Apologies for not re-sending this note to you sooner. This piece was posted originally July 1 in The Communication Initiative (CI). I appreciate sharing this with your network.
The CORE Group Polio Project (CGPP) is working to shape context-specific responses to growing cases of COVID-19 social stigma in our project areas. We are striving to identify, share and rapidly analyze how best to reduce stigma by drawing from our work in the areas of polio, Ebola Virus Disease, measles, and zoonotic disease surveillance activities under Global Health Security. Ahmed Arale, the CGPP Kenya and Somalia Secretariat Director, notes “addressing stigma is key to overcoming the COVID-19 pandemic."
The CGPP is based upon the concept that disease outbreaks are best identified and interrupted at the community level. We know that stigma based on fear and misinformation is contributing to the ongoing COVID-19 community transmission in many of our focal communities. Like many of you reading this post, we need practical guidance to shape our response to the prevalence of COVID-19 social stigma. We are aiming to develop several simple, practical messages for field staff and community volunteers by leveraging the critical engagement of trusted persons.
We are guided by three basic questions: What does stigma look like? What are the root causes? What is the impact? From there, we have been attempting to determine what sort of risk communication and community engagement strategies or lessons learned from polio can be applied to curb stigma for COVID-19. What strategies need to be tweaked for COVID-19? What other approaches should we consider?
In South Sudan, stigma driven by fear and misinformation is quickly emerging as the primary concern. In Nigeria, stigma is the secondary challenge, followed by a low perception of risk. Both countries have directly been implementing COVID-19 response activities; South Sudan’s Boma Health Promoters and Volunteer Community Mobilizers in Nigeria are at the center of our efforts. Elsewhere in India, Kenya, and Somalia, COVID-19 responses are integrated with ongoing CGPP activities also carried out by community health volunteers.
According to South Sudan’s Secretariat Director Anthony Kisanga, “It is harder and harder to fight the pandemic. Cases are going up. Deaths are going up.” Most people are aware of COVID-19 but do not adhere to IPC measures such as social/physical distancing, handwashing hygiene or use of face masks. However, there is a pervasive fear of testing due to the possibility of a positive result. Individuals who test positive and share results with family and friends face the risk of being rejected and end up afraid and isolated. This fear of rejection leads to COVID-19 patients refusing to reveal contacts to avoid further discrimination. Quarantine means the risk of job loss and loss of income. These behaviors result in harmful effects: individuals are not getting tested, hiding their illness, and not practicing healthy behaviors.
South Sudan faces a double-burden. Not only is there fear of the effects of quarantine on survival, but there is also a widespread belief that COVID-19 positivity equates to death. From observations in the field, there is low awareness of the recovery rate. This misinformation is driving stigma. For one, we need to develop tools that explicitly communicate that the majority of COVID-19 cases are recovering in greater numbers than those dying from the disease. On June 29, South Sudan reported 2,006 cases, with 36 dead and 261 recovered: The mortality rate was 1.8%. The recovery rate was 13%. How do we effectively communicate the fact that COVID-19 is not a guaranteed death sentence? How do we tap community knowledge to find solutions: can we enlist the support of those who have recovered (survivors) from COVID-19 to serve as sympathetic role models to expand the circle of influencers? How do we achieve the desired health impact by engaging community members, leaders, and groups who provide reliable and accurate information?
South Sudan has formed a Unity Government, brokered by a September 2019 peace deal between President Salva Kiir and Riek Machar; on June 29, the president appointed governors for eight states (with the exception of with exception of Upper Nile and Jonglei States.) Among armed actors, there is a high level of mistrust of outsiders, harassing, and chasing away contact tracers and Rapid Response Teams who are unfamiliar to local communities. South Sudan CGPP only employs Boma Health Promoters as contact tracers. These individuals are from the community, well-known in the community, and trusted by the community. This point underscores CGPP’s strong history of understanding and responding to the needs of the communities.
In Nigeria, the need to address stigma is a “major, major, major issue,” reported CGPP Nigeria Secretariat Director Dr. Samuel Usman. Low risk perception is presently driving the pandemic. A May 2020 risk perception survey from Kano showed that more than half of respondents “believe COVID-19 is fake � � and adherence to physical distancing and use of face masks is low. There is a fear of testing due to stigmatization; those who test positive are hiding due to the fear of being ostracized. Based on lessons learned from polio, the engagement of traditional and religious leaders (Northern Traditional Leaders Committee on Primary Health Care) successfully countered polio myths and misconceptions in polio high-risk areas. Fast forward to 2020, we are leveraging the polio platform to address stigma in the low-literate Northern states. Drawing from the past successes with the engagement of traditional and religious leaders, Nigeria is now working with trusted and well-informed faith-based leaders to battled COVID-19. To address stigma, a mapping of critical stakeholders is ongoing to identify Qur’anic schoolteachers, and church and mosque leaders. In Kano, the engagement of critical leaders won out over radio jingles to address misinformation, Dr. Usman reported. Likewise, CGPP-trained VCMs are conducting house to house visits, armed with IEC materials to share accurate information on the signs and symptoms of COVID-19 and how to seek help if sick. In addition to the VCMs, CGPP-trained community informants are part of the robust surveillance network which now helps to identify suspected COVID-19 cases in addition to AFP cases.
In Kenya and Somalia, the CGPP is working with Community Health Volunteers to reach high-risk nomadic pastoralists with information on COVID-19 risk and prevention measures, according to Director Arale. This vulnerable population, which moves continuously with its animals owing to their livelihoods and culture, is facing multiple sources of severe stigmatization, including from urban dwellers who believe they are responsible for driving the disease across borders and regions. Along the rural borders, pastoralists are being denied access to grazing and watering sites due to fear of spread COVID-19; these restrictions can easily escalate into conflict. Furthermore, COVID-19 is fueling stigma and elevating fear and tension between IDPs and host communities. In Nairobi’s informal settlements, patients who have recovered from COVID-19 are shunned for fear they continue to spread the virus.
As we look for solutions to curb stigma, we look forward to learning from the pointers and strategies shared on the CI platform.
CORE Group Polio Project
Technical Advisor, Communications