research on schizophrenia than for other illnesses, and less money is allocated for its care and management. As a consequence, people with schizophrenia are less able to benefit from scientific discoveries than they would be if they happened to develop a different illness. Further, the resources available to deliver state-of-the-art treatments are not as well developed as they are for less stigmatized illnesses. Consider further that, as a result of historical processes influenced by stigma, treatment facilities tend to be located either in isolated settings away from other people (Rothman 1971) or in some of the most disadvantaged urban neighborhoods in communities that do not have enough clout to exclude this stigmatized group from their midst (Dear and Lewis 1986). These disadvantaged communities tend to have higher rates of crime, more pollution, higher rates of infectious disease, and inadequate medical care. To the extent that the stigma of schizophrenia has created such a situation, a person who develops this disorder will be the recipient of structural discrimination whether or not anyone happens to treat him or her in a discriminatory way because of some stereotype about schizophrenia. He or she will receive less of the good things and more of the bad things as a simple consequence of having developed a stigmatized illness B stigma has affected the structure around the person, in turn exposing the person to a host of untoward circumstances. Social Psychological Processes Operating through the Stigmatized Person Once a cultural stereotype is in place, it can affect labeled persons in other important ways that, like structural discrimination, do not involve obvious forms of discriminatory behavior. For example, according to a modified labeling theory about the effects of stigma on people with mental illnesses (Link 1982; Link, Cullen, Struening, Shrout, and Dohrenwend 1989), people develop conceptions of mental illness early in life as part of their socialization into our culture (Angermeyer and Matschinger 1996; Scheff 1966; Wahl 1995). Once in place, these conceptions become a lay theory about what it means to have a mental illness (Angermeyer and Matschinger 1994; Furnham and Bower 1992). People form expectations as to whether most people will reject an individual with mental illness as a friend, employee, neighbor, or intimate partner and whether most people will devalue a person with mental illness as being less trustworthy, intelligent, and competent. For a person who develops a serious mental illness, these beliefs take on a special poignancy, because the possibility of devaluation and discrimination becomes personally relevant. If one believes that others will reject and devalue people with mental illnesses, one must now fear that this rejection applies personally. To the extent that it becomes part of a persons world view, that perception can have serious negative consequences. Expecting and fearing rejection, people who have been hospitalized for mental illnesses may act less confidently and more defensively with others, or they may simply avoid a threatening contact altogether. The result may be strained and uncomfortable social interactions with potential stigmatizers (Farina, Allen, and Saul 1968), more constricted social networks (Link et al. 1989), a compromised quality of life (Rosenfield 1997), low self-esteem (Wright, Gronfein, and Owens 2000), depressive symptoms (Link, Struening, Rahav, Phelan, and Nuttbrock 1997), unemployment and loss of income (Link 1982; Link 1987). Again note that, in the modified labeling theory, no one in the immediate context of the person needs to have engaged in obvious forms of discrimination. Rather, the discrimination rests in the formation and sustenance of stereotypes and lay theories, processes that lie anterior to the immediate situation. Still, as with structural discrimination, the consequences are sometimes severe and undoubtedly contribute greatly to differences in the life chances of people with mental illnesses. Stigma as a Persistent Predicament Our conceptualization draws attention to one way in which stigma is a persistent predicament B why its negative consequences are so difficult to eradicate. When powerful groups negatively label and stereotype a less powerful group, the range of available mechanisms for achieving discriminatory outcomes is both flexible and extensive (Lieberson 1985). We mentioned three generic types of mechanisms B direct discrimination, structural discrimination and discrimination that works through the stigmatized persons beliefs and behaviors. But these broad designations comprise a whole multitude of specific mechanisms B there are many ways to directly discriminate, many ways to achieve structural discrimination, and many ways in which stigmatized persons can be discouraged from believing they should enjoy full and equal participation in social and economic life. Moreover, if current mechanisms are blocked or become difficult or awkward to use, new ones can be created. If stigmatized persons cannot be convinced to voluntarily accept their lower status and inferior rewards, direct discrimination can be used to accomplish the same outcome. If direct discrimination becomes ideologically difficult, forms of structural discrimination B like locating people with schizophrenia in disadvantaged areas of the city B can achieve some of the same ends. Stigma thereby becomes a persistent predicament in the following sense B as long as stigmatizers sustain their negative view of the people they would stigmatize, decreasing the use of one mechanism through which disadvantage can be accomplished simultaneously creates the impetus to increase the use of another. The Importance of Stigma Processes in Understanding the Distribution of Life Chances. Stigma processes have a dramatic and probably under-recognized influence on the distribution of life chances, whether those life chances refer to careers, earnings, social ties, housing, criminal involvement, health or life itself. Most research examines the stigma associated with one circumstance at a time (e.g. AIDS, obesity, mental illness, race, gender, homosexuality etc.), and most assesses only one outcome at a time (e.g. earnings, self esteem, housing, social interactions etc.) Proceeding in this way, researchers often find some effect of stigma on a particular outcome for a particular stigmatized group. However, for a given outcome, it is usually true that many factors other than stigma also influence the outcome, so that stigma is left as just one factor among many. This can lead to the conclusion that, although stigma matters, it has relatively modest effects compared to other factors. Such a conclusion is misguided for two reasons. First, one must keep in mind that the stigma associated with any particular characteristic, such as AIDS, simultaneously affects many life chances, not just one. Thus a full accounting must consider the overall effect on a multitude of outcomes. Second, there are a host of stigmatizing circumstances that need to be considered to understand the full impact of stigma on any particular life outcome, such as self esteem. A full assessment of the impact of stigma on such an outcome must recognize that many stigmatizing circumstances contribute to that outcome and not just the one selected for the particular study in question. For these reasons, stigma processes likely play an even greater role in life chances than current research suggests. As a preliminary exploration of these ideas, we examined data from a sample of 487 people, representative of the 48 contiguous United States (see Link et al. 1995 and Phelan et al. 1999 for a detailed description of the sample). These data are instructive because they assess a diverse set of potentially stigmatizing circumstances and two possible consequences of these stigmatizing circumstances B low self-esteem and poor health. The stigmatizing circumstances assessed include having experienced 1) hospitalization for mental illness, 2) multiple marriages (3+), 3) eviction, 4) extreme poverty as indicated by not having enough food to eat, 5) being a foster child, 6) being held back in school, 7) being an orphan, 8) being currently unemployed and 9) being currently on welfare. Self-esteem was assessed using a five-item scale derived from Rosenbergs 10-item scale. We assessed poor health using 1) self-reported health (poor or fair = 1; good, very good, excellent = 0) and 2) a self-report of ever having been unable to work for a month or more because of physical health problems. We used multiple regression to examine the association between the potentially stigmatizing circumstances and self-esteem. If we were to have focused only on one stigmatizing circumstance at a time we would have concluded that the selected circumstance had a small to moderate association with self-esteem. For example, mental hospitalization (4%), having been an orphan (1%), multiple marriages (.7%), and being unemployed (2.1%) explain only moderate to small proportions of variance in self-esteem. But when all of these circumstances are considered together they explain a full 20.2% of the variance above and beyond the effects of age, years of education and gender. In fact the variance explained by the stigmatizing circumstances turns out to be 9 times greater than the combined effect of age, gender and educational attainment. When we turn to physical health we note that the stigmatizing circumstances are, taken together, too rare to account for the relatively large proportion of people experiencing poor health (15.8% fair or poor self-reported health and 36.1% out of work for a month or more due to physical illness). The stigmatizing circumstances range in prevalence from 1% to about 10% (the only exception is being held back at 16.8%). As such, none could be expected to individually explain a large proportion of cases of poor health (that is, the attributable risk of any one of the characteristics cannot be high). But 39% of the sample have at least one of the potentially stigmatizing circumstances. Thus exposure to some form of stigma is quite common and could therefore account for far more cases than one might have thought in an analysis that considered only one form of stigma at a time. Viewed from a slightly different vantage point, only six of a possible 18 associations (9 stigmatizing circumstances x 2 health conditions) are significantly related to poor health. A major reason for this is that power is low for very rare conditions. Proceeding with a focus on only one stigmatizing circumstance at a time might give the impression of a weak, highly variable and inconsistent connection between stigma and health. But shifting focus to a consideration of having any one of the stigmatizing circumstances yields a very different conclusion. A person who is exposed to any one of the stigmatized circumstances is substantially and significantly more likely to have poor physical health and to have been unable to work for a month or more than a person who has none of them (24% versus 11% and 48% versus 28% respectively). Logistic regressions show that this association remains strong with controls for age, gender and education and that the effect of stigma compares to the frequently cited effect of education in terms of the magnitude of its association with the indicators of poor health. Of course not all of the substantial effect of these circumstances can be attributed to stigma processes per se. To a greater or lesser extent various ones of the stigmatizing circumstances may involve disability or other associated attributes that influence self-esteem and health through mechanisms that do not involve stigma. Still, starting the parsing process with 20% of the variance when one includes multiple stigmatizing circumstances is very different than starting 1 or 2% when one considers only one of them. Moreover, when we consider that our list of stigmatizing circumstances is really only a small sample of a large population of such circumstances we must recognize that even the 20% of variance is probably a dramatic underestimate of the association between stigmatizing circumstances and self-esteem. Viewed comprehensively stigma probably plays a major role in shaping access to a broad array of life chances including mental and physical health. Why Stigma Matters for Public Health Health and life itself were included in the list of so called life chances considered above and the examples we provided indicated that stigma may have a strong effect on health. In order to understand why stigma might be related to health it is useful to consider effects on 1) the etiology of diseases and health conditions other than the stigmatized condition and 2) the course and outcome of the stigmatized medical condition itself. Stigma As a Social Cause Of Disease Stigma and Stress. One important way in which stigma can contribute to disease is by generating stressful circumstances and compromising a persons ability to cope with those circumstances. In this scenario, we are thinking of the impact of the stigma of one illness on the likelihood of developing other illnesses. One way to think about stigma-induced stress is in terms of blocked striving. To the extent that discrimination occurs through one of the broad band mechanisms we described above B direct discriminatory behavior by others, structural discrimination, or discrimination that operates through the stigmatized person B the stigmatized person is held back and receives fewer of the good things and more of the bad things our social and economic system has to offer. This kind of blocked striving has been posited as an important source of strain in peoples lives (Merton 1938) that has harmful consequences for mental and physical health (Gibbs and Fuery 1994). Another way to think about stigma-generated stress is to recognize that discrimination produces stressful events B bad circumstances that threaten security. For example, when community-based treatment facilities for people with mental illnesses are located in poor, disorganized and dangerous sections of the city, people with mental illness are placed at higher risk of excessive noise, deteriorated housing and crime victimization. A third way in which stigma induces stress is through the strain of coping with the ever-present possibility of being stereotyped, rejected or discriminated against. For example, social epidemiologist Sherman James puts forward the concept of what he calls John Henryism -- the tendency for some African Americans to work extremely hard and with great pressure to disprove the stereotype of laziness and inability. According to James et al. (1984), under some conditions this coping effort bears costs in the form of hypertension. Finally, stigma can erode generic coping resources such as self-esteem and self efficacy. Although stigma does not always impair these coping resources, it frequently does B sometimes dramatically so (Link et al. 2001). To the extent that it does, stigma will compromise coping capacity and influence stress-related outcomes even if the origin of the stressful exposure has nothing to do with stigma or discrimination. Stigma as a Fundamental Cause of Disease. Stress is by no means the only way through which stigma may be harmful to ones health. Link and Phelan (1995, 2000) propose that some social conditions have a persistent connection with disease because they determine exposure to risk and protective factors no matter what the risk and protective factors are in a given place or at a given time. This is one reason why socioeconomic status (SES) has had such a robust association with disease and death across historical periods that differ so dramatically in terms of risk and protective factors, diseases, and health care systems B people with greater resources of knowledge, money, power, prestige and social connections are better able to avoid risks and to adopt protective strategies no matter what these factors happen to be at a given time. SES is a fundamental cause in the sense that it generates and regenerates mechanisms that link it to disease. Similarly, through various mechanisms of discrimination, stigma places a person at a significant social disadvantage with respect to knowledge, money, power, prestige, and social connections. To the extent that it does, it influences access to protective factors and exposure to risk factors so as to shape patterns of disease and death. Like SES, stigma will have this effect no matter what the risk and protective factors are in a given place or time. To make this concrete, consider once again the example of the placement of treatment facilities for people with serious mental illnesses in the poorest, most disorganized sections of our cities because of stigma-related Not In My Back Yard (NIMBY) sentiments. These disadvantaged communities tend to have higher rates of crime, more pollution, higher rates of infectious disease, and inadequate medical care. People with mental illnesses will receive less of the things that are good for health and more of the things that are bad for health as a consequence. Repeat this circumstance over the range of circumstances that influence health, and one is led to the prediction that stigmatized persons will experience worse health because of stigma. Stigma Shapes the Course and Outcome of the Stigmatized Disease Just as the stigma associated with an illness such as schizophrenia or AIDS may cause or exacerbate other illnesses, stigma may also have a negative impact on the clinical course and other outcomes, such as social and occupational functioning, of the stigmatized illness itself. One way in which this can occur is through the same kind of stigma-related stressful circumstances discussed above. To the extent that stress is involved in relapses or exacerbations of a condition, any stigma processes that generate stress will contribute to exacerbations or relapses of the condition in question. In addition, however, there are more specific ways in which the stigma associated with a disease leads to negative outcomes for that disease. These have to do with access to and utilization of effective treatments. One very important way in which access to treatment is blocked is when people fear being identified and labeled as having a stigmatizing condition and therefore delay or avoid seeking treatment when they develop such a condition. Similarly, individuals who have already been identified and labeled may seek to distance themselves from the stigmatizing label by avoiding treatment, thereby becoming noncompliant with treatment regimens. When either of these processes operate, people miss the benefits of effective treatments. A second way stigma may influence access to treatment is by creating undesirable conditions in treatment settings that make help-seeking far less desirable than it would otherwise be. For example, there exists a tremendous fear of people with psychosis that is out of proportion to the actual risk that such people pose (Link et al. 1999). To the extent that this fear increases the presence of guards, locked wards, searches, barbed wire and the like, stigma produces very negative circumstances in treatment settings that could understandably make people want to avoid those settings. Similarly, if less money is allocated for the treatment of stigmatized illnesses, the facilities where treatment is provided may not be as pleasant, clean or safe as they should be, thereby creating substantial disincentives for attending or attending regularly. A third way stigma influences access to effective treatment can only be recognized by thinking broadly across diseases and time. Reasoning from this vantage point, we see that a stigmatized illness may have received less attention over the years with fewer research and treatment dollars being allocated to that disease. As a consequence, the effectiveness of treatment for the disease lags behind the effectiveness of treatment for other diseases. Thus, when people develop a stigmatized illness, they receive less effective care than they would have received if the disease they developed were not a stigmatized one. What Do We Need to Know? In presenting a review and conceptual analysis of stigma, our goal has been to contribute to a fuller appreciation of the possible impact of stigma on peoples lives. The claims we make about the broad impact of stigma on health and well-being represent a declaration concerning the fundamental importance of stigma processes. Although stigma research is definitely on the rise, and although this conference represents an important indication of an upswing in concern at the national level, if stigma is indeed as important as we claim, then it has been and continues to be a dramatically under-emphasized and under-addressed phenomenon. In light of this, it is critically important for research to examine empirically some of the possibilities we have presented. In some cases, there exists relatively strong evidence to support connections between stigma and negative health consequences, in other instances the connections we have drawn are simply reasonable possibilities in need of empirical investigation. We need more basic research on stigma and its health consequences to fill in these areas of uncertainty. In addition to basic research, at least two types of evaluation research are needed. The first is the familiar and critically important type of research that evaluates carefully designed intervention programs. In studies like these, investigators devise interventions based upon current knowledge and do rigorous evaluations to determine whether the intervention is, in fact, effective. Much more research of this kind is needed, particularly in the area of the health consequences of stigma. But another type of evaluation research is also needed. Efforts to address stigma are not the exclusive domain of professional psychologists, sociologists or social workers. Many anti-stigma campaigns are in some ways social movements carried out by interest groups, by concerned citizens or by the people who are themselves stigmatized. Whether focused on health conditions or other circumstances, social movements can have enormous impacts. Research is needed so that we can comprehensively assess the impact of the anti-stigma efforts that are currently underway. Finally, if future research is to capture the full impact of stigma-related processes, the agenda needs to be broad. We run a real risk of underestimating the overall impact of stigma by parceling our efforts up into the stigma of this and the stigma of that. While some specialization of this sort is both necessary and desirable, it will be important to keep a broader vision so that the overall impact of stigma on public health is not lost. 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Stigma Interventions and Research for International Health Background paper Stigma and Global Health: Developing a Research Agenda An International Conference 5-7 September 2001 Mitchell G. Weiss, M.D., Ph.D. Professor and Head Department of Public Health and Epidemiology Swiss Tropical Institute Socinstrasse 57 CH4002 Basel, Switzerland E-Mail:  HYPERLINK "mailto:Mitchell-G.Weiss@unibas.ch" Mitchell-G.Weiss@unibas.ch and Jayashree Ramakrishna, Ph.D., MPH Additional Professor and Head Department of Health Education National Institute of Mental Health and Neuro Sciences Bangalore, India 3 December 2001 Abstract The concept of stigma is rooted in history and social science, but the historical concept of physical stigmata and the sociological framework of deviance and social interactions fall short as a guide to public health interventions and research to eliminate or mitigate undesirable stigma. A wide range of social phenomena, usually undesirable but not necessarily so, may be considered under the heading of stigma. For public health, however, a suitable framework requires a working definition of stigma that recognizes the distinctive features of particular diseases in particular social and cultural contexts. One or a combination of various approaches to interventions may focus on controlling or treating target health problems, countering tendencies of those who stigmatize others, and supporting those who are stigmatized. Stigma may also influence social policy with effects on research priorities, human rights, and access to health care and social services. Research needs include documenting the burden from the stigma of various health problems; comparing stigma for different conditions and in different health system, social, and cultural settings; and evaluating practical approaches for intervention programs. Such research should consider stigma from various vantage points; these include the experience of stigma among persons with a targeted health problem, and stigmatizing ideas and behaviour in the general population and among health care providers and community leaders. Our review of health studies of stigma considers its role in specific mental health problems and tropical diseases, mainly in low- and middle-income countries. We also discuss the limitations of this research and the need for complementary quantitative, qualitative, problem-specific, and culture-specific approaches to research for effective interventions. Stigma Interventions and Research for International Health Stigma has become an increasingly important priority for health policy and research. The topic encompasses a broad set of interests and specifies a field of study, however, that without critical rethinking may be too broad to contribute as much as we expect to health policy. The diversity of international health problems and the complexity of their social and cultural settings make questions of stigma even more challenging. Too little attention has been paid to the concept of stigma, distinct from its impact; careful consideration of the particular features of a useful formulation to guide public health policy and action is needed, especially with respect to the stigmatizing diseases of low- and middle-income countries. As we critically review of the topic, we begin by considering a few key points from the seminal contribution of the sociologist Erving Goffman. Considering its enduring influence on the field after nearly four decades, Goffman's (1963) treatise may be regarded as the canonical text for students of stigma. As we revisit his formulation and consider its relevance for public health, however, it is also important to recognize its limitations. Goffman's formulation of stigma was a product of the 1950's in North America when deviance and conformity to a social standard were matters of serious concern. Politics, ethnicity, and even the length of one's hair were interpreted with reference to a standard that indicated little regard for the values of cultural pluralism. His treatise was also conceived as a contribution from a specialist in social interaction to social science theory and not as an applied work, even though many of its insights may stimulate and inform applications. In the subtitle, "Notes on the management of spoiled identity," management means something different from the kind of management that managers and policymakers take as their responsibility; it refers to the ways that people in society manage themselves in the course of social interactions. In searching for fundamental principles to explain this aspect of social process, Goffman took on a very broad agenda. His gloss of the term stigma at the outset, as "the situation of the individual who is disqualified from full social acceptance," indicated the immense scope of the topic he had in mind. The variety of conditions that may elicit adverse social judgments is essentially limitless, and the field of stigma studies maintains this broad agenda. For example, a recent book by Gerhard Falk (2001) identifies women, the mentally challenged, homosexuals, single people, prostitutes, African-Americans, the overweight, and even successful people, among others, as targets of stigma. Daunted by the diversity of stigmatized conditions and the "vague and uncritical" conceptualization and use of the term to characterize such a diverse group of social phenomena, some authors identify the need for caution in approaching the study of a concept of stigma with such immense scope (Stafford and Scott 1986). The matter is further complicated by recognition that not all stigma is equally bad, and that some forms of stigma in proper measure may even serve a useful social function. Efforts to avoid stigma may motivate moral and ethical behavior; for some it may prevent suicide or substance abuse, and it may motivate self-help and appropriate medical help seeking. In reflecting on the topic, Goffman himself recognized the inherent problem of efforts to extract a commonality from the diverse conditions that attract stigma. As a scholar, he also appeared to question the explanatory power of a dichotomy characterized by the opposition of conformity and deviance; he hesitated (though not for long) to use the term deviance to characterize the common feature of stigmatized people and groups. "It is remarkable," he wrote, "that those who live around the social sciences have so quickly become comfortable in using the term 'deviant', as if those to whom the term is applied have enough in common so that significant things can be said about them as a whole" (Goffman, 1963, p. 167n). Backing off somewhat from pursuing this line of reasoning, Goffman concluded that sufficient common features justified study of stigma with reference to diverse groups, but he also recommended studying how they differ. This is an especially important consideration for health researchers whose interests reside not so much in developing sociological theories, but rather in a practical appreciation of the impact of stigma and how it operates with reference to particular health problems and in particular settings . Why health research is concerned with stigma Several reasons explain why stigma is such an important consideration for health policy and clinical practice. It adds to the illness burden in various ways, and it may delay appropriate help-seeking or terminate treatment for treatable health problems. For diseases and disorders that are highly stigmatized, the impact of the meaning of the disease may be as great or a greater source of suffering than symptoms of the disease. For example, paucibacillary leprosy may present at an early stage as a painless depigmented or anaesthetic patch; hearing the diagnosis is likely to be more troubling than these symptoms. The emotional impact of such illness meanings indicates the various ways by which stigma operates. Social science research on stigma regards it fundamentally as a problem arising from social interactions. But Goffman and other researchers have also recognized self-perceived stigma, which may be as troubling whether or not it arises from an actual interaction, and whether or not this perceived stigma accurately reflects the critical views of others. In either case, stigma may impair the quality of life from concerns about disclosure, and effects on work, education, marriage, and family life. Although its impact is likely to be overlooked in the calculation of Disability-adjusted life-years (DALYs), stigma contributes to what a WHO fact sheet identifies as the hidden burden of mental illness (WHO 2001), and it constitutes a hidden burden for other stigmatized conditions as well. In addition to the suffering it brings, research also shows that stigma and labelling may affect the course of recovery (Link et al., 1991; Wahl 1999) The stigmatization of HIV/AIDS and specific groups at risk, such as men who have sex with men and injection drug users, interferes with voluntary testing, counselling and treatment. Timely treatment benefits the individual and society, inasmuch as it reduces suffering, improves health and productivity, and limits opportunities for spread (Chesney and Smith, 1999). The distressing prospect of having a stigmatized condition, which is further associated with stigmatized status in society, may be an inducement to ignore or conceal it and forego the kind of help that one might readily acknowledge as useful if the condition were affecting someone else. Although denial may relieve the anxiety that follows from stigma, denial is a problem when a treatable condition remains untreated and progresses to cause avoidable suffering. Leprosy, which has long been the gold standard of stigmatized diseases, may progress later in its course to preventable deformities. Tuberculosis not only becomes more serious for the infected individual, but also poses a threat for contacts and further spread. People with untreated mental health problems may endure an avoidable progression of symptoms that may also make their condition more difficult to treat. For diseases that require a long course of treatment, or chronic disorders that require chronic treatment, like epilepsy, stigma constitutes an obstacle to remaining in treatment. Rethinking stigma for health research In formulating a useful concept of stigma for public health, it is important to identify its salient features that are amenable to study and may guide policy for managing and reducing the impact of stigma. Elements of Goffman's concept of spoiled identity and features of exclusionary and rejecting social process that are elements of the classical theory remain relevant. To clarify the interests of health research on stigma, we propose consideration of the following working definition, which supports the premise that health policy and research is concerned with mitigating stigma by eliminating, minimizing or effectively coping with it. We hope that in the context of this background paper, such a formulation may prove useful in refining the intent of research: Stigma is a social process or related personal experience characterized by exclusion, rejection, blame, or devaluation that results from experience or reasonable anticipation of an adverse social judgment about a person or group. This judgment is based on an enduring feature of identity conferred by a health problem or health-related condition, and the judgment is in some essential way medically unwarranted. In addition to its application to persons or a group, the discriminatory social judgment may also be applied to the disease or designated health problem itself with repercussions in social and health policy. Other forms of stigma, which result from adverse social judgments about enduring features of identity apart from health-related conditions, may also affect health; these are matters of broader interest in the study of stigma as it applies to social and health research. It is important to note that efforts to distinguish stigmatizing behavior from appropriate precautions for some health problems may require consideration of a delicate balance of public health risks and restrictive or exclusionary treatment or policy justified by compelling medical and epidemiological evidence. Though exclusionary, such behavior is different from what we mean by stigma as the term is understood in the context of public health. For example, measures to protect health personnel from actively infectious patients with tuberculosis may be appropriate, such as wearing a protective mask when interacting with them, even though the same behaviors would be stigmatizing after treatment has begun and risk of infection from them eliminated. Similarly, health personnel avoiding contact with patients treated for leprosy who are no longer infectious is indeed stigmatizing, inasmuch as such behavior suggests that a conflicting social judgment has inappropriately overridden a medical judgment. Research is concerned with the questions of how much risk to others there may actually be, and how effective or counterproductive any exclusionary measures to deal with that risk actually are. It is also important to note that health research studies of stigma should recognize that the manifestations of the "exclusion, rejection, blame, or devaluation" and the nature of the adverse social judgments are likely to vary as they apply to different health problems. For example, isolation of a patient with acute immune suppression may be seen in a positive light. In formulating objectives and methods for stigma research, the investigator should identify the particular features of the health problem that require attention and motivate study. In this regard, the interests of health studies of stigma differ from social research on stigma, which is more concerned with the broader social theory than the practical application. Furthermore, one should also recognize that the nature of stigma may vary in different cultures; these cultural differences affect both what is stigmatized and how stigma is manifest. Although some authors have acknowledged differences in what is stigmatized from one setting to another (Becker and Arnold, 1986), less has been written about cultural differences in the articulation of the adverse social judgments that are an essential feature of our formulation of stigma for public health. Studies of the magnitude and nature of stigma need to account both for the disease-specific and culture-specific aspects of stigma. This means that classical approaches to epidemiological research must be modified. A single scale or instrument is likely to be inadequate to fulfill the needs for disease-specific and culture-specific studies of stigma. Cultural epidemiological approaches provide an approach for attending to local concepts and categories with anthropological and epidemiological methods that include quantitative and qualitative assessments (Weiss 2001). Research on AIDS-related stigma in the United States has produced an action-oriented conceptual framework for research and a multi-pronged agenda for reducing this stigma. Attention to disease-specific and culture-specific features of HIV/AIDS has been impressive and instructive. A special issue of the journal American Behavioral Scientist (April 1999) reviews the various aspects of the topic in a series of papers that originated in an NIMH workshop developing a conceptual framework specifically for dealing with AIDS-related stigma in the United States (NIMH 1996). Topics included an overview of AIDS and stigma (Herek 1999), the interaction of AIDS stigma and sexual prejudice (Herek and Capitanio 1999), the impact of policy and law on people with HIV/AIDS (Burris 1999), and others. By linking an action agenda to context, this body of work from experience in the United States demonstrates the value of disease and culture specificity, and it tacitly highlights the need to carefully develop specific strategies for managing the stigma arising from other diseases in the vastly different settings of low- and middle-income countries. Priority of stigma for infectious diseases in low- and middle-income countries The importance of stigma for research and control of tropical diseases has been widely acknowledged. Among them, no disease has been more closely associated with it than leprosy, and it has become a metaphor for stigma. Although the WHO Special Programme for Research and Training in Tropical Diseases (TDR) has been concerned with the impact of stigma for various diseases, leprosy is the only TDR disease for which explicit and exclusive studies of stigma have been supported (Boonmongkon 1994; Paz et al., 1990). Like HIV/AIDS, the motivation for examining the stigma of leprosy has been to help manage the social exclusion, the emotional suffering, and the barriers to effective health care that follow from local cultural meanings of the disease. The impact of leprosy stigma explains some paradoxical preferences in the utilization of health services. Although the availability of nearby health facilities is usually considered an indication of their accessibility and responsiveness to needs, concerns about disclosure of the condition may make nearby health services for leprosy too close for comfort. The preference for more distant services has been documented in Nepal (Pearson, 1988), and the director of a large NGO in Ahmedabad, India, has observed a similar preference for more distant facilities among patients seeking treatment for TB (M. Uplekar, personal communication). Stigmatizing cultural meanings have a serious impact on the illness experience, help seeking, and treatment adherence for tuberculosis in other ways as well. In Southeast Asia stigma of TB is enhanced by association of TB with AIDS, and this has been shown to contribute to treatment delay for tuberculosis in an HIV high endemic area of Thailand (Ngamvithayapong et al., 2000). TB-related stigma, however, is a matter of much broader significance than just its association with AIDS. From research in Thailand, Johansson and colleagues (1999) distinguish two forms of stigma, based on social discrimination and on fears arising from self-perceived stigma. A community resident they quoted in reporting this research advised, "TB treatment takes a long time, and if people keep away from the sick person it will cause a lot of harm to go on with treatment" (p.865). The impact of TB stigma has also been emphasized in recent reports from low- and middle-income countries in other parts of the world, including West Africa (Lawn 2000) and East Africa (Liefooghe et al 1997). The potential for resistance, which increases when control measures fail, makes TB control an ever more important goal. With growing evidence that directly observed treatment (DOT) is effective, questions about the appeal, acceptability, and limitations of DOT programs become more significant. Why do substantial numbers reject them? In a recent study in the Pathanamthittha District of Kerala, Balasubramanian and colleagues (2000) reported that stigma and concerns about not being observed was responsible for 28% of patients not being observed in a DOTS program, and this was a substantially greater problem for women (50%) than for men (21%). Another study of social stigma in rural Pune District of Maharashtra showed that stigma interferes not just with participation in DOTS, but more generally with timely help seeking for TB. Morankar and colleagues (2000) found that 38 of the 80 patients they studied (40 men and 40 women) reported taking measures to hide their disease from the community. Social vulnerability contributed to women's reticence to disclose TB, and such women were typically widows or married and living in joint families. Both women and men who hid their disease sought treatment later than others of their respective sex who did not; being female contributed to the delay, and women who hid their disease sought treatment later than men who did not. Such questions about the effects of gender on TB have recently motivated TDR support of a multi-country study in Colombia, Malawi, India, and Bangladesh, in which quantitative and qualitative assessments, and cultural epidemiological study of stigma play an important role. Other TDR studies have considered the stigma that comes from the intense itching and socially undesirable scratching caused by onchocercal skin diseases. The itching is severe enough that some people report considering suicide. With the availability of ivermectin for annual treatment to control the disease in affected village communities of 16 endemic African countries, the question arose about whether the disease was a serious enough priority to justify mobilizing the resources needed to reach these people. Studies of illness experience also examined the stigma of the disease, and by documenting its role in the burden, findings helped to motivate establishment of the African Programme for Onchocerciasis Control (Pan-African Study Group, 1995). In this case management of stigma was tackled by enhancing efforts to control and eliminate the disease. A framework indicating the focus and approach for interventions to counter undesirable effects of stigma is indicated in Table1. Formulating strategies for particular health problems also requires careful consideration of appropriate interactions between global, national, and local priorities, policies, and resources (Weiss et al., 2001a). Table 1. Focus and approach to Interventions to Mitigate Stigma FocusApproachExample*Health problemPublic health to control the disease Early recognition and treatment for cure or disability preventionOnchocercal skin disease Leprosy StigmatizersIEC and social marketing to enhance compassion and reduce blame Correct misapprehensions of riskEpilepsy Various infectious diseases Emotional impact Counseling Peer support groups and therapeutic communitiesMost conditions Mental health problems Social policyAdvocacy, lobbying, and legislation Research supportHIV/AIDS Diseases of poverty  *Examples are illustrative but incomplete. Stigma-mitigating strategies are not limited to a single focus or approach. (See also Miller and Major 2000) Research Objectives To develop health policy sensitive to the adverse effects of stigma, several kinds of innovative research are needed. Although policy must be epidemiologically informed, the scope of required research to mitigate the effects of stigma--especially in low- and middle-income-countries--is much broader. Document the burden from the stigma of various health problems Appropriate indicators for a descriptive account of stigma, which may also be suitable for scales that facilitate comparison and analysis, are needed to characterize the role of stigma for particular health problems, in different health service settings, and across cultures. Such data indicates the priority of stigma for health policy and for training curricula of health care personnel. Qualitative, in-depth narrative accounts are needed to develop queries, scales, and instruments at the outset, so that they may ensure the validity of large quantitative assessments addressing relevant aspects of stigma and its impact. Qualitative and narrative accounts that complement survey data and elaborate features of stigma are needed to clarify the nature of the burden and indicate particular ways to deal with it. Wahl's (1999) study of mental illness provides an example of the effective use of qualitative data to clarify particular concerns about aspects of stigma identified in a survey. The dimensions of stigma constituting a framework for assessment include consideration of the following points: Reluctance to disclose the problem Exclusion or rejection from school, work, social groups and activities Blame and devaluation Diminished self-esteem Social impact on family Ability to marry and impact on existing marriage Compare stigma for different health problems and in different settings The distinctive features of various health problems, cultural data, and anthropological considerations indicate the need for comparative research. Health programs benefit from a comparative account of the role of stigma for different disorders in the same setting. It is also useful to see how stigma for the same disorders varies across treatment sites (eg, government and private allopathic services and various other kinds of health care facilities). Regional and cultural comparisons indicate how stigma operates in particular settings and provide opportunities to learn from experience at other sites confronting similar problems. Qualitative data play a key role in such comparisons. Identify determinants of stigma and the impact of stigma on other health policy priorities Key indicators of stigma and scales that provide an overall assessment may be studied analytically to answer questions and test hypotheses about the determinants and impact of stigma. An operational formulation and methods for assessing stigma should be used to examine how it influences outcomes of practical significance for public health and clinical practice. Various hypothesized effects of stigma suitable for study may include the lag time to first help seeking, treatment dropout, treatment response, and so forth. When a relationship is identified from quantitative data, analysis of qualitative data clarifies the nature of that relationship, which in turn contributes to the process of translating findings into policy and practice. The study of Raguram and colleagues (1996) provides an example of selectively extracting qualitative data to clarify a quantitative relationship between stigma and depressive symptoms. Evaluate changes in the magnitude and character of stigma over time and in response to interventions and social changes We expect the level and the features of stigma to vary in response to social changes and in response to interventions. For instance, although it is felt that the development of efficacious treatment helps to reduce stigma, this process needs to be documented. The way these changes vary among different segments of the population also requires study, especially among people with limited access to health services that make such treatment available. As health policy and program personnel become more aware of the importance of stigma, and as stigma intervention strategies are designed and implemented, evaluation research to track changes becomes increasingly important. Assessment of the effects of interventions on stigma helps to distinguish effective from ineffective approaches and to guide policy. The quantitative and qualitative assessments described above each contribute to the assessment of such changes over time. Specify background information about diseases and disorders so that laws and health policy have the information required to minimize stigma Fears and fantasies in the absence of scientific information provide fertile ground for stigma to flourish. Community understanding and social policy related to stigma need to be informed by research, so that laws and health policy are not influenced by stereotypes, prejudices, and unfounded speculation that magnify risk, or by misguided expectations about the benefits of restrictive policies. Basic health research on particular diseases, disorders, and conditions helps to minimize stigma or to provide a rationale for restrictive policies, if necessary, based on appropriate evidence. Examples of health problems for which stigma-relevant policy should be better informed by research include driving laws for people with epilepsy, assumptions about the dangerousness of specific subgroups of mental illnesses, and both the risk of spread and the impact of restrictive policies for controlling infectious diseases. Such research should contribute to the public understanding of health science related to stigma. Clinical interactions with patients, public health communications, and scientific writing should each be attentive to ways in which health professionals may contribute to stigma inadvertently and from insufficient self-reflection or consideration of their own prejudices. Clarify ambiguities arising from the need for clear and simple public health messages despite the complexity of stigma-reduction strategies Inasmuch as health information and programs that aim to reach a large segment of the public must be simple, and because health policy related to stigma may be highly complex, questions are likely to arise in the course of policymaking. Research is needed to identify and address them. For example, the final report of the NIMH AIDS and stigma workshop grappled with "the question of how AIDS educational messages can communicate the importance of taking responsibility for one's own safety from HIV (eg, through practicing safer sex) without also communicating the idea that people with HIV are blameworthy for their condition" (NIMH 1996). For TB control, one might also ask how to explain precautions concerning the risk of spreading tuberculosis for smear-positive patients, while also trying to maintain integration of patients in their family and community when in the course of treatment they become smear-negative. Stigma reduction strategies for mental health adopted by both patient activist organizations, such as the National Alliance for the Mentally Ill (NAMI), and mental health professional organizations, emphasize the biomedical basis of mental illness. This approach, however, may promote the idea that "organic" means blameless, and "socially" or "psychologically" based disorders are blameworthy. In the effort to formulate effective strategies and public health communications, research is needed to distinguish simple and effective public health strategies from simplistic approaches that may be counterproductive. Policymakers and the scientists must be attentive both to the need for action-oriented agendas and the need for research to guide such policy and action. Approaches to study of stigma for health research Stigma of a particular health problem is not necessarily perceived and experienced the same way among different segments of a community, especially among people distinguished by whether or not they have a particular health problem. To understand the experience of stigma among people who are stigmatized by their health status, research may inquire directly about their experience. Although this provides an account of self-perceived stigma, it is also useful to examine stigma from other vantage points. Study of community residents who do not have the health problem under consideration provides information about stigma as a feature of social life in that community--important information because it is in this setting that the people with the target health problem reside. After acquiring a stigmatized health problem, acknowledgement and experience of stigma for that condition may be expected to change. Assessing stigmatizing attitudes of health care providers indicates the extent to which stigma is a factor within the health system and how it operates. Stigma there is especially significant, and it must be identified so that it can be eliminated, minimized, or managed. It may also be useful to consider the attitudes of key persons or groups within a community, such as political leaders, policymakers, and teachers. Their attitudes are likely to exert more substantial influence on the community experience of stigma among the general population and among the experience of stigma among people with a stigmatized health problem. The family of people with the target health problem are also a specialized group of particular interest for assessment of stigma. Like the affected individual, family are themselves potentially targets of stigma through the process Goffman described as courtesy stigma. The conceptual framework advanced by AIDS researchers in the United States for study of stigma refers to family members as secondary targets (NIMH 1996). Other potential secondary targets of stigma include friends, loved ones, and the health staff and volunteers who work with affected individuals. In some cases, however, family, and sometimes health professionals, may ally with a discriminatory response in the community and become perpetrators of stigma; this puts the primary target in an especially difficult position when potential family or health service supports contribute instead to the stress of the condition. Wahl's (1999) study of the stigma of mental health problems found that more than a third of respondents identified relatives as perpetrators of stigma. Inasmuch as many of our interests in this review concern both cross-cultural and interdisciplinary interactions, it is useful to note a difference in the usage of the term "insider" across academic disciplines to characterize study groups. Sociologists who study the stigma and discrimination targeting minority groups refer to an "insider's perspective" in a different way from cross-cultural researchers. The insider is the target of stigma for the sociologists (Oyserman and Swim 2001). For the cross-cultural researcher, however, everyone in the community is an insider by virtue of their residence there and membership in the culture. Health status and health care provider status represent useful distinctions among these insiders, as we have suggested, but all are providing a cultural view of stigma within that community, which may also be suitable for comparison with the respective experience of stigma among comparable groups in distinctive settings and other cultures. Survey methods and research on HIV/AIDS Health research studies of stigma have employed various methods to assess the experience of stigma among target groups and in the general population. Surveys have been widely used in the general population, especially for HIV/AIDS research to study potential perpetrators of stigma. Such assessments range from single-item queries to more complex instruments. For example, an assessment of stigma from households in the general U.S. population queried 5,641 respondents by telephone about HIV/AIDS with one question, asking whether respondents agreed with the following assertion: "People who got AIDS through sex or drug use have gotten what they deserve" (MMWR 2000). Herek (1999) has also used a more complex instrument for national telephone surveys in the United States, and a version of that instrument is available on the Internet with a bibliography identifying studies that have used the survey. The extensive interview includes queries about interactions with persons with AIDS, symbolic contact, beliefs about transmission, attitudes towards people with AIDS, trust in authorities and experts, HIV mandatory testing, feelings toward people with AIDS, perceptions of persecution, and the effect of concerns about stigma on HIV testing. The content is highly specific to HIV/AIDS and to the social environment and cultural context of the United States. The survey instrument provides an example of the approach to context-specific health research on AIDS-related stigma discussed earlier in this paper. It also indicates how research strategies may address the particular issues that concern a particular health problem in a particular setting where managing stigma is a priority. Mental health research Apart from HIV/AIDS studies over the last decade, most health research on stigma has been concerned with mental health. This results in large measure from the involvement of social and clinical psychologists, unlike other health scientists, in interdisciplinary collaborations with sociologists in studies of stigma from the outset. In the background section of his research report, Wahl (1999) reviews several of these approaches to study of mental illness-related stigma. Questionnaires have been used for studies of patients and the general population. The questionnaires are typically based on key features of stigma identified by the investigators. Vignettes have been used in the general population to compare the responses when the vignette portrays a protagonist identified as a mental patient or not identified as such. Analysis considers how this is related to respondents' rejection, devaluation, and blame of the protagonist. Analogue behavior studies are based on analysis of how people respond in situations where they are led to believe they are dealing with someone who is mentally ill or who has previously been in treatment. Link's questionnaire for assessing stigma includes items that require scoring along a Likert scale from strongly agree to strongly disagree. These items were formulated under the headings (1) deviation and discrimination and (2) coping orientations that indicate secrecy, avoidance-withdrawal, and education (Link et al., 1991). Link and colleagues have also produced a 20-item scale for studying perceived stigma among people with a psychiatric disorder. This scale was recently used by Sirey and colleagues (2001) to assess the impact of perceived stigma on discontinuing medications among groups of older and younger patients with mild depression. The survey instrument developed by Wahl (1999) included a section on stigma comprising 9 items and a section with 12 items on discrimination experienced by consumers of mental health care (usually identified as patients in other studies). The approach was innovative in several respects. In this NAMI-supported study Wahl involved the consumers at an early stage in the development and design of the research. Consumers helped to identify the relevant indicators of stigma to ensure that the assessment would be relevant to their interests. The study design included both a larger survey (N=1,301) and a subset of respondents followed up with in-depth qualitative telephone interviews, which were transcribed and coded for qualitative analysis. This made it possible to examine not only the frequency of responses from the survey, but also to consider the nature and meaning of response categories. Each of these 21 items under the headings of stigma and discrimination consisted of assertions about the respondent's experience, which were coded never, seldom, sometimes, often, or very often. Some items would likely not have been included without the participation and input of the consumers in the study, which is an advantage but also raises some questions. For example, it is not clear how to interpret affirmative responses to such items as, "I have been advised to lower my expectations in life because I am a consumer." Although this was clearly a matter of concern for many respondents, who considered it stigmatizing, it is unlikely that caregivers who had made the remarks would have characterized their intent or awareness as stigmatizing. Consequently, the finding offers a useful insight for clinicians who had not considered the impact of such remarks, and it also indicates the value of assessing stigma from the vantage points of both consumers and providers. Cultural epidemiology Like the difference in what may be regarded as stigmatizing across patient and provider groups, it is also worth considering differences in what constitutes stigma across cultures. Consider, for example, whether concerns about the inability to marry, which is an important manifestation of stigma in South Asia, are as important elsewhere? Such questions were considered in a comparative study of the cultural basis of the manifestations of self-perceived stigma among patients with clinical depression in Bangalore and London. Several reports discuss the approach for locally validating features of stigma (Weiss et al., 2001b; Raguram et al., 1996). This approach was developed in the context of cultural epidemiological research examining representations of illness-related experience, meaning, and behaviour. For study of self-perceived stigma among persons with a mental or medical problem, queries based on the framework for assessing stigma outlined above under research objective 1 (page 13) are included in an interview. Responses are coded on a four-point scale from a definite yes to definite no, and the database also includes narrative responses to these queries. The coherence of a scale based on these items examined on the basis of their internal consistency. Analysis considers both the individual items and an additive scale of those items retained for a coherent, locally validated measure of stigma. Qualitative data indicate the nature of various aspects of stigma. This cultural epidemiological approach to the assessment of stigma has been used for studying patients coming for treatment of mental health problems (referenced above) and medical problems (Vlassoff et al., 2000). To compare the illness-related stigma among different groups who do not have the health problem, the questions are reformulated as inquiries about the problems of a person depicted in a vignette, which constitute a typical presentation. The interview is then administered to respondents from the general population of the community who have no overt indication of having the condition, and administered also to health care providers representing various approaches to health care available in the community. In separate studies of onchocercal skin disease and leprosy comparing unaffected people in the community with people identified in a clinic (leprosy) or community (onchocerciasis) with these disorders, social stigma reported by the community sample has been higher than self-perceived stigma reported by people with the disorder. We expect that this approach will become even more useful to identify culture and disease-specific features of stigma, and for cross-cultural comparisons of clinic and community-based experience of stigma. Here one might speculate about the implications of possible differences in the cultural strategies for managing stigma. Would the consumers of mental health services identified through NAMI and studied by Wahl report higher self-perceived stigma than the general population with regard to comparable disorders, instead of lower levels of stigma found for infectious diseases in Africa and South Asia? The methodology provides a means for testing such hypotheses, and the answers should inform interventions to manage undesirable stigma. Ethnography and social context Other approaches for assessing the nature and impact of stigma on people and society are also likely to be useful. Lang (1991) used ethnographic methods to study AIDS-related stigma. Kleinman's (1995) background discussion to his presentation of research on epilepsy in China critically examined the concept of stigma, focusing on studies of epilepsy. His review shifted the focus from stigma to the broader context of social experience, considering how epilepsy (and illness more generally) is affected by, and how it affects local worlds. This approach reflects the priority of ethnographic study, for which stigma is one dimension in the analysis of social experience. Policy studies Research on the interaction of stigma and social policy is needed to complement the approaches already discussed for study of self-perceived stigma and stigma in the general population and subpopulations. Social and health policy research should examine questions of access to care, health financing, and research support, inasmuch as they reflect priorities subject to the influence of stigma. HIV/AIDS policy and studies of tuberculosis have been especially concerned with questions about the human rights of infected persons, especially when such people come from segments of the population that are already socially stigmatized (Lerner 1996). AIDS-related stigma studies have considered interactions of the disease with minority status or gender, and the need for research in the field to guide policy (Yoshioka and Schustack 2001; Moneyham et al., 1996; Anon. 1998). Our earlier discussion of research needs (item 5) considered how questions of social policy interact in subtle ways with questions of scientific evidence and stigma. Lerner's account and related questions about such diverse issues as driving privileges for people with controlled epilepsy, forced isolation of people with active TB, involuntary notification of sexual partners of people with HIV/AIDS, and so forth reflect a need not just for health research, but the need to examine how stigma, culture, liability, and ethics interact in the development of policy. Gostin and Lazzarini (1997) outline a seven-step program for generating medical and epidemiological knowledge to assess the public health benefits of proposed policy and its impact on the health and human rights of affected populations. Summary and Conclusion Although initially formulated as an area for social science research, stigma represents an important interest for public health. It contributes to suffering, which may further impair health, and it interferes with appropriate use of health services, even when they are available. The conceptualization of stigma that Goffman developed has guided a wide range of social research studies, and we have suggested a reformulation of the concept more appropriate as a guide for public health research, policy, and action. After examining the role of stigma in selected tropical diseases, we reviewed the broad aims and approaches to stigma research for international health. Our focus on an adverse social response (experienced or reasonably anticipated), based on health status, as the defining feature of stigma underscores the diversity of the concept. International health research on stigma must also be more sensitive to its cultural dimensions, recognizing the relevance of questions not only about what is stigmatized but also how stigma is manifest and how it is maintained. Recognizing aspects of stigma that are particularly relevant for particular health problems is a key issue for research in public health. The need for disease and culture specificity distinguishes an orientation and approach for applied international health research from the larger body of social research that is typically more concerned with the common features of stigma, which as we showed at the outset even Goffman questioned. The kind of interventions suggested by study of stigma vary from consideration of one health problem to another. Documenting the stigma of onchocercal skin disease (OSD) contributed to establishment of an intervention to control the disease, rather than counseling or support groups to deal with the personal impact of stigma, which in the settings where OSD occurs would have been highly inappropriate. Leprosy control programs have made effective use of a simple message, "leprosy can be cured," from the early 1980s when the introduction of multi-drug therapy made that a credible claim (Figure 1). As the message became believable, it changed the condition from an irreversible transformation of personal identity to a treatable disease, and by doing so, it countered the impact of stigma that previously marked leprosy as a condition for which treatment was inconceivable. Table 1. Focus and approach to Interventions to Mitigate Stigma FocusApproachExample*Health problemPublic health to control the disease Early recognition and treatment for cure or disability preventionOnchocercal skin disease Leprosy StigmatizersIEC and social marketing to enhance compassion and reduce blame Correct misapprehensions of riskEpilepsy Various infectious diseases Emotional impact Counseling Peer support groups and therapeutic communitiesMost conditions Mental health problems Social policyAdvocacy, lobbying, and legislation Research supportHIV/AIDS Diseases of poverty  *Examples are illustrative but incomplete. Stigma-mitigating strategies are not limited to a single focus or approach. (See also Miller and Major 2000) Efforts to alleviate the stigma of epilepsy and HIV/AIDS have focused on helping individuals to acknowledge and adjust to life with incurable diseases; a major epilepsy campaign is called "Out of the Shadows," and for HIV/AIDS it is "Breaking the Silence." Other approaches for tuberculosis, various mental health problems, and other stigmatized conditions have been suggested, but far more attention is required to identify and counter the particular ways in which stigma contributes to the suffering of people with these health problems. By considering a relevant formulation of stigma and ways of proceeding with field and policy studies, we have indicated directions for needed research to mitigate undesirable health-related stigma. References Anonymous. Report seeks more research on effects of AIDS stigma. AIDS Policy & Law 13(14):7, 1998. Balasubramanian, V.N.; Oommen, K.; Samuel, R. DOT or not? Direct observation of anti-tuberculosis treatment and patient outcomes, Kerala State, India. Int J Tuberculosis and Lung Dis 4(5):409-413, 2000 May. Becker, G.; Arnold, R. Stigma as a social and cultural construct. Chapter 3, Pp. 39-57. In: In: Ainlay, S.C.; Becker, G.; Coleman, L.M. (Eds.). The Dilemma of Difference: A Multidisciplinary View of Stigma. New York: Plenum Press, 1986. Boonmongkon, Pimpawun. Khi thut, "The disease of social loathing:" An anthropological study of the stigma of leprosy in rural North-East Thailand. Social and Economic Research Project Reports, No. 16. Geneva: WHO, 1994. Burris, S. Studying the legal management of HIV-related stigma. Am Behavioral Scientist 42(7):1229-1243, 1999. Chesney, M.A.; Smith, A.W. Critical delays in HIV testing and care: the potential role of stigma. Am Behavioral Scientist 42(7):1162-1174, 1999. Falk, Gerhard. Stigma: How We Treat Outsiders. Amherst: Prometheus Books, 2001. Goffman, E. Stigma: Notes on the Management of Spoiled Identity. Englewood Cliffs, NJ: Prentice Hall, 1963. Gostin, Lawrence O.; Lazzarini, Zita. Human Rights and Public Health in the AIDS Pandemic. New York: Oxford University Press, 1997. Herek, G.M. AIDS and stigma. Am Behavioral Scientist 42(7):1106-1116, 1999a. Herek, G.M. AIDS and Stigma Survey Items. Document available on the Internet with reference list including studies based on use of the survey. psychology.ucdavis.edu/rainbow/html/Stigma_items_99.pdf. 1999b Herek, G.M.; Capitanio, J.P. AIDS stigma and sexual prejudice. Am Behavioral Scientist 42(7):1130-1147, 1999. Johansson, E.; Long, N.H.; Diwan, V.K.; Winkvist, A. Attitudes of compliance with tuberculosis treatment among women and men in Vietnam. Int J Tuberc Lung Dis 3(10:862-868, 1999. Lang, Norris G. Stigma, self-esteem, and depression: psycho-social responses to risk of AIDS. Human Organization 50(1):66-72, 1991. Liefooghe, R.; Baliddawa, J.B.; Kipruto, E.M.; Vermeire, C.; DeMunynck, A.O. From their own perspective. A Kenyan communitys perception of tuberculosis. Tropical Medicine and International Health 2(8):809-821, 1997. Kleinman, A. The social course of epilepsy: chronic course of illness as social experience in interior China. Chapter 7, Pp. 147-172, In: Kleinman, A. 