By: Jack Nguyen, DDS, MS

What would you do if you actually ran out of toilet paper? Any given answer could plausibly work; however, think about what types of emotions were provoked by that question. What are some things that cause fear? A few examples might be heights, needles, sharks, deep waters, dogs and viruses. There’s an endless list of fears that we all have and somehow, many of us simply accept it. Do you ever wonder why you have the kind of fears you do? What are some of the things you do as a result of fear?

When you look up the word “fear,” various literature and online definitions consistently state something of an emotional response to an immediate danger or threat. Psychologists often pair fear and anxiety; however, the former can be defined as a response to an immediate danger.¹ Anxiety then, is a generalized response to an unknown threat or future danger.^1,2 Consider a patient who experiences anxiety upon learning of treatment that requires anesthetic versus their fear upon first sight of a needle.  

With this generalized idea of fear, where does it come from and why do we all experience it? Without getting lost in the weeds of physiology and biochemistry, scientists posit the emotion of fear originates within the amygdala of the brain and is stimulated and regulated by the interaction of hormones and chemoreceptors.^2,3 Fear can protect us when walking near a cliff. Fear can arouse us as such in horror films. Fear can also hurt us. Think about those who freeze when they encounter a perceived dangerous situation. During a trip to the beach, a close friend walked into the water and stopped when the water reached his knees. After swimming a quarter-mile out and back, I realized he was still standing in the same spot. While shaking his head, he stated, “I can’t go out if I can’t see my feet.” Then he asked, “Aren’t you afraid of sharks or something?” My response was that I was not afraid of sharks, but I’m definitely afraid of being bit by a shark!

Now let’s dig deeper into how we deal with fear. Two mechanisms are described by Steimer, passive coping strategies and active coping strategies.¹ Passive coping is when you feel you cannot escape a threat and you “lock-up.” Active coping is described as one engaging in protective action. Imagine a large brown dog that suddenly barks in front of you. You may squint your eyes, clench your teeth and clinch your fists. On the other hand, you might jump away, swing your arms or even scream. These days, you will seldom walk through a neighborhood with only one dog. Imagine the next several homes with a fence lining the sidewalk and all of them have dogs. Say you fly your drone above the neighborhood and see only a few houses that do not have a dog. Suddenly, the fear is not as intense and in fact, the potential danger is contained because the information provided by your drone confirms future threats or lack thereof. You now walk down the sidewalk with less trepidation but perhaps, on the side farthest from the dogs.

If this is easy to comprehend, then you likely fit a comfortable majority of people. What about the select few who do not react similarly? Think about a person who reacts violently, without fail, every time they encounter a barking dog. A few people in our community walk along the same sidewalk and brace themselves as a perceived protective measure against dogs in the neighborhood. You might suggest the valid possibility of a history of trauma. Although reasonable, such empathy might give us a better understanding of our social history with fear. More relevant to our healthcare community, fear plays a powerful role in our perception and how our societal attitudes are affected.  

Let’s go back to 1984. Ryan White was a 13-year old, born with hemophilia and contracted AIDS during a blood transfusion.⁵ To be clear it is historically accurate to state that Ryan was diagnosed with AIDS because HIV was not known to be the infecting virus until 1986.⁶ Of course, today we know HIV, (Human Immunodeficiency Virus) the virus that can cause AIDS (Auto Immune Deficiency Syndrome), is not airborne, can be contracted indiscriminate of sexual orientation and is not transmitted by hugging or shaking hands.⁶ Yet, Ryan was labeled gay and suffered painful discrimination.

Adding to the difficulties of being diagnosed with a poorly understood disease, Ryan was bullied because of ignorance and fear of HIV/AIDS by adolescents and adults.¹⁰ At the time, there was no privacy protection as HIPAA was not signed into law until 1996.¹¹ A media frenzy spread national attention on Ryan’s health and fear went to such extremes that local parents of Russiaville, IN pressured school officials to ban Ryan from Western Middle School.^5,6,10 Sadly, Ryan died when he was 18 years old, just shy of graduating high school.^5,10 According to the World Health Organization (WHO), approximately 32 million people globally have died of HIV since the beginning of the epidemic.^8,9

Certainly this was not a proud highlight for the 80s. Scientists and healthcare providers were all rapidly mobilizing to understand HIV/AIDS for the first part of the 1980s.⁷ Societal fear demonstrated dark moments and revealed a deeper complexity of how fear can hurt people through xenophobia and social stigmas.

If our basic understanding of fear, anxiety, coping behaviors, xenophobia and social stigmas can be reduced by their own actors, then our willingness to acknowledge and engage this information proactively should result in a vaccination of these conditions.  Sound lofty? This is what the Centers for Disease Control and Prevention (CDC) has labored over for the last few decades. Their cumulative collection of data has precipitated the urgency for not just disease control, but for impactful education for humanity.

Deliberate effort was made to use credible sources in defining the following words in addition to Google, Meriam-Webster and Wikipedia. ^{13,14,16,17,18,31} Most everyone has access to the same sources; however, I find it easier to compile relevant words and definitions in one place.

