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An alternative estimation of the death toll of the Covid-19 pandemic in India
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Publication date (Electronic):
16 February 2022
Journal:
PLoS ONE
Publisher:
Public Library of Science
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Abstract
The absence of reliable registration of Covid-19 deaths in India has prevented proper assessment and monitoring of the coronavirus pandemic. In addition, India’s relatively young age structure tends to conceal the severity of Covid-19 mortality, which is concentrated in older age groups. In this paper, we present four different demographic samples of Indian populations for which we have information on both their demographic structures and death outcomes. We show that we can model the age distribution of Covid-19 mortality in India and use this modeling to estimate Covid-19 mortality in the country. Our findings point to a death toll of approximately 3.2–3.7 million persons by early November 2021. Once India’s age structure is factored in, these figures correspond to one of the most severe cases of Covid-19 mortality in the world. India has recorded after February 2021 the second outbreak of coronavirus that has affected the entire country. The accuracy of official statistics of Covid-19 mortality has been questioned, and the real number of Covid-19 deaths is thought to be several times higher than reported. In this paper, we assembled four independent population samples to model and estimate the level of Covid-19 mortality in India. We first used a population sample with the age and sex of Covid-19 victims to develop a Gompertz model of Covid-19 mortality in India. We applied and adjusted this mortality model on two other national population samples after factoring in the demographic characteristics of these samples. We finally derive from these samples the most reasonable estimate of Covid-19 mortality level in India and confirm this result using a fourth population sample. Our findings point to a death toll of about 3.2–3.7 million persons by late May 2021. This is by far the largest number of Covid-19 deaths in the world. Once standardized for age and sex structure, India’s Covid-19 mortality rate is above Brazil and the USA. Our analysis shows that existing population samples allow an alternative estimation of deaths due to Covid-19 in India. The results imply that only one out of 7–8 deaths appear to have been recorded as a Covid-19 death in India. The estimates also point to a very high Covid-19 mortality rate, which is even higher after age and sex standardization. The magnitude of the pandemic in India requires immediate attention. In the absence of effective remedies, this calls for a strong response based on a combination of non-pharmaceutical interventions and the scale-up of vaccination to make them accessible to all, with an improved surveillance system to monitor the progression of the pandemic and its spread across India’s regions and social groups.
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Excess mortality: the gold standard in measuring the impact of COVID-19 worldwide?
Thomas Beaney, Jonathan Clarke, Vageesh Jain … (2020)
The unprecedented speed and scale of spread of the global COVID-19 pandemic has forced policy-makers and clinicians to operate with limited evidence for the relative success of different control measures. In the words of Dutch prime minister Mark Rutte, ‘with 50% of the knowledge we have to make 100% of the decisions’. 1 Understanding mortality differences will be a key factor in distinguishing the relative effectiveness of prevention and control measures between countries, 2 but as we discuss, comparisons are affected by differences in reporting and testing. Excess mortality can overcome this inherent variation, but without appreciation of its constituent parts, its role in helping us understand why mortality differs between countries remains limited. Throughout the pandemic, ‘league tables’ have tracked cases and deaths globally. Although these figures quantify the overall scale of disease within a country, they are limited as comparative measures by differences in factors such as population size and demographics. As of 31 July 2020, the USA has the highest number of total COVID-19 deaths, but relative to population size, of countries with at least 100 COVID-19 deaths, the USA ranks eighth, while Belgium has the highest COVID-19 mortality. 3 Demographic differences also add to the complexity in drawing comparisons. Increasing age is strongly associated with COVID-19 mortality, and the population age distributions within countries may be very different, impacting on the comparability of COVID-19 statistics between countries. Limitations to COVID-19 mortality estimates: reporting and testing Although we can adjust or standardise for these factors, comparisons of COVID-19 mortality remain limited unless we understand how definitions of a death vary. The World Health Organization defines a COVID-19 death as one where COVID-19 is the underlying cause of death, encompassing both confirmed and suspected cases. 