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HIV-Related knowledge and stigma--United States, 2000. Morbidity and Mortality Weekly Review, 49(47):1062-1064, 2000 Dec 1. Morankar, Sudhakar; Suryawanshi, Nishi; Kudale, Abhay; Deshmukh, Deepali; Patil, Om Prakash; Rangan, Sheela. Social stigma in tuberculosis. In: Thakur, Arun Kumar (ed.), Recent Trends in Tuberculosis and Chest Disease. Patna: Bihar TB Association, 2000; Pp. 41-50. National Institute of Mental Health. AIDS and Stigma: A Conceptual Framework and Research Agenda. Final Report from a Research Workshop. 12-13 April 1996. Ngamvithayapong, Jintana; Winkvist, Anna; Diwan, Vinod. High AIDS awareness may cause tuberculosis patient delay: results from an HIV epidemic area, Thailand. AIDS 14:1413-1419, 2000. Oyserman, Daphna; Swim, Janet K. Stigma: An Insider's View. Journal of Social Issues 57(1):1-14. Pan-African Study Group on Onchocercal Skin Disease. The Importance of Onchocercal Skin Disease: Report of a Multi-Country Study. Applied Field Research Reports, No. 1. Geneva: UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), 1995. Paz, Consuelo J.; Medina, Isagani R.; Ventura, Elizabeth R. A multidisciplinary study of stigma in relation to Hansen's disease among the Tausug in the Philippines. Social and Economic Research Projects Reports, No. 7. Geneva: WHO, 1990. Pearson, M. What does distance matter? Leprosy control in West Nepal. Social Science and Medicine 26(1):25-36, 1988. Raguram, R.; Weiss, M.G.; Channabasavanna, S.M.; Devins, G.M. Stigma, depression and somatization: a report from South India. Am J Psychiatry 153:1043-1049, 1996. Rovner, J. US Congress examines new approach to HIV. Lancet, 349:1078, 1997 Apr 12. Sirey, J.A.; Bruce, M.L.; Alexopoulos, G.S.; Perlick, D.A.; Raue, P.; Friedman, S.J.; Meyers, B.S. Perceived stigma as a predictor of treatment discontinuation in young and older outpatients with depression. Am J Psychiatry 158(3):479-481, 2001. Stafford, M.C.; Scott, R.R. Stigma, deviance, and social control: some conceptual issues. Chapter 5, Pp. 77-91. In: Ainlay, S.C.; Becker, G.; Coleman, L.M. (Eds.). The Dilemma of Difference: A Multidisciplinary View of Stigma. New York: Plenum Press, 1986. Vlassoff, C.; Weiss, M.; Ovuga, E.B.L.; Eneanya, C.; Nwel, P.T.; Babalola, S.S.; Awedoba, A.K.; Theophilus, B.; Cofie, P.; Shetabi, P. Gender and the stigma of onchocercal skin disease in Africa. Social Science and Medicine, 50:1353-1368, 2000. World Health Organization. The 'undefined and hidden' burden of mental health problems. Fact sheet Number 218. Revised November 2001 (http://www.who.int/inf-fs/en/fact218.html). Weiss, M.G. Cultural epidemiology: introduction and overview. Anthropology and Medicine 8(1):5-29, 2001. Weiss, M.G.; Isaac M.; Parkar S.R.; Chowdhury A.N.; Raguram R. Global, National, and Local Approaches to Mental Health: Examples from India. Tropical Medicine and International Health. 6(1):4-23, 2001a. Weiss, M.G.; Jadhav, S.; Raguram, R.; Vounatsou, P.; Littlewood, R., Psychiatric stigma across cultures: local validation in Bangalore and London. Anthropology and Medicine 8(1):71-87, 2001b. Wahl, Otto F. Mental health consumers' experience of stigma. Schizophrenia Bulletin 25(3):467-478, 1999. Yoshioka, M.R.; Schustack, A. Disclosure of HIV status: cultural issues of Asian patients. AIDS Patient Care & STDS 15(2):77-82, 2001. Schulze B, Angermeyer MC.  HYPERLINK "http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12473315&dopt=Abstract" \t "_blank" Subjective experiences of stigma. A focus group study of schizophrenic patients, their relatives and mental health professionals. Soc Sci Med Subjective experiences of stigma. A focus group study of schizophrenic patients, their relatives and mental health professionals.  HYPERLINK "http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&itool=PubMed_Abstract&term=%22Schulze+B%22%5BAuthor%5D" Schulze B,  HYPERLINK "http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&itool=PubMed_Abstract&term=%22Angermeyer+MC%22%5BAuthor%5D" Angermeyer MC. University of Leipzig, Department of Psychiatry, Johannisallee 20, 04317 Leipzig, Germany. BeateMSchulze@web.de Schizophrenia has been found to be one of the most stigmatising conditions. To the present, most research on stigma related to mental illness has drawn conclusions on the adverse reactions faced by people with schizophrenia from studies on public attitudes or analogue behavioural studies. The views of those exposed to the stigmatising reactions, however, has largely been absent. Aiming to explore stigma from the subjective perspective of people with schizophrenia, a focus group study was carried out at the four centres involved in the WPA Global Programme against Stigma and Discrimination because of Schizophrenia in Germany. In order to get a comprehensive picture of how stigma affects the lives of schizophrenic patients, collateral information was sought from relatives and mental health professionals. The focus groups enquired about concrete stigmatisation experiences of the patients and incidences of stigma witnessed by the other two groups. Focus group sessions were tape-recorded and transcripts were coded using an inductive method. Results reveal four dimensions of stigma: interpersonal interaction, structural discrimination, public images of mental illness and access to social roles. Examples are given for the views of patients, relatives and mental health professionals on each of the four stigma types. The consequences for conceptualisations of stigma and the development of effective strategies to reduce stigma and discrimination because of schizophrenia are discussed. Copyright 2002 Elsevier Science Ltd. Herek GM.  HYPERLINK "http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12561266&dopt=Abstract" \t "_blank" Thinking about AIDS and stigma: a psychologists perspective. J Law Med Ethics 2002;30:594607. Chesney MA, Smith AW. Critical delays in HIV testing and care: the potential role of stigma. Am Behav Sci 1999;42:116274.   HYPERLINK "http://www.thebodypro.com/index.shtml" \t "_new"  INCLUDEPICTURE "http://www.thebody.com/images/topnav/tab_pro_off.gif" \* MERGEFORMATINET   HYPERLINK "http://www.thebody.com/index.html"  INCLUDEPICTURE "http://www.thebody.com/images/logo/logo_body.gif" \* MERGEFORMATINET Top of Form  HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Select.1  HTMLCONTROL Forms.HTML:Image.1  HTMLCONTROL Forms.HTML:Hidden.1  HTMLCONTROL Forms.HTML:Hidden.1  HTMLCONTROL Forms.HTML:Hidden.1  HTMLCONTROL Forms.HTML:Hidden.1  Bottom of Form HYPERLINK "http://www.thebody.com/subscribe/joinbody.html"  INCLUDEPICTURE "http://www.thebody.com/images/topnav/tab_email_off.gif" \* MERGEFORMATINET  HYPERLINK "http://www.thebody.com/espanol.html"  INCLUDEPICTURE "http://www.thebody.com/images/topnav/tab_espanol_off.gif" \* MERGEFORMATINET   HYPERLINK "http://www.thebody.com/sitemap.html"  INCLUDEPICTURE "http://www.thebody.com/images/topnav/nav_alltopics_off.gif" \* MERGEFORMATINET  HYPERLINK "http://www.thebody.com/experts.shtml"  INCLUDEPICTURE "http://www.thebody.com/images/topnav/nav_askexperts_off.gif" \* MERGEFORMATINET Stigma By Jeanine Cogan and Gregory Herek 1998 AIDS-related stigma refers to a pattern of prejudice, discounting, discrediting, and discrimination directed at people perceived to have HIV/AIDS, their significant others and close associates, and their social groups and communities. As with other diseases throughout history, such as the Black Death in the fourteenth century and cholera in the nineteenth century, a stigma has been attached to AIDS as a result of both fears surrounding contagion and preexisting prejudice against the social groups most seriously affected by the epidemic. Like AIDS itself, the AIDS stigma is a global problem. It is manifested around the world through ostracism of people with AIDS (PWAs), discrimination against them, and, in a few countries, quarantines. In the United States, the AIDS stigma has been evident in negative attitudes, discrimination, and violence against PWAs and people perceived to be HIV infected. Throughout the epidemic, survey research has consistently shown that a significant minority of the U.S. public endorses coercive measures such as quarantining of HIV-infected persons, universal mandatory testing, laws making it a crime for people with HIV/AIDS to have sex, and mandatory identification cards for PWAs. Public support for such policies has continued despite health officials' arguments that such tactics are ineffective and repressive. Negative attitudes have also been manifested in behavior. AIDS discrimination in employment, housing, school policies, and services has been widespread. Employers have refused to provide insurance coverage for employees with AIDS; property owners have refused to rent to PWAs or have evicted them; parents with AIDS have been faced with legal battles concerning child custody and visitation rights; and PWAs have experienced unwarranted demotions, dismissals, and harassment in the workplace. In addition, some PWAs have been targets for violent attacks because of their HIV status. At least four specific characteristics affect the extent to which any disease is likely to be stigmatized. First, a stigma is more likely to be attached to a disease whose cause is perceived to be the bearer's responsibility. The two most common routes of HIV infection in the United States, sexual intercourse and sharing contaminated drug paraphernalia, are widely perceived as controllable and therefore avoidable behaviors. Second, greater stigma is associated with conditions that, like AIDS, are perceived to be unalterable or degenerative. Third, greater stigma is associated with conditions that are perceived to be contagious or to place others in harm's way. Concern about contagion not only exists in the physical realm but also extends to fears that one will be socially or morally tainted by interacting with the stigmatized individual. Finally, a condition tends to be more stigmatized when it is readily apparent to others and is perceived as repellent, ugly, or upsetting. In its more advanced stages, AIDS often causes dramatic changes to one's appearance. The intensity of the AIDS-related stigma in the United States, however, cannot be accounted for solely on the basis of fears of contagion and disease. Of considerable additional importance is the fact that the AIDS epidemic in the United States has occurred primarily among marginalized groups, such as gay men, injecting drug users, and Haitians, and has been defined socially as a disease of these groups. Consequently, the stigma attached to AIDS also serves as a vehicle for expressing preexisting hostility toward members of disliked social groups. In the United States, where male-male sex has been the primary route of HIV transmission, the AIDS stigma has been focused principally on homosexuality. Societal and individual reactions to AIDS have often provided a vehicle for expressing condemnation of homosexuality and hostility toward gay men and lesbians. Heterosexuals' attitudes toward gay people have been consistently shown to correlate strongly with their AIDS-related fears, attitudes, and beliefs. Furthermore, gay men with AIDS are more negatively evaluated or blamed for their illness than are heterosexuals with AIDS. As the face of the epidemic in the United States changes, it is likely that symbolic expressions of the AIDS stigma will broaden to reflect public hostility to an increasing degree toward other marginalized groups such as immigrants, the poor, and communities of color. The AIDS stigma has negative effects on PWAs, people at risk for HIV infection, and society at large. Because of the AIDS-related stigma, PWAs must bear the burden of societal hostility at a time when they urgently need social support. In addition, some PWAs internalize societal stigmatization, which can lead to self-loathing, self-blame, and self-destructive behaviors. The AIDS stigma also deters people at risk for HIV from being tested and seeking information and assistance for risk reduction; indeed, entire communities have been reluctant to acknowledge their collective risk. Because of the stigma of AIDS, many people may distance themselves from the disease and deny their potential risk. Such behavior serves as a serious obstacle to prevention efforts. In order to ultimately reduce the incidence of AIDS, the stigma associated with it must be directly confronted. Related Entries: Discrimination; Epidemics, Historical; Homophobia; Poverty; Racism; Sexism; Social Construction Key Words: chronic disease, discrimination, homophobia, prejudice, racism, stigma Further Reading Herek, G. M., "Illness, Stigma, and AIDS," in Psychological Aspects of Serious Illness: Chronic Conditions, Fatal Diseases, and Clinical Care, edited by P. T. Costa Jr. and G. R. Vanden Bos, Washington, D.C.: American Psychological Association, 1990 Hunter, N. D., and W. B. Rubenstein, AIDS Agenda: Emerging Issues in Civil Rights, New York: New Press, 1992 Panos Institute, The Third Epidemic: Repercussions of the Fear of AIDS, Budapest, Hungary: Panos Institute, 1990 The Encyclopedia of AIDS: A Social, Political, Cultural, and Scientific Record of the HIV Epidemic,  HYPERLINK "mailto:ras33@columbia.edu" Raymond A. Smith, Editor. Copyright 1998, Raymond A. Smith. Carried by permission of Fitzroy Dearborn Publishers. Encyclopedia of AIDS $25 US/832 pp/Illustrated For more about this book, or to order,  HYPERLINK "http://www.amazon.com/exec/obidos/ASIN/0140514864/thebodyanaidsand/102-0819700-6737756" click here.  HYPERLINK "http://www.thebody.com/encyclo/encyclo.html" Table of Contents  This article is a part of the publication The Encyclopedia of AIDS. Our thanks to HYPERLINK "http://www.thebody.com/encyclo/encyclo.html"   HYPERLINK "http://www.thebody.com/encyclo/encyclo.html"  HYPERLINK "http://www.thebody.com/aboutus.html" Our Mission and Team| HYPERLINK "http://www.thebody.com/content.html" Content Policy| HYPERLINK "http://www.thebody.com/privacy.html" Privacy Policy| HYPERLINK "http://www.thebody.com/sponsors.html" Advertising and Sponsorship| HYPERLINK "http://www.thebody.com/logos.html" Link to Us The Body is a service of Body Health Resources Corporation, 250 West 57th Street, New York, NY 10107. The Body and its logos are trademarks of Body Health Resources Corporation, which owns the copyright of The Body's homepage, topic pages, page designs and HTML code. General Disclaimer: The Body is designed for educational purposes only and is not engaged in rendering medical advice or professional services. The information provided through The Body should not be used for diagnosing or treating a health problem or a disease. It is not a substitute for professional care. If you have or suspect you may have a health problem, consult your healthcare provider.  HYPERLINK "http://www.avert.org/" AVERT.ORG  HYPERLINK "http://www.avert.org/about.htm" AVERT is an international AIDS charity  HYPERLINK "http://www.avert.org/about.htm" avert.org - bringing you information on HIV & AIDS  HYPERLINK "http://www.avert.org/" home  HYPERLINK "http://www.avert.org/about.htm" about AVERT  HYPERLINK "http://www.avert.org/donate.htm" donate here  HYPERLINK "http://www.avert.org/contact.htm" contact us  HYPERLINK "http://www.avert.org/help.htm" help & advice  HYPERLINK "http://www.avert.org/site-guide.htm" site guide  HYPERLINK "http://www.avert.org/aidsinafrica.htm" Africa  HYPERLINK "http://www.avert.org/aids-countries.htm" Countries & Regions  HYPERLINK "http://www.avert.org/educate.htm" Education  HYPERLINK "http://www.avert.org/homosexu.htm" Gay & Lesbian  HYPERLINK "http://www.avert.org/historyi.htm" History & Pictures  HYPERLINK "http://www.avert.org/wwhiv.htm" Issues & Responses  HYPERLINK "http://www.avert.org/hivprevention.htm" Prevention  HYPERLINK "http://www.avert.org/hivquiz.htm" Quizzes  HYPERLINK "http://www.avert.org/faqindex.htm" Sex  HYPERLINK "http://www.avert.org/statindx.htm" Statistics  HYPERLINK "http://www.avert.org/std.htm" STDs  HYPERLINK "http://www.avert.org/stories.htm" Stories & Views  HYPERLINK "http://www.avert.org/yngindx.htm" Teens  HYPERLINK "http://www.avert.org/trans.htm" Transmission & Testing  HYPERLINK "http://www.avert.org/hivtreatment.htm" Treatment & Care  HYPERLINK "http://www.avert.org/aidsuk.htm" UK  HYPERLINK "http://www.avert.org/usa_aids.htm" USA  HYPERLINK "http://www.avert.org/hiv.htm" Virus Top of Form search avert.org  HTMLCONTROL Forms.HTML:Text.1  HTMLCONTROL Forms.HTML:Image.1  Bottom of Form  INCLUDEPICTURE "http://www.avert.org/media/headers/stigmagraph.jpg" \* MERGEFORMATINET  From the moment scientists identified HIV and AIDS, social responses of fear, denial, stigma and discrimination have accompanied the epidemic. Discrimination has spread rapidly, fuelling anxiety and prejudice against the groups most affected, as well as those living with HIV or AIDS. It goes without saying that HIV and AIDS are as much about social phenomena as they are about biological and medical concerns. Across the world the global epidemic of HIV/AIDS has shown itself capable of triggering responses of compassion, solidarity and support, bringing out the best in people, their families and communities. But the disease is also associated with stigma, repression and discrimination, as individuals affected (or believed to be affected) by HIV have been rejected by their families, their loved ones and their communities. This rejection holds as true in the rich countries of the north as it does in the poorer countries of the south. Stigma is a powerful tool of social control. Stigma can be used to marginalize, exclude and exercise power over individuals who show certain characteristics. While the societal rejection of certain social groups (e.g. 'homosexuals, injecting drug users, sex workers') may predate HIV/AIDS, the disease has, in many cases, reinforced this stigma. By blaming certain individuals or groups, society can excuse itself from the responsibility of caring for and looking after such populations. This is seen not only in the manner in which 'outsider' groups are often blamed for bringing HIV into a country, but also in how such groups are denied access to the services and treatment they need. Why there is stigma related to HIV and AIDS? In many societies people living with HIV and AIDS are often seen as shameful. In some societies the infection is associated with minority groups or behaviours, for example, homosexuality, In some cases HIV/AIDS may be linked to 'perversion' and those infected will be punished. Also, in some societies HIV/AIDS is seen as the result of personal irresponsibility. Sometimes, HIV and AIDS are believed to bring shame upon the family or community. And whilst negative responses to HIV/AIDS unfortunately widely exist, they often feed upon and reinforce dominant ideas of good and bad with respect to sex and illness, and proper and improper behaviours. Factors which contribute to HIV/AIDS-related stigma: HIV/AIDS is a life-threatening disease People are scared of contracting HIV The disease's is associated with behaviours (such as sex between men and injecting drug-use) that are already stigmatised in many societies People living with HIV/AIDS are often thought of as being responsible for becoming infected Religious or moral beliefs lead some people to believe that having HIV/AIDS is the result of moral fault (such as promiscuity or 'deviant sex') that deserves to be punished. "My foster son, Michael, aged 8, was born HIV-positive and diagnosed with AIDS at the age of 8 months. I took him into our family home, in a small village in the south-west of England. At first relations with the local school were wonderful and Michael thrived there. Only the head teacher and Michael's personal class assistant knew of his illness.  INCLUDEPICTURE "http://www.avert.org/media/photos/grimreaper.jpg" \* MERGEFORMATINET  "Then someone broke the confidentiality and told a parent that Michael had AIDS. That parent, of course, told all the others. This caused such panic and hostility that we were forced to move out of the area. The risk is to Michael and us, his family. Mob rule is dangerous. Ignorance about HIV means that people are frightened. And frightened people do not behave rationally. We could well be driven out of our home yet again." - 'Debbie' speaking to the National AIDS Trust, UK, 2002 Sexually transmitted diseases are well known for triggering strong responses and reactions. In the past, in some epidemics, for example TB, the real or supposed contagiousness of the disease has resulted in the isolation and exclusion of infected people. From early in the AIDS epidemic a series of powerful images were used that reinforced and legitimised stigmatisation. HIV/AIDS as punishment (e.g. for immoral behaviour) HIV/AIDS as a crime (e.g. in relation to innocent and guilty victims) HIV/AIDS as war (e.g. in relation to a virus which need to be fought) HIV/AIDS as horror (e.g. in which infected people are demonised and feared) HIV/AIDS as otherness (in which the disease is an affliction of those set apart) Together with the widespread belief that HIV/AIDS is shameful, these images represent 'ready-made' but inaccurate explanations that provide a powerful basis for both stigma and discrimination. These stereotypes also enable some people to deny that they personally are likely to be infected or affected. Forms of HIV/AIDS-related stigma and discrimination In some societies, laws, rules and policies can increase the stigmatisation of people living with HIV/AIDS. Such legislation may include compulsory screening and testing, as well as limitations on international travel and migration. In most cases, discriminatory practises such as the compulsory screening of 'risk groups', both furthers the stigmatisation of such groups as well as creating a false sense of security among individuals who are not considered at high-risk. Laws that insist on the compulsory notification of HIV/AIDS cases, and the restriction of a person's right to anonymity and confidentiality, as well as the right to movement of those infected, have been justified on the grounds that the disease forms a public health risk. Perhaps as a response, numerous countries have now enacted legislation to protect the rights and freedoms of people living with HIV and AIDS and to safeguard them from discrimination. Much of this legislation has sought to ensure their right to employment, education, privacy and confidentiality, as well as the right to access information, treatment and support. Governments and national authorities sometimes cover up and hide cases, or fail to maintain reliable reporting systems. Ignoring the existence of HIV and AIDS, neglecting to respond to the needs of those living with HIV infection, and failing to recognize growing epidemics in the belief that HIV/AIDS 'can never happen to us' are some of the most common forms of denial. This denial fuels AIDS stigma by making those individuals who are infected appear abnormal and exceptional. Stigma and discrimination can arise from community-level responses to HIV and AIDS. The harassing of individuals suspected of being infected or of belonging to a particular group has been widely reported. It is often motivated by the need to blame and punish and in extreme circumstances can extend to acts of violence and murder. Attacks on men who are assumed gay have increased in many parts of the world, and HIV and AIDS related murders have been reported in countries as diverse as Brazil, Colombia, Ethiopia, India,  HYPERLINK "http://www.avert.org/aidssouthafrica.htm" South Africa and Thailand. In December 1998, Gugu Dhlamini was stoned and beaten to death by neighbours in her township near Durban, South Africa, after speaking out openly on  HYPERLINK "http://www.avert.org/worldaid.htm" World AIDS Day about her HIV status. Women and stigma  INCLUDEPICTURE "http://www.avert.org/media/photos/hivpositive22.jpg" \* MERGEFORMATINET  The impact of HIV/AIDS on  HYPERLINK "http://www.avert.org/women.htm" women is particularly acute. In many developing countries, women are often economically, culturally and socially disadvantaged and lack equal access to treatment, financial support and education. In a number of societies, women are mistakenly perceived as the main transmitters of sexually transmitted diseases (STDs). Together with traditional beliefs about sex, blood and the transmission of other diseases, these beliefs provide a basis for the further stigmatisation of women within the context of HIV and AIDS HIV-positive women are treated very differently from men in many developing countries. Men are likely to be 'excused' for their behaviour that resulted in their infection, whereas women are not. "My mother-in-law tells everybody, 'Because of her, my son got this disease. My son is a simple as good as gold-but she brought him this disease". - HIV-positive woman, aged 26, India In  HYPERLINK "http://www.avert.org/aidsindia.htm" India, for example, the husbands who infected them may abandon women living with HIV or AIDS. Rejection by wider family members is also common. In some African countries, women, whose husbands have died from AIDS-related infections, have been blamed for their deaths. Families In the majority of developing countries, families are the primary caregivers to sick members. There is clear evidence of the importance of the role that the family plays in providing support and care for people living with HIV/AIDS. However, not all family response is positive. Infected members of the family can find themselves stigmatised and discriminated against within the home. There is also mounting evidence that women and non-heterosexual family members are more likely to be badly treated than children and men. "My mother-in-law has kept everything separate for me-my glass, my plate, they never discriminated like this with their son. They used to eat together with him. For me, it's don't do this or don't touch that and even if I use a bucket to bathe, they yell - 'wash it, wash it'. They really harass me. I wish nobody comes to be in my situation and I wish nobody does this to anybody. But what can I do? My parents and brother also do not want me back." - HIV-positive woman, aged 23, India Employment While HIV is not transmitted in the majority of workplace settings, the supposed risk of transmission has been used by numerous employers to terminate or refuse employment. There is also evidence that if people living with HIV/AIDS are open about their infection status at work, they may well experience stigmatisation and discrimination by others. "Nobody will come near me, eat with me in the canteen, nobody will want to work with me, I am an outcast here". - HIV positive man, aged 27, India Pre-employment screening takes place in many industries, particularly in countries where the means for testing are easily available and affordable. In poorer countries screening has also been reported as taking place, especially in industries where health benefits are available to employees. Employer-sponsored insurance schemes providing medical care and pensions for their workers have come under increasing pressure in countries that have been seriously affected by HIV and AIDS. Some employers have used this pressure to deny employment to people with HIV or AIDS. "Though we do not have a policy so far, I can say that if at the time of recruitment there is a person with HIV, I will not take him. I' ll certainly not buy a problem for the company. I see recruitment as a buying-selling relationship. If I don't find the product attractive, I'll not buy it." - A Head of Human Resource Development, India Health care Many reports reveal the extent to which people are stigmatised and discriminated against by health care systems. Many studies reveal the reality of withheld treatment, non-attendance of hospital staff to patients, HIV testing without consent, lack of confidentiality and denial of hospital facilities and medicines. Also fuelling such responses are ignorance and lack of knowledge about HIV transmission. "There is an almost hysterical kind of fearat all levels, starting from the humblest, the sweeper or the ward boy, up to the heads of departments, which makes them pathologically scared of having to deal with an HIV-positive patient. Wherever they have an HIV patient, the responses are shameful" - A retired senior doctor from a public hospital, currently working in a private hospital, India A survey conducted in 2002, among some 1,000 physicians, nurses and midwives in four  HYPERLINK "http://www.avert.org/aids-nigeria.htm" Nigerian states, returned disturbing findings. One in 10 doctors and nurses admitted having refused to care for an HIV/AIDS patient or had denied HIV/AIDS patients admission to a hospital. Almost 40% thought a person's appearance betrayed his or her HIV-positive status, and 20% felt that people living with HIV/AIDS had behaved immorally and deserved their fate. One factor fuelling stigma among doctors and nurses is the fear of exposure to HIV as a result of lack of protective equipment. Also at play, it appears was the frustration at not having medicines for treating HIV/AIDS patients, who therefore were seen as 'doomed' to die. Lack of confidentiality has been repeatedly mentioned as a particular problem in health care settings. Many people living with HIV/AIDS do not get to choose how, when and to whom to disclose their HIV status. When surveyed recently, 29% of persons living with HIV/AIDS in India, 38% in Indonesia, and over 40% in  HYPERLINK "http://www.avert.org/aidsthai.htm" Thailand said their HIV-positive status had been revealed to someone else without their consent. Huge differences in practise exist between countries and between health care facilities within countries. In some hospitals, signs have been placed near people living with HIV/AIDS with words such as 'HIV-positive' and 'AIDS' written on them. The way forward HIV-related stigma and discrimination remains an enormous barrier to effectively fighting the HIV and AIDS epidemic. Fear of discrimination often prevents people from seeking treatment for AIDS or from admitting their HIV status publicly. People with or suspected of having HIV may be turned away from healthcare services, employment, refused entry to foreign country. In some cases, they may be evicted from home by their families and rejected by their friends and colleagues. The stigma attached to HIV/AIDS can extend into the next generation, placing an emotional burden on those left behind. Denial goes hand in hand with discrimination, with many people continuing to deny that HIV exists in their communities. Today, HIV/AIDS threatens the welfare and well being of people throughout the world. At the end of the year 2005, 40.3 million people were living with HIV or AIDS and during the year 3.1 million died from AIDS-related illness. Combating the stigma and discrimination against people who are affected by HIV/AIDS is as important as developing the medical cures in the process of preventing and controlling the global epidemic. So how can progress be made in overcoming this stigma and discrimination? How can we change people attitudes to AIDS? A certain amount can be achieved through the legal process. In some countries people who are living with HIV or AIDS lack knowledge of their rights in society. They need to be educated, so they are able to challenge the discrimination, stigma and denial that they meet in society. Institutional and other monitoring mechanisms can enforce the rights of people living with HIV or AIDS and provide powerful means of mitigating the worst effects of discrimination and stigma. However, no policy or law can alone combat HIV/AIDS related discrimination. The fear and prejudice that lies at the core of the HIV/AIDS discrimination needs to be tackled at the community and national levels. A more enabling environment needs to be created to increase the visibility of people with HIV/AIDS as a 'normal' part of any society. In the future, the task is to confront the fear based messages and biased social attitudes, in order to reduce the discrimination and stigma of people who are living with HIV or AIDS. Sources: UNAIDS, AIDS epidemic update, December 2004 UNAIDS, AIDS epidemic update, December 2003 UNAIDS, HIV and AIDS-related stigmatization, discrimination and denial: forms, contexts and determinants, June 2000 UNAIDS, India : HIV and AIDS-related stigmatization, discrimination and denial, August 2001 Edited by Jenni Fredriksson and Annabel Kanabus Last updated November 25, 2005  INCLUDEPICTURE "http://www.avert.org/media/layout/bottom-left.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://www.avert.org/media/layout/bottom-right.gif" \* MERGEFORMATINET   HYPERLINK "http://www.avert.org/" home  HYPERLINK "http://www.avert.org/disclaimer.htm" disclaimer  HYPERLINK "http://www.avert.org/siteinfo.htm" siteinformation  HYPERLINK "http://www.avert.org/sitemap.htm" sitemap  HYPERLINK "http://www.avert.org/link.htm" linktous  HYPERLINK "http://www.avert.org/links.htm" otherwebsites Medical news today, 1 May 2006 Stigma biggest hurdle to AIDS prevention in South Asia Main Category:  HYPERLINK "http://www.medicalnewstoday.com/sections/hiv-aids/" HIV / AIDS News Article Date: 13 Jul 2004 - 15:00pm (PDT) Stigma and discrimination against people living with HIV and gender inequality remain the two biggest challenges to AIDS prevention in South Asia, according to experts. A satellite session at the XV International AIDS Conference today reviewed the progress made and challenges in mounting an effective AIDS response in South Asia. In South Asia, women are more vulnerable both socially and economically, said Dr Nafis Sadik, Special Envoy of the UN Secretary-General for HIV/AIDS in Asia and Pacific, and Chair of the satellite session. They have less opportunity to protect themselves. Organized by the UNAIDS South Asian Intercountry Team and South Asias Theme Group on HIV/AIDS, the session brings together AIDS activists, researchers and programme managers from around the world. There are two epidemics spreading AIDS, and the stigma against people living with HIV, said Mr. Zahir Uddin Swapon, Secretary General of the Parliamentary Group on HIV/AIDS and Member of Parliament in Bangladesh. People stigmatise due to fear stemming from ignorance, he said. Protecting the rights of people living with HIV, partnering with health and education sectors to counter stigma, amending laws that criminalise marginalised groups who are vulnerable to HIV, must become priority areas to strengthen the AIDS response. AIDS experts point out that low condom use in South Asia is a major hurdle in AIDS prevention. Indicators suggest a close link between the poor status of women due to patriarchy and their vulnerability to HIV. Poverty, discrimination against women, and violence against women and girls are fuelling the epidemic. The needs of vulnerable groups, including women and young people, continue to be neglected throughout Asia, added Ms Kathleen Cravero, Deputy Executive Director of UNAIDS, who spoke at the session. Until women and girls have equal access to effective HIV prevention and treatment services, there is little hope to beat the epidemic. India has the largest number of people living with HIV outside South Africa an estimated 5.1 million in 2003. Though national HIV prevalence is low between 0.4% and 1.3% -- a closer focus reveals that there are serious epidemics in a number of territories and states. Elsewhere in South Asia, increasingly there are warning signs of serious HIV outbreaks. In some areas, injecting drug use and sex work are so pervasive that even low-prevalence countries could see epidemics surge suddenly. It is a myth that the social fabric and culture of South Asia will give it immunity to the AIDS epidemic, warned Dr Sadik. For more information, please contact Dominique De Santis, UNAIDS, Geneva, mobile (+41 79) 254 6803 or (+661) 250088, Abby Spring, UNAIDS Geneva, mobile (+41 79) 308 9861 or (+661) 2500 874, or Emelia Timpo, UNAIDS South Asia Intercountry Team, (+9111) 2410 4970. You may visit the UNAIDS website -- www.unaids.org -- for more information about the programme. The Body Epidemics, Historical By Peter L. Allen 1998 Disease is understood to be a deviation from the norms that define health in any specific culture. Diseases may be noncommunicable, originating in genetic or environmental factors, or they may be communicable, or infectious, caused by a microorganism that can be transmitted from person to person. Diseases may affect individuals in small numbers, or they may affect large proportions of a population. When substantial numbers of cases are involved, and when these numbers vary significantly over time, the outbreak is called an epidemic. An epidemic affecting a very large area is a pandemic, and one that is consistently present in the population is endemic. Although HIV/AIDS is typically called an epidemic, it is also by now pandemic, in that its reach is worldwide, and it appears to have become endemic among certain populations. Thus, usages of these terms to describe the spread of HIV/AIDS vary. Epidemics, which have existed throughout history, attract attention and cause alarm because of their scope and destructiveness but also because they come and go, often unpredictably. Even today, an outbreak of Ebola hemorrhagic fever, which may result in several dozen deaths, generates far more attention than malaria, which remains endemic in many parts of the world and kills hundreds of thousands of people a year. In the past, when the causes of disease were poorly understood, epidemics frequently caused enormous alarm and were often blamed on unpopular social groups or even on the sufferers themselves. Although medical science has advanced tremendously in its understanding of disease, particularly in the nineteenth and twentieth centuries with the development of germ theory and the use of antibiotic drugs, the social response has changed far less over time. Studying epidemics of the past can, therefore, illuminate social, governmental, and even medical responses to more recent diseases, including AIDS. Disease depends on relationships. Without both hosts and vectors, or organisms that complete the chain of transmission, microorganisms would not be able to reproduce and cause disease; without sizable host populations, diseases would die out quickly. Infectious disease is, therefore, a function of civilization. Until recently in most societies, epidemics were common and frequently devastating. Some of these have left lasting impressions, either because of their destructive force or because of the ways in which they have been understood. The two most memorable diseases of the Middle Ages were plague and leprosy, one a rapid killer of millions, the other very slow but equally horrifying because of the ways in which it was regarded and understood. Plague is caused by a bacillus (Yersinia pestis) that is transmitted by fleas which commonly infest rats and other rodents; its most frequent symptoms include fever, severe headaches, delirium, prostration, and buboes, which are painful, extreme enlargements of the lymph nodes of the groin and armpits. Death commonly occurs within eight days of infection. The most famous episode of plague in Europe, the Black Death, seems to have originated in Central Asia; it arrived in Milan in 1348, carried by shipborne rats. By 1351, all of the European world was affected. In some areas, two-thirds to three-quarters of the population died, perhaps as many as 25 million overall. This mortality caused tremendous social disruption: the Italian author Giovanni Boccaccio wrote that "brother forsook brother, uncle nephew and sister brother and oftentimes wife husband; nay (what is yet more extraordinary and well nigh incredible) fathers and mothers refused to visit or tend their very children, as [if] they had not been theirs." Among the many unfounded theories of origin was one that held that Jews had poisoned the wells; in Basel, Switzerland, city officials carried out the citizens' desires for retribution by enclosing the city's entire Jewish community in a wooden building and burning them to death. The plague ultimately subsided when the flea-carrying rats were displaced by another species of rat that was less habitable to the plague-bearing fleas. Though far less contagious than plague, leprosy has also left deep and painful impressions on historical memory. Caused by Mycobacterium leprae, this disease destroys nerve endings, blood vessels, ligaments, skin tissue, and even bone and can cause marked deformations of the extremities, face, and voice. These deformations often horrify others; consequently, societies have frequently associated leprosy with sin and have expelled its sufferers from their midst. The biblical book of Leviticus, for example, commands that the leper must cry, "'Unclean, unclean,'" and ordains, "He shall dwell alone; without the camp shall his habitation be." Medieval Christianity, too, excluded the leper from society, viewing him or her as a person dead to the world. One eighth-century medieval ritual required the leper to stand in an open grave while a priest announced, "I forbid you ever to enter the church or monastery, fair, mill, market-place, or company of persons ... ever to leave your house without your leper's costume ... ever to touch children or give them anything." This living death was sometimes moderated by the promise of speedy redemption in the afterlife, but the association of leprosy and sin remains a powerful and disturbing one. Mass destruction and social condemnation also characterized two epidemics of the Renaissance, smallpox and syphilis, diseases that may well have sprung into prominence as a direct result of the explorations of the age. Smallpox had existed in Asia, and then in Europe, for centuries but was apparently unknown in the Americas until Europeans arrived there in the fifteenth century. There the disease caused colossal mortality, with as much as half the population dying. It has been argued that smallpox, far more than the military skills of the colonizers, was responsible for the European conquest of the Americas. Meanwhile, syphilis was first recorded in Europe in 1493, which was, perhaps coincidentally, immediately after Christopher Columbus and his sailors returned to Spain. Far more virulent a disease than it is today, syphilis spread furiously through Europe. Meanwhile, every nation tried to categorize it as a disease brought from outside, by foreigners, with the Russians calling it Polish, the Poles ascribing it to Germans, and the Germans, English, and Italians calling it the "French sickness." The Dutch and Portuguese ascribed it to the Spanish, while the Japanese blamed the Portuguese. The process of assigning blame for syphilis was accompanied by severe moral condemnation. Syphilis was obviously transmitted by sex, and so many, like the bishop and physician Gaspare Torella, questioned whether its sufferers even deserved a cure: "Ought one to work against the will of God, who has punished them by the very means in which they had sinned?" Syphilis, other venereal diseases, and AIDS have often incurred such judgments because of the supposedly voluntary and sinful ways in which they are passed from one person to another. Memorable epidemics in the following centuries included the European smallpox pandemic of 1614, outbreaks of plague in London in 1665 and Marseilles in 1720, and an epidemic of yellow fever in the new American capital, Philadelphia, in 1793. These, too, were often seen as punishment for sin; one seventeenth-century English writer described the plague as "a broom in the hands of the Almighty with which he sweepeth the most nasty and uncomely corners of the universe." The nineteenth century was marked by four pandemics of cholera, one of which started in 1826 in India and had spread by 1832 to Russia, Persia (Iran), Continental Europe, Great Britain, and North America. Cholera, which can kill within a day, is caused by fecal contamination of food and water; it brings on severe cramps, vomiting, fever, dehydration, and sudden death. Because cholera often afflicted the overcrowded and malnourished poor, the New York Times in 1866 called it "the curse of the dirty, the intemperate, and the degraded." Similar views of the relationship between social conditions and disease characterized the construction of tuberculosis (TB), the nineteenth century's most devastating chronic disease. TB is typically a chronic disease whose symptoms include fatigue, weight loss, chills, aches, fevers, and a characteristic violent cough that sometimes brings up bloody sputum. It most commonly affects people, such as the urban poor, whose nutrition is inadequate and who live and work in crowded conditions. By the eighteenth century, physicians and the lay public believed that climate and "dissolute and immoral" living made people susceptible to the disease. Tubercular patients were often urged to take up physically active lives in areas with salubrious weather. Rest cures in sanatoriums were common, and treatment often varied according to the gender and class of the sufferer. Only when Robert Koch discovered in 1882 that TB is caused by a bacterium did the stereotypes that its sufferers were inherently weak or tainted begin to fade away. The early twentieth century was marked by epidemics such as those of influenza and poliomyelitis, or polio. The great influenza pandemic of 1918 began when the "Spanish flu" struck Chungking in July, Persia in early August, and France two weeks later; in two months it had covered the entire globe, taking 500,000 lives in the United States, 12,000,000 in India, and 22,000,000 overall -- nearly twice as many as World War I. Polio, though far less widespread, caused tremendous fear because it primarily affected children, causing their paralysis and even death. During the early 1950s, the United States experienced an average of 40,000 cases per year. The Salk and Sabin vaccines caused a dramatic drop in these figures, but their use in developing countries, particularly in Africa and India, remains sporadic. Until recently, at least in the industrialized nations, the 1918 influenza pandemic and infectious disease in general were viewed as parts of a natural history that had more or less come to an end. The remarkable success of vaccines, with smallpox being officially eradicated in 1979, and of antibiotics led to a period from the 1950s to the 1970s during which it seemed that Western medicine could and had introduced an age in which the only remaining threats to health were chronic diseases like cancer. This view was reinforced in 1976 when a recurrence of the 1918 influenza failed to materialize as expected. Antibiosis -- the use of substances produced by one type of microorganism to counteract the effects of another -- caused a revolution in drug therapy in the 1940s. Antibiotics were found to be effective with a broad range of bacterial diseases, including pneumonia, TB, meningitis, diphtheria, syphilis, gonorrhea, and plague. Their effectiveness, however, is increasingly limited by the growth of drug-resistant pathogenic strains. The advent of AIDS made it clear that hopes for a world free of infectious disease were tragically erroneous, but in fact, proof of this error had been visible around the world to those who were willing to look for it. Cholera alone was epidemic in Asia in the 1960s and in the Middle East, Africa, and the Soviet Union in the 1970s; plague struck India in 1995; other diseases, such as malaria and TB, escaped eradication and have re-turned in drug-resistant forms to pose serious threats to world health. In addition, a variety of new infectious diseases have been reported, many of them rapid, highly contagious, and ferociously destructive of the human body, such as Marburg disease (1967), Lassa fever (1969), Ebola hemorrhagic fever (1976), and, of course, AIDS. Susan Sontag describes the future as "not 'Apocalypse Now' but 'Apocalypse From Now On.'" In the face of these dangers, it is essential that all aspects of infectious disease be addressed: pathogenic agents, social and environmental contexts, and individual behavior. Each has a part to play, but without attention to all three, a response can rarely be completely effective. To assume that any disease, whether leprosy, cholera, or AIDS, is evidence of the sufferer's moral failings is a destructive belief that adversely affects medical, social, and individual responses. AIDS is neither accidental nor unique but rather one of many diseases that are a permanent part of human existence. In responding to the current pandemic, humanity has the ability both to learn from the past and to provide models -- good and bad -- for the future. Related Entries: Discrimination; Forecasting; Geography; HIV, Origins of; Seroprevalence; Sexually Transmitted Diseases; Stigma; Tuberculosis Key Words: epidemic, infectious disease, pandemic, plague, public health, syphilis, [specific epidemic by name] Further Reading Brandt, Allan M., No Magic Bullet: A Social History of Venereal Disease in the United States Since 1880, New York: Oxford University Press, 1987 Fee, Elizabeth, and Daniel M. Fox, eds., AIDS: The Burdens of History, Berkeley: University of California Press, 1988 Garrett, Laurie, The Coming Plague: Newly Emerging Diseases in a World Out of Balance, New York: Farrar, Straus, Giroux, 1994 Kiple, Kenneth F., ed., The Cambridge World History of Human Disease, Cambridge: Cambridge University Press, 1993 McNeill, William T., Plagues and Peoples, Garden City, New York: Doubleday, 1976 Morris, R. J., Cholera 1832: The Social Response to an Epidemic, New York: Holmes and Meier, 1976 Qutel, Claude, History of Syphilis, translated by Judith Braddock and Brian Pike, Baltimore, Maryland: Johns Hopkins University Press, 1990 Sontag, Susan, Illness as Metaphor and AIDS and Its Metaphors, New York: Doubleday, 1989 = Epidemics, Historical By Peter L. Allen 1998 Disease is understood to be a deviation from the norms that define health in any specific culture. Diseases may be noncommunicable, originating in genetic or environmental factors, or they may be communicable, or infectious, caused by a microorganism that can be transmitted from person to person. Diseases may affect individuals in small numbers, or they may affect large proportions of a population. When substantial numbers of cases are involved, and when these numbers vary significantly over time, the outbreak is called an epidemic. An epidemic affecting a very large area is a pandemic, and one that is consistently present in the population is endemic. Although HIV/AIDS is typically called an epidemic, it is also by now pandemic, in that its reach is worldwide, and it appears to have become endemic among certain populations. Thus, usages of these terms to describe the spread of HIV/AIDS vary. Epidemics, which have existed throughout history, attract attention and cause alarm because of their scope and destructiveness but also because they come and go, often unpredictably. Even today, an outbreak of Ebola hemorrhagic fever, which may result in several dozen deaths, generates far more attention than malaria, which remains endemic in many parts of the world and kills hundreds of thousands of people a year. In the past, when the causes of disease were poorly understood, epidemics frequently caused enormous alarm and were often blamed on unpopular social groups or even on the sufferers themselves. Although medical science has advanced tremendously in its understanding of disease, particularly in the nineteenth and twentieth centuries with the development of germ theory and the use of antibiotic drugs, the social response has changed far less over time. Studying epidemics of the past can, therefore, illuminate social, governmental, and even medical responses to more recent diseases, including AIDS. Disease depends on relationships. Without both hosts and vectors, or organisms that complete the chain of transmission, microorganisms would not be able to reproduce and cause disease; without sizable host populations, diseases would die out quickly. Infectious disease is, therefore, a function of civilization. Until recently in most societies, epidemics were common and frequently devastating. Some of these have left lasting impressions, either because of their destructive force or because of the ways in which they have been understood. The two most memorable diseases of the Middle Ages were plague and leprosy, one a rapid killer of millions, the other very slow but equally horrifying because of the ways in which it was regarded and understood. Plague is caused by a bacillus (Yersinia pestis) that is transmitted by fleas which commonly infest rats and other rodents; its most frequent symptoms include fever, severe headaches, delirium, prostration, and buboes, which are painful, extreme enlargements of the lymph nodes of the groin and armpits. Death commonly occurs within eight days of infection. The most famous episode of plague in Europe, the Black Death, seems to have originated in Central Asia; it arrived in Milan in 1348, carried by shipborne rats. By 1351, all of the European world was affected. In some areas, two-thirds to three-quarters of the population died, perhaps as many as 25 million overall. This mortality caused tremendous social disruption: the Italian author Giovanni Boccaccio wrote that "brother forsook brother, uncle nephew and sister brother and oftentimes wife husband; nay (what is yet more extraordinary and well nigh incredible) fathers and mothers refused to visit or tend their very children, as [if] they had not been theirs." Among the many unfounded theories of origin was one that held that Jews had poisoned the wells; in Basel, Switzerland, city officials carried out the citizens' desires for retribution by enclosing the city's entire Jewish community in a wooden building and burning them to death. The plague ultimately subsided when the flea-carrying rats were displaced by another species of rat that was less habitable to the plague-bearing fleas. Though far less contagious than plague, leprosy has also left deep and painful impressions on historical memory. Caused by Mycobacterium leprae, this disease destroys nerve endings, blood vessels, ligaments, skin tissue, and even bone and can cause marked deformations of the extremities, face, and voice. These deformations often horrify others; consequently, societies have frequently associated leprosy with sin and have expelled its sufferers from their midst. The biblical book of Leviticus, for example, commands that the leper must cry, "'Unclean, unclean,'" and ordains, "He shall dwell alone; without the camp shall his habitation be." Medieval Christianity, too, excluded the leper from society, viewing him or her as a person dead to the world. One eighth-century medieval ritual required the leper to stand in an open grave while a priest announced, "I forbid you ever to enter the church or monastery, fair, mill, market-place, or company of persons ... ever to leave your house without your leper's costume ... ever to touch children or give them anything." This living death was sometimes moderated by the promise of speedy redemption in the afterlife, but the association of leprosy and sin remains a powerful and disturbing one. Mass destruction and social condemnation also characterized two epidemics of the Renaissance, smallpox and syphilis, diseases that may well have sprung into prominence as a direct result of the explorations of the age. Smallpox had existed in Asia, and then in Europe, for centuries but was apparently unknown in the Americas until Europeans arrived there in the fifteenth century. There the disease caused colossal mortality, with as much as half the population dying. It has been argued that smallpox, far more than the military skills of the colonizers, was responsible for the European conquest of the Americas. Meanwhile, syphilis was first recorded in Europe in 1493, which was, perhaps coincidentally, immediately after Christopher Columbus and his sailors returned to Spain. Far more virulent a disease than it is today, syphilis spread furiously through Europe. Meanwhile, every nation tried to categorize it as a disease brought from outside, by foreigners, with the Russians calling it Polish, the Poles ascribing it to Germans, and the Germans, English, and Italians calling it the "French sickness." The Dutch and Portuguese ascribed it to the Spanish, while the Japanese blamed the Portuguese. The process of assigning blame for syphilis was accompanied by severe moral condemnation. Syphilis was obviously transmitted by sex, and so many, like the bishop and physician Gaspare Torella, questioned whether its sufferers even deserved a cure: "Ought one to work against the will of God, who has punished them by the very means in which they had sinned?" Syphilis, other venereal diseases, and AIDS have often incurred such judgments because of the supposedly voluntary and sinful ways in which they are passed from one person to another. Memorable epidemics in the following centuries included the European smallpox pandemic of 1614, outbreaks of plague in London in 1665 and Marseilles in 1720, and an epidemic of yellow fever in the new American capital, Philadelphia, in 1793. These, too, were often seen as punishment for sin; one seventeenth-century English writer described the plague as "a broom in the hands of the Almighty with which he sweepeth the most nasty and uncomely corners of the universe." The nineteenth century was marked by four pandemics of cholera, one of which started in 1826 in India and had spread by 1832 to Russia, Persia (Iran), Continental Europe, Great Britain, and North America. Cholera, which can kill within a day, is caused by fecal contamination of food and water; it brings on severe cramps, vomiting, fever, dehydration, and sudden death. Because cholera often afflicted the overcrowded and malnourished poor, the New York Times in 1866 called it "the curse of the dirty, the intemperate, and the degraded." Similar views of the relationship between social conditions and disease characterized the construction of tuberculosis (TB), the nineteenth century's most devastating chronic disease. TB is typically a chronic disease whose symptoms include fatigue, weight loss, chills, aches, fevers, and a characteristic violent cough that sometimes brings up bloody sputum. It most commonly affects people, such as the urban poor, whose nutrition is inadequate and who live and work in crowded conditions. By the eighteenth century, physicians and the lay public believed that climate and "dissolute and immoral" living made people susceptible to the disease. Tubercular patients were often urged to take up physically active lives in areas with salubrious weather. Rest cures in sanatoriums were common, and treatment often varied according to the gender and class of the sufferer. Only when Robert Koch discovered in 1882 that TB is caused by a bacterium did the stereotypes that its sufferers were inherently weak or tainted begin to fade away. The early twentieth century was marked by epidemics such as those of influenza and poliomyelitis, or polio. The great influenza pandemic of 1918 began when the "Spanish flu" struck Chungking in July, Persia in early August, and France two weeks later; in two months it had covered the entire globe, taking 500,000 lives in the United States, 12,000,000 in India, and 22,000,000 overall -- nearly twice as many as World War I. Polio, though far less widespread, caused tremendous fear because it primarily affected children, causing their paralysis and even death. During the early 1950s, the United States experienced an average of 40,000 cases per year. The Salk and Sabin vaccines caused a dramatic drop in these figures, but their use in developing countries, particularly in Africa and India, remains sporadic. Until recently, at least in the industrialized nations, the 1918 influenza pandemic and infectious disease in general were viewed as parts of a natural history that had more or less come to an end. The remarkable success of vaccines, with smallpox being officially eradicated in 1979, and of antibiotics led to a period from the 1950s to the 1970s during which it seemed that Western medicine could and had introduced an age in which the only remaining threats to health were chronic diseases like cancer. This view was reinforced in 1976 when a recurrence of the 1918 influenza failed to materialize as expected. Antibiosis -- the use of substances produced by one type of microorganism to counteract the effects of another -- caused a revolution in drug therapy in the 1940s. Antibiotics were found to be effective with a broad range of bacterial diseases, including pneumonia, TB, meningitis, diphtheria, syphilis, gonorrhea, and plague. Their effectiveness, however, is increasingly limited by the growth of drug-resistant pathogenic strains. The advent of AIDS made it clear that hopes for a world free of infectious disease were tragically erroneous, but in fact, proof of this error had been visible around the world to those who were willing to look for it. Cholera alone was epidemic in Asia in the 1960s and in the Middle East, Africa, and the Soviet Union in the 1970s; plague struck India in 1995; other diseases, such as malaria and TB, escaped eradication and have re-turned in drug-resistant forms to pose serious threats to world health. In addition, a variety of new infectious diseases have been reported, many of them rapid, highly contagious, and ferociously destructive of the human body, such as Marburg disease (1967), Lassa fever (1969), Ebola hemorrhagic fever (1976), and, of course, AIDS. Susan Sontag describes the future as "not 'Apocalypse Now' but 'Apocalypse From Now On.'" In the face of these dangers, it is essential that all aspects of infectious disease be addressed: pathogenic agents, social and environmental contexts, and individual behavior. Each has a part to play, but without attention to all three, a response can rarely be completely effective. To assume that any disease, whether leprosy, cholera, or AIDS, is evidence of the sufferer's moral failings is a destructive belief that adversely affects medical, social, and individual responses. AIDS is neither accidental nor unique but rather one of many diseases that are a permanent part of human existence. In responding to the current pandemic, humanity has the ability both to learn from the past and to provide models -- good and bad -- for the future. Related Entries: Discrimination; Forecasting; Geography; HIV, Origins of; Seroprevalence; Sexually Transmitted Diseases; Stigma; Tuberculosis Key Words: epidemic, infectious disease, pandemic, plague, public health, syphilis, [specific epidemic by name] Further Reading Brandt, Allan M., No Magic Bullet: A Social History of Venereal Disease in the United States Since 1880, New York: Oxford University Press, 1987 Fee, Elizabeth, and Daniel