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COMMENTARY
Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 301-305  

COVID-19 social stigma: Causes, consequences, cures


Department of Psychiatry, Dr. D Y Patil Medical College, Hospital and Research Centre, Dr. D Y Patil Vidyapeeth, Pune, Maharashtra, India

Date of Submission02-Oct-2020
Date of Decision11-Apr-2021
Date of Acceptance09-Jul-2021
Date of Web Publication22-Jan-2022

Correspondence Address:
Suprakash Chaudhury
Department of Psychiatry, Dr. D Y Patil Medical College, Hospital and Research Centre, Dr. D Y Patil Vidyapeeth, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_556_20

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How to cite this article:
Dhamija S, Chaudhury S, Saldanha D. COVID-19 social stigma: Causes, consequences, cures. Med J DY Patil Vidyapeeth 2022;15:301-5

How to cite this URL:
Dhamija S, Chaudhury S, Saldanha D. COVID-19 social stigma: Causes, consequences, cures. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 May 24];15:301-5. Available from: https://www.mjdrdypv.org/text.asp?2022/15/3/301/336314



Globally, parallel to the COVID-19 pandemic, there is an unseen and ugly pandemic preying on the minds of the masses, the pandemic of fear and anxiety. This has led to prejudices against certain persons and communities, social isolation, stigma, and discrimination. Under severe stress, people are known to exhibit unreasonable behavior that may culminate into increased hostility, chaos, and unnecessary social disruptions. As a result of terror and misinformation about COVID-19 infection, there are widespread media reports of persons suffering from COVID-19 and also healthcare workers (HCWs), sanitary workers, and those dealing with COVID-19 patients being isolated, shunned, not allowed to use public transport, and even told to leave their rented accommodation. Individuals who have recovered from COVID-19 also face such discrimination.[1] This unfortunate condition has to be combated vigorously. The need of the hour is to improve the health literacy of all citizens so that the community can react appropriately in the face of this adversity.


  History of Pandemic-Related Stigma Top


Nature has always tested humanity since the history of civilization by means of various diseases through the course of time. We have also experienced the “Black Death Stigma” linked with plague, which undoubtedly emerged as one of the most gruesome and terrifying truths of the middle age for the human beings dwelling our mother earth during those times. Not far from now, the memories of “Spanish Flu” (H1N1 Influenza A) still scare humanity, which almost affected one-third of the world's population and caused more deaths than the First World War itself. In the current times, the “COVID-19” pandemic is a prime example of a disease where uncertainty, erroneous analysis, misinformation, and media hype have resulted in “corono phobia” throughout the world.[1] Due to this pandemic, there have been unprecedented chaos and disruptive atmosphere in terms of global health and development, and this has even been more complicated due to newer challenges faced now in terms of access, safety, supply chain, and financial burden.[2]


  Social Stigma Top


Social stigma is “a quality that greatly discredits the person” and that changes the individual “from a completely normal person to a polluted one of no value.”[3],[4] Social stigma is usually observed with respect to gender, ethnicity, intelligence, sexual orientation, and health. Social stigma comprises four interacting elements: anticipated stigma, perceived stigma, experienced stigma, and internalized stigma.[5] During COVID-19 pandemic, all these components of social stigma have been observed. Anticipated stigma led to people modifying their behavior, e.g., avoiding COVID-19 testing due to fear of discrimination; perceived stigma was seen as patients and their families felt that others were judging them adversely; experienced stigma was observed because people who tested positive or even exposed to infected persons were shunned, secluded, and discriminated against by community members, friends, and even their household members; and internalized stigma was seen since some infected persons felt embarrassed and humiliated.


  Stigmatization of the COVID-19 Affected Top


Stigmatization of persons affected by COVID-19 has a number of negative consequences on others. An example of previous innovative approaches that were employed to reduce illness-related stigma during previous pandemics included structured community mobilization, targeted social protection, and differentiated healthcare delivery. Consideration must be given to the fact that the pandemic affects humans without any prejudice – be it any educational status, socioeconomic background, racial or ethnic details, gender, age, abilities or disabilities, and national origin. Hence, it is a wakeup call to global citizens. That is why solidarity across the world is an absolute necessity in the battle against this unusual pandemic.[2] During the COVID-19 pandemic, continuous negative media coverage and spread of unverified information on social media have resulted in an atmosphere in which stigmatization is widespread.[6]


  Stigma for Healthcare Workers Top


HCWs, who are at the frontline in response to the pandemic, are highly exposed to hazards associated with COVID-19, including not only pathogen exposure, long working hours, psychological distress, fatigue, and burnout, but also stigma, discrimination, and even physical and psychological violence. There seems to be a dire need now to implement rules and norms for the safety of the HCWs – be it occupational safety or health management. There is a requirement of systems to identify the health and safety regulations and infection prevention and control measures along with zero tolerance toward workplace harassment and violence which is at large these days.[2]


