This study examined the socio-environmental factors influencing the uptake of methadone treatment in Ukrainian prisons, including changes that evolved during Russia’s full-scale invasion of Ukraine and the displacement of people deprived of liberty (PDL) from conflict to non-conflict regions.After pilot testing, methadone was newly being introduced into Ukrainian prisons in 2021 as part of a national scale-up strategy to treat opioid use disorder and prevent transmission of HIV and HCV infections. Opioid agonist therapy (OAT) scale-up in Eastern Europe and Central Asia prisons has been hampered by varying levels of influence of criminal subculture, an extralegal N = 37) were conducted from January 2021 to October 2022 in the only two Ukrainian prisons where methadone was being introduced with PDL (N = 18). These two prisons continued to provide methadone after the full-scale invasion. Former PDL (N = 4) were also interviewed and prison staff (N = 15). Interviews were audio-recorded, transcribed, and translated into English. Four authors independently reviewed, coded, and applied a phenomenological framework for data analysis, delineating themes related to criminal subculture, drug use, methadone uptake, and evolving changes during the Russian invasion.In-depth qualitative interviews (Criminal subculture perceptions varied, with some seeing it as strongly discouraging drug use among certain groups, while others described it as a residual and weak influence from a more distant past. The influence of the subculture on methadone treatment uptake, however, was less clear. PDL and prison staff struggled to identify and articulate differences between illicit street-bought methadone, used recreationally, and medically prescribed methadone. Thus, the meaning of “methadone” varies in interpretation as it is being introduced, making it potentially conflicting for patients to opt into this evidence-based treatment. As Russia invaded Ukraine in 2022, PDL from conflict zones were transferred to non-conflict regions where methadone was being introduced. The prison environment became more enabling for PDL to start methadone as they were segregated and not subject to the existing criminal subculture’s rules and lacked the social ties necessary to procure drugs illegally.It appears that the criminal subculture is variable and evolving in Ukrainian prisons and appears to be impacted differently by the invasion of Russia. As methadone scale-up in prisons expands, it will be important to distinguish the meaning of methadone perpetuated negatively by the prison subculture versus that in which it is intended as a medical treatment by the formal prison authorities. The current invasion of Ukraine by Russia provides a potential disruption to alter this course. The criminalization of drug use concentrates people with opioid use disorder (OUD) and blood-borne infections like HIV (PWH) and hepatitis C virus (HCV) in prisons , 2. MoreMaintenance with opioid agonist therapy (OAT), using methadone (MMT) or buprenorphine, is the most effective treatment for opioid use disorder  among PWUkraine has the second highest number of PWID in EECA and a high HIV prevalence 19–26%) among PWID , making % among PAs there are data before MMT was introduced that a prison subculture existed within some Ukrainian prisons , this quUntil 2016, Ukraine had one of the highest incarceration rates worldwide. The prison census decreased from 160,000 to 49,000 by 2021 due to legislative changes and the introduction of a new probation system starting in 2016. Pre-decarceration data from 2012 showed that among PDL in Ukraine, HIV prevalence was 19.4% and 48.7% are PWID, with over a third meeting the criteria for OUD . No new N = 540) being a prison for recidivists while the other (N = 415) being for first-time offenders.Qualitative, in-depth interviews were conducted with a number of key stakeholders directly or indirectly involved in the prison-based methadone program . The twoThe 2022 invasion of Ukraine by Russia resulted in major shifts in the population. PDL from the frontline regions in the East were transported to the West, where they were housed within the western prison territories but segregated from the other original resident PDL at those prisons. This segregation was purposeful from a security perspective to reduce the potential for tension between existing residents and large numbers of newly arrived PDL.n = 15). Prison staff were included in this study as they consistently interact daily with PDL and could provide outsider perspectives on the dynamics between PDL. In addition, prison staff can markedly influence the shaping of the prison environment, which consequently influences the implementation and uptake of methadone among PDL. PDL enrolled in the methadone program (n = 10) and PDL not enrolled in the methadone program (n = 8) were also identified and recruited in the same two prisons. The final sample interview was conducted until saturation of themes was observed. Both PDL enrolled and not enrolled in the methadone program were included in this study as we sought diverse perspectives and wanted to identify if there were common themes among PDL who chose to engage in the methadone program versus those who did not. Participants were recruited by being called to the doctor’s office by medical staff, where they were told about a voluntary research study about drug use, addiction treatment, and health. A research assistant then explained the study to them and performed consent procedures. Participants were recruited to understand a range of experiences and perspectives, and interviews continued until thematic saturation was reached (n = 4) were also recruited as a part of this study. Former PDL were included in this study to elucidate if any unique changes in perceptions of prison-based methadone occurred post-release and reduce any potential bias of these perceptions that PDL might not want to disclose while still within the prison setting. There were two interviewers who spoke Russian (DJB and MMT) and one who spoke Ukrainian and Russian (LA). Participants chose the language they preferred to speak in. In-person interviews were conducted in the medical administrative facility. This potentially deterred some PDL of higher status from participating as it may have been seen as collaboration with the formal administration. During COVID and after the start of the full-scale invasion, interviews were conducted via video link. In video interviews, participants wore noise-canceling headphones in private rooms within the prison’s medical facility.Using purposive snowball sampling , we iden reached . Former Between January 2021 and October 2022, participants were initially invited to partake in a semi-structured interview guide that was expanded over time to in-depth interviews that explored how criminal subculture interfaces with drug use in the Ukrainian prison setting and how participants understood and experienced the prison-based methadone program to ensure consistency across interviews . The opeThirty-six interview transcripts were analyzed as part of a single dataset, as one interview was not recorded. Professional Ukrainian translators fluent in Ukrainian, Russian, and English transcribed the audio recordings verbatim in the appropriate language (Ukrainian or Russian) and then into English for analysis. Author LA reviewed all Ukrainian and Russian to English transcripts for quality assurance. Four authors  independently reviewed the transcripts and created a coding scheme relevant to the criminal subculture, methadone treatment, and the Russian invasion. A phenomenological framework was used for data analysis as we sought to understand participant perspectives on an experiential phenomenon of interest; in this case, the role of a criminal subculture within Ukrainian prisons, within the context of participants’ lives. We follow this framework to ask what is meant by the phenomenon of a criminal subculture and how it operates in the lived experience of people in Ukraine to shape their relationship to methadone treatment. Subjective understandings of the criminal subculture shape decision-making regarding the utilization of program methadone, hence the utility of this framework .An open-coding approach was used to develop codes that would be subsequently refined through constant comparison . All autThis study received ethics approvals from the Ukrainian Institute on Public Health Policy IRB (Protocol no. 2016-031-13) and Yale University IRB (Protocol no. 1407014374). Heads of prison administration provided consent for recruiting clinicians, workers, and PDL at their prisons. All participants provided written consent to participate in the interview. A copy of the signed consent form was given to the participant for their records. All participants received de-identified study numbers to maximize confidentiality. Each participant received a hygiene kit as compensation for their time.N = 22, 100%), and three staff (20%) were women. Among the 37 interviews, 48.6% were conducted with current PDL. Ages ranged from 25 to 43 years old, with a median age of 34 years. Most PDL had been incarcerated on average for 3.3 years.All 37 participants interviewed in two Ukrainian prisons were included in this study. Each person invited to participate agreed and completed an interview. A summary of participant characteristics can be found in This qualitative study aims to elucidate the role of a criminal subculture in Ukrainian prisons where methadone treatment was newly introduced for PDL. First, we describe how informal prison structures relate to drug use. Next, we examine conceptualizations of “street methadone” versus “program methadone.” Among PDL, we observed that the two are often viewed as distinct. Street methadone refers to the methadone people obtain illegally and use outside of a treatment setting in the community , while program methadone refers to the liquid methadone offered through methadone treatment programs. Third, we note the changing role of the criminal subculture and shifts toward more Western models of prison governance where informal hierarchies wield less power. Finally, we report on the effects of the Russian invasion on methadone treatment in two Ukrainian prisons.blatní (leaders of the prisons), muzhyký , kozlý (those who have been demoted for cooperating with the prison administration), and opúscheni   . In some“Well, my caste is the lowest in the hierarchy, here. I mean, I communicate well with the highest hierarchies. Very good, because I set myself up like this. I mean, in my case, it doesn’t matter. I mean, me, yeah, if I’m gonna do drugs of any kind, no one’s gonna tell me anything. Here, but maybe there are others to whom they may say something…” —Vyktor .In contrast, prison staff reported the opposite. Prison staff thought that PDL who occupied lower castes in the hierarchy were forbidden to take drugs and that those higher in the hierarchy could use them more freely.