M. Fox, eds., AIDS: The Burdens of History, Berkeley: University of California Press, 1988 Garrett, Laurie, The Coming Plague: Newly Emerging Diseases in a World Out of Balance, New York: Farrar, Straus, Giroux, 1994 Kiple, Kenneth F., ed., The Cambridge World History of Human Disease, Cambridge: Cambridge University Press, 1993 McNeill, William T., Plagues and Peoples, Garden City, New York: Doubleday, 1976 Morris, R. J., Cholera 1832: The Social Response to an Epidemic, New York: Holmes and Meier, 1976 Qutel, Claude, History of Syphilis, translated by Judith Braddock and Brian Pike, Baltimore, Maryland: Johns Hopkins University Press, 1990 Sontag, Susan, Illness as Metaphor and AIDS and Its Metaphors, New York: Doubleday, 1989 Epidemics, Historical By Peter L. Allen 1998 Disease is understood to be a deviation from the norms that define health in any specific culture. Diseases may be noncommunicable, originating in genetic or environmental factors, or they may be communicable, or infectious, caused by a microorganism that can be transmitted from person to person. Diseases may affect individuals in small numbers, or they may affect large proportions of a population. When substantial numbers of cases are involved, and when these numbers vary significantly over time, the outbreak is called an epidemic. An epidemic affecting a very large area is a pandemic, and one that is consistently present in the population is endemic. Although HIV/AIDS is typically called an epidemic, it is also by now pandemic, in that its reach is worldwide, and it appears to have become endemic among certain populations. Thus, usages of these terms to describe the spread of HIV/AIDS vary. Epidemics, which have existed throughout history, attract attention and cause alarm because of their scope and destructiveness but also because they come and go, often unpredictably. Even today, an outbreak of Ebola hemorrhagic fever, which may result in several dozen deaths, generates far more attention than malaria, which remains endemic in many parts of the world and kills hundreds of thousands of people a year. In the past, when the causes of disease were poorly understood, epidemics frequently caused enormous alarm and were often blamed on unpopular social groups or even on the sufferers themselves. Although medical science has advanced tremendously in its understanding of disease, particularly in the nineteenth and twentieth centuries with the development of germ theory and the use of antibiotic drugs, the social response has changed far less over time. Studying epidemics of the past can, therefore, illuminate social, governmental, and even medical responses to more recent diseases, including AIDS. Disease depends on relationships. Without both hosts and vectors, or organisms that complete the chain of transmission, microorganisms would not be able to reproduce and cause disease; without sizable host populations, diseases would die out quickly. Infectious disease is, therefore, a function of civilization. Until recently in most societies, epidemics were common and frequently devastating. Some of these have left lasting impressions, either because of their destructive force or because of the ways in which they have been understood. The two most memorable diseases of the Middle Ages were plague and leprosy, one a rapid killer of millions, the other very slow but equally horrifying because of the ways in which it was regarded and understood. Plague is caused by a bacillus (Yersinia pestis) that is transmitted by fleas which commonly infest rats and other rodents; its most frequent symptoms include fever, severe headaches, delirium, prostration, and buboes, which are painful, extreme enlargements of the lymph nodes of the groin and armpits. Death commonly occurs within eight days of infection. The most famous episode of plague in Europe, the Black Death, seems to have originated in Central Asia; it arrived in Milan in 1348, carried by shipborne rats. By 1351, all of the European world was affected. In some areas, two-thirds to three-quarters of the population died, perhaps as many as 25 million overall. This mortality caused tremendous social disruption: the Italian author Giovanni Boccaccio wrote that "brother forsook brother, uncle nephew and sister brother and oftentimes wife husband; nay (what is yet more extraordinary and well nigh incredible) fathers and mothers refused to visit or tend their very children, as [if] they had not been theirs." Among the many unfounded theories of origin was one that held that Jews had poisoned the wells; in Basel, Switzerland, city officials carried out the citizens' desires for retribution by enclosing the city's entire Jewish community in a wooden building and burning them to death. The plague ultimately subsided when the flea-carrying rats were displaced by another species of rat that was less habitable to the plague-bearing fleas. Though far less contagious than plague, leprosy has also left deep and painful impressions on historical memory. Caused by Mycobacterium leprae, this disease destroys nerve endings, blood vessels, ligaments, skin tissue, and even bone and can cause marked deformations of the extremities, face, and voice. These deformations often horrify others; consequently, societies have frequently associated leprosy with sin and have expelled its sufferers from their midst. The biblical book of Leviticus, for example, commands that the leper must cry, "'Unclean, unclean,'" and ordains, "He shall dwell alone; without the camp shall his habitation be." Medieval Christianity, too, excluded the leper from society, viewing him or her as a person dead to the world. One eighth-century medieval ritual required the leper to stand in an open grave while a priest announced, "I forbid you ever to enter the church or monastery, fair, mill, market-place, or company of persons ... ever to leave your house without your leper's costume ... ever to touch children or give them anything." This living death was sometimes moderated by the promise of speedy redemption in the afterlife, but the association of leprosy and sin remains a powerful and disturbing one. Mass destruction and social condemnation also characterized two epidemics of the Renaissance, smallpox and syphilis, diseases that may well have sprung into prominence as a direct result of the explorations of the age. Smallpox had existed in Asia, and then in Europe, for centuries but was apparently unknown in the Americas until Europeans arrived there in the fifteenth century. There the disease caused colossal mortality, with as much as half the population dying. It has been argued that smallpox, far more than the military skills of the colonizers, was responsible for the European conquest of the Americas. Meanwhile, syphilis was first recorded in Europe in 1493, which was, perhaps coincidentally, immediately after Christopher Columbus and his sailors returned to Spain. Far more virulent a disease than it is today, syphilis spread furiously through Europe. Meanwhile, every nation tried to categorize it as a disease brought from outside, by foreigners, with the Russians calling it Polish, the Poles ascribing it to Germans, and the Germans, English, and Italians calling it the "French sickness." The Dutch and Portuguese ascribed it to the Spanish, while the Japanese blamed the Portuguese. The process of assigning blame for syphilis was accompanied by severe moral condemnation. Syphilis was obviously transmitted by sex, and so many, like the bishop and physician Gaspare Torella, questioned whether its sufferers even deserved a cure: "Ought one to work against the will of God, who has punished them by the very means in which they had sinned?" Syphilis, other venereal diseases, and AIDS have often incurred such judgments because of the supposedly voluntary and sinful ways in which they are passed from one person to another. Memorable epidemics in the following centuries included the European smallpox pandemic of 1614, outbreaks of plague in London in 1665 and Marseilles in 1720, and an epidemic of yellow fever in the new American capital, Philadelphia, in 1793. These, too, were often seen as punishment for sin; one seventeenth-century English writer described the plague as "a broom in the hands of the Almighty with which he sweepeth the most nasty and uncomely corners of the universe." The nineteenth century was marked by four pandemics of cholera, one of which started in 1826 in India and had spread by 1832 to Russia, Persia (Iran), Continental Europe, Great Britain, and North America. Cholera, which can kill within a day, is caused by fecal contamination of food and water; it brings on severe cramps, vomiting, fever, dehydration, and sudden death. Because cholera often afflicted the overcrowded and malnourished poor, the New York Times in 1866 called it "the curse of the dirty, the intemperate, and the degraded." Similar views of the relationship between social conditions and disease characterized the construction of tuberculosis (TB), the nineteenth century's most devastating chronic disease. TB is typically a chronic disease whose symptoms include fatigue, weight loss, chills, aches, fevers, and a characteristic violent cough that sometimes brings up bloody sputum. It most commonly affects people, such as the urban poor, whose nutrition is inadequate and who live and work in crowded conditions. By the eighteenth century, physicians and the lay public believed that climate and "dissolute and immoral" living made people susceptible to the disease. Tubercular patients were often urged to take up physically active lives in areas with salubrious weather. Rest cures in sanatoriums were common, and treatment often varied according to the gender and class of the sufferer. Only when Robert Koch discovered in 1882 that TB is caused by a bacterium did the stereotypes that its sufferers were inherently weak or tainted begin to fade away. The early twentieth century was marked by epidemics such as those of influenza and poliomyelitis, or polio. The great influenza pandemic of 1918 began when the "Spanish flu" struck Chungking in July, Persia in early August, and France two weeks later; in two months it had covered the entire globe, taking 500,000 lives in the United States, 12,000,000 in India, and 22,000,000 overall -- nearly twice as many as World War I. Polio, though far less widespread, caused tremendous fear because it primarily affected children, causing their paralysis and even death. During the early 1950s, the United States experienced an average of 40,000 cases per year. The Salk and Sabin vaccines caused a dramatic drop in these figures, but their use in developing countries, particularly in Africa and India, remains sporadic. Until recently, at least in the industrialized nations, the 1918 influenza pandemic and infectious disease in general were viewed as parts of a natural history that had more or less come to an end. The remarkable success of vaccines, with smallpox being officially eradicated in 1979, and of antibiotics led to a period from the 1950s to the 1970s during which it seemed that Western medicine could and had introduced an age in which the only remaining threats to health were chronic diseases like cancer. This view was reinforced in 1976 when a recurrence of the 1918 influenza failed to materialize as expected. Antibiosis -- the use of substances produced by one type of microorganism to counteract the effects of another -- caused a revolution in drug therapy in the 1940s. Antibiotics were found to be effective with a broad range of bacterial diseases, including pneumonia, TB, meningitis, diphtheria, syphilis, gonorrhea, and plague. Their effectiveness, however, is increasingly limited by the growth of drug-resistant pathogenic strains. The advent of AIDS made it clear that hopes for a world free of infectious disease were tragically erroneous, but in fact, proof of this error had been visible around the world to those who were willing to look for it. Cholera alone was epidemic in Asia in the 1960s and in the Middle East, Africa, and the Soviet Union in the 1970s; plague struck India in 1995; other diseases, such as malaria and TB, escaped eradication and have re-turned in drug-resistant forms to pose serious threats to world health. In addition, a variety of new infectious diseases have been reported, many of them rapid, highly contagious, and ferociously destructive of the human body, such as Marburg disease (1967), Lassa fever (1969), Ebola hemorrhagic fever (1976), and, of course, AIDS. Susan Sontag describes the future as "not 'Apocalypse Now' but 'Apocalypse From Now On.'" In the face of these dangers, it is essential that all aspects of infectious disease be addressed: pathogenic agents, social and environmental contexts, and individual behavior. Each has a part to play, but without attention to all three, a response can rarely be completely effective. To assume that any disease, whether leprosy, cholera, or AIDS, is evidence of the sufferer's moral failings is a destructive belief that adversely affects medical, social, and individual responses. AIDS is neither accidental nor unique but rather one of many diseases that are a permanent part of human existence. In responding to the current pandemic, humanity has the ability both to learn from the past and to provide models -- good and bad -- for the future. Related Entries: Discrimination; Forecasting; Geography; HIV, Origins of; Seroprevalence; Sexually Transmitted Diseases; Stigma; Tuberculosis Key Words: epidemic, infectious disease, pandemic, plague, public health, syphilis, [specific epidemic by name] Further Reading Brandt, Allan M., No Magic Bullet: A Social History of Venereal Disease in the United States Since 1880, New York: Oxford University Press, 1987 Fee, Elizabeth, and Daniel M. Fox, eds., AIDS: The Burdens of History, Berkeley: University of California Press, 1988 Garrett, Laurie, The Coming Plague: Newly Emerging Diseases in a World Out of Balance, New York: Farrar, Straus, Giroux, 1994 Kiple, Kenneth F., ed., The Cambridge World History of Human Disease, Cambridge: Cambridge University Press, 1993 McNeill, William T., Plagues and Peoples, Garden City, New York: Doubleday, 1976 Morris, R. J., Cholera 1832: The Social Response to an Epidemic, New York: Holmes and Meier, 1976 Qutel, Claude, History of Syphilis, translated by Judith Braddock and Brian Pike, Baltimore, Maryland: Johns Hopkins University Press, 1990 Sontag, Susan, Illness as Metaphor and AIDS and Its Metaphors, New York: Doubleday, 1989 INTERNATIONAL CENTER FOR RESEARCH ON WOMEN 36 obstacle. It was certainly an issue for the use of prevention in mother-to-child treatment programs in Botswana and Zambia (Nyblade and Field 2000). Clearly, therefore, HIV and AIDSrelated stigma is having an important impact on the epidemic as a wholeoperating as a key driver of the epidemic. Thus, combating stigma is a matter of utmost urgency for all HIV programs to address. Fear and stigma: the epidemic within the SARS outbreak.(Preparedness And Response)  INCLUDEPICTURE "http://www.highbeam.com/img/free_icon.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://www.highbeam.com/Aspx/GetPubLogo.aspx?pub=Emerging+Infectious+Diseases&type=MAGS" \* MERGEFORMATINET  INCLUDEPICTURE "http://www.highbeam.com/img/spacer.gif" \* MERGEFORMATINET Emerging Infectious Diseases; 2/1/2004; Liang, Arthur Because of their evolving nature and inherent scientific uncertainties, outbreaks of emerging infectious diseases can be associated with considerable fear in the general public or in specific communities, especially when illness and deaths are substantial. Mitigating fear and discrimination directed toward persons infected with, and affected by, infectious disease can be important in controlling transmission. Persons who are feared and stigmatized may delay seeking care and remain in the community undetected. This article outlines efforts to rapidly assess, monitor, and address fears associated with the 2003 severe acute respiratory syndrome (SARS) epidemic in the United States. Although fear, stigmatization, and discrimination were not widespread in the general public, Asian-American communities were particularly affected. ********** Public health strategies that deal with rapidly evolving disease outbreaks of new and emerging infectious diseases require a delicate balance between protecting the public's health and initiating exclusionary practices and treatments that can lead to fear and stigmatization of, and discrimination against, specific populations. The outbreak of severe acute respiratory syndrome (SARS) illustrates these difficulties. SARS spontaneously appeared in the southern province of Guangdong, People's Republic of China, in November 2002 (1,2). By July 2003, the epidemic, had spread to more than 30 countries with 8,427 cumulative probable cases and 916 deaths and was identified as a global threat to health (1). In the United States, 418 cases were reported with 74 classified as probable SARS; no deaths occurred (1). As with many disease outbreaks, scientific information and data related to the disease changed almost hourly, as public health scientists and practitioners responded to the worldwide outbreak, which was coupled with widespread fear (3,4). SARS-related Fear, Stigmatization, and Discrimination While persons, agencies, and governments sought to identify modes of transmission, strategies for disease containment, and treatment for SARS, fear spread unchecked throughout the global community. Fear of SARS arose from the underlying anxiety about a disease with an unknown cause and possible fatal outcome (5). Stigmatization of potential SARS patients emerged early in the outbreak, as global media reported dramatic stories from Asia in print media, television, and the Internet. Headlines from the English-language press heightened the fear. "Concern is mounting over the continuing spread of the deadly SARS virus. Some experts say it could have a similar impact to the 1918 flu epidemic that killed 50 million--or the current world HIV crisis," wrote the British Broadcasting Corporation from London, England (6). "China has threatened to execute or jail for life anyone who deliberately spreads the killer SARS virus," stated the Cable News Network from Beijing, China (7). Studies have shown that during serious disease outbreaks, when the general public requires immediate information, a subgroup of the population that is at potentially greater risk of experiencing fear, stigmatization, and discrimination will need special attention from public health professionals (8-10). The recent SARS outbreak was a classic example of such an outbreak. Fear is further fueled when infection control techniques and restrictive practices such as quarantine and isolation are employed to protect the public's health (11,12). While exclusionary practices based upon the best available scientific evidence may be scientifically and ethically sound for one population, those same practices may not be sound for all populations (5,11). During the SARS outbreak, some persons became fearful or suspicious of all people who looked Asian, regardless of their nationality or actual risk factors for SARS, and expected them to be quarantined. Some Americans did not understand that quarantine and isolation practices appropriate for SARS-affected areas in Asia, where community transmission was a concern, were practices that were not appropriate in the United States where the disease was not community acquired. For example, some persons, who had recently traveled to areas where SARS was spreading, isolated themselves, even though they had no symptoms and had not been exposed to someone with SARS. Mitigating Fear, Stigmatization, and Discrimination through Strategic Community Outreach Fear of being socially marginalizcd and stigmatized as a result of a disease outbreak may cause people to deny early clinical symptoms and may contribute to their failure to seek timely medical care (5). Such fear can ultimately increase stigmatization when cases are identified at a later date (11). Stigmatization associated with discrimination often has social and economic ramifications that intensify internalized stigmatization and feelings of fear (13). Containing fear, which is integral to the public health management of a new and emerging disease such as SARS, is best accomplished by a behavioral strategy that addresses the needs of a segment of the population at risk of becoming stigmatized and discriminated against. This strategy works best as a complement to a larger public health education and communication campaign. Typically during outbreaks, initial risk communication is targeted to frontline public health professionals through vehicles such as the Morbidity and Mortality Weekly Report. Initial communication provides information on case definitions and laboratory-testing strategies, as well as interim guidelines for infection control and other critical issues. Communication strategies for the general public most frequently involve television sound bites, press conferences with dignitaries and health officials, and targeted release of information to mass media outlets such as newspapers and Internet sites (14). Although these risk communication activities are critical for keeping the general public informed during an outbreak, they can fail to meet the personal needs of the affected population and the general public. Methods During the first week of April 2003, the National Center for Infectious Diseases (NCID) at the Centers for Disease Control and Prevention (CDC) formed a 14-member, multidisciplinary NCID/SARS Community Outreach Team as part of its emergency response to the global SARS outbreak. While other NCID/CDC response teams dealt with laboratory investigations, surveillance, communication, and clinical infection control practices, the Community Outreach Team worked to implement rapid public health strategies to document, monitor, and assist in ameliorating specific problems associated with fear, stigmatization, and discrimination attributed to the SARS outbreak in the United States. In creating a rapid public health Intervention to mitigate behaviors and practices associated with SARS-related fear, the team recognized the need to address the experiences of persons at greatest risk for experiencing SARS-related fear, stigma, and discrimination. The team monitored stigmatizing ideas and behaviors in the general population and the media, particularly toward Asian Americans, who were disproportionately reporting fear, stigmatization, and discrimination compared to the general public. The team began working with Asian-American communities to develop a culturally tailored intervention that 1) promoted community understanding of the facts related to the transmission and prevention of SARS; 2) contributed to the strengthening of community resiliency and capacity to mitigate fear, stigmatization, and discrimination; and 3) encouraged appropriate health-seeking behaviors for those who may have been exposed to SARS and were experiencing early symptoms. The team also worked to dispel myths; keep the general public better informed; prevent discrimination against SARS-affected communities; and provide guidance for institutions, agencies, and organizations hosting international visitors from SARS-affected countries. Rapid Situational Assessment During the first 3 weeks of April 2003, the NCID/SARS Community Outreach Team conducted a rapid situational analysis to determine the impact of SARS-related fear, stigmatization, and discrimination within the Asian-American community in the United States. The team carried out the following activities: 1) facilitated group discussions with key opinion leaders within the Asian community in the United States; 2) collected and monitored the CDC Public Response Service data; 3) collected and monitored Asian-language newspapers, Internet sites, and other information sources; 4) reviewed polling data and other communication information; 5) conducted community visits, panel discussions, and media interviews; 6) solicited information from state and regional minority health liaisons nationwide; 7) developed ongoing relationships with the Asian-American communities; particularly in major metropolitan areas throughout the United States; and 8) determined new data-gathering strategies as needed. Group Discussions The team conducted group interviews through teleconferences with national, state, and local influential leaders in the Asian-American community throughout the United States. The team also conducted group interviews with chambers of commerce and trade association members, school officials and representatives, state public health department staff, academicians at universities, mental health professionals, and others. The 11 teleconferences the team conducted reached more than 70 persons who represented more than 50 agencies, organizations, and communities. The goals of the group interviews were the following: 1) determine the impact of SARS-related fear on the Asian community; 2) document examples of fear, stigmatization, and discrimination; 3) determine strategies for identifying and reaching "hidden populations"; 4) develop partnerships with leaders and community members of the affected populations; 5) determine the needs of affected populations; and 6) respond appropriately to those needs through a targeted intervention with activities and Asian-language materials. Five major recommendations were derived from the facilitated group discussions with key informants: 1) develop simple, tailored SARS prevention messages; 2) develop SARS information materials in various Asian languages; 3) disseminate SARS information through multiple and culturally appropriate channels, including (but not limited to) community visits, town hall meetings, and health education and communication channels to complement mass media messages; 4) establish partnerships with local Asian-American community-based organizations to educate the community; and 5) ensure that CDC would continue to provide leadership and coordination in preventing and controlling SARS. The relationships developed during these group discussions allowed team members to monitor and document ongoing stigmatizing situations related to the disease outbreak in real time and to deal more effectively with intentional and unintentional discrimination. CDC Public Response Service CDC operates the Public Response Service (CDC PRS) under contract with the American Social Health Association. This contract provides hotline service to the general public requesting information via telephone and email about bioterrorism and other disease emergencies, including SARS. The NCID/SARS Community Outreach Team worked with the CDC PRS to track a daily sample of incoming SARS-related calls, specifically noting questions associated with fear, stigmatization, and discrimination directed toward the Asian-American community. This system allowed the team to help determine specific answers to frequently asked questions for hotline staff and to develop simple, prerecorded Asian-language messages. Passive data collection of SARS fear-related concerns began on April 29, 2003. During May 2003, 7,327 SARS-related calls were received; 4,013 (54.7%) of these calls were passively sampled. Of these sampled calls, an average of 10% of callers expressed concerns related to fear, stigmatization, and discrimination. A caller could express more than one concern. Major concerns included the following: fear of buying Asian merchandise (187 calls); working with Asians (83 calls); living near Asians (45 calls); going to school with Asians (41 calls); and more generic issus such as being on a cruise ship or airplane (77 calls); and church, school, of workplace issues (65 calls). Most SARS calls related to transmission, symptoms, and treatment of disease and travel advisories. Asian-Language Information Sources One critical component of the team's activities was determining where members of the Asian-American community were getting SARS-related information. Team members monitored English-language and Asian-language electronic, print, and television media coverage and informal chat rooms in the United States and other countries to stay abreast of changing information about the nature of the SARS outbreak that could influence fear, stigmatization, and discrimination. The assessment showed that many people within the Asian-American community were getting information from Asian-language newspapers, television, and Internet sites directly from China, Hong Kong, Taiwan, and other Asian areas--usually hours ahead of information providers in the United States. The information provided by these Asian-language sources was often inconsistent with newspaper, television, and Internet coverage in the United States, thus creating fear and suspicion that the United States government might not be telling the truth about the outbreak in this country. Independent content-analysis research conducted by InterTrend Communications (San Francisco, CA) compared four of the most popular Chinese language newspapers in the United States with two popular national mainstream English-language newspapers from March 21 to April 3, 2003 (15). InterTrend data showed that 1) Chinese-language newspapers were more likely to highlight SARS news related to the Chinese community in the United States or from China more prominently than mainstream English-language newspapers; and 2) Chinese-language newspapers were more likely to have articles on SARS, including featured in-depth articles, than mainstream English-language U.S. national newspapers (15). These findings supported the team's initial assessment (based on an informal convenience sample of Asian-language papers). General email inquiries sent to the CDC communications center and information from public health professionals, health providers, and community members led the team to SARS-related Internet sites that contained rumors and inaccurate information, which added to general misunderstanding, confusion, and fear. Even legitimate public health Internet sites from different parts of the world provided disparate information as the outbreak unfolded, furthering uncertainty and fear in the United States. The team also monitored Internet sites that supported community fears as they promoted home remedies, medicinal cures, and inappropriate and unnecessary protective equipment. Monitoring the information sources of the affected population was a critical activity, allowing the team to separate fact from fiction with accuracy and timeliness and address salient issues and concerns during community visits. Results Rapid Situational Response Based on its rapid situational assessment, the team was able to develop interventions to assist in mitigating fear, stigmatization, and discrimination. Team members carried out the following activities: 1) advised other SARS emergency response teams on how to minimize the risk of stigmatizing groups in their own communications by focusing messages on the virus and the relevant behavioral risk factors; 2) assisted with developing culturally tailored health education materials; and 3) conducted community visits, panel discussions, and media interviews to positively influence negative behaviors occurring in communities. These visits and other contacts with the Asian-American community allowed CDC to develop ongoing relationships and helped the team determine new data-gathering strategies. Targeted Health Education Materials During a disease outbreak, information changes rapidly as scientific evidence is collected and analyzed. Vital components of the team's activities were prioritizing and translating existing information and guidance documents and developing health education materials to address the specific needs of the Asian-American community. An in-house translation service did not exist, and the rapidly evolving scientific evidence challenged the turnaround time for developing, translating, and disseminating information. The team worked to identify priority documents for translation and to ensure Asian-language translation for Web and print products tailored to the Asian-American community. To ensure accurate translations, CDC contracted with professional translation services and had all documents back-translated. Web-based information on SARS included documents in traditional Chinese, simplified Chinese, Korean, Vietnamese, and Japanese, as well as French and Spanish. The team also created brief, recorded educational hotline messages in Chinese and Vietnamese. The main messages for people in the United States were the following: 1) the risk of SARS is low; 2) severe cases of SARS have been uncommon, and there have been no deaths in the United States; 3) methods for disease prevention in the general public are like those of other viral diseases; and 4) although no evidence of community spread currently exists, continued vigilance, aggressive case management, and infection control are needed. Community Field Visits Team members conducted field visits to Asian communities in Boston; New York City; Oakland, California; San Francisco; Washington, D.C.; Edison, New Jersey; and Los Angeles to respond to the direct needs of the communities and gather information. The team met with community leaders, toured the communities, informally gathered further information, and gave community SARS presentations in seven cities, reaching approximately 500 persons. Through community visits, the team was able to 1) provide the latest in evidence-based information on SARS with Asian-language education materials; 2) dispel misconceptions, myths, and rumors; 3) act as a catalyst for bringing together a broad spectrum of organizations and persons in the community to create local networks to promote community resiliency; and 4) provide credibility and reassurance to those who felt vulnerable. Speakers also presented a public health model for mitigating fear, stigmatization, and discrimination that could be instituted by public health officials, clinicians, and community members. Through open discussion sessions and informal information gathering in the community, the team found that SARS-related stigmatization was occurring more frequently within the Asian community than from outsiders directed toward the Asian community. The team also found that those persons with SARS-like symptoms who used traditional herbal physicians and pharmacies were less likely to be referred to, or seek out, public health officials, suggesting that further research into strategies to reach this population is needed. Conducting community visits also showed that CDC was responding to the needs of the community at risk for SARS-related fear, stigmatization, and discrimination and was modeling positive behaviors to the public. Discussion Other infectious disease epidemics have been associated with specific ethnic groups. Fear, stigmatization, and discrimination plagued Russian Jewish immigrants when the 1892 outbreaks of typhus fever and cholera in New York City were traced to Russian Jewish immigrants from Eastern Europe (8). In the spring of 1900, the Chinatown community in San Francisco was faced with extreme discrimination due to an outbreak of bubonic plague, the "black death," attributed to rats transported on a ship from Hong Kong (9). In 1993 an outbreak of hantavirus infection in the Four Comers area (where the borders of four states--Arizona, New Mexico, Utah, and Colorado--meet) of the United States was initially referred to by reporters as a Navajo disease, which led to severe fear, stigmatization, and discrimination of Native Americans in the region (10). Previous scientific studies have shown that fear associated with stigmatization and discrimination has negatively affected public health efforts with chronic conditions and diseases such as mental illness, HIV/AIDS, tuberculosis, leprosy, and epilepsy (16-20). More recently, stigmatization associated with fear and the AIDS epidemic negatively influenced voluntary testing, counseling, and treatment of those infected with the disease (21). Health providers have also seen reluctance by recent refugees and immigrants to get tested and treated for tuberculosis because of possible social stigmatization (22). The potential of being labeled at-risk for having or transmitting a stigmatizing condition such as SARS creates fear and anxiety, and an entire population of people can be at risk for becoming stigmatized in society (23). Protecting the health of the public while preventing stigmatization of segments of the population during a rapidly evolving disease outbreak is complex. The team's experience during the recent SARS outbreak demanded anticipatory insight, perceptive planning, and a rapid response to a targeted audience with specific cultural perspectives and influences. It also required us to recognize the distinctive features of SARS in a medical, social, and cultural context. Weiss states, "Preventing fear and stigmatization depends on controlling of treating the target health problem, countering tendencies of those who stigmatize others, and supporting those who are stigmatized through emotional support and social policies" (11). The data collected during the rapid situational assessment were critical in guiding activities of the team. Both the data and the data collection process assisted the team in establishing interpersonal relationships with community leaders, determining priority needs, identifying responsible intervention strategies, and developing effective communication channels. The team was able to better understand community perceptions and attitudes by identifying the communities' trusted sources of information. When conducting community visits, the team was able to address discordant information, myths, and rumors; provide simple Asian-language messages and materials; and act as a catalyst to build community resiliency and prepare for the possibility of future emerging diseases. The team was also able to keep CDC/NCID leaders informed and to intervene when they identified discriminatory policies, practices, and actions that were inconsistent with evidence-based public health recommendations and guidelines. Quelling fear-driven stigmatization and discrimination during the SARS outbreak required tailored intervention strategies carried out by the SARS Community Outreach Team. These activities complemented traditional risk communication for the general public. To be effective, behavioral intervention approaches, messages, and materials had to be salient for the affected population, in this case Asian-American communities within the United States. Further, these interventions aimed at promoting an accurate understanding of the epidemic both in the general population and within the affected community, that is, the dynamic nature of the outbreak and its cause, treatment options, and prevention strategies. Through interpersonal connections, the team members worked to promote reassurance and enhance community resiliency. Public health professionals must understand the necessary balance needed to protect the public's health with appropriate exclusionary practices, while at the same time preventing fear, stigmatization, and discrimination of specific segments of the population. As we prepare for the next new or reemerging disease outbreak, we should also be preparing to deal with the fear epidemic that will likely accompany it. By developing effective behavioral and health education strategies and providing timely attention to the special needs of affected populations, we can ensure that, no matter what the infectious disease, we can limit the associated epidemic of fear and stigmatization. Acknowledgments We thank the following CDC staff members who volunteered their time to translate critical information into multiple languages during the SARS outbreak: Feng Chai, Rachanee Cheingsong, Feng Xiang Gao, Wenlin Huang, Han Li, Wenkai Li, Xiaofang Li, Timothy Lim, Gang Liu, Yuko Mizuno, Christine Huong Montgomery, Xuanthao Ngo, Doan Quang, Yang Xia, and Yingtao Zhou. References (1.) Centers for Disease Control and Prevention. Update: severe acute respiratory syndrome--worldwide and United States, 2003. MMWR Morb Mortal Wkly Rep 2003;52:664-5. (2.) Rosling L, Rosling M. Pneumonia causes panic in Guangdong province. BMJ 2003;326:416. (3.) Wenzel RP, Edmond MB. Managing SARS amidst uncertainty. N Engl J Med 2003;348:1947-8. (4.) Sandman P, Lanard J. Fear is spreading faster than SARS--and so it should. Peter Sandman Column [serial online] 2003 28 Apr. [cited 2003 May 27]. Available from: URL: http://www.psandman. com/col/SARS-1.htm (5.) Das V. Stigma, contagion, defect: issues in the anthropology of public health. Stigma and Global Health: Developing a Research Agenda; 2001 September 5-7; Bethesda, Maryland. [cited 2003 Aug 8]. Available from: http://www.stigmaconference.nih.gov/FinalDas Paper.htm. (6.) British Broadcasting Corporation. SARS: is global panic justified? BBC News UK Edition. 2003 Apr 24 [cited 2003 Aug 1]. Available from: URL: http://newsvote.bbc.co.uk/mpapps/pagetools/print/ news.bbc.co.uk/1/hi/health/2972927.stm (7.) Cable News Network. Death for SARS spreaders: China. 2003 May 16 [cited 2003 May 16]. Available from: URL: http://www.cnn.com/ 2003/WORLD/asiapcf/east/05/16/china.death/index.html. (8.) Markel H. Quarantine!: East European Jewish immigrants and the New York City epidemics of 1892. Baltimore: Johns Hopkins University Press; 1997. (9.) McClain CJ. In search of equality: the Chinese struggle against discrimination in nineteenth-century America. Berkeley (CA): University of California Press; 1994. (10.) Centers for Disease Control and Prevention. Hantavirus infection--Southwestern United States: interim recommendations for risk reduction. MMWR Morb Mortal Wkly Rep 1993:42(RR-11);1-13. (11.) Weiss MG, Ramakrishna J. Stigma interventions and research for international health. Stigma and Global Health: Developing a Research Agenda; 2001 September 5-7; Bethesda, Maryland. [cited 2003 Aug 1]. Available from: URL: http://www.stigmaconference. nih.gov/FinalWeissPaper.htm (12.) Centers for Disease Control and Prevention. Use of quarantine to prevent transmission of severe acute respiratory syndrome--Taiwan. 2003. MMWR Morb Mortal Wkly Rep 2003;52:680-3. (13.) Agency for Toxic Substances and Disease Registry. A primer on health risk communication principles and practices. The Agency. Available from: URL: http://www.atsdr.cdc.gov/HEC/primer.html (14.) Link B. On stigma and its public health implications. Stigma and Global Health: Developing a Research Agenda; September 5-7; 2001, Bethesda, Maryland. [cited 2003 Aug 1]. Available from: URL: http://www.stigmaconference.nih.gov/FinalLinkPaper.html (15.) InterTrend Communications. Report: SARS article content analysis, comparison between Chinese newspapers and mainstream newspapers in Los Angeles and New York. Torrance (CA): InterTrend Communications; 2003. (16.) Schulze B, Angermeyer MC. Subjective experiences of stigma. A focus group study of schizophrenic patients, their relatives and mental health professionals. Soc Sci Med 2003:56:299-312. (17.) Herek GM. Thinking about AIDS and stigma: a psychologist's perspective. J Law Med Ethics 2002;30:594 607. (18.) Leprosy: urgent need to end stigma and isolation. J Adv Nurs 2003;42:546-9. (19.) Carey JW, Oxtoby M J, Nguyen LP, Huynh V, Morgan M, Jeffery M. Tuberculosis beliefs among recent Vietnamese refugees in New York State. Public Health Rep 1997; 112:66-72. (20.) MacLeod JS, Austin JK. Stigma in the lives of adolescents with epilepsy: a review of the literature. Epilepsy Behav 20113;4:112-7. (21.) Chesney MA, Smith AW. Critical delays in HIV testing and care: the potential role of stigma. Am Behav Sci 1999;42:1162-74. (22.) Sumartojo E. When tuberculosis treatment fails. A social behavioral account of patient adherence. Am Rev Respir Dis 1993;147:1311-20. (23.) Goffman E. Stigma: notes on the management of spoiled identity. Englewood Cliffs (NJ): Prentice-Hall; 1963. Ms. Person is a senior behavioral scientist in the National Center for Infectious Diseases, Centers for Disease Control and Prevention. Her research interests focus on health and behavior, with a specific interest in cross-cultural behavioral interventions for the prevention and control of infectious disease. Address for correspondence: Bobbie Person, Chief, Health Education and Behavioral Science Office of Health Communication, National Center for Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop C14, Atlanta, GA 30333, USA; fax: 404-371-5490; email: bperson@cdc.gov Bobbie Person, * Francisco Sy, * Kelly Holton, * ([dagger]) Barbara Govert, * Arthur Liang, * and the NCID/SARS Community Outreach Team (1) * Centers for Disease Control and Prevention, Atlanta, Georgia, USA; and ([dagger]) Northrop Grumman Mission Systems, Atlanta, Georgia, USA (1) Community Outreach Team: Brenda Garza, Deborah Gould, Meredith Hickson, Marian McDonald, Cecilia Meijer, Julia Smith, Liza Veto, Walter Williams, Laura Zauderer COPYRIGHT 2004 U.S. National Center for Infectious Diseases 17 However, additional, rigorous data are needed to identify the exact mechanisms in greater detail that help reduce stigma and discrimination. A positive step would be the development of widely accepted indicators to measure changes in stigmatizing attitudes. These could then be applied to operations research studies even in cases where the primary area of investigation is not directly related to reducing discrimination. Finally, evaluation and monitoring structures should track trends in this important area throughout the implementation phases of various projects, perhaps using the same indicators adapted to the specific situation. By considering levels and forms of stigma and discrimination throughout the response to the epidemic, the chances of understanding these social constructs would improve. Consequently, so would the ability to counteract them. Course : Epidemics and Economic and Social History: From the Black Death to the Present This information is for the 2005/06 session. Teacher responsible Dr Patrick Wallis, C319 Availability This is an optional course for MSc Economic History, MSc Economic History (Research), MSc Economics and Economic History and MSc Biomedicine, Bioscience and Society students. Students taking other masters degrees may be admitted, space and timetable permitting, and with the approval of their department and the course teacher. Core syllabus This course analyses the impact of epidemic disease on human societies and economies from the Black Death to the present day. It examines arguments and evidence about epidemics relationship to economic, social, demographic and political change and the development and implementation of medical, scientific and social responses. Case studies will focus on epidemics in Europe, Central America, and Asia, but reference may also be made to the experience of other regions, in order to achieve a more global picture. Content The course will explore a range of issues in the history of epidemics from the fourteenth century to the present day. Themes considered will include: the extent to which epidemics act as agents of social, economic, religious and political change; the role of epidemics in demographic change and its political and economic consequences, particularly the Columbian exchange and the epidemiological transition. Aspects of responses to epidemics will include: the significance of the epidemics in the development of public health; popular resistance to public health; epidemics, empire and colonialism in the nineteenth and twentieth centuries; the construction of scientific and medical understandings of epidemic diseases; medical responses, including inoculation, vaccination and policies of herd immunity; language, stigma and policies towards epidemic disease. Epidemic diseases discussed in the course will include plague, smallpox, cholera, and AIDS, and others as required; endemic diseases and endemic forms of epidemics will also be considered as appropriate. Teaching Stigma and HIV/AIDS A Review of the Literature May 2003 DRAFT Deborah L. Brimlow, Ph.D., Jennifer S. Cook, and Richard Seaton, editors Production support provided by Impact Marketing + Communications Contract #231-01-0052 U.S. Department of Health and Human Services Health Resources and Services Administration HIV/AIDS Bureau Room 7-06 5600 Fishers Lane Rockville, MD 20857 (301) 4431993 Introduction This literature review was written at the request of the Health Resources and Services Administration (HRSA) HIV/AIDS Bureau (HAB). The purpose of the review is to (1) provide technical support for attendees at the community consultation Promoting PWA Leadership in Addressing HIV/AIDS Stigma and (2) to provide a technical assistance tool to policy makers, HIV/AIDS service organizations, and researchers concerned with the delivery of services to people at risk for or living with HIV disease. To conduct the review, a team of three individuals carried out three independent searches. The first two searches were conducted via the Internet. The third search was conducted through the Parklawn library. Because of time limitations and the desire to keep the literature review as concise as possible, we limited our search to stigma as it specifically relates to HIV disease. Moreover, we concentrated on literature produced during the past 15 years. In all, we reviewed more than 300 abstracts and 50 publications, 47 of which are discussed in this paper. Summary The quantity of literature available on HIV/AIDS-related stigma differs substantially by topic area. For example, a significant number of articles are available on the evolution of HIV/AIDS stigma, and on policy- related and legal initiatives for addressing it. However, we found that much less material is available on programmatic solutions. This finding is disheartening given providers need for examples of practical, real-world interventions to decrease HIV/AIDS-related stigma. The participation of a few key leaders often propels research in many HIV/AIDS-related fields. The study of HIV/AIDS-related stigma is no exception. Gregory M. Herek, Ph.D., is generally recognized as a leader in the field, and his works are referenced in many of the articles we discuss. The existence of HIV/AIDS-related stigma has been widely documented. In a comparison of two studies conducted among similar samples, the proportion of the U.S. population that harbored HIV/AIDS-related stigma increased from 20.5 percent in 1991 to about 28.8 percent in 1997. However, a more recent Centers for Disease Control and Prevention (CDC) study found a somewhat lower percentage of people who harbor HIV/AIDS-related stigma (18.1 percent). Stigma related to HIV/AIDS appears to be more severe than that associated with other life-threatening conditions. It also extends beyond the disease itself to providers and even volunteers involved with the care of people living with HIV disease. Often, HIV/AIDS-related stigma is expressed in conjunction with one or more other stigmas, particularly those associated with homosexuality, bisexuality, and injection drug use. People with certain religious beliefs and less educated people may be more likely to harbor HIV/AIDS- related stigma. HIV/AIDS-related stigma compromises the well-being of people living with the disease. Stigmatized individuals may suffer discrimination that can lead to loss of employment and housing, estrangement from family and society, and even increased risk of violence. HIV/AIDS-related stigma also fuels new HIV infections because it can deter people from getting tested for the disease, make them less likely to acknowledge their risk of infection, and discourage those who are HIV-positive from discussing their HIV status with their sexual and needle-sharing partners. Efforts to address HIV/AIDS-related stigma have focused on three arenas: programmatic, legal, and policy. The literature on effective interventions is skewed to the legal arena; a comparatively small amount of material is available on community-based interventions. Stigma Defined HIV-related stigma refers to all unfavorable attitudes, beliefs, and policies directed toward people perceived to have HIV/AIDS as well as toward their significant others and loved ones, close associates, social groups, and communities. Patterns of prejudice, which include devaluing, discounting, discrediting, and discriminating against these groups of people, play into and strengthen existing social inequalitiesespecially those of gender, sexuality, and racethat are at the root of HIV-related stigma. Erving Goffman is widely credited for conceptualizing and creating a framework for the study of stigma. His work was seminal in creating an environment for ongoing academic research on the topic. In his landmark book Stigma: Notes on the Management of Spoiled Identity (1963), Goffman described stigma as an attribute that is deeply discrediting within a particular social interaction (p. 3). His explanation of stigma focuses on the publics attitude toward a person who possesses an attribute that that falls short of societal expectations. The person with the attribute is reduced in our minds from a whole and usual person to a tainted, discounted one (p. 3). Goffman further explained that stigma falls into three categories: Abominations of the bodyvarious physical deformities. Blemishes of individual characterweak will, domineering or unnatural passions, treacherous and rigid beliefs, or dishonesty. Blemishes of character are inferred from, for example, mental disorder, imprisonment, addiction, alcoholism, homosexuality, unemployment, suicidal attempts, or radical political behavior. Tribal stigma of race, nation, and religionbeliefs that are transmitted through lineages and equally contaminate all members of a family (Goffman, 1963). The stigma concept has been applied to myriad circumstances (Link and Phelan, 2001). Goffmans ideas are a common thread in much of the published research and provide the theoretical underpinnings for much of the literature on stigma and stereotyping. According to Goffman and other researchers, diseases associated with the highest degree of stigma share common attributes: The person with the disease is seen as responsible for having the illness The disease is progressive and incurable The disease is not well understood among the public The symptoms cannot be concealed. HIV infection fits the profile of a condition that carries a high level of stigmatization (Goffman, 1963; Herek, 1999; Jones et al., 1988). First, people infected with HIV are often blamed for their condition and many people believe HIV could be avoided if individuals made better moral decisions. Second, although HIV is treatable, it is nevertheless a progressive, incurable disease (Herek, 1999; Stoddard, 1994). Third, HIV transmission is poorly understood by some people in the general population, causing them to feel threatened by the mere presence of the disease. Finally, although asymptomatic HIV infection can often be concealed, the symptoms of HIV-related illness cannot. HIV-related symptoms may be considered repulsive, ugly, and disruptive to social interaction (Herek, 1999). The discrimination and devaluation of identity associated with HIV-related stigma do not occur naturally. Rather, they are created by individuals and communities who, for the most part, generate the stigma as a response to their own fears. HIV-related stigma manifests itself in various ways. HIV-positive individuals, their loved ones, and even their caregivers are often subjected to rejection by their social circles and communities when they need support the most. They may be forced out of their homes, lose their jobs, or be subjected to violent assault. For these reasons, HIV-related stigma must be recognized and addressed as a life-altering phenomenon. HIV-related stigma has been further divided into the following categories: Instrumental HIV-related stigmaa reflection of the fear and apprehension that are likely to be associated with any deadly and transmissible illness (Herek, 1999) Symbolic HIV-related stigmathe use of HIV/AIDS to express attitudes toward the social groups or lifestyles perceived to be associated with the disease (Herek, 1999) Courtesy HIV-related stigmastigmatization of people connected to the issue of HIV/AIDS or HIV- positive people (Snyder, 1999, based on Goffman, 1963). Stigma and the General Population Within the literature and within policy and care settings, much attention has been given to stigmatizing attitudes related to HIV/AIDS. Perhaps no contribution has been more significant than that of Gregory M. Herek, Ph.D., a professor of psychology at the University of California at Davis who is an internationally recognized authority on prejudice against lesbians and gay men, hate crimes and antigay violence, and HIV-related stigma. Hereks work frames much of the following discussion about stigma in the general population. Herek (1990) observed that gay men and injection drug users are disproportionately susceptible to HIV-related stigma and discrimination. He has found that HIV-related stigma is not necessarily a stigma of the diseased; rather, it is often related to perceived lifestyle choices of infected populations or to perceptions about racial and ethnic minorities. In contrast, people who acquire HIV through no action of their own (for example, hemophiliacs and babies of HIV-positive women) have been referred to as innocent or blameless. Herek (1990) referred to previous studies that found that people with AIDS are evaluated more negatively than people diagnosed with other incurable diseases, even by health care workers. He also cited studies that found that it was common for caregivers to avoid people with AIDS and to overestimate the risks of casual contact with people living with HIV/AIDS. HIV/AIDS-related stigma extends beyond individuals living with HIV/AIDS to volunteers, caregivers, coworkers, and professionals who provide HIV/AIDS services or advocacy. For example, some patients will switch medical providers when they learn that their provider is HIV positive or cares for HIV-positive patients. Herek (1997) referred to a 1991 study by Gerbert showing that individuals who had direct contact with an HIV-positive person were less likely than those who had no contact with an HIV-positive person to switch health care providers on the basis of the HIV status of the provider or the providers patients. Herek and Capitanio (1993) found that HIV/AIDS-related stigma exists in a significant minority of the U.S. population. They used a 1991 random-digit telephone survey to examine stigmatizing attitudes about HIV/AIDS. Of the 1,145 households surveyed, 538 were defined as black households. Responses differed little by race. The authors found that 27.1 percent of all participants gave a stigmatizing response when asked if they felt angry towards people with AIDS. When asked if people living with AIDS should be separated from the general population, 35.7 percent of the participants gave a stigmatizing response. When participants in the 1991 telephone survey were asked if people with AIDS have gotten what they deserved, 20.5 percent of white respondents and 16.5 percent of black respondents said yes. Thirty-three percent of white respondents agreed that people with AIDS should be legally separated, or quarantined, compared with 40 percent of black respondents. And 19.2 percent of white respondents said they would avoid a coworker with AIDS, compared with 21.1 percent of black respondents. White women were the least likely of any group surveyed to overestimate the risks of casual contact or to anticipate that they would avoid people with AIDS (Herek and Capitanio, 1993). HIV-Related Stigma in the United States: Prevalence and Trends, 1991-1999(a) Support for Coercive AIDS-Related Policies Percent responding agree somewhat or strongly agree.199119971999People with AIDS should be legally separated from others to protect the public health.34.4%16.6%12.0%The names of people with AIDS should be made public so that others can avoid them.28.8%18.6%16.3%Women who are pregnant should be required to be tested for the AIDS virus in order to protect the health of their unborn baby.N/A83.0%81.9%People at risk for getting AIDS should be required to be tested regularly for the AIDS virus.N/A73.8%63.5%People from other countries who want to live in the United States should first be required to have an AIDS test to prove they are not infected with the AIDS virus.N/A77.5%74.1%Attributions of Responsibility and Blame for People with HIV/AIDS Percent responding agree somewhat or strongly agree.199119971999People who got AIDS through sex or drug use have gotten what they deserve.20.3%28.1% 24.8% Most people with AIDS dont care if they infect other people with the AIDS virus.N/A 25.5% 21.8% Most people with AIDS are responsible for having their illness.N/A 53.5% 48.3% Inaccurate Beliefs About HIV Transmission Percent of respondents incorrectly believing that the listed activity is very likely, somewhat likely, or somewhat unlikely to transmit AIDS. (The responses very unlikely and impossible were counted as correct responses).199119971999Kissing someone on the cheek who has the AIDS virus.17.1% 13.3% N/ASharing a drink out of the same glass with someone who has the AIDS virus.47.6% 53.2% 50.1% Using public toilets.34.0% 40.9% 40.8% Being coughed on or sneezed on by someone who has the AIDS virus.45.7%53.6%50.4%Donating or giving blood.32.2% 28.9% 32.9% Exaggerated and Seemingly Irrational Fears About HIV Contagion Researchers measured respondents exaggerated fears about contracting HIV through symbolic contact with an object that had once been touched by a person with AIDS. This phenomenon has also been described as belief in the magical law of contagion. 199119971999Less likely to wear sweater once worn by PWA.(b)N/A26.8%25.7%Uncomfortable about drinking out of a washed, sterilized glass in a restaurant that had been used a few days earlier by a PWA.(c)N/A26.9%25.7%Discomfort and Avoidance of Contact With People With HIV/AIDS199119971999Suppose you had a young child who was attending school where one of the students was known to have AIDS.Percentage who would feel somewhat or very uncomfortable.N/A 26.6% 30.3% Percent who would avoid person with AIDS.14.9% 9.9% 8.5% Suppose you worked in an office where one of the men working with you developed AIDS.Percentage who would feel somewhat or very uncomfortable.N/A 24.7% 22.4% Percent who would avoid person with AIDS.18.6% 11.7% 9.1% Suppose you found out that the owner of a small neighborhood grocery store where you liked to shop had AIDS.Percentage who would feel somewhat or very uncomfortable.N/A 28.6% 27.2% Percent who would avoid person with AIDS.45.2% 32.2% 29.3% a) All the data in this chart appeared in an article by Herek GM, et al. in 2002. Interviews for the 1997 and 1999 surveys were conducted by the Survey Research Center at the University of California at Berkeley, using their computer-assisted telephone interviewing (CATI) system. The median duration of the interview was 44 minutes. For the 1997 survey, the sampling frame was the population of all English-speaking adults (at least 18 years of age) residing in households with telephones within the 48 contiguous states. The sample was drawn using a list-assisted Random Digit Dialing (RDD) procedure. Interviews were fully or substantially completed with 1,309 respondents (a response rate of 65.1%). The 1999 survey was conducted with a new sample, using the same sampling frame and RDD procedure as the 1997 survey. Interviews were fully or substantially completed with 669 respondents, (a response rate of 58%). Data from the 1997 and 1999 surveys were compared with findings from the research teams 1991 national telephone survey. The 1991 survey results presented use unweighted data and are based on that studys primary sample (N = 538), which was selected using a methodology comparable to the later surveys. More detailed information about the methodology is available in the original report. b) Percentage whose self-rated likelihood of wearing sweater worn by PWA was lower than previously rated likelihood of wearing another sweater. Respondents were asked about their willingness to wear a very nice sweater that had been worn once by another person who you didnt know and had been cleaned and sealed in a new plastic package so that it looked like it was brand new. Respondents were then asked about the likelihood that they would wear the same sweater if they found out that the person who had worn it the one time before had AIDS. c) Percentage who would feel not very comfortable or not at all comfortable about drinking out of a washed, sterilized glass used a few days earlier by a PWA. Source: Herek GM, Capitanio JP, Widaman KF. HIV-related stigma and knowledge in the United States: prevalence and trends, 1991-1999. Am J Public Health. 2002;92(3):371-7. Available at: http://psychology.ucdavis.edu/rainbow/html/ajph2002.pdf.Herek and Capitanio conducted follow-up telephone surveys in 1992 and 1997, both of which used similar methodology. The authors documented what appeared to be increasing levels of stigma and a hierarchy of blame regarding HIV/AIDS (Herek and Capitanio, 1999). They wrote, In our 1991 survey, for example, 20.5 percent of respondents agreed that people with AIDS have gotten what they deserve. Approximately 6 years later, in the 1997 survey, 28.8 percent agreed with the statement, an increase of roughly 40 percent (p. 1128). Even more of the 1997 respondents assigned some degree of responsibility when the question was framed less harshly. For example, 55.1 percent agreed that most people with AIDS are responsible for their own illness (Herek and Capitanio, 1999). The authors drew four major conclusions about HIV/AIDS-related stigma in the United States: Most of the heterosexual adults who were surveyed equate AIDS with homosexuality or bisexuality and in turn, harbor higher levels of prejudice. Much of the public continues to label people with AIDS as blameworthy or innocent; moreover, among those who contracted AIDS through sexual activity, gay men are viewed more negatively than are heterosexuals. Some portions of the public equate any same-sex behavior with AIDS; misconceptions and a lack of understanding about AIDS promote the view that all homosexual behavior eventually leads to AIDS. A substantial portion of the public harbors exaggerated fears about symbolic contact with HIV-positive people, such as touching an article of clothing worn by a person living with HIV disease. These attitudes are most prevalent among people who harbor sexual prejudice (Herek and Capitanio, 1999). Herek and Capitanio also examined the relationship between HIV-related stigma and direct or vicarious contact with people with AIDS. Study results indicated that contact with a person living with HIV disease reduced stigma and that such contact was more likely among relatively affluent individualsthose with at least some college and annual incomes greater than $40,000 (Herek and Capitanio, 1997). There is some evidence that HIV/AIDS-related stigma declined over the 1990s. For example, in 2000, the CDC published results from a study of 5,641 people in which 18.1 percent of participants gave a response suggesting that they harbor stigmatizing attitudes toward HIV-positive individuals. Herek et al. (2002) described findings from their 1999 telephone survey that also indicates that some expressions of stigma declined over the 1990s. The proportion of people advocating the most drastic measuresquarantine and public identificationsignificantly diminished. However, although most people surveyed understood how AIDS is transmitted, they were less clear on how AIDS is not transmitted. And despite reductions in stigma, one-fifth of those surveyed feared people with AIDS, and one-fourth felt uncomfortable having contact with people with AIDS. Another result underlines the power of stigma to extend to the economic realm: Nearly one-third of respondents said that they would avoid shopping at a neighborhood grocery known to be owned by a person with AIDS. Other studies have tried to better define populations who harbor HIV-related stigma and who may practice discrimination. Rozin et al. (1994) cited a study that reported an association between fear of AIDS and regular church attendance. Herek and Capitanio (1998) found that 41 percent of heterosexual adults based their HIV-related attitudes on religious or political values; only 13 percent based their attitudes on concerns for personal safety. Herek (1999) cited several studies finding that younger and more highly educated people typically manifest lower levels of HIV-related stigma than do older people and those who are less educated.  