International Journal of Drug Policy 26 (2015) 613–614
Contents lists available at ScienceDirect
International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo
Editorial
Stigma: Time for a hard conversation
In ‘‘Stigma as a Public Health Tool: Implications for Health Promotion and Citizen Involvement,’’ Laura Williamson, Betsy Thom, Gerry Stimson and Alfred Uhl address the moral and utilitarian question posed by the use of stigma as a public health strategy both when it is explicitly embraced and when it is the predictable consequences of preventive measures. ‘‘Public health strategies that undermine individuals and communities, particularly those that urgently need to be engaged and brought within the reach of health services, risk having a negative impact on the fundamental aims of contemporary health promotion. . .. [P]olicies that move too far from respecting civic voices and consistently upholding equity will struggle to achieve gains that are durable.’’ (Williamson, Thom, & Stimson, 2014) This understanding represents a bedrock of contemporary public health thinking that has been inflected by human rights concerns. It is certainly reflected in longstanding efforts to address the social costs of the criminalization of drug users that yokes stigmatization with the punitive exercise of state power. Six years ago one of us (RB) challenged this orthodoxy in ‘‘Stigma and the Ethics of Public Health: Not Can We but Should We?’’ (Bayer, 2008) After years of work on HIV where stigma was viewed as both unjustly burdensome and as an impediment to public health that required systematic challenge, it was starting to discover that in the domain of tobacco control ‘‘denormalization’’ was increasingly embraced as central to the campaign to address the huge cost of morbidity and mortality associated with smoking. Anti-tobacco advocates governing agencies responsible for public health and the World Health Organization embraced this strategy, which, while eschewing the word ‘‘stigma,’’ sought to marginalize smoking, endorsed graphic messaging that depicted smoking as harmful even murderous. More striking still was the fact that these approaches claimed to be evidence-based. In fact there were studies that substantiated that position. Thus, for example, California Health Department asserted that it’s goal was to ‘‘push tobacco use out of the charmed circle of normal desirable practice to being an abnormal practice.’’ (California Department of Health Services, 1998) Further, the Director General of Health and Consumer Protection of the European Commission welcomed the fact that restrictions and limits on public smoking ‘‘contributed to the denormalization of smoking within society.’’ (HCDG, 2007) Thus it became clear that it was no longer credible to argue against stigma by claiming that it would never advance the cause of population health, that it was gratuitously oppressive since it was counterproductive. If denormalization or stigmatization can work it is necessary to pose an empirical question—Under what circumstances can stigma advance the goals of public health?—and a moral question—What limits should be imposed on its use and why? In other words, as http://dx.doi.org/10.1016/j.drugpo.2015.01.017 0955-3959/ß 2015 Elsevier B.V. All rights reserved.
Williamson, Thom, Stimson and Uhl suggest, How far is too far? It is crucial to note how social context matters for the understanding of these questions. With illicit drug use, for example, decades of social science research have sought to demonstrate the profound social consequences that have attended the stigmatization of drug use, which in the United States has produced a costly and destructive pattern of mass incarceration. And so destigmatization has been embraced by reformers as a central moral and political position. How very different from the situation of tobacco, where the public health challenge has been to address a deeply embedded pattern of behavior that, in the mid-1950s, involved more than half of all men and a third of women in the United States. It is in this light that it is important to note that public health campaigns involving messages that many view as stigmatizing have become ever more common. We have just completed an examination of the aggressive evidence based interventions undertaken in New York under the Bloomberg Administration. Focus groups had asked for hard-hitting campaigns. Beyond tobacco there were campaigns against obesity that sought to depict the behaviors that led to weight gain and the consequences as grotesque. In a city where obesity was common and where the human costs were stark, health officials sought to dismiss the charge of stigmatization by asserting that they were duty bound to challenge a commercial and normative structure with deadly implications. In the context of HIV health officials alarmed by the failure to reduce the incidence of infection among men who had sex with men especially Black and Latino men, a decision was made to launch a campaign called ‘‘It’s Never Just HIV,’’ which graphically depicted the physiological consequences of infection including dementia and anal cancer. In these cases, health officials have not actively sought to stigmatize— indeed, they almost uniformly struggled with discomfort over fearbased appeals, being well aware that such campaigns have often been attacked as stigmatizing. And, indeed, some of those who were appalled by these campaigns raised alarms about stigmatization. Regardless of how thoughtfully constructed so as to avoid marginalization, to make clear that fault for behaviors like smoking or excessive portion sizes can be pinned on corporate practices, to promote self-efficacy so that individuals feel empowered to act to save their own lives, to generate fear is necessarily to suggest that a behavior has ‘‘bad’’ consequences. The question, then, that health officials must ultimate answer is, Does death and suffering require us to act in a fashion likely to have the greatest impact, even if some may feel marginalized? In the end all stigmatization is not equivalent, as Bruce Link and Jo Phelan, who are so central to this discussion have noted. (Link and Phelan, 2001) There are differences between stigma that