  Stigma and Prejudice in COVID-19 Scenario Top


The current scenario is full of stigma against the different South Asian communities, the HCWs, and other frontline workers as well as the previously COVID-positive patients who have now been treated and symptom-free. A consequence of stigmatization is the possibility that one will be subjected to prejudice, unfavorable treatment, and discrimination commonly across multiple situations.[6] These invisible stigmas leave individuals with the difficult choice of whether to disclose their stigma to others or to keep this to themselves.[6] This generates severe self-doubt and feelings of guilt as well. Medical illnesses often create conditions that may create a visible or invisible stigma. For instance, someone with a physical disability who uses a wheelchair may have a more visible stigma than someone with a transmittable virus such as HIV.[6] As for COVID virus, the potential for large portions of the population to become ill remains a significant concern. By the end of September 2020, over thirty million people around the globe have tested positive for COVID-19. Doctors are improving their knowledge of symptoms, pathophysiology, management, mode of spread, and prevention of the disease. While still being researched, a vaccine or specific treatment does not currently exist, but a number of candidate vaccines are undergoing trials. The need for potential months of control measures is generated to limit the spread of infection and lower the number of fatalities. These measures will hopefully allow time for treatments and a vaccine to be developed for long-term control of the virus.[6]


  Stigma toward the “Assumed” Infected Top


With many diseases, it is readily apparent who is ill and symptoms, corresponding to the period of being contagious, are outwardly noticeable and known. However, many people with COVID-19 remain asymptomatic, and then, they can spread the virus without their knowledge. Individuals who contract and even die from the disease may be blamed for it, as occurred with the HIV/AIDS epidemic previously. Victims of COVID-19 may be accused of not complying with stay at home orders, lockdown, or taking proper precautions when going outside. People may be stigmatized even when they do not have the virus due to nature and course of this viral infection. For example, someone with previous history of allergies who has congestion and sneezing due to flare up at present may be shamed for leaving their house while “sick.”[6]


  Stigma toward Chinese Community Top


Due to the asymptomatic nature of the virus, individuals are turning to other nonhealth-related traits to identify potential carriers. One of the more disturbing trends is the increase in stigma directed toward those of Chinese descent occurring from systemic racism rooted in age-old stereotypes. A Chinese group in the UK received a Facebook threat allegedly stating “The disgusting, barbaric animal cruelty you people do – you all deserve to get the virus.” Religious and government leaders in India and Singapore have blamed China, citing the wrath of Allah/God for what has transpired with labeling and targeted stigmatization (e.g., COVID-19 being called as the “Chinese virus” creates a sense of divide – as if the ones who do not have the virus are against those who may have it just on the basis of how they look in terms of their ethnicity.). When individuals lack sound information about others, trait-based attributions will be drawn from social categories and stigmas associated with out-group members.[6]

Stigma adversely affects the mental health of not only the patients but also his family and associates including healthcare providers and society at large.[7]


  Incidents of Stigma Worldwide Top


Unfortunately, incidents of stigmatization associated with COVID-19 are being reported all across the globe. Several reports suggest that being accepted back into the society is becoming a challenge for the COVID-19 survivors. Patients have reported being treated like outsiders and something dangerous after surviving COVID-19 or despite having recovered. A report published in the Times of India showed that individuals who recovered from COVID-19 faced discrimination in their immediate surroundings in the state of Bihar and various other regions in the country.

It was further reported that they were not allowed to move around with the excuse of contagious nature of the disease. In another report, published online, in Raipur, a 19-year-old patient had to face criticism and received hate messages because she was tested positive for COVID-19.[7]

Various international organizations have pointed out that the pandemic has led to social stigma and discriminatory behaviors toward certain ethnic groups and those who have been in contact with the virus.[7]


  Past Prevalence of Stigma with Diseases and Mental Health Consequences Top


Studies conducted during and after public health emergencies previously such as epidemics or pandemics because of communicable diseases have highlighted the presence of stigmatization and associated mental health consequences as well. Diseases are stigmatized in circumstances when an individual is believed to be the cause of a disease, the nature of disease is terminal and degenerative, the disease seems to be communicable and adverse for others, and the disease is physically apparent.[7] In the past, several communicable diseases which were new such as leprosy and HIV/AIDS were discriminated against and people still are fearful regarding the stigma associated with newer less known diseases. Patients who had recovered from SARS had also once felt being avoided by family, peers, colleagues, and residents of the neighborhood. They even faced barriers in having access to basic services and employment. Stigma may be seen in many apparent ways such as complete social rejection, physical violence, and mental torture.[7] Usually, in several emergency situations related to the health of a huge portion of population, there is a lot of bias against ethnic groups and communities which largely stem from a place of fear of the new and anxiety related to it.