4 Where COVID-19 is a contributing factor, but not the cause leading directly to death, it is not counted. However, the World Health Organization guidance was introduced in April 2020, by which stage countries may already have introduced their own guidance. Consequently, there are significant differences in how COVID-19 deaths are reported between countries. 5 Russia’s case definition for a COVID-19 death, for example, relies solely on results from autopsy, unlike most European countries. 6 Death must have been due directly to COVID-19, so it is not counted if a patient was found to have COVID-19 but it did not cause their death. 6,7 This will lead to significant underreporting, especially as Russia has one of the highest numbers of COVID-19 cases worldwide and yet has a case fatality rate of only 1.7% as of 31 July 2020. 3 Spain’s definition requires a positive polymerase chain reaction or antibody test for COVID-19, with only hospital deaths included in the death count despite a significant number of deaths from COVID-19 in the community and care homes. 8,9 Belgium, by contrast, has one of the broadest definitions for a COVID-19 death, including all suspected cases. Care home deaths in Belgium account for around half of all excess deaths, but only 26% of care home deaths were confirmed (rather than suspected) COVID-19, 10 leading to possible overcounting relative to other countries. 11 Criteria may also differ within country. In the UK, for example, the Department of Health and Social Care and National Health Service England report COVID-19 deaths where the person tested positive, whereas the Office for National Statistics additionally include cases where COVID-19 is mentioned anywhere on a death certificate. 12 Availability of, and criteria for, testing will also affect the number of COVID-19 deaths, particularly where only confirmed cases are included. At the start of the pandemic, no ‘off-the-shelf’ method of diagnosing COVID-19 infection was readily available. In the UK, for example, availability of diagnostic tests was limited to hospital settings in March 2020, and reserved for the most unwell, with community testing largely being stopped; however, over time testing has been extended as testing capacity has increased. 13 For weeks into the pandemic, particularly outside of the hospital, many patients who died with clinical features consistent with COVID-19 infection will have gone untested. Whether, in the absence of testing, clinicians overestimate or underestimate COVID-19 as a cause of death during the pandemic is unknown, but both are equally plausible. There is wide variation in clinical decision-making and in how doctors complete death certificates based on personal, professional and contextual factors. 14 There may be many deaths misattributed to COVID-19 and, conversely, others not attributed to COVID-19 where it was the underlying cause, contributing to uncertainty surrounding the true number of COVID-19 deaths. Excess mortality As the pandemic has progressed, there has been a growing focus on excess mortality as a more reliable metric for comparing countries. 15 Excess mortality provides an estimate of the additional number of deaths within a given time period in a geographical region (e.g. country), compared to the number of deaths expected (often estimated using the same time period in the preceding year or averaged over several preceding years). 15 In encompassing deaths from all causes, excess mortality overcomes the variation between countries in reporting and testing of COVID-19 and in the misclassification of the cause of death on death certificates. Under the assumption that the incidence of other diseases remains steady over time, then excess deaths can be viewed as those caused both directly and indirectly by COVID-19 and gives a summary measure of the ‘whole system’ impact. Excess mortality can also be standardised for age or population size to aid comparability between countries. Beyond excess mortality Despite this, when seeking to understand the full impact of deaths due to COVID-19 and explain why excess deaths vary, there is a need to distinguish the component parts – of direct COVID-19 and indirect, non-COVID-19 deaths. Figure 1 summarises the multiple factors impacting on COVID-19 and non-COVID-19 deaths during the pandemic, ranging from individual risk factors and attitudes to restriction measures, to public health policies and changes to health systems. Individual fears of contracting the disease or of overburdening the system may alter health-seeking behaviours and lead to increased deaths from non-COVID-19 causes: for example, the number of patients presenting with heart attacks and stroke has declined in the USA during the outbreak. 16,17 Urgent referrals for suspected cancer have fallen in the many countries, 18 which may reflect a decrease in patients presenting with ‘red flag’ symptoms or changes to clinician thresholds for referral due to health system pressures, leading to both short- and long-term impacts on indirect mortality. 