“Talking about the hierarchy, it is blatní and their environment that basically have access to injectable drugs… It is generally not allowed for the opúscheni and for an ordinary hard-working prisoner according to the hierarchy of the colony. They can get punished for it by their own folk…” —Leonid .Participants would refer explicitly to the “thieves’ law” or “thieves’ code.” This code governs criminal subculture and sets limitations on all aspects of life, including drug use. In contrast to low-status PDL, some participants explained that PDL belonging to higher levels in the hierarchy were not allowed to use drugs.“The problem is that, according to their, let’s say, thieves’ laws, the blatní is the one who looks after the unit, after, well, and so, there, they do not have the right to use any narcotic substances. They decide, as they say, people’s fates, they have to be of sound mind. Thus, drugs are forbidden for them on the whole. It is forbidden to use any drugs according to their laws…” —Mila .Drug use appeared prohibited among the higher-ups because they had more influence and responsibility over others’ “fates,” alluding to the governing responsibility of the higher-ups and the potential for drug use to disrupt their governance. It also was part of a moral code that was expected of those in the hierarchy.“Like, not everyone should use [drugs]. Understand that, we have a hierarchy in this system. You know? From the little person to the big one. If he’s a big man, he decides people’s fates – he can’t use. He can’t use even a small amount, he must have a 100% consciousness. So, he can’t use and he won’t use” —Anton .Other participants noted that their drug use could threaten their position in the caste system. This phenomenon was described among those in higher castes.“R: In general. According to the notions, the blatní cannot be using. When I started using it, I was no longer there…They didn't want to push me away, but I said I was using myself…I: When you started using again, once more, were you able to stay in that caste?R: I stayed, but unofficially, everyone knew I was there, but I didn't shout out about it, figuratively speaking. But according to our law – it is impossible. You have no right” —Vamava .Some remarked that methadone treatment, specifically, was not an exception to this rule. Methadone treatment was likened to using drugs and was therefore prohibited among members of the informal prison hierarchy. The criminal subculture, in some instances, was understood to dissuade or actively stop PDL from entering methadone treatment.“Well, each society has its understanding of life and has its principles and concepts that they would not want to be crossed… and they don’t want to allow, for example, those from the [methadone] program to be among them. They will achieve this by some other methods, and so on. There, bypassing the police, not listen to the administration” —Aleksander .“Well, they [the hierarchy] are basically against it. They do not welcome drug addicts in their circles, well … There are people who use, but they kind of do not welcome it all. Opium is possibly okay, but methadone… not, in their own circles” —Peter .While some participants did note the role of the thieves’ code and the criminal subculture in delimitating rules surrounding drug use, others rejected this notion. Some explained that the rules of the hierarchy have begun to take a “back seat.” Consequently, seeking methadone treatment among some PDL was not understood to be at odds with the informal hierarchy.“There's no such thing [as the hierarchy] now, now if you cooperate with the administration, you cooperate. If you want to be treated [with methadone], you can be treated, no convict will say anything to you, because now all these their concepts, their beliefs, have started to take a bit of a back seat… If the convict wants to be treated, let him be treated” —Mila .The study prisons were located in western or central Ukraine, and the Russian invasion began in the East. As a result, PDL in the East were transferred to central or western prisons as Russia continued to move in on eastern Ukrainian territory. The prison in Vinnytsia was cordoned off to allow for PDL from the East to be housed but segregated from the locals. New PDL who were recently transferred to western prisons from the East because of the war also noted the limited influence of the criminal subculture.“We lived like people. And here it's not clear at all. The blatní here, they have some kind of rules, but no one respects them” —Taras .Interviews produced blurred boundaries between “street”  and “program” (prescribed) methadone. Program methadone refers to the liquid methadone administered by prison clinical staff that is given to PDL participating in the prison-based methadone treatment program. Many struggled to identify and articulate the differences between street and program methadone, although they acknowledged the two were different. Methadone was conceptualized by some as a nameless, ambiguous substance."Well, we call it methadone. But it's not that kind of methadone… Well, crystal, it's methadone… they just call it crystal, and actually they call it methadone too, but it turns out that methadone is a little bit another concept, as I already understood after the lecture… That's the problem, it doesn't have any particular name, this drug" —Mila .Prison staff reported that some PDL would consider the program methadone a “legal drug.” To delineate the difference between street and program methadone, some prison staff would try to differentiate the two by providing information on the medicinal effects of the program methadone.“Some inmates ask, ‘are they going to give us legal drugs?’ I explain to them that the methadone they're going to give you, it's not that kind of drug, it's just going to block those receptors that cause you to have that craving for drugs” —Mila .During interviews, participants often explained that they were not on “methadone” but, rather, “street methadone.” The greatest differences between the two are how they were taken and their concentration—street methadone was injected, bought illegally, and more concentrated. In contrast, program methadone was imbibed under clinical supervision.R: No, I wasn’t on any methadone. I was on, like you said, street methadone, yeah.I: What do you call it if it’s not street?R: Methadone.I: Just methadone?R: Yes.I: And your opinion or that of others, what is the difference between program methadone and street methadone?R: Well, for example, program methadone, we drink it, right? And street methadone, we shoot. That’s the difference. And the difference is great —Vyktor .The same participant continued to say that he could differentiate the different highs between the two forms of methadone. This was understood to be, in part, due to how the drugs are taken.R: Yes. From the program methadone, is not high. It acts in about twenty minutes, half an hour. And the street – it immediately acts, because through the vein injected, here. Although through the vein when injected with street methadone it evaporates faster, that is, it passes faster, the effect. And street methadone keeps longer.I: Does the street methadone? keep longer?R: Yes. Because it’s absorbed into the stomach. So it keeps longer. I mean, it’s different. And in the other thing, I don’t see the difference —Vyktor .Other participants felt that street methadone was more addictive and worse for the body. Additionally, participants noted the social stressors that accompanied street methadone, such as financial concerns and potential jail time, and described methadone as free of these consequences.“Firstly, more addiction, more pulling [from street methadone], it’s worse for the body, much worse than the program [methadone]. And firstly, this is a constant problem, looking for money, not working, there is no way to support yourself. When you're on drugs, there's nothing you can do. It is easier for people on the program, they can work already, they can just get their dose, and they don’t have to look for money or problems. It doesn't lead to jail” —Aleksander .Furthermore, as “street methadone” availability preceded the introduction of program methadone, the participants began to conflate them, believing in some instances that they were the same. In contrast, others believed them to be different. This blurring of meaning has the potential to disrupt the way that methadone provided within a treatment program could be as negative as illegal “street methadone” and undermine uptake. One participant considered the physical sensations the same but noted that taking methadone through the treatment program transformed the psychological and mental experience.“Although they say that methadone, well, the OAT program, the drug is the same crystal methadone… on my own, I can say that’s far from true…The feelings are the same. Although physically the same, but psychologically and mentally [different] when you sit in the system” — Ehor .Prison staff commented on how the program methadone, administered by the prison staff, may be uniquely conceptualized among potential users. While drug use in prison occurs, it was understood to be prohibited by the PDL’s subculture, and it was unclear whether methadone fit into this framework as an “illegal” drug or a medication prescription. The legality of using methadone among PDL was further complicated by the fact it was distributed by the prison administration. This, in turn, may have been seen as cooperation with the administration, which would threaten one’s position in the prison hierarchy.