  Psychological Response to Stigma Top


Stigma often is an extremely stress-inducing situation, related to infectious diseases with a potency of spread, it becomes even more debilitating. Some of the common stress responses during the current phase are disturbed sleep, panic attacks, anxiety, worry about illness, and sometimes rise in substance use. During previous such lockdown measures, affected areas were socially avoided, and the residents of these areas faced discrimination at workplace and their properties were also attacked. Often, there are various reactions due to the measure of quarantine, leading to different psychological troubles and triggers. It was highlighted that tenure of quarantine, fear of infection, frustration, boredom, insufficient supplies, lack of information, financial constraints, and stigma are the key stressors these days. It was emphasized that stigma was a postquarantine stressor and a significant theme which has been evident in the recent times.[7] Several people with a past infection by COVID virus were later avoided socially by members of their own groups as they were fearful and suspicious about the nature of the illness and largely unaware about the newly COVID-negative declared population. Increased psychiatric morbidity is commonly reported during the outbreak of infectious diseases when individuals or families have to be quarantined. Due to the fear of stigma, it is likely that people may not report the illness to avoid discrimination, leading to delay in access to healthcare facilities, thereby increasing the spread of the virus.[7]


  Suggestions to Reduce Stigma Top


Several guidelines are produced by the UNICEF, WHO, and IRFC which focus on universal prevention by encouraging everybody to trust the healthcare services and to be empathetic with those suffering. Further, there are suggestions to avoid usage of language that have negative connotations which can increase stigmatization; for instance, to avoid attaching location or ethnicity to the disease, it is imperative to avoid labeling patients using the terms that create the impression of putting blame on the patients such as “transmitting COVID-19.” Some other ways suggested include encouraging spreading of facts and authentic information by even involving social influencers such as leaders and celebrities, involving community volunteers, and boosting voices of those who have experienced the virus previously. The primary aim is to generate a positive environment where people can be empathetic.[7],[8],[9]


  Measures to Combat Stigma Top


Several new strategies need to be formed for primary prevention of COVID-19. This may consist of education of the masses regarding the nature and course of the disease, and why and when quarantine may be necessary. This knowledge may also prevent the stigma attached with COVID-19 in our society. The media can contribute in shaping the public attitude. Further, positive stories of persons who have recovered from COVID-19, and the role of social support should be highlighted by news channels and social media. There is a dire need for filtering out rumor-generating information which is not legitimate, and hence, sources need to be monitored for that. The message conveyed to the patients and hardworking HCWs must come from an accepting and nonjudgmental space. There is a need for sentiments of hope and positivity as well as a sensitive attitude regarding the current situation. This leads to a better step toward reducing the stigma and mental health issues because of it. Selective prevention programs should target individuals who have increased risk, for instance, those going for COVID testing and HCWs. Stigma may not only precipitate and perpetuate mental health challenges but also acts as an impediment to treatment.[7] Secondary prevention of mental health issues can be attained by screening and early identification along with treatment for the affected persons. We must address and deal with the stigma faced by the survivors immediately. The psychological intervention offered must be as early as possible so that the long-term damaging psychological effects may not restrict the recovery process.[7],[8],[9]