HYPERLINK "http://hab.hrsa.gov/publications/stigma/references.htm" \l "a1" \o "skip header and navigation"   INCLUDEPICTURE "http://hab.hrsa.gov/publications/stigma/stigma-title.gif" \* MERGEFORMATINET  Contents  HYPERLINK "http://hab.hrsa.gov/publications/stigma/front.htm" Front matter  HYPERLINK "http://hab.hrsa.gov/publications/stigma/introduction.htm" Introduction  HYPERLINK "http://hab.hrsa.gov/publications/stigma/summary.htm" Summary  HYPERLINK "http://hab.hrsa.gov/publications/stigma/stigma_defined.htm" Stigma Defined  HYPERLINK "http://hab.hrsa.gov/publications/stigma/stigma_and_the_general_population.htm" Stigma and the General Population  HYPERLINK "http://hab.hrsa.gov/publications/stigma/stigma_and_access_to_care.htm" Stigma and Access to Care  HYPERLINK "http://hab.hrsa.gov/publications/stigma/violence.htm" Violence  HYPERLINK "http://hab.hrsa.gov/publications/stigma/interventions.htm" Interventions  HYPERLINK "http://hab.hrsa.gov/publications/stigma/references.htm" References References Annas G. 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Behavioral consequences of AIDS antibody testing among gay men. JAMA. 1987;258:1889. Durham JD. The changing HIV/AIDS epidemic: emerging psychosocial challenges for nurses. Nurs Clin North Am. 1994;29:9-18. Fehrs LJ, et al. Trial of anonymous versus confidential human immunodeficiency virus testing. Lancet. 1988;2(8607):379-82. Gerbert B, Maguire BT, Bleeker T, Coates TJ, McPhee SJ. Primary care physicians and AIDS: attitudinal and structural barriers to care. JAMA. 1991:266:2837-42. Gerbert B, Sumser J, Maguire BT. The impact of who you know and where you live on opinions about AIDS and health care. Social Science and Medicine. 1991;32:677-81. Gielen AC, OCampo P, Faden RR, Eke A. Womens disclosure of HIV status: experiences of mistreatment and violence in an urban setting. Womens Health. 1997;25:19-31. Goffman E. Stigma: Notes on the Management of Spoiled Identity. New Jersey: Prentice Hall, 1963. Herek GM. AIDS and stigma. Am Behav Scientist. 1999;42(7):1106-16. Available at: http:// psychology.ucdavis.edu/rainbow/html/bibabs.html. Herek GM. Illness, stigma and AIDS. In: VandenBos GR, ed. Psychological Aspects of Serious Illness. Washington, DC: American Psychological Association; 1990. Herek GM, Capitanio JP. AIDS stigma and sexual prejudice Am Behav Scientist. 1999;42(7):1126-43. Herek GM, Capitanio JP. Symbolic prejudice or fear of infection? A functional analysis of AIDS-related stigma among heterosexual adults. Basic App Soc Psychol. 1998;20(3):230-41. Herek GM, Capitanio JP. AIDS stigma and contact with persons with AIDS: effects of direct and vicarious contact. J Appl Soc Psychol. 1997;27(1):1-36. Herek GM, Capitanio JP. Public reactions to AIDS in the United States: a second decade of stigma. Am J Public Health. 1993;83(4):574-7. Herek GM, Capitanio JP, Widaman KF. HIV-related stigma and knowledge in the United States: prevalence and trends, 19911999. Am J Public Health. 2002;92(3):371-7. Herek GM, Gillis JR, Cogan J. 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Course Academic Year 2004-5 Dr Patrick Wallis (Course Proprietor) EH411 Epidemics and Economic and Social History: From the Black Death to the Present Scope This course analyses the impact of epidemic disease on human societies and economies from the Black Death to the present day. It examines arguments and evidence about epidemics relationship to economic, social, demographic and political change and the development and implementation of medical, scientific and social responses. Case studies will focus on epidemics in Europe, Central America, and Asia, but reference may also be made to the experience of other regions, in order to achieve a more global picture. The course will explore a range of issues in the history of epidemics from the fourteenth century to the present day. Themes considered will include: the extent to which epidemics act as agents of social, economic, religious and political change; the role of epidemics in demographic change and its political and economic consequences, particularly the Columbian exchange and the epidemiological transition. Aspects of responses to epidemics will include: the significance of epidemics in the development of public health; popular resistance to public health; epidemics, empire and colonialism in the nineteenth and twentieth centuries; the construction of scientific and medical understandings of epidemic diseases; medical responses, including inoculation, vaccination and policies of herd immunity; language, stigma and policies towards epidemic disease. Epidemic diseases discussed in the course will include plague, smallpox, cholera, and AIDS, and others as required; endemic diseases and endemic forms of epidemics will also be considered as appropriate. Structure The course is structured as follows: Two introductory lectures will present a background to epidemics and a long-run introduction to medical theory and practice. Part 1: In this part we use the Black Death and subsequent plague epidemics as the means to introduce four of the basic areas that dominate studies of epidemics their social, economic, and political impact, and the nature and impact of their representation. The Black Death serves in many ways as an archetype for later European responses to epidemics, and the material dealt with here provides an essential background to understand much of the later history of epidemics. Part 2: This substantial section deals with the decline of epidemics. Essentially, we will be examining how Europe moved from the situation apparent in the 14th to 17th century of repeated exposure to epidemics and high mortality to the late 19th and 20th century situation of much lower vulnerability to epidemic disease. Part A examines the demographic outlines of this transition, looking first at the apparent retreat of epidemics in the eighteenth century, and then at the larger question of the decline of mortality in the 19th century. Part B then examines the ways in which responses to disease were changing in this period. We first look at the broad issue of the role of the state in public health. We then move on to two case studies in order to analyse how interventions developed and were accepted in the 18th and 19th centuries (in the case of smallpox), and how societies responded to epidemics in the nineteenth century (the example of cholera). Implicit here is a contrast with the response to plague. EH411, 2004-5 1 Part 3: This section examines the relationship of epidemic disease and empire. It begins with an examination of one of the key concepts in globalisation that of the spread of disease and its role in imperial expansion from the 16th century onwards. We then turn to the relationship between imperial and colonial regimes and disease, largely in the context of 19th and early 20th century India. Part 4. This section moves to the more recent history of epidemics, particularly AIDS. We first examine the relationship between marginalization, stigma and sexually transmitted disease in the case of syphilis. The next two weeks examine, first, reactions to AIDS, and second, the socio-economic impact of AIDS. Finally, we close the course with a view on some of the broad trends in global public health and policy. Course Organisation This course will be taught be weekly seminars, from 16.00 to 18.00 on Mondays in room Y002. The course begins with two lectures; eighteen seminars take up the remainder of MT and LT. All students should complete the course readings for each week given in the list below. Please note that the questions given for each week are issues to consider while reading; they are not a set agenda for each session. A suggested essay question is also given. Seminar Papers You are required to write two seminar papers, one for a topic from part 2 or 3, and one for a topic from part 4 or 5. Papers must be submitted in advance of the seminar to which they relate. Topics will be selected at the second lecture, and should not normally be changed thereafter. Questions are suggested for each week, but alternative titles are acceptable if agreed in advance. Every paper must address a question. You will find suggested questions at the top of the reading list for each topic. Papers should be of 2,500-3,000 words and typed (single-spaced). Be sure to give references, in footnotes. Please list the sources you have used at the end of the essay. References and bibliography do not count towards the word-limit. It is important to note that a decent essay is likely to require at least six to eight readings. For each topic a selection of initial readings are given; further readings are available in the supplemental reading list or through your own research. Please tell me of any readings which you find particularly helpful or unhelpful. What we are looking for in a seminar paper is your analysis of the matter: a systematic, reasoned discussion of the theoretical and empirical issues. Your conclusions do not have to be original but they do need to be the product of your own critical examination of the material available to you. The questions are largely open to a variety of approaches; good answers will engage in a rigorous way with the issue and concepts involved. When you have finished your paper, you should send it by e-mail attachment to all members of the group (including me: p.h.wallis@lse.ac.uk). This must be by noon the day before the seminar, to give everyone time to read it in advance. The previous Friday is better still! I will return these papers with detailed comments and a grade for your information (it will not count in the assessment of the degree). Providing the paper comes in on time, I will usually be able to give it back to you at the end of the seminar to which it relates. Once you have read my comments you are welcome to see me individually to discuss the paper and the course as a whole. Discussants of Papers In weeks where papers are submitted, another student will be responsible for giving a short commentary on the paper (a maximum of 8 minutes). Respondents must therefore be familiar with the material. EH411, 2004-5 2 Assessment An assessed essay to be handed in during the year the course is taken counts for 30% of the marks. It must be not more than 2,500 words (excluding references and bibliography). The remaining 70% of the marks are accounted for by a three-hour written examination in summer term. Summary of Written Work All students are required to produce three papers. Two of these are circulated to the seminar; a third is submitted for formal Assessment. Titles must be approved in advance. Additional resources Nearly all of the readings are available at the Wellcome Library for the History of Medicine, at 210 Euston Road, London NW1 2BE (nearest tubes: Euston Road, Euston, Warren Street). This very comfortable library contains a massive number of works relevant to the course. Its collections will be almost essential for preparing essays, in particular. You are all strongly advised to visit it and get a readers ticket (open to all) as soon as possible. Details are available at: http://library.wellcome.ac.uk/ Individual consultation: To see my individually, either speak to me at the end of the seminar, e-mail me (p.h.wallis@lse.ac.uk), or come to my office (room C.319: tel. 020 7955 7074). During the Michaelmas and Lent Terms my office hours (i.e. when I am guaranteed to be in my room) will normally be Mondays, 11-12am. I will give advance notice of any variations on these times in class and on my door. General readings: In addition to the specific works given for each topic, and the general theoretical works and introductions listed for lectures 1 and 2, these books may provide a useful background and general introduction: M. Harrison, Disease and the Modern World: 1500 to the present. J.N. Hays The Burdens of Disease: Epidemics and Human Response in Western History (1998) J. Diamond, Guns, germs and steel (1997) S. Watts, Epidemics and History: Disease, power and imperialism (1997) For further information on modern understandings of disease: Anderson & May, Infectious Diseases of Humans (1991) The US Centers for Disease Control website also provides useful background information on many diseases (www.cdc.gov) If you are considering taking a broader analysis of an epidemic as a research project, you may be interested in these studies of the impact of epidemics on growth (see also seminars 4 and 19): E. Brainerd and M. Siegler, 'The Economic Effects of the 1918 Influenza Epidemic', CEPR Discussion Paper No. 3791 (2003). J. Fisher, Influenza and inflation in Tudor England, EcHR (1957) (nb: see Moore article in EcHR 1993 plus Zell and Moores comments in EcHR 1994) EH411, 2004-5 3 Lee, Jong-Wha and McKibbin, Warwick J. Estimating the global economic costs of SARS, Asian Economic Papers (MIT 2004) [and in Learning from SARS] N. Crafts & M. Haacker, Welfare Implications of AIDS, IMF Working Paper, No. 03/118 (http://www.imf.org/external/pubs/cat/longres.cfm?sk=16567.0) For a mix of relaxation and reference you may enjoy some epidemic novels, such as: Albert Camus, La Peste/The Plague Gabriel Garcia Marquez, Love in the Time of Cholera Geraldine Brooks, Year of Wonders Part 1: Introduction: 1. Lecture 1: Approaches to diseases and epidemics A. L. Caplan, 'The Concepts of Health, Illness, and Disease', in W. F. Bynum and R. Porter (ed.), The Companion Encyclopedia to the History of Medicine (London, 1993), pp. 233-48. R. P. Hudson, 'Concepts of Disease in the West', in K. F. Kiple (ed.), The Cambridge World History of Human Disease (Cambridge, 1993), pp. 45-52. C. E. Rosenberg, Explaining Epidemics and Other Studies in the History of Medicine (Cambridge, 1992), chapters on Framing P. Strong, 'Epidemic Psychology: A Model', Sociology of Health and Illness, 12 (1990), pp. 249-59. L. Jordanova, 'The Social Construction of Medical Knowledge', Social History of Medicine, 8 (1995), pp. 361-81. A. Wilson, 'On the History of Disease-Concepts: The Case of Pleurisy', History of Science, 38 (2000), pp. 271-319. A. Cunningham, 'Transforming Plague: The Laboratory and the Identity of Infectious Disease', in A. Cunningham and P. Williams (ed.), The Laboratory Revolution in Medicine (Cambridge, 1992), pp. 209-44. R. McCaa, the big killers?, Social Science History (1996) 2. Lecture 2: Theories of Disease and Histories of Epidemics General Reference: R. Porter, The Greatest Benefit to Mankind: a medical history of humanity (1997) I. Loudon (ed.), Western Medicine: an Illustrated History (1997) K. Kiple (ed.), The Cambridge world history of human disease (1993) Bynum & Porter (ed) Companion Encyclopedia of the history of medicine (1993) Good explanations of changing theories of disease: EH411, 2004-5 4 M. Pelling, Contagion/Germ Theory/Specificity in Companion Encyclopedia of the history of medicine (1993), reprinted in A. Bashford & C. Hooker (ed.), Contagion: historical and cultural studies (2001) V. Nutton, 'The Seeds of Disease: An Explanation of Contagion and Infection from the Greeks to the Renaissance', Medical History, 27 (1983), pp. 1-34. EJ [= ELECTRONIC JOURNAL] M. Worboys, Spreading Germs: Disease, Theories, and Medical Practice in Britain, 1865-1900 (Cambridge, 2000) N. Tomes, The Gospel Of Germs: Men, Women And The Microbe In American Life PART 2: Great Plagues and Four Core Themes in Epidemic History 3. Social Impact: The Arrival of the Black Death. General themes: What characteristics marked the immediate and medium-term social impact of the Black Death? Was the Black Death a shock that exposed the basic elements of social organisation? Are there archetypal patterns in psychological responses to epidemics? Question: Assess the extent to which the Black Death was an assault on public order? P. Strong, 'Epidemic Psychology: A Model', Sociology of Health and Illness, 12 (1990), pp. 249-59. O. Benedictow The Black Death 1346-1353: The Complete History (2004), chapter M. Dols, The comparative communal response to Black Death in Muslim and Christian societies, Viator, 5 (1974) D. Herlihy The Black Death and the Transformation of the West (1997), ch. 3. 4. Economic Impact: The Economic Consequences of the Black Death: General themes: Analyse the methodological and theoretical differences in approaches to the economic impact of the epidemic. In what ways did the epidemic affect the economy in the short, medium and long-term? Question: To what extent was the black death a period of creative destruction? A. R. Bridbury, The Black Death EcHR, 26/4 (1973), 577-92 EJ W. Bean The Black Death: the crisis and its social and economic consequences, in D. Williman (ed.), The Black Death: the Impact of the Fourteenth-century Plague (1982) J. Hatcher, 'England in the Aftermath of the Black Death', Past and Present, 144 (1994), pp. 3-25. EJ M. Bailey, "Demographic Decline in Late Medieval England: some Thoughts on Recent Research." EcHR 49.1 (1996): 1-19. EJ EH411, 2004-5 5 S. R. Epstein, Freedom and Growth: The Rise of States and Markets in Europe, 1300-1750 (2000), ch. 3 5. Political Responses: Plague and Emergence of Public Health General themes: Why were political responses to plague created at different times by cities and states from the fifteenth to seventeenth centuries in Europe? Was state intervention in public health inevitable in early modern Europe? What was the relationship between vulnerability, social status and state intervention? Question: To what extent were political measures against plague determined by pragmatic experience? *C. E. Rosenberg, Explaining Epidemics and Other Studies in the History of Medicine (Cambridge, 1992), ch. 13 A. Carmichael, Contagion theory and contagion practice in 15th-century Milan, Renaissance Quarterly, 44 (1991) EJ B. Pullan Plague and the perception of the poor in early modern Italy in Ranger & Slack, Epidemics and Ideas (1992) pp. 101-24 M. Jenner, 'The Great Dog Massacre', in W. G. Naphy and P. Roberts (ed.), Fear in Early Modern Society (Manchester, 1997), pp. 44-61. L. Brockliss and C. Jones, The Medical World of Early Modern France (Oxford, 1997), pp. 347-56 6. Representations: Stories and Historiographies of Epidemics General themes: What are the problems and possibilities of literary evidence on epidemics? Can particular literary forms be identified in contemporary accounts of epidemics? Are these meaningful? What purposes did memory have for contemporaries? Do such patterns persist in the modern historiography of plague? Question: Analyse any of the texts below (in Horrox or Defoe) in light of the critical readings. The arrival of the plague, The arrival of the plague in Florence, The arrival of the plague in Padua in R. Horrox ed. The Black Death (1994), pp. 14-35. D. Defoe, Journal of the Plague Year (1722). Read pages 184-189 of the Perseus online edition (this is 136-40 of the Norton edition). The Perseus edition can be found in the London section of the Persues Digital Library (http://www.perseus.tufts.edu/). A. G. Carmichael, 'The Last Past Plague: The Uses of Memory in Renaissance Epidemics', Journal of the History of Medicine, 53 (1998), pp. 132-60. C. Jones, Plague and its metaphors in early modern France, Representations, 53 (1996) EJ F. M. Getz, 'Death and the Silver Lining: Meaning, Continuity, and Revolutionary Change in Histories of Medieval Plague', Journal of the History of Biology, 24 (1991), pp. 265-89. EH411, 2004-5 6 PART 3: The defeat of epidemics? A. Changes in the Demographic Impact of Epidemics: 7. The decline of epidemics in the 18c: General Themes: In what ways did the effect of epidemics on mortality change during the eighteenth century? What factors explain these changes? Do social and economic factors offer a sufficient explanation for the reduction in vulnerability to crisis? Question: How well can changes in mortality be explained through environmental variation or human action? M. W. Flinn, The European Demographic System, 1500-1820 (Brighton, 1981), ch. 4. OR: M W Flinn, The stabilization of mortality in pre-industrial Europe, J Eur Ec H, 3 1974 J. Post, Famine, Mortality and epidemic disease in the process of modernization, EcHR 39/1 (1976): 14-37 OR J. Post, Food shortage, climactic variability and epidemic disease in preindustrial Europe: the mortality peak in the early 1740s (1985), ch.8. S. J. Kunitz, Speculations on the European mortality decline EcHR 36 (1983): 349-64. EJ A. Perrenoud, 'The Attenuation of Mortality Crises and the Decline of Mortality', in R. Schofield, D. Reher, and A. Bideau (ed.), The Decline of Mortality in Europe (Oxford, 1991), pp. 18-37. M. Dobson, Contours of Death and Disease in Early Modern England (Cambridge, 1997), ch. 8 8. Mortality Crises and the Rise of Population General themes: What patterns are apparent in mortality over the nineteenth century? What is McKeowns explanation for these changes? What are the problems with this model? Assess the value of alternative explanations in demographic change. Question: To what extent does economic growth serve as an explanation for mortality decline? Thomas McKeown, The modern rise of population (1976) Schofield and Reher, The decline of mortality in Europe, in Scholfield, Reher and Bideau, eds. The Decline Of Mortality In Europe (1991), 1-18 Simon Szeter, 'The importance of social intervention in Britain's mortality decline, c.1850-1914: a reinterpretation of the role of public health', Social History of Medicine, 1 (1988), 1-39 Sumit Guha, 'The importance of social intervention in England's mortality decline: the evidence revisited', Social History of Medicine, 7 (1994), 89-113 see also Szreters reply. R. A. Easterlin, Growth Triumphant: The Twenty-First Century in Historical Perspective (1996), ch. 6. Hardy, Anne. The Epidemic Streets: Infectious Disease and the Rise of Preventive Medicine,1856-1900 (1993), concluding chapter EH411, 2004-5 7 R. Woods, The Demography of Victorian England and Wales (2000), Ch. 8 B. Transformations in Public and Private Responses to Disease 9. Theories of Action: Medical Police and the changing role of the state General Themes Did medical practitioners attain a new relationship with the state during the 18c? What characteristics separate Rosen and Foucaults approach to medical police? Question: To what extent was medical police a political or economic initiative, and how does this inflect historical analyses of it? M. Foucault, The politics of health in the Eighteenth Century in Michel Foucault, Power/Knowledge, ed. C. Gordon (1988), pp. 166-182. G. Rosen, From Medical Police to Social Medicine, pp. 120-158. M. Ramsey, Public health in France, in D. Porter (ed.), The history of public health and the modern state (1994), pp. 45-69 C. Hannaway, The Socit royale de mdecine and epidemics in the ancien regime, Bull H Med 46 (1972), 257-73. L. Jordanova, 'Medical Police and Public Health: Problems of Practice and Ideology', Bulletin of the Society for the Social History of Medicine, 27 (1980), pp. 15-19. D. Lupton, The Imperative of Health, ch.1. B.i. Case Study 1: Smallpox and Human Intervention 10. The adoption of new knowledge: smallpox and inoculation General Themes Does inoculation have a significant effect on smallpox mortality in the 18c? How is knowledge of inoculation constructed and transmitted? What factors explain variations in attitudes to inoculation? Question: How well can the success of smallpox inoculation be explained as a trickle down effect? England P. E. Razzell, The Conquest of Smallpox: The Impact of Inoculation on Smallpox Mortality in Eighteenth Century Britain, 2nd edn. (London, 2003). A. Wilson, 'The Politics of Medical Improvement in Early Hanoverian London', in A. Cunningham and H. R. French (ed.), The Medical Enlightenment of the Eighteenth Century (Cambridge, 1990), pp. 4-39. Lobo, 'John Haygarth, Smallpox and Religious Dissent in Eighteenth-Century England', in A. Cunningham and H. R. French (ed.), The Medical Enlightenment of the Eighteenth Century (Cambridge, 1990), pp. 217-53. EH411, 2004-5 8 Scotland D. Brunton, 'Smallpox Inoculation and Demographic Trends in Eighteenth Century Scotland', Medical History, 36 (1992), pp. 403-29. Africa E. W. Herbert, Smallpox inoculation in Africa, Journal of African History 16 (1975), 539-59. EJ M. Vaughan, Slavery, smallpox and revolution: 1792 in Ile de France (Mauritius), Social History of Medicine 13 (2000), 1-28 11. Intervention, Trust and Risk: Smallpox and Vaccination General Themes Why did countries pursue different policies on vaccination? What accounts for resistance to vaccination? Question How did vaccination strategy understand the bodies of the poor? A possible account of resistance B. Wynne, Public uptake of science, Public Understanding of Science 2 (1993), 321-337. Europe C. Huercamp, 'The History of Smallpox Vaccination in Germany: A First Step in the Medicalization of the General Public', Journal of contemporary history, 20 (1985), pp. 618-19. EJ P. Baldwin, Contagion and the State in Europe, 1830-1930 (Cambridge, 1999), ch. 4 E. P. Hennock, 'Vaccination Policy against Smallpox, 1835-1914: A Comparison of England with Prussia and Imperial Germany', Social History of Medicine, 11 (1998). D. Porter and R. Porter, 'The Politics of Prevention: Anti-Vaccinationism and Public Health in Nineteenth-Century England', Medical History, 32 (1988), pp. 231-52. EJ N. Durbach, '"They Might as Well Brand Us": Working-Class Resistance to Compulsory Vaccination in Victorian England', Social History of Medicine, 13 (2000), pp. 45-62. Deborah Brunton, 'The problems of implementation: The failure and success of public vaccination against smallpox in Ireland, 1840-1873', in Greta Jones and Elizabeth Malcolm (eds), Medicine, disease and the state in Ireland, 1650-1940 (1999), pp. 138-57 India Arnold, David. Colonizing the Body: State Medicine and Epidemic Disease in Nineteenth-Century India. (1993), ch. 3 S. Bhattacharya, 'Re-Devising Jennerian Vaccines? European Technologies, Indian Innovation and the Control of Smallpox in South Asia, 1850-1950', in B. Pati and M. Harrison (ed.), Health, Medicine and Empire: Perspectives on Colonial India (Hyderabad, 2001), pp. 217-69. B.ii: Case Study 2: Dealing with Cholera 12. Cholera: the social impact of disease General Themes What impact did cholera have? EH411, 2004-5 9 Did cholera heighten social tension? How were different explanations (religious, political, class) of cholera deployed? Question Is disease ever responsible for disorder? Answer with reference to cholera? Richard J Evans, 'Epidemics and revolutions: cholera in nineteenth-century Europe', Past and Present, no. 120 (1988), 123-46 C. J. Kudlick, Cholera in Post-Revolutionary Paris: A Cultural History (1996), ch. 1 Durey, Michael. The Return of the Plague: British Society and the Cholera, 1831-32 (1979), ch. 6, 8. Rosenberg, Charles E. The Cholera Years: The United States in 1832, 1849, and 1866 (1962), pp. 13-101 13. Cholera: the politics of public health General Themes Do interpretations and responses to epidemics correlate with national political cultures? Why has Ackerknechts argument been so successful? Did cholera present a problem for sanitationists? Is this a period of modernization in public health? Question: Do political analyses of public health possess any validity in understanding responses to cholera? E. H. Ackerknecht, 'Anticontagionism between 1821 and 1867', Bulletin of the History of Medicine, 22 (1948), pp. 562-93. Peter Baldwin, Contagion and the state in Europe, 1830-1930 (1999), chapters 2-3 Richard Evans, Death in Hamburg: Society and Politics in the Cholera Years, 1830-1910 (1987), esp. pp. 226-84, 474-90 M. Pelling, Cholera, Fever and English Medicine, 1825-1865 (1978), ch.1-2, conclusion. R. Cooter, 'Anticontagionism and History's Medical Record', in P. Wright and A. Treacher (ed.), The Problem of Medical Knowledge: Examining the Social Construction of Medicine (Edinburgh, 1982), pp. 87-108. Part 4: Epidemics and Empire 14: The Columbian Exchange General themes: Does the 15th and 16th centuries witness the globalisation of disease? What was the role of disease in creating early modern empires? Question What problems remain with the smallpox hypothesis in New World Conquest? The Columbian Exchange W.H. McNeill, Transoceanic exchanges, 1500-1700 in id., Plagues and Peoples (1976) EH411, 2004-5 10 E. Le Roy Ladurie, A concept: the unification of the globe by disease (14th to 17th centuries) in Ladurie, The Mind and the Method of the Historian (1981) The Americas N.D. Cook, Born to Die: Disease and New World Conquest, 1492-1650 (1998) D.E. Stannard American Holocaust: Columbus and the Conquest of the New World (1992), ch. 3 R McCaa, Spanish and Nahuatt views on smallpox and demographic catastrophe in Mexico, JIH (1995) F. Brooks, 'The Impact of Disease', in G. Raudzens (ed.), Technology, Disease and Colonial Conquests, Sixteenth to Eighteenth Centuries: Essays Reappraising the Guns and Germs Theories (Leiden, 2001), pp. 127-66. For reference: The Pacific A.W. Crosby Hawaiian depopulation as a model for the Amerindian experience, in Slack & Ranger, Epidemics and Ideas S.J. Kunitz Disease and Social Diversity: the European Impact of the Health of Non-Europeans (1994), ch. 3 15. Disease and Empire General themes: Did imperial expansion offer a stimulus to innovation? Did morbidity or mortality matter most in the imperial enterprise? Was medical knowledge of climate an impediment to colonialism? Question: To what extent was medicine a tool for creating empire in the nineteenth century? Harrison, Mark. Public Health in British India: Anglo-Indian Preventive Medicine,1859-1914. (1994), ch. 4. M. Harrison, Climates and Constitutions: Health, Race, Environment and British Imperialism in India, 1600-1850 (New Delhi, 1999), ch. 3 Curtin, Philip F. Death by Migration: Europe's Encounter with the Tropical World in the Nineteenth Century (1989), ch. 1-2. Headrick, Daniel F. The Tools of Empire: Technology and European Imperialism in the Nineteenth Century (1981), ch. 3 D. Arnold, ed. Imperial Medicine and Indigenous Societies (1988), Introduction A. Marcovich, 'French Colonial Medicine and Colonial Rule: Algeria and Indochina', in R. M. MacLeod (ed.), Disease, Medicine and Empire: Perspectives on Western Medicine and the Experience of European Expansion (London, 1988), pp. 103-18. 16. The third pandemic of plague: (a) the public health response to plague EH411, 2004-5 11 (b) the investigation of plague General themes Was the epidemic an opportunity for colonial public health? Compare the politics of plague control and the politics of cholera control. Did a colonial context affect the understanding and discovery of plague? How convincing is Cunninghams accounts of the discovery of plague Question In what ways did racial and epidemiological knowledge interact in the plague epidemic? Harrison, Mark. Public Health in British India: Anglo-Indian Preventive Medicine,1859-1914 (1994), pp. 134-58. I. J. Catanach, 'Plague and the Tensions of Empire: India, 1896-1918', in D. Arnold (ed.), Imperial Medicine and Indigenous Societies (Manchester, 1988), pp. 149-71. R. Chandavarkar, 'Plague Panic and Epidemic Politics in India, 1896-1914', in P. Slack and T. O. Ranger (ed.), Epidemics and Ideas: Essays on the Historical Perception of Pestilence (Cambridge, 1992), pp. 175-202. N. Shah, Contagious divides (2001), ch. 5 A. Cunningham, 'Transforming Plague: The Laboratory and the Identity of Infectious Disease', in A. Cunningham and P. Williams (ed.), The Laboratory Revolution in Medicine (Cambridge, 1992), pp. 209-44. Part 5: Sex, Disease and Marginalisation 17. Sexual epidemics before AIDS General themes; Does the construction of venereal disease reflect and reinforce societys basic assumptions and fears? How have attitudes to sexuality affected efforts to control STDs? Do associations between VD and marginal groups fit with Mary Douglass arguments about the association of marginality, power and pollution? Are epidemics of STDs somehow more socially constructed than other epidemics? Question: How successful are social constuctivist analyses of venereal disease? M. Douglas, Purity and Danger: An Analysis of the Concepts of Pollution and Taboo (London, 1966), ch. 6. P. Baldwin, Contagion and the State in Europe, 1830-1930 (Cambridge, 1999), ch. 5. A. M. Brandt, No Magic Bullet: A Social History of Venereal Disease in the United States since 1880 (Oxford, 1985), ch. 2, 5 M. Vaughan, 'Syphilis in Colonial East and Central Africa: The Social Construction of an Epidemic', in T. Ranger and P. Slack (ed.), Epidemics and Ideas: Essays on the Historical Perception of Pestilence (Cambridge, 1992), pp. 269-302. 18. AIDS: the resurgence of epidemics: EH411, 2004-5 12 General Themes: Did AIDS represent a new paradigm of epidemic disease? Why did policies to control AIDS differ from policies used against other epidemics? What were the consequences of the focus of the disease being among marginal groups in the West? Question: To what extent does has history provided a frame of analysis for AIDS? How well does Berridges contrast between emergency and normalisation explain shifts in policy and public responses to AIDS? R. Shilts And the Band Played On (1987), esp. part V. D. M. Fox, The politics of HIV infection: 1989-90 as years of change, in E. Fee & D. M. Fox (eds), AIDS: the making of a chronic disease (1992), pp. 125-142 V. Berridge The early years of AIDS in the UK: 1981-6: historical perspectives, in Ranger & Slack, Epidemics and Ideas (1992), 303-328.. S. Epstein Impure Science: AIDS, Activism and the Politics of Knowledge (1996), ch.5, 7 P. A. Treichler, How to Have Theory in an Epidemic: Cultural Chronicles of Aids (1999), ch. 5, 9. 19. AIDS, Epidemics and Growth General Themes: Why do views the macroeconomic impact of epidemics differ? Do expectations about individual incentives operate comparably in AIDS and other epidemics? How successfully can these approaches be applied to historical epidemics? Question: How well is the economic impact of AIDS outside the West captured in Posners analysis? D. E. Bloom and P. Godwin (ed.), The Economics of HIV and AIDS (Delhi, 1997), ch. 2. R. A. Posner, Private Choices and Public Health (Harvard, 1996), ch. 4 K. Christensen, Economics Without Money; Sex Without Gender: A Critique of Philipson and Posner's "Private Choices and Public Health: The AIDS Epidemic in an Economic Perspective, Feminist Economics 4/2 (1998), 1-24 EJ T. J. Philipson and R. A. Posner, 'The Microeconomics of the Aids Epidemic in Africa', Population and development review, 21 (1995), pp. 835-48. EJ E. Gaffeo, The Economics of HIV/AIDS: A survey, Development Policy Review 21/1 (2003), 27-49. EJ 20. International responses to AIDS and Emerging infectious disease General Themes Has AIDS changed Western attitudes to development? Does the idea of show structural violence capture the impact of AIDS outside the West? Has AIDS changed international public health to a post-national form? Question: To what extent have recent epidemics driven an internationalisation of public health? EH411, 2004-5 13 Randall Packard, 'Visions of Post-war Health and Development and Their Impact on Public Health Interventions in the Developing World.' in International Development and the Social Sciences: Essays on the History and Politics of Knowledge, eds. F Cooper and R Packard (1997), 93-118. L. Garret, Betrayal of Trust, ch. 6. N. B. King, 'Security, Disease, Commerce: Ideologies of Post-Colonial Global Health', Social Studies of Science, 32 (2002), pp. 763-90. P. Farmer, Infections and Inequalities (Berkeley, 1999), chs. 2, 7, 9 EH411, 2004-5 14 A CULTURAL APPROACH TO HIV/AIDS PREVENTION AND CARE UNESCO/UNAIDS RESEARCH PROJECT HIV/AIDS Stigma and Discrimination: An Anthropological Approach Proceedings of the round table held on 29 November 2002 at UNESCO - Paris Studies and Reports, Special Serie, Issue n20 Division of Cultural Policies and Intercultural Dialogue UNESCO, 2003 1 Introduction Stigmatization and Discrimination: What Does a Cultural Approach Have to Offer? Alice DESCLAUX Professor of Medical Anthropology Doctor Laboratory of Human Ecology and Anthropology, University of Aix-Marseille1 The history of diseases especially epidemics is not merely a history of microbial spread and medical efforts to check it: it is also a history of mistrust of the sick, avoidance measures, marginalization and, at the same time but less obviously, a history of compassion and solidarity. From the plague victims of the European Middle Ages to the African lepers of the last century, from tuberculosis sufferers in all societies to Asians regarded as potential SARS carriers in Paris at the start of 2003 all have suffered to varying degrees from what may be called a social disease, that is to say a set of representations that each culture associates with disease and its victims, together with all the concomitant attitudes. HIV/AIDS does not carry with it any positive connotation of the kind that attached to tuberculosis in the nineteenth century, when the disease was regarded in Europe as a romantic fever (Ruffi & Sournia, 1995). Running the gamut from mistrust to criticism, from ostracism to discrimination, from rejection to desertion, and from stigmatization to spoliation, hostile attitudes towards AIDS sufferers, reinforced by the negative associations of the disease, seem to be a cultural invariant. It is often more difficult for infected persons and those around them to live with this social disease than with the clinical manifestations of infection by the virus. Stigmatization and discrimination are very general terms that cover a wide variety of practices and attitudes rooted in representations and modes of discourse, ranging from an unconscious gesture to a conscious decision, from passive negligence to rejection tinged with violence, and encompassing all spheres of existence, from the microcosm of interpersonal relations to the macrocosm of relations among social groups and between peoples. Given their very diverse aspects, it is not our intention to categorize these expressions those affected being best placed to catalogue their local forms as shaped by social and cultural context. The point they have in common is: (1) to establish a distinction or difference; (2) that is devaluing or pejorative; and (3) is based on a mark, or stigma, associated with the disease or the risk of transmission. These three notions, present to a greater or lesser degree depending on the case, constitute the hard core of practices that will be referred to in this article under the generic heading of discrimination. Discrimination-linked issues The issues surrounding HIV/AIDS-related discriminations are of several kinds. We are dealing with a violation of the principle of natural justice that should apply to all individuals regardless of the situation in which they find themselves; the right not to be to be subjected to discrimination is enshrined in Article 2 of the Universal Declaration of Human Rights and in many international legal texts. 1 Email address: adesclaux@free.fr. 1 Introduction Stigmatization and Discrimination: What Does a Cultural Approach Have to Offer? Alice DESCLAUX Professor of Medical Anthropology Doctor Laboratory of Human Ecology and Anthropology, University of Aix-Marseille1 The history of diseases especially epidemics is not merely a history of microbial spread and medical efforts to check it: it is also a history of mistrust of the sick, avoidance measures, marginalization and, at the same time but less obviously, a history of compassion and solidarity. From the plague victims of the European Middle Ages to the African lepers of the last century, from tuberculosis sufferers in all societies to Asians regarded as potential SARS carriers in Paris at the start of 2003 all have suffered to varying degrees from what may be called a social disease, that is to say a set of representations that each culture associates with disease and its victims, together with all the concomitant attitudes. HIV/AIDS does not carry with it any positive connotation of the kind that attached to tuberculosis in the nineteenth century, when the disease was regarded in Europe as a romantic fever (Ruffi & Sournia, 1995). Running the gamut from mistrust to criticism, from ostracism to discrimination, from rejection to desertion, and from stigmatization to spoliation, hostile attitudes towards AIDS sufferers, reinforced by the negative associations of the disease, seem to be a cultural invariant. It is often more difficult for infected persons and those around them to live with this social disease than with the clinical manifestations of infection by the virus. Stigmatization and discrimination are very general terms that cover a wide variety of practices and attitudes rooted in representations and modes of discourse, ranging from an unconscious gesture to a conscious decision, from passive negligence to rejection tinged with violence, and encompassing all spheres of existence, from the microcosm of interpersonal relations to the macrocosm of relations among social groups and between peoples. Given their very diverse aspects, it is not our intention to categorize these expressions those affected being best placed to catalogue their local forms as shaped by social and cultural context. The point they have in common is: (1) to establish a distinction or difference; (2) that is devaluing or pejorative; and (3) is based on a mark, or stigma, associated with the disease or the risk of transmission. These three notions, present to a greater or lesser degree depending on the case, constitute the hard core of practices that will be referred to in this article under the generic heading of discrimination. Discrimination-linked issues The issues surrounding HIV/AIDS-related discriminations are of several kinds. We are dealing with a violation of the principle of natural justice that should apply to all individuals regardless of the situation in which they find themselves; the right not to be to be subjected to discrimination is enshrined in Article 2 of the Universal Declaration of Human Rights and in many international legal texts. 1 Email address: adesclaux@free.fr. 2 Discrimination must also be regarded as a public health issue in that it is an obstacle to the provision of information on the risks of transmission, which should be as broadly based as possible to boost prevention; it inhibits personalization of the risk of HIV for fear of generating mistrust or criticism, which reduces chances of negotiating preventive measures; it makes people less willing to learn about their serostatus and limits recourse to screening; it makes infected individuals deny that they have the disease and makes them less likely to seek treatment; it causes the specific needs of infected persons to be neglected and encourages inaction by public health institutions and a lack of commitment on the part of health professionals. Apart from this direct impact on the ability of prevention to limit the spread of the epidemic and on the ability of health systems to meet patients needs, discrimination (especially in the world of work or as regards access to resources) may increase the social vulnerability of individuals and their families and indirectly increase vulnerability to the risk of HIV. In very broad terms, research on the concept of social capital has shown that highly inegalitarian societies lacking social cohesion which develop stigmatizing modes of thought or deny HIV infection are particularly vulnerable to the epidemic (Barnett & Whiteside, 2002). Human rights and public health would therefore seem closely interlinked. In the history of public health, this represents a change of perspective, theorized by Jonathan Mann and the Harvard School of Public Health, and then by Peter Piot and UNAIDS, and a departure from protection measures based on constraint and segregation such as quarantine, cordon sanitaire provisions and confinement in State-run leper houses and lazarettos as practiced from the eighteenth to the twentieth centuries. HIV/AIDS lent itself particularly well to this change of approach: the duration of the asymptomatic phase, extending over several years, and the fact that prevention is impossible without the agreement and participation of the persons concerned limited the scope of purely authoritarian measures. Moreover, the experience of countries that had hoped to limit infection by denying entry to HIVpositive persons or by establishing AIDS sanatoria has shown such eviction measures to be ineffective and to have unwanted effects. As we enter the twenty-first century, UNAIDS considers that no population group is completely safe from the epidemic and that only a global approach based on mechanisms that strengthen social cohesion, in which people are respected regardless of their background and lifestyle and of the group or social category to which they belong, can reduce the spread and impact of the disease (UNAIDS, 2001). The cultural approach to discrimination The cultural approach to discrimination is predicated on the analysis of its roots and rationales. Two acceptations that may be singled out from the hundred or so definitions of culture proposed by anthropologists (Journet, 2002) are also valuable in this context. The first views culture in general terms as the whole complex of habits and customs acquired by people living in society, including their knowledge and values, symbolic and technical productions and modes of social organization. Culture is in no way rigidly set in tradition but is constantly being reshaped; it is inseparable from the physical and economic contexts in which it develops and constitutes a form of adaptation to an evolving environment. The second sense of the term focuses on the diversity of cultures. This approach does not define cultures a priori in ethnic terms but rather analyses in comparative terms their differences and invariances, their coherence and dynamics, on the basis of the identity-based categorizations that various social groups have developed. In an age of globalization, when individuals are becoming individualized and references are being globalized, cultural affiliations do not depend on fixed categorizations: most population are experiencing acculturation and each individual negotiates his or her affiliation(s) within the limits of the scope for manoeuvre. It is therefore in terms of dynamics that this cultural approach to discrimination must be envisaged. Intellectually, it presupposes an analysis of the rationales underlying discrimination and of the role played by culture in this regard and a study of the forces that sustain or oppose discrimination. 3 Rationales of discrimination Discrimination against HIV-infected persons is based on several kinds of rationale, which we summarize here with no claim to comprehensiveness.2 Some take illness as their basis: they express in a new form what has been observed in other ages confronted by other epidemics. Thus the attribution of a foreign origin to the disease, in simple terms implying that the disease came from elsewhere, compounded by the near-universal representation of alterity as dangerous, is at the root of forms of exclusion that their initiators often defend as a means of protecting their own social group. The interpretation of the disease as punishment involves holding sufferers culpably responsible for their sickness. Rooted in age-old explanatory theories according to which disease is caused by breaking taboos, an act punishable by supernatural powers, this rationale regards AIDS as the consequence of a failure to observe social norms and patients as guilty persons who have been punished and have to bear the consequences of their reprehensible behaviour. Because of its links with behaviour relating to sex and blood, both carrying high symbolic charges, HIV infection particularly lends itself to this interpretation legitimizing rejection and condemnation. Another rationale grounded in illness is fear of contagion. Many people still regard AIDS as a contagious disease and shun infected persons so as to avoid transmission by direct or indirect contact. While not being exposed to moral judgement, infected persons in this way suffer daily marginalization in their place of abode. This is often the case in African families in which the women and girls who look after the patient have to bear the burden of constant fear in addition to their heavy workload. Infected persons themselves often contribute to this fear by not daring to assert that they are not contagious and by practising self-exclusion, hoping thereby to protect their close relations. This rationale of exclusion can be countered by informing people about the way transmission takes place and the precautions that need to be taken. Fear of contagion apart, some attitudes of avoidance particularly noticeable among health professionals in the South who know about prevention measures and show a certain compassion towards patients seem to stem from the sense of helplessness induced by caring for an AIDS patient when no medicines are available. Here, it is not a matter of fear of contagion or moral condemnation, but rather of avoiding a sense of helplessness and the prospect of death. In this case, ensuring access to antiretroviral drugs is the only way of restoring hope, which is crucial to any genuine therapeutic relationship. In some cases, HIV infection serves to highlight earlier forms of discrimination. The AIDS epidemic has often been said to be simultaneously generative and revelatory of social issues. During the early years of the epidemic, the language of prevention in North America emphasized on four high-risk groups, termed the 4 Hs: homosexuals, heroine addicts, hemophiliacs and Haitians. Paul Farmer has shown that the inclusion of Haitians in that categorization had no epidemiological basis, but reflected the low status of that community in American society in the 1980s (Farmer, 1996). Very often, in North and South alike, prostitutes have been stigmatized as a high-risk group, whereas in fact their knowledge and prevention practices (in particular, use of the condom) were far superior to those of their customers, who were rarely regarded as a high-risk group and were not stigmatized at all. As numerous examples show, HIV-related discrimination draws on pre-existing discrimination or at least inegalitarian relations arising in particular from xenophobia, unequal gender relations, racism and homophobia. 2 The observations and ideas presented here derive mainly from research conducted in Burkina Faso and France. 4 Another type of discriminatory rationale leads to patients being rejected or deserted by their families in the countries of the South. In Faso Fights AIDS,3 Mamadou Sawadogo graphically describes the process whereby a modest African family, after spending all its savings on a patients initial treatment, falls into what is now generally known as the medical poverty trap (Whitehead et al., 2001) and is faced with the dilemma of whether to support the patient for a further course of treatment, in the knowledge that there is no cure, or whether to abandon him to his fate so as to have some hope of feeding his widow and children. Analyzed in coldly pragmatic terms, abandoning the patient is the rational choice; it is nonetheless extremely painful for the family, unless it has developed a reaction of denial-based indifference, which makes it possible to bear the humanly unbearable as elsewhere described in cases of populations confronted by life-or-death situations (see for example Turnbull, 1973; Scheper-Hughes, 1993). The cultural approach thus reveals that economic inequalities are one of the underlying rationales of discrimination: communities that find themselves in dire straits quickly arrive at the limits of the obligation of solidarity. The same situation arises when, against a background of scarce resources, HIV-infected persons are treated last: the rationalization of resource allocation dictates that those who are most likely to recover should be treated first. It would be wrong to criticize such choices or rather decisions made under constraint: the focus of the ethical demand should rather be on securing the broadest possible access to treatment as one of the primary means of combating discrimination. These limited examples show that the underlying rationales of discrimination can be very diverse. This diversity becomes even more complex when we analyze the various levels individual, microsocial and macrosocial at which these rationales operate. Cultural resources for countering discrimination Understandably, the role of culture varies greatly with the different rationales that give rise to discrimination. The fact that discrimination is determined by the fault lines of social organization, that it reflects inter-group tensions and oppositions and that it is sustained by certain explanatory models of the disease, leading different communities and different cultures to tolerate or to reject discriminatory arguments and attitudes, shows that it is not wholly cultural. Economic, political and social factors are also important elements in the production of discrimination, along probably with epidemiological factors among others: although the phenomenon has yet to be documented, it may be supposed that a substantial and steady rise in prevalence, spread evenly throughout the population, would mitigate discriminatory attitudes by encouraging a process of social adaptation. It would be excessive and ethnocentric to regard the abandonment of a patient by a family unable to afford treatment as a cultural trait. The varied forms assumed by discrimination and by the rationales that underpin it call for a diversity of responses. Some of them involve a public health approach: information on modes of transmission and access to methods of prevention will reduce the fear of contagion; making access to treatment generally available will among other things serve to recreate satisfactory therapeutic links; the availability of drugs free of charge for the general public will enable families to avoid the spiral of impoverishment; the introduction of social, economic and nutritional support measures will protect families already afflicted by the disease, enabling them to look after their patient. Other responses involve a legal approach: UNDP and UNAIDS have made great efforts to strengthen laws to ensure that they are more effective in defending the rights of infected persons subjected to discrimination. 3 Faso Fights AIDS. Documentary film by S. Rawdin and A. Desclaux, 2002, Paris, Europroject. Part 1: Living together despite the virus. 5 What are the cultural resources that UNESCO proposes to muster in the fight against discrimination? While it is possible to argue that some cultures or subcultures favour discrimination to a greater or lesser extent because of their receptivity to some of the previously mentioned rationales, public pronouncements on the question come from institutions for the most part religious, medical, political, legal or community-based: these are the institutions that express and fashion, or conversely combat, discrimination. As in the case of cultures, it is not possible in most instances to distinguish a priori and definitively those institutions that foment discrimination from those that curb it; most institutions proclaim vis--vis their members at least the values of equity and solidarity, whose real impact is not always immediately perceptible. However, an analysis of pronouncements concerning HIV and infected persons shows that some institutions develop a language of exclusion that is turned to a variety of social uses. By declaring that PLWHA (persons living with HIV/AIDS) have been infected because they did not respect the social and moral norms that are laid down in their own prescriptive texts, some religious authorities assert the value of their own rules by maintaining that disease is the consequence of a failure to observe those rules. By calling for infected persons to be evicted (despite the fact that this measure has proved inapplicable and ineffective), political authorities exploit very ancient but enduring representations, which ensure a measure of support for their cause and strengthen their popularity. For these institutions, the impact of such propositions in terms of discrimination against PLWHA is secondary to other more immediate concerns, in particular their own legitimacy and popularity. Other institutions may adopt ambivalent postures: public health officials have often based their prevention campaigns on stigmatizing stereotypes, believing this to make for more effective communication. It was to protect people in overseas departments or of foreign origin from stigmatizing attitudes that public health officials in France said little about their specific epidemiological situation, depriving them of targeted preventive measures that might have been better adapted to their situation. Discriminatory language and practices thus embody a whole range of meanings and usages, which have still to be analyzed in many contexts. Moreover, the dividing line between singling something out for attention so that particular features may be taken into account and drawing a distinction that provides grounds for stigmatization is sometimes a fine and shifting one. In this field too, careful analysis in each case with the involvement of all concerned is essential for an understanding of the untoward effects of health-related initiatives. The history of AIDS shows that the main resources to counter discrimination have been devised by persons infected or affected by the disease. A large number of community-based associations and organizations in the countries of the North and South have set up self-supporting projects to minimize the effects of discrimination, working on an individual basis, collecting personal testimonies, assisting the victims of abuse, contacting the abusers especially when they are close relations to make them understand the consequences of their attitudes and negotiate change through mediation, providing a network of solidarity and support for legal action, and working a great deal at the microsocial level. At another level, advocacy based mainly on public testimonies by infected persons and supported by international organizations has enabled the associations concerned to inform the public at large with a view to forestalling discriminatory reactions and strengthening social cohesion in the face of the epidemic. The impact of such action at the collective level, which varies from one context to the other, remains to be analyzed. During the last 20 years an AIDS subculture has grown up in biomedical institutions and associations, fashioned mainly with the support of UNAIDS, and has found its way through a host of international meetings and conferences into research and action programs and inter-association networks. This globalized culture, which has taken shape largely under pressure from militant 6 activists, has established higher ethical standards than those that existed previously, which were based mainly on the dissemination of a number of concepts (such as the notions of confidentiality, enlightened consent, etc.) and on recognition of the rights of infected persons. It has also transformed the hierarchical relationship between doctors and patients and has modified, to a certain extent, the balance of power among researchers, practitioners and association members. This AIDS subculture, which is more egalitarian than that of contemporary health-care systems and now constitutes the benchmark culture for many association members and health professionals, constitutes a resource from several standpoints. Community dynamics and the AIDS subculture are unique in the history of epidemics. They suggest that progress in the area of patients rights acquired in the HIV/AIDS context might also be applied to other pathologies, provided these achievements are widely known. Social science research and the cultural approach to combating discrimination How can social science research, especially anthropology, contribute to the cultural approach to combating discrimination? Anthropologists are often called upon to act as cultural translators by providing interpretative elements that make it possible to distinguish between cultural practices that are a priori harmful and others that are in principle positive, the latter being regarded as resources. A careful examination of discriminatory practices in various fields suggests that this kind of demand calls for responses at different levels. The first approach highlights constants in attitudes and similarities of rationale with regard to discrimination and other HIV-related fields, reflecting the unity of humankind underlying cultural diversity. Such an analysis may seem paradoxical on the part of researchers specializing in cultural specificities; however, it points out the need for caution as regards both ethnocentric and xenocentric approaches to the relationship between ethics and culture. The second approach reveals that the same institutions whether scientific, political, communitybased or religious may employ and apply a double language in relation to discrimination, without departing from their basic principles: it is therefore by interpreting their texts and references, and by examining the forms that their pronouncements assume when translated into practice, that their concern (or lack of concern) with the risks of discrimination becomes apparent. A personal interpretation by one or more key individuals is often enough to cause a provision to be construed in discriminatory terms. Such flexibility makes institutions particularly sensitive to local issues and to clusters of associations or other institutions that regard discrimination as an issue. More than the existence of favorable or unfavorable local cultural practices, an effective resource for combating discrimination would seem to be the presence in institutions of persons who are sensitive to the question of discrimination and can serve as go-between, introducing at the local level the egalitarian norms of the AIDS culture and building transcultural bridges between seemingly very distant subcultures. This has been done by the lawyer David Kabor:4 steeped in the egalitarian culture of AIDS, he has turned to account existing legislation and successfully alerted the Naaba of Bazoul, a respected Mossi tribal chief in Burkina Faso, to the need to select those customary-law rules most favorable to PLWHA and proclaim them to his people with the full weight of his authority. The role of social science researchers, especially in anthropology, may take various forms, in keeping with the principles and methods of that discipline. It may involve: describing discriminatory 4 Filmed in the documentary Faso Fights AIDS. 7 practices and language in the minute detail characteristic of ethnographical observation; reporting on the viewpoints of individuals (whether the victims or the source of discriminatory practices and propositions), thereby applying the principle of restoring subjectivities to their own cultural systems of reference; analyzing the rationales and concepts underlying discrimination and the different issues at stake for each institution; dissecting the local dynamics of discrimination and solidarity, while observing the principle that no object can be studied without also analyzing its converse and compiling an inventory of resources; or elaborating concepts that refine our understanding of discrimination. The challenge, however, lies in using the findings of such research to combat discrimination. This ancient challenge is that of changing representations, attitudes and behaviour: attempts to do so over 30 years in the field of public health induce modesty in the setting of objectives, showing that cultural change tends to be possible only when external conditions, particularly material and social, are favorable. As to discrimination, experience has shown that campaigns relying on prescriptive injunctions asserting moral or social values, such as Show solidarity, do not reject AIDS patients! employed at the beginning of the epidemic, were ineffective and perceived as guilt-inducing. A cultural approach that produced such a result would be pointless. Some of the initiatives of Act Up can be seen as an accomplished and particularly effective cultural approach to combating discrimination. In the early 1990s, Act Up engaged in a genuinely cultural campaign to modify, with the help of powerful symbols, the significance that health-care institutions gave to their decisions and programs (Lestrade, 2000). Brandishing the slogan AIDS = death and inviting ministerial officials to step over the bodies of activists lying on the ground during demonstrations called zaps, Act Up put a face on the death statistics, breaking with the quantifying hence abstract scientific culture of the public health services and signaling the practical implications of the lack of treatment. Act Ups aim was to make scientific and political decision-makers see that the lack of care, previously viewed with fatalism, was a sign of a lack of activism on the part of government agencies, conducive to a particular form of discrimination against infected persons. The distinctive feature of their action was that it gave physical embodiment to ideas, by showing the faces of people who were the victims of such discrimination. One of the most effective resources of anthropology for bringing about cultural change could be its capacity to make the connection between individual experience and the analysis of social and cultural phenomena affecting communities and societies. It is perhaps by means of personal accounts, which speak directly to people belonging to different sociocultural universes in terms of their common humanity, that relevant notions can be transmitted with respect to combating discrimination. If the writings of Paul Farmer have helped to create awareness of the inequalities experienced by Haitians, it is not only through his conceptual analyses but also through the use of photographs depicting the persons whose cases he was describing in the context, moreover, of medical articles published in journals that rarely carry illustrations. This gives his publications a tangible dimension, of a kind likely to transcend cultural barriers and to be understood regardless of the codes of cultural subgroups. The same approach was used in the making of the documentary film Faso Fights AIDS. The history of epidemics and of their litany of social maladies has shown that the introduction of treatment has had the effect of reducing discrimination, both individually and collectively, by lessening the physical, social and economic impact of the disease and by removing stigma, just as long as access is not reserved to certain categories of patients established on the basis of the membership of a particular community or social or cultural group or of their ability to pay. It is now up to social scientists to analyze the rationales underlying the production of inequities in access to treatment in the North and in the South, which may be at once the consequence and the cause of discrimination. 8 Bibliographical references Barnett, T. Whiteside, A. AIDS in the Twenty-First Century. Disease and Globalization. Basingstoke, Palgrave. 2002. Farmer, P. AIDS and Accusation. Haiti and the Geography of Blame. Berkeley. University of California Press. 1992. Journet, N. (ed.) La culture, de luniversel au particulier [Culture, From the Universal to the Particular]. Auxerre, Sciences Humaines. 2002. Lestrade, D. Act Up, une histoire [Act Up, a history]. Paris, Denol. 