19 Overburdening of the health system and changes to clinical pathways as a response to prioritising COVID-19 cases may leave deficiencies in standard care pathways. 19 Globally, the World Health Organization has found that 42% of countries have experienced disruptions to cancer services, 49% for diabetes and 31% for cardiovascular disease services. 20 Concerns about the efficacy of the pandemic response will arise if deaths from COVID-19 are limited only at the expense of deaths from other causes. Excess mortality has limitations in explaining differences between countries; and in understanding why excess mortality differs, we must differentiate the cause of death. Figure 1. Factors impacting on excess mortality, COVID-19 and non-COVID-19 excess deaths. Variation between countries There is significant variation in total excess deaths, and in the relative contributions from COVID-19 and non-COVID-19 excess deaths between countries, as shown in Figure 2. Data on weekly all-cause deaths and COVID-19 deaths were sourced from the Human Mortality Database 21 and European Centre for Disease Prevention and Control 3 (Office for National Statistics for England and Wales 22 ), respectively. We selected the 10 countries with the highest total COVID-19 deaths of those with data on all-cause deaths. Cumulative excess deaths were calculated as the number of deaths per week in 2020 minus the number of deaths per week averaged across 2015–2019 (2016–2019 for Germany) starting from the week of the first reported COVID-19 death. Non-COVID-19 deaths were calculated as the number of excess deaths minus the number of COVID-19 deaths. Figures are reported as counts per million to account for population size. Reporting time frames are not uniform across countries, and data were censored when mortality fell below 90% of the historic average to account for possible reporting delays. Figure 2. Total excess deaths with relative contribution of COVID-19 and non-COVID-19 excess deaths per million population for 10 countries. Note. Data on weekly mortality from the Human Mortality Database. 21 COVID-19 deaths from the European Centre for Disease Prevention and Control. 3 COVID-19 deaths for England and Wales from the Office for National Statistics. 22 BEL: Belgium; CHE: Switzerland; DEU: Germany; ESP: Spain; FRA: France; GBR: England and Wales; ITA: Italy; NLD: Netherlands; SWE: Sweden; USA: United States of America. The highest excess mortality per million population is seen in Spain, followed by England and Wales. The majority of these excess deaths are caused by COVID-19, but a significant proportion of 39% in Spain are not directly related to COVID-19. Data from Belgium, France and Switzerland suggest that non-COVID-19 deaths could be lower than expected. This may reflect the broader case definition for COVID-19 deaths in Belgium, resulting in some non-COVID-19 deaths being misclassified as COVID-19 deaths. In the case of France, following the peak of the pandemic in April, mortality from 1 to 18 May 2020 was 6% lower than in the same period in 2019, with larger reductions in mortality in younger age groups. 23 Although this may represent delays in reporting of deaths, rather than a genuine decline in non-COVID-19 deaths, analyses from the Office for National Statistics have shown a similar effect in many European countries: by the end of May, cumulative mortality returned to expected levels, or even lower-than-expected levels, particularly in the under-65 s. 24 Some vulnerable individuals who died of COVID-19 might otherwise have died from alternate causes, a concept known as ‘mortality displacement’. Short-term increases in mortality due to COVID-19 may result in a relative reduction in mortality from other causes in subsequent weeks and a gradual fall in total excess mortality over time. However, mortality displacement is unlikely to explain the falls in mortality in younger age groups where mortality from COVID-19 is low. Factors such as a lowering of air pollution during the pandemic may have had positive impacts on mortality. 25 Deaths from suicide, injury and poisoning are the leading causes of death in younger adults in England and Wales, and social restrictions may have led to falls in deaths from these causes. 26 However, registration of these deaths can take many months, often following a coroner’s inquest, so it will be some time before we understand whether any suspected reductions in mortality in younger people are real. 27 In the UK, the Office for National Statistics has begun to investigate the causes of non-COVID-19 excess deaths. 27 Up until 1 May 2020, 28% of excess deaths did not involve COVID-19, with significant numbers of non-COVID-19 deaths occurring in care homes or in private homes, and a corresponding decline in non-COVID-19 excess deaths in hospitals. Dementia, along with old age and frailty, was among the most common causes of non-COVID-19 deaths. A recent study of deaths in four UK care homes found that 43% of residents testing positive for COVID-19 had no symptoms in the two weeks before death, and 18% had atypical symptoms only, suggesting that identification of disease may be more difficult in this setting and that some COVID-19 deaths have gone unrecognised. 