The stigma of COVID-19 has provoked social stigma and discriminatory behaviors against people of certain ethnic backgrounds as well as anyone perceived to have been in contact with the virus. This can result in more severe health problems and difficulties in controlling a disease outbreak. The basic idea fuelling this stigma is that we view disease to be located extraneously. The underlying idea is the belief that, 'we were normal and un-diseased' till outsiders barged in and spread this deadly infection.
Homeopathy, or Homeopathic Medicine embraces a holistic, approach to the treatment of the sick. According to its principles Human beings are susceptible to infection and contagion in varying degrees. Susceptibility is the vulnerability or sensitivity of an individual to get diseases. When susceptibility becomes morbid and perverted there is an influx of disease causing agents resulting in disease. So Homeopathy believes that the basic cause of disease is the inner susceptibility; so blaming others for it would be imprudent. Acceptance rather than Avoidance should be a key theory to deal with COVID-19 stigma.
Mary Mallon (a.k.a., Typhoid Mary) as her name suggests has been the most notorious historical figure to bear the blight of disease-associated-Stigma. During the early 1900s, Mary Mallon was shunned and captured by local authorities for her role in spreading typhoid. Mary represented a healthy carrier of typhoid and unknowingly spread the disease to people for whom she prepared meals. Mary underwent a great deal of trauma and hardship as a result of her unfavorable condition and her permanent label (i.e., Typhoid Mary) signifies the stigma she endured (Merrill & Timmreck:,2006)1.
Stigma is defined as an 'attribute that is deeply discrediting' and that reduces the bearer from 'a whole and usual person to a tainted, discounted one'. (Erving Goffman). It commonly results from a transformation of the body, blemish of the individual character, or membership of a despised group.2 In Greek society, stizein was a mark placed on slaves to identify their position in the social structure and to indicate that they were of less value. The modern derivative, stigma, is therefore understood to mean a social construction whereby a distinguishing mark of social disgrace is attached to others in order to identify and to devalue them. Thus, stigma and the process of stigmatization consist of two fundamental elements, the recognition of the differentiating 'mark' and the subsequent devaluation of the person.3
There are a number of diseases that are stigmatized – mental disorders, AIDS, venereal diseases, leprosy, and certain skin diseases. People who have such diseases are discriminated in the health care system, they usually receive much less social support than those who have non-stigmatizing illnesses and – what is possibly worst – they have grave difficulties in organizing their life if their disease has caused an impairment that can lead to disability and handicaps.4
Stigma and Disease Stigmatization looms large in global health ethics because it prevents those with disease from seeking care, engenders fear of those who have disease, causes prejudice against entire groups or communities, and has, in some cases, led to violence against the stigmatized group5. In one study of medical access patterns in Taiwan, Chang and colleagues found that "fear of SARS" led to substantial reductions in seeking medical care: a 23.9% reduction for ambulatory care, a 35.2% reduction for inpatient care, and a 16.7% reduction for dental care. Presumably, people avoided seeking medical care out of fear of becoming infected with SARS in these medical settings.6 This provides us with insight into the stigma associated with emerging infectious diseases and the potential consequences of such stigmatization.
COVID-19 Stigmatization and Xenophobia:
Coronavirus disease 2019 (COVID-19) is illness caused by a novel coronavirus now called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; formerly called 2019-nCoV), which was first identified amid an outbreak of respiratory illness cases in Wuhan City, Hubei Province, China. It was initially reported to the WHO on December 31, 2019. On January 30, 2020, the WHO declared the COVID-19 outbreak a Public Health Emergency of International Concern (PHEIC). On March 11, 2020, the WHO declared COVID-19 a global pandemic, its first such designation since declaring H1N1 influenza a pandemic in 2009.
Illness caused by SARS-CoV-2 was termed COVID-19 by the WHO, the acronym derived from "coronavirus disease 2019." The name was chosen to avoid stigmatizing the virus's origins in terms of populations, geography, or animal associations.7
Why is COVID-19 causing so much stigma?