“The inmate’s main point of concern is, especially if he is, so to speak, on the other side of the barricade, that he will become vulnerable and weak after joining the treatment program… And it corresponds with the culture. It’s contraband, it’s under the proper inmate culture, let’s say so, this is normal. But methadone is different, it’s a legal narcotic, it comes from the prison administration. It’s distributed by the administration. If it was done by an outsourced doctor, well, perhaps it would somehow be different. It could be something totally different, it could be cool, you have a doctor from the outside making daily visits. A doctor from the outside comes to you and gives you, like, narcotic drugs. But, it’s like, it’s a whole different ball game…” —Stepanida (NGO staff).The program methadone is conceived as being different in terms of how you ingest it, its intoxicant properties, and how it is conceived as a drug versus a medication, but it was still difficult to disentangle from street methadone. Prison staff also struggled to separate street and prison methadone. The differences observed evolved from a moral and legal standpoint rather than disentangling how the two substances differed in terms of euphoric effect, how it is taken, and how it is obtained. One participant expressed their frustration that someone could be imprisoned for dealing drugs and then receive methadone legally in prison."Well, what do you think if, bloody hell, if the two medics are involved in something like that and then we get this as well. Two people are in for dealing drugs, so here have some methadone as well, like, I haven’t seen anything like that before, I cannot wrap my mind around it… Two staff members at the medical unit are involved in dealing drugs, and they also get a kilo of methadone, here you go, here’s for you to distribute in the framework of some program" —Inessa .On the other hand, some prison staff viewed methadone as a purely medical treatment, separate, and different from other illicit drugs in prison.R: They can’t just get drugs in and inject them without permission. If they want permission, they have to pay.I: Methadone including? Is methadone included?R: Methadone is purely… medical… — Leonid .Many participants commented on the existence of different prison governing systems. More specifically, the existence of “black” versus “red” prisons, or prisons run primarily by PDL versus prisons run by the formal administration, respectively—a distinction that exists throughout the post-Soviet space. Though the Ukrainian prison system is perceived to have been transitioning more toward “red” prisons that espouse organization and treatment more aligned with Western Europe, a legacy from the Soviet system remains in part in the prison system. Prison staff considered administration-run prisons a more European model and PDL-led prisons a Soviet model of prison governance. Some staff, however, felt that Ukrainian prisons still followed a Soviet model and were, therefore, poorly equipped to host methadone treatment programs:"You are perfectly aware of what the difference between our Ukrainian and European intellect is. They can give drugs to European convicts and would rather not give them to ours. Because their convicts fear the administration, whereas our convicts can do harm. This is a threat to the lives and health of workers and convicts themselves" —Stefan .Criminal subculture, however, was understood to be shifting toward a “western” model. Although not extinct, the deterioration of the informal prison structure was seen as symptomatic of a shift toward Europe.“The biggest one [thief-in-law] in the hierarchy is almost gone. We are moving forward, we are going to Europe. And in Europe, there is no such thing” —Vyktor .Participants often considered this shift away from red and black prisons not only as a movement toward Europe but specifically as a shift away from Ukraine’s Soviet past. This has been an especially salient trajectory for Ukraine since Russia invaded Ukraine in 2014 and illegally annexed Crimea.“A lot has changed, probably. We became more independent from our Soviet past. From the gulag culture and so on. There is more humanity now” —Stasya .The hierarchy’s perceived diminished influence was understood as a result of this cultural shift.“I believe that 20 years ago the prison hierarchy was much more rigid, the inmates themselves followed those rules and supported the hierarchy with much more vigor as compared to now. The rules themselves are being simplified, the people are changing, I believe that 20 years ago the inmates much more closely followed the rules and stayed true to the lifestyle. Nowadays, the people have changed, and I know that the hierarchy’s impact has diminished. Perhaps it has changed because the world is changing, and it has impacted the hierarchy” —Nyusha .Some felt that the diminished influence of the hierarchy, due to the observed cultural shift, manifested in the form of more relaxed rules surrounding selling and using drugs among PDL. Additionally, participants felt a more egalitarian social order was forming among the PDL."For example, if someone sold drugs, he was considered lower and could no longer consider himself a normal convict. There is no such division now… They used to be called hucksters in prison slang, who had traded in drugs, so they could not talk to others. It was in 2007, 2008, and 2009. Now they are all equal. That’s how it is" —Dobrushin .After the 2022 Russian invasion, many Ukrainian prison populations were displaced and transferred to prisons in more western regions. The local people in prisons  commented on the large swaths of PDL newly placed in their prisons, and they had the perception that there were distinct cultural differences in which the new individuals were more aligned with Russia.“They [recently transferred people in prison] have a different way of thinking, their mentality is more like Russia. It is the Russian mentality. If Russians had come after them, there was that zone, they would have taken machine guns and gone against Ukrainians. And they were offered methadone, they were given food and water” — Artur .Other participants describe that these new transfers arrive with withdrawal symptoms, potentially as their illegal drug supplies were interrupted. These individuals are often transferred from prisons that lack methadone treatment programs and are perceived as having a higher need for methadone and, therefore, more readily engaged with the methadone treatment program.“Well, look, now I'll tell you something interesting. Due to the war, the current one, a zone was transported from Zaporizhzhia. One hundred and twenty people came here… And they all came; Well, not all, but not a small mass with withdrawals. Here they are put on the program, yes. They didn't have this program” —Ehor .New transfers were described as less well-connected than the local PDL. This, in turn, limited new PDL arrivals’ ability to procure drugs illegally. Consequently, their greater participation in the methadone treatment programs was understood to be a result of necessity.“They [transferred PDLs] came here, again, a new place, and as we said, it's not so easy to get it [methadone]. Especially for the new people, nobody's going to tell them these ways of getting high on methadone, let's say street methadone, nobody's going to tell them. Because new people, everybody's afraid to tell their secrets, right. So it's like, I've seen them feel bad, they've been starting to get kumar, they've realized that they can't find the drug fast enough and so they've decided to get into the programs” —Olek .New transfers confirmed the perceptions of others as they reported enrolling in the methadone program after their arrival.“I: So, let me get this straight: you abused [drugs] a lot, you were arrested, you went to jail, where you stopped abusing from one day to the next?R: No, I stopped using it here in the camp.I: Oh.R: Well, I came here from the pre-trial detention center, and I started a program, this one here, methadone.I: Yeah, yeah.R: And in the jail, I was using, yes. We've been doing it there, there's no program in the pre-trial facility —Roman .Our findings point to new insights into how criminal subculture in Ukrainian prisons relates to illegal drug use and evidence-based treatment. While most participants did acknowledge the existence of an informal hierarchy among PDL, perceptions of its influence and strength of this influence varied and appeared to be waning over time. In some cases, the criminal subculture was understood to vehemently prohibit drug use, particularly among those of a higher caste. In contrast, others felt the criminal subculture was waning and, therefore, had less ability to dictate a person’s within-prison drug use. Whether methadone treatment and even illegal drug use were supported by the informal hierarchy was also ambiguous and in flux, especially as there was the perception of moving toward a more European perspective. This, in part, is reflected in the data in which PDL and prison staff struggled to identify and articulate differences between street and program methadone and how the meaning of street methadone can be transformed when administered in prison settings. Finally, the Russian invasion seemed to impact the uptake of methadone treatment programs as newly transferred PDL were understood to have more need, especially as they were observed to have psychological distress from being on the frontline and experiencing symptoms of withdrawal. Consequently, displaced PDL were more likely to engage with these programs, potentially as the prison subculture did not interfere. It appeared that the informal hierarchy provided some empathy toward them by virtue of their proximity to the war and did not actively dissuade them from treatment. To the best of our knowledge, these were the first interviews ever conducted in Ukrainian prisons during wartime.While we cannot fully explain why the influence of the criminal subculture is waning, there are a few possible explanations. First, each of the countries of the former Soviet Union has had its own distinct political, economic, and social trajectory, which may, in turn, impact the criminal subculture. For example, the influence of the criminal subculture was nearly erased in Georgia, where there were major economic and anti-corruption activities, which markedly reduced the influence of the prison hierarchies . The sitParts of our data regarding the criminal subculture in prisons in Ukraine are consistent with the literature from other EECA countries like Moldova and the Kyrgyz Republic, which illustrates how criminal subcultures can inhibit the uptake of prison-based methadone treatment programs , 21, 44.Findings here, however, resonate with data elsewhere that drug use is prohibited by the thieves’ code and can be actively enforced by those who occupy a higher caste via ostracization . As methOf importance is the observed conflation between “street” and “program” methadone, which may explain the lack of consensus as to whether the program-delivered methadone qualified as an illicit drug or a medication. Even outside prisons, negative attitudes toward methadone as treatment exist . InterviThe invasion of Ukraine by Russia has the potential to transform both the prison subculture and the perceptions of methadone as a treatment. While the government has clearly aligned itself more with the West during the violent invasion of Ukraine by Russia, it may have the potential to interrupt the existing perception of program methadone being conflated as street methadone and further support its scale-up. At least on the surface, it appears that the early trajectory is to potentially transform methadone as a treatment. However, within prison, training and peer training may be needed as prisons are often insulated from perceptions outside this “hidden” context.Despite many of our findings aligning with other prison-based methadone program studies, Ukraine’s prison setting was unique as it appeared to be “in transition” away from criminal subculture-dominated prisons and not as easily categorized into black versus red prisons. This may bode well as methadone is scaled up within prisons, and there is the perception that people become healthier. Alternatively, as was observed in Kyrgyzstan, PDL on methadone were also provided “dimedrol” (diphenhydramine), resulting in the deteriorating health of methadone patients and undermining methadone as an effective treatment . PreviouFinally, we explored the effects of the Russian invasion on the Ukrainian prison-based methadone treatment programs. We found that recently transferred PDL were perceived as more aligned with Russian identity and more likely to participate in these programs. Non-displaced PDL understood this to be a result of necessity, as newly transferred PDL were less likely to have existing social ties that would enable them to access drugs through other means. This finding may also be reflective of Emergent Norm Theory, which stipulates that “non-traditional behavior develops in crowds as a result of the emergence of new behavioral norms in response to a precipitating crisis .” While While prison transfers across borders heightened perceived participation in methadone programs, the Russian invasion of Ukraine placed the country’s methadone programs in peril . Within Despite these important findings, there are some limitations. First, we only conducted interviews with PDL and staff from two prisons in the western region. These two prisons were the first ones to introduce methadone after the initial pilot program that has since closed. Qualitative data are highly contextual and hypothesis-generating, so our findings may not be generalizable to other PDL. Second, social desirability bias may have impacted the data gathered. Despite interviewers making it clear that they were not associated with the prison administration, PDL may have assumed that research staff would share information about drug use with the formal administration. Consequently, participants may have been less likely to disclose details of their lives and habits that went against the law.The evolving relationship between criminal subculture and a nascent methadone program in Ukrainian prisons appears to impact the understanding and uptake of MMT programs among PDL. During this process, it will be important to initiate education programs for PDL and custodial staff to recognize that two forms of methadone exist and compare and contrast them in terms of their impact on health, with one having greater potential to harm if not dosed adequately. The Russian invasion also provides a unique context for program rollout as it may function to rapidly shape methadone into a more well-defined object. It is critical that as prison-based programs continue to grow, they account for the changing influences of criminal subculture as Ukraine progressively makes political and social shifts toward the West.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving humans were approved by Ukrainian Institute on Public Health Policy IRB and Yale University IRB. A certificate of confidentiality was provided by the National Institutes of Health to protect participants. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.FLA and LA contributed to the conception and design of the study as they have conducted research on the criminal subculture in Moldova and the Kyrgyz Republic previously. IP, TK, and NS adapted the protocol and arranged the fieldwork. LA, MT, and DB conducted the interviews. MP, LA, MT, and DB performed the qualitative analysis. MP wrote the first draft of the manuscript. All authors contributed to the article and approved the submitted version.


Human language is supported by a cortical network involving Broca’s area, which comprises Brodmann Areas 44 and 45 (BA44 and BA45). While cytoarchitectonic homolog areas have been identified in nonhuman primates, it remains unknown how these regions evolved to support human language. Here, we use histological data and advanced cortical registration methods to precisely compare the morphology of BA44 and BA45 in humans and chimpanzees. We found a general expansion of Broca’s areas in humans, with the left BA44 enlarging the most, growing anteriorly into a region known to process syntax. Together with recent functional and receptorarchitectural studies, our findings support the conclusion that BA44 evolved from an action-related region to a bipartite system, with a posterior portion supporting action and an anterior portion supporting syntactic processes. Our findings add novel insights to the longstanding debate on the relationship between language and action, and the evolution of Broca’s area. What is the relationship between language and action, and do they share a common neural basis? Comparison of the cytoarchitectural subdivisions of Broca’s area in humans and chimpanzees reveals that BA44 expanded from a purely action region to a bipartite system, with an action-related posterior section and a syntax-related anterior section. Language processing is a human trait that recruits Broca’s area in the inferior frontal gyrus –3. PreviBoth views—favoring and opposing a shared basis for language and action—built their arguments on theoretical and empirical grounds –7. At thTo date, only 3 studies directly compared the neural underpinning of action and syntactic aspects of language in humans. Two are meta-analyses, comparing peak activations of syntactic tasks against motor-related ones , and synTo help settle the debate on the language/action relationship, we can turn to our close evolutionary relatives . AnthropEarlier cross-species comparisons have shown that the prefrontal cortex is a region that allometrically scales to increase at a disproportionate rate across primates , leadingIn the present study, we examined the phylogenetic changes of Broca’s area by comparing cytoarchitectural segmentations of BA44 and BA45 in humans and chimpanzees, derived from published histological data ,29. Levep = 0.49; BA45 T = 10, p = 0.16).Through a semisupervised pipeline  in the left hemisphere, and 1,955 mm3 (SD: 935) in the right hemisphere. In contrast, Amunts and colleagues .http://www.editorialmanager.com/pbiology/, click the "Update My Information" link at the top of the page, and update your user information to ensure an efficient production process.Please take a minute to log into Editorial Manager at PRESSbiologypress@plos.org. If you have previously opted in to the early version process, we ask that you notify us immediately of any press plans so that we may opt out on your behalf.We frequently collaborate with press offices. If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximise its impact. If the press office is planning to promote your findings, we would be grateful if they could coordinate with http://www.plos.org/about/media-inquiries/embargo-policy/.We also ask that you take this opportunity to read our Embargo Policy regarding the discussion, promotion and media coverage of work that is yet to be published by PLOS. As your manuscript is not yet published, it is bound by the conditions of our Embargo Policy. Please be aware that this policy is in place both to ensure that any press coverage of your article is fully substantiated and to provide a direct link between such coverage and the published work. For full details of our Embargo Policy, please visit Thank you again for choosing PLOS Biology for publication and supporting Open Access publishing. We look forward to publishing your study. Sincerely, Paula---Paula Jauregui, PhD, Senior EditorPLOS Biologypjaureguionieva@plos.org


The stigma associated with coronavirus disease (COVID-19) is relatively neglected in policies for handling the disease. Stigmatization occurs only within specific social contexts in local societies.This study aims to examine COVID-19 survivors’ experiences of social stigma and discrimination in South Korea in the first 2 years of the pandemic.Semi-structured interviews were conducted.Of 52 participants, 45 reported that they had to cope with stigma and discrimination in their intimate social relationships, workplaces, and children’s schools, ranging from subtle actions to job loss. Sexual minorities who were involved in mass disease transmission in the early part of the pandemic experienced a higher level of stigmatization. The stigmatization dealt with in this study was related to two themes: survivors’ sense of causing trouble and possibility of transmission.By intertwining this stigma with the experiences of public health measures through the voices of survivors, this study reveals the local context of East Asia in terms of culture-specific aspects of COVID-19-related stigma. Emerging infectious diseases (EIDs) are accompanied by stigma , 2, and Stigma is defined as an defining characteristic of disgrace that is related to a particular context, quality, or person. It is a deleterious label that makes the stigmatized person or group feel secluded from main stream society and that can further lead to segregation, devaluation, and discrimination –8. SinceDisease-related stigma is originated fear of infection and death, disfiguring caused by the disease and ignorance of the cause, infectivity and the nature of the disease . ParticuAs seen in the cases of HIV , 16, EboNowadays, no one in the public health sector would disagree that disease-related stigma is as harmful as the disease itself and that we should be prepared for effective stigma-reduction interventions for the future occurrence of EID. To do so, it is crucial to understand what attributes were attached to COVID-19 survivors and how stigmatization was enacted in local societies. Stigma is recently explored as situational social process. In other words, although stigmatization