2000. Ruffi, J.; Sournia, J.C. Les pidmies dans lhistoire de lhomme [Epidemics in Human History]. Paris, Flammarion. 1995. Scheper-Hughes, N. Death Without Weeping: The Violence of Everyday Life in Brazil. Berkeley/Los Angeles, University of California Press. 1993. Turnbull, C. The Mountain People. New York, N.Y., Simon and Schuster. 1972. UNAIDS. Press release: Stigma and Discrimination Fuel AIDS Epidemic, UNAIDS Warns, Durban, South Africa. 21 September 2001. Whitehead, M.; Dahlgren, G.; Evans, T. Equity and Health Sector Reforms: Can Low-Income Countries Escape the Medical Poverty Trap? The Lancet, Vol. 358, p. 833-836. 2001. 11 The Shortcomings of Culturalism and the Relevance of the Social Dimension in the Approach to AIDS in Africa Laurent VIDAL Anthropologist at the Institut de Recherche sur le Dveloppement1 Some analyses have strongly emphasized the causal link between behaviour and representations regarded as culture-specific and the dynamics of the AIDS epidemic in Africa. These analyses can lead to culturalist interpretations of the epidemic interpretations that pose two major problems with which I should like to deal here. Firstly, they lead to an excessive characterization usually but not exclusively negative of African societies in terms of their cultures; and, secondly, they tend to mask the real factors that explain the AIDS situation. I shall begin by looking at the approach to the question of circumcision, which has assigned to culture a role that, while admittedly protective, remains ambiguous. I shall then review a number of analyses of cultural practices put forward as being responsible for the spread of HIV. Thirdly, I shall try to show the value of refocusing the debate on the social dimensions of the epidemic, which presupposes paying special attention to individuals. A tendentious over-emphasis on culture: the case of circumcision Circumcision is a recurring topic of discussion in the specialized literature on AIDS, and is emblematic of an ambiguous process involving the culturalization of AIDS in Africa. In the early 1990s, epidemiologists put forward differing interpretations of the role of circumcision in HIV infection. Some believed that the statistical link between circumcision and a lower rate of contamination was proven, while others thought that it had not been. In any case, no one knew for certain whether circumcision has a direct effect on HIV transmission or an indirect one through, for example, its protective role in relation to ulcerative STDs (Ferry, 1999). These uncertainties concerning the effect of circumcision on HIV transmission did not, however, prevent the development of culturalist analyses. Circumcision was defined as a cultural practice (this remains to be demonstrated), and one could therefore point to the cultures at risk (those that did not practice circumcision) and position them on a map of the circumcision belt (Caldwell & Caldwell, 1993). This led to the designation of good and bad cultures. What such categorizations overlooked were the conditions governing such practices, their uneven spatial distribution, and the existence of other factors that might explain why HIV is more prevalent in the non-circumcising populations. More recently, epidemiological studies have advanced our understanding of the link between circumcision and the reduced risk of HIV infection. First of all, herpes is very clearly associated more systematically than the absence of circumcision with a strong prevalence of HIV. The protective function of circumcision is attested in some areas, and less so in others. Nonetheless, the epidemiological and clinical studies allow us to conclude that the effect of circumcision in the reduction of the risk of HIV transmission to which all analyses tend to point are probably not due to the cultural and behavioural factors with which they are supposed to be associated (Weiss & Lagarde, 2000). What this means is that a statistical association does not signify a causal relationship, 1 Socioanthropology of Health Research Unit, BP 1386 Dakar, Senegal. Email address: vida@ird.sn. 1 2 since numerous other factors come into play, contrary to what was advanced in the early culturalist simplifications. Thus, in practice, what is critical from both an epidemiological and sociological standpoint, more so than a given religion or culture, is the age at which the first sexual relation or marriage takes place and the presence of other STDs (especially herpes). The identification of circumcision cultures thus formed part of a kind of culturalization of AIDS. While undoubtedly hasty and ill-founded, it was aimed in a way at enhancing the status of cultures that practiced circumcision. Yet this leaves an essential question unanswered: even if one accepts the conclusions of recent epidemiological studies that specify the role of circumcision in protection against HIV, what public health measure can reasonably be promoted on this basis? How are populations to be encouraged to practice circumcision from now on? One solution would be to highlight its medical value, without however decrying populations that rejected it; the rejection of circumcision should not be assimilated to cultural inertia. In any case, it is important that this objective should not be made the be-all and end-all of an information campaign on ways of controlling the spread of HIV infection. The rhetoric of cultures as obstacles to prevention Because of their restricted vision of reality, some culturalist interpretations of AIDS go so far as to designate cultures in negative terms: with reference, for example, to the levirate, polygamy, recourse to hairdressers and traditional nail-cutters, and the use of condoms. The perpetuation of these practices or, in the case of sexual relations, the reluctance to adopt them has long been viewed as the archetypal expression of African cultures potentially at risk from and exposed to AIDS. As regards the levirate, the question needs to be carefully weighed: firstly, the real issue is access to the HIV test and information on AIDS prevention; and, secondly, anthropologists have stressed the importance for a woman whose husband has died from AIDS, for example of remaining in the family circle, whereas breaking with the practice of the levirate would lead to the abdication of family responsibility towards infected women (with the very real risk of their infecting other partners) (Taverne, 1996). In the case of polygamy, no higher prevalence has been noted for polygamous couples compared with monogamous ones. What is essential is that each partner should know the others HIV status and that sexual relations within and outside the couple should be protected, whether the couple is polygamous or monogamous. Where so-called traditional practices are concerned, no case of HIV infection has been formally attested consequent upon a visit to the hairdressers or to a nail-cutter. Lastly, with respect to the use of condoms, obstacles can also arise as the result of inappropriate information. The conclusion to be drawn from all these observations is that greater prudence should be exercised with regard to the culturalization of explanations for the spread of HIV infection in Africa. The myth of isolated and immutable cultures Prudence requires that we should pause to consider a number of universals in the field of HIV prevention. Although the link between information on AIDS, the way it is interpreted and its effects in terms of changing behaviour remains a complex question (involving psychological, economic and social factors at once universal and culturally delimited), there is broad agreement that without information on AIDS, however delivered, the behaviour required to avoid HIV infection cannot be adopted. It is a minimal position admittedly, but one universally held. When arguments predicated on African cultural traits are advanced, it is findings of this kind that, although virtually beyond 1 3 dispute, are either called into question or else overlooked by this culturalist reductionism. It is moreover striking that the cultural dimension should obscure the social in this way. An image of asocial cultures is thus gradually built up in which urbanization, the search for work, the processes of individualization and many other phenomena are sidelined. Culture is thus isolated from other cultures, creating an illusion of cultural isolates. The illusion is that of a culture capable of defining itself in relation to and for itself, whereas a culture essentially defines itself in its relationship to other cultures. J.L. Amselle speaks in this regard of interconnections, placing the emphasis on the analysis of relationships rather than on the elements brought together, so as to dispense with the image of cultures as closed systems. Finally, an obstacle that is deemed cultural is judged, in the minds of those who so define it, to be insurmountable. This is the case when the reluctance to use condoms is attributed to cultural obstacles (always leaving open the possibility of having children, not wasting ones sperm, not accepting reduced sexual pleasure ) The inference is that it is impossible ipso facto to overcome them. This amounts to a fixation of cultures which is purely arbitrary. Taking the social dimension into account Anthropology has endeavored to show that the conditions governing the spread of AIDS and its consequences are predominantly social. This shift of analysis from the cultural to the social is not to be construed as a denial of any explanatory value to the former: what is being contested is the reduction of a set of behaviours or representations to a uniquely cultural thesis. In the processes of urbanization and migration, the organization of schooling and the plantation economy (for example, in Cte dIvoire), population movements resulting from conflict and, more generally, the everyday relations between men and women, it is possible to identify a whole range of situations that contribute to the exposure of individuals to HIV. It is certainly reductionist to assert that such situations remain culturally determined; we are dealing here with social issues that cut across cultures. They do not exclusively concern either given linguistic communities, the followers of a particular religion or the inhabitants of a given region or town. These different factors contain within them explanations for the spread of the HIV infection. It is indisputable that they combine to intensify the risk of infection and that they are linked to cultural particularities; it is essential to underscore the paramount importance of social conditions as distinct from cultural considerations in the spread or control of the epidemic. The individual as the key to the social dimension Under the common denominator of social conditions, we must group the patterns of family life of the infected person, the everyday situations of all concerned whether it be a sick person, a woman in a relationship, a young man looking for work, a midwife in a health clinic and also the functioning of a variety of structures (medical, public health, the fight against AIDS, associations) The diversity of forms of the social should always be approached through individual experience. In order to understand the way therapeutic treatment functions, one should therefore explore the motivations of the sick and the way they organize their lives, or describe the fear that midwives have of contracting AIDS in the course of their work. But the main thing is to view the situation from the point of view of others. Many lessons are to be drawn from the way HIV-positive individuals perceive the work of health personnel or AIDS-prevention campaigns. This is also true when HIV-positive people talk about the experiences of their sick friends and their attempts to secure treatment or to cope with the reactions of the people around them who know about their HIV status. Placing individuals at the center of our thinking implies analyzing their 1 4 choices and exploring their representations for what they can teach us not only about their own attitudes but also those of other people. The way the caregiver sees the patient should also be scrutinized to understand the way the patient sees the doctor or the nurse, as well as to have a better grasp of the issues governing the patients choice of treatment as well as the caregivers. This focus on individuals their relations to others, what they reveal of others and what others in turn reveal of them takes us into the social arena as a place where collective strategies are expressed. In concrete terms, when the observer of a society notes the development of an association that assumes responsibility for health problems, the researchers acquired knowledge of the way therapeutic treatment functions and the representations of risk among health personnel can be turned to account. Moreover, a researcher who is familiar with the political, statutory and economic strategies of the leaders of religious movements will be best placed to understand the complexity of the issues that arise on the appearance of a new form of worship or church. The conclusion we draw is not only that familiarity with the field is important and that it immediately permits a relevant and operational approach, thereby facilitating sociological or anthropological analysis, but that the familiarity that is really necessary and the anthropological expertise that is crucial are those that enable the connection to be made between the individual and social levels of a practice. That is to say, describing the process whereby a set of individual attitudes expresses a social tendency, namely a series of positions or reactions shared by groups whose interests and strategies may diverge (family groups, associations of the sick, professional bodies, members of a faith) Conclusion The culturalist interpretations of AIDS have been part of a confining movement of stigmatization: confining because the impugning of individuals because of their practices (punished by HIV infection) finds a discreet echo in a culturalist approach in which, above and beyond the individual, it is a whole culture that is placed beyond the pale. It is a case, then, of stigmatization dictated on the one hand by behaviour and on the other by cultural referents. True, this process of stigmatization does not have the same cause in both instances, and is not aimed at the same people or expressed in the same way. Nonetheless, the image that emerges is in the final analysis, that of cultural individuals, with presuppositions of inertia and immobilism, whereas individuals who try to come to terms with the threat of AIDS or to live with the disease are also, and possibly above all, social individuals. Bibliographical references Amselle, J. Branchements. Anthropologie de luniversalit des cultures [Interconnections. Anthropology of the Universality of Cultures]. Paris, Flammarion. 2001. Caldwell, J. & Caldwell, P. The Nature and Limits of the Sub-Saharan African AIDS Epidemic. Population and Development Review, 19, 4, pp. 817-48. 1993. Ferry, B. Systmes dchanges sexuels et transmission du VIH/SIDA dans le context Africain [Systems of Sexual Exchanges and HIV/AIDS Transmission in the African Context]. In: C. Becker; J.P. Dozon; C. Obbo; M. Tour (eds.) Vivre et penser le sida en Afrique/Experiencing and Understanding AIDS in Africa, pp. 237-255. Paris, Codesria-IRD-Karthala (coll. Hommes et socits). 1999. Taverne, B. Stratgie de communication et stigmatisation des femmes aux Burkina Faso [Communication strategy and the stigmatization of women in Burkina Faso]. Sciences Sociales et Sant, 14, 2, pp. 87-104. Vidal, L. Le silence et le sens. Essai danthropologie du sida en Afrique [Silence and meaning. Towards an anthropology of 1 5 AIDS in Africa]. Paris, Anthropos-Economica (Sociologiques). 1996. ____. Femmes en temps de sida. Expriences dAfrique [Women in a Time of AIDS. African Experiences]. Paris, PUF. (Politique daujourdhui). Weiss, H.; Lagarde, E. Circoncision et transmission du VIH [Circumcision and HIV Transmission]. ANRS Information Transcriptase Le Journal du sida et de la dmocratie sanitaire. Special issue, pp. 54-55. 2000. 5 5 ANNEX II Indicative Bibliography HIV/AIDS: Stigma and Discrimination This bibliography has been compiled by the Ile-de-France Centre Rgional dInformation et de Prvention du SIDA (CRIPS) on the basis of the Docsida database belonging to the French CRIPS network, consisting of eight CRIPS in France, all of which provide inputs to the database. Most of the documents included in this bibliographic selection can be consulted in the documentary resources centre of the Ile-de-France Centre Rgional dInformation et de Prvention du SIDA (CRIPS Ile-de-France, France). CRIPS Ile-de-France Tour Maine-Montparnasse 33, avenue du Maine BP 53 75755 Paris cedex 15 FRANCE Tel: 01 56 80 33 33 Fax: 01 56 80 33 00 e-mail: info@lecrips.net http://www.lecrips.net and www.vihinternet.org All the documents published under the project A Cultural Approach to HIV-AIDS Prevention and Care are available on the projects webpage: http://www.unesco.org/aids ABRIOL, S.; LOUX, F. Stigmatisation et discrimination des personnes atteintes: pour des recherches qualitatives sur les phnomnes dexclusion [Stigmatization and Discrimination against Infected Persons: The Case for Qualitative Research on the Phenomena of Exclusion] Article; French; Review: Transcriptase; 2000/05; No. 83; ISN: 1166 5300; pp. 6-8 Main theme: DISCRIMINATION DISCRIMINATION; EUROPE; CENTRAL AND EASTERN EUROPE Reference IDF: Transcriptase, No. 83 AGGLETON, P. UNAIDS, Geneva Comparative Analysis: Research Studies from India and Uganda HIV and AIDS-related Discrimination, Stigmatization and Denial Study; French; Geneva: UNAIDS; 2002/05; UNAIDS Best Practice Collection; ISN: 92-9173-147-1; 42 pp. Main theme: DISCRIMINATION DISCRIMINATION; STIGMATIZATION; DENIAL; SURVEY; COMPARISON; UGANDA; INDIA Abstract: This survey presents the comparative findings of two studies on the nature, determinants and consequences of HIV and AIDS-related discrimination, stigmatization and denial in India and Uganda. This document is part of a collection entitled: UNAIDS Best Practice Collection relating to discrimination, stigmatization and rejection. Location: RA 5 6 AGGLETON, P.; PARKER, R. UNAIDS, Geneva A Conceptual Framework and Basis for Action HIV/AIDS Stigma and Discrimination Report; French; Geneva: UNAIDS; 2002/06; ISN: 92 9173 209 5; 22 pp. Main theme: DISCRIMINATION DISCRIMINATION; STIGMATIZATION; CONCEPT; HUMAN RIGHTS; FIELD WORK; INTERNATIONAL Abstract: This document provides a definition of stigmatization and discrimination together with examples relating to HIV (Human Immunodeficiency Virus) infection. It restates fundamental human rights, reports on actions to combat discrimination against infected people, and finally proposes strategies for undertaking such actions. Reference IDF: 0606, A/0059 BARLERIN, R.; BOCHENT, S.; COQUET RAVISY, C. Universit Blaise Pascal, Clermont-Ferrand Erreur fondamentale et SIDA [Fundamental Error and AIDS] Report; French; 1994; 14 pp. Main theme: STIGMATIZATION STIGMATIZATION; REPRESENTATION OF THE ILLNESS; BELIEFS Abstract: This document shows how and why HIV-sufferers are declared more responsible for their illness than other patients BOUJENAH, P.; Frouma Films International; HENRY, M.; NIEDA, J. 3,000 scnarios contre un virus: Lexclusion [3,000 Scenarios against a Virus: Exclusion] Video; Short film; French; 1994; 2.35 mins. Main theme: DISCRIMINATION DISCRIMINATION; CHILDREN; EDUCATION SYSTEM; PARENTS; FRANCE Public: PUBLIC AT LARGE; CHILDREN; PARENTS Abstract: Short film from the competition 3 000 scnarios contre un virus. A ring of children in a playground. A mother informs other parents that little Pierre is seropositive. Reactions by mothers and other children, and so forth. Production: Paris: Mdecins du Monde; Paris: CRIPS Ile-de-France; Paris: AESSA Diffusion: CRIPS Ile de France VHS SECAM; Beta; 35 mm 15 euros for the complete videocassette; Rental upon request Reference IDF: B01, V/0203 CARAEL, M. dir.; CURRAN, L.; GACAD, E.; GNAORE, E.; HARDING, R.; MANDOFIA, B.M.; STAHLHFER, M.; TIMBERLAKE, S.; UMMEL, M.; MURPHY, T. UNAIDS, Geneva Protocol for the Identification of Discrimination against People Living with HIV Report; French; Geneva: UNAIDS; 2001/09; UNAIDS Best Practice Collection; ISN: 92 9173 118 8; 40 pp.; questionnaire Main theme: DISCRIMINATION DISCRIMINATION; HUMAN RIGHTS; CONCEPT; EVALUATION; SURVEY; METHODOLOGY; ACCESS TO HEALTH CARE; CONFIDENTIALITY; COMPULSORY SCREENING; EMPLOYMENT; JUSTICE; LEGISLATION; LAW ON FOREIGNERS; INSURANCE; INTERNATIONAL; DEVELOPING COUNTRIES Abstract: This document is designed to help decision-makers in drawing up surveys to identify VARIOUS forms of arbitrary discrimination. After defining arbitrary discrimination (basic concepts, criteria for assessing its existence, main sources), this document sets out the precise methodology for the survey to be conducted: fields to be covered, proposed indicators, selection and training of interviewers and interviewees, data collection, verification of information. A table is appended summarizing the basic forms of discrimination in 5 7 key areas (health, employment, justice and legal procedures, administration, social rights, insurance and other financial services). Reference IDF: 0606, A/0048 CHAUVIN, I. Inadmissible Forms of Discrimination Article; French; Review: Journal du SIDA (Le); 2001/07; No. 136-137; ISN: 1153 0863; 29 pp. Main theme: DISCRIMINATION DISCRIMINATION; MIGRANTS; SOCIAL INTEGRATION; ACCESS TO HEALTH CARE; REINTEGRATION IN THE WORK FORCE Abstract: Isabelle Chauvin, in charge of integration at Arcat-SIDA, attests to the difficulties encountered in France by HIV-infected foreigners in gaining access to health care and employment. The increasingly rigid legislative and regulatory framework is here revealed. Reference IDF: Journal du SIDA, No. 136-137 DESCLAUX, A. La recherche anthropologique peut-elle contribuer la lutte contre la discrimination envers les personnes atteintes par le VIH? [Can Anthropological Research Help in Combating Discrimination against HIV-infected Persons?] in: Anthropologie et SIDA: bilan et perspectives [Anthropology and AIDS: Situation and Prospects] Extract; French; 1996; pp. 267-286 Main theme: DISCRIMINATION DISCRIMINATION; ANTHROPOLOGY; RESEARCH; ETHICS; AFRICA; BURKINA FASO Reference IDF: 12, A/0055 DIJKER, A. ANRS (Agence Nationale de Recherches sur le SIDA), France Aspects socio-psychologiques de la stigmatisation des personnes atteintes [Socio-psychological Aspects of the Stigmatization of Infected Persons] in: Le SIDA en Europe, nouveaux enjeux pour les sciences sociales: 2e confrence europenne sur les mthodes et les rsultats des recherches en sciences sociales sur le SIDA [AIDS in Europe, New Challenges for the Social Sciences: Second European Conference on the Methods and Findings of Social Science Research on AIDS] Extract; French; Paris: Agence Nationale de Recherches sur le SIDA; 1998/07; Coll.: Sciences sociales et SIDA; ISN: 2 910143 12 0; pp. 125-132 Congress: Le SIDA en Europe: nouveaux enjeux pour les sciences sociales, Paris, 1998/01/12-15 Main theme: STIGMATIZATION SOCIAL PSYCHOLOGY; SOCIAL NORMS; BEHAVIOURAL CHANGE; REPRESENTATION OF THE ILLNESS; SUFFERING; STIGMATIZATION; INTERNATIONAL Abstract: The author, drawing on a study of the literature, shows that AIDS-infected persons belong to one of the most stigmatized groups in society as compared with other people suffering from chronic illnesses and disabilities. The stigmatization of this group by their entourage and the medical service staff is expressed by the refusal of social contact and by negative emotional reactions, such as fear, disgust and anger. Reference IDF: 12, A/0073 DUBOIS-ARBER, F., ed.; HAOUR-KNIPE, M., ed. Identification des discriminations institutionnelles lencontre des personnes vivant avec le VIH en Suisse [Identification of Institutional Forms of Discrimination against People Living with HIV in Switzerland] Special issue; French; Review: Raisons de sant; 1998; No. 18; ISN: 1420 2921; 140 pp.; questionnaire Main theme: DISCRIMINATION DISCRIMINATION; RESEARCH METHODOLOGY; SURVEY; PERIOD 1995-1999; ACCESS TO HEALTH CARE; MEDICAL SECRECY; INFORMING ONES PARTNER; EMPLOYMENT; PRIVATE SECTOR; JUSTICE; SOCIAL AID; ACCOMMODATION; INSURANCE; HUMAN RIGHTS; 5 8 RECOMMENDATION; SWITZERLAND Description: The study is presented in three languages: French, German and English. Abstract: This study, conducted in accordance with a UNAIDS protocol covering a two-year period (1996- 1997), was designed to: highlight possible forms of institutional discrimination against HIV-infected persons in Switzerland; determine in which areas and in what forms discrimination manifests itself; propose, as appropriate, recommendations to put an end to such discrimination. Reference IDF: 0603, A/0295 GROSSHANS, D. Lenvers de lexclusion [The Obverse of Exclusion] in: Psychologues au temps du SIDA dossier No. 2 Article; French; Review: Psychologues et psychologies; 1995/10; No. 126-127; ISN: 0297 6234; pp. 37-38 Main theme: DISCRIMINATION DISCRIMINATION; TRAUMA; PSYCHOLOGY; FRANCE Reference IDF: 0706, A/0181 HAMBLIN, J. UNDP (United Nations Development Programme), New York Personnes vivant avec le VIH: le droit, lthique et la discrimination [People Living with HIV: The Law, Ethics and Discrimination] Summary; French; 1993/11; 10 pp. Main theme: DISCRIMINATION DISCRIMINATION; LEGISLATION; ETHICS; SEROPOSITIVE PERSON; HUMAN RIGHTS Reference IDF: 0603, A/0031 HANDMAN, M.-E. La stigmatisation des femmes travers les reprsentations du SIDA vhicules par les mdias [The Stigmatization of Women through Representations of AIDS Conveyed by the Media] Article; French; Review: Transcriptase; 1997/01; No. 52; pp. 12-13 Main theme: DISCRIMINATION DISCRIMINATION; WOMEN; PREGNANT WOMEN; MEDIA; REPRESENTATION; SEXUAL ROLE; UNITED STATES Reference IDF: Transcriptase, No. 52 Lintrt suprieur de lenfant, le droit la non-discrimination et au respect de la vie [Best Interests of the Child: The Right to Non-discrimination and Respect for Life] in: Droits de lenfant et infection par le VIH [Rights of the child and HIV infection] Extract; French; Paris: Institut de lEnfance et de la Famille; 1994; ISN: 2 11 088396 0; pp. 78-82 Main theme: DISCRIMINATION DISCRIMINATION; CHILDREN; LEGISLATION; INTERNATIONAL; EUROPE Reference IDF: 0702, A/0398 LACOSTE-DEGUIRARD, C.; PRATO, F.; FERMAN, I. Universit Blaise Pascal, Clermont Ferrand Les strotypes et les malades du SIDA [Stereotypes and AIDS Sufferers] Report; French; 1994; 21 pp. Main theme: STIGMATIZATION STIGMATIZATION; REPRESENTATION OF THE ILLNESS; PSYCHOLOGY Abstract: This document analyses the stereotypes to which AIDS sufferers are subject and highlights the factors that can cause them to evolve. 5 9 Lutte contre lexclusion des personnes sropositives [Combating the Exclusion of Seropositive Persons] Article; French; Review: Education sant; 1995/02; No. 94; ISN: 0776 2623; p. 23 Main theme: DISCRIMINATION DISCRIMINATION; WORK ENVIRONMENT; ETHICS; BELGIUM Abstract: This article was prompted by the first collective agreement, signed by a Belgian firm, relating to non-discrimination against seropositive workers. The firm concerned entered into an undertaking to practise and promote non-discrimination at three points in an employees career: recruitment, while under contract and in the event of separation. Reference IDF: Education Sant, No. 94 MARECHAL, I. Le poids du silence: un combat quils vont mener seuls, car personne ne doit savoir [The Weight of Silence: A Struggle They Will Pursue Alone, for no one Must Know] Book; French; Paris: Anne Carrire; 1996/02; ISN: 2 910188 73 6; 287 pp. Main theme: DISCRIMINATION DISCRIMINATION; THE COUPLE RELATIONSHIP; SOLITUDE; FAMILY SUPPORT; SUPPORTING THE SICK PERSON; TESTIMONY; LIVING WITH HIV/AIDS; DENIAL; BISEXUAL; FRANCE Abstract: Gilles, a top civil servant and father, died in the prime of life. Cancer? That is what they said. In reality, Gilles was bisexual and died from AIDS. Since that illness is socially taboo and he had feared the unpredictable reactions of his entourage, he had asked his wife to hide the truth: neither their friends nor colleagues or even their children were to know. But where can she turn for support? In this true account, Isabelle Marchal powerfully describes the terrible in camera fears, hopes and anger but also the love into which the couple retreats. The author has written this first-hand account for all those women who are experiencing the same situation and who feel alone as they dare not speak about it. Reference IDF: 0603, A/0173 MARTIN, J. SIDA et discriminations sociales [AIDS and Social Discrimination] Article; French; Review: Prvenir; 2000; No. 39; ISN: 0247 2406; pp. 205-207 Main theme: DISCRIMINATION DISCRIMINATION; POVERTY; SOCIAL EXCLUSION; HEALTH INSURANCE; CMU (universal health coverage) Reference IDF: 0606, A/0024 Mutuelles de France, Montreuil Discriminations sur critres de sant ou de handicap [Discrimination on the Grounds of Health or Disability] Report; Seminar proceedings; French; Montreuil: CVM; 2001; ISN: 2 908255 14 6; 72 pp.; table Congress: Discriminations sur critres de sant ou de handicap, Paris, 2001/05/17 Main theme: DISCRIMINATION DISCRIMINATION; DISABLED PERSONS; HIV-INFECTED PERSONS; WORK ENVIRONMENT; INSURANCE; SURVEY; TESTIMONIES; EMPLOYMENT; LEGISLATION; COMPLEMENTARY INSURANCE; ASSOCIATION; RECOMMENDATION; FRANCE; EUROPE Abstract: This document is divided into two parts. In the first part, the results of the IFOP survey on discrimination on the grounds of health and disability are presented and analysed. The survey was conducted between 22 March and 6 April 2001 on a sample of 1,986 people, representative of the French population aged 18 and over. The results are accompanied by a series of testimonies, collected on the basis of semidirective interviews. The second part is given over to the proceedings of the seminar of 17 May: discrimination and insurance, discrimination and employment, action against discrimination on the grounds of health and disability in the European Community. Every type of disability is covered. One of the testimonies comes from a seropositive person, and the round 6 0 table Discrimination and employment was centred on the experience of the association Aides and its information and campaign to prevent discrimination against HIV-infected persons in the work place. Reference IDF: 0606, A/0039 NAP+ (Network of African People Living with HIV/AIDS), West and Central Africa; UNAIDS. Inter- Country Team for West and Central Africa Situation Analysis of Discrimination and Stigmatization against People Living with HIV/AIDS in West and Central Africa: Ethical and Legal Considerations Report; French; Abidjan: UNAIDS. Inter-Country Team for West and Central Africa; 2002/05; 47 pp.; list of addresses Main theme: DISCRIMINATION DISCRIMINATION; LIVING WITH HIV/AIDS; HUMAN RIGHTS; ETHICS; MEDICAL SECRECY; PROFESSIONAL ETHICS; STIGMATIZATION; RELATIONS; SITUATION ANALYSIS; CENTRAL AFRICA; WEST AFRICA; BURKINA FASO; CAMEROON; COTE DIVOIRE; GABON; GHANA; MAURITANIA Abstract: This analysis, which was carried out from March to July 2001 in six countries of West and Central Africa Burkina Faso, Cameroon, Cte dIvoire, Gabon, Ghana and Mauritania highlights daily situations of discrimination and stigmatization against people living with HIV in the areas of employment, education, individual freedoms, access to medical care, social security and access to bank loans. After defining the concepts of stigmatization and discrimination and presenting testimonies, it proposes a number of actions that could improve the situation as regards the rights of these persons. This analysis forms part of the UNAIDS 2002-2003 World AIDS Campaign, aimed at combating stigma and discrimination. Location: CRIPS Aquitaine (Bordeaux) NASSI, S.; GRIMAUD, C.; SIMON, K. Universit Blaise Pascal, Clermont-Ferrand Strotype du siden [Stereotype of the AIDS Sufferer] Report; French; 1994; 19 pp. Main theme: STIGMATIZATION STIGMATIZATION; REPRESENTATION OF THE ILLNESS; SOCIOLOGY; BELIEFS Abstract: This document focuses on the danger of the kind of stereotype that gives rise to biased judgements conducive to discrimination Location: CRIPS Auvergne (Clermont-Ferrand) PECHENY, M. Argentina: Discrimination and AIDS Prevention in: Drug Abuse and AIDS Stemming the Epidemic Article; English; Review: Peddro: networking of information in the field of drug abuse prevention through education; 2001/12; Special issue; pp. 55-57; table Main theme: DISCRIMINATION DISCRIMINATION; INJECTIBLE DRUG USERS; EPIDEMIOLOGY; IMPACT; RISK REDUCTION; ARGENTINA Abstract: The author explains how the confusion between the domain of health and that of social and moral values and the consequent stigmatization of drug users are obstacles to the introduction of risk-reduction measures. Reference IDF: Peddro, Special issue PRESTEL, T. Aviation: le rgne de la discrimination [Aviation: The Realm of Discrimination] Article; French; Review: Remaides; 2000/09; No. 37; ISN: 1162 0544; pp. 15 Main theme: DISCRIMINATION DISCRIMINATION; WORK ENVIRONMENT; EMPLOYABILITY; EMPLOYMENT; 6 1 SEROPOSITIVE PERSON; FRANCE Abstract: This article denounces the decree of 5 July 1994 of the Ministry of Transport, which disqualifies seropositive applicants for air hostess and steward posts in civil aviation. Reference IDF: Remaides, No. 37 ROBBE, A.; ROBBE, A.; AIDES Fdration Nationale. Mission entreprises, France VIH/SIDA et milieu de travail: Sensibilisation formation (2 sketches) [HIV/AIDS and the Workplace: Awareness-raising Training] in: VIH/SIDA et milieu de travail: spots TV et Sketches Video; Preventive-education film; French; 2001; 10 [ 2 x 5 ] mins. Main theme: DISCRIMINATION DISCRIMINATION; WORK ENVIRONMENT; REINTEGRATION IN THE WORK FORCE; PERSONAL DISCLOSURE OF SEROPOSITIVITY; BELIEFS; RUMOURS; FRANCE Public: EMPLOYER Abstract: These sketches are intended to serve as resources for awareness-raising and training in integrating HIV-infected persons in the workplace. Lentretien dembauche [Job Interview] addresses the question of the access to work by HIV-infected persons under treatment. The attitudes of an applicant and a human resources manager during a job interview are acted out. La rumeur [The Rumour] exposes false beliefs and suspicious attitudes towards other employees. In the restaurant, the rumour spreads as soon as a colleague has a health problem. Production: Pantin: AIDES Fdration Nationale Diffusion: AIDES Fdration Nationale VHS SECAM Diffusion free of charge Reference IDF: B01, V/0815 TARABAY, M. Les stigmates de la maladie: Reprsentations sociales de lpidmie du SIDA [Stigmas of the Illness: Social Representations of the AIDS Epidemic] Payot Lausanne, 2000, 217 pp. Abstract: Through many testimonies, the author is concerned in particular to show that the everyday situation of caregivers, close relatives and AIDS sufferers is sometimes different from that one might think. The book also retraces the way in which the concept of the illness in our society has evolved since the start of the epidemic. THERY, I.; TASSERIT, S. SIDA et exclusion [AIDS and Exclusion] in: Lexclusion, ltat des savoirs [Exclusion, the State of the Art] Extract; French; Paris: La Dcouverte; 1996; ISN: 2 7071 2540 7; pp. 363-373. Main theme: DISCRIMINATION DISCRIMINATION; REPRESENTATION; UNDERPRIVILEGED ENVIRONMENTS; SOCIAL EXCLUSION Reference IDF: 0603, A/0093 VELTER, A.; MOREL, M. SIDA Info Service, France SIDA Info Droit, tmoin de lexclusion et des discriminations: le VIH, un obstacle linsertion sociale [SIDA Info Droit, a Witness to Exclusion and Discrimination: HIV: An Obstacle to Social Integration] Article; French; English; Review: Enable; 2000/07; No. 4; pp. 11-12 Main theme: DISCRIMINATION DISCRIMINATION; LEGAL AID; TELEPHONE HOTLINE; SOCIAL EXCLUSION; FRANCE Description: Review in bilingual inverted format. Abstract: The calls received on the SIDA Info Droit hotline for legal aid highlight the situations of exclusion 6 2 that the HIV infection generates and reinforces in some cases. Extracts from telephone calls illustrate some typical situations. Reference IDF: Enable, No. 4 WELZER-LANG, D., dir.; DUTEY, P., dir.; DORAIS, M., dir.; GENTAZ, C.; GUILLEMAUT, F.; RYAN, B.; FRAPPIER, J.-Y.; BOCHOW, M.; LESSELIER, C. La peur de lautre en soi: du sexisme lhomophobie [The Fear of the Other Within: From Sexism to Homophobia] Book; French; Montreal: VLB diteur; 1994; Coll.: Des hommes en changement, No. 9; ISN: 2 89005 587 6; 302 pp. Main theme: DISCRIMINATION DISCRIMINATION; REPRESENTATION; HOMOSEXUAL; ADOLESCENT; RESEARCH; METHODOLOGY; ANTHROPOLOGY; LANGUAGE; HOMOSEXUALITY; SEXISM; SOCIAL NORMS; ETHICAL VALUES; BEHAVIOUR; LESBIAN; TAKING A STAND; HOMOPHOBIA; GERMANY; FRANCE Reference IDF: 0601, A/0349 out of print Additional references in English: AIDS Law Project and Lawyers for Human Rights, South Africa HIV/AIDS and the Law: A Resource Manual Manual; English; 1997/05; 300 p. ALCORN K., dir. NAM (National Aids Manual), United Kingdom The Law and HIV in: AIDS reference manual Manual; Abstract; English; London: NAM Publications; 1997/05; 20 ed.; ISN: 1 89839771 6; pp. 368-400 ANNAS G.J. Protecting Patients from Discrimination: The Americans with Disabilities Act and HIV Infection Article; English; Review: New England Journal of Medicine (The); 1998/10/22; vol. 339; n 17; ISN: 0028 4793; pp. 1255-1259 DE BRUYN T. Canadian HIV/AIDS Legal Network; Canadian Aids Society, Ottawa HIV/AIDS and Discrimination: A Discussion Paper Report; English; 1998/03; ISN: 1 896735 14 2; 138 [123+15] p. DE COCK K.M.; MBORI-NGACHA D.; MARUM E. Shadow on the Continent: Public Health and HIV/AIDS in Africa in the 21st Century Article; English; Review: Lancet (The); 2002/07/06; vol. 360; ISN: 0140 6736; pp. 67-72 European Project Aids and Mobility, Utrecht Report of the Second European Meeting for the Exchange of Information on: Ethnic minorities, Migrants and AIDS, focus on Human Rights and AIDS, Alden Biesen, Belgium, 2-5 June 1994 Proceedings of Congress; English; 1995/08; 57 p. Congress: Ethnic minorities, migrants and aids, Alden Balden, 1994/06/02-05 FROGIER L. Homosexuals and the AIDS Crisis in France: Assimilation, Denial, Activism in: Acting on aids: sex, drugs and politics Abstract; English; London: Serpent's Tail; 1997; ISN: 1 85242 5539; pp. 346-359 6 3 From Vulnerability to Human Rights in: Aids in the world II: global dimensions, social roots and responses Abstract; English; 1996; ISN: 0 19 908994 4; pp. 463-476 GRIMSHAW J. The Nature of AIDS-related Discrimination in: Acting on aids: sex, drugs and politics Abstract; English; London: Serpent's Tail; 1997; ISN: 1 85242 5539; pp. 379-393 GRUSKIN S.; HENDRIKS A.; TOMASEVSKI K. Human Rights and Responses to HIV/AIDS in: Aids in the world II: global dimensions, social roots and responses Abstract; English; 1996; ISN: 0 19 508994 4; pp. 326-340 HAOUR-KNIPE M.; RECTOR R. Crossing Borders: Migration, Ethnicity and AIDS Book; English; London: Taylor & Francis; 1996; ISN: 0 7484 0378 7; 250 p. HARVEY D. Legal Issues in: Children, families, and HIV/aids: psychosocial and therapeutic issues Abstract; English; New York: the Guilford Press; 1995; ISN: 0 89862 502 5; pp. 270-288 HORTON M. Its a Straight World after all - Heterosexualizing the Pandemic in: Acting on aids: sex, drugs and politics Abstract; English; London: Serpent's Tail; 1997; ISN: 96 69725; pp. 254-269 HUSSEY J. NAT (National Aids Trust), United Kingdom Employment and AIDS: A Review of the Companies Act, Business Charter on HIV and AIDS Report; English; 1996/08; 14 p. ICASO (International Council of AIDS Service Organizations), Canada HIV/AIDS and Human Rights: The International Guidelines on HIV/AIDS and Human Rights, How are they Being Used and Applied? Report; English; 2002/05; 38 p. ICASO HIV/AIDS and Human Rights: Stories from the Frontlines Report; English; 1999/06; 25 p. ICASO ICASO, Human Rights and Social Equity: A Framework Document Study; English; 1998/06; 36 p. Israel AIDS Task Force, Tel-Aviv Declaration of Rights of Persons Living in Israel with HIV/AIDS Report; English; 1996; 10 p. JURGENS R.; FISHER J.; VASSAL A.; HUGHES R. Canadian HIV/AIDS Legal Network; Canadian Aids Society, Ottawa Gay and Lesbian Legal Issues and HIV/AIDS: Final Report Report; English; 1998/03; ISN: 1 896735 12 6; 164 [133+31] p. 6 4 MCKENNA N. Panos Institute, London On the Margins: Men who have Sex with Men and HIV in the Developing World Report; English; London: Panos Institute; 1996; ISN: 1 870670 37 X; 112 p. MARQUET J.; BELTZER N. Knowledge and Discrimination: What Kind of Relationship? in: Sexual behaviour and HIV/Aids in Europe: comparisons of national surveys Abstract; English; London: Taylor & Francis; 1998; Coll.: Social Aspects of Aids; ISN: 1 85728 819 X; pp. 375-400 NADIC (National Aids Documentation and Information Center), Uganda The Rights of the Child in the Context of HIV/AIDS Flyer; English; 1999/12; 6 [2A4] p. NAPWA (National Association of People With AIDS), Australia Declaration of the Rights of People with HIV/AIDS Flyer; English; s.d.; 6 [2A4] p. NZP+ (Network of Zambian People with HIV/AIDS) Human Rights and HIV/AIDS Flyer; English; s.d.; 6 [2A4] p. PATTERSON D. Taking a Rights-base Approach to AIDS Research Article; English; Review: IAVI report: the newsletter on international aids vaccine research; 2003/02; vol. 7; n 1; pp. 10-12, 14 PYNE H H. World Bank, United States; European Commission. Directorate-General for Development, Brussels International Law and the Rights of People Living with HIV/AIDS in: Confronting AIDS, evidence from the developing world: selected background papers for the World Bank Policy Research Report, Confronting AIDS: public priorities in a global epidemic Abstract; English; 1998; ISN: 92 828 4991 0; pp. 79-92 SACKS V. Women and AIDS: An Analysis of Media Misrepresentations Article; English; Review: Social Science and Medicine; 1996; vol. 42; n 1; pp. 59-73 SHEON A.-R.; WAGNER L.; Mc ELRATH M.-J.; KEEFER M.-C.; ZIMMERMAN E.; ISRAEL H.; BERGER D.; FAST P. Preventing Discrimination against Volunteers in Prophylactic HIV Vaccine Trials: Lessons from a Phase II Trial Article; English; Review: Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology; 1998/12/15; vol. 19; n 5; ISN: 1077 9450; pp. 519-526 SHRIVER M.D.; EVERETT C.; MORIN S.F. Structural Interventions to Encourage Primary Prevention among People Living with AIDS in: Structural factors in HIV prevention Article; English; Review: AIDS; 2000/06/01; vol. 14; n Supplement 1; ISN: 0269 9370; pp. S57-S62 Congress: Structural barriers and facilitators in HIV prevention, Atlanta, 1999/02/22-23 STUDDERT D.M. Charges of Human Immunodeficiency Virus Discrimination in the Workplace: The Americans with Disabilities Act in Action Article; English; Review: American Journal of Epidemiology; 2002; vol. 156; n 3; ISN: 0002 9262; pp. 219- 229 6 5 UNAIDS, Geneva Report on the Global HIV/AIDS Epidemic, 2002 Report; English; 2002/07; ISN: 92 1973 185 4; 226 p. UNAIDS, Geneva A Human Rights Approach to AIDS Prevention at Work: the Southern African Development Communitys Code on HIV/AIDS and Employment Report; English; 2000/06; 56 p. UNAIDS, Geneva HIV and AIDS-related Stigmatization, Discrimination and Denial: Forms, Contexts and Determinants: Research Studies from Uganda and India Report; English; 2000/06; 40 p. UNAIDS, Geneva Protocol for Identification of Discrimination against People Living with HIV Guide; English; 2000/05; Coll.: Best Practice; 40 p. UNAIDS, Geneva The UNAIDS Guide to the Unites Nations Human Rights Machinery Report; Legislation; English; 1997; 90 p. UNESCO, Paris; UNAIDS, Geneva HIV/AIDS and Human Rights, Young People in Action: A Kit of Ideas for Youth Organizations Guide; English; 2001; 60 p. WHO (World Health Organization). Regional Office for Europe, Copenhagen Health Legislation and Human Rights: The AIDS Experience Report; Proceedings of conference; English; 1996; 35 p. 67 ANNEX III Selected Articles on Stigma and Discrimination ALUBO O.; ZWANDOR A.; JOLAYEMI T.; OMUDU E. Acceptance and Stigmatization of PLWA in Nigeria. AIDS Care. 2002 Feb;14(1):117-26. There is now an acknowledged burden of AIDS and the HIV in Nigeria. In treatment centers, AIDSrelated disorders account for up to 40% of admissions, while many communities have recorded regular losses within the last five years. In December 1999, the federal government announced that 2.9 million people (or 5.4% of the Nigerian population) were already infected by HIV. An important aspect of HIV/AIDS programs is the care of persons living with AIDS (PLWA), both in curative centers and in communities. Based on operations research of a STD/AIDS Management Project, this paper examines acceptance of PLWA in communities in Southern Benue State, an area of high prevalence. From interviews with PLWA, their family members and others in the communities, it was found that the level of stigmatization is high and acceptance of PLWA is low. These reactions stem mainly from the fear of contracting 'the disease that has no cure', believed to be transmittable through any form of physical contact. Based on beliefs, which are further reinforced by the local terms for AIDS, some suggested that PLWA be eliminated before they infect others. These findings suggest that the challenges of AIDS control programs include coming to terms with the epidemic and fostering more acceptance for PLWA and, above all, changing the current perception of HIV/AIDS from a personal to public health problem. The challenges are daunting but urgent, particularly because Nigeria's HIV/AIDS epidemic is reaching an explosion phase and more care will be provided at home. DUBOIS-ARBER F.; HAOUR-KNIPE M.; Discrimination work group. HIV/AIDS Institutional Discrimination in Switzerland. Soc Sci Med. 2001 May; 52(10):1525-35. A UNAIDS protocol designed to identify discrimination against people living with HIV/AIDS was applied in Switzerland, a country where policies against such discrimination had been actively promoted since the beginning of the HIV epidemic. Discrimination, in its strict legal definition, was examined in nine areas of everyday life, and at three levels: legislation, written regulations, and actual practices. Data concerning both expert opinion and subjective experience of discrimination was gathered by members of an interdisciplinary work group by means of: (1) interviews with over 200 key informants and experts, covering each of the areas investigated, and (2) actively seeking testimonies as to experiences of discrimination through local AIDS groups and through informal contacts of work group members. The study revealed little institutional discrimination in the region investigated, attesting to the efficacy of clear and actively promoted anti-discrimination policies. Individual discrimination and stigmatization persist, however. It is in combating individual discrimination and stigmatization that efforts must now concentrate. The UNAIDS protocol was found to be a valuable tool for tracking the sorts of discrimination that can most easily be influenced by policy measures. FORTENBERRY J.D.; MCFARLANE M.; BLEAKLEY A.; BULL S.; FISHBEIN M.; GRIMLEY D.M.; MALOTTE C.K.; STONER B.P. Relationships of Stigma and Shame to Gonorrhea and HIV Screening. Am J Public Health. 2002 Mar; 92(3):378-81. OBJECTIVES: The purpose of this study was to assess the relationships between stigma and shame associated with seeking treatment for sexually transmitted diseases (STDs) and undergoing testing for gonorrhea and HIV. METHODS: Participants were 847 males and 1126 females (mean age: 24.9 years) in 7 cities. Two scales assessed STD-related stigma and STD-related shame. RESULTS: Rates of stigma and shame were higher among participants without a gonorrhea test in the past year and among 68 those without an HIV test. Sex, age, health service use, previous suspicion of gonorrhea, and low levels of stigma were independently associated with gonorrhea testing. Age, enrollment site, use of health services, gonorrhea testing, and low levels of stigma were independently associated with HIV testing. CONCLUSIONS: Shame is part of the experience of seeking STD-related care, but stigma may be a more powerful barrier to obtaining such care. HAYES R.A.; VAUGHAN C.; MEDEIROS T.; DUBUQUE E. Stigma Directed toward Chronic Illness is Resistant to Change through Education and Exposure. Psychol Rep. 2002 Jun; 90(3 Pt 2):1161-73. In the mid-1980s, research reported that people living with HIV were viewed differently on measures of competence, dependence, morbidity, depression, and moral worth from those living with other chronic illnesses. 443 students were surveyed to evaluate present attitudes in comparison to this earlier research. The usefulness of imaginal exposure, i.e., imagining a loved one living with HIV, in reducing stigma toward people with HIV was also investigated. Analysis indicated no difference in the rating of AIDS and cancer patients on measures of competence, depression, and morbidity and patients with heart disease, the latter being rated significantly less competent and more depressed than AIDS or cancer patients. AIDS patients were rated significantly less dependent than cancer and heart disease patients. While these results suggest that stigma associated with an HIV/AIDS diagnosis, in general, may have decreased over the years, ratings of moral worth were still lower for AIDS patients than for patients with cancer and heart disease. Robustness of this specific aspect of stigma may be associated with sexual prejudice. Also, an imagined loved one who lives with HIV was rated significantly more favorably on all 5 composite scales than a generic person living with HIV, suggesting the usefulness of exposure as an intervention for attitude change. Limitations of the research are discussed. HEREK G.M.; CAPITANIO J.P.; WIDAMAN K.F. HIV-related Stigma and Knowledge in the United States: Prevalence and Trends, 1991-1999. Am J Public Health. 2002 Mar; 92(3):371-7. OBJECTIVES: This study assessed the prevalence of AIDS stigma and misinformation about HIV transmission in 1997 and 1999 and examined trends in stigma in the United States during the 1990s. METHODS: Telephone surveys with national probability samples of English-speaking adults were conducted in the period 1996 to 1997 (n = 1309) and in 1998 to 1999 (n = 669). Findings were compared with results from a similar 1991 survey. RESULTS: Overt expressions of stigma declined throughout the 1990s, with support for its most extreme and coercive forms (e.g., quarantine) at very low levels by 1999. However, inaccurate beliefs about the risks posed by casual social contact increased, as did the belief that people with AIDS (PLWAs) deserve their illness. In 1999, approximately one third of respondents expressed discomfort and negative feelings toward PLWAs. CONCLUSION: Although support for extremely punitive policies toward PLWAs has declined, AIDS remains a stigmatized condition in the United States. The persistence of discomfort with PLWAs, blame directed at PLWAs for their condition, and misapprehensions about casual social contact are cause for continuing concern and should be addressed in HIV prevention and education programs. PARKER R.; AGGLETON P. HIV and AIDS-related Stigma and Discrimination: A Conceptual Framework and Implications for Action. Soc Sci Med. 2003 Jul; 57(1):13-24. Internationally, there has been a recent resurgence of interest in HIV and AIDS-related stigma and discrimination, triggered at least in part by growing recognition that negative social responses to the epidemic remain pervasive even in seriously affected communities. Yet, rarely are existing notions of stigma and discrimination interrogated for their conceptual adequacy and their usefulness in leading to 69 the design of effective programs and interventions. Taking as its starting point, the classic formulation of stigma as a 'significantly discrediting' attribute, but moving beyond this to conceptualize stigma and stigmatization as intimately linked to the reproduction of social difference, this paper offers a new framework by which to understand HIV and AIDS-related stigma and its effects. It so doing, it highlights the manner in which stigma feeds upon, strengthens and reproduces existing inequalities of class, race, gender and sexuality. It highlights the limitations of individualistic modes of stigma alleviation and calls instead for new programmatic approaches in which the resistance of stigmatized individuals and communities is utilized as a resource for social change. VALDISERRI R.O. HIV/AIDS Stigma: An Impediment to Public Health. Am J Public Health. 2002 Mar; 92(3):341-2. Publication Types: Comment; Editorial. Terms: Acquired Immunodeficiency Syndrome/prevention & control; Acquired Immunodeficiency Syndrome/transmission; Adult; Attitude of Health Personnel/ethnology; Fear; HIV Infections/prevention & control; HIV Infections/transmission; Health Promotion; Human; Knowledge, Attitudes, Practice; Prejudice; Public Health Practice/standards; Risk-Taking; Sex Behavior/ethnology; Stereotyping; Substance Abuse, Intravenous/virology; United States. Additional references CRAWFORD I. Psychologists Atitudes toward Prsons with AIDS: Stigmatization or Just a Less Positive Outlook? Professional psychology, research and practice, 1998, vol. 29, no 3, pp. 306-07 DELVAUX M. Being-not-one - L'autre siden Texte: (Toronto), 1998 , no 23-24 , pp. 247 - 260 DOWSETT G.W. HIV/AIDS and Homophobia: Subtle Hatreds, Severe Consequences and the Question of Origins Culture, health & sexuality, 2003, vol. 5, no 2, pp. 121 - 136 ERIN C.A.; HARRIS J. Aids: Ethics, Justice, and Social Policy Journal of applied philosophy, 1993, vol. 10, no 2, pp. 165 - 173 GILMORE N.; SOMERVILLE M.A. Stigmatization, Scapegoating and Discrimination in Sexually Transmitted Diseases: Overcoming Them and Us Social Science & Medicine, 1994, vol. 39, no 9, pp. 1339 - 1358 GOLDIN G.S. Stigmatization and AIDS: Critical Issues in Public Health Social Science & Medicine, 1994, vol. 39, no 9, pp. 1359-1366 LE POIRE B.A. Attraction Toward and Nonverbal Stigmatization of Gay Males and Persons with AIDS: Evidence of Symbolic over Instrumental Attitudinal Structures Human communication research, 1994, vol. 21, no 2, pp. 241-279 70 LEMELLE A.J. Racialized Social System and HIV Infection: The Case of African Americans International journal of sociology and social policy, 2002, vol. 22 , no 4-6, pp. 133 - 158 QUAH S.R. Ethnicity, HIV/AIDS Prevention and Public Health Education International journal of sociology and social policy, 1998, vol. 18, no 7-8, pp. 1-26 Varas Daz, N., Toro-Alfonso, J., & Serrano-Garca, I. (2005). My body, my stigma: Body interpretations in a sample of people living with HIV/AIDS in Puerto Rico. The Qualitative Report, 10(1), 122-142. Retrieved [Insert date], from http://www.nova.edu/ssss/QR/QR0-1/varas diaz.pdf The Qualitative Report Volume 10 Number 1 March 2005 122-142 http://www.nova.edu/ssss/QR/QR10-1/varas diaz.pdf My Body, My Stigma: Body Interpretations in a Sample of People Living with HIV/AIDS in Puerto Rico.1 Nelson Varas-Daz, Jos Toro-Alfonso, and Irma Serrano-Garca University of Puerto Rico AIDS related stigma continues to impact the lives of People Living With HIV/AIDS (PLWHA) negatively. Although the consequences of stigmatization have been widely documented, certain areas of study need to be further addressed in order to better understand their implications for PLWHA; such is the case of the perceptions of the bodys role in AIDS stigma. A qualitative study was implemented including 30 in-depth interviews of PLWHA in Puerto Rico in order to explore their perceptions of the bodys role in the process of stigmatization. Results include: participants perceptions on how their bodies evidence their serostatus, description of past body marks, personal experiences with body marks, meanings attributed to their bodies with HIV/AIDS, and personal criteria used to describe the perfect body. These issues are described in the context of the social stigma faced by PLWHA in Puerto Rico and individual perceptions of bodys role in the process of self-stigmatization. Recommendations for intervention and research are described. Key Words: HIV/AIDS, Stigma, Body, and Puerto Ricans The HIV/AIDS pandemic can be described as one plagued by social meaning. More than twenty years into the epidemic it is evident that we are not only dealing with the biological effects of a virus; we are also facing the negative social meanings attributed to HIV/AIDS and the people who live with it. These negative socially shared meanings ascribed to the epidemic have been described as AIDS stigma and its consequences are disastrous for people living with HIV/AIDS (PLWHA) as they entail depression, denial of health services, and ostracism, among others (Herek & Glunt, 1988). Further research needs to be carried out in areas that are of significance for PLWHA and that have been neglected by AIDS stigma researchers. Such is the case of the bodys role in AIDS stigma (Chapman, 1998). Due to the evident biological dimensions of HIV for the body, the latter is seldom addressed when elaborating on the social dimensions of the epidemic; even when the body is also a social phenomenon. 1 This study was funded by a National Institute of Mental Health grant (1 R03 MH65159-01). The first author can be contacted through regular mail at University of Puerto Rico, Graduate School of Social Work, P.O. Box 23345, San Juan, PR 00931-3345 or by e-mail at nvaras@rrpac.upr.clu.edu. 123 The Qualitative Report March 2005 What is Stigma? The concept of stigma dates to ancient Greece and was used to describe people with bodily marks or tattoos which evidenced their involvement in a bad deed and were therefore to be avoided (Crawford, 1996). The concept has also been defined as an unnatural mark on the bodies of saints, a mark made with a hot iron on the flesh of slaves, a bad reputation, and even a physical dysfunction (Real Academia Espaola, 1984). Other authors have described stigma as a social construction associated with the recognition of a difference, based on a specific characteristic, which is used to devalue the person who possesses it (Dovido, Major, & Crocker, 2000). All of these definitions share the idea that a stigma is the negative evaluation of a particular difference that may be associated with a person. One of the most widely recognized conceptual frameworks on the subject was developed by sociologist Erving Goffman (1963). He defined stigma as a profoundly discreditable attribute, which could lead a person to be deemed almost inhuman. He identified three types of stigma: abominations of the body, blemishes of individual character, and tribal stigmas. Abominations of the body were described as stigmas associated with physical deformations or deviations from a social norm, such as people with physical challenges, missing limbs, or physical deformities, among others. Blemishes of individual character were stigmas associated with a persons character, identity, or simply their particular way of being. Some of these blemishes can be attributed to people in jail, drug users, alcoholics, and people with poor mental health, among others. Finally, tribal stigmas referred to the negative evaluation of particular persons due to their association with a group. Some of these stigmas are related to race, ethnicity, and sexual preference. According to Goffman, all of these types of stigmas contribute to devaluing people. Goffmans definition is particularly important to understand AIDS stigma since PLWHA can encompass all three: abominations of the body (wasting syndrome), blemishes of individual character (responsibility over infection), and tribal stigmas (notions attributed to homosexuals as a group). Other authors have expanded Goffmans (1963) framework by describing multiple dimensions of stigma (Jones et al., 1984). These include: concealability, course (of the stigmatizing condition), disruptiveness, aesthetic qualities, origin, and peril. According to these dimensions a stigma will have more negative effects if it is not concealable (therefore evident to others), if it is perceived as advanced in its course (such as an illness in its final stages), if it disrupts or hinders social interaction, if it is not beautiful or aesthetically pleasing to the observer, if the stigmatized person or group is blamed for its origin, and if it is associated with death. Goffman (1963) stressed the importance of visibility of the stigmatizing attribute, and therefore its bodily dimension. According to him persons whose stigmatizing mark is clearly visible will be discredited by others, while those whose stigma is not visible are considered discreditable, since the possibility of being identified as stigma bearers is always imminent in social relationships. This possibility of being identified as a stigma bearer evidences the complexity through which those that are stigmatized must engage in on a daily basis, in order to avoid social interactions through which their marks may be identified. Daily life becomes a hide and seek game in which the outcome can be truly devastating. Nelson Varas-Daz, Jos Toro-Alfonso, and Irma Serrano-Garca 124 The Bodys Role in Stigmatization One of the most relevant aspects of Goffmans (1963) conceptual framework to this current investigation is the bodys central role in it. The body, as a biological and social entity, sets boundaries for particular types of stigmas. Although more evident in some cases than others, the body plays a central role in the types of stigma Goffman (1963) identified. The most obvious are probably abominations of the body in which particular deformations or missing body parts elicit stigmatizing attitudes. Stigmas associated with blemishes of individual character also entail bodily dimensions. For example, this type of stigma can be found in an imprisoned person whose reality lies behind bars and whose bodily freedom is restricted due to a transgression of social norms. This transgression in turn may be interpreted as a fault of his/her character or personal identity. The same can be said about drug users whose bodies evidence their addiction either by physical marks of drug injection or by lack of bodily control under the influence of drugs (Capitano & Herek, 1999). Finally, tribal stigmas also evoke the body since they serve as identifiers of members of a particular group. This occurs through skin color, tattoos, body modification (Featherstone, 2000), or other types of marks such as those of a particular sickness. These examples highlight the bodys role in the stigmatization process. The importance of this role increases when the body is afflicted by a disease that is considered degenerative and deadly. Such is the case of HIV/AIDS. Living in a Body with HIV/AIDS Since the body is our vehicle for interaction with the world and others, it is through it that people experience the HIV epidemic. In this sense, the body cannot be separated from the experience of living with HIV/AIDS. People are exposed to infection through their bodies. In social interactions, in which bodies are embedded, the consequences of infection and subsequent stigmatization are evidenced. Goffmans (1963) conceptual framework facilitates understanding the stigma that surrounds HIV/AIDS, and particularly of the bodys role in such stigma. For example, PLWHA can encompass all three types of stigma identified by Goffman. They are perceived as having abominations of the body when they have visible marks associated with their condition, they suffer from blemishes of individual character when they are perceived as responsible for their HIV/AIDS status, and are victims of tribal stigmas when they are described as part of a risk group. The same can be said for the multiple dimensions of stigma defined by Jones et al. (1984). Since HIV/AIDS may not be concealable in some cases, it may disrupt social interactions with those who are afraid of contagion, and since it is associated with death PLWHA are very likely to be stigmatized. Since stigmatizing attitudes may be difficult to hide for the stigmatizer, they can make it harder, or even impossible to interact with PLWHA. This is particularly plausible when the marks that foster stigmatization are evident and clearly visible. The role of the body living with HIV/AIDS in the stigmatization process can be dual: (1) it can provide physical or visual evidence of the condition; described by Goffman (1963) as the discredited or (2) can work as a generator of self-stigmatizing attitudes even when the condition is not clearly visible to others (described by Goffman 125 The Qualitative Report March 2005 as the discreditable). Evidence of the condition arises from bodily marks. Some of these include, but are not limited to, lesions, skin infections, fungus, and rashes (Murphy, 1995). Other health complications such as lipodystrophy, the condition in which fat is disproportionately accumulated throughout the body, can serve as markers of the disease (Velenti, 2001). Its consequences entail accumulation of abdominal fat and the development of a buffalo hump in the top part of the back. The same can be said of wasting in which the individual is physically debilitated due to loss of body fat and muscle tone (Kalichman, 1998a). This wasting is manifested in loss of mass in the cheeks and gluteal muscles. Although some of these changes can happen to people with other health conditions, for PLWHA they entail other meanings due to the social stigma attached to the infection. On the other hand, the second manifestation mentioned above refers to asymptomatic people who can internalize negative perceptions widely held throughout society regarding their infected bodies. This is not surprising considering that the HIV/AIDS body has been conceptualized as a site of death and contagion, an instance of prejudice, an entity suspended between health and sickness, and as an entity that succumbs as it faces the epidemic (Chapman, 2000; Murphy, 1995; Waldby, 1996). People living with HIV/AIDS are acutely aware of these interpretations, and in some cases may hold them to be true (Varas-Daz, 2002; Varas-Daz, Serrano-Garca, & Toro-Alfonso, 2004). This stigmatized body living with HIV/AIDS must not be considered a natural or given phenomenon. On the contrary, it is a socially constructed body that lives within collectively created discourses of stigmatization. It provides evidence to others, and to themselves, that the stigmatization process can be continuous and imminent. When this process occurs, its consequences can be dire. The Consequences of AIDS Stigma The magnitude of the stigma surrounding HIV/AIDS is reflected in the coining of the term AIDS-related stigma or AIDS stigma (Herek & Glunt, 1988, pg. 886). The myths that surround the HIV/AIDS epidemic contribute to this stigmatizing process (Cunningham & Ramos-Bellido, 1991). Among the social meanings attributed to the epidemic we find that HIV+ people are sometimes perceived as invasive agents in a healthy society (Bunting, 1996; Sontag, 1990). This notion fosters the social exclusion of those perceived as risk agents because they are interpreted as a threat to others, as deviating from what is normal, and as not contributing to societys development. Research has documented the negative personal and social implications of AIDS stigma for PLWHA. Some of its negative psychological effects include: anxiety, depression, guilt, isolation, disruption of family dynamics, physical and emotional violence, intensification of grief, loss of social support, lack of sexual activity, and the deterioration of productive relations with health professionals (Chesney & Smith, 1999; Kalichman, 1998b; Nord, 1997). AIDS stigma also has the potential to generate other situations that have negative effects on mental health such as loss of health insurance, social discrimination, unemployment, and problems accessing health related services (Herek, 1999; Leary & Schreindorfer, 1998). Nelson Varas-Daz, Jos Toro-Alfonso, and Irma Serrano-Garca 126 AIDS stigma researchers have barely begun to tap the surface on the implications of the body living with HIV/AIDS. Nevertheless, some published research has documented that PLWHA who suffer from lipodystrophy can suffer from bodily discomfort, low self-esteem, and depression (Power, Tate, McGill, & Taylor, 2003). These negative consequences foster social isolation in people who feel self conscious about their bodies due to HIV infection and therefore avoid social interaction (Tate & George, 2001). In such cases the body with HIV/AIDS contributes to feelings of stigmatization from society in general and, in the worst cases, to self-stigmatization (Chapman, 1998). The potential social exclusion and discrimination associated with AIDS stigma evidences the need to address its consequences on social interactions with different people, particularly, those consequences that may arise from feeling stigmatized in relations that are important to PLWHA. Researchers still need to carefully address the role of the body in the lives of PLWHA since it can be a vehicle for social, and personal, stigmatization. Those people who are important to the lives of PLWHA can identify body changes, particularly if the interact with them on a regular basis. These include family members, sexual partners, and personnel in health scenarios who are trained to examine the body for signs of sickness. The HIV/AIDS Epidemic in Puerto Rico Examining AIDS related stigma, and the role of the body in its process, is particularly urgent in Puerto Rico. The HIV/AIDS epidemic has severely impacted the Island and the numbers of reported AIDS cases are alarming. Out of the more than 29,205 reported cases of AIDS, 18,370 have already died (OCASET, 2004). Men represent 77% of these cases and women 23%. The most common means of infection are sharing needles for injected drug use (50%), heterosexual transmission (24%) and transmission between men who have sex with men (17%). Along with Haiti, Puerto Rico accounts for the vast majority of AIDS cases in the Caribbean, which in turn has the second highest prevalence of the epidemic in the world (PAHO, 2001; World Bank, 2001) after Sub-Saharan Africa. To make this scenario even worse, HIV cases were not reported until 1999 and seroprevalence data is unavailable at this time (Sosa Pascual, 2003). Just as in many other countries around the world, these numbers are just one face of the epidemic. Research has shown that PLWHA in Puerto Rico face stigma on a daily basis (Santiago, 1998; Varas-Daz, Serrano-Garca, Toro-Alfonso, 2004; Vargas DeLen, 1996). Some of the research documenting this stigma, as recently as this decade, reports difficulties accessing health services, ostracism, and open discrimination by families, friends, sexual partners, and employers (Kaiser Family Foundation, 2001; Porbn, Torres Burgos, & Bernal, 2000; Torres Burgos, Porbn, & Bernal, 2000; Varas-Daz, 2002). In this context, research concerning stigmas manifestations in the lives of PLWHA is essential to address the epidemic. As researchers engaged in a qualitative study we would like to address the issue of context before describing the implemented method. Our lives have been touched by friends and colleagues affected by this epidemic. We have incorporated HIV into our research agenda in order to contribute to the development of knowledge that can better Nelson Varas-Daz, Jos Toro-Alfonso, and Irma Serrano-Garca 142 women with HIV/AIDS]. Unpublished doctoral dissertation, Caribbean Center for Postgraduate Studies, San Juan, Puerto Rico. Velenti, B. (2001). Lipodystrophy and metabolic complications in HIV infection. NUMEDX, 3, 50-57. Waldby, C. (1996). AIDS and the body politic. New York: Routledge. World Bank (2001, December). HIV/AIDS in the Caribbean: Issues and options. Washington, DC: Author. Author Note Nelson Varas Daz, Ph.D., is an assistant professor in the Graduate School of Social Work, University of Puerto Rico, Ro Piedras Campus. His work addresses issues of social stigmatization, access to health services, and identity concerns of people living with HIV/AIDS. Jos Toro-Alfonso, Ph.D., is an associate professor of psychology, University of Puerto Rico, Ro Piedras Campus. His research work addresses HIV prevention, domestic violence among same sex couples, and issues of masculinity among men who have sex with men. Irma Serrano-Garca, Ph.D., is a professor of psychology, University of Puerto Rico, Ro Piedras Cam pus. Her research work addresses issues of HIV prevention among women and public policy. For more information on this study contact Nelson Varas-Daz at University of Puerto Rico, Graduate School of Social Work, PO Box 23345, San Juan, PR 00931-3345; Email: nvaras@rrpac.upr.clu.edu Copyright 2005: Nelson Varas Daz, Jos Toro-Alfonso, Irma Serrano-Garca, and Nova Southeastern University Article Citation Varas Daz, N., Toro-Alfonso, J., & Serrano-Garca, I. (2005). My body, my stigma: Body interpretations in a sample of people living with HIV/AIDS in Puerto Rico. The Qualitative Report, 10(1), 122-142. Retrieved [Insert date], from http://www.nova.edu/ssss/QR/QR0-1/varas diaz.pdf Leprosy STIGMA unwanted difference or discrediting attributes- Bringing social exclusion & negative reactions Usual "sources" of stigma deformity or abnormal feature of body imputed character aberration group features -- such as race or religion or class Typical reaction to stigmatization: social isolation or avoidance  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/stigma_btn.gif" \* MERGEFORMATINET Stigma, Social Risk, and Health Policy: Public Attitudes Toward HIV Surveillance Policies and the Social Construction of Illness Gregory M. Herek, Ph.D. John P. Capitanio, Ph.D. Keith F. Widaman, Ph.D. Department of Psychology University of California at Davis Note: This report is based on a paper published in 2003 in Health Psychology (volume 22, #5, pp. 533-540). Download a  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/healthpsych2003_pre.PDF" printer-friendly version of this report.  