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Editorial / International Journal of Drug Policy 26 (2015) 613–614
causes discomfort and that which deeply wounds. There is a difference between stigma that is enduring and that which can be shed. Additional, like fear-based appeals, stigmatization may not always work. Any claim—that stigma works, that stigma backfires—must be substantiated by the best available evidence. We must take on the ethical challenge of weighing burdens and benefits at the population level, aware that crude utilitarian calculations are never enough. No longer protected by the assumption that stigma can never work we must address the questions of How? and When?, guided by principles of fairness and decency. But we cannot have the kind of searching, candid discussion that is required if we frame prohibitions against the use of stigma, even in its softer forms, in absolutist terms. This strategy forces thoughtful health professions who would carefully weigh this issues into a politically perilous position, inevitability leading to denial or mere strategizing about how to avoid the charge of stigmatizing the most vulnerable. We believe this discussion long overdue. It is such a dialogue to which we invite your readers to join. Conflict of interest The authors declare that they have no conflict of interest.
References Bayer, R. (2008). Stigma and the ethics of public health: Not can we but should we. Social Science and Medicine, 6, 463–472. California Department of Health Services (1998). A model for change: The California experience in tobacco control. http://www.cdph.ca.gov/programs/tobacco/ Documents/CTCPmodelforchange1998.pdf Health and Consumer Protection Directorate-General, European Commission (2007). Towards a Europe free from tobacco smoke: Policy options at the EU level, Green Paper, 27 final. http://ec.europa.eu/health/ph_overview/health_forum/docs/ ev_20071128_rd03_en.pdf Link, B., & Phelan, J. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363–385. Williamson, L., Thom, B., Stimson, G. V., & Uhl, A. (2014). Stigma as a public health tool: Implications for health promotion and citizen involvement. International Journal of Drug Policy, 25(3), 334–335.
Ronald Bayer Amy L. Fairchild Center for the History & Ethics of Public Health, Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, United States
Contents lists available at ScienceDirect
International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo
Editorial
Stigma: Time for a hard conversation
In ‘‘Stigma as a Public Health Tool: Implications for Health Promotion and Citizen Involvement,’’ Laura Williamson, Betsy Thom, Gerry Stimson and Alfred Uhl address the moral and utilitarian question posed by the use of stigma as a public health strategy both when it is explicitly embraced and when it is the predictable consequences of preventive measures. ‘‘Public health strategies that undermine individuals and communities, particularly those that urgently need to be engaged and brought within the reach of health services, risk having a negative impact on the fundamental aims of contemporary health promotion. . .. [P]olicies that move too far from respecting civic voices and consistently upholding equity will struggle to achieve gains that are durable.’’ (Williamson, Thom, & Stimson, 2014) This understanding represents a bedrock of contemporary public health thinking that has been inflected by human rights concerns. It is certainly reflected in longstanding efforts to address the social costs of the criminalization of drug users that yokes stigmatization with the punitive exercise of state power. Six years ago one of us (RB) challenged this orthodoxy in ‘‘Stigma and the Ethics of Public Health: Not Can We but Should We?’’ (Bayer, 2008) After years of work on HIV where stigma was viewed as both unjustly burdensome and as an impediment to public health that required systematic challenge, it was starting to discover that in the domain of tobacco control ‘‘denormalization’’ was increasingly embraced as central to the campaign to address the huge cost of morbidity and mortality associated with smoking. Anti-tobacco advocates governing agencies responsible for public health and the World Health Organization embraced this strategy, which, while eschewing the word ‘‘stigma,’’ sought to marginalize smoking, endorsed graphic messaging that depicted smoking as harmful even murderous. More striking still was the fact that these approaches claimed to be evidence-based. In fact there were studies that substantiated that position. Thus, for example, California Health Department asserted that it’s goal was to ‘‘push tobacco use out of the charmed circle of normal desirable practice to being an abnormal practice.’’ (California Department of Health Services, 1998) Further, the Director General of Health and Consumer Protection of the European Commission welcomed the fact that restrictions and limits on public smoking ‘‘contributed to the denormalization of smoking within society.’’ (HCDG, 2007) Thus it became clear that it was no longer credible to argue against stigma by claiming that it would never advance the cause of population health, that it was gratuitously oppressive since it was counterproductive. If denormalization or stigmatization can work it is necessary to pose an empirical question—Under what circumstances can stigma advance the goals of public health?—and a moral question—What limits should be imposed on its use and why? In other words, as http://dx.doi.org/10.1016/j.drugpo.2015.01.017 0955-3959/ß 2015 Elsevier B.V. All rights reserved.
