Johns Hopkins University Press, 2019. 288 pages.
Dr. Alexandra Brewis & Dr. Amber Wutich—anthropologists at Arizona State Universities School of Evolution and Social Change and The Center for Global Health—make a provocative argument: people at the receiving end of health interventions are stigmatized and harmed by even the most well-intentioned public and global health projects (pg. 10). Blame, shame, and disgust should be expelled as means to address the most pressing global health issues such as the “obesity epidemic” and public defecation. The authors utilize case studies, ethnographic fieldwork, empirical evidence, and vignettes (some discussed below) to show how tools like blame and shame are not only ineffective in many cases, but they also further harm people who are already ostracized. The hopeful news? We can do something about it structurally, materially, and individually. In Lazy, Crazy, and Disgusting: Stigma and The Undoing of Global Health, the authors bring needed nuance & context to the most pressing global health issues, problematize how they’ve been addressed, and present readers with a bottom line of possibilities for the future. The delightful orange-yellow book cover—with its subtitle overlaying stigmatizing words to cross them out—elicits an impression that the authors will undo and transform the readers thinking about global health. They do just that, leaving readers with a humbled and measured direction for the future. In using combined years of ethnographic fieldwork and long-term collaboration writing this book, the authors keenly balance storytelling as a medium to convey information, without wandering down the path of “poverty pornography” (pg.14). As such, readers from academia, industry, and the general public can find value from critically engaging this text. In Disgusting the authors focus on dirty things & people, public defecation, and disempowerment. Lazy examines fatness, badness, weight judgement, and obesity. Crazy takes on mental health, the myth of destigmatisation, and potential solutions moving forward.
The “complex, dangerous dance” (pg. 3) between public health and stigma is introduced through a vignette about Emma, a person recently diagnosed with lung cancer. In a struggle to obtain adequate health care and skirt public shame, we find out Emma was never a smoker. The anti-tobacco campaign transformed smoking and smokers into ‘disgusting’ and ‘unwanted’ (pgs. 3-4). This is contrasted with narratives of ‘blameless’ middle-class women struggling with breast cancer (pgs.1, 5). While both cancers are horrific and invariably challenge and devastate the lives of countless individuals, the authors question the role stigma plays in reproducing harm and valuing some cancer patients over others. Even more, the anti-tobacco campaign would continue to stigmatize low-income regions of high-income countries where smoking itself may be one small way to cope with social, material, and economic inequalities (pg. 5). Within this first example, the reader can see how the concept of self-efficacy is undermined in many public health interventions.
The authors ask: how do well-intentioned public health campaigns become undermined by stigma? Through countless examples, such as inducing shame to operationalize Community-Led-Total-Sanitation efforts (CLTS), stigma’s role in the HIV/AIDS epidemic, pondering the nuances of “breast is best”, and the globalizing nature of weight stigma, Brewis and Wutich invite the readers into the messy world of stigma. Public Health interventions may become problematic when layering in the material realities of racialization, class, social, economic, or health status, and many interventions have questionable histories of using shame, blame, and disgust to motivate behavior change. It’s not all bad though, Brewis and Wutich assert change is possible: human dignity can be restored and anthropologists along with other researchers and practitioners can engage in theory building around stigma and health (pgs.10, 18-20). They leave us with food for thought as we dive into chapter 1 by posing: How can we combine what we know about global health, political economy, anthropology, and other fields to create a just and sustainable health for all?
So, what is stigma anyway? A (very very) brief primer to the authors’ brief primer
Stigma is discussed at length throughout the text and the authors have a concise and informative primer on stigma in the appendix. They define stigma as a process through which people become “socially stained and discredited because they hold a characteristic that is classified as unacceptable or undesirable” (pg. 207). Stigma at its core is about “failure to meet social norms” (pg. 207). As they outline in this appendix, there are many forms of stigma and stigmatization is especially efficient when moral meanings are attached to it (see appendix). Early in the book, the authors present a paradox of stigma: on the one hand, stigma is used to exert control and exploit but are also embedded in cultural norms, behaviors, and institutions (pg. 11). In that way, global health interventions attempt to provide solutions to poverty and illness. On the other hand, there are evolutionarily minded researchers who study how behaviors related to stigma may offer a different story: there are tendencies to be physically or socially distant from things “deemed disgusting, improper, or undesirable” suggesting potential protective benefits that would aid survival and reproduction (for more detailed coverage of the global health and evolutionary perspectives such as the behavioral immune system, see the appendix). The authors nudge readers to consider that evolutionary and global health perspectives on stigma need not be incompatible: “an evolved mechanism to aid survival and reproduction in the deep human past could easily be exploited for power as societies grow more complex and inequalities begin to emerge” (pg. 215). They thus call for a more profound theoretical & interdisciplinary synthesis to understand stigma within global health contexts before we can fully solve public health problems and absolve stigmatization in the process (pg. 215).
