無污名地接觸弱勢群體
資料來源：http://www.thelancet.com/infection VOL 2022 年 8 月 22 日 / 財團法人台灣紅絲帶基金會編
截至 6 月 30 日，在流行地區（西非和中非）以外，已有 5,323 例猴痘病例。這些病例主要集中在美國和西歐，大多數報告發生在男男性行為者 (MSM) 中，但並非全部。這就提出了一個問題，如何向處於危險中的人群（此處為 MSM）提供健康信息而不給他們帶來污名？
隨著疫情的爆發，例如目前的猴痘，最重要的事情是那些感染者尋求醫療照護。污名——即因感染而責備和羞辱個人——可以防止這種情況發生，進而阻止接觸者追踪和其他遏制措施。有些人可能希望污名能夠糾正（真實的或感知的）行為。然而，我們從持續的愛滋病毒大流行中知道，羞恥並不能阻止傳播，只會導致個人遭受孤立的痛苦和死亡。與 MSM 的關聯並不是當前猴痘爆發引發的第一個潛在的恥辱風險。 5 月 21 日，非洲外國記者協會發表聲明，譴責在英國和北美報導猴痘的文章中使用「深色/黑色和非洲膚色」的人。使用此類圖像可能會進一步強化猴痘是一種「非洲」疾病的觀念，增加對這些群體的懷疑和恐懼感。謹慎傳遞信息的責任不僅適用於公共衛生當局，也適用於新聞媒體。
透過僅顯示深色皮膚來突出猴痘也可以逆轉醫學中的常見問題。醫學教科書通常會展示白色或淺色皮膚的皮膚疾病，這會導致對深色皮膚的類似疾病進行診斷的困難。與猴痘相關的媒體圖像可能使那些皮膚較淺的人（即歐洲和北美的大部分人口）更難注意到自己的症狀。例如，與猴痘相關的皮疹在淺色皮膚上看起來比在深色皮膚上的類似症狀更紅。
將公共衛生信息的重點放在特定群體上，也會在該群體之外的人中產生自滿情緒；給人的印像是他們沒有風險，因此不需要採取預防措施或尋求幫助。如果一種疾病被認為只是某個特定群體的問題（或者甚至是錯誤），它可能會阻止產生足夠的政治意願來分配適當的衛生資源和人員來解決它。
因此，消息傳遞非常重要。任何信息都必須提供事實——某些群體的風險更大，可能更可能需要醫療照護——而不是分擔責任。它還需要承認不確定性——例如，某個群體現在處於危險之中，但病毒沒有歧視，任何人都可能被感染。這既可以防止其他公眾產生虛假的安全感，也可以減少信息更新時的挫敗感或困惑感。最後，理想情況下，任何此類信息都將得到目標人群信任的團體的批准和響應，正如特倫斯希金斯信託基金在英國的猴痘信息所示。
COVID-19 已經向我們展示如果我們傳遞錯誤信息會發生什麼。在整個大流行期間，團體和個人（無論是出於惡意還是出於無知）齊心協力將 SARS-CoV-2 貼上「中國病毒」的標籤，這一標籤與反亞洲情緒的抬頭和針對亞洲社區。 SARS-CoV-2 變體甚至以希臘字母（alpha、beta 等）命名，而不是最初發現它們的地方（英國、南非等），部分是為了減少地理污名。已提議重命名猴痘進化枝（目前指定為中非和西非進化枝）以消除類似的污名。這樣的舉動是受歡迎的，重要的是要避免暗示指責的名字，但我們還必須確保在焦點轉向非流行地區時，最需要支持的地區不會從談話中消失。
雖然相信一種疾病只會影響他人可能令人欣慰，但這種想法並不能控制疫情的爆發，而且污名化很可能會擴大它。
■ 刺胳針傳染病
Reaching the vulnerable without stigma
http://www.thelancet.com/infection VOL 22 August 2022
As of June 30, there have been 5323 cases of monkeypox outside of endemic regions (west and central Africa). The cases have largely been centred in the USA and western Europe and most have been reported in men who have sex with men (MSM), but not all of them. This raises the question, how to provide health information to a population at risk (here MSM) without stigmatising them?
With outbreaks, such as the current monkeypox one, the most important thing that needs to happen is that those infected seek medical care. Stigma—ie, blaming and shaming an individual for their infection— can prevent this and, in turn, prevent contact tracing and other containment measures. Some might hope that stigma serves as a corrective of (real or perceived) behaviour. However, we know from the ongoing HIV pandemic that shame does not prevent transmission and only leads to individuals suffering and dying in isolation. An association with MSM is not the first potential stigma risk the current monkeypox outbreak has raised. On May 21, the Foreign Press Association, Africa, released a statement decrying the use of people with “dark/black and African skin complexion” to accompany articles reporting on monkeypox in the UK and North America. The use of such images runs the risk of further intrenching the idea that monkeypox is an “African” disease, increasing feelings of suspicion and fear towards these groups. The responibility of careful messaging not only applies to public health authories but to news media as well.
Highlighting monkeypox by only showing dark skin also presents a reversal of a common problem in medicine. Medical textbooks typically showcase skin ailments with white or lighter skin, leading to difficulties in diagnoses of similar conditions in those with darker skin. The media images related to monkeypox might have made it more difficult for those with lighter skin—ie, large portions of the populations in Europe and North America—from noticing their own symptoms. For instance the rash associated with monkeypox can look redder on light skin than similar symptoms on dark skin.
The focus of public health messages on a particular group can also generate, in those outside of this group, feelings of complacency; the impression that they are not at risk and so do not need to take precautions or seek help. If a disease is seen to be only the problem (or perhaps even the fault) of a particular group, it can prevent the generation of sufficient political willpower to allocate appropriate health resources and presonnel to tackle it.
The messaging is therefore incredibly important. Any message must provide the facts—that certain groups are more at risk and might be more likely to require medical attention—without apportioning blame. It also needs to be accompanied by admissions of uncertainty—eg, that a certain group is at risk now, but that the virus does not discriminate, and anyone could become infected. This both prevents a false sense of security in the rest of the public and also reduces feelings of frustration or confusion when information is updated. Lastly, any such messaging would ideally be approved and echoed by groups trusted by the target population, as seen with the Terrance Higgins Trust’s monkeypox information in the UK.
COVID-19 has already shown us what can happen if we get the messaging wrong. Throughout the pandemic, groups and individuals (either through malice or ignorance) have made concerted efforts for SARS-CoV-2 to be labelled the “Chinese virus”, a labelling that has been implicated in the rise of anti-Asian sentiment and attacks against Asian communities. SARS-CoV-2 variants were even named after Greek letters (alpha, beta, etc) as opposed to where they were first identified (the UK, South Africa, etc), in part, to reduce geographical stigma. Renaming of monkeypox clades (currently designated as central African and west African clades) has been proposed to remove similar stigma. Such a move is welcome, it is important to avoid names that imply blame, but we must also ensure that regions needing the most support are not erased from the conversation as focus turns to non-endemic areas.
While it may be comforting to believe that a disease can only affect others, such thinking will not control an outbreak and stgimatising may well extend it.
■ The Lancet Infectious Disease