• Outbreak: a rise of a disease in excess of normal expectancy.
• Epidemic: an occurrence of an infectious disease within a community at a given time.
• Pandemic: the worldwide spread of a new infectious disease.
• Discrimination: unjust or prejudicial treatment of different categories of people.
• Racism: discrimination or prejudices directed against someone of a different race based on the belief that one’s own race is superior, or another is inferior.
• Stereotype: a widely held but fixed and oversimplified image or idea of a particular type of person or thing.
• Xenophobia: fear or contempt of strange or foreign people, places or things.
• Social stigma: negative social meanings or stereotypes assigned to people when their attributes are considered both different and inferior to societal norms.

Since most of the above were already described, let’s use some examples to understand the later definitions. 

Notice that stereotypes do not necessarily have a negative connotation. Also, racism assumes a certain superiority/inferiority belief. As of this writing, I must admit a correction to my past usage of the word racism. In contrast, most all xenophobia and social stigmas have a negative implication. The later words have more frequently been among the many unfortunate outcomes of a disease outbreak.^{6,12,13,18,42,43} Any discrimination of a group of people based on perceived social characteristics undermines the fabric of diversity and inclusiveness. Consider why the CDC would create an entire site for this issue.¹⁸

We often make facetious comments not realizing how they can reinforce social stigmas.  It could have been when we were innocent kids or naïve teenagers. Even if not ill-intended, there are moments when we need to realize our words can have a greater negative impact on people, say during a pandemic when fear and vulnerability are heightened. Simply saying it’s “wrong” all these years has only been the first step. A STOP sign has merely been put in front of us. By redirecting the traffic of social stigma, people can be more proactive in their everyday dialogue.

In a recent correspondence, I received an email from a banker offering assistance for the “business hardship related to the Wuhan virus.” Would this be an example of xenophobia or a social stigma? To be fair, I did not believe the email came from a hateful place. Nevertheless, I was caught off-guard as I had worked with this banker in the recent past. Instead of replying with condemning language, hence a STOP sign, a proactive email was sent outlining the potential harm that was counter-productive to social stigmas. 

Another example many of us can relate to would be the toilet paper hoarding. Fear and anxiety play an immense psychological role that support coping mechanisms. Somehow the perceived threat of running-out of toilet paper superseded washing of hands or covering ones cough. Combine misleading online searches, viral videos showing empty store shelves and the social media storm that magnifies the response. Research shows that people will take precautionary actions during a pandemic to comfort their vulnerability even if these actions do not decrease risk.^19,20,31 However irrational, including failure to comply with Shelter-In ordinances, hoarding toilet paper follows the pathogen prevalence theory by Fincher et. Al, where populations will behave collectively as an antipathogen defense function.²⁰

But are we perpetuating the problem unknowingly? Why would anyone be afraid of running-out of toilet paper? Above any response, the answer will ultimately point to the simmering fear of the coronavirus pandemic. So then, how frequently do we hear the phrase, “people are crazy”? A proactive response might be to inform people of what the coronavirus is and what can/cannot prevent exposure. Even in a safe circle of friends, this reflex response can unconsciously enable dismissive language that passively reinforces xenophobia.    

If you are in the healthcare community, I challenge you to do your research and strengthen your applied biological science background. You already have the training to research PubMed and learn a little about virology. You might be surprised that we’ve known about coronaviruses since the mid-1900s.^29,32 For example, while reading about the 2003 SARS coronavirus, the virus structural lipoprotein envelope was described in great detail.^29,32,33 The prefix “lipo” is Greek for fat.³⁵ When washing our hands and dishes, soap is commonly used to emulsify fats and oils owing to the hydrophobic/hydrophilic properties of fatty acids and salts like sodium stearate.³⁴ We can surmise that washing our hands using basic soap is effective in breaking up lipoproteins of coronaviruses. More specifically, a virus is not a living organism like bacteria, so anti-bacterial soap is not necessarily more effective if you want to kill viruses.³⁰

We need heroes. We need to be reminded of the heroes that lead with their selfless courage to face fear and protect others. Heroes have supernatural abilities that transcend peoples’ understanding of the status quo.

Ryan White is my hero! What makes Ryan a superhero is the fact that at age 14, he faced a debilitating disease, endured the many stigmas associated with HIV/AIDS and chose to do more. In an interview with his mother, Jeanne White Ginder, Ryan expressed his desire to go to school and see his friends. Instead of sitting around, Ryan got a J-O-B, paying a mere $3.50 an hour at a skateboard shop. Can you imagine your friend, sibling or child saying “…you don’t get it. I got a job just like everyone else does.”?¹⁰ Raise your hand if you and your patients have benefitted from the Ryan White HIV/AIDS Program.  

Jeanne White Ginder is my hero!  Being a single mother to Ryan was hard enough but despite all the doctor visits, media attention, public criticism, moving across cities so Ryan could go to school, Jeanne’s fear turned into superpowers so that her son could live forward. Let us not forget men are born of the mothers that made them.

