Stigma, discrimination, health impacts and COVID-19
This blog post was written in early March 2020. The global situation with COVID-19, which has now been declared a pandemic, continues to evolve. For up-to-date information on the virus, please visit the Government of Canada’s outbreak update page.
In this blog post, Vivian Chau, project coordinator at the Rotman Research Institute at Baycrest Health Sciences, and Dr. Lawrence Loh, associate medical officer of health at Peel Public Health, explore the relationship between stigma, discrimination and the novel coronavirus (COVID-19).
As public health practitioners who are read as Chinese, they reflect on incidents in early 2020 and identify opportunities for improved public health responses.
COVID-19, a new respiratory virus
The emergence and global outbreak arising from the respiratory virus COVID-19 has placed healthcare and public health agencies on high alert while capturing media attention and public imagination across the globe. 
COVID-19 originated in Wuhan, China, originally diagnosed as pneumonia in late 2019 before being designated as a unique virus in early 2020.  In the absence of any evidence of institutional or community transmission in Canada in the early months of 2020, the direct risk of COVID-19 to the health of the Canadian public was still classified as low in early March 2020. 
For current information on COVID-19
Echoes of Severe Acute Respiratory Syndrome (SARS)
For Canadians, the emergence of COVID-19 conjures recollections of the 2003 emergence of Severe Acute Respiratory Syndrome (SARS). In that outbreak, the worst cluster of the epidemic outside of the Asian continent was largely centered around the Greater Toronto Area, which saw hundreds of confirmed cases and 44 deaths. [5,6]
Current understanding suggests that COVID-19 shares some disease dynamics with SARS. Both diseases are caused by a coronavirus that causes a respiratory syndrome; in rare but severe cases, mild infections can progress to pneumonia and death. It is these similarities that have prompted an abundance of caution in healthcare settings, where airborne precautions are used to prevent COVID-19 transmission despite evidence suggesting the virus is currently transmitted by droplets. 
Like SARS, COVID-19 is associated with stigma and discrimination
For public health practitioners, applying a holistic lens to the novel outbreak identifies another important parallel to Canada’s SARS experience: the growing risk to health associated with a rise in stigma and discrimination based on race. 
Resurgent narratives and stereotypes have already disproportionately impacted Chinese people and those who are read as Chinese in Canada and around the world.  The Canadian government has tried to strike a balance between vigilance and openness (see the official Canadian response,  as well as current travel advisories  and Twitter updates from Canada’s chief public health officer, Dr. Theresa Tam).  However, growing discrimination has been observed. As of February 16, 2020, over 55 countries have imposed travel bans or restrictions on Chinese nationals or non-citizens who have visited Mainland China, including Australia, New Zealand and the United States. 
US politicians have advanced unfounded conspiracy theories around the origins of the virus.  Discrimination has been reported against people who are read as Chinese, including: [13,14,15,16,17,18,19,20]
- acts of bullying;
- verbal and physical attacks;
- targeted nuisance calls;
- avoidance of businesses;
- petitions against the inclusion of students in schools; and
- Uber and Lyft drivers refusing to pick up patrons.
Following an outbreak of the virus in Iran, reports of anti-Iranian racism and avoidance of Iranian-Canadian businesses have also emerged. 
For those who experience discrimination related to COVID-19, there are longer-term risks to health
In Canada, racist incidents increase the risk of perpetuating stereotypes and driving health inequities. This is particularly true for people who are newly arrived and those with fewer financial resources. Exclusion and avoidance drive losses in opportunity, income and social capital, which in turn can negatively impact health status through bankruptcy, social isolation, isolation, stress and trauma. [22,23]
As an example, bullying and aggression can threaten one’s sense of security and well-being; for children and youth, even a single altercation can have detrimental impacts over the life course. [22,23] Stigma also presents barriers to accessing essential health and social services. More specifically, evidence suggests that many individuals might delay seeking care or avoid fully disclosing health conditions out of fear of being denied service or treated with bias. 
