Addressing Stigma Related to COVID-19: A lesson learn from tuberculosis

    Stigma related coronavirus SARS-CoV-2 (COVID-19) occurs when people associate the risk of the disease to a particular group of people. Stigmatization to people with COVID-19, their close contact and people with higher risk are one of the important issues during the pandemic. People with higher risk are people with contact history to confirmed cases or with travel history from local transmission provinces and countries at the last 14 days. They are contacts, health worker, domestic and international travellers. The process of stigma related diseases through multiple pathways, individual, interpersonal and community. A lesson learned from tuberculosis (TB) should be a good guide to study and address stigma related to COVID-19. Both are respiratory diseases and have some similarity in the mode of transmission and prevention. People with the disease are the source of transmission, they spread the diseases through droplet infection. Early detection and prompt treatment are important to prevent further transmission. The main difference is on the onset of the disease, TB is chronic communicable disease hence COVID-19 is an acute communicable disease with high infectivity and fast spreads. TB already has an established guideline to measure and reduce stigma. The definition of TB stigma, types and populations may be adopted on COVID-19. This article aimed to identify stigma related to COVID-19 and provide solutions to address it.

    The type of stigma consists of internalized stigma, anticipated stigma and experienced stigma. The population of stigma including people with the disease, closed contacts, people with higher risk and the general population. News and information regarding stigma related to COVID-19 in Indonesia gained from mainstream media, task force press conference and social media. The information is important data to identify the type, effect of stigma to pandemic prevention program and arrange solutions to address stigma. Experienced stigma may occur because of misconceptions, rumours and misinformation regarding the disease. For example, the concept of COVID-19 transmission mode is spread person-to-person through the droplet. Parts of people believe that is air-bone and dangerous if people with the disease and higher risk pass through in their area. The misconception leads to incorrect action such as rejection and discrimination. Another example of miss conception is about risk definition, people with higher risk was labelled as confirm cases even the fact they were not confirmed yet. Stigmatization by the community to particular people associated with a disease called social stigma. The COVID-19 related stigma not only to the health and migrant workers but also to their family. People in the community keeping distance to the family of people with COVID-19, health and migrant workers. Negative attitudes or rejections because of their association with the disease and/or patients called secondary stigma.    

    Experienced stigma is psychological and physical violence that lead to internalized and anticipated stigma. Self-stigma is belief being unwanted, careless, avoidance, rejection and discrimination if associated or confirmed as people with COVID-19. Internalized stigma causes irrational and fear. Fear being unwanted, careless, avoidance, rejection and discrimination called anticipated stigma. Internalized and anticipated stigma have a negative impact on health behaviour. People tend to hide the illness avoiding rejection and discrimination, hinder seeking health care immediately and discourage them in implementing prevention action. In term of contact tracing, internalized and anticipated stigma causes people to conceal their contact, works and travel history if associated with COVID-19. In overall stigma is a major barrier for detection, prevention and control capacity. People with persistent internalized and anticipated stigma tend to enacted stigma to people around. Enacted stigma is the synonym of experienced stigma. This circle make the stigma issue in the community become larger if without any intervention.

    Strategies to reduce stigma should be a multilevel approach, starting from intrapersonal, interpersonal, organizational, community, and policy. At the intrapersonal level, the patient centre approach should be implemented starting from screening for people with higher risk, further evaluation and confirmed case management. Risk communication, comprehensive education and psychological support should be provided for them. People with higher risk and confirmed COVID-19 who without or with mild symptom may follow self-isolation in their house if meet the requirements. At the interpersonal level, care and support and from family are important them comply with the procedure. providing food, laundry and other instrumental support during self-isolation. Interpersonal support is also important for people with COVID-19 who take care in a hospital. The implementation patient-centred care by increasing the capacity of nurses and doctors who treating COVID-19 including communication, information and education. At the community level, campaigns to raise awareness about COVID-19 as a shared problem must be carried out on an ongoing basis. Policies in the related sectors must continue to be encouraged to be in line with the TB control program.

    In overcoming the problem of stigma in Covid-19 can learn from efforts to overcome the stigma of tuberculosis. Erving Goffman in his book titled "Stigma: Notes on the management of spoiled Identity" wrote, "The normal and the stigmatized are not persons, but rather perspectives". So the basic thing that must be corrected to eliminate stigma against disease is to improve perspective. Not only the perspective of the patient and his family but more importantly the perspective of the community and all stakeholders involved in disease management. TB and COVID-19 is not a punishment for certain people but can happen to everyone. They should not be shunned, excluded and ignored but must always be supported to heal. Tuberculosis and COVID-19 is not a problem of people who are sick and their families, but the problem of all community. As you breathe the same air, live on the same earth, anyone can experience it and is obliged to play a role in overcoming it.