In the midst of health sector and state inefficiencies, we are unable to target improvements for social and behavioural problems related to the pandemic
Human history is riddled with its pandemics. Eventually, these pass and medical treatment protocols for the specific infection become more certain. What remains less deliberated, however, is the exact behavioural response during the pandemic and the socio-psychological consequences on populations after the pandemic is over. Previous research on AIDS and SARS has shown that infectious disease stigma/scare is extremely high when there is little information about the disease, treatment and vaccination. This is true currently of Covid-19. The extreme pressure and suffering of the general public in terms of enforced lockdowns, closed schools and public spaces, reduced economic and business opportunities, risk of infection, and having to adapt to the ‘new normal’ may also be contributing to the build-up of a stigmatising behaviour.
Predominant areas of debate during the coronavirus pandemic have remained ineffective governance, inconsistent lockdown measures, and healthcare shortfalls. It is because of this that there has been a deficiency in both discussion and research on behavioural responses and social support for patients afflicted by Covid-19. Ground research shows that shaming of infected Covid-19 patients and their family members is a problem and a hidden reality of the ‘new normal’. Infected people and their families are facing unaccounted stigma/scare from government authorities, police, and the Health Department. Many are also facing stigma from close relatives and neighbours they expected support and assistance from.
Encouraging stigmatising behaviour
Till July 8, an estimated 237,489 people had been found infected with Covid-19 and around 5,000 had succumbed to the infection in Pakistan. However, plans by the government to conduct a prevalence survey suggest that infected populations, both symptomatic and asymptomatic, might run into millions. People have argued historically, that in many ways infectious-disease stigmas and adoption of social shunning can be a good thing. Stigma against infected families can lead to physical segregation, thus serving the adaptive function of helping to contain the contagion and facilitate prevention. For the coronavirus, with uncertain treatment management and lack of vaccine, stigma and exclusion against infected populations and their families appear to be a rational defence.
Pakistani society is not unknown for illiteracy, superstition and fallacious beliefs. There has been great worry that the response of some in the country when dealing with coronavirus has been through: (i) rejection that the virus exists, (ii) blaming doctors for ‘creating a myth of virus’, injecting poison and causing death, or (iii) believing that if you are afflicted it is a punishment from God. When rationality and hard facts do not register in certain populations, it may serve the interests of many to let stigmatising behaviour grow in order to facilitate prevention.
Some might even claim that stigmatising behaviours have been latently encouraged by the health sector and government as a defence strategy for prevention and detection. Tactics of using the police, rangers, and the army to close infected neighbourhoods, accompany infected patients to isolation centres, and repeatedly check on their family members at their homes regarding symptoms and test results, have been akin to treating patients and their families like offenders.
Negative impact of stigmatising behaviour
However, we are also compelled to ask what, if any, are the short- and long-term negative effects on society and individual of sustaining stigmatising behaviour? Unfortunately, stigmatising behaviour is known to lead to other forms of abuse, including institutional discrimination and individual-level abuse. Institutional discrimination, like job loss and inability to access state resources, can lead to loss of income, capacity development, and skill expansion. In Pakistan, state policy in managing Covid-19 has been to compromise lockdown in favour of economic survival of the majority poor and daily-wage earners in the country. However, less understood is the fact that stigmatising behaviour can contribute to huge economic losses. Stigma of infected persons from the informal economy can lead to non-renewal of contracts. Infected neighbourhoods that are known as economic or retail hubs, can suffer from discrimination in buying and trade.
Individual-level abuse, such as verbal harassment and physical violence, can contribute to mental health deterioration and even suicide ideation in victims and their families. It can also prevent individual families from receiving the support and assistance that they need in terms of delivery of food and necessities, while maintaining social distance protocols, which is essential for wellbeing and recovery rates during infective period. Public rejection and social shaming can also lead to permanent seclusion and loss of self-esteem. From a socio-psychological perspective we must ask ourselves the overall effect of stigmatising behaviour on the collective spirit and community solidarity within a nation.
We also need to recognise that it is not just families of those infected that suffer from the consequences of infectious disease scare, but also healthcare workers dealing with infected populations.
