I think that fear is not good for things. What fear does… is it causes one to make mistakes.— Latino focus group participant

Infectious diseases have shaped the course of human history, resulting in more deaths than any other pathological cause [1]. And when diseases are thought to be lethal, people who perceive a great risk of infection sometimes cope with their fears by blaming new disease outbreaks on someone, or some group of people, who live outside of their own social sphere. In many societies, people whose national, ethnic or religious backgrounds differ from those of the majority group have historically been accused of spreading germs [2,3]. Such lay theories of disease transmission, often based on inaccurate risk perceptions and pre-existing social prejudices, serve two immediate functions: they temporarily soothe the anxiety felt by the accusers, while also stigmatizing those who are blamed [4,5]. This same sort of disease narrative captured the public imagination in April 2009 when A(H1N1), a novel strain of human influenza, appeared in Mexico and spread rapidly around the world. Some of the earliest cases were discovered near Mexican pig farms (hence, the “swine flu” nickname) and Latino^a immigrants from that country, and others, were often pronounced guilty by association. Soon, Mexican nationals and the products they produced were shunned across the globe; in the United States, some talk show hosts portrayed Mexican immigrants as disease vectors who threatened the health and security of other citizens [3,6]. This was especially unfortunate since disadvantaged groups in any society, including racial/ethnic minorities, suffer disproportionately during disease outbreaks [7,8]. US Latinos have high rates of chronic health conditions such as diabetes, obesity and asthma, which put them at greater risk for getting the flu – and for developing complications once they have it [9,10]. Compared to other social groups, Latinos have less access to healthcare, wait longer to seek medical help, and have fewer opportunities to obtain sick leave – or to utilize this benefit when they have it [11,12]. If the lessons of history hold true, the consequences of H1N1 stigmatization may deepen the sense of social marginality that many US Latinos already feel [13,14].

In order to mitigate the negative consequences of stigmatization during pandemic outbreaks, public health officials must learn to recognize the dynamics that underlie this process, with special emphasis on protecting members of disadvantaged population groups [7,15]. Hence, it is important to understand how people’s fear of contagion during the 2009 H1N1 outbreak became associated with a broader set of fears about Latinos and the roles they play in American society. An emerging body of literature points to the competing goals of three interested stakeholder groups: media organizations and journalists; the public health officials that journalists relied upon for information about H1N1; and citizens who feared the spread of this disease and struggled to make sense of it. Figure 1 suggests one way in which competing frames about pandemic illness and US Latinos – including the social consequences of Latino immigration – collided and combined during the spring and summer of 2009.

Through the process of frame-setting, the news media actively develop the frames of reference that readers or viewers use to understand public events [16,17]. Yet the interpretations that journalists convey in their stories are often rooted in factors that lie beyond the simple reporting of facts. They are complex products of organizational constraints and professional judgments which are, in turn, influenced by the frame-building efforts of external sources [16,17] – including, in the case of H1N1, the US Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). Among its many functions, WHO is responsible for monitoring disease outbreaks and warning the public when they cross borders and become international pandemics [18]. When cueing the CDC (and, hence, the US news media) about the threat of H1N1 in April 2009, WHO relied on a communication campaign that had actually been created to address a lethal outbreak of avian influenza; hence the ready analogies that some officials made to the deadly Spanish Flu pandemic of 1918 [19]. This strategy was a contributing factor in the sensational media coverage of H1N1 that developed in the US, a circumstance that challenged the ability of disease experts to communicate about the virus in a calm and dispassionate manner [20-22]. This campaign would ultimately cause a great deal of confusion, as the overall impact of the H1N1 in the US was significantly milder than public health officials first feared [23-26].

Nonetheless, nearly half of the respondents in an April 2009 national survey [27] were concerned that they or someone in their family might get sick. 59 percent said they had begun to wash hands or use hand sanitizer more frequently, and 25 percent said they were avoiding malls, sporting events or public transportation. And since media reports pegged the origin of H1N1 to Mexican pig farms, heavy coverage of the outbreak likely helped to activate a broader set of fears which held that Mexicans and other Latinos might actually be spreading the disease. Indeed, 20 percent of respondents to the same survey said they would avoid people who they thought may have recently travelled to Mexico; another 17 percent said they would avoid Mexican restaurants and stores [27].

