**3. Stigma in previous pandemics**

Throughout history, human beings have been exposed to dangerous diseases that force them to change their behavior to adapt to new conditions. WHO has defined a pandemic as "the worldwide spread of a new disease". From smallpox of the 19th century to COVID-19 of the 21st century, epidemics and pandemics have always been associated with stigma and serious social consequences [12]. Apart from natural disasters or wars affecting a certain geographical region, infectious diseases affect the whole world and humanity without borders, as we witnessed in the COVID-19 epidemic. To date, there have been 21 pandemics affecting humanity. The most wellknown and most severe of these is the plague epidemic that emerged in the fourteenth century. In previous studies, it was reported that the population of the whole world decreased by 1/4 in the plague pandemic and the population of many important cities was completely destroyed [13, 14]. Other major pandemics are Spanish Flu (1918–1920), HIV epidemic, Smallpox in the former Yugoslavia (1972), severe acute respiratory syndrome (SARS) (2003), "Swine Flu" or H1N1/09 (2009), Middle East Respiratory Syndrome (MERS), Ebola (2014–2016), and ZIKA (2015–2016) pandemics. These pandemics have caused many casualties [15]. There are differences between the first known pandemics and more recent pandemics because during the first pandemics the population was independent of each other, that is, isolated. However, in the present times when human mobility has increased, the significant increase in interregional and even intercontinental communication and interaction has changed the course of today's pandemics. On the other hand, the development of transportation and communication in the global arena and increased contact with a different human, animal, and ecosystem populations facilitated the spread of the pandemic [16]. Medical stigma is seen in almost every period of history. Diseases such as leprosy, plague, syphilis, tuberculosis, cancer, AIDS, which affect societies, are the diseases that cause stigmatization [17, 18]. As diseases such as tuberculosis and syphilis became treatable, stigmatizing attitudes towards these diseases decreased over

time [19]. Leprosy, which has a history as old as human history and is one of the first stigmatized diseases, was described as an "evil" given to man by God [20]. Those who contracted syphilis in the fifteenth century were condemned by society. Tuberculosis, named in the eighteenth century, was seen as a disease belonging to the lower class. Since the 1900s, with the recognition of cancer types and the increasing number of people receiving this diagnosis, prejudiced behaviors have been made against cancer patients, and discriminatory approaches against cancer patients have continued until the last 20 years. There were comments about AIDS, which emerged in the 1980s and was formerly known as a homosexual disease, as "a punishment given by God to sinners". Along with cancer, tuberculosis, leprosy, syphilis, and epilepsy, AIDS has also become one of the diseases that create stigma [20].

#### **4. COVID-19 and stigma**

During the pandemic process, people's relationships with each other have changed. Newborn baby visits could not be made, university graduates could not share their graduation moments with their loved ones. Many people were not able to physically meet with their elderly family members. Many people were unable to attend the funerals of their closest relatives and friends, and could not adequately mourn their loss [21]. As a result of all these changes, stigma has been an important problem during the COVID-19 pandemic period. It has been modified through human interactions, social distancing, and other restrictions to limit the spread of the virus. Much more emphasis has been put on health systems, which are often under heavy load, and they have become inadequate. Inadequacies in health systems have led to inequalities among people in accessing health. As a result of health inequalities, the COVID-19 pandemic has rekindled or strengthened sensitive social issues such as stigma, discrimination, and racism [22]. In a qualitative study conducted in Pakistan, participants described their neighbors' hostile attitudes when COVID-19 was detected in their family members. Neighbors asked some people to leave the neighborhood. A person whose spouse had COVID-19 reported that other family members were reluctant to meet with him, even though his spouse's test result was negative. This stigma has even been reported among doctors. A 55-yearold doctor whose wife contracted the coronavirus explained that despite a negative test result and taking protective measures at work, he was treated as if he was a carrier of the infection. People who have been found to have COVID-19 in their relatives have also been exposed to discrimination in the workplace. Some participants felt that the stigma and discrimination they faced in their region were so great. They reported that they had a problem and that they were planning to change their houses [23]. We can say that this group is at high risk of stigmatization since the disease especially affects the population over the age of 65. At the same time, returnees from abroad face stigma [24]. Stigma has become a serious problem for healthcare professionals, especially during the COVID-19 pandemic. During such epidemics of widespread infectious disease, healthcare workers are often stigmatized by people in their own community [3]. During the COVID-19 pandemic, healthcare workers are hailed as "heroes" in the media. However, this does not eliminate the possibility of discriminatory attitudes towards healthcare professionals based on the fear that healthcare professionals are carriers of COVID-19. In a study conducted in the United States and Canada during the COVID-19 pandemic, an online questionnaire about stigmatizing healthcare professionals was administered to 3551 non-healthcare workers. More than a quarter of respondents reported that health workers should be kept separate from their communities and families. More than one-third of respondents reported avoiding healthcare workers for fear of infection. People