The level of stigma associated with COVID-19 is based on three main factors:
- It is a disease that's new and for which there are still many unknowns;
- We are often afraid of the unknown; and
- It is easy to associate that fear with 'others'.
It is understandable that there is confusion, anxiety, and fear among the public. Unfortunately, these factors are also fueling harmful stereotypes.[^8 ]
What is the impact?
Stigma can undermine social cohesion and prompt possible social isolation of groups, which might contribute to a situation where the virus is more, not less, likely to spread. This can result in more severe health problems and difficulties controlling a disease outbreak.
- Drive people to hide the illness to avoid discrimination
- Prevent people from seeking health care immediately
Discourage them from adopting healthy behaviours 8
The current COVID-19 outbreak has provoked social stigma and discriminatory behaviours against people of certain ethnic backgrounds as well as anyone perceived to have been in contact with the virus. Stigma associated with COVID-19 poses a serious threat to the lives of healthcare workers, patients, and survivors of the disease. In May 2020, a community of advocates comprising of 13 medical and humanitarian organisations including, among others, the International Committee of the Red Cross, the International Federation of the Red Cross and Red Crescent Societies, the the International Hospital Federation, and World Medical Association issued a declaration that condemned more than 200 incidents of COVID-19 related attacks on healthcare workers and health facilities during the ongoing pandemic. According to the declaration, "The recent displays of public support for COVID-19 responders are heart-warming, but many responders are nevertheless experiencing harassment, stigmatization and physical violence." In a Mar 18, 2020 statement, WHO also unveiled that "some healthcare workers may unfortunately experience avoidance by their family or community owing to stigma or fear. Such situations can make an already challenging situation far more difficult." Several incidents of stigmatization of healthcare workers, COVID-19 patients, and survivors were reported across the world. For instance, in Mexico, doctors and nurses were found to use bicycles, as they were reportedly denied access to public transport and were subjected to physical assaults. Similarly, in Malawi, healthcare workers were reportedly disallowed from using public transport, insulted in the street, and evicted from rented apartments. In India, media reports revealed that doctors and medical staff dealing with COVID-19 patients faced substantial social ostracism; they were asked to vacate the rented homes and were even attacked while carrying out their duties. With respect to social stigma of COVID-19 patients, there was an incident where a pregnant woman was reportedly abandoned by her family in India, after she gave birth to a child at a hospital in Maharashtra state, and was found positive for SARS-CoV-2. In some cases, COVID-19 survivors in India were stalked in social media. A COVID-19 survivor in Harare, Zimbabwe, got surprised, according to a media report, when the road in front of his house was named as "corona road" and some people even preferred to avoid the road fearing the possibilities of infection.9 The situation is believed to be serious because a number of people diagnosed as corona positive have committed suicide (The Indian Express, 10 May 2020), and the instances of mental health crises (depression, substance abuse, violence, post-traumatic stress syndromes and loneliness) have increased manifold.10 As a result of stigmatization there were increased reports of suicides, depression and even resignation from offices. The The Telegraph (13 June 2020) reported that nine doctors from the K. P. C. Medical College and Hospital (Jadavpur, Kolkata) resigned apprehending their aged relatives at home would be at risk if they continued to treat corona patients.11 The severity of Xenophobia associated with COVID-19 stigma demarcated the society into two groups – the affected and the spreaders; which though ridiculous but is surprisingly evident in society. As Sherman points out that "when quarantine becomes a social policy, its effects can be pernicious: it can isolate more than those labeled as 'diseased' and can stigmatize an entire group."6
Demonisation and Externability:
