During the first week of April 2003, the National Center for Infectious Diseases (NCID) at the Centers for Disease Control and Prevention (CDC) formed a 14-member, multidisciplinary NCID/SARS Community Outreach Team as part of its emergency response to the global SARS outbreak. While other NCID/CDC response teams dealt with laboratory investigations, surveillance, communication, and clinical infection control practices, the Community Outreach Team worked to implement rapid public health strategies to document, monitor, and assist in ameliorating specific problems associated with fear, stigmatization, and discrimination attributed to the SARS outbreak in the United States.
In creating a rapid public health intervention to mitigate behaviors and practices associated with SARS-related fear, the team recognized the need to address the experiences of persons at greatest risk for experiencing SARS-related fear, stigma, and discrimination. The team monitored stigmatizing ideas and behaviors in the general population and the media, particularly toward Asian Americans, who were disproportionately reporting fear, stigmatization, and discrimination compared to the general public. The team began working with Asian-American communities to develop a culturally tailored intervention that 1) promoted community understanding of the facts related to the transmission and prevention of SARS; 2) contributed to the strengthening of community resiliency and capacity to mitigate fear, stigmatization, and discrimination; and 3) encouraged appropriate health-seeking behaviors for those who may have been exposed to SARS and were experiencing early symptoms. The team also worked to dispel myths; keep the general public better informed; prevent discrimination against SARS-affected communities; and provide guidance for institutions, agencies, and organizations hosting international visitors from SARS-affected countries.
Rapid Situational Assessment
During the first 3 weeks of April 2003, the NCID/SARS Community Outreach Team conducted a rapid situational analysis to determine the impact of SARS-related fear, stigmatization, and discrimination within the Asian-American community in the United States. The team carried out the following activities: 1) facilitated group discussions with key opinion leaders within the Asian community in the United States; 2) collected and monitored the CDC Public Response Service data; 3) collected and monitored Asian-language newspapers, Internet sites, and other information sources; 4) reviewed polling data and other communication information; 5) conducted community visits, panel discussions, and media interviews; 6) solicited information from state and regional minority health liaisons nationwide; 7) developed ongoing relationships with the Asian-American communities; particularly in major metropolitan areas throughout the United States; and 8) determined new data-gathering strategies as needed.
The team conducted group interviews through teleconferences with national, state, and local influential leaders in the Asian-American community throughout the United States. The team also conducted group interviews with Chambers of Commerce and trade association members, school officials and representatives, state public health department staff, academicians at universities, mental health professionals, and others. The 11 teleconferences the team conducted reached more than 70 persons who represented more than 50 agencies, organizations, and communities. The goals of the group interviews were the following: 1) determine the impact of SARS-related fear on the Asian community; 2) document examples of fear, stigmatization, and discrimination; 3) determine strategies for identifying and reaching “hidden populations”; 4) develop partnerships with leaders and community members of the affected populations; 5) determine the needs of affected populations; and 6) respond appropriately to those needs through a targeted intervention with activities and Asian-language materials.
Five major recommendations were derived from the facilitated group discussions with key informants: 1) develop simple, tailored SARS prevention messages; 2) develop SARS information materials in various Asian languages; 3) disseminate SARS information through multiple and culturally appropriate channels, including (but not limited to) community visits, town hall meetings, and health education and communication channels to complement mass media messages; 4) establish partnerships with local Asian-American community–based organizations to educate the community; and 5) ensure that CDC would continue to provide leadership and coordination in preventing and controlling SARS. The relationships developed during these group discussions allowed team members to monitor and document ongoing stigmatizing situations related to the disease outbreak in real time and to deal more effectively with intentional and unintentional discrimination.
CDC Public Response Service
CDC operates the Public Response Service (CDC PRS) under contract with the American Social Health Association. This contract provides hotline service to the general public requesting information via telephone and email about bioterrorism and other disease emergencies, including SARS. The NCID/SARS Community Outreach Team worked with the CDC PRS to track a daily sample of incoming SARS-related calls, specifically noting questions associated with fear, stigmatization, and discrimination directed toward the Asian-American community. This system allowed the team to help determine specific answers to frequently asked questions for hotline staff and to develop simple, prerecorded Asian-language messages. Passive data collection of SARS fear-related concerns began on April 29, 2003. During May 2003, 7,327 SARS-related calls were received; 4,013 (54.7%) of these calls were passively sampled. Of these sampled calls, an average of 10% of callers expressed concerns related to fear, stigmatization, and discrimination. A caller could express more than one concern. Major concerns included the following: fear of buying Asian merchandise (187 calls); working with Asians (83 calls); living near Asians (45 calls); going to school with Asians (41 calls); and more generic issus such as being on a cruise ship or airplane (77 calls); and church, school, or workplace issues (65 calls). Most SARS calls related to transmission, symptoms, and treatment of disease and travel advisories.
Asian-Language Information Sources
One critical component of the team’s activities was determining where members of the Asian-American community were getting SARS-related information. Team members monitored English-language and Asian-language electronic, print, and television media coverage and informal chat rooms in the United States and other countries to stay abreast of changing information about the nature of the SARS outbreak that could influence fear, stigmatization, and discrimination. The assessment showed that many people within the Asian-American community were getting information from Asian-language newspapers, television, and Internet sites directly from China, Hong Kong, Taiwan, and other Asian areas—usually hours ahead of information providers in the United States. The information provided by these Asian-language sources was often inconsistent with newspaper, television, and Internet coverage in the United States, thus creating fear and suspicion that the United States government might not be telling the truth about the outbreak in this country. Independent content-analysis research conducted by InterTrend Communications (San Francisco, CA) compared four of the most popular Chinese language newspapers in the United States with two popular national mainstream English-language newspapers from March 21 to April 3, 2003 (15
). InterTrend data showed that 1) Chinese-language newspapers were more likely to highlight SARS news related to the Chinese community in the United States or from China more prominently than mainstream English-language newspapers; and 2) Chinese-language newspapers were more likely to have articles on SARS, including featured in-depth articles, than mainstream English-language U.S. national newspapers (15
). These findings supported the team’s initial assessment (based on an informal convenience sample of Asian-language papers).
General email inquiries sent to the CDC communications center and information from public health professionals, health providers, and community members led the team to SARS-related Internet sites that contained rumors and inaccurate information, which added to general misunderstanding, confusion, and fear. Even legitimate public health Internet sites from different parts of the world provided disparate information as the outbreak unfolded, furthering uncertainty and fear in the United States. The team also monitored Internet sites that supported community fears as they promoted home remedies, medicinal cures, and inappropriate and unnecessary protective equipment. Monitoring the information sources of the affected population was a critical activity, allowing the team to separate fact from fiction with accuracy and timeliness and address salient issues and concerns during community visits.