key: cord-0683796-6x9604xi
authors: Grover, Sandeep; Singh, Pranshu; Sahoo, Swapnajeet; Mehra, Aseem
title: Stigma related to COVID-19 infection: Are the Health Care Workers stigmatizing their own colleagues?
date: 2020-08-27
journal: Asian J Psychiatr
DOI: 10.1016/j.ajp.2020.102381
sha: 3b6de4b14eb8fc715b7e0d7bd5644a329d79be15
doc_id: 683796
cord_uid: 6x9604xi

nan

Stigma is understood as a process of negative discrimination against people with certain physical, behavioral or social attributes (Goffman, 1963) . In the context of health, stigma is described as labeling, stereotyping, and discriminating against people because of a particular disease or illness. Epidemics and pandemics of various infectious diseases have almost always given rise to the stigma against the sufferers (Barrett and Brown, 2008) . The ongoing pandemic is probably the first instance when the stigma against healthcare workers (HCWs) is J o u r n a l P r e -p r o o f being discussed at length and has been reported from the many places in the world (Bagcchi, 2020 ; "Stop the coronavirus stigma now," 2020).

Stigma can force people to hide the illness to avoid discrimination and prevent them from choosing healthy behaviors. During the ongoing COVID-19 Pandemic, stigma has been mostly discussed in the context of general population discriminating HCWs and those with the infection (Bagcchi, 2020; Ng, 2020; Singh and Subedi, 2020) and stigmatizing behaviors towards specific communities (Chinese/Asian) (Kahambing and Edilo, 2020; Rzymski and Nowicki, 2020) .

However, stigma has not been discussed in the context of one HCW discriminating against the other. Here we describe 2 cases of stigma and discrimination faced by the HCWs in the hand of other HCWs. The first case describes a grim instance where a HCW was stigmatized (because of opting to undergo a COVID-19 RT-PCR test) by her colleagues despite being tested negative for COVID infection. The extent of stigma was so severe that it ultimately led to severe psychological distress and psychiatric consultation. The second case describes the experience of another HCW, working with patients with COVID-19.

A 35 year old female HCW presented to the psychiatric services with severe psychological distress. On evaluation, she was found to have symptoms amounting to Adjustment Disorder.

Her medical history revealed that she was suffering from hypothyroidism. Further exploration of the history revealed that about 3 weeks prior to presentation, she developed symptoms of fatigue, aches and pain. Although she had not come in contact with any known high-risk contact for COVID-19, she decided to get herself tested for COVID-19. Just prior to getting herself tested, she informed her supervisors about her going for the testing. However, immediately, after getting herself tested, she started receiving messages and phone calls from the colleagues about the rumors of her being tested positive. Everyone at her workplace was informed that she is positive for COVID-19. She felt very bad and helpless about the same. Next day her COVD-19 test came out to be negative, but she had to undergo a quarantine/self-isolation for 2 weeks. Throughout these 2 weeks she would hear about the rumors of her being COVID-19 positive and people blaming her for carrying the infection to the workplace. Due to this, she started remaining distressed, would often break into tears, had difficulty in falling asleep and maintaining asleep, her appetite reduced, was not able to concentrate on her work, would feel helpless, would be worried about the reaction of others in the future. During the self-isolation, she found that other HCWs living close to her accommodation, who were earlier friendly with her had started to avoid her, would walk in the corridor in such a way, as if trying to avoid physical contact with her. This would make her more distressed; make her feel an outcast and being ridiculed at. After the completion of the self-isolation, when she went to meet her supervisor to discuss her ongoing work, she was ridiculed and shouted at, was blamed for entering the premises with high-grade fever and putting everyone else at risk of infection. She was asked to leave the workplace, not to come to the workplace and to seek supervision electronically. This led to further worsening of her psychological distress and she developed ideas of self-harm. This also led to a further reduction in her sleep. This was when she was referred to the crisis helpline services and was seen by the psychiatry services. She was managed with supportive psychotherapy and low dose clonazepam. Additionally, efforts were made to address the issues she was facing at the workplace by liaising with the concerned colleagues. Over the period of next 2 weeks her symptoms reduced and the benzodiazepines were tapered off and the supportive psychotherapy sessions were continued.

A 28 year old female HCW was evaluated as part of the routine mental health screening after the duty in the COVID-19 ward. When asked about the experience of doing duty in the COVID-19 area, she broke down and discussed her experience about how she was ill treated by her colleagues who were directly not in contact with the COVID-19 patients. According to her, when she finished her COVID-19 duty and approached the colleagues for some work, she was again and again reminded of working with patients with COVID-19 in a derogatory tone, was asked to maintain a distance, was asked not to come in person to discuss the relevant issues, rather, should use electronic modes of communication. All this made her feel humiliated. She felt that doing duties in the COVID-19 ward was not of any worth, if she had to face such stigma and discrimination. No specific psychiatric diagnosis was considered for her. She was managed with supportive psychotherapy.

Stigma has emerged as an important social issue associated with COVID-19 infection (Bagcchi, 2020; Ng, 2020) and had changed the social perspectives of human life (Tandon, 2020) . World Health Organization and Ministry of Health and Family Welfare, Government of India and many J o u r n a l P r e -p r o o f other organizations, have released guides to address stigma associated with COVID (Ministry of Health and Family Welfare and Government of India, 2020; World Health Organization, 2020).

These information guides in general advise that people should not stigmatize people undergoing quarantine, those with travel history, those who are diagnosed with COVID-19, and those who have recovered from the COVID-19 infection. However, it is still rampantly prevalent.

In general stigma has been reported from the perspective of general population and the HCWs are considered to be at the receiving end. There are reports of HCWs being not allowed to enter their rented accommodations, being not given house on rent, not allowed to use public transport and hence have to use bicycles and being attacked while on duty (Bagcchi, 2020) . There are also reports from India of HCWs being denied a dignified funeral (Shalini Lobo, 2020) . The stigma associated with COVID-19 is attributed to the fear of being getting infected in the general population . However, little is known about the stigma expressed by one group of HCWs towards others.

These cases beg the question whether there is more stigma than that meets the eye. Healthcare professionals are expected to be empowered with the facts and not give in to the fear related to the pandemic. However, the panic created by the huge infectivity of the virus as well as the social implications of being infected seemingly can grip even the HCWs. This case report highlights the fact that even the HCWs are behaving the way, as others who are less knowledgeable about the mode of transmission.

HCWs are at a greater risk of exposure and may face several work-related dilemmas on a day to day basis leading to increased stress or anxiety. As the number of cases is increasing in India, the risk of HCWs coming in contact with high risk contact, needing to undergo testing and being tested positive is going to increase. In such a scenario, it is important that all the HCWs need to understand that undergoing testing for COVID-19 should not be equated with the COVID-19 positive status and people should avoid stigmatizing their own colleagues. Further, if any of the colleagues is positive for COVID-19, they should be supported in this hour of crisis in all possible ways. In terms of dissemination of information, the training programs which are focusing on the HCWs, should target to disseminate appropriate information about mode of transmission, type of contacts (high risk, low risk, secondary contact), the importance of testing negative, etc, to the HCWs so that they don't end up discriminating and stigmatizing their own

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