Instead of sympathetically understanding the predicament of people and the conditions that have caused it, whenever the crisis remains unmitigated we look for a cause outside our domain. The underlying idea is the belief that, 'we were normal and un-diseased' till outsiders barged in and spread this deadly infection. The disease is viewed as located extraneously. In fact, a study of pandemics from the Plague of Athens to the Ebola (December 2013) informs us that the genesis of the illness was always zeroed down to an external human or animal cause: the enemy is the outsider. About the Athenian plague the thesis was that it originated in Ethiopia from where it spread to Egypt and Greece. The Plague of Galen (or Antonine Plague, 165–180 AD) was attributed to the soldiers returning from a campaign in the Near East; similarly, the first plague pandemic (the real plague), the Plague of Justinian (541–549 AD), was supposed to have originated in Ethiopia and the global outbreak of the bubonic plague (the Black Death) of the mid-1300s was traced to China (Tuchman, 1987). Likely to have been introduced by fruit bats, the Ebola virus appeared in a village in Guinea from where it spread to Sierra Leone and Liberia (Preston, 1995). The same was also said about the Spanish Flu (Kolata, 2001). The externality of causation is one of the conducive factors of stigma. There is also a legion of other factors, like the ease of its transmission, overlapping symptoms of ailments, its virulence, absence of cure and physical isolation from others, including family members, thus causing psychological traumas. In an environment of suspicion, misconceptions about the disease breed, contributing cumulatively to positing the other as the enemy. Unsurprisingly, such a social situation gives birth to discrimination, xenophobia, racism and, what I would call, ethnicism.10
HOMEOPATHIC APPROACH OF COVID-19 STIGMA
Homeopathy, or Homeopathic Medicine embraces a holistic, approach to the treatment of the sick. Homeopathy is holistic because it treats the person as a whole, rather than focusing on a diseased part or disease diagnosis. According to Homeopathic philosophy, health is considered a perfect state of harmony of functions in mind –body –spirit and illness is often the result of disharmony. Recognizing this disharmony, homeopathy seeks to treat that whole person.
Susceptibility and Disease
Susceptibility is considered as the state or fact of being likely or liable to be influenced or harmed by certain things. It is the vulnerability or sensitivity of an individual to get diseases. Susceptibility speaks about the defensive mechanism in the human body. It is the state of being predisposed to, sensitive to or of lacking the ability to resist a pathogen, familial disease or a drug. When there is susceptibility, that individual is easily affected, influenced or harmed by something. The general capability of the organism to receive impression or the power of the organism to react to stimuli is determined by susceptibility. It is one of the fundamental attributes of life.11
In The Principles and Art of Cure by Homoeopathy, Dr Herbert A Roberts has stated we may define susceptibility primarily as the reaction of the organism to external and internal influences. Human beings are susceptible to infection and contagion in varying degrees. One man will become infected in contact with diseased individuals while another will experience no ill effects whatever. One person is made ill by noxious plants while another man can handle them with impunity.12
So it is the altered susceptibility in an organism which causes disease.
The Differential susceptibility Associated with COVID-1913
It has been observed that SARS-CoV-2 coronavirus that causes COVID-19 has affected some people more be it in infection or severity. Not just this pandemic similar situation has been seen in earlier pandemics but in other infections too. Not all the 10 million individuals infected annually with tuberculosis develop life-threatening disease. Most, in fact, remain asymptomatic. While the majority of confirmed COVID-19 cases result in mild symptoms, the virus does pose a serious threat to certain individuals.
What makes some people more vulnerable than others to SARS-CoV-2? What role do gene networks play in determining or influencing efficiency of infection, the immune response to infection, or the severity of COVID-19 symptoms? For example, genetic polymorphisms exist in the ACE2 gene which encodes the cellular receptor for SARS-CoV-2; allelic variants of the ACE2 may influence the protein's binding with the virus and subsequent invasion of the cell. In addition, polymorphisms of cellular proteases—believed to facilitate the entry of SARS-CoV-2 into the cell, along with furin and TMPRSS2 have been shown to exist. Indeed, a recent preprint suggests that TMPRSS2 variants and resulting expression may influence COVID-19 severity.