can be observed everywhere and at any time  and the South Korea is well-known for its rapid and nation-wide preventative interventions. Wearing masks both indoor and outdoor was mandatory and people cooperated with the government-leading policies while the fatality of COVID-19 remained low. This paper examines how COVID-19 survivors in South Korea experienced social stigma and discrimination in the first 2 years of the pandemic. By probing what COVID-19 survivors went through from the time of infection to after recovery, this paper answers the following questions: (1) What kind of stigmatization, either perceived or enacted one, did survivors encounter? (2) What was the attributes of stigma that were attached to COVID-19 survivors in South Korea? (3) In what social relationships and under what circumstances did survivors experience stigmatization? By seeking answers to those questions, we would like to make suggestions to prevent future EID-related stigma.This study was part of a large-scale research project exploring COVID-19 survivors’ experiences and psychosocial distress related to COVID-19 treatment, quarantine/isolation, and post-recovery experiences. Semi-structured, in-depth interviews were conducted with the participants.via phone.Coronavirus disease survivors were recruited from six hospitals in Seoul and Gyeonggi-do. A total of 61 participants were recruited through their attending physician’s suggestions, advertisement flyers distributed to the hospitals, and snowball sampling. Among the recruited patients, 52 participants finally enrolled and participated in this study; nine patients lost contact for unknown reasons. All participants were informed about the purpose and methods of the study. Written consent was waived by the hospitals’ IRB because the study took place when the survivors were reluctant to meet in person due to their deteriorated condition, fear of stigma, and the possibility of a second infection. Instead, verbal consent was recorded at the beginning of each interview. All interviews except one were conducted In the research preparation stage, a list of questions was prepared to guide the semi-structured interviews . The intFour members of the research team, with experience in qualitative research in the fields of medical anthropology, gender studies, and pedagogy, conducted the semi-structured interviews. With the participants’ approval, the interviews were recorded and transcribed. All identifying data were deleted from the transcripts. Theoretical saturation was reached when no new issues were addressed in the interviews, and consequently, recruitment was closed.The transcripts were analyzed based on grounded theory . In the The ethics committees of Seoul National University Hospital (No. H-2010-048-1163), Seoul National University Bundang Hospital, National Medical Center, Armed Forces Capital Hospital, Seongnam Citizens Medical Center, and Boramae Medical Center approved the study protocol and materials between April and June 2020. This study adhered to the Declaration of Helsinki. All names used in this paper are pseudonyms.In total, 52 COVID-19 survivors participated in the study between February 2020 and October 2021. All interviews lasted 60–90 min. The participants’ demographic characteristics are displayed in The period in which the participants were infected span between January 2020 and August 2021 was the time that “3T policy” and social distancing policy of the Korea Disease Control and Prevention Agency (KDCA) were strongly enforced until the third vaccination (2021.10.12) and deregulation of social distancing (2021.11.1) began . The 3T via ambulance; the latter was reserved for those with only minor symptoms.The participants took a PCR test when symptoms such as coughing, fever, and muscle pain appeared or when they had physical contact with a confirmed COVID-19 patient. After receiving PCR tests at screening centers, which were installed at hospitals, public health centers, schools, and sports facilities, near their homes or workplaces, they received positive results the same day or at least the next day. Subsequently, they were soon transferred to a hospital isolation ward or residential treatment center After the participants were taken away, their homes were disinfected by the public health center staff. In the treatment center or hospital, all physical contact with the outside world was prohibited, except for extremely limited contact with medical staff. Voice/video calls, the internet, and TV were allowed. If the participants no longer had severe symptoms 10 days after being admitted, they were discharged.via PCR test, everyone who had physical contact with the patient in the last 3–7 days also received a PCR test. Those who tested positive were taken to a hospital or residential treatment center, where they had to remain for at least 10 days. Those who were in close contact with a patient also had to self-quarantine at home for the incubation period (14 days), even if they had a negative result. If a negative result was obtained on the last day of quarantine, the at-home quarantine order was lifted. Some patients and individuals in isolation were provided with short-term emergency COVID-19 relief funds for their labor loss.Once a COVID-19 patient was identified An epidemiological investigation was conducted after each positive result. Through phone calls, epidemic intelligence officers  asked the participants about their whereabouts, whom they had met, and whether they had followed the COVID-19 guidelines during their incubation period. In addition to the interviews, the epidemiological investigators sometimes reviewed CCTV footage and patients’ credit card records. Those who were identified as close contacts of infected patients were tested for COVID-19.From the onset of the COVID-19 pandemic, the KDCA disclosed statistics  in press briefings and on its website every day. Each patient was given a case number by the local government. The local government sent a text message to all residents every morning to notify them of the number of new and accumulated confirmed cases in the local district. The recent routes of each case number were disclosed on the KDCA and local government websites. In the early phase of the pandemic, each patient’s routes and times of visitation at each location were disclosed; however, as concerns about privacy infringement increased, information about newly infected patients’ routes was collectively disclosed so that an individual patient’s route was untraceable.The requirement to wear a mask in public spaces, including in public transport vehicles, movie theaters, religious facilities, educational institutes, schools, bus, and train stations, and department stores, was enforced beginning in May 2020. Enforcement was limited to indoor places, but people always wore masks both indoors and outdoors. Public facilities, such as restaurants, provided thermometer machines and hand sanitizers at their entrances. All visitors were supposed to fill in entry logs (or tag a QR code) to access the facilities, and these logs were used to trace close contacts whenever a patient was confirmed.Of the 52 participants, 45 (86.5%) reported that they recognized perceived stigma against COVID-19 survivors and that this expectation was a major concer after being infected. From the moment of diagnosis, they internalized COVID-19-related stigma. They felt as if they became “conspicuous” and “separated from ordinary people,” and they were afraid that people would see them as “virus carriers.” Mr. Eom (#031), in his early thirties, remarked, “I feel like no one will try to set me up on dates anymore because I caught COVID-19.” Feelings of guilt, shame, and labeling were experienced, as Ms. Hahm (#058), a woman in her forties and a senior staff member at her workplace, described: “When I went back to my workplace, even though no one mentioned my infection, I felt as if a scarlet letter was on my chest. At lunchtime, I could not hold my head up in the cafeteria. I felt guilty. The effect of self-stigmatizing was powerful.”Of those 45 participants, 37 reported experiences of enacted stigma as well. The scope and type of enacted stigma addressed by the participants included both subtle and indirect reactions, such as uncomfortable looks, rumors, and attempts to uncover the infected, and obvious and direct reactions, such as avoidance, termination of a relationship, expressions of fear against the survivors, public blame, and job loss. As consequences of stigma and discrimination, the participants reported depression, anxiety, feeling of isolation, guilt feeling, psychological shrinking, and suicidal thought. Some of the participants reported that the perceived stigma delayed them to get a test promptly.The attributes of COVID-19-related stigma appeared as two themes: the sense of causing trouble and the possibility of transmission. First, the participants shared the idea that COVID-19 patients ended up creating “big troubles” for people around them by causing others to get tested and quaranteened, become infected, and be hospitalized. The participants tended to internalize this attribute and consider themselves, in part, contributors to others’ “troubles,” and some of them were faced with overt blame for their “carelessness.” For instance, Ms. Ahn’s (#029) neighbor accusingly commented, “You could have avoided catching COVID-19 if you wore a mask properly and washed your hands. Didn’t you wear a mask?” With the sense of responsibility the participants felt for their infection and transmission of the virus, it was critical to their psychological distress whether they actually caused an additional infection. Mr. Koo (#012) expressed relief that he did not cause any additional infections, saying, “I was much relieved that no one was infected by me. That was why I could go back to everyday life quickly.” In contrast, Mr. Jang (#009), in his seventies, blamed himself, “Because of me, five family members out of six were infected. It was beyond expression.”In the participants’ accounts, COVID-19 survivors were classified into two groups: innocent victims and individuals responsible for their own infection and after management. For example, if a patient became infected despite their best efforts to follow preventive policies  and tried to minimize the scope of close contact with people , they deserved to receive enough sympathy and support. However, if a patient visited multiple places while having symptoms or concealed some locations they had visited during the epidemiological investigation, they deserved criticism. While interacting