Williamson, Thom, Stimson and Uhl suggest, How far is too far? It is crucial to note how social context matters for the understanding of these questions. With illicit drug use, for example, decades of social science research have sought to demonstrate the profound social consequences that have attended the stigmatization of drug use, which in the United States has produced a costly and destructive pattern of mass incarceration. And so destigmatization has been embraced by reformers as a central moral and political position. How very different from the situation of tobacco, where the public health challenge has been to address a deeply embedded pattern of behavior that, in the mid-1950s, involved more than half of all men and a third of women in the United States. It is in this light that it is important to note that public health campaigns involving messages that many view as stigmatizing have become ever more common. We have just completed an examination of the aggressive evidence based interventions undertaken in New York under the Bloomberg Administration. Focus groups had asked for hard-hitting campaigns. Beyond tobacco there were campaigns against obesity that sought to depict the behaviors that led to weight gain and the consequences as grotesque. In a city where obesity was common and where the human costs were stark, health officials sought to dismiss the charge of stigmatization by asserting that they were duty bound to challenge a commercial and normative structure with deadly implications. In the context of HIV health officials alarmed by the failure to reduce the incidence of infection among men who had sex with men especially Black and Latino men, a decision was made to launch a campaign called ‘‘It’s Never Just HIV,’’ which graphically depicted the physiological consequences of infection including dementia and anal cancer. In these cases, health officials have not actively sought to stigmatize— indeed, they almost uniformly struggled with discomfort over fearbased appeals, being well aware that such campaigns have often been attacked as stigmatizing. And, indeed, some of those who were appalled by these campaigns raised alarms about stigmatization. Regardless of how thoughtfully constructed so as to avoid marginalization, to make clear that fault for behaviors like smoking or excessive portion sizes can be pinned on corporate practices, to promote self-efficacy so that individuals feel empowered to act to save their own lives, to generate fear is necessarily to suggest that a behavior has ‘‘bad’’ consequences. The question, then, that health officials must ultimate answer is, Does death and suffering require us to act in a fashion likely to have the greatest impact, even if some may feel marginalized? In the end all stigmatization is not equivalent, as Bruce Link and Jo Phelan, who are so central to this discussion have noted. (Link and Phelan, 2001) There are differences between stigma that
614
Editorial / International Journal of Drug Policy 26 (2015) 613–614
causes discomfort and that which deeply wounds. There is a difference between stigma that is enduring and that which can be shed. Additional, like fear-based appeals, stigmatization may not always work. Any claim—that stigma works, that stigma backfires—must be substantiated by the best available evidence. We must take on the ethical challenge of weighing burdens and benefits at the population level, aware that crude utilitarian calculations are never enough. No longer protected by the assumption that stigma can never work we must address the questions of How? and When?, guided by principles of fairness and decency. But we cannot have the kind of searching, candid discussion that is required if we frame prohibitions against the use of stigma, even in its softer forms, in absolutist terms. This strategy forces thoughtful health professions who would carefully weigh this issues into a politically perilous position, inevitability leading to denial or mere strategizing about how to avoid the charge of stigmatizing the most vulnerable. We believe this discussion long overdue. It is such a dialogue to which we invite your readers to join. Conflict of interest The authors declare that they have no conflict of interest.
References Bayer, R. (2008). Stigma and the ethics of public health: Not can we but should we. Social Science and Medicine, 6, 463–472. California Department of Health Services (1998). A model for change: The California experience in tobacco control. http://www.cdph.ca.gov/programs/tobacco/ Documents/CTCPmodelforchange1998.pdf Health and Consumer Protection Directorate-General, European Commission (2007). Towards a Europe free from tobacco smoke: Policy options at the EU level, Green Paper, 27 final. http://ec.europa.eu/health/ph_overview/health_forum/docs/ ev_20071128_rd03_en.pdf Link, B., & Phelan, J. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363–385. Williamson, L., Thom, B., Stimson, G. V., & Uhl, A. (2014). Stigma as a public health tool: Implications for health promotion and citizen involvement. International Journal of Drug Policy, 25(3), 334–335.
Ronald Bayer Amy L. Fairchild Center for the History & Ethics of Public Health, Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, United States