It is now evident that not all infected patients develop a severe respiratory illness; the reason for this is currently not clear. Moreover, very little is understood about inter individual genetic differences in the immune response to this new and novel version of the old coronavirus. A possible association between the genetic variability in histocompatibility complex (MHC) class I genes (human leukocyte antigen [HLA] A, B, and C) and the susceptibility to SARS-CoV-2 and severity of COVID-19 has recently been suggested. Specifically, the HLA-B* 46:01 gene product is predicted to exhibit the lowest binding capacity to SARS-CoV-2 peptides, suggesting individuals with this allele may be more vulnerable to COVID-19—due to reduced capacity for viral antigen presentation to immune cells. Conversely, the authors identified that the HLA-B* 15:03 - encoded protein is predicted to have the greatest capacity to present highly conserved SARS-CoV-2 peptides that are shared among common human coronaviruses —suggesting patients possessing this HLA genotype may be more likely to develop immunity. Finally, during some viral infections (including HIV), the ADF/cofilin complex (ADF, actin-depolymerizing factor, is encoded by the DSTN gene; cofilin is encoded by CFL1 and CFL2 genes) is activated. In the initial stages of viral infection, hyperactivation of cofilin and inefficient actin polymerization is known to occur. The possible implication of allelic variants in the DSTN, CFL1, and CFL2 genes, as well as the ACE2 gene, with the spectrum of clinical phenotypes of COVID-19, is therefore intriguing and warrants further exploration.
Our understanding of genetic susceptibility to SARS-CoV-2 infection and the severity of COVID-19 is still in its infancy. The scientific community is trying to address this issue by combining research efforts using existing genetic databases. Why are some patient cohorts and ethnicities having a greater problem with this virus than others? This concept of "differential susceptibility" within a population, needs to be understood not only for SARS-CoV-2, but for all infections, both known and yet to be encountered.
Thus it is evident that it is the inner terrain which is responsible for infection and disease severity in an individual. Susceptibility of an individual to any disease be it flu, tuberculosis or COVID-19 is his own characteristic and it is this morbid susceptibility which is responsible for occurrence of disease. According to Stuart Close morbid susceptibility could be regarded as a state of negative or minus condition-a state of lowered resistance. When susceptibility becomes morbid and perverted there is an influx of disease causing agents resulting in disease.14
So, understanding the fact that it is the inner self which is chiefly responsible for disease occurrence and the weakness is internal. There is no externability of disease and so there is no question of associating COVID-19 stigma to some outer source. One should be prudent enough to look beyond the realms of Blame theory and accept others as comrades of crisis. Acceptance rather than Avoidance should be a key theory to deal with COVID-19 stigma.
Addressing COVID-19 Stigma8
Evidence clearly shows that stigma and fear around communicable diseases hamper the response. What works is building trust in reliable health services and advice, showing empathy with those affected, understanding the disease itself, and adopting effective, practical measures so people can help keep themselves and their loved ones safe.
How we communicate about COVID-19 is critical in supporting people to take effective action to help combat the disease and to avoid fuelling fear and stigma. An environment needs to be created in which the disease and its impact can be discussed and addressed openly, honestly and effectively. Here are some tips on how to address and avoid compounding, social stigma: 1]: Words matter: dos and don'ts when talking about the new coronavirus (COVID-19) 2]: Spreading the facts 3]: Communication tips and messages.
When talking about coronavirus disease, certain words (i.e suspect case, isolation…) and language may have a negative meaning for people and fuel stigmatizing attitudes. They can perpetuate existing negative stereotypes or assumptions, strengthen false associations between the disease and other factors, create widespread fear, or dehumanise those who have the disease.
This can drive people away from getting screened, tested and quarantined. We recommend a 'people-first' language that respects and empowers people in all communication channels, including the media. Words used in media are especially important, because these will shape the popular language and communication on the new coronavirus (COVID-19). Negative reporting has the potential to influence how people suspected to have the new coronavirus (COVID-19), patients and their families and affected communities are perceived and treated.