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/rainbow_small.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET CONTENTS  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "abstract" Abstract  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "background" Background  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "methods" Methods  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "results" Results  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "table1" Table 1: Distributions of Responses to Questions About Perceptions and Concerns Related to HIV Stigma  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "table2" Table 2: Support for Different Policies for Reporting Information About HIV-Positive Individuals  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "conclusions" Discussion HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "references" References HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "end_notes" End Notes   INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET ABSTRACT This study examined how illness-related stigma can be symbolically expressed through public attitudes toward health policies. Data from a 1999 national telephone survey with a probability sample of English-speaking US adults (N = 1,335) were used to assess how support for HIV surveillance policies is related to AIDS stigma and negative attitudes toward groups disproportionately affected by the epidemic. Anonymous reporting of HIV results to the government was supported by a margin of approximately 2-to-1, but name-based reporting was opposed 3-to-1. Compared to other respondents, supporters of name-based surveillance expressed significantly more negative feelings toward people with AIDS, gay men, lesbians, and injecting drug users. More than one third of all respondents reported that concerns about AIDS stigma would affect their own decision to be tested for HIV in the future. Implications for understanding the social construction of illness and for implementing effective HIV surveillance programs are discussed.   INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET BACKGROUND & RATIONALE In his account of 19th century cholera epidemics in the United States, historian Charles Rosenberg (1987) observed, "A disease is no absolute physical entity but a complex intellectual construct, an amalgam of biological state and social definition" (p. 5n). In the course of socially constructing an illness, symptoms are identified and the disease is named. Theories of origin, transmission, prevention, and cure are formulated, promulgated, criticized, and revised. Responsibility and blame often are assigned. Those who contract the disease come to be regarded as victims or patients, guilty or innocent, dangerous or benign, heroic or pitiable (Herek, 1990). Public health policy is created and implemented within this context, and efforts to track, treat, and prevent a disease are part of the latter's social construction. The social nature of illness is particularly evident with a stigmatized disease such as AIDS. Since the earliest days of the epidemic, people with AIDS (PWAs) and those suspected of being infected with HIV have been subjected to social ostracism, discrimination, and even violence (Gostin & Webber, 1998; Herek & Glunt, 1988; Herek, Mitnick, et al., 1998; Kegeles, Coates, Christopher, & Lazarus, 1989; Zierler et al., 2000). These reactions are rooted not only in fears of HIV transmission but also in the use of AIDS as a vehicle for expressing disapproval of the communities it disproportionately affects, especially gay people and injecting drug users, or IDUs (Capitanio & Herek, 1999; Herek, 2000; Herek & Capitanio, 1999a; Pryor, Reeder, & Landau, 1999). When a disease is stigmatized, public health policy can help to protect those who are ill from popular prejudice or it can promote discrimination against them. Examples of both uses of policy can be found in the history of the AIDS epidemic in the United States. Antigay and conservative political groups have often advocated policies that would seriously compromise the human rights of PWAs and members of at-risk minority groups under the guise of protecting public health. During the 1980s, for example, California voters were asked four times to enact sweeping AIDS policies that would have subjected PWAs to various public health restrictions. These initiatives included provisions to eliminate anonymous HIV testing, repeal legislation prohibiting employment discrimination on the basis of HIV status, and quarantine PWAs (Dannemeyer, 1989; Herek & Glunt, 1993; Krieger & Lashof, 1988). By contrast, the public health profession has recognized that fears of AIDS stigma and its attendant discrimination could deter people at risk for HIV from being tested, obtaining treatment, and seeking assistance with risk reduction (Chesney & Smith, 1999). Reflecting this concern, early AIDS-related public health policies in the United States included extraordinary protections for the privacy and confidentiality of PWAs and people at risk for HIV (Bayer, 1991). At the end of the twentieth century, however, many public health officials began to advocate changes in AIDS-related policies, especially in the area of HIV surveillance. AIDS has long been a reportable disease but, until relatively recently, asymptomatic HIV infection was not reported in most states. Historically, there were many reasons for this policy, including that HIV infection was often detected only when AIDS symptoms appeared, effective treatments were not available, and public health workers feared that mandatory reporting of the names of the infected would discourage high-risk individuals from being tested for HIV and thereby hamper prevention efforts (Bayer, 1999). During the 1990s, however, as treatment advances widened the time gap between initial infection and the appearance of symptoms, health officials recognized a need for monitoring new HIV infections in order to track the epidemic, allocate resources, and plan for the future. This need, coupled with beliefs that AIDS stigma had diminished and that anonymous reporting systems had only limited effectiveness, eventually led many influential public health authorities to support mandatory name-based reporting of new HIV infections (Gostin, Ward, & Baker, 1997; see generally Beckerman & Gelman, 2000; Centers for Disease Control and Prevention, 1999; Steinbrook, 1997). Opponents to such policies argued that fears of prejudice and discrimination still played a significant role in personal decisions to seek HIV testing and treatment, and that mandatory names reporting would deter many people from being tested (Aragn & Myers, 1999; Katz, 1998; "Privacy in H.I.V. reporting," 1997; Rotello, 1997; Woods, Binson, Morin, & Dilley, 1999). Burris (2000) attempted to reframe this debate by introducing the construct of social risk, which he defined as "the danger that an individual will be socially or economically penalized should he or she become identified with an expensive, disfavored, or feared medical condition" (p. S122). Social risk comprises both the objective threat of harm and the subjective perception of risk for harm. Burris (2000) noted that perceived risk often has little to do with objective probabilities of actual harm, but may play an important role in shaping responses to public health policies. This idea is consistent with Scambler's (1989) hidden distress model, which posits that shame and fear of discrimination (which he termed felt stigma) motivate individuals with a stigmatized condition to attempt to pass as members of the nonstigmatized majority. Successful passing reduces their likelihood of experiencing actual discrimination (enacted stigma) but significantly disrupts their lives and often increases their psychological distress. The constructs of social risk and felt stigma both highlight the important role played by the social climate in defining the behavioral options available to individuals with a stigmatized illness. Social risk and felt stigma are heightened to the extent that stigma is perceived to be widespread. The more strongly that specific illness-related policies are promoted by perpetrators of stigma, the greater the potential for members of the stigmatized group to react to those policies in terms of felt stigma. Public health authorities who began to advocate named reporting in the late 1990s clearly were not attempting to promote stigma, nor is it reasonable to believe that they had any malicious intent in promulgating new surveillance policies. Indeed, named reporting has many potential public health benefits (Gostin et al., 1997) and the objective risks associated with it are probably small (Burris, 2000). However, to the extent that a policy such as named reporting is linked with AIDS-related stigma in public perceptions, its adoption may heighten perceived risk among HIV-infected people and those at risk for infection. Debates about health policies such as HIV surveillance procedures, therefore, should be understood in the context of the ongoing social construction of AIDS as an illness. If a policy such as named reporting becomes widely perceived as an instrument of stigma, its adoption may increase the social risk experienced by people with HIV despite the best efforts of public health officials to reduce the likelihood of enacted stigma. This report uses survey data from a national probability sample to examine public perceptions of AIDS stigma, attitudes toward HIV surveillance policies, and relationships between the two. We hypothesize that: (a) the continuing existence of AIDS stigma is widely recognized among the US public, (b) concerns about stigma potentially affect decisions to be tested for HIV, and (c) public support for named reporting is strongest among those who are the most likely to stigmatize people with HIV and members of other groups symbolically linked to the epidemic, such as gay men, lesbians, and IDUs. To the extent that the data support these hypotheses, much of the perceived social risk associated with name-based HIV surveillance can be understood as reflecting an accurate assessment of the realities of AIDS-related stigma.   INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET METHOD Data were collected in a national telephone survey conducted between September 1998 and May 1999 by the Survey Research Center at the University of California at Berkeley, using their computer-assisted telephone interviewing system. Sample  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "end_notes" End note links are shown in hypertext. The sampling frame was the population of adults (> 18 years) residing in households with telephones in the 48 contiguous states. Within households, respondents were randomly selected from among the English-speaking adult residents. Data were collected simultaneously from two samples, both drawn with a list-assisted random-digit dialing (RDD) procedure (Casady & Lepkowski, 1993). One sample consisted of 666 respondents who had participated in a 1997 survey on AIDS stigma and consented to be recontacted for a follow-up interview.  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "Note1" (Note 1) The completion rate for follow-up interviews was 78%. The second sample consisted of 669 new respondents and had a response rate of 58% using AAPOR Response Rate Formula 2 (American Association for Public Opinion Research, 1998). The two samples did not differ in terms of gender (56% female for the combined samples), race and ethnicity (82% non-Hispanic White), education level (Median = some college or post-secondary education without a degree), or annual household income (Median = $40-50,000).  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "Note2" (Note 2) In preliminary analyses, the two samples were compared on items relevant to the present paper. Response distributions did not differ between the samples except for one item (noted below). Consequently, data from the samples were combined for the analyses reported here. More information about the sample and data collection procedures is reported elsewhere (Herek, 2002; Herek, Capitanio, & Widaman, 2002).  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET Measures Perceptions of HIV Stigma. Respondents were asked how much people with AIDS have been unfairly persecuted over the years whether they have faced "a great deal" of unfair persecution, "some," "a little bit," or "no unfair persecution at all." Next, they were asked whether people with AIDS now face a great deal of unfair persecution, some, a little bit, or no unfair persecution at all. Social Risk and HIV Testing. Respondents were asked whether they had ever been tested for HIV and, if so, their most recent test year and result. The next question was "If you were going to be tested in the future for some reason, how concerned would you be that you might be treated differently or discriminated against if your test result were to come out positive for the AIDS virus - very concerned, somewhat concerned, a little concerned, or not at all concerned?" They were then asked how much their level of concern (very concerned, etc.) would affect their decision to be tested.  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "Note3" (Note 3) Attitudes Toward HIV Surveillance Procedures. To assess the effect of type of surveillance policy (named versus anonymous) on support for HIV case reporting, we embedded a split-ballot experiment within the survey. Respondents were randomly assigned to answer one of three versions of a question about HIV case reporting.  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "Note4" (Note 4) Version 1 asked whether respondents would "favor or oppose a law that required doctors to report the names and addresses of anyone who tests positive for the AIDS virus to the federal government." Version 2 measured attitudes toward a "law that required doctors to report statistical information, but not names, about anyone who tests positive for the AIDS virus to the federal government." Version 3 was similar to Version 2, but added the proviso that "strict measures" would be taken "to preserve the privacy of those who test positive."  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "Note5" (Note 5) Attitudes Toward PWAs and Other Stigmatized Groups. Attitudes toward "people with AIDS," "men who are homosexual," "women who are lesbian or homosexual," and "people who inject illegal drugs" were measured with 101-point feeling thermometers (e.g., Herek & Capitanio, 1999b). Higher ratings indicate warmer, more favorable feelings toward the target whereas lower ratings reveal colder, more negative feelings.   INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  RESULTS Perceptions of AIDS Stigma The vast majority of the sample believed that people with HIV have been and continue to be targets of persecution (Table 1): 86% believed that PWAs faced "some" or "a great deal" of unfair persecution in the past, and 77% believed that such persecution continued in 1999. Most respondents (59%) gave the same response to both questions (e.g., "a great deal"). Of those whose responses to the two items differed, most (36% of the sample) perceived less stigma in the present. Their modal response pattern (evidenced by 23% of the sample) was that PWAs faced "a great deal" of persecution in the past and "some" persecution in the present. Only 6% perceived more stigma in the present than the past. Social Risk and HIV Testing Slightly more than half of the sample (52%) reported having been tested for HIV. Most had been tested once (33% of those tested) or twice (21%); 12% had been tested 10 times or more. About half of those tested (51%) reported that their most recent test was in the previous 2 years, whereas 11% had not been tested since 1991. No respondents reported a positive test result. As shown in Table 1, most respondents would be "very concerned" (39%), "somewhat concerned" (29%), or "a little concerned" (15%) about being stigmatized if they were to test positive in the future.  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "Note6" (Note 6) Table 1 also shows that such concerns would affect the actual decisions of less than half of the respondents who felt them. Of those reporting any concern about being stigmatized, 56% said it would have no effect on their decision to be tested. The remainder reported that their concerns would affect their decision "a great deal" (13%), "some" (19%), or "a little" (12%). In the total sample, 37% of all respondents indicated that their decision to be tested for HIV would be affected to some extent by concerns about stigma. Table 1 Distributions of Responses to Questions About Perceptions and Concerns Related to HIV Stigma  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  Item/Responses % PWAs unfairly persecuted in past? A great deal 44.1 Some 41.6 A little bit 9.8 Not at all 3.1 PWAs unfairly persecuted now? A great deal 21.9 Some 55.3 A little bit 17.4 Not at all 4.3 How concerned about stigma if tested positive? Very concerned 38.7 Somewhat concerned 29.2 A little concerned 15.4 Not at all concerned 15.4 Effect of concern on decision to be tested? (asked only of those who reported any concern about being stigmatized if they were to test positive) A great deal 13.1 Some 19.0 A little 12.1 No effect 55.8 Note. Percentages do not sum to 100% because of "Don't know" responses and refusals.  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET Attitudes Toward HIV Surveillance As shown in Table 2, attitudes toward surveillance strategies were significantly affected by whether seropositive individuals' names would be reported (Version 1 of the question) or not (Versions 2 and 3). Only about one fourth of respondents who were asked about name-based reporting supported it. By contrast, those who were asked about anonymous reporting supported it by margins of roughly 2-to-1. The difference between support for named reporting (Version 1) and anonymous reporting (Versions 2 and 3) was highly reliable, as indicated by the wide gaps (more than 30 percentage points) between 95% confidence intervals (CIs) shown in Table 2. Support for the various types of HIV surveillance did not differ significantly by whether respondents had themselves been tested for HIV. Although most respondents believed that people with AIDS faced persecution, this belief was significantly less likely to be expressed by supporters of name-based reporting than by supporters of anonymous reporting: 72.5% of those who favored name-based reporting perceived that PWAs faced "some" or "a great deal" of persecution in the past, versus 85.3% of those who supported anonymous reporting and 87.3% of those who supported anonymous reporting with strong privacy protections, chi-square (2, N = 711) = 12.72, p < .01. The proportions perceiving that PWAs currently faced persecution were, respectively, 59.8% versus 78.6% and 75.8%, chi-square (2, N = 712) = 14.95, p < .001. Among those opposed to reporting, no significant differences were observed across experimental conditions for the proportions perceiving that PWAs were persecuted in the past (range = 87.4% to 91.9%) or currently (range = 81.1% to 84.2%).  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET Table 2 Support for Different Policies for Reporting Information About HIV-Positive Individuals  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  Item Version % Support Confidence Interval (95%) Names reporting (n = 417) 24.7 20.6 28.8 Statistical information only (n = 478) 71.5 67.5 75.5 Statistical information with privacy safeguards (n = 423) 64.1 59.5 68.7 Note. Table excludes 17 refusals and "Don't know" responses, which were distributed nearly equally across the three item versions.  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET Correlates of Support for Name-Based Reporting  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_figures.html" \l "Fig1" Figure 1 (PWAs)  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_figures.html" \l "Fig2" Figure 2 (gay men)  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_figures.html" \l "Fig3" Figure 3 (lesbians)  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_figures.html" \l "Fig3" Figure 4 (IDUs) Figures 1-4 show thermometer means for respondents opposing and supporting each surveillance policy, with 95% confidence intervals depicted by error bars.  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "Note7" (Note 7) Differences between groups are significant (p < .05) when CIs do not overlap. Although the magnitude of thermometer scores varied across targets, a consistent pattern emerged: Supporters of name-based reporting gave significantly lower ratings (more negative attitudes) for all targets than did opponents of name-based reporting. Indeed, for PWAs ( HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_figures.html" \l "Fig1" Figure 1), gay men ( HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_figures.html" \l "Fig2" Figure 2), and lesbians ( HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_figures.html" \l "Fig3" Figure 3), supporters of name-based reporting gave significantly lower ratings than all other respondents. The point-estimate of their ratings of IDUs was also the lowest ( HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_figures.html" \l "Fig3" Figure 4), but the CIs overlapped with three of the five other respondent groups. Across the other five response groups (i.e., excluding supporters of named reporting), thermometer scores did not differ significantly for any of the targets, as indicated by the overlapping CIs. DISCUSSION The findings help to illuminate the social milieu in which U.S. adults perceived public health policy and made decisions about getting tested for HIV at the end of the 20th century. Clearly, AIDS was widely regarded as a stigmatized disease although about one third of the public believed that the level of stigma was lower than in the past. More than three fourths of respondents believed that PWAs continued to experience more than incidental persecution. Given this perception, it is not surprising that most would be concerned about being stigmatized if they themselves were to test positive for HIV in the future. For more than one third, such concern would affect their decision to be tested. The public's concerns about stigma provide a context for interpreting their attitudes toward HIV surveillance policies. Clear majorities of respondents supported anonymous case reporting but opposed name-based reporting, which suggests that widespread opposition to name-based reporting reflected concerns about privacy and stigma rather than opposition to reporting per se. Support for anonymous testing was somewhat lower when the question stipulated that privacy would be protected than when such protections were not mentioned, although the difference in responses to the two items was not statistically significant. We suspect that the mere fact that the Version 3 question mentioned privacy raised respondents' concerns about this issue and made them somewhat more reluctant to endorse even anonymous reporting. Compared to other respondents, supporters of name-based reporting perceived AIDS stigma to be less extensive and they expressed more negative attitudes toward PWAs and other groups associated with HIV in popular perceptions (gay men, lesbians, IDUs). Only attitudes toward IDUs overlapped between supporters of name-based surveillance and other respondents, which may reflect the generally negative ratings that all respondents gave to IDUs. These patterns reveal a clear association between support for name-based reporting and AIDS-related stigma, and are consistent with the interpretation that the former was a proxy for the latter. The link between AIDS stigma and support for name-based reporting highlights a potential impediment to effective implementation of a national name-based surveillance policy. Such a policy may evoke anxiety and encounter resistance to the extent that it is perceived as insensitive to - or even fostering - preexisting AIDS stigma. The accurate perception that people who stigmatize PWAs also support name-based reporting may have created widespread suspicion about such reporting through a kind of guilt by association. Such concerns are especially likely in communities with a strong collective memory for the previously mentioned ballot initiatives and other past attempts to enforce AIDS-related stigma through health policy. They are probably strongest in communities with members whose behavior places them at higher risk for HIV infection than was typical of respondents in the present sample, such as the gay male community (Woods, Binson, et al., 1999; Woods, Dilley, et al., 1999). Even if many individuals in those communities are unaware of the surveillance policies in effect in their home state (as is probably the case for most people; Hecht et al., 2000), community norms may foster a heightened sense of social risk in response to policies that are perceived to be linked to stigma. The survey findings highlight the ways in which the stigma associated with a disease or the groups affected by it can influence public attitudes toward health policy. Historical examples abound of stigma interfering with effective collective response to diseases ranging from cholera to syphilis (Brandt, 1987; Rosenberg, 1987). In all of these cases, the social construction of the illness incorporated moral judgments about the circumstances in which it was contracted as well as preexisting hostility toward the groups perceived to be most affected by it. Such constructions can contribute substantially to the social risk and felt stigma associated with a disease and, consequently, influence the behavior of individuals at risk for contracting it. The data reported here were collected in 1999, at the height of a national debate about named reporting policies. Because of the passage of time since the survey was completed, we have described the present findings in historical terms. However, the issue of HIV surveillance policies remains controversial. Whereas a majority of states have implemented a named reporting policy, California, the nation's most populous state, has not. Instead, reflecting concerns about the impact of stigma on testing, California and several other states use anonymous identifiers to report new HIV infections (Heredia, 2002). Moreover, given the substantial differences we found between attitudes toward named reporting versus anonymous reporting, as well as the strong association between support for named reporting and negative attitudes toward PWAs and other groups, it seems unlikely that attitudes toward surveillance policies have reversed themselves since the survey was completed. Public health officials have acknowledged the need for safeguarding confidentiality in HIV surveillance (Centers for Disease Control and Prevention, 1999). The present study underscores the importance of working actively to allay public concerns about stigma and possible suspicions about HIV reporting policies. To be effective, surveillance policies should not only include stringent confidentiality safeguards but should also make the public aware of those safeguards and of public health professionals' ongoing commitment to eradicating AIDS stigma and discrimination. This commitment could be demonstrated by initiation of explicit antistigma campaigns related to HIV at the national, state, and local levels. In addition, the public health establishment's credibility with key groups affected by the epidemic (whose cooperation is vital to the success of HIV surveillance programs) would be enhanced by taking strong, well-publicized stands against the ongoing stigmatization of those groups. Given the strong linkage in the United States between AIDS stigma and negative attitudes toward gay and bisexual men (e.g., Herek & Capitanio, 1999a), it may be especially important for the public health community to initiate and promote programs to combat sexual prejudice and discrimination against gay, lesbian, and bisexual people. In the early years of the AIDS epidemic, health workers and researchers were able to enlist support from affected groups, in part because of their willingness to distance themselves from government policies that were hostile and discriminatory toward those groups. As the epidemic continues, successful collaborations between affected communities and public health professionals will continue to depend on the latter's willingness to publicly oppose laws, policies, and individuals that are perceived as perpetuating stigma.   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Centers for Disease Control and Prevention. (1999). Guidelines for national human immunodeficiency virus case surveillance, including monitoring for human immunodeficiency virus infection and acquired immunodeficiency syndrome. Morbidity and Mortality Weekly Report, 48(RR-13), 1-35. Chesney, M. A., & Smith, A. W. (1999). Critical delays in HIV testing and care: The potential role of stigma. American Behavioral Scientist, 42, 1162-1174. Dannemeyer, W. (1989). Shadow in the land: Homosexuality in America. San Francisco: Ignatius Press. Gostin, L. O., Ward, J. W., & Baker, A. C. (1997). National HIV case reporting for the United States: A defining moment in the history of the epidemic. New England Journal of Medicine, 337, 1162-1167. Gostin, L. O., & Webber, D. (1998). The AIDS litigation project: HIV/AIDS in the courts in the 1990s, part 2. AIDS and Public Policy Journal, 13, 3-19. Hecht, F. M., Chesney, M. A., Lehman, J. S., Osmond, D., Vranizan, K., Colman, S., Keane, D., Reingold, A., Bindman, A. B., & MESH Study Group. (2000). Does HIV reporting by name deter testing? AIDS, 14, 1801-1808. Heredia, C. (2002, July 1). California to track HIV cases by code. San Francisco Chronicle, pp. A1, A8. Herek, G. M. (1990).  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/bibabs.html" \l "abs90g" Illness, stigma, and AIDS. In P.T. Costa, Jr. & G.R. VandenBos (Eds.), Psychological aspects of serious illness: Chronic conditions, fatal diseases, and clinical care (pp. 107-150). Washington, DC: American Psychological Association. Herek, G. M. (2000).  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/bibabs.html" \l "abs2000a" \t "reporting" The social construction of attitudes: Functional consensus and divergence in the US public's reactions to AIDS. In G.R. Maio & J.M. Olson (Eds.), Why we evaluate: Functions of attitudes (pp. 325-364). Mahwah, NJ: Lawrence Erlbaum. Herek, G. M. (2002).  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/bibabs.html" \l "abs2001a" \t "reporting" Gender gaps in public opinion about lesbians and gay men. Public Opinion Quarterly, 66, 40-66. Herek, G. M., & Capitanio, J. P. (1999a).  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/bibabs.html" \l "abs99b" \t "reporting" AIDS stigma and sexual prejudice. American Behavioral Scientist, 42, 1130-1147. Herek, G. M., & Capitanio, J. P. (1999b).  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/bibabs.html" \l "abs99e" \t "reporting" Sex differences in how heterosexuals think about lesbians and gay men: Evidence from survey context effects. Journal of Sex Research, 36, 348-360. Herek, G. M., Capitanio, J. P., & Widaman, K. F. (2002).  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/bibabs.html" \l "abs2002a" \t "reporting" HIV-related stigma and knowledge in the United States: Prevalence and trends, 1991-1999. American Journal of Public Health, 92, 371-377. Herek, G. M., & Glunt, E. K. (1988).  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/bibabs.html" \l "abs88a" \t "reporting" An epidemic of stigma: Public reactions to AIDS. American Psychologist, 43, 886-891. Herek, G. M., & Glunt, E. K. (1993). Public attitudes toward AIDS-related issues in the United States. In J.B. Pryor & G.D. Reeder (Eds.), The social psychology of HIV infection (pp. 229-261). Hillsdale, NJ: Lawrence Erlbaum. Herek, G. M., Mitnick, L., Burris, S., Chesney, M., Devine, P., Fullilove, M. T., Fullilove, R., Gunther, H. C., Levi, J., Michaels, S., Novick, A., Pryor, J., Snyder, M., & Sweeney, T. (1998).  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/bibabs.html" \l "abs98c" \t "reporting" AIDS and stigma: A conceptual framework and research agenda. AIDS and Public Policy Journal, 13(1), 36-47. Katz, M. (1998, September 28). Names will never hurt? In HIV reporting, they can. San Francisco Examiner, p. A-17. Kegeles, S. M., Coates, T. J., Christopher, T. A., & Lazarus, J. L. (1989). Perceptions of AIDS: The continuing saga of AIDS-related stigma. AIDS, 3(Suppl 1), S253-S258. Krieger, N., & Lashof, J. C. (1988). AIDS, policy analysis, and the electorate: The role of schools of public health. American Journal of Public Health, 78, 411-415. Privacy in H.I.V. reporting. (1997, October 24). New York Times, p. A18. Pryor, J. B., Reeder, G. D., & Landau, S. (1999). A social-psychological analysis of HIV-related stigma: A two-factor theory. American Behavioral Scientist, 42, 1193-1211. Rosenberg, C. E. (1987). The cholera years: The United States in 1832, 1849, and 1866. Chicago: University of Chicago Press. Rotello, G. (1997, August 22). AIDS is still an exceptional disease. New York Times, p. A19. Scambler, G. (1989). Epilepsy . London: Routledge. Steinbrook, R. (1997). Battling HIV on many fronts. New England Journal of Medicine, 337, 779-781. U.S. Census Bureau. (2002) United States Census 2000 [Web Page]. URL http://www.census.gov/main/www/cen2000.html [2002, November 15]. Woods, W. J., Binson, D., Morin, S., & Dilley, J. W. (1999). HIV testing after implementation of name-based reporting (Letter). Journal of the American Medical Association, 281, 1378. Woods, W. J., Dilley, J. W., Lihatsh, T., Sabatino, J., Adler, B., & Rinaldi, J. (1999). Name-based reporting of HIV-positive test results as a deterrent to testing. American Journal of Public Health, 89, 1097-1100. Zierler, S., Cunningham, W. E., Andersen, R., Shapiro, M. F., Bozzette, S. A., Nakazono, T., Morton, S., Crystal, S., Stein, M., Turner, B., & St. Clair, P. (2000). Violence victimization after HIV infection in a US probability sample of adult patients in primary care. American Journal of Public Health, 90, 208-215.   INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/dot_clear.gif" \* MERGEFORMATINET END NOTES 1. For more details about the 1997 survey, see Capitanio & Herek, 1999; Herek & Capitanio 1999a, 1999b; Herek et al., 2002).  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "fn1" (return to text) 2. By comparison, the US adult population was approximately 52% female and 72% non-Hispanic White, with a median educational level of some college (no degree) and a median 1999 household income of approximately $42,000 (U.S. Census Bureau, 2002). Thus, the sample somewhat overrepresented women and non-Hispanic Whites.  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "fn2" (return to text) 3. The questions about future HIV testing were designated only for respondents who did not report having already tested positive for HIV. Because no respondents had tested positive, all of them were asked the follow-up questions.  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "fn3" (return to text) 4. A randomization check showed that respondents in the three experimental conditions did not differ significantly on gender, race, age, educational level, marital status, geographic residence, employment status, religiosity, and political party.  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "fn4" (return to text) 5. The three versions of the HIV-surveillance item were worded as follows: Version 1. Names Reporting: "Some people think that doctors should be legally required to report the names and addresses of anyone who tests positive for the AIDS virus to the federal government, so that a central list of these people could be made and better statistics could be kept on the AIDS epidemic. Other people oppose this kind of law because they think that such reporting would expose those who test positive to discrimination and would actually discourage many people from getting tested for AIDS. How about you? Would you favor or oppose a law that required doctors to report the names and addresses of anyone who tests positive for the AIDS virus to the federal government?" Version 2. Statistical Information Only: "Some people think that doctors should be legally required to report the age, sex, and other statistical information about anyone who tests positive for the AIDS virus to the federal government, so that better statistics could be kept on the AIDS epidemic. Other people oppose this kind of law because they think that such reporting would expose those who test positive to discrimination and would actually discourage many people from getting tested for AIDS. How about you? Would you favor or oppose a law that required doctors to report statistical information, but not names, about anyone who tests positive for the AIDS virus to the federal government?" Version 3. Statistical Information with Privacy Safeguards: "Some people think that doctors should be legally required to report the age, sex, and other statistical information about anyone who tests positive for the AIDS virus to the federal government, with strict measures taken to preserve the privacy of those who test positive. Other people oppose this kind of law because they think that no matter how hard the government tries to protect people's privacy, such reporting would still expose those who test positive to discrimination and would actually discourage many people from getting tested for AIDS. How about you? Would you favor or oppose a law that required doctors to report statistical information, but not names, about anyone who tests positive for the AIDS virus to the federal government, with strict measures taken to preserve the privacy of those who test positive?" The wording of  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS%20Stigma%20Items%201999.pdf" other AIDS-stigma items in the survey can be downloaded in PDF format.  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "fn5" (return to text) 6. This was the only item for which significant differences were observed between subsamples. Respondents in the follow-up sample were significantly less likely than those in the new RDD sample to be "very concerned" at the prospect of stigma if they tested positive for HIV (35% vs. 44%, respectively) and more likely to report that they would not be concerned at all (18% vs. 13%, chi-square [3, n = 1318] = 11.99, p < .01).  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "fn6" (return to text) 7. These analyses excluded 92 respondents who believed it was "very likely" that they were HIV-positive; described themselves as lesbian, gay, or bisexual, or declined to report their sexual orientation; or reported having ever injected illegal drugs or declined to answer the injecting drugs question. These exclusions of target group members left an effective sample of n = 1243.  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/AIDS_names_reporting_paper.html" \l "fn7" (return to text)   INCLUDEPICTURE "http://psychology.ucdavis.edu/rainbow/assets/images/rainbow_big.gif" \* MERGEFORMATINET  HYPERLINK "http://psychology.ucdavis.edu/rainbow/index.html" Home |  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/hate_crimes.html" Hate Crimes |  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/aids.html" AIDS |  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/sacramento_study.html" Sacramento |  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/facts.html" The Facts |  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/military.html" Military |  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/sexual_prejudice.html" Sexual Prejudice  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/contents.html" Contents |  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/bibliography.html" Publications |  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/library.html" Library |  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/search_page.html" Web Search |  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/contact.html" Contact Us |  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/useful_links.html" Useful Links |  HYPERLINK "http://psychology.ucdavis.edu/rainbow/html/hookerprograms.html" APF Awards All original content of this website is copyright 1997-2006 by Gregory M. Herek, Ph.D. All rights reserved   HYPERLINK "http://www.deathreference.com/forum/" Black Death forum  HYPERLINK "http://www.deathreference.com/index.html" Encyclopedia of Death and Dying ::  HYPERLINK "http://www.deathreference.com/Bl-Ce/index.html" Bl-Ce BLACK DEATH The Black Death pandemic of 1349 is considered to be one of the major events in world history, and it is still the subject of medical, historical, and sociological analysis. The evidence of the plague is found in the broad swath it cut across North Africa, Asia, and Europe, its terrifying symptoms, and its impact on society. History of the Disease Ancient history includes vivid descriptions of epidemics that seized their victims suddenly and produced an agonizing death. One such episode occurred in Athens, Greece, in 430 B.C.E., and another occurred in Egypt, Persia, and Rome a century later. Some historians believe these lethal outbreaks were caused by the same disease responsible for the Black Deaththe bubonic plague. Other historians, though, note some differences between the symptoms observed in the ancient episodes and those reported during the fourteenth century. The growth of international trade and military invasions later provided the opportunity for diseases to spread rapidly from one population to another. Smallpox and measles came first, both causing high mortality within populations that had not previously been exposed. Bubonic plague arrived in force in the sixth century C.E., raging throughout most of Arabia, North Africa, Asia, and Europe. The death toll from what became known as "Justinian's Plague" was even greater than that of the previous epidemics. The powerful and still expanding Byzantine empire, centered in Constantinople (now Istanbul, Turkey), was so devastated that its political and military power sharply declined. The plague did not entirely disappear but entered a long phase of withdrawal with occasional local outbreaks, especially in central Asia. When it did return it was with a furious rush that created widespread panic in populations already beset with both natural and human-made disasters. The fourteenth century suffered an entire catalog of catastrophes, including earthquakes, fires, floods, freezing weather, nauseating mists, and crop failuresall of which did not even seem to slow down the incessant warfare and banditry. Social order was weakened under the stress, and a hungry and exhausted population became more vulnerable to influenza and other opportunistic diseases. It was within this already precarious situation that the plague once again crossed into Europe. There had been rumors about a deadly new epidemic sweeping through the Middle East, probably starting in 1338. The plague had taken hold among the Tartars of Asia Minor. Somebody had to be blamedin this case, the Christian minority. (Later, as the plague devastated Europe, Jews were not only blamed but burned alive.) The Tartars chased Genoese merchants to their fortified town (now Feodosiya, Ukraine, then Kaffa) on the Crimean coast. The besieging army soon was ravaged by the plague and decided to leave. As a parting shot, the Tartars used catapults to hurl plague-infected corpses over the city walls. Some residents died almost immediately; the others dashed for their galleys (a type of oar-propelled ship) and fled, taking the disease with them. Sicily and then the rest of Italy were the earliest European victims of the plague. It would spread through almost all of Europe, wiping out entire villages and decimating towns and cities. It is estimated that a third of the European population perished during the Black Death. The death toll may have been as high or even higher in Asia and North Africa, though less information is available about these regions. The world was quickly divided between the dead and their frequently exhausted and destitute mourners. The Disease and How It Spread As for the disease itself the bacterial agent is Yersinia pestis. It is considered to have permanent reservoirs in central Asia, Siberia, the Yunan region of China, and areas of Iran, Libya, the Arabian Peninsula, and East Africa. Yersinia pestis infects rodents, producing blood poisoning. Fleas that feed on the dying rodents carry the highly toxic bacteria to the next victimperhaps a human. Among the first symptoms in humans were swollen and painful lymph glands of the armpit, neck, and groin. These swellings were known as buboes, from the Greek word for "groin." Buboes became dreaded as signals of impending death. Occasionally these hard knobs would spontaneously burst, pus would drain away and the victim might then recover if not totally exhausted or attacked by other infections. More often, however, the buboes were soon accompanied by high fever and agony. Sometimes the victim died within just a few hours; others became disoriented and either comatose or wildly delirious. Another symptom perhaps even more certain than the buboeswas the appearance of postules, or dark points on various parts of the body. These splotches were most often called lenticulae, from the Italian word for "freckles." Medical historians believe that the plague can spread in several ways but that it was the pneumonic or respiratory form that accounted for most of the deaths, being easily spread through coughing and sneezing. An interesting alternative was suggested in 1984 by the zoologist Graham Twigg, who had studied rat populations in more recent outbreaks of the plague in Asia. He doubts that the bubonic plague could have spread so rapidly in the fourteenth-century population; instead he nominates anthrax as the killer. Anthrax can be borne on the wind; it is known as a threat to sheep, goats, cattle, and pigs. Both plague and anthrax, then, are primarily found in animal populations, with humans becoming "accidental" victims under certain conditions. Whatever its specific cause or causes, the Black Death killed until it ran out of large numbers of vulnerable people. There have been subsequent plague epidemics, some also with high death tolls, and public health authorities continue to monitor possible new occurrences. Impact on Society Historians often divide European history into periods before and after the plague. There are several persuasive reasons for doing so. First, the population declined sharplyand then rebounded. Both the loss and the replenishment of the population had significant effects on all aspects of society, from agriculture to family structure to military adventuring. Second, influential writers, such as the English clergyman Thomas Malthus (17661834), would propose that overpopulation produces its own remedy through epidemic, famine, and other means. Some areas of Europe might have been considered ripe for mass death because agricultural production had not kept up with population growth. The overpopulation theory has been criticized as inadequate to explain the catastrophic effects of the Black Death. Nevertheless, concerns about overpopulation in more recent times were foreshadowed by analyses of the plague years. Third, feudalismthe political and social structure then prevalent in Europemay have been the underlying cause of the mass mortality. A few people had everything; most people had very little. Those born into the lower classes had little opportunity for advancement. This situation perpetuated a large underclass of mostly illiterate people with limited skills, thereby also limiting technological and cultural progress. Furthermore, the feudal system was showing signs of collapsing from within in the years preceding the Black Death. In his 1995 book The Black Death and the Transformation of the West, David Herlihy explained: The basic unit of production was the small peasant farm, worked with an essentially stagnant technique. The only growth the system allowed was . . . the multiplication of farm units . . . subject to the law of diminishing returns. As cultivation extended onto poorer soils, so the returns to the average family farm necessarily diminished. . . . As peasant income diminished, they paid lower and lower rents. . . . The lords took to robbery and pillage . . . and also hired themselves out as mercenaries . . . and pressured their overlords, notably the king, to wage wars against their neighbors. (Herlihy 1995, p. 36) The almost continuous wars of the Middle Ages were attempts by hard-pressed nobles to snatch wealth from each other as well as grab whatever the peasants had left. The decline and crisis of the feudal system, then, probably did much to make people especially vulnerable to the plague, while the aftereffects of the plague would make feudal society even more of a losing proposition. Fourth, loosely organized and short-lived challenges to authority arose from shifting coalitions of peasants and merchants. People laboring in the fields started to make demands, as though they toonot just the high and mightyhad "rights." Heads of state would remember and remain nervous for centuries to come. Finally, the devastating and immediate impact of the Black Death prepared the way for a reconstruction of society. Deserted towns and vacant church and governmental positions had to be filled with new people. At first the demand was specific: more physicians, more clergy, andof special urgencymore gravediggers were needed. The demand for new people to move into key positions throughout society opened the door for many who had been trapped in the ancient feudal system. It was also a rare opportunity for women to be accepted in positions of responsibility outside of the home (e.g., as witnesses in court proceedings). People who lacked "social connections" now could find more attractive employment; merit had started to challenge social class membership. These developments fell far short of equality and human rights as understood today, but they did result in significant and enduring social change. Long-term Influences of the Plague The plague years enabled European society to shake off the feudal system and make progress on many fronts. Death, however, had seized the center of the human imagination and would not readily ease its grip. The imagination had much to  INCLUDEPICTURE "http://www.deathreference.com/images/medd_01_img0013.jpg" \* MERGEFORMATINET  In this drawing, Saint Borromeo assists plague victims. In its most lethal periods, the ancient epidemicwhatever its causekilled as many as four out of ten people in the areas affected. BETTMANN/CORBIS work on. Daily experience was saturated with dying, death, and grief. Religious belief and practice had given priority to helping the dying person leave this world in a state of grace and to providing a proper funeral with meaningful and comforting rituals. This tradition was overstressed by the reality of catastrophic death: too many people dying too quickly with too few available to comfort or even to bury them properly. Furthermore, the infectious nature of the disease and the often appalling condition of the corpses made it even more difficult to provide the services that even basic human decency required. Fear of infection led many people to isolate themselves from others, thereby further contributing to social chaos and individual anxiety and depression. The fear for one's own life and the lives of loved ones was rational and perhaps useful under the circumstances. Rational fear, however, often became transformed into panic, and at times panic led to rage and the adoption of bizarre practices. Some extremists became flagellants, whipping their bodies bloody as they marched from town to town, proclaiming that the plague was a well-deserved punishment from God. Others took the lead in persecuting strangers and minorities as well as those unfortunates who were perceived as witches. As though there was not enough death ready at hand, innocent people were slaughtered because somebody had to be blamed. Medieval medicine was not equal to the challenge of preventing or curing the plague, so there was a ready market for magic and superstition. A personified Death became almost a palpable presence. It was almost a relief to picture death as a person instead of having to deal only with its horrifying work. Personified Death appeared as the leader in the Danse Macabre (the Dance of Death), and as "poster boy" for the Ars Moriendi (the art of dying) movement. (The now-familiar skull-andcrossbones image was highly popular, showing up, for example, on rings adorning the fingers of both prostitutes and ladies of high social standing.) Portraying Death as an animated skeleton was not entirely new; there are surviving images from ancient Pompeii as well. Depictions of Death as skeleton, corpse, or hooded figure, however, had their heyday during the plague years. This connection is not difficult to understand when one considers that social disorganization under the stress of the Black Death had severely damaged the shield that had protected the living from too many raw encounters with the dead. Did another tradition also receive its impetus from the plague years? Throughout the post-Black Death years there have been people who identify themselves with death. The Nazi and skinhead movements provide ready examples. One way of trying to cope with overwhelming aggression is to identify with the aggressor, so perhaps this is one of the more subtle heritages of the Black Death. Furthermore, the fear that death is necessarily agonizing and horrifying may also owe much to the plague years and may have played a role in the denial of death and the social stigma attached to dying. See also:  HYPERLINK "http://www.deathreference.com/A-Bi/Ars-Moriendi.html" ARS MORIENDI;  HYPERLINK "http://www.deathreference.com/Ce-Da/Christian-Death-Rites-History-of.html" CHRISTIAN DEATH RITES, HISTORY OF;  HYPERLINK "http://www.deathreference.com/Ce-Da/Danse-Macabre.html" DANSE MACABRE;  HYPERLINK "http://www.deathreference.com/Da-Em/Death-System.html" DEATH SYSTEM;  HYPERLINK "http://www.deathreference.com/Nu-Pu/Personifications-of-Death.html" PERSONIFICATIONS OF DEATH;  HYPERLINK "http://www.deathreference.com/Nu-Pu/Public-Health.html" PUBLIC HEALTH Bibliography Aris, Phillipe. The Hour of Our Death. New York: Knopf, 1981. Calvi, Giulia. Histories of a Plague Year. Berkeley: University of California Press, 1989. Cohen, Samuel K., Jr. The Cult of Remembrance and the Black Death in Six Central Italian Cities. Baltimore, MD: Johns Hopkins University Press, 1997. Geary, Patrick J. Living with the Dead in the Middle Ages. Ithaca, NY: Cornell University Press, 1994. Gottfried, Robert S. The Black Death. New York: Free Press, 1983. Herlihy, David. The Black Death and the Transformation of the West. Cambridge, MA: Harvard University Press, 1995. Malthus, Thomas. An Essay on the Principle of Population. Hammondsworth: Penguin, 1970. Platt, Colin. King Death: The Black Death and Its Aftermath in Late-Medieval England. Toronto: University of Toronto Press, 1997. Tuchman, Barbara W. A Distant Mirror. New York: Knopf, 1978. Twigg, Graham. The Black Death: A Biological Reappraisal. London: Batsford, 1983. Fears of disease, often coupled with ignorance, have led to horrifying treatment of the afflicted. Outbreaks of plague in Europe were often blamed on Jews, who were beaten and driven from their homes. During an epidemic in 17th-century Italy, people suspected of being carriers of the plague were tortured and burned alive. Through the ages people with leprosy were often isolated in leper houses, forbidden to marry, and forced to wear a distinctive cloak or shake a rattle to announce their presence. Even in supposedly advanced cultures, the stigma of disease remains. In recent years, people with AIDS have heard that their illness was God's punishment for immoral behavior. Many have been ostracized by family, friends, and even physicians who are fearful of contagion. People with AIDS have also been denied housing, medical treatment, and the right to travel to foreign countries. ==  HYPERLINK "http://www.hospitalconnect.com/hospitalconnect/index.jsp"  INCLUDEPICTURE "http://www.hhnmag.com/common/admin/usradmin/images/logo.gif" \* MERGEFORMATINET    The Quiet Epidemic How MENTAL DISORDERS affect health care in ways you don't realize By Gloria Shur Bilchik Monday November 15, 2004 If you had to list the three medical conditions that account for the fastest rise in health care spending in the United States, which would you name? Heart disease? Right. Lung disease? Right again. But would your third choice be mental health? It should be. A report published in Health Affairs in August reveals that spending for mental disorders ranks third among the top 15 most expensive medical conditions. In fact, according to the report, expenditures for mental disorders nearly doubled between 1987 and 2000--an increase that surprised even the researchers. "We usually expect rising expenditures to be driven by advancing technologies and medications," says the study's principal author, Kenneth Thorpe, of Emory University's Rollins School of Public Health, Atlanta. "In this instance, the increase in mental health spending comes from a rise in the number of patients who report a condition and get treatment." The technical term for that phenomenon is "treatment prevalence." Couple it with the ever-expanding cornucopia of psychotropic medications on the market, add in inexorably rising costs of insurance and physicians' fees, plus the estimated $63 billion annual cost in loss of productivity from mental illness and you have an unmistakable trend. In fact, according to the World Health Organization, mental illness tops all other diseases as a cause of disability in the United States, Canada and Western Europe, accounting for 25 percent of all disability. But while overall spending is up, there's still a long way to go in diagnosing and treating mental disorders. Longer still is the journey toward social acceptance and equitable allocation of funds, say researchers, doctors, policy-makers and health care executives. "Most health care leaders and caregivers are aware of the problems created in their ERs by psychotic people with no place else to go," says Dennis King, CEO, Spring Harbor Hospital, a not-for-profit psychiatric facility in Westbrook, Maine. "CEOs are the ones who get the phone calls in the morning describing the backlog in the ER the night before." Most health care leaders also are familiar with the disparity in insurance coverage for general medical care and mental health care. But other facets of the mental health picture remain largely unacknowledged and widely misunderstood. Ignorance is Costly Treating mental disorders is an expensive business, as any insurer will tell you. But the cost of untreated mental disorders is equally significant. Researchers generally agree that as many as one-third to one-half of patients seen by primary care doctors have some type of undiagnosed mental disorder that impacts their health. Although there's less data on mental disorders in the general hospitalized population, some researchers estimate that the prevalence is equal or even higher, particularly at the time of admission. Unrecognized depression is the most common disorder, purported to affect 40 million Americans each year. And there's increasing evidence that depression complicates other conditions, such as heart disease, cancer and diabetes, thus adding to the cost of treatment. "Many patients come in to the office complaining of chronic pain, headaches, or just generally not feeling well," says Donald Nease, M.D., of the University of Michigan Health System, Ann Arbor. "You're the third, or fourth or fifth doctor they've seen. They've had multiple invasive and expensive procedures, but no one has found anything. After they've been referred for so many tests, they're convinced that it's a medical problem, so it's hard to open up a discussion about depression or anxiety." Long discredited is the notion that ailments reported by such patients are merely "in their heads." In fact, contemporary medical literature asserts that physical symptoms often are generated by mental illness. Recent studies indicate that more than 50 percent of patients reporting fatigue and more than 30 percent of those reporting chest pain have a psychosocial problem. Plus, there's solid evidence that treating mental illness can alleviate physical symptoms. But when depression, anxiety and other mental illnesses go unrecognized, they can balloon into larger, chronic problems with big price tags. Some studies suggest that depressed patients visit their doctors twice as often as people without mental disorders and generate vast amounts of testing and utilization. Untreated psychiatric illnesses have been shown to worsen many chronic conditions, including arthritis, asthma and diabetes. Undiagnosed anxiety disorders can result in symptoms that mimic those of other illnesses, such as stomach ailments and heart disease. "Huge amounts of health care dollars are spent on vague aches and pains, back trouble, stomach distress, headaches and other complaints that amount to very little as physical problems, despite expensive and unnecessary workups," says Elizabeth Berger, M.D., a psychiatrist based in Elkins Park, Pa. "The patient's distress is actually related to emotional pressures, stress, interpersonal problems or diagnosable mental disorders, which need medications. If we could really understand the interaction between mental health issues and medical dollars, we could save a huge percent of ineffectively used health care dollars," Berger says. Multiple Complications Mental disorders also complicate the medical encounter itself. People with mental disorders often communicate poorly, are unable to adequately describe their medical histories, and don't advocate well for themselves. Their disease presents at a later, more complicated status. And they have problems with consent, judgment and the logistics of their care. "Depression and anxiety interfere with every step of the process--getting timely help, describing the symptoms accurately, asking relevant questions, following through with the treatment plan and being organized about appointments, medications and communications," Berger says. "As a result, chronic illnesses, cardiovascular disease and obesity are rampant among the mentally ill." Diabetes care offers a good example. Effective management entails lifestyle changes. "People with mental illness often have a tough time getting out of bed, let alone taking their medications, making healthy meals and checking their blood sugar," says Nease. "Depression affects a person's sense of self-efficacy--the sense that they can make these changes. I often hear depressed patients say, 'I'll never get my blood sugar under control, so why try?' And then we're into the downward spiral." Mental disorders contribute to shortened life expectancy and worse outcomes for other medical conditions, too. People with severe and persistent mental illness, on average, engage in more high-risk behaviors, including smoking, substance abuse and unprotected sex. "There's an additive effect," says David Brody, M.D., professor of medicine at Drexel University School of Medicine in Philadelphia. "A patient who's had a recent heart attack, and who's also clinically depressed, has a greater likelihood of dying within 18 months. If we treat the depression, we improve the odds for a better outcome." Obstacles to Care Issues of access and barriers to care exacerbate these negative impacts. Patients are finding fewer options as state-funded psychiatric hospitals continue to close. That trend is far from over. Earlier this year, the National Association of State Mental Health Program Directors reported that, during the past five years, 23 states have experienced declines in the number of general-hospital, specialty-unit psychiatric beds, and 26 states have seen a decrease in the number of private psychiatric beds. The result is a well-documented extra burden on community hospitals and their emergency departments. "Worse yet, psych is viewed--justifiably in today's system--as a financial loser," says Spring Harbor's King. The result is even less access, as hospitals reduce psychiatric coverage and services. Personal finances also affect access to mental health services. "Mental illness is often a disease of impoverishment," King adds. "People with mental disorders often lose their jobs and, if their employers offered it, their insurance coverage, which puts them into a further vicious cycle." The much-discussed disparity between insurance coverage for general health care services and mental health services adds another dimension to the access issue. The split system is a constant source of frustration for physicians, mental health caregivers and patients. "Patients with mental disorders often need more than the 15 minutes allotted by most insurance plans," Nease says. "It's easy to bill for depression. But there's no code for constant reassurance." A 'Black Hole' Coding and billing problems like those are well-known. But the isolation and second-class status of mental health care also engender some lesser-known logistical issues. For example, primary care physicians complain that, under some insurance plans, they can't refer their patients directly to a mental health specialist. "All I can do is give them a mental health triage phone number, where they get a provider's name. It's usually not someone I know or can get feedback from," Brody says. "Referring a patient to mental health is like sending them into a black hole." Hospitals face similar reimbursement issues. "There are a lot of hoops to go through, whether you're looking at public or private funders," says Marge Brehmer, director of behavioral health services for Munson Healthcare, an eight-hospital system based in Traverse City, Mich. "Even when we get pre-authorization, it can be hard to get reimbursed for psychiatric care." The reimbursement scenario makes collaboration virtually impossible. "It's hard to share records between the 'silos' of care," Nease says. "It's even hard to find out what psychiatric medications your patient is on. Sometimes they don't tell you. Sometimes they don't know or can't remember. It's even worse if patients cross health system boundaries." Beyond Voodoo A more subtle, but equally insidious barrier is social stigma. Society's negative view of mental illness has a long and hard-to-overcome history. But some of the blame for this phenomenon falls squarely on the shoulders of psychiatry itself, say some practitioners. "Our field owns the problem of not having produced evidence-based results and not demonstrating the effectiveness of treatment," King says. "We have to develop evidence-based practices. There's a real movement to provide a standardized toolkit. But until we pull the evidence together, people will continue to look at mental health treatment as part voodoo, part medicine show." Although much progress has been made in awareness of mental health and in treatment protocols, research indicates that social stigma remains strong. And many observers agree that the stigma has become institutionalized, as demonstrated by the way that mental health care has been carved out and treated as second class in reimbursement structures. Furthermore, despite public awareness programs sponsored by government agencies and nonprofit groups, patients still hesitate to seek help, refuse to acknowledge problems and resist referrals because of the shame factor. "It's a scenario I see over and over," Nease says. "A patient has a full workup, with no significant findings. I say, 'Have you ever thought about depression?' The response is, 'Oh, no, doc! I know it's not that!' " Surprisingly, the social stigma may even be getting worse. "People today are more likely than before to characterize those with mental illness as 'dangerous,' " says Pat Corrigan, executive director of the University of Chicago's Center for Psychiatric Rehabilitation. "This notion seems to come from the way mentally ill people are portrayed on TV as violent individuals." Corrigan's assertion is backed by a 1999 Surgeon General's Report on mental health, which states that, "stigma was expected to abate with increased knowledge of mental illness, but just the opposite occurred....One series of surveys found that selective media reporting reinforced the public's stereotypes linking violence and mental illness and encourage people to distance themselves from those with mental disorders." 