Structural Stigma, Legal Epidemiology, and COVID-19: The Ethical Imperative to Act Upstream

The primary claim of this paper is that COVID-19 stigma must be understood as a structural phenomenon. Doing so will inform the interventions we select and prioritize for the amelioration of such stigma, which is an ethical priority. Thinking about stigma as a macrosocial determinant of health driven by structural factors suggests that downstream remedies are unlikely to be effective in significantly reducing stigma. This paper develops and defends this claim, setting up a recommendation to use a "bundle" of legal and policy levers at meso- and macro- levels to reduce the adverse and inequitable impact of COVID-19 stigma. In Section II, this commentary offers a basic account of the concept of stigma in general, the justification for conceptualizing it as a structural phenomenon, and some of the basic advantages of doing so. Section III moves on to frame infectious and communicable disease stigma in Western history not only as a way of demonstrating its structural features, but also to highlight the use of laws and policies as levers for public health change. Section IV urges explicit adoption of insights and methods from legal epidemiology and offers examples of specific legal and policy recommendations for addressing these stigmas. Section V concludes.