Part 1- Disgusting
Part 1 encompasses the dirty and the disgusting. The authors explore how shame and disgust are used to address the global health problem of public defecation across sites such as Kiribati with the advent of Community-Led Total Sanitation, or in Sierra Leone. The authors pose an open question: do shame and disgust work in the long term? Do they actually help reduce disease exposure? In short, sometimes. Shame—feelings elicited from not meeting social norms—as the authors suggest, in small doses can be helpful. However, things get complicated, because many people unconsciously connect evolved feelings of aversion—also known as disgust, part of the behavioral immune system—to moral worth and value and that is where tools such as shame and disgust get…muddled.
Across sites in chapters 1-3, the authors find that hygiene stigmas can result in chronic & humiliating forms of social banishment. This is seen in examples from Sierra Leone and Bangladesh where hygiene policing resulted in fine systems or even more severe outcomes such as withholding pensions for violating hygiene expectations (pgs. 29,36). While CLTS may have been noted as a success through behavior-change interventions, these new forms of stigma were affecting poor families especially for those already marginalized. Other times, behavior-change based interventions nudge up against cultural norms that can have interpersonal consequences. Some individuals in the Pemba community reflected on the ways public defecation is a sign of sociality and practicality, not a manner of disgust and shame. For example, one interlocutor remarks in regard to keeping newly installed latrines clean: “why would you want all your shit piled up in one place? That’s disgusting” (pg. 26). The authors argue in the case of public defecation, global health efforts attempt to utilize social desirability as a tool to intervene. For example, in the United States handwashing is commonly accepted as a social hygiene norm that is desirable especially at work or in public, yet many don’t wash their hands at home (pgs. 26-27). CLTS across many examples in the book illuminate how social divisions of all kinds are employed in shame-interventions, and that collective action is a likely solution. However, many CLTS campaigns are not designed to utilize collective action (pg. 39). The authors leave us with one hopeful example of non-stigmatizing sanitation campaigns. In an internally displaced person camp in Iraq (2008) social scientists and public health experts placed soap into children’s toys which prompted playfulness and inquisitiveness (pg. 40). They found the children who got the glittery soap were 4x more likely to wash their hands after the intervention. Hope for non-stigmatizing public health interventions, I believe, is especially true in the middle of a COVID-19 pandemic and syndemics, one year after this book was published. However, methods of shame and disgust can be ruinous. The authors leave us with a question: does behavior change work? And, are hygiene norms ‘healthy’ anyway? As the COVID-19 pandemic continues to ravage on, illuminating the syndemics of our time, this question and the book more broadly, is of extreme utility.
Chapter 2 outlines a brief anthropological history of hygiene norms and calls into question what is dirty versus what is dangerous, and the stigmatization within. Drawing from Douglas’ (1966) work Purity & Danger, the authors introduce a study they conducted at four sites to test concepts from Purity & Danger (such as the idea that hygiene norms function to maintain social order) against evolutionary predictions about hygiene norms as a function of the “behavioral immune system” (pgs. 42-45). The authors argue, in these specific ethnographic contexts and study designs, that stigmas were likely unrelated to conscious fear of infectious disease (pgs. 45-50, see appendix for more about theory building between evolutionary oriented scientists and global health). Building on the themes of dirty, disgusting, and dangerous in the last chapter of Part 1, we hear stories from other ethnographic work throughout the rest of the book. We are introduced to Tonya, a woman living in Appalachia struggling to get adequate and affordable dental care and about Doña Juana in Bolivia who fears her children will be further stigmatized as dirty due to water shortages. In both examples, the authors reflect on how damaging stigma can be, and how it further disenfranchises and marginalizes people when access to healthcare and clean water are not universally accessed or distributed.
Chapters in part two focus on the weight judgement, globalizing fat stigma, and obesity epidemics. In examining weight judgement and fat stigma, the authors explore core cultural beliefs about fatness versus some medical concern over ‘excess’ weight. In exploring the belief, you can control your weight they discuss examples across many cultures where weight gain and loss are conflated with blaming individuals for “achieving” or failing to enact “control.” (pg. 97). For those who opt for bariatric surgery, other beliefs such as weight loss surgeries are the easy way out are explored in multiple examples, notably from Dr. Sarah Trainers work illuminating how bariatric surgery patients cope with stigma and weight surveillance. They tackle other beliefs such as fat is dangerous, the helping professionals help, and shame spurs weight loss (pgs. 98-105).
