Stigma and Aggression Against Health Care Workers in India Amidst COVID-19 Times: Possible Drivers and Mitigation Strategies

Sir,

As the COVID-19 pandemic rages across the globe, frontline as well as backend health care workers (HCW) face tremendous pressure owing to shortage of staff, concerns about their personal safety, the safety of loved ones, and shortage of equipment such as ventilators and protective gear.

In addition to these challenges, globally HCW are increasingly battling against a peculiar problem of stigma and aggression against them. ¹ Moreover, stigma against infectious diseases has been a perennial problem in India. ² This has manifested itself in several unsavoury incidents such as eviction of doctors from their homes, ³ acts of violence against field health workers, ⁴ and denial of burial space to HCW who expired in the line of duty. ⁵ More common stigmatizing behaviours include isolation within residential communities, local stores, as well as among friends and relatives. ⁶

That this development happened in spite of the repeated appeals to the citizens to show appreciation to the health care personnel through social and community acts of clapping and saluting, by a person no less than the Prime Minister himself, ⁷ warrants closer examination. Further, stigma against HCW may have many negative ramifications; it may demotivate frontline HCW, increase their anxiety, reduce their efficiency, and trigger suicide, although rarely. Further, we offer some insights into the potential drivers of this behaviour in India and also outline some approaches to mitigate the stigma against HCW.

Potential Drivers of the Stigma and Aggression

1. Spread of misinformation through old as well as new age media platforms: Mass media, and now social media, have long been recognized as powerful instruments that shape public opinion. Sadly, a virtual “infodemic” composed of misinformation and rumours is spreading rapidly and promoting fear, confusion, and ostracization of HCW in a frantic attempt by the public to stay safe.

2. Fears against an extension of measures such as distancing, containment, and lockdown: Imposition of lockdown and social distancing norms have prevented the poor from earning their livelihood. Additionally, supply line disruptions have led to a struggle for essential supplies and a feeling of “being controlled” by the lockdown. ⁸ Any potential source of infection, such as bodies of expired HCW, which may contribute to a further extension of lockdown measures in an area, is therefore looked at with trepidation, and HCW are targeted as they are seen as COVID-19 carriers.

3. Perception of the poor that COVID-19 is a “disease of the rich”: The coronavirus was brought to India, initially, by students studying at the Wuhan University. Subsequently, the media sources highlighted incoming international travellers as potential sources of the virus. This, together with the subsequent embargo on the incoming flights, supported the notion of COVID-19 being a “disease of the rich.” ⁹ In a hitherto socially polarized society, this would understandably trigger considerable angst among the poor who perceive themselves to be receiving collateral damage for the “excesses” of the rich. Doctors are a perceived affluent lot in India, and this may explain some of the aggression against doctors and other HCW.

Suggestions to Reduce the Stigma and Aggression

The Indian government has recently promulgated an ordinance to protect HCW from acts of aggression. This is a good move, though restricted to pandemic times. Below, we offer some suggestions, a few of which may have more durable effects:

1. Greater community participation in COVID-19 response measures: Governments and local administration have to involve civil society volunteers to a greater extent in response measures than is being done currently. When the civil society participates more actively, the stigma against HCW may lessen because health becomes a shared responsibility. To implement this in India, we need to look no further than the Kerala model ¹⁰ that has been successful in flattening the curve using a variety of measures, including the involvement of community volunteers. ¹¹

2. Regular press releases and media briefings by hospitals: Every hospital and institution involved in COVID-19 care should issue regular press releases that contain all relevant information and updates in the firefighting exercise. This should include steps being taken to ensure the safety of HCW, such as the zoning of COVID-19 hospitals for better infection control, ¹² the usage of protective equipment, and the mandatory quarantine for HCW on COVID-19 duty. This would lessen the tendency to view HCW as a potential source of infection and promote positive attitudes towards them. To further improve the accuracy and quality of official communications, institutions should consider appointing a doctor as a dedicated public relations officer during COVID-19 times.

3. Online support groups for HCW: This will help them to stay connected with their peers and draw upon each other’s experiences in finding strategies that may work against stigma. Opportunities to talk openly about stigma may promote positive coping. Additionally, sharing of positive experiences while dealing with COVID-19 patients can boost their morale. ¹³

4. Share credible sources of information with the public: Myths and misconceptions regarding the spread of coronavirus abound. Fear, fuelled by ignorance, is driving the mob behaviour against HCW.4 Wrong notions about the spread of the disease should be proactively targeted through repeated and sustained information campaigns in the mass media as well as social media.

5. Immediate condemnation of stigma-related incidents by all stakeholders: This includes government, non-governmental organizations, andmembers of the civil society who must be prepared to speak out and issue statements condemning such incidents as soon as they occur. These statements may also be shared on social media and official government Twitter handles for wider reach and acceptance. The Prime Minister connecting with the village heads (sarpanch) in the country over COVID-19 is a positive move. ¹⁴ As the sarpanch holds considerable sway over the rural folk, their services could be utilized to reduce stigma and spread awareness.

6. Rewarding and positive portrayal of HCW: Positively portraying HCW in the media and rewarding them with due recognition for their services could also be considered to reduce stigma.

In summary, stigma is a modifiable reaction to a disease. This is no time for stigma; on the contrary, pandemics are a time to stay more connected than ever. We must remember that our fight is against the COVID-19, not against HCW taking care of those affected with COVID-19.