DOS and DON'TS
Below are some dos and don'ts on language when talking about the new coronavirus disease (COVID-19):
DO - talk about the new coronavirus disease (COVID-19) Don't - attach locations or ethnicity to the disease, this is not a "Wuhan Virus", "Chinese Virus" or "Asian Virus". The official name for the disease was deliberately chosen to avoid stigmatisation - the "co" stands for Corona, "vi" for virus and "d" for disease, 19 is because the disease emerged in 2019. DO - talk about "people who have COVID-19", "people who are being treated for COVID-19", "people who are recovering from COVID-19" or "people who died after contracting COVID-19" Don't - refer to people with the disease as "COVID-19 cases" or "victims" DO - talk about "people who may have COVID-19" or "people who are presumptive for COVID-19" Don't - talk about "COVID-19 suspects" or "suspected cases". DO - talk about people "acquiring" or "contracting" COVID-19 Don't talk about people "transmitting COVID-19" "infecting others" or "spreading the virus" as it implies intentional transmission and assigns blame.
Using criminalising or dehumanising terminology creates the impression that those with the disease have somehow done something wrong or are less human than the rest of us, feeding stigma, undermining empathy, and potentially fuelling wider reluctance to seek treatment or attend screening, testing and quarantine. DO - speak accurately about the risk from COVID-19, based on scientific data and latest official health advice. Don't - repeat or share unconfirmed rumours, and avoid using hyperbolic language designed to generate fear like "plague", "apocalypse" etc. DO - talk positively and emphasise the effectiveness of prevention and treatment measures. For most people this is a disease they can overcome. There are simple steps we can all take to keep ourselves, our loved ones and the most vulnerable safe. Don't - emphasise or dwell on the negative, or messages of threat. We need to work together to help keep those who are most vulnerable safe. DO - emphasise the effectiveness of adopting protective measures to prevent acquiring the new coronavirus, as well as early screening, testing and treatment.
2. Spreading the facts:
Stigma can be heightened by insufficient knowledge about how the new coronavirus disease (COVID-19) is transmitted and treated, and how to prevent infection. In response, prioritise the collection, consolidation and dissemination of accurate country- and community-specific information about affected areas, individual and group vulnerability to COVID-19, treatment options and where to access health care and information. Use simple language and avoid clinical terms. Social media is useful for reaching a large number of people with health information at relatively low cost.
3. Communication Tips And Messages
An "infodemic" of misinformation and rumours is spreading more quickly than the current outbreak of the new coronavirus (COVID-19). This contributes to negative effects including stigmatization and discrimination of people from areas affected by the outbreak. We need collective solidarity and clear, actionable information to support communities and people affected by this new outbreak.
Misconceptions, rumours and misinformation are contributing to stigma and discrimination which hamper response efforts.
- Correct misconceptions, at the same time as acknowledging that people's feelings and subsequent behaviour are very real, even if the underlying assumption is false.
- Promote the importance of prevention, lifesaving actions, early screening and treatment. Collective solidarity and global cooperation are needed to prevent further transmission and alleviate the concerns of communities.
- Share sympathetic narratives, or stories that humanize the experiences and struggles of individuals or groups affected by the new coronavirus (COVID-19).
- Communicate support and encouragement for those who are on the frontlines of response to this outbreak (health care workers, volunteers, community leaders etc). - Share facts and accurate information about the disease.
- Challenge myths and stereotypes.
- Choose words carefully. The way we communicate can affect the attitudes of others
Facts, not fear will stop the spread of novel coronavirus (COVID-19)
These steps will play a pivotal role in dissociating the COVID-19 stigma and help to fight together the pandemic. As put down by António Guterres ninth Secretary-General of the United Nations in his address on 13 March 2020, COVID-19 is our common enemy. We must declare war on this virus. We must act together to slow the spread of the virus and look after each other. This is a time for prudence, not panic. Science, not stigma. Facts, not fear.
Preventing the further spread of COVID-19 is a shared responsibility for us all. We are in this together – and we will get through this, together.15
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