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OPINION

Stigma is making the COVID-19 pandemic more invisible

While the stigma of socializing may deter people from doing so, it may inadvertently also drive some of these activities underground. This can and does make transmission chains harder to detect and trace.

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Recently, two friends of mine from high school taught me something about COVID-19 that my research on the virus over the past nine months had not.

We’ll call them Jim and Bob. The two were golfing when they were interrupted by one of the club staff saying Bob’s wife was on the phone with what sounded like an emergency. After hanging up, Jim asked Bob what had happened, given the unusual urgency on an otherwise relaxed afternoon.

Bob brushed it off, saying he had recently been exposed to someone with COVID-19 and his wife was worried. Astounded, Jim — whose wife was pregnant — demanded that Bob leave and get tested

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After testing positive, Bob revealed to Jim that the day his wife called, she had actually told him she had tested positive. Out of embarrassment, he didn’t tell Jim the whole story at the time. Fortunately, Jim tested negative.

While many would be quick to blame Bob for his carelessness, the more important question is why Bob didn’t quarantine and get tested, or reveal that he had a close exposure, even to a friend he presumably trusted and cared about.

The reality is that these types of situations are probably more prevalent than we think — and will probably be more so given the Thanksgiving gatherings and the expected uptick in COVID-19 infections in the coming days and weeks. Some of us may have experienced this already. And we have to better understand to what extent stigma is dissuading people from being tested or disclosing their status and, as a result, perpetuating the spread of COVID-19.

Stigma in epidemics is not new. During the HIV epidemic, the stigma of having the disease was one of the biggest challenges faced in the response. The same was true for leprosy, tuberculosis, Ebola, and almost any other major infectious disease epidemic in history.

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To Bob, testing positive could have burdened him with the scorn of his friends, including Jim. They may judge him for how he got exposed or infected. For instance, if transmission happened while Bob was out partying, people may regard him as selfish. For myself, as a physician treating COVID-19 patients, I may not receive that same blame if I was infected on the job. My route of spread may be judged as more understandable, even noble.

But regardless, our judgments of Bob and his actions don’t help stop the epidemic. While the stigma of socializing may deter people from doing so, it may inadvertently also drive some of these activities underground. This can and does make transmission chains harder to detect and trace. If Bob tested positive and didn’t tell Jim or others he had come into contact with for fear of being reprimanded, he would undoubtedly spread the virus even further.

Battling stigma is a critical part of epidemic control. We need more people to get tested regularly. We also need people to actively disclose their testing status to their close contacts. While contact tracers can help anonymize tracing, traditional contact tracing has not always been as efficient as we need it to be, and it can certainly be supplemented by self-tracing (people calling their own close contacts), which is important, since the pandemic spreads far more quickly than we can track. But stigma will impede this.

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So how do we create a more open environment? A number of experts have pointed toward empathy as a starting ground for how we approach others. Take socializing for example — a controversial topic at a time when there are people literally dying on the job. I understand both sides of this; I’m a doctor who has treated countless COVID-19 patients, a number of whom have died; and many who were poor front-line workers who couldn’t afford to socialize at all, let alone “stay home.”

But on the other end of this, I have also treated a number of patients who have reverted to alcoholism and other drug addictions because they have lost the social supports and connections that they relied on before the days of social distancing. It’s key to remember that we don’t always know what others are going through at this time. Unemployment, depression, anxiety, and stress are epidemics as well. Loneliness and social disconnectedness can literally be deadly — a recent CDC report highlighted a staggering 1 in 4 people aged 18 through 24 had considered suicide in the past 30 days.

As doctors, we are often faced with patients toward whom we are inclined to have negative feelings. Some patients are racist, some are sexist, others are discriminatory in other ways, or rude to us. Yet in these moments, we have to tap into empathy to be good doctors. If we are overcome by judgment or negativity, we will fail to do our jobs. Similarly, if the public’s response to people becoming infected with COVID-19 is judgment, scorn, or reprehension, we will fail to control this epidemic. Ultimately, the virus doesn’t care how we feel about one another; but stopping it will absolutely depend on it.

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Dr. Abraar Karan is an internist at Brigham and Women’s Hospital and Harvard Medical School.