28 Social isolation in older adults is known to be associated with increased all-cause mortality, 29 and the social restrictions imposed to limit transmission may have had the unintended effect of increasing mortality from non-COVID-19 causes in this age group. Measuring the impact of COVID-19: beyond mortality statistics In measuring the impact of COVID-19 and considering control strategies, mortality is only one of many factors. Even in ‘mild’ cases not requiring hospitalisation, symptoms can be long-lasting, and pulmonary 30 and cardiac 31 complications are common, affecting quality of life and ability to work. The enforcement of social restrictions may have negative health consequences, with mental health problems increasing during the pandemic. 32 Beyond the effects on health, the pandemic has disrupted all aspects of society – many countries have experienced record economic recessions, while school closures may impact children’s educational attainment. Mortality, and, specifically, excess mortality, should not therefore be used as the only measure of the impact of COVID-19. Using excess mortality to inform policy Usefully comparing COVID-19 mortality between different countries requires systems that are standardised, a significant shift from the status quo. To harness the potential of excess mortality in informing and guiding pandemic responses, data must be timely and comprehensive, including out-of-hospital deaths and reporting of all causes of deaths. Where countries have robust systems to collect this data, they should be reported, ideally in real time, to show trends within country. Further in-depth reporting such as that from the Office for National Statistics in the UK is urgently needed for all nations impacted by COVID-19. This will allow a robust assessment of the direct and indirect impact and help to guide national or local public health policy. It will also allow comparison of the effectiveness of different control, suppression and mitigation policies, which in turn will allow countries to prepare better for a second wave of infection or a future pandemic from a different pathogen. Experience to date suggests that countries that responded rapidly to implement suppression measures, such as South Korea, have fared considerably better than the UK. 33 Conclusion Excess mortality is a measure that encompasses all causes of death and provides a metric of the overall mortality impact of COVID-19. When seeking to draw comparisons between countries, it is necessary to understand why mortality varies, through disentangling the constituent parts – of direct COVID-19 deaths and indirect, non-COVID-19 excess deaths – and there is urgent need for national bodies to report all-cause mortality. Where data collection and reporting systems are timely and comprehensive, excess mortality, used alongside cause-specific mortality, can be useful to monitor trends within and between countries and inform international, national and local public health policies.
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The “Untold” Side of COVID-19: Social Stigma and Its Consequences in India
Prama Bhattacharya, Debanjan Banerjee, TS Rao (2020)
“Imagine a society of saints, a perfect cloister of exemplary individuals. Crimes or deviance, properly so-called, will there be unknown; but faults, which appear venial to the layman, will there create the same scandal that the ordinary offense does in ordinary consciousnesses. If then, this society has the power to judge and punish, it will define these acts as criminal (or deviant) and will treat them as such.” —Émile Durkheim, Rules of Sociological Methods, 1895, p. 123 1 The Canadian sociologist Erving Goffman theorized that social stigma is an attribute or behaviour that socially discredit an individual by virtue of them being classified as the “undesirable other” by society. 2 There has been a long association of social stigma with illness. Through the process of othering, social stigma segregates the healthy from the ill. It creates stereotypes and prejudice. “Othering,” originally a philosophical concept given by Edmund Husserl, describes the reductive action of labeling and defining a person as a subordinate in terms of category. 3 This generates a “we versus they” dichotomy that helps in the establishment of a socioeconomic hierarchy. During times of social crisis (pandemics in this case), it can lead to discrimination and blame. Those who have any association with the illness are discriminated against and socially isolated, with their human rights being violated. The unknown factors about illness create fear, myths, and rumours around them that heighten social stigma. This can negatively affect the treatment and prevention of the illness. Especially, pandemics of infectious disease outbreaks have had a historical relationship with stigma and prejudice. Mary Malon, in the 18th-Century England, became infamous as “Typhoid Mary,” guilty of spreading the infection amongst affluent families, though she was unaffected. The concept of “asymptomatic carriers” came quite later; however, the textbooks still bear her name associated with an illness. 