In exploring these processes, we do not suggest that certain groups of fearful US citizens made conscious decisions to vent their frustrations on Latinos. Instead we posit a subtler form of bias that medical historian Howard Markel describes as a “fear of people we do not know or who look different”. In an interview with msnbc.com, Markel – a senior CDC consultant on pandemic preparedness – said that when “you take the fear of the unknown that already exists and then combine that with a real or perceived threat that is contagious disease… it’s explosive” [3]. Following this train of logic, we can begin to understand how the fear of contagion can become associated in an anxious person’s mind with a generalized fear of minorities [28]. Social psychologists suggest that this sort of associational trajectory develops in a part of the human brain that stores the network of interconnected cognitions which comprise long-term memory [29]. Given a vast array of possible connections, any singular concept that is encoded into memory (e.g., anxiety about flu outbreaks) may become associated with other constructs (e.g., the urge to assign causes and cures). And every time these concepts are activated in tandem, the connections between each member of the “concept set” become stronger. Regarding our study, the presence of threatening linguistic “cues” in news stories about pandemic illness may trigger or activate other constructs that are stored in long term memory (e.g., fears that immigrants are disease vectors). This process of cue convergence, and the resulting activation of associated constructs (associative priming) [29], represents one pathway through which a person’s memories about flu pandemics may combine with historical or latent racial/ethnic fears to make incidental contact with Latinos seem like a dangerous proposition (Figure 1).

To be clear, these processes do not imply that the news media are solely or even mostly to blame, as high-profile talk show hosts (who do not follow the professional conventions of journalists) arguably took a more active role in developing and propagating certain lay theories about the pandemic. Some dubbed it the “fajita flu” and took the growing number of cases as evidence that the uncontrolled flow of illegal aliens across the southern US border posed a clear and present danger; others suggested that the H1N1 outbreak could be part of a larger conspiracy in which terrorists targeting the US would infect Mexican immigrants and turn them into walking, talking weapons of germ warfare [3,5,6,30]. Given the public’s fear of the unknown, and the ways in which the media stoked this fear with a variety of associative cues, many US Latinos were likely stigmatized and stereotyped during the pandemic. In general terms, stereotypes are cognitive shortcuts that help a person to develop quick, superficial “readings” of people from other social groups [15]. Whether conscious or implicit, stereotypes are a frequent by-product of stigmatization – the “marking” of certain individuals or groups according to a socially-conferred judgment that they are somehow tainted, or less than, members of the majority population group [31]. Stigmatization stems from the fears that people often face during times of uncertainty, including public health emergencies like the H1N1 pandemic [30-33]. Apart from disparaging media portrayals of Latinos, a series of interviews with US public health advocates in 2009 showed that Latino seasonal farm workers often felt stigmatized or shunned by other people in the communities where they lived or worked [5]. Government officials, Latino advocacy organizations and public health groups moved to denounce these occurrences [34,35], yet it is likely that stigmatization exacted a toll. People who are subjected to social avoidance or rejection often internalize the stigma they experience, a process that leads to heightened psychological stress and anxiety – and, in some cases, to an increased susceptibility to illness [15,36,37]. It is also important to note that the process of stigmatization may negatively impact the psychological and physiological health of people who hold derogatory or prejudicial beliefs about members of another social group [38-40].

How did US residents deal with the stressful circumstances of the 2009 pandemic? One plausible framework for understanding this is Lazarus and Folkman’s transactional model of stress and coping [41]. We have adapted this model (Figure 2) in a way that describes a process that both stigmatizers and the stigmatized go through when confronted with distressing social situations.