Importantly, the authors contend that the behavior-change approach may not be as good as once was thought: “no country to date has truly reversed the obesity epidemic through promoting behavior-change” (ch.6). ‘Individual choice’ and ‘agency’ to simply eat, do, or behave ‘better’ operates under an assumption that choice and agency are viable options in the first place (pg. 126); this has been shown to be a farce especially where publicly funded programs are few and far between or healthcare is privatized and thus responsibility is pushed onto individuals, with no systemic material transformations to follow. In terms of stigma, there have been important efforts, notably movements towards fat positivity and neutrality. It is known that excess weight has potential to be linked to medical conditions, though defining what “excess” weight really entails is complicated. Similarly, health or metabolic conditions associated with higher Body Mass Index (BMI) are not cut and dry, and body shape and size are not indicators in and of themselves of health problems. Deeming obesity a disease may have had the potential to de-stigmatize similar to that of the disease of alcoholism, however, the authors argue it’s done more harm than good. Defining obesity as a disease is very arbitrary and there is little evidence thus far justifying ‘obesity’ as a disease in and of itself, as it only holds clinical correlations to other diseases.
Fat stigma and bodily stigmas take many forms the authors argue, especially when it comes to internalized and externalized stigmas. They affect individuals but also hold macro-level effects with evidence of quickly globalizing fat stigmas (pgs. 83-94). Many countries are dealing with high rates of obesity where roughly 2/3 of adults are classified as obese (US, Egypt, Iceland, Mexico, Hungary & Saudi Arabia) and thus there are questions about what is driving these epidemics. At the same time, it’s a delicate balance to aim to address obesity epidemics without utilizing stigma, shame, and blame. The authors argue, diet and exercise alone aren’t really enough to address these issues nor is stigmatizing people. What is needed is widespread material and social support (pg. 201). Ultimately, the authors contend that even if interventions aren’t perfect when it comes to obesity and other public health issues, we (as researchers, practioners, and the public) must do no harm (see pages 120-124 for examples of interventions that have used blame that may be doing more harm than good).
Part 3: Crazy
In chapters 7-10, Brewis and Wutich examine approaches to destigmatization, mental illness, myths about small-scale societies, and overall recommendations for solving some of the problems presented in previous parts of the book. A key example outlined in chapter 8, discusses the social and economic demands placed on individuals in industrialized societies which may result in higher rates of mental illness. However, the authors combat the myth that mental health is only an issue in large, industrialized societies with rich ethnographic evidence to support the concept of social pressure and demand in ‘small-scale’ societies (166-170). They further highlight how ethnographic studies can help understand what is going on, on the ground (pg. 166) and to situate mental health stigma and other stigmas discussed throughout.
Another prominent example highlights stigma of being schizophrenic (pg. 141). The authors mention how being labeled a schizophrenic induces many feelings of fear, notably from films depicting people who are schizophrenic as criminals and maniacs. There are also stigmas around schizophrenia because it’s perceived to be untreatable. However, the authors highlight with complete treatment, recovery is possible. Barriers to treatment often have more to do with lack of access or even distribution rather than individual fault. Another gripping example in Crazy is in chapter 9, where the readers are introduced the anthropological work on “Food, Social Failure, and Depression” (pg. 175). Dr. Leslie Jo Weavers work in Brazil focused on social discrimination (in that context: body shape, not being light skinned, not eating prestige foods) and how those at the receiving end are stigmatized as not being “modern” or deemed “behind the times” (pg. 176). Furthermore, through interviews, Dr. Weaver found a “shameful” diet was comprised of foods with little variety, very little meat, and lacking fresh foods. Diets implying shame were linked to food insecurity. Ultimately, Dr. Weaver and Dr. Craig Hadley found that food insecurity was related to depression, such that failing to meet social expectations of food quality deepened depression (pg. 176).
In Lazy, Crazy, and Disgusting readers will embark on a journey into the research and practical implications of stigma, global health interventions, and critiques of existing measures to address some of the major domains of public health intervention. The readers leave with social and health indicators to investigate the existence of stigma and to track stigma over time; in addition to basic destigmatisation strategies (pg. 191-205). Reading Lazy, Crazy, and Disgusting during the global COVID-19 pandemic and the syndemics existing within, has amplified the need to deeply consider and integrate the insights presented here which will maintain relevance and urgency for the foreseeable future.
Delaney Glass is a doctoral student at the University of Washington in Seattle. She studies human biology and anthropology. Her specific research interests currently include the effects of steroid hormones on the timing and tempo of growth and development in puberty and the complexity of cultural transmission, conflict, and resilience in early adolescence.