BOOK REVIEW

How stigma subverts public health

A hard-hitting study exposes the devastating effects of shame and discrimination. Julie Pulerwitz reviews.
Julie Pulerwitz directs the HIV and AIDS programme at the Population Council, an international non-profit organization based in New York City.
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An HIV patient in the late stages of the disease at a clinic in Thailand, near the border of Myanmar

A person with HIV in the Mae Tao Clinic in Thailand.Credit: Alvaro Ybarra Zavala/Getty

Lazy, Crazy, and Disgusting: Stigma and the Undoing of Global Health Alexandra Brewis & Amber Wutich Johns Hopkins University Press (2019)

As a public-health researcher working on HIV around the globe, I have seen the devastation that stigma can cause. It leads to people being shunned and isolated, and discriminated against in health care, at work and at school. And it inhibits them from accessing life-saving services and medications. As a new book by medical anthropologists Alexandra Brewis and Amber Wutich convincingly argues, stigma strips people of dignity and exacerbates the already-difficult circumstances of the poorest and most vulnerable. It can itself have major impacts on health, such as depression and even suicide.

Brewis and Wutich work in low-income countries. Their book’s title, Lazy, Crazy, and Disgusting, highlights their areas of focus: obesity, mental illness and community sanitation. The authors focus on detailed, qualitative case studies in diverse arenas. These demonstrate three things: how stigma arises and affects the most marginalized; why stigma is so difficult to combat; and how public-health efforts can unwittingly fuel it.

It is this third issue — the unintended consequences of big campaigns — that forms their main argument. And it is a rarely heard and compelling one. When, for example, the US public-health community framed smokers as putting others at risk of getting cancer from ‘second-hand’ smoke, the messages hit home. Social norms regarding whether it was acceptable to smoke changed, and many smokers were motivated — and managed — to quit. But there were also negative consequences. Smokers were blamed for their addiction, and people with smoking-related diseases (even those who had never smoked) were often castigated as bringing their conditions on themselves. Meanwhile, tobacco companies escaped criticism.

Similarly, the authors demonstrate how concerns about the effects of obesity — such as diabetes and cardiovascular disease — have led to fat-shaming, depression and more. Yet obesity is strongly linked to socio-economic circumstances, and a lack of access to high-quality foods such as fresh fruit and vegetables. It is counterproductive and unfair to blame individuals. As obesity and associated conditions become increasingly prevalent across the global south, Brewis and Wutich caution against a snowball effect of harmful messaging and impacts.

The book is less strong on ways forward. I second the authors’ calls for increased awareness among health practitioners, for tracking of stigma levels and for policy to be evidence-based. But, in my view, a more comprehensive and nuanced response is needed. There are important distinctions between, for example, public-health measures to reduce people’s internalized feelings of blame and shame, and legislative efforts to minimize ‘enacted’ stigma — that is, instances of discrimination. Internalized stigma might lead to depression, and those who experience it might benefit from counselling, say. By contrast, human-rights abuses must be countered with anti-discrimination policies and laws.

Moreover, Brewis and Wutich fail to explore an important concept: intersecting stigmas. For example, a person with HIV who works in the sex industry and injects drugs might experience compounded bias and discrimination. The authors use HIV as an example of a success story in which concentrated efforts from the global health community, such as health policies and mass-media campaigns, have greatly reduced stigma.

But this is true only in some communities — especially in high-income countries where living with HIV has been transformed into a chronic illness through the use of antiretroviral medications. These medications are often not reaching the most vulnerable, and in many contexts — for example, where drug users are criminalized and struggle to access health care — intersecting stigmas remain rampant.

This engaging book nevertheless fills a significant gap in the literature by providing a wake-up call to scholars and practitioners unfamiliar with the topic. And it reminds me that we should all be working together to avoid any unintended consequences of promoting health.

Nature 575, 438-439 (2019)

doi: 10.1038/d41586-019-03531-2

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