Dear Editor,
Coronavirus disease 2019 (COVID-19) has become one of the most important challenges currently facing the world. One month after the first official case of unusual pneumonia was reported by the Wuhan Health Authority, China, the World Health Organization stated COVID-19 as a public health emergency at the international level due to the rapid spread of the disease, and less than two months later declared it to be a pandemic (1).
The COVID-19 pandemic has had adverse health, social, economic, and even political consequences for numerous communities. One of its apparent consequences is the negative social evaluation or social stigma associated with the disease (2). Historically, epidemics were associated with stigmatization and discrimination. Leprosy, tuberculosis, and acquired immunodeficiency syndrome are among the most well-known and highly stigmatized diseases. The contagious nature, rapid disease spread in different countries, high mortality, and lack of drugs and vaccines for the treatment and prevention of COVID-19 have led to anxiety and stress about the illness and its stigmatization (1, 3), which attacks the dignity of the infected and those suspected of being infected.
Erwing Goffman (1963), in his book “Stigma: Notes on the Management of Spoiled Identity”, considers stigma to be a fragmented identity that attributes characteristics to an individual or group that invalidates the credibility of the individual or group members and results in an unwanted distinction being imposed on him/her (4). A stigmatized individual is not considered healthy and competent enough for full acceptance in society. A stigma is rooted in both social and interpersonal relationships and is a social process characterized by the rejection or devaluation resulting from an unfavorable social judgment about a person or group. Social stigma is the opposition or dissatisfaction of an individual or group due to the social characteristics perceived by them, which are used to distinguish them from other members of society. Therefore, a distinct individual or group might be discredited by that community. Social stigma (rightly or wrongly) can arise from illness, illiteracy, skin color, ethnicity, nationality, and similar issues.
The social stigma caused by COVID-19 is a global phenomenon that has attracted much attention. Social stigma can have a negative effect on patients, their families, friends, and communities (5). The stigma of the disease leads to behavioral manifestations, including discrimination. Stigma and discrimination can lead to rejection by society and reduced opportunities for the treatment and control of the disease (6). In addition to bearing the burden of pain and stress caused by illness and fear of death, an individual with COVID-19 has to endure opposing views and feelings, such as rejection, humiliation, and all kinds of discrimination by society. The consequences of social stigma associated with COVID-19 appear to be more painful than the disease itself, leading to depression or anger, which can result in isolation or retaliatory reactions.
Stigmatization is visible during the disease, and COVID-19 survivors have to endure and cope with the stigma, especially from neighbors and locals (2). Individuals who survive COVID-19 and reach the final stage of treatment also have difficulty normalizing social relationships. Because their complete cure might meet with distrust in society, this will lead to the avoidance of the normalization of relationships, which can eventually result in social exclusion and social isolation of individuals with a history of the disease.
Healthcare providers are also victims of COVID-19 stigmatization. The reluctance or refusal to provide transportation, restaurant, and hotel services to hospital staff and the refusal to accept hospital staff in the neighborhood are notable instances (7). This can lead to discouragement of service delivery.
Consequences of COVID-19 Stigma: Stigma and discrimination have different social, physical, and psychological consequences, which significantly affect disease control and management. Victims of stigmatization are more likely to experience psychological problems, violence or harassment, poor quality of life, increased economic burden, and elevated feelings of shame and low self-esteem (1). The stigma of the disease has serious consequences, including inciting fear, anger, and intolerance among other individuals. A person facing the stigma of COVID-19 might lose their income and job, albeit temporarily, and be marginalized in society.
The stigma of COVID-19 has short-term and long-term psychological consequences in the post-pandemic period. The effects of social stigmatization might increase due to the experience of fear, social exclusion, and isolation. In individuals with mental disorders, their condition might worsen, and other individuals might develop new psychological problems due to the experience of loneliness, anxiety, depression, and post-traumatic stress disorder. Incidents related to previous epidemics show an increase in suicidal ideation during the pandemic (8).
Stigmatization and discrimination might cause individuals with, or suspected of having the disease, to begin to hide their symptoms and illness, refrain from visiting a doctor or testing until the onset of acute symptoms of the disease, and fail to participate in the tracking and follow-up of individuals with a history of COVID-19 (2). This makes problems in identifying new disease cases and preventative measures disrupts the identification and monitoring of patients, and creates substantial barriers to caring for individuals suspected of having COVID-19. Patients with social stigma are reluctant to seek treatment, which delays treatment and ultimately increases morbidity and mortality. In general, social stigma worsens the epidemic by distorting public perceptions of the disease (3).
A prolonged and persistent stigma might result in the internalization of the stigma in patients and reinforces discrimination against them due to shame and negative self-judgment. If the individual agrees with the stereotypes, then guilt can increase anxiety and depression (3). The psychological impact of the COVID-19 stigma can persist for a long time after the epidemic and can increase psychiatric disorders after the epidemic. Therefore, examining stigma during a pandemic is essential in managing this issue (9).
• Refusal to perform diagnostic tests by individuals suspected of having the disease
• Hiding the disease in infected individuals
• Failure to quarantine that increases the likelihood of spreading the disease
• Increased difficulties in monitoring, tracking and identifying individuals with a history of COVID-19
• Causing a delay in seeking health and care services
• Increased risk of late-onset mortality
• Anger due to social stigma and the possibility of retaliatory actions
• Feelings of shame and guilt following the internalization of stigma by sufferers
• Discouragement of healthcare providers from providing services
• Spreading differences within communities
• Decreased social cohesion and solidarity
Management and Reduction of COVID-19 Stigma: Managing and controlling the consequences of the stigma should involve a wide range of measures (5). Recommendations, actions, and interventions to prevent and reduce the social stigma caused by COVID-19 are as follows:
• Increasing public knowledge and awareness
• Monitoring the business environment and tackling discrimination
• Producing appropriate content to help affected individuals to cope with the social stigma of the disease using official and unofficial media
• Using influential social and religious capacities to reduce the consequences of stigma and support victims
• Providing operational and usable training to prevent infection in different segments of society
• Dealing with false news and rumors
• Avoiding instilling fear of the disease
• Providing appropriate and positive reports about those who have recovered
• Incorporating anti-stigma messages into the proposed health protocols
• Providing instrumental and operational support for individuals facing stigma and social exclusion
• Providing financial support for families who have lost their jobs or income due to the current situation
• Social work
• Using the experiences of previous pandemics to develop strategies to deal with the stigma
• Using individuals with a history of COVID-19 infection to develop and implement strategies and interventions to reduce the stigma