In this model, stressful experiences are conceptualized as person-environment transactions which depend, first of all, on the impact of an external stressor (e.g., media coverage of H1N1). Research suggests that we humans are “spring-loaded” to evaluate our informational environment, and that our initial evaluation of stressors may happen subcortically, prior to any conscious awareness or emotion [42,43]. This orienting response can be sudden and unintentional; and since it functions as a psychological early warning system, it often assigns priority to stimuli that are threatening in nature [43]. From the standpoint of those who stigmatize, it is thus possible that certain media cues about pandemics can quickly activate elements of historical or latent stereotypes about Latinos that are stored in long-term memory – without any sort of conscious intent or present-day belief on the part of a person having this response [44,45]. These same media cues may activate a different sense of apprehension on the part of Latinos who have often, and in various ways, felt the burden of prejudice and discrimination during times of widespread social unease, including the early stages of pandemics.

The next step in our model is primary appraisal, in which individuals evaluate the demands of the potential stressor to determine whether it is important to their own well-being or the welfare of people they hold dear. When people judge the stimulus at hand to be irrelevant or benign, they spare themselves from psychological stress [41,42,45]. But when a threatening event seems likely to produce negative consequences, their agitated response hastens a secondary appraisal. Here, people evaluate the resources they might use to mitigate the threat. During this process, individuals may evaluate whether their available psychological resources (e.g., self-esteem, optimism, self-control), personal resources (e.g., income, education, occupational status) and social resources (e.g., family resilience, social support, ingroup identification and evaluation) will help them to stay resilient in times of danger [33,46]. During secondary appraisal people ask, in effect, whether they have what it takes to manage the challenges of a threatening circumstance [41-43,45-47] (Figure 2).

When individuals go through primary and secondary appraisal, yet continue to experience the stressor in a threatening manner (e.g., because of a steady stream of H1N1 news) they experience psychological stress and must find ways to respond. Our model of stress and coping acknowledges the distinction between involuntary responses to stress and voluntary coping responses. Regarding the first category, people may have involuntary emotional, behavioral, psychological and cognitive responses to stress that do not serve to regulate stressful experiences, including physiological and emotional arousal, rumination and intrusive thoughts, and impulsive actions. Whether conscious or unconscious, these responses “are experienced as being largely outside of the person’s control” [48]. Coping, on the other hand, denotes “conscious volitional efforts to regulate emotion, thought, behavior, physiology and the environment in response to stressful events or circumstances” [48,49].

If the resources a person can draw upon seem sufficient for dealing with a stressor, that person may select a positive-engaged coping strategy^b such as problem-solving, finding a good balance between emotional expression and emotional regulation, or cognitive restructuring – a strategy discussed more thoroughly in our Results section. To give an example of a positive-engaged problem-solving strategy, a White person who is troubled by the prospect of Mexico’s role in the H1N1 outbreak – but confident in his/her ability to cope – may reduce stress by learning all that he/she can about the virus through respectful conversations with Latino acquaintances. But if news coverage of the outbreak stimulates a threatening response, and the individual does not feel up to the challenge, that person may choose a negative-disengaged coping strategy such as avoiding or denying the problem, or antagonizing people who seem threatening (e.g., Latino restaurateurs or travellers who have just returned from Mexico). Members of traditionally stigmatized groups may also employ the whole range of voluntary and involuntary responses to stress. Of special concern to public health practitioners, people who feel stigmatized during pandemic outbreaks may turn inward or isolate themselves from social contact, making it more difficult for them to receive appropriate medical care [11,12]. Finally, we suggest – by inference, not empirical evidence – that the strategy a person chooses for coping with a public health crisis will ultimately have an impact on disease susceptibility and health outcomes (Figure 2).

In this study, we will demonstrate the ways in which public health officials can recognize and understand the potentially harmful dynamics that underlie the stigmatization process during pandemic outbreaks. Specifically, we will utilize the model of stress and coping outlined above to inform an exploratory analysis of five focus group sessions conducted in New England during the H1N1 outbreak of 2009. By revisiting these transcripts with an eye toward the structural elements of our model, we will highlight the primary and secondary appraisals of focus group participants following their exposure to media reports about the pandemic. We will show, in various ways, how the appraisals these people made are linked to the involuntary and voluntary responses that resulted. And we will show how recent research on the psychological makeup of stigmatizers and the stigmatized can offer guidance on the design of anti-stigma interventions whose effects may be longer-lasting than traditional education-based interventions. This study makes no claim to generalizability in the broadest social-scientific sense. Instead, we follow Sim’s conception of theoretical generalizability[50], with the intention that our results will produce theoretically useful insights for others who may conduct future studies about stress and coping during public health emergencies.