An important component of stigmatising behaviour is imposing blame. Blaming infected populations and their families for catching the infection is very common. This blame can be allocated deliberately as well as unintentionally. Statements and conclusions like ‘you must have forgotten to wash your hands that one time’, ‘sanitising the house is not easy’, and ‘I noticed that you don’t wear your mask correctly’, are obvious reactions in concerned friends, relatives and healthcare professionals when talking to Covid-19 patients and families. Yet, they can lead to an inordinate amount of guilt and remorse in people, ultimately adding to feelings of incompetence and self-doubt. Accepting blame, can lead to permanent feelings of guilt, which can exacerbate challenges related to health access, health recovery, and even more importantly, seeking social support and formal and informal counseling.
We also need to recognise that it is not just family members of infected populations that suffer from the consequences of infectious disease stigma/scare, but also healthcare workers dealing with infected populations. This includes medical assistants, doctors, nurses, paramedic and pharmaceutical staff, community health workers, field laboratory technicians, and especially ICU and emergency healthcare teams for Covid-19 wards and isolations centres. Stigmatising behaviour against healthcare practitioners at the frontlines can contribute to higher stress and burnout, thus leading to inefficient care delivery. Can we afford sub-optimal care practices from our frontline healthcare providers at this time, when their deliverance quality is directly associated with patient mortality? In fact, we can argue that it is practitioner service and emotions that we are dependent on until there is more certainty about the epidemiology of Covid-19.
The real fear is that in order to avoid stigma, many may be adopting coping strategies of ‘passing’ – which is a form of hiding disease to avoid shame and discrimination. Passing in the age of coronavirus would dangerously include reluctance to test, non-reportage of results, and avoidance of health-seeking behaviours. Passing is known to complicate the public health safety standards and collective unity for battling infectious disease burdens. As a nation right now we must ask ourselves if stigmatising behaviours can be complicating the burden of disease and, maybe even, giving strength to it.
Those practicing stigmatising behaviour can also face negative consequences. It is assumed that people who practice stigmatising behaviour benefit from optimal preventive behaviour by maintaining distance from infected populations. Yet, there is great concern that stigma-imposing healthy populations also start avoiding health seeking behaviour in order to prevent contamination. This includes delaying hospital visits for non-coronavirus health problems, such as surgical care, dental care, and chronic health follow-up. Ultimately, there is great complexity in trying to determine and estimate the direct and indirect negative consequences of stigmatising behaviour in both stigma-facing and stigma-imposing populations.
Measurement and criminalisation
Is social behaviour important? Do we, as a society, want to move towards the assessment and recording for the prevalence of stigmatising behaviour? Since, we do not know the actual numbers of the population facing stigma, we are unable to measure the effect and impact of stigma, or design policy to recommend social and institutional reform. This is a major problem for Pakistan. In the midst of critical health sector and state inefficiencies, we are simultaneously unable to target improvements for social and behavioural problems related to the pandemic.
This leads us to the question: is there a means to reducing stigmatising behaviour? Governments in the developed world have dealt with the problem in the past. This includes improving public awareness and education by using mass media campaigns using TV, radio, social media, and pamphlet delivery to homes. For Pakistan specifically, the utilisation of religious leaders and community notables who can make the public aware of the pernicious effects of stigmatising behaviour would be most helpful. There are also legal recourses like criminalisation laws against stigmatising behaviour, which can deter perpetrators and use formal social control to improve public support for infected families. The state can also legislate to guarantee job resumption or contract renewal after two negative test results in the private and public employment sector.
Having determined that stigmatising behaviour can be reduced, for Covid-19 in Pakistan we must weigh in two last things. The first being the benefits of stigmatising behaviour in aiding social distancing and prevention and the current crisis to control the pandemic being at the forefront. Many would argue that given lack of funds and resources, targeting correction in social behaviour and its consequences should not be a priority. Secondly, it is immensely difficult, if not impossible, to correct regressive health beliefs and punitive values, which the society is traditionally known for. Ultimately, stigmatising behaviour is inherent in the fabric of our society. It may be manifesting itself during the pandemic, but it is not unknown for us to practice stigma against populations suffering from other diseases, even for socio-biological eventualities like the birth of a girl child, divorce, ethnic minority status, third gender status, infertility, and special needs or disability. Since the escalation of Covid-19 in late February, the nation has had to adapt to a ‘new normal’. In some ways, it could be that Covid-19 stigma – even though new – is a comfortably familiar ‘normal’ in our society.
The writer is an assistant professor at the Forman Christian College University. She can be reached at sarajafree @fccolllege.edu.pk