'Dirty Little Secrets' Social stigma may also result in a reduced quality of medical care for patients with mental disorders. For example, in a study published in 2000 in the Journal of the American Medical Association, Yale University researchers found that patients with mental disorders were 25 percent less likely to receive angioplasty procedures, 32 percent less likely to undergo cardiac bypass surgery and 28 percent less likely to undergo cardiac catheterization than those without mental disorders. And while the Yale study doesn't speculate as to the underlying reasons for this disparity, Corrigan isn't afraid to say it: "People with mental disorders are seen as less worthy of getting care." "That's one of the dirty little secrets," King says. "Mental health patients get categorized all through the system, and that stigma drives assumptions. Their medical care is filtered through that view." The mental health patients clogging up your emergency department sense that covert attitude, adds Ed Shapiro, M.D., CEO of the Austen Riggs Center, a not-for-profit psychiatric hospital in Stockbridge, Mass. "People with mental disorders get the message that what they're struggling with is not taken seriously, so they look elsewhere," he says. "They focus on their physical symptoms, which they know will get attention in the emergency department. It's a systemic problem: If you can't get your psychiatric illness taken care of, you go to the ER, or you act out and go to jail." Already in play are multiple strategies to address the mental health dilemma. In primary care circles, physicians are asking more questions about mental disorders, developing standardized toolkits for identifying depression, anxiety and other mental conditions, and they're building bridges with mental health providers. "In treating mental disorders, we've come a long way in catching up with how we treat medical diseases," says Kurt Kroenke, M.D., professor of medicine at Indiana University, and a leading researcher into the overlap between physical symptoms and depression. "But we're only halfway around the racetrack." In addition, many community hospitals are re-examining their cutbacks in psychiatric services, and some are shoring up psychiatric emergency services. Munson Healthcare's Cadillac Mercy Hospital closed its 20-bed psychiatric unit five years ago. Lately, Brehmer has been lobbying to add six beds to a 14-bed unit at Munson Hospital. "Right now, that's just a wish," she says. "My argument to administration is simple: If you don't have a psych unit, you'll be putting these patients into much more costly med-surg beds." Virtually everyone is lobbying for more funding for mental health services provided by community hospitals, primary care physicians and mental health professionals. But there's still a great deal of work to be done, and it won't be easy. "We are in desperate need of comprehensive, family-oriented, prevention-minded, community accessible evidence-based mental health care for all citizens. We need to integrate mental health with physical health," Berger says. "Pretending that it's too expensive to look at mental health is the utmost folly. It's much more expensive not to look at it." Gloria Shur Bilchik is a freelance writer based in St. Louis. GIVE US YOUR COMMENTS! Hospitals & Health Networks welcomes your comments on this article. Simply click on the computer mouse next to the appropriate headline, then type in your comments. Alternatively, you can e-mail your comments to  HYPERLINK "http://hhn@healthforum.com/" hhn@healthforum.com, fax them to H&HN Editor at (312) 422-4500, or mail them to Editor, Hospitals & Health Networks, Health Forum, One North Franklin, Chicago, IL 60606. Hartford: History of Epidemics and Plagues (October 2001)Plague in Medieval times: As with most mysterious, unknowable, and uncontrollable tragedies, the thin veneer of human rationality is peeled back to expose a dark undersurface capable of incomprehensible horrors and unimaginable evil. People sought to blame others; scapegoating was in season; xenophobia was the normall strangers were suspected of spreading disease. As had happened before and since, Jews were the targets of choice (even though they died of Plague at the same rate as others). Rumors of their having poisoned wells ran rampant. There were pogroms and massacres. The rabble was loose. Zurich expelled all its Jews and closed its gates to them. On a single day in 1349, 2000 Jews were burned to death by a mob in Strausborg. Even officialdom entered the fray. The canton of Basel gathered all 4500 of its Jews in a specially built structure on an island in the Rhine and burned them to death, after which the town fathers passed a law forbidding Jewish residence in the canton for 200 years. The largest Jewish community in Europe was in Mainz, Germany where at least 6,000 Jews were incinerated after they fought and killed 200 of an attacking mob. Pogroms also occurred in Baden, Brussels, Burren, Dresden, Eisenach, Erfurt, Freiburg, Gotha, Landsberg, Lindau, Memmingen, Solothurn, Speyer, Stuttgart, Ulm, Worms, and Zofingen. There were over 350 separate recorded massacres of Jews during the years of the Plague. The approach of a group of flagellants frequently incited townsfolk to embark on pogroms and when they didn't, the Brethren proceeded posthaste to the Jewish quarter where they murdered and looted with a viciousness, ferocity, and completeness that foretold the Final Solution of the Nazis in the twentieth century. Western Europe killed or expelled the Jews even as Pope Clement VI issued papal bulls forbidding plundering and killing them. As if on cue, local clergy either instigated anti-Semitic actions or failed to stop them, likely because properties of the Jews reverted to the Catholic Church upon the death of the families. What the Church lost in clergy and followers, it gained in tangible assets. Your  HYPERLINK "http://wikimediafoundation.org/wiki/Fundraising" \o "wikimedia:Fundraising" continued donations keep Wikipedia running! Pandemic From Wikipedia, the free encyclopedia Jump to:  HYPERLINK "http://en.wikipedia.org/wiki/Pandemic" \l "column-one" navigation,  HYPERLINK "http://en.wikipedia.org/wiki/Pandemic" \l "searchInput" search This article is about large epidemics. For the video game developer, see  HYPERLINK "http://en.wikipedia.org/wiki/Pandemic_Studios" \o "Pandemic Studios" Pandemic Studios. A pandemic (from  HYPERLINK "http://en.wikipedia.org/wiki/Greek_language" \o "Greek language" Greek pan all + demos people) is an  HYPERLINK "http://en.wikipedia.org/wiki/Epidemic" \o "Epidemic" epidemic (an outbreak of an  HYPERLINK "http://en.wikipedia.org/wiki/Infectious_disease" \o "Infectious disease" infectious disease) that spreads worldwide, or at least across a large region. Contents [ HYPERLINK "javascript:toggleToc()" hide]  HYPERLINK "http://en.wikipedia.org/wiki/Pandemic" \l "Common_killers_and_pandemics" 1 Common killers and pandemics  HYPERLINK "http://en.wikipedia.org/wiki/Pandemic" \l "World_Health_Organization_pandemic_phases" 2 World Health Organization pandemic phases  HYPERLINK "http://en.wikipedia.org/wiki/Pandemic" \l "Pandemics_and_notable_epidemics_through_history" 3 Pandemics and notable epidemics through history  HYPERLINK "http://en.wikipedia.org/wiki/Pandemic" \l "Concern_about_possible_future_pandemics" 4 Concern about possible future pandemics  HYPERLINK "http://en.wikipedia.org/wiki/Pandemic" \l "Ebola_virus_and_other_quickly_lethal_diseases" 4.1 Ebola virus and other quickly lethal diseases  HYPERLINK "http://en.wikipedia.org/wiki/Pandemic" \l "HIV" 4.2 HIV  HYPERLINK "http://en.wikipedia.org/wiki/Pandemic" \l "SARS" 4.3 SARS  HYPERLINK "http://en.wikipedia.org/wiki/Pandemic" \l "Avian_flu" 4.4 Avian flu  HYPERLINK "http://en.wikipedia.org/wiki/Pandemic" \l "See_also" 5 See also  HYPERLINK "http://en.wikipedia.org/wiki/Pandemic" \l "External_links" 6 External links  HYPERLINK "http://en.wikipedia.org/wiki/Pandemic" \l "Reference" 7 Reference[ HYPERLINK "http://en.wikipedia.org/w/index.php?title=Pandemic&action=edit§ion=1" \o "Edit section: Common killers and pandemics" edit] Common killers and pandemics According to the  HYPERLINK "http://en.wikipedia.org/wiki/World_Health_Organization" \o "World Health Organization" World Health Organization, a pandemic can start when three conditions have been met: the emergence of a disease new to the population the agent infects humans, causing serious illness the agent spreads easily and sustainably among humans A disease or condition is not a pandemic merely because it is widespread or kills a large number of people; it must also be infectious. For example  HYPERLINK "http://en.wikipedia.org/wiki/Cancer" \o "Cancer" cancer is responsible for a large number of deaths but is not considered a pandemic because the disease is not infectious. [ HYPERLINK "http://en.wikipedia.org/w/index.php?title=Pandemic&action=edit§ion=2" \o "Edit section: World Health Organization pandemic phases" edit] World Health Organization pandemic phases The  HYPERLINK "http://en.wikipedia.org/wiki/World_Health_Organization" \o "World Health Organization" World Health Organization (WHO) has developed a global influenza preparedness plan, which defines the stages of a pandemic, outlines the role of WHO, and makes recommendations for national measures before and during a pandemic. The phases are: Interpandemic period: Phase 1: No new influenza virus subtypes have been detected in humans. Phase 2: No new influenza virus subtypes have been detected in humans, but an animal variant threatens human disease. Pandemic alert period Phase 3: Human infection(s) with a new subtype but no human-to-human spread. Phase 4: Small cluster(s) with limited localized human-to-human transmission Phase 5: Larger cluster(s) but human-to-human spread still localized. Pandemic period: Phase 6: Pandemic: increased and sustained transmission in general population. [ HYPERLINK "http://en.wikipedia.org/w/index.php?title=Pandemic&action=edit§ion=3" \o "Edit section: Pandemics and notable epidemics through history" edit] Pandemics and notable epidemics through history There have been a number of significant pandemics in human  HYPERLINK "http://en.wikipedia.org/wiki/History" \o "History" history, generally  HYPERLINK "http://en.wikipedia.org/wiki/Zoonose" \o "Zoonose" zoonoses that came about with  HYPERLINK "http://en.wikipedia.org/wiki/Domestication" \o "Domestication" domestication of animals such as  HYPERLINK "http://en.wikipedia.org/wiki/Influenza" \o "Influenza" influenza and  HYPERLINK "http://en.wikipedia.org/wiki/Tuberculosis" \o "Tuberculosis" tuberculosis. There have been a number of particularly significant  HYPERLINK "http://en.wikipedia.org/wiki/Epidemic" \o "Epidemic" epidemics that deserve mention above the "mere" destruction of cities:  HYPERLINK "http://en.wikipedia.org/wiki/Peloponnesian_War" \o "Peloponnesian War" Peloponnesian War,  HYPERLINK "http://en.wikipedia.org/wiki/430_BC" \o "430 BC" 430 BC.  HYPERLINK "http://en.wikipedia.org/wiki/Typhoid_fever" \o "Typhoid fever" Typhoid fever killed a quarter of the Athenian troops and a quarter of the population over four years. This disease fatally weakened the dominance of  HYPERLINK "http://en.wikipedia.org/wiki/Athens" \o "Athens" Athens, but the sheer virulence of the disease prevented its wider spread; i.e. it killed off its hosts at a rate faster than they could spread it. The exact cause of the plague was unknown for many years; in  HYPERLINK "http://en.wikipedia.org/wiki/January_2006" \o "January 2006" January 2006, researchers from the  HYPERLINK "http://en.wikipedia.org/wiki/University_of_Athens" \o "University of Athens" University of Athens analyzed  HYPERLINK "http://en.wikipedia.org/wiki/Teeth" \o "Teeth" teeth recovered from a  HYPERLINK "http://en.wikipedia.org/wiki/Mass_grave" \o "Mass grave" mass grave underneath the city, and confirmed the presence of  HYPERLINK "http://en.wikipedia.org/wiki/Bacteria" \o "Bacteria" bacteria responsible for typhoid.  HYPERLINK "http://www.sciam.com/article.cfm?articleID=000BF619-9B78-13D6-9B7883414B7F0135&ref=sciam&chanID=sa003" \o "http://www.sciam.com/article.cfm?articleID=000BF619-9B78-13D6-9B7883414B7F0135&ref=sciam&chanID=sa003" [1]  HYPERLINK "http://en.wikipedia.org/wiki/Antonine_Plague" \o "Antonine Plague" Antonine Plague,  HYPERLINK "http://en.wikipedia.org/wiki/165" \o "165" 165 HYPERLINK "http://en.wikipedia.org/wiki/180" \o "180" 180. Possibly  HYPERLINK "http://en.wikipedia.org/wiki/Smallpox" \o "Smallpox" smallpox brought back from the Near East; killed a quarter of those infected and up to five million in all. At the height of a second outbreak (251266) 5,000 people a day were said to be dying in  HYPERLINK "http://en.wikipedia.org/wiki/Rome" \o "Rome" Rome.  HYPERLINK "http://en.wikipedia.org/wiki/Plague_of_Justinian" \o "Plague of Justinian" Plague of Justinian, started  HYPERLINK "http://en.wikipedia.org/wiki/541" \o "541" 541. The first recorded outbreak of the  HYPERLINK "http://en.wikipedia.org/wiki/Bubonic_plague" \o "Bubonic plague" bubonic plague. It started in  HYPERLINK "http://en.wikipedia.org/wiki/Egypt" \o "Egypt" Egypt and reached  HYPERLINK "http://en.wikipedia.org/wiki/Constantinople" \o "Constantinople" Constantinople the following spring, killing (according to the Byzantine chronicler Procopius) 10,000 a day at its height and perhaps 40 percent of the city's inhabitants. It went on to eliminate up to a quarter of the human population of the eastern  HYPERLINK "http://en.wikipedia.org/wiki/Mediterranean" \o "Mediterranean" Mediterranean. The  HYPERLINK "http://en.wikipedia.org/wiki/Black_Death" \o "Black Death" Black Death, started  HYPERLINK "http://en.wikipedia.org/wiki/1300s" \o "1300s" 1300s. Eight hundred years after the last outbreak, the  HYPERLINK "http://en.wikipedia.org/wiki/Bubonic_plague" \o "Bubonic plague" bubonic plague returned to  HYPERLINK "http://en.wikipedia.org/wiki/Europe" \o "Europe" Europe. Starting in  HYPERLINK "http://en.wikipedia.org/wiki/Asia" \o "Asia" Asia, the disease reached Mediterranean and western Europe in 1348 (possibly from Italian merchants fleeing fighting in the  HYPERLINK "http://en.wikipedia.org/wiki/Crimea" \o "Crimea" Crimea), and killed twenty million Europeans in six years, a quarter of the total population and up to a half in the worst-affected urban areas.  HYPERLINK "http://en.wikipedia.org/wiki/Cholera" \o "Cholera" Cholera first pandemic  HYPERLINK "http://en.wikipedia.org/wiki/1816" \o "1816" 1816 HYPERLINK "http://en.wikipedia.org/wiki/1826" \o "1826" 1826. Previously restricted to the  HYPERLINK "http://en.wikipedia.org/wiki/India" \o "India" Indian subcontinent, the pandemic began in  HYPERLINK "http://en.wikipedia.org/wiki/Bengal" \o "Bengal" Bengal, then spread across India by 1820. It extended as far as  HYPERLINK "http://en.wikipedia.org/wiki/China" \o "China" China and the  HYPERLINK "http://en.wikipedia.org/wiki/Caspian_Sea" \o "Caspian Sea" Caspian Sea before receding. The second pandemic (18291851) reached  HYPERLINK "http://en.wikipedia.org/wiki/Europe" \o "Europe" Europe,  HYPERLINK "http://en.wikipedia.org/wiki/London" \o "London" London in 1832,  HYPERLINK "http://en.wikipedia.org/wiki/Ontario" \o "Ontario" Ontario  HYPERLINK "http://en.wikipedia.org/wiki/Canada" \o "Canada" Canada and  HYPERLINK "http://en.wikipedia.org/wiki/New_York" \o "New York" New York in the same year, and the Pacific coast of North America by 1834. The third pandemic (18521860) mainly affected  HYPERLINK "http://en.wikipedia.org/wiki/Russia" \o "Russia" Russia, with over a million deaths. The fourth pandemic (18631875) spread mostly in Europe and  HYPERLINK "http://en.wikipedia.org/wiki/Africa" \o "Africa" Africa. In 1866 there was an outbreak in North America. The sixth pandemic (18991923) had little effect in Europe because of advances in public health, but Russia was badly affected again. The seventh pandemic began in  HYPERLINK "http://en.wikipedia.org/wiki/Indonesia" \o "Indonesia" Indonesia in 1961, called  HYPERLINK "http://en.wikipedia.org/wiki/El_Tor" \o "El Tor" El Tor after the strain, and reached  HYPERLINK "http://en.wikipedia.org/wiki/Bangladesh" \o "Bangladesh" Bangladesh in 1963, India in 1964, and the  HYPERLINK "http://en.wikipedia.org/wiki/Soviet_Union" \o "Soviet Union" USSR in 1966.  HYPERLINK "http://en.wikipedia.org/wiki/Influenza" \o "Influenza" Influenza The "Asiatic Flu", 18891890. Was first reported in May of 1889 in  HYPERLINK "http://en.wikipedia.org/wiki/Bukhara" \o "Bukhara" Bukhara, Russia. By October, it had reached  HYPERLINK "http://en.wikipedia.org/wiki/Tomsk" \o "Tomsk" Tomsk and the  HYPERLINK "http://en.wikipedia.org/wiki/Caucasus" \o "Caucasus" Caucasus. It rapidly spread west and hit North America in December 1889, South America in FebruaryApril 1890, India in February-March 1890, and Australia in MarchApril 1890. It was purportedly caused by the H2N8 type of flu virus and had a very high attack and mortality rate. The " HYPERLINK "http://en.wikipedia.org/wiki/Spanish_flu" \o "Spanish flu" Spanish flu", 19181919. First identified early March 1918 in US troops training at  HYPERLINK "http://en.wikipedia.org/wiki/Fort_Riley" \o "Fort Riley" Camp Funstan,  HYPERLINK "http://en.wikipedia.org/wiki/Kansas" \o "Kansas" Kansas, by October 1918 it had spread to become a world-wide pandemic on all continents. Unusually deadly and virulent, it ended nearly as quickly as it began, vanishing completely within 18 months. In six months, 25 million were dead; some estimates put the total of those killed worldwide at over twice that number. An estimated 17 million died in India, 500,000 in the United States and 200,000 in the UK. The virus was recently reconstructed by scientists at the  HYPERLINK "http://en.wikipedia.org/wiki/Centers_for_Disease_Control_and_Prevention" \o "Centers for Disease Control and Prevention" CDC studying remains preserved by the Alaskan  HYPERLINK "http://en.wikipedia.org/wiki/Permafrost" \o "Permafrost" permafrost. They identified it as a type of  HYPERLINK "http://en.wikipedia.org/wiki/H1N1" \o "H1N1" H1N1 virus. The " HYPERLINK "http://en.wikipedia.org/wiki/Asian_Flu" \o "Asian Flu" Asian Flu", 195758. An H2N2 caused about 70,000 deaths in the United States. First identified in China in late February 1957, the Asian flu spread to the United States by June 1957. The " HYPERLINK "http://en.wikipedia.org/wiki/Hong_Kong_Flu" \o "Hong Kong Flu" Hong Kong Flu", 196869. An H3N2 caused about 34,000 deaths in the United States. This virus was first detected in Hong Kong in early 1968 and spread to the United States later that year. Influenza A (H3N2) viruses still circulate today.  HYPERLINK "http://en.wikipedia.org/wiki/Typhus" \o "Typhus" Typhus, sometimes called "camp fever" because of its pattern of flaring up in times of strife. (It is also known as "gaol fever" and "ship fever", for its habits of spreading wildly in cramped quarters, such as jails and ships.) Emerging during the  HYPERLINK "http://en.wikipedia.org/wiki/Crusades" \o "Crusades" Crusades, it had its first impact in Europe in 1489 in  HYPERLINK "http://en.wikipedia.org/wiki/Spain" \o "Spain" Spain. During fighting between the Christian Spaniards and the Muslims in  HYPERLINK "http://en.wikipedia.org/wiki/Granada" \o "Granada" Granada, the Spanish lost 3,000 to war casualties and 20,000 to typhus. In 1528 the French lost 18,000 troops in  HYPERLINK "http://en.wikipedia.org/wiki/Italy" \o "Italy" Italy and lost supremacy in Italy to the Spanish. In 1542, 30,000 people died of typhus while fighting the  HYPERLINK "http://en.wikipedia.org/wiki/Ottoman_Empire" \o "Ottoman Empire" Ottomans in the Balkans. The disease also played a major role in the destruction of  HYPERLINK "http://en.wikipedia.org/wiki/Napoleon" \o "Napoleon" Napoleon's  HYPERLINK "http://en.wikipedia.org/wiki/La_Grande_Arm%C3%A9e" \o "La Grande Arme" Grande Arme in Russia in 1812. Typhus also killed numerous prisoners in the Nazi  HYPERLINK "http://en.wikipedia.org/wiki/Concentration_camps" \o "Concentration camps" concentration camps during World War II. Effects of  HYPERLINK "http://en.wikipedia.org/wiki/Colonization" \o "Colonization" Colonization. Encounters between European explorers and populations in the rest of the world often introduced local epidemics of extraordinary virulence. Disease killed the entire native ( HYPERLINK "http://en.wikipedia.org/wiki/Guanches" \o "Guanches" Guanches) population of the  HYPERLINK "http://en.wikipedia.org/wiki/Canary_Islands" \o "Canary Islands" Canary Islands in the 16th century. Half the native population of  HYPERLINK "http://en.wikipedia.org/wiki/Hispaniola" \o "Hispaniola" Hispaniola in 1518 was killed by  HYPERLINK "http://en.wikipedia.org/wiki/Smallpox" \o "Smallpox" smallpox. Smallpox also ravaged  HYPERLINK "http://en.wikipedia.org/wiki/Mexico" \o "Mexico" Mexico in the 1520s, killing 150,000 in  HYPERLINK "http://en.wikipedia.org/wiki/Tenochtitl%C3%A1n" \o "Tenochtitln" Tenochtitln alone, including the emperor, and  HYPERLINK "http://en.wikipedia.org/wiki/Peru" \o "Peru" Peru in the 1530s, aiding the European conquerors.  HYPERLINK "http://en.wikipedia.org/wiki/Measles" \o "Measles" Measles killed a further two million Mexican natives in the 1600s. As late as 184849, as many as 40,000 out of 150,000  HYPERLINK "http://en.wikipedia.org/wiki/Hawaii" \o "Hawaii" Hawaiians are estimated to have died of  HYPERLINK "http://en.wikipedia.org/wiki/Measles" \o "Measles" measles,  HYPERLINK "http://en.wikipedia.org/wiki/Whooping_cough" \o "Whooping cough" whooping cough and  HYPERLINK "http://en.wikipedia.org/wiki/Influenza" \o "Influenza" influenza. There are also a number of unknown diseases that were extremely serious but have now vanished, so the  HYPERLINK "http://en.wikipedia.org/wiki/Etiology" \o "Etiology" etiology of these diseases cannot be established. The cause of  HYPERLINK "http://en.wikipedia.org/wiki/Sweating_sickness" \o "Sweating sickness" English Sweat in 16th-century England, which struck people down in an instant and was more greatly feared even than the  HYPERLINK "http://en.wikipedia.org/wiki/Bubonic_plague" \o "Bubonic plague" bubonic plague, is still unknown. [ HYPERLINK "http://en.wikipedia.org/w/index.php?title=Pandemic&action=edit§ion=4" \o "Edit section: Concern about possible future pandemics" edit] Concern about possible future pandemics [ HYPERLINK "http://en.wikipedia.org/w/index.php?title=Pandemic&action=edit§ion=5" \o "Edit section: Ebola virus and other quickly lethal diseases" edit] Ebola virus and other quickly lethal diseases  HYPERLINK "http://en.wikipedia.org/wiki/Lassa_fever" \o "Lassa fever" Lassa fever,  HYPERLINK "http://en.wikipedia.org/wiki/Rift_Valley_fever" \o "Rift Valley fever" Rift Valley fever,  HYPERLINK "http://en.wikipedia.org/wiki/Marburg_virus" \o "Marburg virus" Marburg virus,  HYPERLINK "http://en.wikipedia.org/wiki/Ebola" \o "Ebola" Ebola virus and  HYPERLINK "http://en.wikipedia.org/wiki/Bolivian_hemorrhagic_fever" \o "Bolivian hemorrhagic fever" Bolivian hemorrhagic fever are highly contagious and deadly diseases with the theoretical potential to become pandemics. As of  HYPERLINK "http://en.wikipedia.org/wiki/As_of_2004" \o "As of 2004" 2004, these diseases have been so virulent as to limit their transmission (an effect known as "burning out"). However, genetic mutations could occur at any time which could elevate their potential for causing widespread harm, thus close observation by contagious disease specialists is merited. Antibiotic-resistant  HYPERLINK "http://en.wikipedia.org/wiki/Superbug" \o "Superbug" superbugs may also revive diseases previously regarded as "conquered". [ HYPERLINK "http://en.wikipedia.org/w/index.php?title=Pandemic&action=edit§ion=6" \o "Edit section: HIV" edit] HIV  HYPERLINK "http://en.wikipedia.org/wiki/HIV" \o "HIV" HIV the virus that causes  HYPERLINK "http://en.wikipedia.org/wiki/AIDS" \o "AIDS" AIDS can be considered a global pandemic but it is currently most extensive in southern and eastern Africa. It is restricted to a small proportion of the population in other countries, where it is spreading more slowly. [ HYPERLINK "http://en.wikipedia.org/w/index.php?title=Pandemic&action=edit§ion=7" \o "Edit section: SARS" edit] SARS In  HYPERLINK "http://en.wikipedia.org/wiki/2003" \o "2003" 2003, there were concerns that  HYPERLINK "http://en.wikipedia.org/wiki/Severe_acute_respiratory_syndrome" \o "Severe acute respiratory syndrome" SARS, a new highly contagious form of  HYPERLINK "http://en.wikipedia.org/wiki/Pneumonia" \o "Pneumonia" pneumonia, might become pandemic. [ HYPERLINK "http://en.wikipedia.org/w/index.php?title=Pandemic&action=edit§ion=8" \o "Edit section: Avian flu" edit] Avian flu Main article:  HYPERLINK "http://en.wikipedia.org/wiki/H5N1" \o "H5N1" H5N1 In February  HYPERLINK "http://en.wikipedia.org/wiki/2004" \o "2004" 2004,  HYPERLINK "http://en.wikipedia.org/wiki/Avian_influenza" \o "Avian influenza" avian influenza virus was detected in pigs in  HYPERLINK "http://en.wikipedia.org/wiki/Vietnam" \o "Vietnam" Vietnam, increasing fears of the emergence of new variant strains. It is feared that if the avian influenza virus combines with a human influenza virus (in a pig or a human), the new subtype created could be both highly contagious and highly lethal in humans. Such a subtype could cause a global influenza pandemic, similar to the  HYPERLINK "http://en.wikipedia.org/wiki/Spanish_Flu" \o "Spanish Flu" Spanish Flu, or the lower mortality pandemics such as the  HYPERLINK "http://en.wikipedia.org/wiki/Asian_Flu" \o "Asian Flu" Asian Flu and the  HYPERLINK "http://en.wikipedia.org/wiki/Hong_Kong_Flu" \o "Hong Kong Flu" Hong Kong Flu. From October 2004 to February 2005, some 3,700 test kits of the 1957  HYPERLINK "http://en.wikipedia.org/wiki/Asian_Flu" \o "Asian Flu" Asian Flu virus were accidentally spread around the world from a lab in the US HYPERLINK "http://www.newscientist.com/article.ns?id=dn7261" \o "http://www.newscientist.com/article.ns?id=dn7261" [2]. In May 2005, scientists urgently call nations to prepare for a global  HYPERLINK "http://en.wikipedia.org/wiki/Influenza_pandemic" \o "Influenza pandemic" influenza pandemic that could strike as much as 20% of the world's population. In October 2005, cases of the Avian flu (the deadly strain  HYPERLINK "http://en.wikipedia.org/wiki/H5N1" \o "H5N1" H5N1) were identified in Turkey. EU Health Commissioner Markos Kyprianou said: "We have received now confirmation that the virus found in Turkey is an avian flu H5N1 virus. There is a direct relationship with viruses found in Russia, Mongolia and China." Cases of bird flu were also identified shortly thereafter in  HYPERLINK "http://en.wikipedia.org/wiki/Romania" \o "Romania" Romania, and then  HYPERLINK "http://en.wikipedia.org/wiki/Greece" \o "Greece" Greece. Possible cases of the virus have also been found in  HYPERLINK "http://en.wikipedia.org/wiki/Croatia" \o "Croatia" Croatia,  HYPERLINK "http://en.wikipedia.org/wiki/Bulgaria" \o "Bulgaria" Bulgaria and in the  HYPERLINK "http://en.wikipedia.org/wiki/United_Kingdom" \o "United Kingdom" United Kingdom. HYPERLINK "http://news.bbc.co.uk/1/hi/world/europe/4348404.stm" \o "http://news.bbc.co.uk/1/hi/world/europe/4348404.stm" [3]. However, by the end of October only 67 people had died as a result of H5N1 which was atypical of previous influenza pandemics. History of Quarantine  INCLUDEPICTURE "http://www.pbs.org/wgbh/nova/typhoid/images/nav_titlelines_p1.gif" \* MERGEFORMATINET   INCLUDEPICTURE "http://www.pbs.org/wgbh/nova/images02/spacer.gif" \* MERGEFORMATINET  INCLUDEPICTURE "http://www.pbs.org/wgbh/nova/images02/spacer.gif" \* MERGEFORMATINET   HYPERLINK "http://www.pbs.org/wgbh/nova/typhoid/" Most Dangerous Woman homepage The practice of quarantinethe separation of the diseased from the healthyhas been around a long time. As early as the writing of the Old Testament, for instance, rules existed for isolating lepers. It wasn't until the Black Death of the 14th century, however, that Venice established the first formal system of quarantine, requiring ships to lay at anchor for 40 days before landing. ("Quarantine" comes from the Latin for forty.) The Venetian model held sway until the discovery in the late 1800s that germs cause disease, after which health officials began tailoring quarantines with individual microbes in mind. In the mid-20th century, the advent of antibiotics and routine vaccinations made large-scale quarantines a thing of the past, but today bioterrorism and newly emergent diseases like SARS threaten to resurrect the age-old custom, potentially on the scale of entire cities. In this time line, follow the evolution of quarantine, from Roman times to the present.Peter Tyson  INCLUDEPICTURE "http://www.pbs.org/wgbh/nova/typhoid/images/nav_dingbat.gif" \* MERGEFORMATINET  A.D. 549 In the wake of one of history's most devastating epidemics of bubonic plague, the Byzantine emperor Justinian enacts a law meant to hinder and isolate people arriving from plague-infested regions. 583 The Council of Lyons restricts lepers from freely associating with healthy persons. 600s China has a well-established policy to detain plague-stricken sailors and foreign travelers who arrive in Chinese ports. 1179 The Third Lateran Council decrees living arrangements for lepers and how their necessary separation from society is to take place. 1200 Europe now has some 19,000 leprosaria, or houses for leper patients; France alone boasts roughly 2,000. 1300s A number of European and Asian countries begin enforcing quarantines of infected regions by encircling them with armed guards. Those caught escaping from afflicted areas are returned and sometimes executed as a warning to others. 1348 Venice establishes the world's first institutionalized system of quarantine, giving a council of three the power to detain ships, cargoes, and individuals in the Venetian lagoon for up to 40 days. The act comes in the midst of the Black Death, a plague epidemic that eventually takes the lives of 14 to 15 million people across Europe, or up to one-fifth of the population. 1374 The Duke of Milan draws up an edict mandating that all those suffering from plague should be taken outside the city to a field or forest until they either recover or die. Three years later, the town of Ragusa establishes a quarantine station where all people arriving from plague-infested regions are kept isolated for a month for "purification by sun and wind." 1403 Venice establishes the world's first known maritime quarantine station, or lazaretto, on Santa Maria di Nazareth, an island in the Venetian lagoon. 1521 France's first maritime quarantine opens at Marseilles. A century later, city officials enact a law forbidding travelers from entering the city without a preliminary medical examination. 1629 Sanitary legislation drawn up in Venice requires health officers to visit houses during plague epidemics and isolate those infected in pest-houses situated away from populated areas. 1647 With infectious diseases in mind, officials in Boston draw up an ordinance requiring all arriving ships to pause at the harbor entrance or risk a $100 fine. 1656 After a plague epidemic kills 100,000 people in Naples, Rome begins inspecting all incoming ships and patrolling its border in hopes of keeping the plague out. When Romans start dying from plague in the city's Trastevere slum and Jewish ghetto, officials seal and monitor these districts. It does little good: in the coming months, about 10,000 people in Rome succumb to plague. 1663 During a smallpox epidemic in New York City, the General Assembly passes a law forbidding people coming from infected areas from entering the city until sanitary officials deem them no threat to residents. 1663 With plague ravaging parts of continental Europe, the English monarchy issues royal decrees calling for the establishment of permanent quarantines. All London-bound ships, whether English or foreign, must pause at the mouth of the Thames River for 40 days (and sometimes 80). The quarantine fails, however, to stave off the disease, which assails the country in 1665-1666. 1664-1665 When the plague epidemic reaches Russia, officials organize quarantines and prohibit entry into Moscow of people from other countries, under threat of death. 1666 The city of Frankfurt issues a decree prohibiting people living in plague-infected houses from visiting churches or markets, and from removing and selling the clothing of plague victims without first fumigating, washing, and airing the garments. 1700s All major towns and cities along the eastern seaboard of the United States have now passed quarantine laws, though typically these laws are enforced only when epidemics appear imminent. 1701 A Massachusetts statute stipulates that all individuals suffering from plague, smallpox, and other contagious diseases must be isolated in separate houses. 1712 A plague epidemic around the Baltic Sea leads England to pass the Quarantine Act. During a mandatory 40-day quarantine for arriving ships, goods cannot be removed, and serious breaches of the act can result in the death penalty. 1738 With smallpox and yellow fever threatening to strike New York, the City Council sets up a quarantine anchorage off Bedloe's Island (home of the Statue of Liberty today). The island becomes a quarantine station for contagious passengers and crew from arriving ships. 1799 With memories still fresh of a nasty 1793 yellow fever epidemic that struck Philadelphia, then the capital of the United States, the city builds an expansive quarantine station called the Lazaretto along the Delaware River about 10 miles south of town. Occupying ten acres, the building still exists today. 1808 The Boston Board of Health orders that, between May and October of every year, ships arriving from the Caribbean, Mediterranean, and other tropical ports be quarantined for three full days or until 25 days have passed since they left port, whichever is longer. 1832 After about 30,000 people in Britain alone die in a cholera epidemic in 1831-1832, New York mandates in June 1832 that no ship can approach within 300 yards of any dock if its captain suspects or knows the ship has cholera aboard. The disease slips through the safety net, however, killing nearly 3,500 of the city's 250,000 residents before it ends in September. 1850-1851 Following horrific epidemics of plague and cholera that spread through Europe from Egypt and Turkey towards the middle of the 19th century, the first international sanitary conference is held in Paris, with an eye to making quarantine an international cooperative effort. These sanitary conferences continue well into the 20th century. 1863 New York State's new Quarantine Act calls for a quarantine office run by a health officer who has the power to detain any ship entering the port of New York for as long as he deems necessary. The health officer can also order all cargo to be removed and a ship cleaned and fumigated. 1866 In April the steamer Virginia arrives in New York harbor from Liverpool, its passengers riddled with cholera. Discovering that 35 steerage passengers and two crew have died during the voyage, the city's health officer orders a swift quarantine. This and other strict quarantines undertaken during the ensuing epidemic prove successful in limiting deaths to about 600, a modest number compared to previous outbreaks. 1879 Amid concern about yellow fever, the U.S. Congress establishes the National Board of Health, in part to assume responsibility for quarantine in cases where states' actions had proven ineffective. The board tries but fails to impose a national quarantine, and it dissolves for lack of funding in 1883. 1890s As the era of bacteriology arrives, with major diseases like typhoid and cholera determined to arise from germs, the length and nature of quarantine evolves, now often based on the life cycles of specific microbes. 1892 When an Asiatic cholera epidemic reaches the U.S. in the fall, President Benjamin Harrison has his surgeon general issue an order holding that "no vessel from any foreign port carrying immigrants shall be admitted to enter any port of the United States until such vessel shall have undergone quarantine detention of twenty days, and such greater number of days as may be fixed in each special case by the State authorities." 1893 The U.S. Congress passes the National Quarantine Act. The act creates a national system of quarantine while still permitting state-run quarantines, and it codifies standards for medically inspecting immigrants, ships, and cargoes, a task now in the hands of the federal Marine Hospital Service. 1894 Epidemics of plague in China, Hong Kong, and Taiwan, as well as in India two years later, fly in the face of arguments promulgated by most European scientists of the day that the widespread scourges that ransacked Europe in the Middle Ages are history. 1900 In March, Chick Gin, the Chinese proprietor of a lumberyard, dies of bubonic plague in a flophouse in the Chinese quarter of San Francisco. Authorities immediately rope off the 15-block neighborhood, quarantining roughly 25,000 Chinese and closing businesses owned by nonwhites. In June, a court rules the quarantine racist and lifts it, declaring that health officials acted with an "evil eye and an unequal hand." 1902 The Pan American Sanitary Bureau is established. It is the first of a series of international health organizations formed in the 20th centuryculminating with the World Health Organization in 1948that help to bring issues of quarantine and the control of disease to a global stage. 1903 In an attempt to isolate tuberculosis patients, the New York City Department of Health opens a quarantine facility at Riverside Hospital on North Brother Island, an islet in the East River. Mary Mallon, aka "Typhoid Mary," begins what becomes a total of 26 years of quarantine here in 1907. (For more on Mallon's quarantine, see  HYPERLINK "http://www.pbs.org/wgbh/nova/typhoid/letter.html" In Her Own Words and  HYPERLINK "http://www.pbs.org/wgbh/nova/typhoid/mary.html" Typhoid Mary: Villain or Victim?.) 1916 When an epidemic of poliomyletis strikes New York residents, authorities begin forcibly separating children from their parents and placing them in quarantine. Wealthy parents, however, can keep their stricken children at home if they can provide a separate room and medical care. By November the epidemic has runs its course, but not before killing more than 2,300 mostly young New Yorkers. 1917-1919 During World War I, American authorities incarcerate more than 30,000 prostitutes in an effort to curb the spread of venereal disease. The historian Allan Brandt has called this effort "the most concerted attack on civil liberties in the name of public health in American history." 1944 The Public Health Service Act is codified, clearly establishing the quarantine authority of the federal government, which has controlled all U.S. quarantine stations since 1921. 1945 In Baltimore, the mayor passes an ordinance giving health authorities the power to isolate at the city's hospitals those patients with syphilis or gonorrhea who refuse penicillin treatment. The ordinance is rarely invoked, however, as the treatment takes at most only a few days, and most patients willingly accept the assistance. 1949 To help stem the spread of tuberculosis, Seattle creates a locked ward for TB sufferers who deny treatment. The ward becomes a model for other cities. 1967 The U.S. Department of Health, Education, and Welfare transfers responsibility for quarantine to the National Communicable Disease Center, now the Centers for Disease Control and Prevention (CDC). 1986 Treating the first cases of HIV/AIDS in the country as a public health emergency, Cuba begins compulsory, indefinite quarantine for citizens testing positive for HIV. Three years later, rules are relaxed to allow such patients to leave sanatoriums for long stretches, and beginning in 1993, HIV patients can choose to live at home after an eight-week course at a sanatorium. 1990s To help control multidrug-resistant tuberculosis, New York City detains more than 200 people who refuse voluntary treatment, confining most of them to the secure ward of a hospital for about six months. One patient said the hardest part of this enforced treatment was "being bored like an oyster." 2001 In the wake of the September 11 terrorist attacks, health officials, at the behest of the CDC, release in December a draft of the proposed Model State Emergency Health Powers Act. The act gives states greater powers to quarantine people in the event of a bioterrorist attack involving a lethal microbe such as smallpox. By July 2002, emergency health powers legislation has passed in 19 states and been introduced in 17 others. 2003 An outbreak of severe acute respiratory syndrome, or SARS, in Asia and Canada occurs in the spring. Officials credit the use of both isolation (for those sick with SARS) and quarantine (for those exposed to the sick) with forestalling an even more severe epidemic. In April, President George W. Bush adds SARS to the list of quarantinable diseases, which also include cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, and viral hemorrhagic fevers such as the Ebola and Marburg viruses. 2004 The Division of Global Migration and Quarantine, part of the CDC's National Center for Infectious Diseases, controls quarantine issues in the United States today. The Division oversees eight national quarantine stationsin New York, Atlanta, Miami, Chicago, Seattle, San Francisco, Los Angeles, and Honolulu. At present, federal, state, and some city health officials have the right to isolate or quarantine individuals who are ill or may become ill with a potentially lethal infectious disease.  INCLUDEPICTURE "http://www.pbs.org/wgbh/nova/images02/nav_end.gif" \* MERGEFORMATINET  Obesity 1 Extraits Jean-Marie LE GUEN OBSIT, LE NOUVEAU MAL FRANAIS TextePromo Page 1 Mardi, 15. fvrier 2005 2:48 14 O BSIT , LE NOUVEAU MAL FRANAIS 8 Pr Arnaud Basdevant, elle est une maladie de la modernit, une maladie de la transition urbaine, de la transition sociale et de la transition conomique qui touche les populations vulnrables . Ltude pidmiologique est, l encore, trs clairante. Elle fait clairement apparatre que lobsit est troitement lie au statut conomique des mnages. Toutes les tudes le prouvent : cest dans lenfance, lcole, que les traumatismes lis ces discriminations sont les plus violents et les plus blessants. Ignores, tolres parce que considres comme de simples plaisanteries, les moqueries dont les enfants obses sont les victimes, tournent souvent la perscution. Ces agressions accroissent leur trouble, aggravent leur dtresse psychologique et les enferment dans un statut part , comme le souligne, par exemple, une expertise collective de lInserm de juin 2000 1 . Que disent les douze experts ? Que lenfant obse est montr du doigt non seulement par les autres enfants, mais souvent aussi par les adultes. Cet enfant obse entre ainsi dans un vritable cercle vicieux : lenfant exclu se sent dvaloris et adopte alors des comportements alimentaires compensatoires. Pour lutter contre la sgrgation dont il est victime et pour attirer lattention du public, du secteur ducatif et mdical sur lisolement de lenfant obse, les experts recommandaient, il y a plus de quatre ans dj, une campagne dinformation. Cette recommandation est reste lettre morte. Rien ne change, et rflexions blessantes, brimades diverses, quolibets, injures, violences, dans les collges et lyces, continuent faire des enfants gros leurs cibles privilgies. Certains refusent de se rendre 1. Obsit. Dpistage et prvention chez lenfant , ditions INSERM, juin 2000 Elle est galement source de discrimination, de stigmatisation quune socit dmocratique ne saurait admettre. Stigmatisierung  HYPERLINK "http://www.sign-lang.uni-hamburg.de/projekte/slex/seitendvd/konzepte/L54/L5403.htm" \o "Blttert zum folgenden Eintrag um."  INCLUDEPICTURE "http://www.sign-lang.uni-hamburg.de/projekte/slex/seitendvd/Resource/Fwd.gif" \* MERGEFORMATINET   HYPERLINK "http://www.sign-lang.uni-hamburg.de/projekte/slex/seitendvd/KonzeptG/L54/L5402.htm" \o "Schaltet um auf die Definition in Deutscher Gebrdensprache."  INCLUDEPICTURE "http://www.sign-lang.uni-hamburg.de/projekte/slex/seitendvd/Resource/ToSign.gif" \* MERGEFORMATINET  Englisch stigmatisation Definition Stigmatisierung bezeichnet einen Prozess, in dessen Verlauf innerhalb einer  HYPERLINK "http://www.sign-lang.uni-hamburg.de/projekte/slex/seitendvd/konzepte/L51/L5170.htm" \o "Zeigt die Definition zu diesem Fachbegriff" Gesellschaft bestimmte uere Merkmale von Personen und Gruppen, zum Beispiel farbige Haut oder eine sichtbare Behinderung ( HYPERLINK "http://www.sign-lang.uni-hamburg.de/projekte/slex/seitendvd/konzepte/L50/L5049.htm" \o "Zeigt die Definition zu diesem Fachbegriff" behindert), mit negativen Bewertungen belegt und die Betroffenen, als "die Farbigen", oder "die Krperbehinderten" in eine  HYPERLINK "http://www.sign-lang.uni-hamburg.de/projekte/slex/seitendvd/konzepte/L53/L5342.htm" \o "Zeigt die Definition zu diesem Fachbegriff" Randgruppenposition gedrngt werden. Stigmatisierte Personen werden somit bei gesellschaftlichen  HYPERLINK "http://www.sign-lang.uni-hamburg.de/projekte/slex/seitendvd/konzepte/L52/L5214.htm" \o "Zeigt die Definition zu diesem Fachbegriff" Interaktionen primr ber dieses negativ konnotierte Merkmal wahrgenommen; andere Merkmale, zum Beispiel der Charakter oder Bildungsstand knnen dieses Stigma nicht kompensieren. Ein stigmatisierter Mensch ist diesem Prozess meistens hilflos ausgeliefert und wird die ihm zugeschriebene negative Bewertung im Normalfall allmhlich verinnerlichen. Dies hat zur Folge, dass der Betroffene sich selbst als defizitr erlebt und sich zum Beispiel bemht, das negativ bewertete Merkmal geheimzuhalten. Immer kleiner werdende Hrgerte untersttzen zum Beispiel das Bemhen vieler stark schwerhriger Menschen, trotz Hrbehinderung mglichst unauffllig zu bleiben. Gleichzeitig ist Stigmatisierung aber auch relativ: Was in einer Gesellschaft oder in einer Gruppe als positives Merkmal oder Normalitt gesehen wird, kann woanders oder zu einem anderen Zeitpunkt zu Stigmatisierung fhren. Dies lsst sich gut am Beispiel der Gebrdensprachkultur verdeutlichen: Hier ist es normal, in Gebrdensprache zu kommunizieren, eine differenzierte Gebrdensprache wird sehr positiv bewertet. Die gleiche Gebrdensprache ist in der hrenden Gesellschaft aber schnell eine Aufflligkeit, die zur Stigmatisierung fhrt ("Der Mann kann ja nicht mal richtig sprechen."). Stigmatisierung psychisch Kranker Autor:  HYPERLINK "http://www.hausarbeiten.de/suchmaschine?searchstring=9885&search=id_autor&page=0" MoniqueZimmermann-Stenzel Fachbereich:  HYPERLINK "http://www.hausarbeiten.de/faecher/sot_0.html" Soziologie - Individuum, Gruppe, Gesellschaft Kategorie: Seminararbeit Veranstaltung: ProSeminar Devianz Institut: Institut fr Soziologie Hochschule: Universitt Heidelberg Jahr: 1997 Seitenzahl: 20 Note: 1,7 Gre: 201 KB Kommentar: Anhand der Werke "Stigma" und "Asyle" des modernen Klassikers Erving Goffman und einer Fallstudie wird die Situation (scheinbar) psychisch Kranker analysiert und Widersprchlichkeiten aufgezeigt. Archivnummer: V23071 1. Einleitung Erving Goffman schreibt in seinem Buch Stigma ber die Situation des Individuums, das von vollstndiger sozialer Akzeptierung ausgeschlossen ist. Dabei wird unter einem Stigma eine besondere Andersartigkeit verstanden, sei sie krperlich, seelisch oder erblich bedingt. Goffman untersuchte dabei verschiedene Personengruppen, die Stigmatisierte akzeptieren, z.B. solche, die selber stigmatisiert sind oder solche, die mit dem Stigmatisierten zusammenleben oder zusammen arbeiten. Dabei stellt sich die Frage, inwiefern bei in eine Klinik eingewiesenen psychisch Kranken eine Stigmatisierung dieser durch das Krankenhauspersonal und durch andere psychisch Kranke erfolgt. 2. Stigma Nach Goffman kann diese Andersartigkeit, die zur Stigmatisierung fhren kann, aus einer physischen Deformation, z.B. ein fehlendes Bein, einem individuellen Charakterfehler, z.B. psychische Krankheit, oder aus einem phylogenetischem Stigmata, das von Geschlecht zu Geschlecht weitergegeben wird, z.B. Rasse, bestehen. Das stigmatisierte Individuum wird mit negativen Attributen von der Gesellschaft versehen. Die Andersartigkeit wird dabei als Abweichung von normativen Erwartungen empfunden, wobei diejenigen, die nicht von den jeweiligen normativen Erwartungen abweichen, als die Normalen bezeichnet werden. Die Zuschreibung von Attributen ist abhngig von dem, was Goffman als virtuale soziale Identitt und als aktuale soziale Identitt unterscheidet. Bei der virtualen sozialen Identitt erfolgt die Zuschreibung bezglich einer bestimmten Personenkategorie, der ein bestimmtes Individuum zugeordnet wird, ber vermutbare, nicht gesicherte Eigenschaften. Die aktuale soziale Identitt konstituiert sich im Gegensatz dazu aus den tatschlich wahrgenommenen und somit gesicherten Attributen. Stimmt die virtuale soziale Identitt nicht mit der aktualen Identitt berein, wird das Individuum umdefiniert und einer anderen Personenkategorie zugeordnet. Diejenigen, deren negative Attribute offensichtlich und von vorhinein bekannt sind, werden die Diskreditierten genannt, z.B. psychisch Kranke gegenber dem Personal einer psychiatrischen Anstalt: Wenn es eine Diskrepanz zwischen der aktualen sozialen Identitt eines Individuums und seiner virtualen Identitt gibt, ist es mglich, da uns dieses Faktum bekannt ist, noch bevor wir Normale den Kontakt zu ihm aufnehmen, oder da es ganz evident ist, wenn das Individuum sich uns vorstellt.1 DA Lentine, JC Hersey, VG Iannacchione, GH Laird, K McClamroch, L Thalji, Research Triangle Institute, Research Triangle Park, North Carolina. The survey included one question that was considered a proxy indicator for a stigmatizing attitude. Participants were identified who strongly agreed or agreed with the statement "People who got AIDS [acquired immunodeficiency syndrome] through sex or drug use have gotten what they deserve." Although this question addresses only one element of HIV/AIDS stigma, for this report, these answers were considered a "stigmatizing" response. Two questions concerned knowledge about HIV transmission. Persons who responded that it was very unlikely or impossible to become infected through sharing a glass or being coughed or sneezed on were considered informed; those who stated that it was very likely, somewhat likely, or somewhat unlikely were classified as misinformed. Percentage estimates were weighted to provide representative estimates, and confidence intervals (CIs) and p-values were computed using SUDAAN. Among the 5641 respondents, 40.2% (95% CI=38.8%--41.6%) responded that HIV transmission could occur (i.e., it was very likely, somewhat likely, or somewhat unlikely) through sharing a glass, and 41.1% (CI=39.7%--42.5%) responded that it could occur from being coughed or sneezed on by an HIV-infected person. A total of 18.7% responded that persons who acquired AIDS through sex or drug use have gotten what they deserve. Stigmatizing responses were more common among men (21.5%), whites (20.8%), persons aged >55 years (30.0%), those with only a high school education (22.1%), those with an income <$30,000 (23.4%), and those in poorer health compared with others (23.6%) ( HYPERLINK "http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4947a2.htm" \l "tab1" Table 1). For both transmission questions, approximately 25% of those who were misinformed gave stigmatizing responses, compared with approximately 14% who were informed (p<0.05). The findings in this report suggest that most U.S. adults do not hold stigmatizing views about persons with HIV infection or AIDS. However, a substantial minority gave a response that suggests they may have stigmatizing attitudes about persons with HIV. The smallest proportion of respondents who gave this response was black, the racial/ethnic group with the highest rates of AIDS in the United States. Significantly more of the respondents who were misinformed about HIV transmission gave a stigmatizing response, suggesting that increasing understanding about behaviors related to HIV transmission may result in lower levels of stigmatizing beliefs about infected persons. However, many other factors are probably related to stigma. Over 29% of Americans believe that people who got AIDS through sex or drug use have gotten what they deserve, compared to 20% who felt that way in 1991, according to a new study funded by the National Institute of Mental Health (NIMH). Gregory Herek, Ph.D., a research psychologist at the University of California at Davis, conducted the research, using scientific telephone survey methods to interview a representative sample of more than 1700 American adults. Today at the World AIDS Conference in Geneva, Dr. Herek reported that approximately half of the new survey respondents incorrectly believed that AIDS might be transmitted through sharing a drinking glass with a person with AIDS, being coughed or sneezed on, or using a public toilet. This represents a slight increase since 1991, when Dr. Herek conducted a similar survey. Revue critique de l'actualit scientifique internationale sur le VIH et les virus des hpatites n83 - mai 2000 CONFERENCE DAMSTERDAM Stigmatisation et discrimination des personnes atteintes : pour des recherches qualitatives sur les phnomnes dexclusion Stphane Abriol Centre dethnologie franaise, Muse national des arts et traditions populaires (Paris) Franoise Loux Centre dEthnologie Franaise Muse National des Arts et Traditions Populaires (Paris) Deux numros rcents de Transcriptase (78 et 79) soulignaient dans leur ditorial les multiples causes de prcarit qui sopposent encore, en France, une prise en charge adquate de lensemble des personnes atteintes par le VIH, et la crainte que n'apparaissent de nouvelles formes de discrimination ou de stigmatisation. L'optimisme des mdias face la prtendue "normalisation" ou "chronicisation" du sida les a conduits passer sous silence ces phnomnes d'exclusion explicite ou latente dans les socits europennes. La confrence d'Amsterdam a mis l'accent sur l'importance de ces problmes. Deux ateliers - "Counteracting stigma" et "Social impact and stigma"- y taient directement consacrs et plusieurs sances relatives diverses formes de prcarit (prostitu(e)s, prisonniers, migrants, sans-papiers, etc.) les ont abordes. On peut cependant regretter que, souvent, le constat des discriminations ne conduise pas une vritable analyse du phnomne. Les recherches qualitatives, indispensables pour ces questions, font le plus souvent dfaut. Enfin, une distinction prcise entre stigmatisation, discrimination et comportement de crainte ou d'vitement de la discrimination n'apparat pas toujours. C'est cependant le plan qui, par souci de clart, sera suivi dans ce compte rendu. Les diffrences entre pays d'Europe de l'Ouest et d'Europe de l'Est constituent un point marquant de la confrence. Dans les pays de l'Est, la stigmatisation est non seulement trs prsente, mais elle est galement le plus souvent accompagne de pratiques discriminatoires. Pour l'Europe de l'Ouest, les recherches montrent que, dans les milieux socio-conomiques dfavoriss, la discrimination ne vient pas uniquement de la socit globale mais aussi du milieu social dont est issue la personne. Ainsi, Berlin, la stigmatisation des homosexuels est beaucoup plus violente de la part des jeunes adultes de la classe ouvrire l'gard de leurs pairs que celle qui peut exister dans les classes moyennes et bourgeoises (1). Plusieurs recherches ont port sur la stigmatisation des migrants dans leurs milieux d'origine et d'accueil. Dans son travail auprs de jeunes immigrants turcs, bien insrs dans la communaut gay de Berlin, Michael Bochow montre qu'il existe chez eux une fragilit psychologique particulire, lie des difficults d'insertion dans leur communaut d'origine (1). D'o l'insistance dans plusieurs dbats de faire porter des actions d'information et de sensibilisation spcifiques sur les communauts de migrants elles-mmes. De mme, une tude conduite au centre de dpistage de la Piti-Salptrire (Paris) montre l'importance de l'environnement socioculturel pour les immigrs africains, dont il convient de tenir compte, non pour les stigmatiser, mais pour mieux les aider s'insrer dans leur culture et leurs racines ce moment particulirement fragilisant de la rvlation de la sropositivit (2). Dans une recherche anthropologique mene auprs de prostitus masculins La Haye, Rotterdam et Amsterdam, on constate que, dans les interactions sociales avec les clients, les prostitus marocains, plus que les hollandais, sont doublement stigmatiss, par la prostitution et par l'homosexualit (3). Enfin, une enqute mene entre 1995 et 1997 sur 202 prisonniers Marseille met en vidence des scores moyens, tant de connaissance sur la maladie que de tolrance l'gard des personnes contamines, plus bas que dans la population gnrale (4). Paralllement ces formes de stigmatisation explicite, d'autres formes plus insidieuses ont t tudies Marseille dans le cadre de la cohorte MANIF 2000 (lire ausi page 21). La construction strotype, chez certains mdecins, de l'image de l'usager de drogue comme non adhrent lorsqu'il n'est pas sous traitement substitutif, les conduirait retarder ou mme viter la prescription de multithrapies (5). Il ne s'agit pas vritablement de stigmatisation, mais plutt de strotypes. Dans le cas des usagers de drogue, par exemple, on doit se demander si la non adhrence ventuelle ne serait pas davantage due la prcarit des conditions de vie qu' des caractristiques psychologiques particulires. Plusieurs recherches insistent galement sur le rle du lien social dans la lutte contre la stigmatisation. Dans son analyse des campagnes de prvention, Genevive Paicheler souligne l'efficacit en France des campagnes dites "de solidarit", qui ont apport visibilit et proximit la maladie (6). Avec l'action des associations, elles auraient permis une meilleure tolrance de l'homosexualit et une plus grande solidarit vis--vis des malades. La proximit sociale et la connaissance de la maladie jouent un rle important dans la construction des attitudes vis--vis des personnes atteintes. Ainsi, une enqute tlphonique mene aux Pays-Bas montre que les ractions du public ne sont que modrment positives et que ceux qui manifestent les ractions les plus stigmatisantes sont les personnes ges et celles qui ont un faible niveau d'ducation (7). Cela est confirm par l'analyse secondaire des tudes KABP menes en France en 1992, 1994 et 1998 (8). Elle montre que le fait de connatre une (ou des) personne(s) touche(s) par le VIH induit une plus grande ouverture et une meilleure tolrance l'gard des sropositifs. Cependant, 70% seulement de ces personnes (personnes interroges ?) laisseraient leur enfant en compagnie d'une personne atteinte. Les auteurs insistent sur ce constat, se demandant si cela s'explique par une reprsentation de l'enfant comme particulirement vulnrable ou si cela ne relve pas plutt de l'homophobie. Discriminations En ce qui concerne la discrimination, ses marques sont terriblement visibles dans les pays de l'Est. En Slovaquie par exemple, o le taux de contamination semble relativement faible, on observe dans la population gnrale une peur panique entranant des ractions d'accusation et de culpabilisation des personnes contamines. C'est ce que montre une analyse des campagnes de presse concernant le sida (1er dcembre 1996, ts 1996 et 1997), o la maladie est dramatise et prsente comme la "mort noire" (9). Une communication portant sur la Russie (Saint-Ptersbourg) insiste sur les marques de discrimination, qui touchent les femmes plus que les hommes (10). A partir d'une enqute auprs de 157 femmes, l'auteur souligne leur grand isolement, leurs conditions socio-conomiques dramatiques, en dpit d'un niveau d'tudes relativement lev. Cet isolement tient en particulier l'article 12 du Code criminel russe (criminalisation de la transmission du VIH) qui donnerait lieu des condamnations en cas de relation sexuelle avec une personne srongative, y compris dans le cadre d'un couple mari. De plus, dans les maternits, il arrive souvent que les femmes contamines soient spares de leur enfant nouveau-n. Aussi, du fait de ces discriminations, beaucoup de femmes craignent de rvler leur statut srologique (11). En ce qui concerne l'Europe de l'Ouest, une recherche apporte des nuances sur lesquelles il convient de porter une rflexion attentive et qui devrait conduire d'autres analyses (12). Il s'agissait d'valuer le niveau de discrimination, dans diffrentes institutions en Suisse, partir de la dfinition suivante : "toute mesure conduisant des distinctions arbitraires entre les personnes sur la base de leur statut sropositif confirm ou suspect et de leur tat de sant". Ces mesures taient observes dans les textes officiels, dans les rglements intrieurs et dans les pratiques, dans 9 domaines de la vie sociale institutionnelle (sant, emploi, justice, administration, aide sociale, accs au logement, ducation, vie familiale). Un groupe de travail en lien avec les associations de lutte contre le sida n'a dgag aucune discrimination dans la loi, ni dans les rglements. En ce qui concerne les pratiques, sur 31 tmoignages, 3 cas de discrimination ambigu ont t dgags concernant les dpistages l'insu, la non communication des rsultats, et l'impossibilit d'accder une assurance vie. En revanche, des pratiques limites, ne s'appliquant pas seulement au VIH, ont t mises en vidence. Cela concerne des problmes de confidentialit, l'absence d'information et de consentement sur les examens pratiqus, une protection sociale inadquate, la stigmatisation de groupes spcifiques tels que les usagers de drogue, les gays, les migrants. Dans un atelier a t prsente une tude gnrale sur les politiques et les pratiques de prvention dans 28 pays d'Europe (13). Plusieurs points de ce rapport ont trait la discrimination. Un des 3 objectifs gnraux est en effet de "prvenir la discrimination des groupes vulnrables". Parmi les recommandations faites pour la prvention primaire, figurent "trouver des moyens d'ajustement la marginalisation, faire participer au lieu de victimiser les groupes vulnrables" et "assurer des accs gaux aux services (migrants et prisonniers)". Parmi les principales lacunes, il est not que les rponses spcifiques aux groupes vulnrables (prisonniers, migrants, jeunes femmes, jeunes hommes ayant des relations sexuelles avec des hommes) ne sont pas suffisantes, qu'il n'y a pas assez de messages spcifiques leur gard, et que ces groupes ainsi que les populations rurales souffrent d'accs ingal aux traitements. Cette tude confirme la ncessit, dj note pour les pays d'Europe de l'Est, d'accrotre l'acceptation des groupes marginaliss, l'information et la prise de conscience du public, notamment par l'intermdiaire des mdias. La confrence a permis de rvler l'apparition de craintes en matire de stigmatisation ou de discrimination, sans en parler directement. Les craintes d'tre discrimins sont frquentes et elles entranent certains cacher leur statut srologique, ce que les multithrapies rendent parfois plus difficile. Ainsi, Janine Pierret, analysant comment les traitements par inhibiteurs de protase s'inscrivent dans la vie quotidienne, note que prs de la moiti des personnes interroges se cachent pour prendre leurs mdicaments (14). Elle note aussi que la moiti des personnes voquent la contrainte de la rgularit des prises en relation avec leur travail (travail avec des horaires irrguliers, travail en quipe, etc.), exprimant ainsi le risque de nouveaux dangers de stigmatisation ou de discrimination (15). Un autre danger de la "normalisation" du sida est qu'une nouvelle attitude de blme et de stigmatisation pourrait se dvelopper l'gard de ceux qui ne sont pas de "bons malades", respectant scrupuleusement les consignes prventives ou thrapeutiques. Utilisant la dimension historique et comparative avec d'autres types de maladies, Michael Wright montre que l'adhrence totale un traitement est un mythe; ce n'est pas du point de vue du mdecin qu'il faut se placer, en termes mdicaux, mais du point de vue du patient et du sens que prend le traitement par rapport l'ensemble de sa vie (16-17). Il tablit ainsi un parallle pertinent avec les recherches menes sur les relations sexuelles non protges, qui montrent le caractre illusoire du risque zro. De leur ct, Peter Keogh et Peter Weatherburn, propos des relations non protges entre homosexuels srodiffrents, combattent galement l'ide de la seule responsabilit du partenaire sropositif, qui soutiendrait une forme de stigmatisation (18). Ils insistent sur la ncessaire prise de conscience d'un partage des risques entre les partenaires. Sur ce point aussi, de nouvelles recherches qualitatives seraient ncessaires, sur la signification concrte et symbolique du rapport au prservatif et de la protection des rapports sexuels l'heure des multithrapies. En conclusion, trois points mritent d'tre souligns. En premier lieu, la situation dramatique, ces gards comme d'autres, de la plupart des pays d'Europe de l'Est. Ensuite, les nouvelles menaces de stigmatisation/discrimination, ventuellement plus sournoises, pouvant natre du contraste entre la volont de considrer le sida comme une maladie chronique ou "normalise" et le vcu complexe des personnes atteintes aux niveaux par exemple de l'adhrence, de la protection des relations sexuelles, des transformations physiques lies aux traitements ou de l'injonction du retour au travail -ces deux derniers points cruciaux n'ayant malheureusement pas t abords directement au cours de la confrence. Enfin, la ncessit de dpasser les seules approches quantitatives pour les complter par des recherches qualitatives, encore trop peu nombreuses, portant la fois sur des populations particulirement vulnrables et mettant en jeu la totalit de la personne. - Stphane Abriol, Franoise Loux  1 - Bochow M "Gay turkish immigrants and HIV prevention in Germany" 5.2 2 - Apostolidis T et al. "Vulnerability towards HIV infection and modalities of access to testing: a qualitative study among users of Salptrire hospital's testing center (Paris, France)" 102.14 3 - Van Gelder P ""Just a little hop": the subcultural context of male prostitution and its relevance for AIDS/STD education" 8.1 4 - Escaffre N et al. "Knowledge, attitudes and beliefs of inmates toward AIDS and HIV infection: a survey in the prison of Marseille" 16.2 5 - Escaffre N et al. "Anticipating and evaluating intravenous drug user's adherence to HIV antiretroviral treatments: evaluation process and physicians" 12.4 6 - Paicheler G "The influence of NGOs on the implementation of public communication on HIV/AIDS in France" 36.3 7 - Bos A et al. "AIDS-related stigmatization: determinants and reduction strategies" 9.3 8 - Stuart M et al. "People who know persons living with HIV/AIDS: implications for the social impact of the HIV/AIDS epidemic" 15.2 9 - Luksik I "The social representations of HIV/AIDS and their implication for prevention" 9.2 10 - Bakulina TV "Quality of life of woman with HIV/AIDS: main problems" 10.4 11 - Cette ralit dramatique a motiv les organisateurs de la confrence, lors de la sance plnire de clture, demander aux personnes atteintes originaires de pays plus libraux se lever en signe de solidarit. Il est intressant de noter que des personnes atteintes ont cependant refus de participer cette dmarche, arguant que pour elles, il pouvait s'agir d'une expression dtourne de stigmatisation. 