Twelve themes emerged in the final wave of coding, with most of them appearing at distinctive points in the stress and coping trajectories of our focus group participants (Table 3).

Our study has attempted to explain the ways in which two separate strands of concern about disease, and the “exotic others” who threaten to spread it, came together in the spring of 2009 to make it seem as though Mexican and other Latino immigrants were largely responsible for the spread of H1N1 onto US soil. It has also attempted to explain the ways in which some US residents either created, or coped with, the stigmas and stereotypes that soon became evident in this charged emotional environment. Our focus group data do not contain direct evidence of the involuntary stress responses that developed when participants first encountered news reports about H1N1. But comments about primary appraisals – their initial assessments about whether H1N1 would pose a threat to themselves or to loved ones – suggest that most participants did become emotionally aroused by H1N1 news. There were subtle differences in the precise kinds of stress these people mentioned, depending on their race and ethnicity. For instance, we found little evidence that Latino participants first considered the spread of H1N1 to be a significant threat to themselves or their loved ones. It is possible that respondents from City C found it difficult to discern such a threat, given the many stressors that people in their community face on a daily basis. Some Whites, on the other hand, became aroused by H1N1 news in a manner that suggested fear, disgust and anger. In terms of secondary appraisals, our focus group participants reported having more negative experiences than positive ones – and this trend was most pronounced among Latinos. While they did not perceive an immediate or outsized threat from the flu, these participants did question whether they had enough resources to combat it – noting the ubiquity of airborne viruses and the lack of social support mechanisms in the event that one actually becomes ill.

In terms of voluntary coping strategies, both Whites and Hispanics addressed their anxiety over H1N1 news, at times, through affirmative problem-solving strategies. People from both groups also made conscious efforts to balance their desire to express feelings about H1N1 with a perceived need to do so in an even-handed way. When focus group discussions did not focus on flu-related stereotypes or stigmas, Latino participants reported much greater use of positive-engaged coping strategies than Whites or Non-Hispanic Blacks. When stereotypes were part of the conversation, Latinos reported fewer positive strategies and many more negative-disengaged strategies. This observation can be interpreted, perhaps, by way of reference to David Williams’ assertion that we humans “tend to think with our hearts” – that the emotional context which surrounds sensitive public conversations has a powerful impact on whether participants feel empathy or antipathy toward people from other social groups.^e Interestingly, Hispanic participants engaged in cognitive restructuring in order to make sense of H1N1 (and related stigma) within their own cultural framework. This allowed them to understand the prospect of present-day discrimination in light of their perceptions of historical discrimination at the hands of Whites. This coping strategy also became manifest when Latinos fused their sense of natural self-efficacy with strong religious beliefs, embodying the culturally-specific trait known as destino.

While our results cannot be broadly generalized, they do contribute to the scholarly literature in at least three important ways. First, our work corroborates other studies that describe the racial and ethnic tensions that sometimes lurk beneath the surface of public discourse on H1N1. Second, we demonstrate that two strands of social-psychological theory, cue convergence/associative priming and a transactional model of stress and coping, can help public health practitioners understand more clearly that disease outbreaks are social stressors – threatening stimuli that can activate a set of latent fears some people may hold about members of other racial/ethnic groups. Finally, our work has implications for public health and emergency management officials who want to mitigate the impact of stigmatization during future outbreaks. It is important to note that anti-stigma interventions are not likely to curb this problem completely. Since subgroup identification is an important basis for sifting one’s way through a sea of complex interpersonal interactions, it is likely that these interactions will always embody some sense “us” and “them” [31]. Despite this cautionary note, scholars of stigma – and of H1N1 stigma, in particular – do suggest certain fruitful possibilities for intervention. First, they maintain that local officials should make people in their communities aware of the prospects of stigmatization before the next pandemic hits. For example, they can teach their staff members about the harm that results from stigmatization; work with the media to tell their story in a way that does not single-out one group or location as the “source” of disease; create mechanisms for the rapid portrayal of accurate information on disease risk; and ensure that people who feel stigmatized have a means of expressing their concerns [15]. Second, other community and faith-based organizations should be reminded to transmit accurate messages that address people’s concerns about getting sick; to actively work to mitigate harmful rumors and misinformation; and to model respectful and compassionate behavior when interacting with members of stigmatized groups [56]. These guidelines speak to the acknowledged importance of building social and cultural-level processes into any intervention that hopes to address community-wide stigmatization [31,57].