with people in their everyday lives, such as in conversations with neighbors and through online forums, the participants learned about this classification and internalized it both before and after their infections. Ms. Joo (#056) recalled how she recognized people blamed for COVID-19 patients before her own infection, “I kept reading things on the mom forum, like critical comments, and it was like a witch hunt. I was very nervous. People on the forum blamed those who did not follow the rules, such as those who wandered around after their test.”By going through the screening, treatment, and quarantine/isolation, the participants learned that it was impossible to prevent infection and transmission through perfect self-discipline and that rules may often be violated without selfish intentions. Yet, they reflected with anxiety on whether their “carelessness” caused the infection. Simultaneously, the participants tried to differentiate themselves from the “irresponsible” survivors, thinking that it would be unfair if they were generalized as “the careless infected.” For instance, Mr. Choi (#004), who was infected by an unknown source, said, “It would be less unfair if I went to a pub, but I did not. I felt it was very unfair.” In constrast, Ms. Min (#019) felt guilty and blamed herself. She was infected by a taxi driver and passed it on to her entire family. She believed that the adversity of her family resulted from her negligence of hygiene. “My friend and I took the taxi and had a lot of conversation with the driver. I did not wash my hands right after going home. I think that was the problem because my friend was not infected.”This attribute of causing trouble could be applied to those who passed COVID-19 on to the participants. Although many participants commented on those infected them, “They did not do it intentionally,” some participants criticized their carelessness. Mr. Paeng (#056) did not hide his anger against his colleague at work. Four of colleague went on a trip together during a weekend and were infected. Even though they all had a fever, they took a Tylenol and went to the office, which led a dozen of infection cases at the company. “I was so pissed off and was going to sue them. I wanted to kill them in the ICU. I still feel anger. When I hear their voice at work, I feel rage.”The second attribute of COVID-19-related stigma was a collective fear that recovered patients might still be able to transmit the virus because some “dead virus” could remain in their bodies. Not to mention the people around them, the participants were also unsure whether they were “totally safe” to others. Hence, many participants commented that they understood their friends’ and neighbors’ avoidance and voluntarily tried to avoid physical contact for a while. Ms. Moon (#018) reported, “Because we had been infected, I was hesitant to meet people. We (she and her children) could not go to the playground, of course, and when we encountered people there, I kept a distance and told them, “I was isolated. Would it be okay? You’d better keep away from me.” I did this for a couple of weeks.”The discharge process also reinforced the fears of transmissibility, as the participants did not receive any tests when they were released. Instead, they were informed by the medical staff that they would test positive for a while because of the remaining virus in their bodies. This explanation of the remaining virus and the process of discharge without assurance failed to end the anxiety and fear of the participants and the people around them. Mr. Hong (#005), a man in his sixties, said, “People asked, ‘Did you receive the negative result or not? Can’t we trust my safety only after you test negative?”’This no-test discharge policy caused problems, particularly in schools and workplaces. Due to the fear of transmission, some schools and workplaces required the participants to submit a negative result, and the KDCA and the healthcare center did not endorse the participants’ return in an official way. Some participants, thus, had to wait an additional couple of weeks for their negative results, which jeopardized their job stability. We will return to this issue in “section 3.3.3 Contexts in workplaces.”The participants’ infections were known to their relatives, friends, acquaintances, and neighbors through voluntary disclosure or involuntary disclosure such as official notice, transportation and disinfection processes, rumors, and notices from educational institutes . This category was most frequently addressed as the stigmatizers. Compared to their workplaces, their private social networks were places where the participants could control information disclosure to some degree. They carefully selected to whom and in what circumstances they disclosed this information and often chose to hide their infection to avoid uncomfortable situations. The scope of disclosure varied, ranging from no one (including family members) to only family members and close friends or to those the participants interacted with in daily life. Some participants thought that not telling about the infection could be considered a lie and they were reluctant to meet people for a while to avoid this distress.Because of the intimate nature of their relationships, the participants’ relatives and friends tended to explicitly reveal their fear of COVID-19 and blame the participants for “the trouble.” For example, Ms. Yim (#036), a woman in her thirties, was infected by an unknown source. She had met many relatives and friends before her positive COVID-19 result since it was during a holiday break. Among the friends she had met, only one was infected, and the rest tested negative. However, her friends still suffered economic damage due to quarantine and isolation. Ms. Yim’s friend’s husband called Ms. Yim and swore at her. The rest of Ms. Yim’s friends did not blame her to her face, but she heard from others about the difficulties her friends endured. When she gathered up the courage to call some of her friends, she sensed that they were avoiding her. Ms. Yim felt very regretful that she could no longer reach out to her friends.Ms. Yim’s parents-in-law were also forced to be quarantined at home. This 2 weeks quarantine caused such great psychological distress that her father-in-law could not eat properly for several months. While going through a hard time, Ms. Yim’s father-in-law asserted that she should not have included her parents-in-law on the contact list. He vowed to disown Ms. Yim and her husband. It took a long time for Ms. Yim and her husband to convince Ms. Yim’s father-in-law that cooperation with the epidemiological investigation was inevitable.Ms. Jee (#040), a woman in her forties who was infected at her workplace, recalled a scene from her discharge day. Coming back home, she passed by a supermarket across from her house, and some people who were hanging out there literally ran away as soon as they saw her. “Word must have spread throughout the neighborhood. They looked at me and ran away. The adults took their children’s hands. I was really shocked.”This outright avoidance of her close neighbors shocked Ms. Jee so deeply that, for a while, she avoided any encounter. She developed a new habit of looking around when she left home to make sure no one was around her. Although she had regularly frequented the market before her COVID-19 infection, she stopped going post-discharge because she believed that she would no longer be welcome. Ms. Jee remarked, “They treated me as if I made a huge mistake. You would not do that, even for sex offenders. They are not strangers; they are my next-door neighbors.”Due to the government’s policy of posting notices of infected individuals’ routes, some participants were involuntarily detected as infected. Ms. Ahn (#029), who was infected in a club, said, “The epidemiological investigators told me that they would not reveal the name of my store unless I wanted to do so, but the address and name of the store were posted on the city homepage. I got calls from everyone I knew. I was so freaked out and made up a story that a patient had come by my store. I felt like I was being bullied.”Even when infected individuals’ personal information were not revealed, their neighbors tried to investigate and identify who the infected were out of fear. Although these investigations might be an adaptive behavior to make sure their own safety , but, resultingly, these investigations in many cases ended up blames the survivors for their carelessness and made the participants feel guilty and isolation. South Korea has well-established online communities for each local society, and these web-based forums acted as channels through which public opinions and information regarding COVID-19 were shared. Ms. Hahm (#058), who lived in an apartment complex, experienced the following after her family’s infection: “(On the online community of the apartment complex), (t)he neighbors tried to find out which house was the one. It was an atmosphere in which people would say, “Why on earth did they (not stay at home but) thoughtlessly wander around during this pandemic crisis?” People living in the same building posted on the forum, saying, “I have just called my boss, and she told me to take the day off tomorrow because the infected lives in the same building as me. Should I get a test now? Please tell me which floor the infected lives on.” I thought it was just a matter of time before people detected us. I thought people would hate us because they suffered damage because of us. (B)ut I wondered if I really made such a big mistake. I could not stop self-flagellating.”It is natural for people to expect warm support and empathy from their relatives, friends, and neighbors, especially during a crisis. On the one hand, close relationships were the main source of emotional and financial support for the participants. On the other hand, these close people’s casting of blame and attempts to detect who was infected deeply impacted the participants psychologically. In particular, the negative reactions from neighbors broke their sense of serenity in their homes, and some participants reported that they had considered moving after being infected. When faced with the responses of their relatives, friends, and neighbors, some participants felt skepticism about the social relationships they had built, which caused psychological shrinkage, feelings of isolation, alienation, and depression to the participants.Unlike the private networks, the participants hardly controlled the scope and timing of disclosure at their workplaces. Once they reported