4 Transmission of infections has always been associated with “poverty, filth, and class,” to maintain a false sense of assurance and safety for the higher sections of society. The “pestilences” of bubonic plague, Asiatic flu and cholera, Middle East respiratory syndrome, and Ebola outbreak in Africa, all have been associated with polarization, racism, blame against certain ethnicities, and resultant psychological distress. 5, 6 The concept of naming illnesses by the country or place of origin has been termed as “epidemic orientalism” and is considered to be a form of social labelling. 5 Even acquired immunodeficiency syndrome (AIDS) had been termed as the “Gay Plague,” being theorized as a “divine punishment” for homosexuality. 7 The tradition is reflected in the legislation of many countries that still prevent homosexual men from donating organs and blood. Research has shown that the fear and uncertainty of unknown infections affect human behavior significantly. Panic, illogical beliefs, aggression, blame, and “othering” are some of the unhealthy offshoots. 8 The need to hold someone accountable based on power and social hierarchy has been explained by the social attributional theories. 9 Through decades, humans have paid the price for being “social beings” by fostering hate-mongering as an inevitable accompaniment of biological disasters. The outbreak of coronavirus disease 2019 (COVID-19) has created social stigma and discriminatory behavior towards individuals who are perceived to have any contact with the disease. This is one of the most large-scale outbreaks known to the modern world. It has affected more than 10 million globally and killed nearly 516,000—the numbers rising as we speak. 10 Pandemics such as these are much beyond just biological phenomena. They create lasting psychosocial consequences that persist longer than the infection itself. Besides the direct psychological impact of stress, fear, anxiety, and mass hysteria, COVID-19 has led to the emergence of significant stigma, “othering,” prejudice, and blame that have strained both inter-regional and international relations. From the very time of its origin at Wuhan, China, the infection has been termed as “Chinese virus” or “Kung Flu,” which later fostered conspiracy theories about biological warfare, which strained international relations. Ironically, social stigma has spread faster than the virus itself. This commentary briefly glances at the resultant social stigma of COVID-19 pandemic in India, the vulnerable populations, and the impact of it on the society at large. It then highlights the ways forward to mitigate this “social evil” associated with the outbreak. The Victims of Social Stigma During the COVID-19 Pandemic The stigma around COVID-19 stems from the fact that a lot is unknown about it. Scientists, researchers, and medical professionals around the globe are still working at a breakneck pace to figure out the strategies to deal with the novelty of this virus. The fear of the unknown has overwhelmed humankind evolutionarily. Human beings tend to distance and segregate themselves from the unknown. Deviant has been branded and stigmatized in all eras of human history, particularly in the history of medical science. Whenever there has been a lack of explanation, be it scientific or supernatural, the affected individuals have been segregated, labelled, and stigmatized, and therefore, ostracized as a consequence. Social stigma towards the segregated appears to be normal behavior to the common mass. It gains social acceptance amidst the chaos of the unknown. Institutional segregation of those who are affected by a disease, at present COVID-19, further strengthens the stigma. We are aware of the social stigma experienced by those who are admitted to institutions for mental illness, leprosy, HIV Aids, or tuberculosis, even today. 11, 12 Even the prevention of COVID-19 demands segregation; terms like quarantine, social distancing, and isolation have become an integral part of the household vocabulary. Hospitals have been allocated particularly for the treatment of COVID-19, separate laboratories been assigned, quarantine zones been set, containment zones have been created, and the country has been divided into color zones depending on the incidence rate. Indeed, these are steps to flatten the ever-rising graph. However, since a pandemic is much more than a biomedical phenomenon, all these steps have their own social implications as well. For example, the Air India crew members who brought hundreds of stranded Indians back home experienced being stigmatized by their neighbors when their homes were stamped “quarantined.” 