Stigma and COVID‐19 crisis: A wake‐up call

To the Editor

Public health emergencies in times of epidemics and the effects of contagion mitigation strategies such as emergency lockdown may cause intense fear and anxiety particularly among the at‐risk populations. Correia ¹ has also emphasized that health systems globally have diverted attention and resources toward the fight of COVID‐19. This has significantly hampered the management of other serious health issues such as mental and chronic conditions particularly in low‐ and middle‐income countries where resources for health are often limited. ² This may certainly have both immediate and long‐term deleterious public health impacts during and even beyond the pandemic. More importantly, the emergence of COVID‐19 and the concomitant contagions have resulted in prejudices, community rejection and intense stigma against the infected and affected persons. ³ , ⁴ , ⁵ The allied neuropsychological impacts on the direct medical issues of the pandemic such disruptions, anxiety, stress, stigma and xenophobia may also cause mayhem in the society and social lives. ⁶ Pervasive social stigma and discriminatory behaviors are being demonstrated toward the frontline health and social workers and the vulnerable, at‐risk population including older adults.

Emerging evidence from many parts of sub‐Saharan Africa (SSA) shows that many people who have recovered and those recovering from COVID‐19 as well as their families and close relevant others have been thrust into extreme stigmatization. ⁵ , ⁷ , ⁸ , ⁹ Diverse media reports document instances where COVID‐19 suspected persons have been ejected from their rented apartments and turned away from shops especially after completing mandatory quarantine. ¹⁰ , ¹¹ Such behaviors and actions may likely cause not only hostility and social disruptions but also interfere vehemently with the countermeasures against COVID‐19.

Lessons from previous outbreaks such as the MERS‐COV, HIV and Ebola epidemic suggest that stigma tends to persist during and postepidemic. We offer viewpoints on how COVID‐19‐related stigma affects the mental health of the infected and affected people and propose measures to address this social canker especially in SSA.

1. COVID‐19‐RELATED STIGMA AND MENTAL HEALTH

Growing evidence suggests that stigma associated with COVID‐19 is a major source of mental distress such as stress, anxiety and depression among the frontline health workers, and affected individuals with serious implication for their well‐being. ¹² , ¹³ , ¹⁴ COVID‐19‐induced stigma can profoundly plunge individuals especially, the health workers into isolation and worthlessness with respect to their inability to effectively contribute to the fight against the pandemic. ¹⁴ , ¹⁵ This resonates with the stadpoint of Javed et al. who explain how COVID‐19‐related stigma may aggravate mental health issues for the affected persons. ⁶ For instance, individuals discharged from quarantine and self‐isolation experience stigmatization and the associated drastic negative impacts on the mental health due to mixed of emotions. At the same time, recovered COVID‐19 patients in their initial stage of family integration may have to practise some cautious social distancing from family members, close relatives and friends due to the rapid spread of the virus. Meanwhile, frontline health workers charged to save and protect lives and society may encounter social distancing and stigmatization for the misconception that they remain carriers of the virus. Previously infected persons may also develop anger, frustration and sadness due to broken relationships as friends and loved ones may have unfounded fears of contracting the disease through personal contacts. ⁶

Crucially, the possible mental health effects of stigma on people might be further exacerbated by fear, community rejection and self‐isolation. ² , ⁶ , ¹⁶ At the same time, stigmatized people with psychiatric disorders might witness worsening conditions while others might develop new psychological problems as a result of loneliness, anxiety, depression and posttraumatic stress. ¹² Psychological and mental sequelae of COVID‐19‐related stigma are likely to present short‐ and long‐term postpandemic impacts. Lessons from previous epidemics show that the rate of suicide thoughts, ideation and attempts during COVID‐19 will inevitably heighten chiefly because of stigma. ¹² , ¹⁴ Moreover, evidence points to the view that suicide was a serious concern and caused several fatalities during the Ebola and Zika outbreaks in SSA, Influenza in the USA and SARS‐COV‐1 in Hong Kong. ¹⁷ , ¹⁸ Many countries have paid the price for not paying much attention to stigma‐related psychological and mental health issues. ¹⁹