*Perspective Chapter: Psychosocial Impact of COVID-19 – Stigma and Xenophobia DOI: http://dx.doi.org/10.5772/intechopen.101527*

who stigmatize healthcare workers also tend to avoid other people, avoid pharmacies and supermarkets, and stay at home all the time [25]. In a study conducted in Egypt with 509 physicians, 138 of whom directly care for COVID-19 patients, 159 (31.2%) physicians reported severe COVID-19-related stigma. The overall COVID-19-related stigma score was higher in those working in the quarantine hospital. A significant number of physicians have experienced the stigma associated with COVID-19 [26]. In another study conducted with 529 physicians during the COVID-19 process, approximately one-third (31%) of the participants reported that they were concerned about stigma due to their profession as a healthcare workers. About 13.8% reported that they were worried about avoiding family members due to stigma [27]. Stigma adds an unnecessary burden to healthcare workers' lives and can contribute to healthcare worker burnout [28]. For this reason, protective measures should be taken against stigmatization, especially among healthcare professionals, and more support should be provided to healthcare professionals in this regard. In cases where stigma is high, people may tend to hide the disease as a coping strategy to avoid discrimination. Hiding infections and avoiding testing is a serious problem and can contribute to an increased risk of infection and a decrease in protective behaviors [29]. Additionally, the stigma associated with COVID-19 can become a barrier to control and prevent COVID-19. It is because people with high levels of stigma are less likely to explain their health status and seek treatment [13]. WHO Director-General Dr. As Tedros Adhanom Ghebreyesus stated that "Honestly, stigma is more dangerous than the coronavirus itself" [30]. The stigma associated with infectious diseases is associated with the clinical features of such diseases and socio-cultural factors [31, 32]. For example, hepatitis A survivors rarely suffer from stigma, but hepatitis B and C survivors often experience high levels of stigma due to more serious long-term effects [33]. Because COVID-19 disease is caused by a new virus, it is not clear how widespread or severe stigma is among survivors. The effect of stigma in the future is a matter of curiosity.

#### **5. Definition of xenophobia**

Xenophobia is literally a compound word formed by two Latin words. It found its semantic equivalent with the combination of the words xénos, which indicates the difference, and phóbos, which means fear and/or horror, and entered the literature in the sense of the individual or society's fear of the foreign and different from themselves. The state of being afraid of strangers, which is mentioned within the scope of the definition of xenophobia, also includes a discriminating, hateful, humiliating, and standardizing hostile attitude towards a different person. In this context, the target audience includes people who are not those from the relevant region, who are not citizens, or who differ in this context [34]. Xenophobia is defined as "attitudes, prejudices, and behaviors that reject, exclude, and often disparage people who are foreign to the society or national identity or who are perceived as a foreign" [35]. In order to understand the concept of xenophobia, it is useful to distinguish it from the concept of racism, which is often confused with each other. While xenophobia expresses a behavior based on the idea that the other is alien to the group; racism explains discrimination based on differences in physical characteristics such as skin color, hair type, and face shape. Racism is also considered the most extreme level of xenophobia [35]. In recent years, migration movements have increased and continue to increase in the world with the expectation of regional conflicts, climate change, security, employment, education, health, and generally higher welfare [36]. While the concept of alien can be considered a universal concept, this is not the case for xenophobia. Xenophobia is an emerging

concept: it was first used by Anatole France in 1901 in Monsieur Bergeret a Paris. Situations such as the term anti-Semitism of the Dreyfus affair that shook domestic politics in France at the turn of the twentieth century, and the violent form of nationalism that emerged at the time provided a social and political background for xenophobia [37]. In 1906—the full year of Dreyfus' rehabilitation - xenophobia was first listed in a French dictionary: Nou eau Larousse illustre. In the following years, it was included in the dictionary in many languages, especially in English [38]. The concept of xenophobia came to the fore again in the COVID-19 epidemic and became the subject of research.