13 Similar experiences have been reported by home-quarantined individuals when the Delhi Government decided to put up notices outside their home. 11 Incidents of social stigmatization towards those who are affected with COVID-19, including their family members, have been rampant. Individuals who have succumbed to the illness have been denied their last rites. In many cases, the families have refused to accept the bodies, and the state governments have performed the cremations instead. 14, 15 As an action towards such ostracizing behaviors, some states of India even issued orders to bring criminal charges against anyone obstructing the performance of the last rites. 16 Many incidents have come to light where the survivors have been isolated by the neighborhood, forcing them to live a life that is far from ordinary. Being labelled with multiple tags like “super-spreader” only worsens their suffering. 17 The medical symptoms of COVID-19 subside, leaving behind the society to ostracize the survivors for days innumerable. The stigma is directed not only towards those who have recovered from COVID-19, those who are undergoing treatment, or who are presumed to be affected or who have succumbed to it or their families. The brunt of social stigma is also faced by frontline workers, medical practitioners, nurses, police personnel, etc. They have been forced to leave the neighborhood and denied access to their houses and the families have been threatened. The insurmountable atrocities that they have been undergoing to win this race against the virus have been ignored. Instead, social stigma has overpowered the goodwill of those for whom they are fighting. 11 The way mental health practitioners are labelled as paagolon ka doctor (doctor for the mad person), the frontline workers who are tending to those affected by COVID-19 are being stereotyped against. Social stigma towards certain marginalized groups like the homeless or the migrant laborers has also been witnessed. On returning home after months of being stranded in various parts of the country, the workers and their families have been singled out, sneered at, and harassed by the community members. At some places, they have been cast off even after completing the mandatory 14 days’ quarantine. 18 Similarly, in the wake of the spurt of cases following a religious gathering in Delhi, the social media was flooded with communalistic and provocative sentiments. 19 In a country like India, with a history of multiple communal riots, such stigmatization might bear significant consequences. The Government of India issued an advisory on April 8, 2020, asking its citizens to act more responsibly in such a critical time and to refrain from stigmatizing any community or area. 20 The “Dual” Burden: Struggle with COVID-19 and Related Social Stigma Social stigma towards different stakeholders during a pandemic like COVID-19 might play a significant role in undermining social cohesiveness, enforcing social segregation. 21 The International Federation of Red Cross, WHO, and UNICEF issued guidance to prevent and address the social stigma around COVID-19. 21 The report identifies the impact social stigma might have on both treatment and prevention of the disease. There have been multiple instances reported in various states of India where individuals have not reported their history of foreign travel or symptoms of COVID-19 due to the fear of facing social boycott and discrimination, leading to low testing and high mortality rates. 22, 23 According to public health experts, the social stigma associated with being diagnosed is creating a fear among the public and is acting as a deterrent to the effective management of the disease, particularly in the urban setup. The stigmatization is taking a heavy toll on the mental health of the frontline workers as well as those who are recovering or have survived the disease. Media has reported the influence of isolation and discrimination on suicides in India. 24 Experiencing isolation and stigma from social boycotting and religious discrimination can increase the risk of loneliness and self-harm. 25 Data related to suicides during the COVID-19 period in India is scarce. As per the cases reported in the media, 168 out of 326 non-coronavirus-related deaths in India (data till May 9, 2020) are due to suicide 26 ; however, the source of this statistics has not been clearly mentioned. Reverse migration, the two-months-long lockdowns, and fear of job loss are making individuals vulnerable to self-harm and depression. Social stigma, as well as the self-inflicted stigma associated with the pandemic, is further catalyzing the process. However, these are largely media reports that can have their inherent bias. Systematic population-based studies over the next few months after the pandemic will help us estimate the actual risk of suicide attributable to COVID-19. In an unprecedented event, hundreds of nurses (more than 350, as on May 17, 2020) quit their job from multiple private hospitals in West Bengal in two days. 27 Most of these nurses belong to other states, and they started returning to their native states. While the experts are still at a loss in understanding what led to such a mass resignation, fear of treating those who are affected with COVID-19 