  Psychosocial Impact Top


COVID-19 itself along with the various measures to combat it including nationwide lockdown and quarantine can precipitate mental health issues and psychiatric disorders, including acute worry, panic, obsessions, hoarding, paranoia, anxiety disorders, obsessive–compulsive disorders, depression, and posttraumatic stress disorder (PTSD) in long term due to lack of understanding or knowledge about the significance of these measures. There is a social media “infodemic” which leads to the generation of stigma and bias against particular communities or racial groups, and it fuels mental health triggers. People working at the frontline have a significantly higher risk in getting infected and for being troubled by several adverse psychological consequences such as burnout or anxiety about transmitting the infection as well. There is possibility for more depressive features, substance use, and PTSD. The measures taken to prevent the transmission of disease do disrupt the normal way of living, especially for children, and their usual play time and may cause them stress. The lifestyle and care measures for older population as well as those caring for them, patients in in- and out-patient departments of psychiatry, and marginalized communities get affected and would require specific attention and concern.[10] The community that gets discriminated against or faces stigma tends to seek treatment later and may not be forthcoming with important relevant history of travel or medical comorbidities, furthermore posing a challenge in treatment and increasing the risk of community transmission.[8],[9] In countries where the healthcare system is still developing, the increase in the number of positive cases leads to increased burden as well as more frustration and anxiety among the HCWs. There is also a shortage of personal protective equipment and hygiene products among the front liners who are at significant risk for getting infected.[8] The patients who have been admitted to COVID-19 wards may have several traumatizing experiences. There is anxiety about infecting those close to them, stigma by external and internal factors, guilt, and fear. Remaining away from family members and having no visitors become add on factors for their stress. Expectedly, the specialists and medical administrators are more concerned and attentive to the needs of severely ill patients, availability of beds with oxygen and/or ventilator support, along with supply of medicines and oxygen. Unfortunately, however, the mental health needs of a large number of people who are going to develop mild-to-moderate symptoms of COVID-19 infection are not being highlighted. The experiences of people with the pandemic just remind us how important mental health is and what would be the consequence of ignoring this sphere of healthcare. As we move forward this pandemic and a future free from it – newer challenges are being posed for the mental health professionals in terms of anger, guilt, and internalized stigma by the patients and several healthcare front liners as well which would need to be addressed early.


  Concluding Remarks Top


Despite many uncertainties, the current consensus is that:

  • COVID-19 being highly infectious can infect any one of us. We can protect ourselves by maintaining social distance, avoiding crowded places, frequent hand washing with soap and water or alcohol-based sanitizers, and following proper way of coughing/sneezing
  • However, people will and do get infected despite complying with all the advised precautions. This should not be construed as their fault and they should not be blamed for it. It must be emphasized that the mortality is low and majority of infected persons will recover completely
  • In distressful situations, the patient and the family need support and help from the authorities
  • HCWs of various categories are working round the clock putting themselves in harm way to deliver medical care/clinical support in this situation of crisis. In addition, workers of sanitation department and police are also exposing themselves to risk of infection to serve the community. They all deserve our support, praise, and appreciation[9]
  • Stigma can only be combated by dissemination of correct information and knowledge.




 
  References Top

1.
Khan SC. COVID-19, an infodemic associated with pandemic. Pak Armed Forces Med J 2020;70:278-80.  Back to cited text no. 1
    
2.
Lulseged S, Melaku Z. COVID 19 pandemic: An eerie challenge to the global community. Ethiop Med J 2020;58:283-6.  Back to cited text no. 2
    
3.
Goffman E. Stigma: Notes on the Management of Spoiled Identity. Englewood Cliffs, NJ: Prentice Hall; 1963.  Back to cited text no. 3
    
4.
Dowdy DW, Zwerling AA, Stennett A, Searle A, Dukhanin V, Taylor HA, et al. Measuring stigma to assess the social justice implications of health-related policy decisions: Application to novel treatment regimens for multidrug-resistant tuberculosis. MDM Policy Pract 2020;5:2381468320915239.  Back to cited text no. 4
    
5.
Kane JC, Elafros MA, Murray SM, Mitchell EM, Augustinavicius JL, Causevic S, et al. A scoping review of health-related stigma outcomes for high-burden diseases in low- and middle-income countries. BMC Med 2019;17:17.  Back to cited text no. 5
    
6.
Roberto KJ, Johnson AF, Rauhaus BM. Stigmatization and prejudice during the COVID-19 pandemic. Adm Theory Prax 2020;42:364-78.  Back to cited text no. 6
    
7.
Singh S, Bhutani S, Fatima H. Surviving the stigma: Lessons learnt for the prevention of COVID-19 stigma and its mental health impact. Ment Health Soc Inclusion 2020;24:145-9.  Back to cited text no. 7
    
8.
Bagcchi S. Stigma during the COVID-19 pandemic. Lancet Infect Dis 2020;20:782.  Back to cited text no. 8
    
9.
Addressing Social Stigma Associated with COVID-19. Available from: https://home.iitd.ac.in/uploads/addressingsocialstigma associated with covid19.pdf. [Last accessed on 22 Sep 2020].  Back to cited text no. 9
    
10.
Dubey S, Biswas P, Ghosh R, Chatterjee S, Dubey MJ, Chatterjee S, et al. Psychosocial impact of COVID. Diabetes Metab Syndr 2020;14:779-88.  Back to cited text no. 10
    




 

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  In this article
   History of Pande...
  Social Stigma
   Stigmatization o...
   Stigma for Healt...
   Stigma and Preju...
   Stigma toward th...
   Stigma toward Ch...
   Incidents of Sti...
   Past Prevalence ...
   Psychological Re...
   Suggestions to R...
   Measures to Comb...
  Psychosocial Impact
  Concluding Remarks
   References

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