Image: A January 2020 Twitter thread from Chief Public Health Officer Theresa Tam. In it, Dr. Tam condemns the influx of anti-Chinese and anti-Asian sentiment stemming from COVID-19 
Opportunities for improved public health responses
In protecting, promoting and optimizing the health of communities, public health practitioners and agencies need to be aware of how stigma and discrimination related to COVID-19 can impact the health of people who are read as Chinese. Health system leaders, including public health leaders, can then give appropriate priority and attention to this important issue. At the same time, these same leaders can work to secure adequate resources to combat the underlying fear and misinformation that give rise to such incidents.
In episode 4 (11 minutes), NCCDH Knowledge Translation Specialist Pemma Muzumdar discusses the importance that Canadian public health staff be aware of and respond to the rise of anti-Chinese-Canadian sentiment associated with the emergence of 2019-nCoV.
In her 2019 national report, Canada’s Chief Public Health Officer Dr. Theresa Tam identifies several ways to address stigma and discrimination. 
Recognizing a clear need for committed funding and resources to do this work, here are specific actions that the public health community can take to address stigma related to COVID-19:
1. Make systemic stigma visible and take action to address it
Public health agencies and staff can reflect on their role and mandate, identifying the potential for bias to impact the essential work of public health. In order to recognize unconscious biases, it is essential to:
- reflect about one’s role;
- use destigmatizing language; and
- be thoughtful in actions. 
These strategies are also key for removing organizational stigma and optimizing service delivery with the specific needs and health outcomes of impacted communities in mind. 
Public health’s experience in surveillance and expertise may also support data collection around incidents as they arise. These skills can also be applied to the assessment of future impacts through careful follow-up. Such data will be invaluable in identifying root causes and associations to inform specific work in this area.
2. Engage people with lived experience
Public health practitioners can promote acts of compassion and solidarity with impacted communities through their work and in their everyday lives. Work with intersectoral partners and communities will help draw out and address the health impacts of stigmatizing action. For example, public health agencies could work with school boards or community services to recognize and respond to situations that may arise.
Incidents such as a 2020 petition asking an Ontario school board to limit the attendance of students who are read as Chinese  can serve as teachable moments for us all. These situations highlight the need to incorporate health evidence and knowledge as we combat misinformation regarding COVID-19 — particularly that which unfairly targets Racialized groups.
3. Offer ongoing training to health providers to be aware and inclusive of difference
The anti-Chinese stigma and discrimination that has emerged in the wake of COVID-19 further validates the need to increase public health capacity for racial equity, as well as cultural safety and humility.
Implementing anti-stigma and anti-oppression training will better equip practitioners to respond to the current need while also preparing their teams for community health issues in the future. That future engagement will require continuous quality improvement processes to ensure that training remains relevant and up to date.
4. Create more positive health messaging
As leading communication stakeholders in the COVID-19 response, public health practitioners and agencies have a dual role:
- First, to ensure that their updates and messaging do not inadvertently associate the virus with any one community or perpetuate misinformation and stereotypes.
- Second, to bring a credible voice to the very real threat that discrimination presents on the health and wellbeing of those who may be read as Chinese.
On the latter point, openly opposing racism and working with community partners to promote cultural safety is a critical step. Enacting these measures helps keep impacted communities connected to services and opportunities that reduce the long-term impacts of racism on health and wellbeing.
The bottom line
Overall, public health practitioners and agencies are well-placed to respond to COVID-19 with a more holistic lens.
Recognizing all the health impacts of the COVID-19 outbreak, including stigma and discrimination, and taking steps to address all of these impacts, will hold great value for future public health work and racial equity efforts.
Thanks to NCCDH Knowledge Translation Specialist Pemma Muzumdar for her guidance on the development of this blog and contributions to earlier drafts.
Photo credit: Centers for Disease Control and Prevention
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