and the social stigma associated might have encouraged such unfortunate behavior. Mitigating the Social Stigma: The Way Forward Social stigma might threaten the basic structure based on which a society grows. In times like this, when “physical distancing” and “physical isolation” are much-required steps to keep oneself and the loved ones safe and healthy, society might need to act together to stand against all things, be it COVID-19 or the stigma associated, that challenge its cohesiveness. Wording Sensitively Historically, it has been seen that the terms that are used in connection to a disease, pagal (mad) for individuals with mental illness or pagalkhana for hospitals treating mental illness, can possibly shape the lens through which society is likely to perceive that disease. Illness creates othering. Coining terms to address those who are affected with COVID-19, or for that matter, any illness, widens the gap between self and others, instead of bridging it. It thus becomes critical to consider the words that are used in relevance to COVID-19 by not only medical professionals but also organizations like WHO and UNICEF, public directives and notices, promotional campaigns and advertisements, and media. 20 For example, “a person suffering from COVID” is more appealing than “COVID positive.” Terms like “coronized,” used in casual humor, can be perceived as labelling. Acknowledging the affected as victims of the pandemic, rather than the source, is helpful. Also, the frontline COVID warriors need community support and encouragement rather than discrimination. Amplifying the Voices It is relevant to involve and amplify the voices of those who are affected by COVID-19 the most, to develop stigma-mitigating strategies. It would involve those who have recovered from it, those who are undergoing treatment, their families, families of those who have succumbed to the disease, as well as frontline workers. Their lived experiences of COVID-19 and other intersecting stigmas can contextually inform public health strategies to mitigate stigma. Furthermore, the stories of recovery are likely to create hope in public that might help individuals come out with their symptoms instead of hiding them. As identified earlier, social stigma is deterrent to testing for the disease. Thus, learning from the survivors that recovery is possible would encourage people to deal with this stigma. Furthermore, the everyday struggle of the frontline workers should also be focused on. Their experiences, when remaining unheard, might not generate the gratitude that they deserve from society. The life risk that is undertaken by them to provide us with a safe and healthy society stays in the background, while we express stigmatized behavior towards them. Acting Responsibly It is not only on the government and frontline workers to act responsibly in a critical circumstance like this. Apart from them, political leaders, media, and, most importantly, the citizens need to act responsibly and do their parts sincerely in fighting the pandemic and related stigma. One must stay informed. Stigma can be heightened by insufficient knowledge. It is thus necessary to spread the knowledge about COVID-19 (e.g., what causes it, how it is transmitted, treatment, and prevention) without using medical jargons. While social media can be a useful platform to reach the maximum people while lockdown is practiced, its use must be done responsibly. In the past, the misuse of social media had created further stigma than reducing it. 28 At the same time, journalistic reports that focus on an individual’s behavior or role in “spreading the virus” might create stigma among the public. Such publication must be dealt with sensitively, keeping in mind the disruption it might create in the life of those who are involuntarily forced under societal scrutiny. The Ministry of Health and Family Welfare, Government of India, has also issued a directive that highlights the importance of the responsible role the citizens need to play to empower the community to respond effectively and appropriately in the face of adversities. 29 Knowledge, attitudes, and practice (KAP) can actually be improved through community awareness. Based on the Zika outbreak model, Banerjee and Nair have proposed a community-based psychosocial toolkit that involves all levels of health care, with an active health-media liaison, to improve the information–education–communication (IEC) activities during the COVID-19 pandemic. 30 Engaging social influencers such as religious leaders and celebrated actors and cricketers, and their take on COVID-19 and stigma, might also be influential in fighting stigma. The recently launched “Break the Stigma” campaign, featuring Amitabh Bachchan, is one such initiative undertaken by the Government of India. 