their infection, this news was immediately delivered to their seniors and teams, and, in nine cases, the whole workforce was notified. For instance, Mr. Eom (#031), who was a soldier, found out that his name as the infected was disclosed to the whole military. Within the military intranet, anyone could figure out his private information, including his university, military service number, and contact number. He said: “It was just like how laypeople know a celebrity, but the celebrity does not know the laypeople. “He is the infected.” People at work knew everything about me, and not because of a good event but because of my COVID-19 infection. This made me scared.”The sense of causing trouble amplified in terms of workplaces because the participants could not go to the office at least 10 days, and further, their infection resulted in the colleague’s COVID-19 test and quarantine. Particularly, in the case of workplaces, there were many cases that the first patient of serial infection was clear. After returning to work, some participants sensed reinforced policies, such as wearing only KF94 masks, not being allowed to talk during breaks, and undergoing surveillance through CCTV, which made the participants feel guilty.The perceived and internalized stigma at workplaces caused the participants to feeling of guilt, being overt blamed, rumors, and being distracted. In some cases, involuntary disclosure hampered the participants’ work. After Mr. Oh’s (#032) infection, the epidemiological investigators contacted every business he worked with, and a rumor that Mr. Oh was infected at a political rally, which was regarded as an inappropriate site to visit “during this crisis,” spread among his business contacts. Some of them were so upset that they considered suing Mr. Oh, which intimidated him for a while.The most distinguishable and critical feature of workplace stigmatization was that survivors could end up experiencing serious economic damage including job loss if they were held responsible for the “trouble” they caused their workplaces. Some participants, such as Mr. Shin (#028), a financial company employee who was hospitalized in an ICU for 3 weeks, reported that he was more worried about whether he would be paid properly and whether he would be dismissed due to the labor loss and great trouble he caused than the actual physical pain. Although Mr. Shin was not face with a threat of layoff, some participants’ concerns turned out to be valid. Ms. Jung (#008) recalled her return: “All hell broke loose at my workplace. About 30 people worked together, and everything stopped for almost 2 weeks. I was totally on my boss’ blocklist because three more people were infected by me. My boss was not willing to let me work again, which caused me a lot of distress.”Some participants ended up quitting their jobs after returning to their workplaces. Mr. Jin (#041) was working as a facility manager at a middle school when he and his three children were infected by his wife. After the news of his infection broke out, many teachers and students at his school were tested and isolated for 2 weeks. Mr. Jin was very hurt and intimidated when one of the teachers reproached him, “If your wife was so sick, you should have gotten her tested. Why did you do nothing and cause everyone such trouble?” After being released from the 2 weeks isolation, Mr. Jin was faced with an impossible demand from the school: provide a certificate of COVID-19 negative result. In response to this unfair demand, the public health center did nothing except say, “You talk to the school.” Eventually, Mr. Jin quit his job.A total of 15 participants reported cases similar to Mr. Jin’s. After returning to the workplace, they were asked to quit for different reasons. Some of the participants thought that they deserved it because of the “great damage” they caused to their workplace. Ms. Yim (#036) also felt pressure from her boss and finally submitted her resignation. Recalling her last week at work, she said, “I could not help but cry. I thought, “This company fired me, so why am I working here for them?” I could have quit immediately, but I insisted on working until the end of the month so that I could earn 100,000 won. But I was upset about that.”Children’s school was one of the places where the perceived stigma of survivors was most salient. The participants with young children were most worried and anxious about their children’s social lives after infection. In this study, there were no cases of children being exposed to enacted stigma, but the participants were widely concerned about whether their children would be disadvantaged at school or bullied by friends, particularly due to the sense of causing trouble. Since schools did not announce who was infected, the participants could exert control over disclosure in some sense, but the fact that children were involved in it often made handling disclosure more complicated.At schools and private educational institutes, students’ infections were followed by all their close contacts’ being tested and quarantined for 2 weeks. This caused the participants the greatest psychological pressure and anxiety about bullying. Ms. Pyo (#057) said: “There was an long line at the screening station when one infection case was confirmed at the school. Working mothers had to take the day off to take their children to the screening center and wait there for a couple of hours. I knew what it was like, and it was a great psychological burden when we were infected.” This guilty feeling was observed in participants who were mothers of young children. They were afraid if their children would be teased, blamed, or excluded for causing the troubles to friends and their families. For this reason, many participants with minor children reported that protecting children from COVID-19-related stigma by hiding their infection was the most crucial mission to them.Officially, schools did not reveal who was infected to protect the children. However, the participants had to juggle with crisis of involuntary disclosure that their child’s infection would become known to other students, particularly through online mom forums and social network services. For instance, Ms. Pyo (#057) related to the group chat for her child’s class. Each class has its own group chat, where the class teacher and all the students’ parents gather. This group chat is supposed to circulate relevant information in real-time, but during the COVID-19 pandemic, it could function as a channel through which information about who was infected was circulated. After Ms. Pyo’s daughter’s infection, the whole class was tested: “Mothers began to report the test results in the group chat, saying, “My kid tested negative.” I could not say anything. One mother said, “It will be so obvious soon who is the (infected) one.” The teacher interrupted and notified the group, “Please report it (the children’s test results) to me directly, not in this group chat.” After this notification, the reports of negative results stopped, and I avoided the awkward situation.”Regarding the issue of disclosure, some participants addressed the difficulty of having their young children hide their infection. They felt that they had no choice but to hide it and told their children not to talk about the infection as well. However, this instruction confused the children. Every time the participants chose to make up a story of “self-quarantine at home” (not isolation of infected patient) in front of their children, they were worried if the young children knew that their parents were lying.As seen in Ms. Pyo’s case, it was because of individual teachers’ efforts to protect infected students from involuntary disclosure that no participants reported their children’s exposure to stigmatization. Ms. Joo (#039) and her 9 years-old girl, Ajin, were infected. Ms. Joo thought that they were fortunate because her daughter tested positive during the at-home quarantine period, which was not followed by other students getting tested. Yet, it was natural for the children in Ajin’s class to wonder why Ajin did not come to school. Ajin’s teacher told them that Ajin was absent because of her atopy treatment. Ms. Joo considered this “gloss over” and a “white lie,” to convince the children of the situation from their level. She felt much gratitude toward the teacher for her efforts to protect Ajin from being exposed to social blame as well as her daily calls to Ajin to tell her how the school day was.In South Korea, mass infections occurred in some LGBTQ clubs in May 2020, and the mass media heavily covered these cases with sensational expressions, such as “94 infected out of gay clubs” . In thisFirst, while the KDCA did not address concerns regarding hate speech toward sexual minorities and the risk of outing them, LGBTQ patients were directly exposed to the public’s accusations. Combined with the idea that they were infected in “clubs,” which were regarded as inappropriate places to visit during the pandemic, they were regarded to be responsible for both their own infection and troubles to the whole country. Their sexual identities stimulated further blame with the use of homophobic slurs. Reading the newspapers and the replies the papers received that insulted the gay COVID_19 patients from the mass infections, Mr. Chae and Mr. Hahn experienced a traumatic shock to the extent that Mr. Hahn thought of suicide. He said, “I should not have read them, but I had to. Since then, I have felt the urge to jump out of the window during nights of broken sleep. I was prescribed psychotropic medication because of it.”Although both Mr. Chae and Mr. Hahn voluntarily visited a screening center to get tested even before the KDCA’s recommendation, it did not help lessen the responsibility of transmission or the public blame. They could not receive emotional support from the gay community either. Mr. Chae said, “Many of my friends regarded going to a club as my fault, and I could not confidently claim that I did not do anything wrong.” Both had many relationships severed. Mr. Chae was rejected by someone he was dating after telling that person about his infection. Mr. Hahn recalled, “I had lost half of my friends in the gay community. I drifted apart from them.”With regard to the exposure of personal affairs, Mr. Hahn was more acutely afflicted than anyone in this study. In the period of his infection, the KDCA revealed the names of infected parties’ worksites, the names of apartments, ages, and whereabouts by time. Being covered by the mass media, Mr. Hahn’s information was publicly exposed. Even the mayor of the city posted