Abstract
In Crazy, Lazy and Disgusting: Stigma and the Undoing of Global Health authors and medical anthropologists Alexandra Brewis and Amber Wutich discuss stigma as a key driver of global disease, where global health efforts time and again are undermined by processes in which stigma is created and reinforced. The book consists of three core segments, each part addressing a wide-spread, contemporary and distinct global health crisis. This global health triptych spans highly stigmatized mental health (crazy), obesity (lazy) and sanitation (disgusting) epidemics in order to showcase why humans stigmatize, how stigma becomes embedded in global health efforts and what we can do about it. Drawing on decades-long fieldwork experience, Brewis and Wutich use ethnographic exemplars from all corners of the globe to unravel “the complex, dangerous dance between stigma and public health” (p. 3).
Part I (Disgusting) focuses on sanitation efforts to illustrate how and why humans so readily stigmatize, underscoring the ways in which society’s most vulnerable are disproportionately impacted by stigma. In exploring how public health responses begin to conflate dirty things with dirty people, Brewis and Wutich point to poor villages around the world like Micronesia’s Butaritari, and a program entitled Community-Led Total Sanitation in which shame was used to eliminate outdoor defecation and encouraged villagers to incur high costs to build and maintain toilets. A lack of proper building materials and expertise meant that when the costs exceeded what villagers could afford to upkeep their toilets (if they could afford one at all), that not only was the main freshwater source on the islands being contaminated, but outdoor defecation continued in spite of public health efforts—villagers still did it, they just did not want to be seen doing it. Instead of defecating on the beach like they used to and where tides would wash away excrement, villagers hid in bushes allowing feces to pile up on land, increasing the transmission of hookworm and dysentery. Poignantly, the authors note that the stigma and shame embedded by the public health program “may endure even if the behavior change doesn’t” (p. 35), bringing with it many other unintended health consequences.
Part II (Lazy) considers the obesity epidemic in order to understand how new stigma is generated, and how it enters global health undetected and ubiquitously. Pointing to the spread of neoliberalism, the authors claim that historically fat-positive societies, like Mexico and Samoa, have increased prevalence of fat stigma where none previously existed. Cultural ideals of beauty and status attached to large bodies have not insulated these places from thin-idealizing body norms and the fat stigma that goes along with it—rendering weight as a globally negative characteristic. The pervasive moralizing views of fat also sanction systematic discrimination. People who are the largest find it more difficult to find a job, get accepted to college or land a promotion—it’s well documented that “when body fat goes up, wages go down” (p. 78). The neoliberalist thinking which promotes individualism and self-responsibility is further examined in the authors’ collaboration with the Mayo Clinic’s bariatric clinic, where those undergoing weight loss surgeries were studied. They found that those who experienced and internalized the effects of stigma in everyday life found it harder to follow postsurgical diet and exercise plans. Even after substantial weight loss, it was internalized self-stigma (rather than, e.g., the actual experiences while exercising) which prevented them from being active. In this way, stigma is a silent driver of obesity, undermining weight loss efforts and driving weight gain in the longer-term. The real problem, according to Brewis and Wutich, is the focus on individual responsibility—common health efforts are misplaced in trying to eradicate individuals’ ignorance about obesity as everyone knows eating better and more exercise leads to weight loss. Similarly, it is not due to lack of effort—the Mayo Clinic study found that morbidly obese people put considerable effort into weight loss. Rather, the authors claim, the focus on individual responsibility needs to shift to one of shared responsibility and a collective effort focused on structural factors “like how our work, schools and neighborhoods are organized” (p.16).
Part III (Crazy) addresses mental illness and explores the half-century long efforts around destigmatization, highlighting the relatively small long-term gains made by such efforts. Brewis and Wutich point out that challenges to mental illness stigma have encompassed strategies such as relabelling illnesses (the authors refer to “people diagnosed with schizophrenia” rather than schizophrenics, although numerous other examples are proffered), advocacy (celebrity advocates are highlighted as drawing heightened awareness of various mental illnesses, with both positive and negative outcomes) and other forms of activism. However, these and other efforts fall short in the long-term since “public stigma has barely changed at all, and yet the strategies employed have also largely remained the same” (p. 157). Stigma is difficult to shift once it is attached to conditions and groups of people, but efforts are further stymied when stigma is attached to those marginalized, vulnerable or poverty-stricken. This is because “stigma rarely travels solo” (p.185), and the intersectional nature of stigma compounds and complicates its fix: stigma does not just block access to services or discourage health-seeking behavior, it makes those suffering with mental illness more vulnerable to poverty, stress and a host of other issues, ultimately bringing on more depression in a vicious, self-reinforcing cycle. And those found to harbor the worst stigma against people with mental illness? Health professionals. The irony of those who are most able to help being those who perpetually reinforce stigma is not lost on the authors, who note a fundamental flaw in most destigmatization efforts lie in the focus on changing public attitudes, rather than those of health professionals.
While moving the needle on stigma is incredibly hard, it is not impossible—the example of society’s shifting view of homosexuality is offered as one of the few success stories. Previously considered immoral (even classified as a psychiatric disease, and, depending on where you lived, criminal), homosexuality is now accepted by a majority of citizens who disavow discrimination and rejection based on sexual orientation, and support symbolic and legal changes such as same-sex marriage.
Taken together, the three parts comprising Crazy, Lazy and Disgusting serve to develop a cogent, cohesive and compelling claim. However, the authors underestimate the strength of their argument in the conclusion of the book, in which Brewis and Wutich outline a potential way forward and hail optimism in preventing, challenging and reversing stigma. Their call for optimism appears in the wake of the rich detail, enthralling storytelling and persuasive figures that divulge what an unseen monstrosity that is stigma. The potential solutions, which include redeploying some of the same tactics that were part of failed efforts detailed in earlier sections of the book, leave me feeling that despite tools such as increasing practitioner awareness, tracking stigma and improving evidenced-based policy, the issues around stigma remain insurmountable.
This feeling is heightened when considering how stigma infiltrates some of the most widely used practices across industries and organizations. As workplaces become more diverse and team-based, the increased visibility of marginalized groups in the workforce also means that the potential for stigma to creep into organizational processes is growing (Bento et al., 2012; Summers et al., 2018). There is an acknowledged risk that without reflexive practices, organizational processes inadvertently serve to amplify stigma and reproduce discrimination, harming individuals, organizations and communities (Romani et al., 2019). The dangers of stigma outlined by Brewis and Wutich are not limited to health outcomes and the implications they so vividly illustrate hold relevance that extends well beyond global health initiatives.
The global perspective and illuminating detail in Lazy, Crazy and Disgusting bring the social, cultural and structural elements of stigma into focus for the reader. A satisfyingly simple symmetry in construction belies complex and intricate theory knitted effortlessly into rich ethnographic evidence. This text is both academic and accessible, making it an engrossing read for those interested in medicine and public health, anthropology and sociology. I would argue it is also incredibly relevant to those who experience, resist or perpetuate stigma: each and every one of us.