2. STIGMA AND THE FIGHT AGAINST COVID‐19

Fear, rumours and stigma have been described as the key challenges accompanying COVID‐19. Previous outbreaks have shown that stigmatization hampers public health response to epidemics. ³ , ⁴ Stigmatization may potentially create a negative motivator for people to either hide illness symptoms and important medical history, delay healthcare seeking and could discourage adoption of healthy behaviors among populations. ⁸ , ²⁰ In many countries in SSA including Ghana and Kenya, COVID‐19‐related stigma has demonstrated barriers to contact tracing, prompt testing and treatment. This could lead to under‐reporting of COVID‐19 cases and contribute to fatalities. ²¹ Having accurate data on the COVID‐19 cases is essential for understanding the national and global burden of the disease, management practices and preventive efforts.

Stigma has also intertwined with other structural issues and ills of the society such as poverty, illiteracy and social exclusion to increase the risk of community transmission of SARS‐COV‐2. ⁵ Stigmatization of frontline health and social workers and volunteers can lead to higher rates of stress and burnout and potentially result in a lack of interest in fighting the outbreak. ²² Stigmatizing people with COVID‐19 and health workers is tantamount to social isolation and could seriously undermine the fight against the pandemic. Stigma is also seen as counterproductive and social injustice and may derail the public health strategies and political investments to arrest the pandemic. ²³

3. AVERTING STIGMA DURING COVID‐19

First, using experiences and applying lessons from previous epidemics such as Ebola and HIV/AIDS‐related stigma reduction strategies to COVID‐19 can be important teaching points. The role of community‐based approaches such as social mobilization and community engagement and participation were effective in generating solidarity and reclaiming identities. In this sense, people affected by COVID‐19 should actively and genuinely be involved in the development and implementation of stigma mitigation strategies and interventions. This can help create contextually and culturally appropriate and stigma‐informed approaches.

Second, misinformation and lack of accurate information are key drivers of fear and stigma and should be considered in stigma mitigation strategies. In lieu of this, COVID‐19‐related information should be communicated concisely and in culturally appropriate manner in diverse local languages across broader segments of the population with particular attention on stigmatized communities. Again, COVID‐19 precautionary protocols such as quarantine and self‐isolation could include anti‐stigma public messaging. In this regard, the media, recognized as a powerful force, in the fight against COVID‐19 has a crucial role to play by not spreading unverified rumours and exaggerated claims that may promote stigma, xenophobia and scapegoating which may potentially compromise response to the outbreak and increase public confusion. The media should rather spread accurate information to convey hope, unity and togetherness reaching large audiences.

Third, although access to accurate information is important in addressing stigma, applying an intersectional lens can improve understanding of the ways that COVID‐19 stigma intersects with social determinants of health such as gender, race, immigration status, housing security and health status, among other may be highly effective. Balancing tensions between stigma mitigation and the COVID‐19 prevention and containment can inform immediate and long‐term strategies to build empathy and social justice in current and future pandemics.

Finally, engaging social influencers and community leaderships (such as traditional, faith leaders and celebrities), creating public awareness and paying attention to cultural features and expanding public trust and confidence would be important opportunities to fight the pandemic without stigma.

The effects of COVID‐19‐related stigma in the health and social lives of individuals and societal functioning are enormous. These may have some serious consequences in the response strategies and efforts to fight the pandemic. Addressing stigma toward people with COVID‐19 and their families and the associated risks should be a priority for policy and practice. We, therefore, call for a collaborative effort to urgently address COVID‐19‐related stigma particularly in SSA.

CONFLICT OF INTEREST

The authors declare no potential conflict of interest.

AUTHOR CONTRIBUTIONS

All authors have equal contributions.