Remember Earvin Johnson? Better known as Magic Johnson, on November 7, 1991, he announced to the world that he was HIV-positive, thereby retiring his basketball career.²¹ With an impressive five championship titles, three MVP awards and an Olympic Gold Medal, Magic set his entire athletic career aside so he could selflessly protect others.^21,22 Magic gave candid interviews to discuss his experience with HIV from his initial anxiety to learning and understanding HIV and how to live with it.²² After his public announcement, he became a staunch advocate for getting HIV testing and motivating people to talk about these issues. Undeterred by fear, Magic Johnson wanted to educate people by discussing his most private information, his medical health. For his courage to speak out, Magic Johnson is my hero.

In more recent news, on March 11, 2020, Tom Hanks and wife Rita Wilson publicly stated they tested positive for the coronavirus via Twitter.³⁷ That very same day, the World Health Organization officially declared the COVID-19 outbreak a pandemic.²³ Both Tom Hanks and Rita Wilson are heroes. I don’t believe Mr. Hanks was trying to promote his next film by disclosing his viral infection. Amidst all the uncertainty with the coronavirus, even trusted and respected celebrities understand the power of their influence and these two decided to share their initial experience to ease public anxiety.

You are my hero! The healthcare community is where the people turn during these fearful times. Our Hippocratic Oath matters most now. The medical and scientific team were fighting to keep Ryan White alive. Magic Johnson put his trust and fear behind his doctors. Tom Hanks and Rita Wilson professed their confidence in the expertise of medical professionals. Heroes lean on each other and fight the greater threats together. They are leaning on you.

You don’t have to be among the army of first responders on the front lines of this pandemic. What makes you a hero is your choice to be a healthcare professional. The public trusts you to simply share words of comfort to alleviate their fear and anxiety. The public respects how hard the healthcare community is working to fight this pandemic and they trust that you will be their hero. Governors from different states are in short supply of heroes like you.²⁵ Still need convincing? Think about the citizens that are staying in and cheering for you from their balconies in Italy, Spain and here in the United States.^38,39 

It’s imperative that doctors use their powers responsibly. Treatment planning and clinical skills are one set of responsibilities. Running a business is something else entirely. But what does it mean to be a doctor? You have specialized training to read and understand scientific literature. You have acquired the skills to decode complex medical language with uncanny mental stamina. You have the responsibility to compassionately disseminate useful guidance to your patients. You have the collective power to fight fear, irrational purchasing of toilet paper, xenophobia and social stigmas. Demonstrating your leadership to your team and patients helps the healthcare community understand the greater good and how to protect their loved ones. By then, you might notice toilet paper becomes more accessible!

Simply telling a patient not to worry is easy. It’s human nature to worry, but to have unanswered worry builds anxiety and stress behavior.^4,36 When you talk to a patient on what they can do to protect themselves and others, it is more effective in restoring their sense of control. Letting a patient know why they need to stay-in, has greater impact coming from a healthcare professional.

As healthcare professionals, we engage in casual conversation every day, but we are not exempt from the effects of innocent humor as it relates to xenophobia. Even those nearest may be afraid but show fear in an atypical way. Sometimes a person may express fear through laughter. I’m sure you have observed this in your office. It’s important to recognize this clinical occurrence outside your practice. Fear underlies dangerous social stigmas and at times, signals a false green light to reinforce them even without evil intent. Stigmas can be more dangerous and longer lasting than an infection itself.¹⁹ How often do you still hear the stigma of dentists and suicide? One might laugh it off, but are we afraid of being judged? Maybe you can inform them of what profession has consistently ranked in the “Best Jobs” by US News and World Report since 2007.⁴⁰   

Using your powers to educate employees and providing security to their families reinforces long-term faith in your leadership. Having a plan of action on how to appropriately communicate facts through your team to your patients enables a continuity of trust. Connect with your colleagues, local and state leadership because they too see a bigger picture and share your concerns. They too are aware of the delicate balance between you as a healthcare superhero and your family’s safety. When socializing with friends and families, listen to their words and help redirect the dialogue away from social stigmas by empathizing with peoples’ fears, just like Park Hyun, a coronavirus survivor in South Korea who is adapting to life after infection.¹²

Courage is calling all, healthcare providers! You can do more. When providers battling the front lines announced their need for medical supplies, your impressive response in donating personal protective equipment demonstrated national unity. Behind the scenes, researchers have been able to replicate the coronavirus and sequence the entire genetic make-up in rapid fashion, taking less than two months.²⁶ Companies like Moderna and Johnson & Johnson have partnered and have been given unprecedented FDA clearance for vaccination testing and scaling production.^27,28 The National Guard and U.S. Navy were deployed to help expand a mobile hospital facility for up to 1,000 patients in New York and Los Angeles.⁴¹ The technological coordination of information through intercontinental organizations has demonstrated an immense global effort to fight this pandemic. The environment of healthcare is changing fast and I’m proud to do more with heroes like you to strengthen our healthcare community and the lives of others.

Thank you for being my hero! 

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Jack Nguyen, DDS, MS is a graduate of the University of the Pacific, Dugoni School of Dentistry and has been in private practice for over 10 years in Denver, CO. When not swimming or diving, Dr. Jack devotes his time towards R&D in science, healthcare technology and product development. Dr. Jack is involved with organized dentistry with a focus on integrity and leadership.