The public health consequences of stigma-based interventions

Judging others is a very human behavior. Stigma — treating people with specific traits as unwanted within society — is a particularly harmful manifestation of that. Feeling stigmatized is extremely painful, but it also creates barriers to health care.

Anthropologists and Arizona State University President’s Professors Alexandra Brewis Slade and Amber Wutich have spent decades studying stigma. They argue that current methods in public health policy can actually amplify or create troublesome offshoots of the problems they are meant to help solve, particularly for those in the most vulnerable groups.

These findings are distilled in a new book released this month: “Lazy, Crazy, and Disgusting: Stigma and the Undoing of Global Health.” Based on Brewis Slade and Wutich’s combined decades of fieldwork experience around the globe, it tackles what happens when interventions go sour because of stigma and addresses three of the most concerning and complicated areas of current public health focus — sanitation, mental illness and obesity.

This team long has worked together on research, and also as administrators. Brewis Slade founded the Center for Global Health in 2008 at ASU’s School of Human Evolution and Social Change, and Wutich is the center’s current director.

Alexandra Brewis Slade  

Question: What got you interested in studying the science behind stigma and its direct impact on individuals?

Alexandra Brewis Slade: We have both long had a research focus on understanding how social norms and institutions act to push some people down and out of society. I started my career working on women’s struggles with infertility in Micronesia, and early in her career Amber was working in Bolivia on how people cope with water scarcity. More recently, we’ve been working together devising projects to understand what it means to live with high body weight. These strands are all ultimately about the causes and consequences of stigma for people in their everyday lives, a theme that ties our work together.

Q: How do you define stigma for the purposes of your studies, and has that understanding changed or evolved over time?

Amber Wutich  

Amber Wutich: Much of what we know about the effects of stigma was gleaned using anthropological methods like ethnography — by listening to people in their own terms and trying to understand the world as they see it. Stigmas are always changing, since what is stigmatized is a reflection of what is treated as unwanted or disgusting in a particular social context.

ABS: Leprosy was once an incredibly stigmatized disease in medieval Europe because it was associated with sin against God. As ideas changed throughout the middle ages, and people saw those with leprosy as being closer to God, stigma toward the disease reduced. Similarly, we see a lot of rising stigma around obesity and large bodies, a relatively recent phenomenon that seems related to neoliberal ideas of individualism. These ideas are often reproduced in the media, including in public health messaging.

Q: What are some of the ways that stigma collectively shapes the ideas, beliefs, policies or institutional structures of communities or entire countries?

ABS: In our varied fieldwork, we’ve learned that people everywhere tend to connect specific reactions with not just behaviors but also with the people associated with those behaviors. This can happen even where health messages are trying to help.

For example, smoking rates have rapidly decreased in high-income countries as an effect of stigmatizing campaigns that made smoking — and smokers — socially unacceptable. The highest smoking rates are now seen in the most vulnerable groups — the young, the less educated, and those living with mental illness. This reinforces the stigma and means that people who do smoke and become ill are often treated with a lack of empathy both within and outside of health care systems.

AW: Another example is the community-led approaches to total sanitation first introduced in the 1990s in South Asia. The basic UNICEF manual for creating open-defecation-free (ODF) communities relies on using disgust to change hygiene behaviors and social shaming to maintain the new hygiene behaviors. This worked well at first. Lots of people built toilets. But once norms there shifted, families who could not afford household toilets became subjected to highly damaging forms of social rejection.

Q: Why did you focus on these three prominent issues in the book: bringing sanitation to all, treating mental illness and preventing obesity?

AW: We chose these particular issues exactly because they are the most complicated and intractable of them all. Sanitation remains at the center of the global health agenda because — despite decades of focused work — many people globally do not have basic sanitation. Public health workers know mental illness is greatly worsened by stigma and worked hard to remove it, yet it persists.

ABS: And anti-obesity efforts globally have yet to yield any real “success” stories. We suspect part of the reason is related to the latent stigma that the anti-obesity efforts carry with them.

Q: What do you hope readers take away from the book?

AW: The book isn’t just for those working in public health. Our hope is that readers from all backgrounds are better able to recognize stigma in their daily lives. We are all part of its production, and most of us are targeted by it. Awareness and empathy seems to be what best undermines the power of stigma to harm.

Q: What other innovations do you hope for regarding social stigma and health policy in the next 10 years?

ABS: One of our biggest concerns we address in the book is the ideas of a “sweet spot” where you can apply just the right amount of stigma to encourage desirable action, without doing damage. Our observations as anthropologists suggest that — in reality — this is incredibly hard to do, especially among groups that are more vulnerable. Almost all seem to miss the target. This is why we are suggesting that stigma should never be deployed as a tool in any behavior change interventions, most especially when the groups being targeted are not those with political or economic power.