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Stigma is defined as a collection of attitude, belief, and cognition (A B C), associated with labeling, stereotyping, separation, status loss, and discrimination in a context in which power is exercised (Hatzenbuehler et al. 2013). Stigma can stem from multiple sources and span an umbrella such as sexual orientation, disability, HIV status, obesity, racism, ethnicity, etc. On the contrary, discrimination is understood as the behavioral component; physical expression of the stigma. According to Goffman (2017), ‘the stigma theory is an ideology meant to explain a persons inferiority, account for a persons danger or rationalize an animosity based on other ground. It may be seen at an individual level where it arises due to unequal treatment or at a structural level which arises due to societal constraints on an individuals opportunities, resources, and wellbeing (Link et al, 2001). Stigma impairs and streamlines certain thinking processes and is an added burden. Additionally, substantial evidence demonstrates that social crystallization of stigma is associated with multiple interfaces between individual, society, and state responses and circumstances resulting in psychological, financial, and health crises. The effect or impact of the stigma associated with these conditions has been related to a large and diverse group of outcomes, perpetual fear, loss of self-confidence, and trust in social and public institutions that ultimately lead to adverse health outcomes. Each of these stigma-induced processes mediates the relationship between stigma and overall health outcomes in society.
Repeated stigmatization is associated with discrimination that often intensifies internalized stigmatization and feelings of fear (13). Internal stigma (felt or imagined) is caused due to the shame associated with the disease/infection and the fear of being discriminated against. It is derived from actual or perceived (anticipated) social experiences forming stereotypes about public reactions and appraisals from others. Fear of COVID-19 arose from the underlying anxiety about a disease with an unknown cause and possible fatal outcome (Das, 2003). Unlike tuberculosis, HIV, starvation, COVID-19 has three fundamental abilities to transverse; its ability to also inflict powerfully and the rich; scarcity of resources to control and ease of transport in a globalized economy (Kumar, 2020). Responses to illnesses by an individual are shaped by their perceived construction and interpretation of seriousness of the illness/infection during containment and confinement that contributes to social rejection, [1, 10]. When the government was trying to build strategies for containment of the spread and identifying the modes of transmission, a sort of fear is generated due to the association of the infection with death. Adopting social distancing strategy by cordoning off and isolating people may be based upon the best available scientific evidence and maybe scientifically and ethically sound but it generated stigma. Especially if a subgroup, including family members, is at greater risk of spreading the disease, the COVID-19 became vulnerable to social stigma.
The fear of being stigmatized and isolated from family members at the time of crisis along with the fear of death outweighs the chances of health-seeking behavior. People avoided testing, tried to escape quarantine, cut themselves off from other people, avoided disclosing their disease status, and at times even avoid treatment. The invisible stigma infects self-esteem and confidence that affect health-seeking behavior and recovery. Only when the people start believing that they have the disease and can infect their family members, irrespective of whether they have contracted the disease does the fear of death override lack of stigma, and people rush to the hospital. This gives rise to various other problems such as an excessive burden on the healthcare infrastructure and delay or lack of access to the health facilities for people approaching with mildest symptoms or critical patients. The fear among people can initiate stigma in society, which can generate fear in those affected. Discrimination and fear are observable and can be dealt with. People who are affected by the stigma associated with COVID 19 and are afraid may delay health-seeking behavior and go undetected in the community. Stigma is not observable and is hard to be controlled in the masses. This article tries to outline the pathways of socialization of stigma and modes to address its association with fear with respect to COVID-19 in India.
Institutions introduce practices of isolation to prevent the spread of the disease. People fear these subgroups because they had been carrying the disease. Socialization of stigma is reinstated in individuals through constant interaction with the state and society. The state’s discriminatory response to individual needs due to overstretched health systems or by health care providers creates a sense of despair. The segregation arose due to differential treatment and its affordability and the power status of individuals. People realize that healthcare providers don’t show an empathetic treatment, and the patient is treated as an infectious object, unable to access elite treatment at a private health facility. The state of despair further crystalizes stigma. The individual reinforces his/her stigmatic experience with his/her peers. Internalization of stigma offshoots to the outside world through a process of universalization by encircling victims of stigma. They have to fight with the disease and the environment alone in the absence of their family members care and support which leads to a breakdown of trust in the system and determination to fight back. It becomes a cyclic process; victims give rise to more victims. The model of socialization of stigma depicts that discriminatory behavior and fear has emerged due to affected people being socially marginalized and stigmatized. Further, this may generate fear in the subgroup such as fear of inequality, fear of isolation, fear of losing status/power, fear of rejection, fear of not being loved, fear of not being able to perform death rituals. Especially in the Indian context as the mortality rate is high and it is difficult to handle the death rituals of a person who has died of COVID 19. Family members themselves need to be isolated in case the deceased was suffering from COVID. People avoid attending the last rights of the person as well. It also heightens the fear associated with the spread of the disease and its potency to take lives. Superstitious beliefs such as that of rebirth also factor in generating stigma in society. The root cause of stigma maybe i. State induced Stigma, ii. Society Induced Stigma.Unless discriminatory behaviors are not abolished, the stigmatic practices associated with them will not go away. People have even resorted to barring the homes of the people with someone affected by COVID to prevent their contact with society. Resolving fear associated with getting affected will help people approach authorities early and prevent the spread of transmission.
Treatment involving isolation can negatively affect those with the disease, as well as their caregivers, family, friends, and communities (Unicef, 2020). People who are well off can still think of treatments like plasma therapy or even a ventilator, butthe poor and marginalized are having trouble even trying to admit their loved ones. With limited resources and an absence of social support, health-seeking behavior decreases substantially. State induced discrimination creates imbalances between civilians and the health system. It is becoming increasingly difficult to provide medical facilities as the demand is rising.Studies have also shown that in the presence of others sharing the stigma, which is also seen in cases where television programs share the stories of COVID survivors and stories of recovery, people do tend to experience elation in mood and self-esteem.
Public health scientists and practitioners are supposed to respond to the COVID outbreak to mitigate fear. It is commonplace and affects a large section of the population; thus it should be viewed in its entirety. Along with the scientific knowledge including facts related to transmission and prevention, they should develop a culturally tailored intervention strategy that mitigates fear and discrimination and encourage appropriate health-seeking behavior. It is important to address issues regarding discriminatory practices by the health system to bring the community better informed. Additionally, the team may review time to time and encourage partnership with the local people to involve themselves to address the community to dispel myths and particular situations such as death-rituals. Building trust in the health system and showing empathy while not disregarding safe and practical measures to prevent the spread of the disease is important. Communication is critical and an effective medium to convey relevant information to combat fear and stigma and will go a long way against the fight with COVID.
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