his information on the official social network service. When combined, these pieces of information could easily identify Mr. Hahn such that acquaintances were able to determine that the infected person in question was Mr. Hahn. Being continuously asked, “Is this you?” he felt terrified and resentful: “It was more painful and traumatic than getting COVID-19. I was skeptical if I could go back home after discharge and was thinking of moving away.”Involuntary disclosure posed an additional risk to Mr. Chae and Mr. Hahn, which was the risk of being outed. Inevitably, Mr. Chae had to hide his infection from his parents who were unaware of his sexuality. Mr. Hahn also recounted: “The issue of sexual identity was the hardest thing because even my family, work colleagues, and friends from high school came to know it . Even though I told my mom a good excuse, (she) heard an insult directed at me in her workplace.”Mr. Chae and Mr. Hahn both reported discrimination from healthcare workers, which was rarely mentioned by the rest of the participants. In Mr. Chae’s case, a staff member from a local healthcare center came to his home to pick him up and instructed him not to use the elevator. As a result, Mr. Chae had to climb down the stairs to the ground floor from his 18th-floor-apartment. The staff also instructed him to wear a protective suit and to spray disinfectant around himself on his way down to the ground. Of the participants, Mr. Chae was the only one who was instructed to do so. Although Mr. Chae was deeply ashamed of this instruction, feeling as though he had become “a carrier,” he thought to himself, “The virus is coming out of me, so I must do this.”Neither Mr. Chae nor Mr. Hahn could return to work, even after recovery. Mr. Hahn reported that he still had not been able to visit near his workplace at the time of the interview (1 year after his infection). “I could not go back to my work. They said I could, but honestly, everyone knows it (the infected gay) was me. How can I go there? I still cannot go the area, even though it is so close to my home. It would be correct to say that I gave up on being reinstated. The company said I could, but they felt uncomfortable, and I heard a rumor that I would be sent to another branch. I just quit.”This study showed that the attributes, contexts, consequences, and disclosure management of COVID-19-rerlated stigma that the survivors went through in South Korea in the first 2 years. The main attributes of stigma that were attached to the COVID-19 survivors were the sense of causing trouble and the fear of transmission. The survivors had to cope with both perceived and enacted stigma in their intimate social relationships, workplaces, and children’s schools, ranging from subtle actions to job loss, and some of them reported internalized stigma. While the survivors could control over the disclosure of infection in their private network to some degree, they experienced involuntary disclosure at workplace. Due to the sense of causing trouble and the fear of transmission after the recovery, the survivors could not be treated merely as a patient who needed care and support.via ambulance, being assigned a case number, having their route posted publicly, and enduring isolation and quarantine maximized the participants’ sense of being distinguished and becoming “other.” The no-test discharge policy played a barrier to the survivor’s return to workplaces and schools, and the public post regarding a patient’s whereabout policy was in part abused to detect who was infected.The results of the study revealed that labeling, attributes, and disclosure of COVID-19-related stigma were closely linked not only to the biological characteristics of the disease but also to socio-cultural aspects of the public health preventive measures , 38–41. Particularly, it is noteworth that the sense of causing trouble appeared as a main attribute. In the participants’ account, “trouble” refers to implicating family, friends, neighbors, and colleagues at work in a test, quarantine at home, and isolation. Through the preventative measure process, the survivors were changed from “a patient” to “a transmitter,” which was susceptible to blaming. The survivors were easily internalized the subdivision those who do not follow public health guidelines  and those who do , viewing the latter as responsible citizens , which iThe underlying idea of responsibility and causing trouble reflects the belief that the prevention of infectious disease depends upon an individual’s efforts and self-discipline. This silent pressure, both from inside and outside, may function to encourage individuals to discipline themselves . HoweverAnother aspect essential to stigma is the fear of transmissibility. This fear has been regarded as the representative driving factor of COVID-19-related stigma , 44, 45.The LGBTQ survivors’ cases in this study revealed the power structure of stigma . The higDrawing upon the results of this study, we would like to make some suggestions for the next pandemic. Since stigma is ultimately a matter of power structures, eliminating disease-related stigma must not be left to individuals. Active governmental intervention is needed to reduce the stigma related to COVID-19 and new EIDs . The finThird, the government and the mass media industry should reach an agreement on how to cover EIDs and their patients/survivors. As noted, the discriminatory and exclusive metaphors used by some media and newspaper outlets often fuel stigma , 55–58 aWith regard to taking care of the survivors, mental health care for survivors must be provided. Previous studies have reported that COVID-19 patients and survivors may suffer from psychological symptoms, such as post-traumatic stress symptoms, depressive symptoms, insomnia, and suicidal thoughts –64. In tTo successfully prevent a new EID, civil cooperation with the policies is crucial, especially, the cooperation of the affected people. The COVID-19-related stigma that survivors have undergone is detrimental to halting and controlling pandemics. If the public health guidelines focus on only the narrow biomedical aspects, this limits our understanding of how policies should be shaped to offer the most effective and equitable response . This stThe limitation of this study is that this study focused on survivors in the first 2 years of the infection onset. Since then, public anxiety and the intensity of preventive measures have decreased. Because stigma is essentially historical and circumstantial , furtherpsychepark@gmail.com.The datasets presented in this article are not readily available because of participant privacy. Requests to access the datasets should be directed to HYoP, The studies involving human participants were reviewed and approved by the Ethics Committees of Seoul National University Hospital (No. H-2010-048-1163), Seoul National University Bundang Hospital, National Medical Center, Armed Forces Capital Hospital, Seongnam Citizens Medical Center, and Boramae Medical Center. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.HYoP and J-WP: conceptualization. JK, HK, HJY, and YL: data curation. JK, HK, HJY, YL, and HYoP: formal analysis. JK, K-HS, HO, MS, SL, J-WP, and HYoP: methodology. JK: draft of the manuscript. All authors: investigation, critical revision and editing of the manuscript, and contributed to the article and approved the submitted version.


We appreciate the interest in our article addressing the modeling of the force–velocity relationship in acyclic lower-limb extensions. While we agree with some of the recommendations made, our main disagreement with Alcazar et al.  rests onIn the letter , a hybriThe simpler the model, the clearer it is which of its characteristics are essential to the observed effect” [We invested considerable effort in our paper to describe this equilibrium and to apply the principle of parsimony. Model selection consists of determining which candidate model is the most appropriate considering several performance criteria. For example, in our paper we (i) used common indicators of goodness of fit , (ii) quantified residuals’ distribution across the dependent variable, (iii) sought external physiological validation and discussed reliability of outputs based on other works, and (iv) applied a statistical method to critically analyze each model regarding their degrees of freedom for the sake of parsimony. In comparison, under the pretext of common sense, Alcazar et al. appear to only consider goodness of fit to choose between two models displaying physiologically relevant outputs. As mentioned above, and in our paper, goodness of fit rarely provides a unique criterion for model selection. Furthermore, a significant difference between models’ outputs does not necessarily indicate which model is superior, especially when the true outcome is unknown. In this specific case , we recommend selecting the simpler model. By choosing the model with fewer degrees of freedom, we can mitigate risks of overfitting and reduce uncertainty in outputs determination. As suggested by R. McNeil Alexander, “ effect” .Beyond the selection of performance criteria of a model, the analysis detailed in the letter  focuses is linear” is untenable, as an absolute truth will never be reached. Nevertheless, even if a model might be considered “wrong”, it can adequately represent reality when based in rigorous analyses. These analyses should strike a balance between the risk of overfitting and the potential of omitting crucial information. In this sense, and beyond the practical advantages in some specific contexts underlined by Alcazar et al. (1), we maintain that the force–velocity relationship of lower limbs in acyclic movements can be well described by a linear model. This is because the linear model (i) has displayed physiologically relevant outputs, (ii) aligns with the principle of parsimony, and (iii) consistently yields reliable outputs  than with the hybrid model or models with higher degrees of freedom. The hybrid model may yet be the best to describe the external force production capabilities of the lower-limb (neuro)muscular system, but this is based almost entirely on certain fitting performance criteria. In the current context, unless there are compelling reasons—be they physiological rationale or clear experimental evidence—to adopt a more complex model, we think that the simplest model is the best option.In conclusion, we appreciate the opportunity to clarify our perspectives. Asserting that “the force–velocity relationship e et al. ), even iSimplicity is the ultimate sophistication” (L. da Vinci).After all, “