12 - Dubois-Arber F et al. "Implementing an UNAIDS protocol institutional discrimination in Switzerland: yields and limitations" 15.3 13 - Weilandt C et al. "HIV prevention in Europe: differences in national policies, their backgrounds and consequences" 18.1 14 - Pierret J "Modifications in the everyday life of persons treated for eight months with a protease inhibitor" 4.2 15 - Pierret J "HIV infection as a chronic disease" 2.2 16 - Wright M "The old problem of adherence: a critical review of research on treatment adherence and its relevance for HIV/AIDS" 18.3 17 - Wright M "AIDS and other epidemics: an opportunity for public health to address the disproportionate rate of illness in lower social classes" 28.1 18 - Keogh P et al. "Relative safety: risk and unprotected anal intercourse (UAI) among gay men with diagnosed HIV infection" 32.2 PREFECTURE DE LA REGION DILE-DE-FRANCE INSTITUT NATIONAL POUR LA PREVENTION ET DE LEDUCATION A LA SANTE REGION ILE-DE-FRANCE AGENCE NATIONALE DE RECHERCHES SUR LE SIDA Les connaissances, attitudes, croyances et comportements face au VIH/sida en France Evolutions 1992 1994 1998 2001 2004 Novembre 2005 Etude ANRS-EN15-KABP 2004 Etude ralise par Nathalie BELTZER conomiste de la sant, Mylne LAGARDE, Xiaoya WU-ZHOU, Natalie VONGMANYcharges d'tudes, et Isabelle GRMY directrice l'Observatoire rgional de sant d'Ile-de-France. PREFECTURE DE LA REGION DILE-DE-FRANCE INSTITUT NATIONAL POUR LA PREVENTION ET DE LEDUCATION A LA SANTE REGION ILE-DE-FRANCE AGENCE NATIONALE DE RECHERCHES SUR LE SIDA Novembre 2005 Etude ANRS-EN15-KABP 2004 Etude ralise par Nathalie BELTZER conomiste de la sant, Mylne LAGARDE, Xiaoya WU-ZHOU, Natalie VONGMANYcharges d'tudes, et Isabelle GRMY directrice l'Observatoire rgional de sant d'Ile-de-France. PREFECTURE DE LA REGION DILE-DE-FRANCE INSTITUT NATIONAL POUR LA PREVENTION ET DE LEDUCATION A LA SANTE REGION ILE-DE-FRANCE AGENCE NATIONALE DE RECHERCHES SUR LE SIDA Principales conclusions 169 Ce rapport est consacr la prsentation des premiers rsultats de lenqute KABP ralise entre avril et juillet 2004 auprs de la population gnrale adulte rsidant en France mtropolitaine et parlant le franais. Au total, depuis 1992, date de la premire enqute KABP56 sida en mtropole ralise par tlphone, 14 042 individus gs entre 18 et 69 ans ont t interrogs tous les trois ans environ : 1 927 en 1992, 1 501 en 1994, 2 222 en 1998, 3 321 en 200157 et 5 071 en 2004. Lorsque les donnes le permettaient, diffrents indicateurs ont t compars entre ces diffrentes vagues denqutes, permettant ainsi de suivre lvolution des connaissances, attitudes, croyances et comportements de la population adulte vivant en France. Ainsi, les donnes de lenqute KABP ralise en 2001 avaient permis de fournir des indicateurs objectifs dun certain relchement des comportements de prvention dans cette population. Lenqute de 2001 avait plus prcisment montr une forte modification de la reprsentation sociale du sida. Cette modification dj amorce en 1998 stait renforce en 2001, notamment auprs de la gnration des jeunes gs entre 18 et 24 ans. La crainte dtre contamine par le virus du sida tait reste leve, bien que le risque du sida lui mme tait peru comme moins dangereux. La perception du risque de contamination apparaissait donc comme moins nette et larrive des traitements anti-rtroviraux avait sembl susciter un certain optimisme face la maladie. Cette banalisation de la maladie stait de plus accompagne pour la premire fois des signes dun relchement des comportements de prvention en population gnrale, puisque la proportion dindividus dclarant avoir utilis un prservatif au cours de lanne avait diminu entre 1998 et 2001, sans toutefois que la proportion de personnes dclarant plusieurs partenaires au cours de lanne nait augment (elle a mme diminu parmi les hommes les plus exposs au risque de contamination). Dautres enqutes avaient conduit des rsultats similaires et parfois mme plus proccupants : ltude NATSAL en Angleterre58 avec une moindre utilisation systmatique du prservatif et une augmentation de la proportion de rpondants dclarant plusieurs partenaires au cours de lanne ou encore lenqute auprs des lecteurs de la presse gay59. Les acteurs de la prvention en Europe et en France, dj alerts par diffrents signaux tels que laugmentation de la prvalence des Infections Sexuellement Transmissibles (IST) ou encore le ralentissement de la dcroissance de lpidmie, ont galement vu se confirmer une reprise des risques de contamination par le virus du sida. On assiste en effet depuis le dbut des annes 2000 une recrudescence des IST60, telles que les infections chlamydiae, les infections gonocoque (+37% chez 56 Les premires enqutes KABP ont t ralises ds 1987 en Ile-de-France et 1990 en France, mais cest seulement partir de 1992 que ces enqutes reposent sur un protocole dinterviews identiques permettant la comparaison des principaux indicateurs. 57 Contrairement aux autres enqutes o lge est de 18 69 ans, les personnes interroges en 2001 taient ges entre 18 et 54 ans. 58 Johnson AM & al., Sexual behaviour in Britain: partnerships, practices, and HIV risk behaviour, The Lancet, vol 358, decembre 1, 2001: 1835-1842. 59 Adam P., Hauet E., Caron C., Recrudescence des prises de risque et des MST parmi les gays Rsultats prliminaires de lEnqute Presse Gay 2000, mai 2001, InVS. 60 M. Herida A. Michel, , V. Goulet, Les Infections sexuellement transmissibles en France en 2003-2004 , Institut de Veille Sanitaire Les connaissances, attitudes, croyances et comportements face au VIH/sida en France : Evolutions 1992, 1994, 1998, 2001 et 2004 170 les femmes et + 27% chez les hommes en 2003 dans le rseau de surveillance RENAGO61 par rapport 2002) ou la syphilis. Cette augmentation de la prvalence des IST, infections qui constituent un facteur de risque supplmentaire de transmission du VIH, confirme le relchement des comportements de prvention et notamment une moindre utilisation des prservatifs. Les caractristiques des personnes touches par lpidmie continuent de se modifier : les personnes contamines par rapports htrosexuels reprsentent 50% des nouveaux cas de sida en 2003 en augmentation depuis 200062, et les personnes contamines lors de rapports htrosexuels sont en majorit des femmes (63%). Par rapport 2001, les rsultats de lenqute ralise en 2004 marquent apparemment peu dvolutions de la reprsentation sociale du sida et des pratiques risque. Cependant, une analyse plus fine de lensemble des donnes souligne une volution contraste de plusieurs indicateurs. Tout dabord, alors que les connaissances des modes de contamination et des moyens de protection lgard du virus du sida taient devenues plus floues entre 1998 et 2001, elles samliorent lgrement en 2004. Les rpondants sont en effet moins nombreux penser que le virus du sida peut se transmettre par une piqre de moustique (20,6% contre 24,4% en 2001) ou encore considrer les spermicides comme un moyen de protection efficace pour viter la contamination par le virus du sida (12,9% contre 15,4% en 2001). Plus dune personne sur deux crot en lefficacit du prservatif fminin, proportion plus importante quen 2001. Toutefois, la comprhension des mcanismes de la transmission du virus reste incomplte. Ainsi, les personnes interroges sont toujours aussi nombreuses penser que le virus du sida peut tre transmis lors de rapports sexuels avec un prservatif (16,6% en 2004) ou lors dune piqre de drogue avec une seringue neuve (14,2%). De plus, les proportions de fausses croyances sont non ngligeables, restant pour certaines des niveaux comparables ceux de 1992 ou de 1994. Ainsi, 38,5% pensent que le sida peut tre transmis en donnant son sang , 20,6% par une piqre de moustique , 16,7% en tant hospitalis dans le mme service quune personne contamine , ou encore 15,4% croient quil est tout fait ou plutt efficace de se laver aprs lacte sexuel pour se protger du virus (proportion en augmentation par rapport 2001). 61 Rseau National Gonocoques. Il sagit dun rseau de laboratoires de biologie mdicale. 62 Surveillance du VIH/sida en France Rapport semestriel n2 - Donnes au 31 mars 2004. Dpartement maladies infectieuses, Institut de veille sanitaire, sur www.invs.sante.fr/publications/2005/vih_sida_france Association SIS : Auteur : E. DE CARVALHO Contributions : M. MOREL, S. LAVERGNE, M. OHAYON, H. ROBERT - Validation : X. BERTIN 4 III - Rsultats Discrimina Renoncb Tairec De manire gnrale, pensez-vous avoir dj t discrimin(e) du fait de votre sropositivit : (en %, non-rponses exclues) 57,3 % -- -- Domaines voqus (en %, non-rponses exclues) Vie sociale : Milieu mdical 43,7 % 23,4 % 36,0 % Emploi et vie professionnelle 33,7 % 29,3 % 65,2 % Assurances et banques 33,6 % 39,8 % 57,3 % Connaissances et voisinage 31,7 % 36,4 % 72,2 % Services publics 16,2 % 11,8 % 40,6 % Loisirs 14,2 % 23,5 % 44,9 % Vie prive Conjoint ou ex-conjoint 29,6 % 42,4 % 29,7 % Partenaire sexuel 37,2 % 50,1 % 47,7 % Famille 28,9 % 26,0 % 52,1 % Amis 31,1 % 32,0 % 50,4 % Variables cres (en % sur lensemble des personnes interroges) Au moins une fois oui lun des domaines 81,4 % 78,2 % 92,0 % Au moins une fois oui dans lun des domaines de la vie sociale 71,9 % 68,2 % 90,3 % Au moins une fois oui dans lun des domaines de la vie prive 63,3 % 64,5 % 75,6 % Par ailleurs, avez-vous le sentiment d'avoir t discrimin(e) pour un autre motif ? 49,4% -- -- a Plus particulirement, pensez-vous avoir dj t discrimin dans (domaine) ? b Dautre part, pour ne pas tre discrimin(e) du fait de votre sropositivit, avez-vous dj renonc (domaine) ? c Pour ne pas tre discrimin(e), avez-vous dj prfr taire votre sropositivit dans le cadre (domaine) ? ۾ Sentiment gnral La dfinition retenue du terme discrimination a t prcise aux personnes interroges en dbut de questionnaire7. Avant d voquer les diffrents domaines lists prcdemment, la premire question a recueilli le sentiment gnral des personnes interroges. Cette anne, la question se limitait au sentiment davoir t discrimin ou non, tandis quen 2003, elle incluait les attitudes dauto-exclusion. Compte tenu dune dfinition moins large, la valeur observe en 2005 reste proche de celle de 2003. Prs de 6 personnes sur 10 disent avoir t discrimines du fait de leur sropositivit (57,3 % en 2005 versus 64 % en 2003). Les diffrences observes selon lge et le sexe sont peu significatives. La proportion de personnes ayant indiqu avoir t discrimines ne varie que de 2 points selon le groupe considr (ex. femmes 59 %, hommes 56,7 %). Lanciennet du diagnostic de sropositivit, mme si elle est corrle lge, est un indicateur davantage significatif : plus le diagnostic est ancien, plus la proportion de personnes ayant le sentiment davoir t confrontes une discrimination a tendance augmenter. Elle est leve ds les premires annes du diagnostic. 7 La discrimination est le fait de mettre lcart ou de traiter diffremment une personne ou un groupe de personnes en raison dun critre spcifique. Johnson, A.M. and Mercer, C.H. and Erens, B. and Copas, A.J. and McManus, S. and Wellings, K. and Fenton, K.A. and Korovessis, C. and Macdowall, W. and Nanchahal, K. and Purdon, S. and Field, J. (2001) Sexual behaviour in Britain: partnerships, practices, and HIV risk behaviours. The Lancet, 358 (9296). pp.1835-1842. ISSN 01406736 Abstract Background: Sexual behaviour is a major determinant of sexual and reproductive health. We did a National Survey of Sexual Attitudes and Lifestyles (Natsal 2000) in 19992001 to provide population estimates of behaviour patterns and to compare them with estimates from 199091 (Natsal 1990). Methods: We did a probability sample survey of men and women aged 1644 years who were resident in Britain, using computer-assisted interviews. Results were compared with data from respondents in Natsal 1990. Findings: We interviewed 11 161 respondents (4762 men, 6399 women). Patterns of heterosexual and homosexual partnership varied substantially by age, residence in Greater London, and marital status. In the past 5 years, mean numbers of heterosexual partners were 38 (SD 82) for men, and 24 (SD 46) for women; 26% (95% CI 2231) of both men and women reported homosexual partnerships; and 43% (95% CI 3750) of men reported paying for sex. In the past year, mean number of new partners varied from 204 (SD 84) for single men aged 2534 years to 005 (SD 03) for married women aged 3544 years. Prevalence of many reported behaviours had risen compared with data from Natsal 1990. Benefits of greater condom use were offset by increases in reported partners. Changes between surveys were generally greater for women than men and for respondents outside London. Interpretation: Our study provides updated estimates of sexual behaviour patterns. The increased reporting of risky sexual behaviours is consistent with changing cohabitation patterns and rising incidence of sexually transmitted infections. Observed differences between Natsal 1990 and Natsal 2000 are likely to result from a combination of true change and greater willingness to report sensitive behaviours in Natsal 2000 due to improved survey methodology and more tolerant social attitudes.  HYPERLINK "http://eprints.ucl.ac.uk/view/subjects/subjects.html" UCL Eprints  HYPERLINK "http://eprints.ucl.ac.uk/view/subjects/1.html" UCL Departments and Research Centres  HYPERLINK "http://eprints.ucl.ac.uk/view/subjects/H.html" Faculty of Clinical Sciences  HYPERLINK "http://eprints.ucl.ac.uk/view/subjects/6800.html" Department of Primary Care and Population Sciences Centre for Sexual Health and HIV Research Eurobaromtre Spcial LE SIDA Terrain : octobre-dcembre 2002 Publication : novembre 2003 Eurobaromtre Spcial 183-2 / Vague 58.2 - European Opinion Research Group EEIG Sondage commandit par la Direction gnrale Sant et protection des consommateurs et coordonn par la Direction gnrale Presse et communication. Le prsent document ne reprsente pas le point de vue de la Commission europenne. Les interprtations et les opinions qu'il contient n'engagent que les auteurs. Commission europenne LE SIDA EUROPEAN OPINION RESEARCH GROUP EUROBAROMETRE SPECIAL 183-2 VAGUE 58.2 AUTOMNE 2002 3 Lanalyse par pays et lanalyse dmographique ne prsentent pas de diffrences significatives dans les rsultats. Relevons seulement quil y a tout de mme 4% des Autrichiens qui pensent quon ne peut pas attraper le SIDA en recevant du sang qui vient dune personne malade ou sropositive. Les autres propositions recueillent des avis plus partags. _ Si 85% des citoyens interrogs pensent que lon ne peut pas attraper le SIDA en serrant la main dun malade su SIDA ou dune personne sropositive, 8% des rpondants pensent que cest peut-tre le cas. Ce chiffre atteint 16% pour les cantons de lAllemagne de lEst (13% pour lAllemagne runifie), 14% au Portugal et en Autriche et 10% en Irlande. Et cest une faon de lattraper pour 3% des citoyens de lUE. _ 83% des rpondants dclarent que lon ne peut pas attraper le SIDA en manipulant des objets qua touch un malade du SIDA ou une personne sropositive. Cest une possibilit pour 9% des personnes et on peut lattraper de cette faon pour 3% dentre-elles. Au Portugal, ces deux derniers chiffres atteignent respectivement 19% et 8%. _ Pour 79% des citoyens, le SIDA ne peut pas tre attrap en mangeant un repas prpar par un malade du SIDA ou une personne sropositive. Ce chiffre descend 61% au Portugal. 12% des personnes estiment que cest peut-tre un mode de contamination, dont 20% des Portugais, 17% des Allemands, 16% des Grecs et 14% des Italiens. 10% des Portugais pensent que le SIDA peut tre attrap de cette faon (pour une moyenne europenne de 3%). _ Ils ne sont plus que 63% penser que lon ne peut pas attraper le SIDA en soignant un malade du SIDA ou une personne sropositive et ce chiffre descend mme 51% en France et au Portugal. 23% des citoyens europens et jusqu 29% des Belges estiment eux que cest peut-tre le cas et 9% pensent que le SIDA peut effectivement sattraper de cette faon. Ce taux atteint 18% en France. _ 58% des rpondants ne croient pas que le SIDA sattrape en sasseyant sur un sige de toilette qui vient dtre utilis par un malade du SIDA ou une personne sropositive, 24% pensent que cest possible et 10% pensent que le SIDA sattrape de cette faon. Dans quatre Etats membres, moins de la moiti de la population pense que le SIDA ne sattrape pas de cette faon. Il sagit de la Grce (28%), du Portugal (35%), de lAutriche (47%) et de lItalie (48%). En revanche les Grecs sont 36% rpondre oui et 29% rpondre peuttre . _ 26% des citoyens de lUnion europenne croient quil est peut-tre possible dattraper le SIDA en buvant dans un verre que vient dutiliser un malade du SIDA ou une personne sropositive. 54% estiment que ce nest pas possible et 11% pensent quon lattrape de cette faon. Comme prcdemment ces deux dernires catgories de rponse atteignent leurs taux de rponse les plus levs au Portugal. Plus de trois Allemands et trois Italiens sur dix pensent eux aussi que cest une faon possible de lattraper. For personal use. Only reproduce with permission from The Lancet Publishing Group. REVIEW Introduction Although initially isolated from the global HIV pandemic by draconian Soviet restrictions on contact with foreigners and harsh social control, there has been a growing epidemic in eastern Europe since the mid 1990s. The first outbreaks were reported in 1995 among injecting drug users in Odessa and Nikolayev in southern Ukraine.1,2 They were rapidly followed by other drug-related HIV outbreaks, notably in the Russian territory of Kaliningrad in 1996,3-5 and a few months later in other regions of the Russian Federation (Krasnodar, Rostov on Don, Tver) and in neighbouring Belarus and Republic of Moldova.6-11 In 1999, two very large outbreaks were identified, again in the Russian Federation, in the Moscow and Irkutsk regions.12 Since then, the situation has continued to worsen rapidly, affecting more regions and countries.13 UNAIDS and WHO14,15 recently reported that, with an estimated 1 million HIV-positive individuals at the end of 2001 compared with only 30 000 at the start of 1995, eastern Europe and Central Asia are the regions of the world with the fastest growing HIV epidemic. By contrast, in central Europe, epidemics that began in the late 1980s have remained at low levels, apart from specific outbreaks in Romania and Poland, and do not seem to be expanding. To further understand the development and recent trends of the HIV epidemic in central and eastern Europe, we analysed HIV/AIDS surveillance data for the 27 countries of the former communist bloc, including all countries of the former Soviet Union, some of which are in Central Asia. We also reviewed published and unpublished studies and reports. We then examined the contributions of different vulnerable populations and discussed factors influencing the past increases in rates of HIV infection and the potential for future increases, taking into account the public-health response. Lancet 2003; 361: 103544. Published online Feb 18, 2003 http://image.thelancet.com/extras/02art6024web.pdf EuroHIV, Department of Infectious Diseases, Institut de Veille Sanitaire, 94415 Saint-Maurice Cedex, France (F F Hamers MD, A M Downs PhD) Correspondence to: Dr Francoise Hamers (e-mail: f.hamers@invs.sante.fr) Methods and data sources Definition of geographical areas We searched for data on the 27 countries. This region is large and heterogeneous covering 24 million km2, and is home to a population of 413 million. We grouped the 27 countries into two geographical areas: the East region (the 15 Newly Independent States of the former Soviet Union in eastern Europe and Central Asia: Armenia, Azerbaijan, Belarus, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Republic of Moldova, Russian Federation, Tajikistan, Turkmenistan, Ukraine, Uzbekistan; 292 million population) and the Centre region (the other 12 countries in central Europe: Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Hungary, Former Yugoslav Republic of Macedonia, Poland, Romania, Slovakia, Slovenia, Yugoslavia; 121 million population; table 1, figure 1). Although this division cannot fully account for the complexity of the epidemiological, social, and political situation, it remains useful because HIV spread later but much faster in the former Soviet Union than in central Europe. EuroHIV databases Individual, anonymous data on cases of AIDS and data on new HIV diagnoses are reported every 6 months to the European Centre for the Epidemiological Monitoring of AIDS (EuroHIV), on the basis of common HIV and AIDS case definitions and standardised database formats.13,16 Because these data are HIV in central and eastern Europe Franoise F Hamers, Angela M Downs Review THE LANCET Vol 361 March 22, 2003 www.thelancet.com 1035 We describe recent trends in the HIV epidemic and the differences between eastern and central Europe, using surveillance data, and published and unpublished reports. During the past 5 years, most countries of the former Soviet Union have been severely affected by HIV epidemics that continue to spread as a result of injecting drug use. With an estimated 1 million individuals already infectedmostly injecting drug usersand high rates of syphilis, the region may soon also face a large-scale epidemic of sexually-transmitted HIV infection. Indeed, data indicate that an HIV epidemic, fuelled by heterosexual transmission, is emerging; its expansion will depend on the size of so-called bridge populations that link high-risk groups with the general population. The lack of evidence to indicate increased rates of HIV as a result of homosexual transmission could indicate the social vulnerability of homosexual and bisexual men in the region rather than the true epidemiological picture. In view of the current levels of HIV prevalence, eastern Europe will soon be confronted with a major AIDS epidemic. By contrast, rates of HIV in central Europe remain low at present, but behaviours that promote HIV transmission are present in all countries. Improved measures to prevent further HIV spread are urgently needed. Search strategy and selection criteria We used the EuroHIV databases on HIV/AIDS case reporting and HIV prevalence, together with data collated by the WHO regional office for Europe and UNAIDS, and unpublished reports from national and regional HIV/AIDS surveillance. We searched the literature up to May, 2002, using the appropriate MeSH terms and the explode function in PubMed, and identified grey literature (government and other institution reports) from journal articles and conference abstracts in AIDSLINE. Among substantial publications (government and other institution reports) in the Russian language, we retained only those references for which an abstract in English provided sufficient information to understand the study methods. Social Science & Medicine 56 (2003) 13731384 Social representations of HIV/AIDS in Central and Eastern Europe Robin Goodwina,*, Alexandra Kozlovab, Anna Kwiatkowskac, Lan Anh Nguyen Luud, George Nizharadzee, Anu Realof, Ahto K. ulvetf, Andu R.ammerf aDepartment of Human Sciences, Brunel University, Uxbridge, UB8 3PH, London, UK bDepartment of Psychology, St. Petersburg State University, St Petersburg, Russia cThe Warsaw School of Advanced Social Psychology, ul. Podlesna 61, Warsaw, Poland d Social and Educational Psychology Department, Eotvos Lorand University, H-1064 Budapest, Izabella u.46, Hungary eD. Udnadze Institute of Psychology, Georgian Academy of Sciences, 22 Paulo Iashvili Street, Tblisi, GA 380007, USA f University of Tartu, Estonia Abstract Although a relatively recent epidemic, HIV is now increasing in Eastern Europe faster than anywhere else in the world. In the study reported in this paper, we interviewed 511 business people and health professionals in five Central and Eastern European nations: Estonia, Georgia, Hungary, Poland and Russia, deriving our questions primarily from a Social Representations perspective. Respondents also freely completed their associations with the stimulus word AIDS. Our findings indicate that, although there is considerable agreement about the threat posed by the epidemic, there are also notable cultural differences in attributions about the origin and spread of the virus and the nature of those groups at risk of infection. These findings are interpreted in the light of the historical legacies of the Communist era, as well as the real economic and social challenges faced by the population of this region. r 2002 Elsevier Science Ltd. All rights reserved. Keywords: HIV/AIDS; Social representations; Central and Eastern Europe Introduction The HIV/AIDS epidemic is a relatively recent phenomenon in Eastern Europe, not beginning until the early 1990s. Although obtaining exact prevalence figures in this region is problematic, WHO AIDS surveillance figures indicate a recent rapid growth in both HIV and AIDS in Eastern Europe (Atlanti, Carael, Brunet, Frasca, & Chaika, 2000), with Central and Eastern Europe now showing the worlds steepest increase in HIV infection (European Centre for Epidemiological Monitoring of AIDS in Europe, 1999). In the towns and cities surrounding Moscow, HIV infection increased five-fold in the first 9 months of 1999 (UNAIDS, 2000), and there have also been recent rapid increases in infection in Estonia (Estonian Health Protection Inspectorate, 2001). In addition, the geographical location of other, currently less infected nations on drug routes, and high rates of migration, raise the prospect of rapid increases in infection across the whole region (Dehne, Khodakevich, Hamers, & Schwartlander, 1999; de Jong, Tsagarelli, & Schouten, 1999). Rhodes and his colleagues (Rhodes et al., 1999a, b) have identified a number of features of the macro risk environment that act as major factors in sustaining epidemic growth and mediate the efficacy of prevention responses. These include the growth of both prostitution *Corresponding author. Tel.: +44-1895-816200; fax: +44- 1895-203018. E-mail address: robin.goodwin@brunel.ac.uk (R. Goodwin). 0277-9536/03/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 0 2 ) 0 0 1 3 5 - 1 Racism, Racial Discrimination and HIV/AIDS Shalini Bharat Tata Institute of Social Sciences, Mumbai, India (Paper Prepared for the UNESCO/OHCHR Workshop To Develop Educational Material to Foster Tolerance and to Eliminate Prejudice at Paris, France, February 19-20, 2002) Introduction It is an increasingly acknowledged reality today that through out the world those most deeply affected by the HIV epidemic are also the most severely disadvantaged, whether on grounds of race, economic status, age, sexual orientation or gender. As in the case of most other stigmatized health conditions such as tuberculosis, cholera and plague, fundamental structural inequalities, social prejudices and social exclusion explain why women, children, sexual minorities and people of colour are disproportionately impacted by AIDS and the accompanying stigma and discrimination. The nearly two decades old global history of the HIV epidemic reinforces yet again the well documented interaction of disease, stigma and `spoiled social identities based on race, ethnicity, sexuality and so on. The strong linkages established early on of HIV/AIDS with gay men and other so called `risk groups, seem to have blinded social researchers and others to the factors of racial, class and gender relations that frame AIDS as a social and not a bio-medical problem alone. Race, class and gender have been found to serve as important determinants of a persons health and well-being status affecting his/her perception of illness, health seeking behaviour, accessibility to services and coping mechanisms. Further, because these factors usually operate in tandem, they severely compromise the persons overall health status and ability to respond to the problem. Although, some amount of empirical evidence now exists on linking poverty and gender to HIV/AIDS, there are not enough data on the relationship between HIV/AIDS, ethnicity and race (UNAIDS/WHO, 2001). This paper makes an attempt to explore the links between racism, racial discrimination and HIV/AIDS. 1.a)The Phenomena : Racism, Racial and AIDS Related Discrimination Race is a form of `group identity and arguably the basis of some of the most extreme and serious acts of discrimination and violations of human rights globally. In the domain of health, race is identified as, a central determinant of social identity and obligations (and) an empirically robust predictor of variations in morbidity and mortaility(Williams, 1997). To understand how race is relevant to questions of public health, care and treatment issues, it is important to first examine the phenomena of stigma and discrimination, in general, and as related to illness and diseases. The concept of `stigma was first elaborated in the classic work of Erving Goffman (1963). Goffman defined stigma as an attribute that is significantly discrediting and which serves to reduce the person who possesses it, in the eyes of society. Relating the concept to conditions of mental illnesses, physical deformities and socially deviant behaviours such as homosexuality, Goffman argued that the stigmatized individual was seen to be a person with an undesirable difference (Goffman, 1963). In other words, he maintained that stigma is constructed by society on the basis of perceived `difference or `deviance and applied through socially sanctioned roles and sanctions. The result is a kind of `spoiled identity for the person concerned (Goffman, 1963). Three kinds of stigma were identified by Goffman: The first was called stigma derived from physical deformities; the second was the stigma associated with perceived `blemishes of individual character (eg., due to mental disorder or homosexuality); and the third was designated the tribal stigma of race, nation and religion. This third type of stigma, transmitted through lineages and possessed equally in all members of a family, implies that group membership and group identity could (in themselves) be sources of stigma (Wailoo, 2002). Race, then is one such group identity that is a source of stigma, prejudice and discrimination for those possessing that racial identity. When the racial identity combines with a health condition such as, HIV/AIDS, it contributes to double stigma (tribal stigma and stigma due to HIV/AIDS status). An early work of Postell (1951), on `Health of Slaves on Southern Plantations makes pictorial representations of the popular public images of African-American group identity in relation to diseases and health care. The health seeking behaviour of black Americans, for instance, is symbolized in one of the pictures by a black woman on foot, with images of quackery-chicken head, frog and snake parts representing her health practices and beliefs, and dense vegetation and darkness framing her background. This picture is contrasted with that of a White American doctor on buggy, with images of medicinal bottles the tools of his trade and a sunlit background with limited vegetation. The image so created is one of backwardness, ignorance and cultural inferiority of the Black people. Citing another example, Wailoo (2001), points out how the hookworm was designated the `germ of laziness because of the lethargy it produced in its patients, a majority of whom were Negroes. And the fight against TB among the Negroes was described as not just a fight against the disease, but against physical, mental and moral inferiority, against ignorance and superstitions, against poverty and filth (Wailoo, 2001). In all these descriptions, notes Wailoo, one image that dominated was the image of the carriers a portrait of a social menace whose collective superstitious, ignorance and carefree demeanor stood as a stubborn affront to modern notions of hygiene and advancing scientific understanding. (a people best understood as) a disease vector Wailoo (2002) goes on to show how the scientific advancements of that time in the field of bacteriology gave the notion of `human disease vectors in the context of `Typhoid Mary or the `asymptomatic carrier. And as Wailoo comments, coming from the pioneering scientists of that time, such images also bore the stamp of scientific authenticity. To illustrate this point, Wailoo cites the example of the noted hook worm researcher Charles W. Stiles who declared that the disease incidence `possibly indicates that the Negro has brought (it) with him from Africa and we must frankly face the fact that the Negro because of his unsanitary habit of polluting the soil is a menace to others (Stiles, 1909). Thus, observes Wailoo one important feature of stigma in public health was associated with both scientific and social ideas about `the carrier of disease (Wailoo, 2002, p.5). It is clear from this example how the notion of the `disease vector is quite old and how it was used to stigmatise the Negro character itself. When Goffman elaborated his concept of stigma in the early 60s he referred to this negative characterization as the creation of the `spoiled identity (Goffman, 1963). The stigmatization of the African American identity in relation to diseases in the early twentieth century shows a remarkable continuity today in the context of HIV/AIDS at the turn of the century. An illustration of this is the stigmatization and harassment of the Haitian people in the early 1980s, who were accused of having brought AIDS into the USA (Farmer & Kim, 1991). The concept of stigma is integrally linked to that of `discrimination. According to the Oxford Dictionary of Sociology, the concept of discrimination simply means treating unfairly and is most commonly used in the context of sociological theories of ethnic and race relations. However, more recent sociological analyses of discrimination concentrate on patterns of dominance and oppression, viewed as expressions of a struggle for power and privilege (Marshall, 1998, p.163). While this sociological definition of discrimination emphasizes the structural dimensions of discrimination (Parker & Aggleton, 2002), Hereks social psychological analyses defines discrimination in behavioural terms discrimination is behaviour (Herek, 2002). In other words, discrimination is the differential treatment of individuals according to their membership in a particular group. Herek differentiates discrimination from `stigma, which `resides in the structure and relations of society and `prejudice which, `resides in the minds of individuals (Herek, 2002, p.2). In the context of race, racism is the stigma and racial discrimination is the behaviour that gives expression to that stigma. Racism is rooted in the ideology of cultural superiority and results in the generalized and definitive valorization of biological differences, whether real or imagined, favorable for the racist, devaluing the other, with the aim to justify an aggression or privilege (Aissata De Diop, 2001). Racism is transmitted through generations and serves to rationalise the hierarchical patterning in society whereby one group dominates over other(s). Racism express itself through institutional norms, cultural values and individual or and/or collective discriminatory behaviour patterns. Race based discrimination or racial discrimination is defined in Article 1 (1) of the International Convention on the Elimination of All Form of Racial Discrimination as ... any distinction, exclusion, restriction or preference based on race, colour, descent, or national or ethnic origin which has the purpose or effect of nullifying or imparing the recognition, enjoyment or exercise, on an equal footing, of human rights and fundamental freedoms in the political, economic, social, cultural or any other field of public life. In recent years concern about AIDS related stigma and discrimination has grown (see Parker & Aggleton, 2002; Bharat with Aggleton and Tyrer for UNAIDS, 2001; Bharat, 1999). Parker and Aggletons analysis (2002) seeks to conceptualise stigma and discrimination not just as individual processes but as social and cultural phenomena linked to the actions of whole groups of people, not the consequences of individual behaviour. Further, they combine the works of Foucault (1977, 1978) which emphasise the cultural production of difference in the service of power, and the work of Goffman (1963) that relates to stigma associated with deviance, to make the point that stigma and stigmatization function at the point of intersection between culture, power and difference. Conceptualizing stigma thus implies that it is not merely an expression of individual attitudes or of cultural values but central to the constitution and continuity of a given social order. It is within such a framework that one may understand and analyse racism and racial discrimination related to HIV/AIDS status. AIDS related stigma and discrimination are complex social processes. They are neither unique and nor randomly patterned (UNAIDS/WHO, 2001). They usually build upon and reinforce pre-existing fears, prejudices and social inequalities pertaining to poverty, gender, race, sex and sexuality, and so on. In this sense, racist attitudes and racial discrimination linked to HIV/AIDS status are only playing into, and reinforcing, already existing racial sterotypes and inequalities concerning people of colour in general. Just like other forms of stigma, AIDS related stigma also results in social exclusion, scapegoating, violence, blaming, labeling and denial of resources and services meant for the consumption of all. Research shows that it is not necessary for people to actually experience stigma directly or personally (often called, Enacted Stigma); stigma may be perceived or presumed to be there (often called, Felt Stigma) (Scambler & Hopkins, 1986). This latter type of stigma is psychologically more damaging and difficult to challenge in public (Bharat, 1999; UNAIDS, 2001). There are two other forms of stigma courtesy stigma and self-stigma. Courtesy stigma is the stigma shared by all those associated with the stigmatized person (for eg. health care providers of HIV infected individual). Self-stigma is the stigma that is accepted and internalized by the person and used to legitamise others negative actions such that challenging the same becomes difficult. Instead the person self-restricts own behaviour out of a sense of vulnerability or indulges in self-blame (Bharat, 1999). Since it is primarily the disliked sectors of society gay and bisexual men, injecting drug users, and sex workers who have been most closely associated with the epidemic since its early onset, Herek (2002) has further differentiated between `Instrumental and `Symbolic stigmas. The former derives from fear of AIDS as a communicable and lethal illness while the latter refers to the use of AIDS as a vehicle for expressing hostility toward groups that are already stigmatized in society. Racism and racial discrimination linked to HIV status, may be categorized as `Symbolic stigma as the already stigmatized and marginalized racial groups are stigmatized further on account of their association with HIV. Conversely, HIV is assumed to be high among certain racial/ethnic groups on the basis of their past association with diseases such as cholera, plague, hookworm etc.(See Wailoo, 2001). Herek (1990) has described a four part process of stigmatization on the part of a society: first, by identifying and defining the disease; second by assigning responsibility for its appearance to some person, group or thing; third, by determining whether those affected by the disease are to be viewed as innocent or guilty; and fourth, by assigning responsibility for identifying a cure or solution to another segment of society. Race, Gender, Class and HIV/AIDS: The intersection The linkage between race and HIV/AIDS cannot be seen in isolation from the dimensions of gender, class, and sexual orientation. As stated by Aggleton, intersectionality is central to an understanding of how gender, race, age, sexuality combine together to determine who is infected and once infected who is able to access medications and health care (UNAIDS/WHO, 2001). This intersectionality is what contributes to double and sometimes multiple stigmas and stigmatization of the infected. Gender differences in patterns of HIV infection vary widely around the world. In regions where the HIV transmission is mainly heterosexual, more young women are infected than men. In most of Africa infection rates among young women are at least twice that among young men (UNAIDS, 2000). In some parts of Kenya and Zambia, teenage girls have rates of 25% compared with 4% among teenage boys (UNAIDS & WHO, 1999). The gendered dimension of the HIV epidemic is closely related to patriarchal values and norms and to the fact that women bear the major consequences of the epidemic on account of loss of livelihood, economic pressures, care of sick family members and stigma of AIDS (Bharat and Aggleton, 1999; Bharat, 1999; UNAIDS, 2001). In many parts of Asia it is marriage that is posing a greater risk of HIV infection to women who themselves report monogamous behaviour. The impact of this can only be imagined in countries where marriage is a cultural ideal and near universal, as is the case in India. Gendered norms and values in these countries ordain that women accept their `lot in marriage and dare not question their husbands demand for sex. Further, they prevent women from seeking knowledge about sex, sexuality and reproductive health matters. Women and young girls thus lack the necessary information resources and the power to make choices such as, in matters of contraceptive use, by which they may reduce their risk of infection. Lack of adequate education and training for earning livelihood further marginalize women, particularly those from disadvantaged racial and ethnic backgrounds. In situations of armed conflict, migration and crisis displacement, once again it is the women who bear the consequences of sexual assault and rape. Evidence gathered from Croatia, Bosnia and Rwanda suggest how rape and sexual abuse are used as weapons of war enhancing risk of HIV and other STIs for women (Human Rights Watch, 1996). Poverty is yet another dimension that combines with race and gender to multiply HIV related risk several times over. Worldwide the AIDS epidemic is most severe in the poorest countries and among people of colour(UNAIDS/ WHO, 1999). The reason is that conditions of poverty, hunger, powerlessness, and ignorance provide fertile ground for the spread of HIV and most Black people and other ethnic minorities live in these very conditions. Poverty increases chances of taking personal risks. For example, in Nicaragua economic hardships are making young women agree to sex with older married men (Zelaya et al, 1997) whose demand for younger, clean women is increasing in the hope of warding off the infection of HIV. But while poverty enhances the risk of HIV, HIV also accentuates poverty. In sub-saharan Africa, for example, where labour shortage due to HIV related morbidity and mortality has cut crop production by more than 40% in affected households, the epidemic has caused a major developmental crisis (Toupouzis and de Guerny, 1999). 1 (b) Geographical Dimensions of the Problem and Trends AIDS or the Acquired Immunodeficiency Syndrome was recognized as a global crisis by the mid-1980s. An estimated total of 40 million people are living with HIV/AIDS at the end of 2001 18.5 million women and 3 million children (UNAIDS, 2002). Almost 22 million people have already died of AIDS while nearly 3 million AIDS deaths were reported in 2001 alone (UNAIDS, 2002). HIV/AIDS is the fourth largest cause of death globally and the leading cause of death in Africa (WHO, 1999). Sub-Saharan Africa continues to lead with 28.1 million HIV infected people but new HIV infections as percentage of existing cases are the highest in Eastern Europe and Central Asia( 43%) and Asia and the Pacific ( 26%) as against the global average of 11% (UNAIDS, 2001). HIV/AIDS epidemiological data is generally reported by countries and by risk groups and not by ethnicity / race due to the political sensitivity involved in doing so (PAHO/WHO & UNAIDS, 2001). It is also argued that race/ethnicity based data may further serve to perpetuate stigma linked to those groups and that in part the problem may also be a `definitional one with respect to racial categories (UNAIDS & WHO, 2001). However, some country specific data provides racial / ethnic dimensions of the problem. These figures may not present the true racial profiling of HIV prevalence but they are suggestive of levels of social inequalities related to race, gender and class. Epidemiological data from the US suggest that increasingly Africa-American men and women are accounting for larger proportion of the HIV/AIDS cases. Although Afro-Americans make up for only 13% of the US population, they accounted for an estimated 54% of all new infections in 2000 and of all the women estimated to have acquired HIV in 2000, nearly 82% were African-American and Hispanic (UNAIDS, 2002, p.40). Reports also suggest that AIDS has become the leading cause of death among African-Americans aged 25 to 44 in the US (Centres for Disease Control-CDC, 2000). Among the African-American gay men, HIV prevalence rates were found to be 30% in a 6-city US survey (reported in UNAIDS, 2002, p.40). Similarly, Latinos who comprise only 9% of the US population accounted for 17% of all male AIDS cases and 21% of all female AIDS cases in 1995 (CDC, 1995). The AIDS incidence rate in mid 90s for Latino men and women was 2.5 and 6 times that of non-Latino white men and women respectively (CDC, 1995). In Canada, the proportion of reported AIDS cases has steadily increased among ethnic groups. Between 1991 and 1999, for example, the proportion of White AIDS cases declined from 88.6% to 66.1%, while a corresponding rise was registered among various ethnic groups. According to one report, of the cumulative AIDS diagnoses reported to December 1998, 78.6 were reported by ethnicity (Health Canada, 1998). This trend was found to be particularly significant after 1994 among the Aboriginal persons and among Black people. Statistics reported for Canada for the year 2000 further reveals that whereas the Aboriginals and Blacks comprise 2.8% and 2.0% of Canadas population respectively, they accounted for nearly 9.2% and 8.3% of all reported cases of AIDS in that year (Canada Bureau of HIV/AIDS, STD and TB, 2001). In the Honduras, HIV infection among the Black Carib minority known as Garifunas is six times that of Honduran national average, at 8.2% in men and 8.5% in women. Among men and women in their 20s, HIV infection was reported to be a high of 16% (PAHO/WHO & UNAIDS, 2001, p.36). In Australia, significantly higher proportion of HIV infection is reported among indigenous women (26%) than among the non-indigenous women (8%) (Common Wealth of Australia, 1997). Within Europe, HIV infection rates among African people in France especially among the women, are reported to be increasing (Bungener, Marchand-Gonod, & Jouvent, 2000). In the UK Ugandan migrants are found to be the second largest group to be affected by HIV-1, after gay men (Low etal 1996). Recent statistics also reveal a narrowing gender gap in HIV infection rates. Globally women accounted for 40% of all new infections in 2001 and of the total AIDS deaths in 2001, 37% occurred among women (UNAIDS, 2001). Within minority racial and ethnic groups too, women are found to be increasingly at greater risk of infection and targets of greater levels of stigma and discrimination. The UNAIDS report for 2002 notes that young, disadvantaged women (especially African-American and Hispanic) are increasingly vulnerable to infection (UNAIDS, 2002 p.40). In most parts of Africa too, HIV prevalence among women is climbing faster than among men. In Botswana, for example, median HIV prevalence among pregnant women increased from 38.5% in 1997 to 44.9% in 2001 while in Zimbabwe the prevalence rate rose from 29% in 1997 to 35% in 2000 (UNAIDS, 2002 p.23). 2.Empirical Data on Racism and Racial Discrimination Related to HIV/AIDS Status As stated earlier the relationship between racism, racial discrimination and HIV/AIDS has not been explored sufficiently well. Besides anecdotal evidence and a few small scale research studies, there is no comprehensive documentation of racial discrimination linked to HIV/AIDS. The earliest racist pronouncements were in relation to African sexuality and the blaming of `Haitians in the US for being the `vectors of the disease (Parker & Aggleton, 2002). Although the fear seems real that documentation of such data might further polarize the international community, the significance of reliable racially disaggregated data on HIV/AIDS for developing policies and programs sensitive to race-based discrimanation cannot be underestimated. Such data can serve as advocacy tool for promoting and protecting rights of racial groups (UNAIDS/WHO, 2001). Before discussing the available evidence on race based data linked to HIV/AIDS, it may be useful to examine the general picture of race relations in the US. Findings of a recent electronic survey (Randall, 2001) reveal that an overwhelmingly large proportion of both people of colour (92%) and Whites (79%) believe that racial minorities in the US today are routinely discriminated against. More than half the respondents (66% people of colour and 56% Whites) believed that race relations will always be a problem in the US and nearly half of them also endorsed the statement that many White people dislike minorities (56% people of colour and 45% Whites). Throughout the world HIV/AIDS related stigma is known to have triggered a range of negative and unsupportive reactions. Various contexts - family, community, work place, health care setting have been identified where stigma and discrimination is known to occur (UNAIDS, 2001; Malcolm et al, 1998). In the beginning of the epidemic, travel restrictions were placed on `foreigners most of whom belonged to racial / ethnic, minorities. For example, African students traveling to USSR and parts of Western Europe were detained, isolated or even expelled from their university programs for reasons that included their HIV status (Sabatier, 1988). In the Gulf countries mandatory testing is followed for all foreign nationals (Solon & Berrazo, 1993) and the HIV infected foreigners continue to be denied permission to enter the US. African-Americans, in general, have reported greater levels of stigma and discrimination in the health care sector due to their HIV status compared to Whites. Some of the most common reactions reported are those of scapegoating and blaming. For example, many Haitians were harassed and stigmatized in the early period due to the belief that they were the carriers of the infection to the US (Farmer & Kim, 1991). In countries that are particularly hard hit, instances of violence and assault against HIV infected persons have been recorded. This often follows the public disclosure of ones HIV status as happened in the case of a young community volunteer Gugu Dlamini in South Africa who was stoned and beaten to death. It is not surprising that HIV positive people fear disclosing their serostatus. In an evaluation of TASO (The AIDS Support Organisations) in Uganda, 58% of the clients reported fear of stigma as the main reason for non-disclosure of their serostatus to others (Kaleeba etal, 1997). Families and individuals are known to have gone to great extent to hide the presence of HIV infection from others in the community (Bharat, 1999). Such secrecy serves to keep the epidemic socially invisible and greatly enhances the potential of silent spread of the epidemic in the community as those infected fail to seek services to learn constructive ways of living with HIV (Lie & Biswalo, 1996). Although direct evidence of racial discrimination due to HIV/AIDS is not so readily available, there is a plethora of research findings reporting wide health disparities among racial minorities that are inextricably related to racism and other forms of discrimination in society (WHO, 2001). Studies in the US, for instance, indicate higher infant and adult mortality due to diabetes, homicide and HIV/AIDS among Afro-Americans than among White population (Nickens, 1995). A study of 107 US cities confirmed higher disease specific mortality among African-Americans than among other groups (Williams, 1995). In Peru, provinces with a higher concentration of Afro-Peruvians such as, Piura, report higher infant mortality (93/1000 live births) compared with Lima (45/1000 live births), which has low African population (Cowater Interntional Inc; 1996). Similar sharp disparities are reported in Brazil where infant mortality among Afro-Americans is 62/1000 compared to among Whites, which is 37/1000 (FOASE, 2000). Access to health insurance too is generally poorer for racial groups. By 1986, 39% Hispanics in the USA had no coverage, a figure three times higher than that of Whites and double that of African-Americans (Bollini, 1995). In the Latin American and Carribean Region, the Afro-Venezullan population lacks health services and health workers refuse to visit due to violence (Cowater Interntional Inc; 1996). Access to modern medical technologies is generally poorer such that fewer elderly Afro-American in the US, compared to elderly White people, consult health specialists, receive less preventive care and poorer quality hospital services, and lack access to sophisticated medical technologies for heart problems etc. (Fiscella et al, 2000). More specifically in relation to HIV/AIDS, there is some evidence to show why racial minorities may be particularly vulnerable to HIV/STIs risk. In most countries men and women from indigenous groups and racial minorities generally have fewer opportunities for schooling and employment than the majority population. Consequently there is greater gravitation towards drug abuse and paid sex work. In the US city of Baltimore, for instance, over one half of drug injectors never graduated from secondary school and 97% of these were African-Americans (PAHO/WHO & UNAIDS, 2001). Because of the lack of racially disaggregated HIV/AIDS data and because prevention services first started among White, gay men, culturally appropriate preventive services for racial minorities are fewer. This may partly explain why unsafe sex fell by a smaller margin among Black teenagers (15%) compared to White teenagers (35%) between 1988 and 1995 and why among the Hispanics, risk exposure actually increased over the same period (PAHO/WHO & UNAIDS, 2001). It is argued that ignorance may not be a reason for disparities in safe sex practices. For example, while over 95% of Garifuna men and women knew about HIV transmission, almost 40% of Garifuna men and 13% of women reported unsafe sex behaviour in the previous 6 months. Despite insufficient direct evidence linking racial discrimination to HIV/AIDS, given wide health disparities between White majority population and the people of colour, it is not too difficult to appreciate how racism, class and gender intensify these already existing inequalities in the context of HIV/AIDS. 3. International Response Legal Regime As early as 1983, 12 countries had adopted legal instruments on AIDS. By 1995 this number had increased to 120 (Paget, 1998). Legal responses, thus far, have included (i) the compulsory screening and testing of groups and individuals, (ii) the prohibition of people with HIV from certain occupations; (iii) the medical examination, isolation, detention and compulsory treatment of infected persons; (iv) limitations on international travel and migration; and (v) the restriction of certain behaviours such as IDU and prostitution (Gostin & Lazzarini, 1997). The legislatures largely reflect the conflict between protection of public health and protection of individual health. In India, for example, a Supreme Court ruling has suspended HIV positive peoples right to marry, ostensibly to protect the marital partner. But even where supportive legislation exists, fear of social exclusion and blame, prevents positive people from accessing legal action. The resolution adopted by the 99th Inter-Parliamentary Union Conference urged parliamentarians around the globe to implement the International Guidelines on HIV/AIDS and Human Rights, particularly those dealing with public health legislation; criminal law and prison systems; anti discrimination legislation; privacy, confidentiality and ethics including in conducting research; and public and private sector standards and mechanisms for implementing the guidelines (UNAIDS/IPU, 1999). (b) Strategies Today HIV/AIDS is largely recognized as a human rights issue (UNAIDS, 2002). At the international level the strategy has been to integrate principles of non-discrimination, confidentiality, participation, equality and beneficence into existing international human rights instruments, national legislatures, NGO work and AIDS related research and intervention initiatives (UNAIDS, 2002). The London Declaration on AIDS Prevention in 1988 was the first international statement to call for destigmatising HIV/AIDS. Subsequently Resolution WHA 41.24 of the 41st World Health Assembly of 1988, made recommendations to Member States to protect human rights of affected individuals. In 1989 the UN Center for Human Rights organized the first international consultation on HIV/AIDS and Human Rights. This was followed by a second consultation in 1996 in which a set of twelve International Guidelines on HIV/AIDS and Human Rights were drafted. Significantly many HR Instruments have now included `HIV/AIDS status under the more general phrase Health status. For example a General Comment adopted by the committee to monitor the International Covenant on Economic, Social and Cultural Rights, enumerates the grounds for non-discrimination in health by proscribing any discrimination in access to health care and the underlying determinants of health as well as to means and entitlements for their procurement on the grounds of race, colour, sex , language, birth, health status (including HIV/AIDS) ..or other status, which has the intention or effect of nullifying or impairing the equal enjoyment or exercise of the right to health. Further, Resolution 49/1999 of the UN commission on HR reaffirms that . the term `or other status in non-discrimination provisions in international human rights texts should be interpreted to cover health status including HIV/AIDS. The UN commission on HR Resolution 2001/33 on `Access to medication in the context of pandemics such as, HIV/AIDS recognizes peoples right to highest standards of health care. The UN General Assembly special session on HIV/AIDS, June 2001, endorsed the establishment of a Global AIDS Fund to strengthen AIDS work in developing countries and with disadvantaged populations. The UNGASS also called upon States to enact, strengthen and enforce legislation to eliminate all forms of AIDS related discrimination and confront stigma, silence and denial by 2003. The need is to recognise and make explicit the inclusion of race based discrimination a ground for legal action In the specific context of the racial dimensions of HIV/AIDS the World Conference Against Racism, Racial Discrimination, Xenophobia and Related Forms of Intolerance, held at Durban in September 2001, marks the strong resolve of the international community to challenge the racial linkages of the AIDS epidemic. At the regional level, the South African Development Communitys Code on HIV/AIDS and Employment seeks to protect rights of HIV positive workers. (UNAIDS, 2000). 4. Examples of Legal Action at National Levels. Examples of good legislative and national action to protect HR globally are beginning to emerge. In Costa Rica, a local NGO successfully helped a HIV positive college student seek combination therapy through intervention of the Supreme Court. In Venezuela, local NGOs, and lawyers and health activists were able to secure the right to free treatment for positive people under the Social Security System. (UNAIDS, 2002, p.64-65). In India, Lawyers Collective has successfully defended positive workers who lost their jobs due to HIV status and the Population Councils Horizons program is helping set up HIV-patients friendly hospitals in the capital (UNAIDS, 2002, p.66). The centre for the study of AIDS at the University of Pretoria, South Africa, is working to create an environment where it would be possible to challenge stigma, racism, and discrimination related to AIDS, (p.66). The AIDS Law Project at the University of Witwatersrand represents yet another success story of winning precedent - setting judgement on unfair dismissal of HIV positive persons and on discrimination against HIV positive prisoners (p.69). The National Human Rights Institutions in Ghana, India and South Africa have also launched activities to promote and protect HIV related human rights in their respective countries. 5. Conclusion Although some good understanding about the production and maintenance of AIDS related stigma and discrimination exists, there is still a need to develop a much deeper understanding of the links between racism, racial discrimination and HIV/AIDS, the dynamics and the impact of race based stigma on positive people and strategies to challenge the linkage. Specifically, the following actions are suggested Promote race disaggregated data to ensure that racial dimensions are recognised in all work related to AIDS research, prevention and care. Develop a research programme to document the evidence, nature and forms of racist based AIDS related stigma; develop suitable research framework and race sensitive data collection instruments to examine the interplay of race, class, gender and sexuality in the production of AIDS stigma and its impact on quality of life of affected people and on AIDS prevention and care programs and policies. Support government and NGO efforts to challenge racial discrimination related to HIV/AIDS by promoting the understanding and use of HR instruments of the UN and other international institutions. Document evidence of good legislative practice and national responses countering AIDS related racist attitudes and stigma Create awareness about anti-racist and supportive legislatures and HR instruments among all sections of society, and especially among young people using the formal educational curricula for school students and the non-formal education method for out of school youth. 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In this drawing, Saint Borromeo assists plague victims. In its most lethal periods, the ancient epidemic—whatever its

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