Many individual-level interventions have been developed to combat stigma against certain population subgroups, including people with AIDS or mental illness. In general, these interventions have focused on educating people about the impact of stereotypes and stigmas, and on ways in which people can overcome their fears of social out-groups through sustained contact with members of those groups. Recent reviews of these studies suggest mixed results, especially in terms of sustainable effects over the long term [31,37,58]. However, one promising line of scholarship suggests the possibility of greater success with interventions that eschew traditional challenges to the “us vs. them” content of stigma and focus, instead, on enhancing the psychological flexibility of all parties involved. According to Masuda et al, psychological flexibility is “the process of engaging with private thoughts and feelings without trying to judge, evaluate, alter, fix, down-regulate or change them”. These authors, and others, suggest that a psychologically flexible person is less likely to respond to negative thoughts or feelings with maladaptive coping strategies. Interventions based on these principles attempt to undermine the psychological impact of stigmatization for all parties involved by increasing mindfulness, acceptance and perspective-taking – including the development of empathy toward self and others [59-63]. Efforts like these could be an important asset for local health officials who sense the need to develop in-depth, community-wide interventions. To be sure, it is difficult to imagine that any local health department could develop and deploy this sort of anti-stigma intervention without investing a great deal of time and energy beforehand on education and community-building. But recent studies converge on an interesting finding that could indicate a hopeful future for such interventions – namely, that people from disadvantaged social groups are not the only ones harmed by stigmatization. For example, two studies by Masuda and colleagues suggest that stigmatization directed toward other people is positively related to the stigmatizer’s own psychological distress [40]. And Friedman et al have found that perceptions of “reverse discrimination” by White people may have significant health consequences, including the hastening of inflammatory processes that could increase the risk of cardiovascular disease [39]. Armed with this knowledge, public health officials could design campaigns that increase the motivation of stigmatizing groups to curtail prejudicial statements by saying, in effect, that “this hurts you, too!” This notion is consistent with one of the basic tenets of stigma theory, which suggests that “undermining the distance or distinction between self and others is an important process in stigma reduction interventions” [40,59]. It is also consistent with the long-standing observation that individuals who stigmatize must be motivated to change their ways “not only because it helps those that are stigmatized, but also because it is in one’s own self-interest” [40,64].

With respect to traditionally vulnerable population groups, local practitioners should also take care to understand the particular coping resources that group members may soon be required to use; resources that may enhance their experience of self-control, optimism and social support. This is especially important when considering the case of Latino immigrants, as a prevailing backdrop of immigration-based stigma can hasten the choice of maladaptive coping strategies, including self-enforced social isolation. In addition, perceived discrimination and other psychosocial stressors may impact the body’s ability to ward off viruses, or to gain full protection from antiviral vaccines [65]. When the impact of stereotypes and stigmas is reasonably low, or when the prevailing social milieu permits open and frank discussion, Latinos and members of other disadvantaged groups can be quite resourceful in terms of protecting themselves from the flu, and in getting the support they need if they actually become ill. Here, the concept of destino seems important; suggesting, perhaps, that pandemic planners should direct more effort to supporting the religious and community organizations that can help local residents cultivate this resilient quality.

