Abstract
Stigma is undoing global health, plain and simple. This is the core proposition of Alexander Brewis and Amber Wutich’s eponymous book Lazy, Crazy, and Disgusting: Stigma and the Undoing of Global Health. According to authors Brewis and Wutich, stigma has been integrated into and/or become a product of a number of public health efforts to improve global health, and it is perpetuating or reinforcing systems of discrimination and marginalization that undermine the effectiveness of these policies and interventions. In the words of Brewis and Wutich, “global health processes often unwittingly create and reinforce stigma, and this undermines global health’s basic goals to create both health and justice” (p. 12). The authors use ethnographic cases—periodically weaving in epidemiological and quantitative data—to explore how stigma has wriggled its way insidiously into public health efforts using hygiene (disgusting), obesity (lazy), and mental illness (crazy) as topics. In Part I of the book, for example, Brewis and Wutich discuss hygiene stigma using examples ranging from perceptions of individual failures associated with marginalized communities having “bad” or “decaying” teeth to assumptions about entire villages being “dirty” because of cholera or leprosy outbreaks despite being systematically excluded from accessing adequate basic amenities and medical services. While it is somewhat hard to follow the hygiene stigma thread throughout the entirety of Part I as Brewis and Wutich weave through many, sometimes disjointed examples to make their point, their bottom line is worth the wait: “Hygiene stigma is very damaging because it connects to our core emotions and is then easily projected onto whole groups. By defining those with less power as unsanitary, hygiene stigmas can be all-too-easily deployed for the political and economic gain by those who already have it” (p. 73).
What I appreciate most about Lazy, Crazy, and Disgusting is the authors’ social justice approach to investigating the harmful role of stigma in global health—recognizing that “stigmatization deepens and entrenches massive, systemic injustices” (p. 188) and, in doing so, “harm[s] our health, our economy, and the quality of all our lives” (p. 188). Countering the common public health narrative that health is rooted in individual and household behaviors, Brewis and Wutich reiterate over and over throughout the book that public health interventions that use shame as a tool to motivate individual behavior change lead to stigmatization of already marginalized groups—creating deeper inequalities in health and, overall, cancelling out or reversing positive health outcomes or swapping them out for worse ones. In Part II, for example, Brewis and Wutich pull off a cohesive illustration of how fat stigma is undermining global health efforts to end the “obesity epidemic.” Critically, the authors draw our attention to the fact that fat stigma, like hygiene stigma, “most affects those with less social, economic, or political power” (p. 116) and benefits those who can capitalize on weight loss or perceptions of weight as an individual responsibility—working to maintain unjust social orders and undermining efforts to systematically address growing obesity rates.
Brewis and Wutich formally introduce intersectionality theory into their discussion on multiple axes of risks for stigma on page 185—acknowledging that, “those who hold socially devalued roles with much less power (such as women, racial and ethnic minorities, immigrants, people living in poverty) are often more likely to develop stigmatized health conditions and more likely to be blamed for them” (p. 189). Many of Brewis and Wutich’s examples throughout the book highlight the compounding constraints and related effects of stigma for people who have overlapping or intersecting minoritized identities and are navigating the systems and structures of oppression, domination, and discrimination in global health. In Part III, for example, the authors emphasize that the axes of risks for mental health stigma (such as being racially minoritized, female gendered, large-bodied, living in a devalued neighborhood, or belonging to a marginalized or disadvantaged social group) do not act alone (p. 185), and they call for a new agenda to minimize mental health stigma that replaces the “emphasis on public education that has been favored in the past” with the “identif[ication] and creat[ion] of social roles in which people with mental illnesses can contribute to and participate in society and the economy” (p. 169).
Brewis and Wutich end the book with an important message: “stigma should not be used in any way, for any reason, to promote public health” (p. 187) and, relatedly, “shame in all its forms needs to be removed from the public health tool kit” (p. 188). The authors provide a multistep approach to addressing stigma in global health that includes (1) increasing practitioner’s awareness of stigma and the way it manifests in health; (2) tracking the nature and depth of stigma experiences, the systems and mechanisms that create and perpetuate stigma, the ways in which stigma reinforces or generates inequalities and injustices, and the ways in which those who are stigmatized find hope and improve their lives; and (3) connecting the evidence to policy. Brewis and Wutich’s invitation to focus on systemic approaches to preventing and undoing stigma in global health—for example, interventions and policies focused on adequate provision of water and sanitation for all (hygiene), better access to public transportation (obesity), and creation and identification of social roles where people with mental illness are valued (mental illness)—is refreshing. In their efforts to shift the narrative away from individual-level public health approaches and, relatedly, the shaming and stigmatization of marginalized individuals and communities, however, Brewis and Wutich do seem to minimize the importance of individual-level efforts to undo stigma in our own lives and direct spheres of influence. There is an important balance to be struck that both recognizes systemic-level intervention while not minimizing the role that individuals play in perpetuating stigma—one that also highlights how we, individually and collectively, can work toward destigmatization in global health. It is not an oversight in the book but an area for future work in this field. Overall, this is a social justice–informed and critically important book for students, scholars, professionals, and policy makers in public health, medical anthropology, health-related social work, and health justice.