31 Such steps would not only ease the struggle of the survivors against the stigma but would also deal with the infodemic of misinformation and rumor that is playing a crucial role in creating stigma and racism. Understanding the crisis in humanitarian perspectives is a collective responsibility. The “we versus they” dichotomy mentioned before can only add to a set of common processes and conditions that amplify group-based inequalities and marginality. Knowledge, awareness, care, and empathy are probably the generic but neglected pillars to change “othering” into inclusiveness, collectiveness, and belonging for better coping and resilience against the ongoing crisis. Conclusion At this juncture, when the number of individuals affected with COVID-19 has crossed six lakhs in India, 10 we are in dire need of more than just information to reduce the tension related to the pandemic and to mitigate the stigma surrounding it. Multilevel strategies are required to address the underlying stigma drivers and facilitators. 32 An intersectional lens can improve the understanding of the ways in which COVID-19 stigma might be intersecting with gender, race, immigration status, and health status, among others. 33 We had long taken the shelter of science to understand diseases and their pathogenesis. But, unfortunately, stigma exists beyond scientific understanding of diseases, at all societal levels. This is aided by misinformation and xenophobia during pandemics. Certain sections of the society are already vulnerable—for them, being targeted by society is a “dual pandemic” apart from COVID-19 itself. Very few times in history has the human race faced such uncertainty about itself. The pandemic will eventually cease, but the resultant stigma might prevail in the society for times unknown. Historically, pandemics have flared up hate but not “caused” it. It is unfortunate to see a civilization dealing better with medical rather than social management of infectious outbreaks. As COVID-19 is still in its early stages, unchecked stigma can lead to dire psychosocial comorbidities, the risk of psychiatric disorders and suicidality being one of them. 21 Pandemics or epidemics do not discriminate based on sociopolitical, ethnic, or economic divisions. More than ever, society requires its solidarity and cohesiveness to deal with this pandemic. By reducing the stigma around this pandemic, its prevention, and containment, we might be able to develop immediate and long-term strategies to build empathy and social justice for the days ahead. COVID-19 just gives us one more such opportunity to strengthen our social resilience
Author and article information
Contributors
Christophe Z. Guilmoto:
ORCID: https://orcid.org/0000-0003-4082-4664
Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole:
MethodologyRole: Project administrationRole: ValidationRole: Writing – original draftRole:
Writing – review & editing
Bernardo Lanza Queiroz: Role: Editor
Journal
Journal ID (nlm-ta): PLoS One
Journal ID (iso-abbrev): PLoS One
Journal ID (publisher-id): plos
Title:
PLoS ONE
Publisher:
Public Library of Science
(San Francisco, CA USA
)
ISSN
(Electronic):
1932-6203
Publication date
(Electronic):
16
February
2022
Publication date Collection: 2022
Publication date PMC-release: 16
February
2022
Volume: 17
Issue: 2
Electronic Location Identifier: e0263187
Affiliations
Author notes
* E-mail:
czguilmoto@
123456gmail.com
Author information
Christophe Z. Guilmoto
https://orcid.org/0000-0003-4082-4664
Article
Publisher ID: PONE-D-21-20010DOI: 10.1371/journal.pone.0263187
PMC ID: 8849468
PubMed ID: 35171925
SO-VID: 5bb00928-6a80-453c-bfee-b0d369f2d751
Copyright © © 2022 Christophe Z. Guilmoto
License:
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
History
Date
received
: 19
June
2021
Date
accepted
: 13
January
2022
Page count
Figures: 2,
Tables: 2,
Pages: 14
Funding
The authors received no specific funding for this work.
Categories
Subject:
Research Article
Subject:
Medicine and Health Sciences
Subject:
Medical Conditions
Subject:
Infectious Diseases
Subject:
Viral Diseases
Subject:
Covid 19
Subject:
Biology and Life Sciences
Subject:
Population Biology
Subject:
Population Metrics
Subject:
Death Rates
Subject:
People and Places
Subject:
Geographical Locations
Subject:
Asia
Subject:
India
Subject:
Medicine and Health Sciences
Subject:
Epidemiology
Subject:
Pandemics
Subject:
Social Sciences
Subject:
Economics
Subject:
Labor Economics
Subject:
Employment
Subject:
Biology and Life Sciences
Subject:
Population Biology
Subject:
Population Metrics
Subject:
Age Distribution
Subject:
People and places
Subject:
Geographical locations
Subject:
South America
Subject:
Brazil
Subject:
Medicine and Health Sciences
Subject:
Diagnostic Medicine
Subject:
Virus Testing
Custom metadata
Data Availability 1. data available online The original data used are available from the following sources,
as duly quoted in the paper:
https://dashboard.kerala.gov.in/deaths.php
https://transparencia.registrocivil.org.br/especial-covid
https://data.cdc.gov/NCHS/Provisional-COVID-19-Death-Counts-by-Sex-Age-and-S/9bhg-hcku
http://www.epid.gov.lk/web/index.php?option=com_content&view=article&id=233&lang=en 2. Computed data are provided as Table A1 and Supplementary
S1 Table.
Outbreaks COVID-19
ScienceOpen disciplines: Uncategorized
Data availability:
ScienceOpen disciplines: Uncategorized