It is important to acknowledge the limitations of our study. Again, a small sample size means that our conclusions cannot be broadly generalized to other people and groups. And though we argue strongly for the validity of our results, we must note that they are based upon a fraction of the content available in our focus group transcripts; simply put, these groups were not designed to elicit discussion about stigmas or stereotypes. With all of this said, our study design was entirely appropriate for the task at hand. The focus group is an optimal research method for exploring people’s knowledge and experiences in their own language [66,67]. This enhances the validity of our participants’ comments, since discussions about the stigma associated with H1N1 arose organically, without heavy-handed prompts from the moderator. Focus groups are also useful for examining people’s perspectives on sensitive topics, especially when participants might otherwise be marginalized in the realm of public discussion [66-68]. The conversation that developed freely between moderators and respondents, within the safe confines of a small group, allowed for “extensive probing, follow-up questions, discussion and the observation of emotional reactions” [67]. For all of these reasons, we feel confident in our choice of research methods and in the results they produced.

Our study has highlighted some of the ways in which flu pandemics can be significant sources of individual and social stress. Apart from anxiety over personal and family health, and disruptions to jobs and social relations, flu-related stress can also lead to the stigmatization of marginalized social groups. Our data show how certain elements of stigmatization – perceived and actual – were present in four Massachusetts communities shortly after the onset of the 2009 H1N1 pandemic. And apart from simply illustrating these problems, the data also suggest ways in which public health and emergency management officials can anticipate and mitigate the negative impacts of future pandemics. Armed with a thorough understanding the racial/ethnic makeup of a community – including historical patterns of stress responses and coping behaviors during emergencies – local officials can develop community-wide efforts to prepare for the possibility of stigmatization and, in some cases, to prevent it. They can work with churches and community groups to communicate about the coming threat in a way that eases social tensions and helps members of traditionally marginalized groups to draw upon their own unique resources in crafting resilient responses to pandemic outbreaks. Recent studies have also shown the importance of anti-stigma interventions that go beyond simple community-wide education about stereotypes and prejudice, and developing these interventions should be a key focus of future research. In particular, it seems important to address the underlying social and psychological factors that permit stigma to surface and persist – hence, the importance of interventions that bolster the psychological flexibility of both stigmatizers and the stigmatized.

Community resilience during pandemics and other disasters is, in the words of Shoch-Spana, “a complex process of adaptation – a collective roll with the punches – that taps into a locality’s social and material strengths” and communal stories [69]. The task of designing pandemic communication campaigns that work in harmony with these dynamics can be difficult, however, since it is not always clear that the residents who are most vulnerable – in terms of health status, socioeconomic position (SEP) and health literacy – can access, understand and act upon credible information about the risk of contracting the disease [22]. For example, people who live in high SEP communities may have access to better information about public health threats than people from low SEP communities. They may also be more likely to comprehend important health communication messages, and to take effective action based on preventive measures that are suggested. With these factors in mind, future research on stigma prevention might consider various ways in which public health practitioners can limit, or even prevent these communication inequalities when pandemics threaten their communities [22,70].

To protect the health of all Americans, public health officials must do more to combat the historical tendency to conflate the spread of infectious disease with the innate characteristics of foreigners and members of racial/ethnic minority groups. When outbreaks occur, officials must hold this tendency in check until scientists are able to convey a more accurate picture regarding the etiology of the disease in question [71]. Research on this and other communication problems during pandemic outbreaks will become increasingly important in years to come, as we strive for greater knowledge about the ways in which social and cultural forces influence the origin and propagation of disease. Armed with a better understanding of social vulnerabilities, we can develop pandemic planning policies that are more responsive to the basic human needs that arise during times of crisis [72].

The authors declare they have no competing interests.

MM designed the present study, was the primary focus group analyst, and conceptualized the manuscript. VV is Principal Investigator for the LAMPS project (see Acknowledgements); he supervised all aspects of the present study and provided scientific direction and guidance. SM is Project Director for the LAMPS study; she was responsible for study implementation and supervised data gathering throughout the focus group process. All authors reviewed MM’s analyses and contributed to successive drafts of the manuscript. All authors read and approved the final manuscript.

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2458/13/1116/prepub