Review of Lazy, Crazy, and Disgusting: Stigma and the Undoing of Global Health. Alexandra Brewis and Amber Wutich, Baltimore, MD: Johns Hopkins University Press, 2019, 270 pp.

Reviewed Book

Lazy, Crazy, and Disgusting: Stigma and the Undoing of Global Health. Alexandra Brewis and Amber Wutich, Baltimore, MD: Johns Hopkins University Press, 2019, 270 pp.

Lazy, Crazy, and Disgusting: Stigma and the Undoing of Global Health introduces the reader to the social power that wrings through interventions in public health and medicine. Through multiple cases, Alexandra Brewis and Amber Wutich argue that the impact of these interventions lingers beyond the intentions of international policies, programs, and efforts. By illuminating links between shame and being “dirty” (toilets), “lazy” (fat), and “crazy” (mentally ill), Brewis and Wutich expertly deconstruct “the complex, dangerous dance between stigma and public health” (p. 3). In doing so, they push the needle from the large number of global health texts that emphasize structural problems to the social aspects of stigma and health. From tackling Big Tobacco to building latrines and preventing obesity, this book unpacks the hidden moments that produce stigma within policies and programs in public health and medicine that have become status quo. In doing so, the authors explain where stigma comes from, how and why it lingers, and what to do about it.

Lazy, Crazy, and Disgusting reveals how shaming deepens all types of social divisions, wreaking social havoc with consequences that often outlast well-intentioned public health and medical interventions. By drawing from an impressive array of their own independent and collaborative research, their students’ work, and the work of other anthropologists, Brewis and Wutich illuminate how, “when shame and disgust collide, humans too easily connect instinctive feelings of revulsion to moral ideas about people’s worth” (p. 34). They demonstrate that shaming is not always visible (such as physically banishing a family member to a hut behind the home during menstruation). Rather, shaming can be subtle (such as a physician castigating an unemployed single mother of three for not eating better food and exercising more to lose weight or control diabetes). The authors argue that “shame itself—while dreadful and painful—[is worse] when you mix it with poverty or any other marginalized social status” (pp. 6–7). In this way, they complicate notions of the social with structural dimensions that determine who has the power to wield shame, how it is perpetuated, and who experiences it the most.

Part I, “Disgusting,” introduces hygiene stigma in three chapters. Together, the chapters show how labeling people as dirty or disgusting causes social ostracization, displacement, illness, and suffering. Beginning with toilets, Brewis and Wutich ask, “[W]hy do ruinous processes always seem to flow down social hierarchies, piling up on the least powerful?” (p. 41). They suggest that in some cases, such as Community-Led Total Sanitation, well-intentioned interventions reify existing social hierarchies and produce more social isolation among low-income families by encouraging communities to police the introduction of new sanitation infrastructures (such as forcing people without savings to pay for in-home toilets or shaming people to become more discrete about open defecation). Expertly describing findings from their Global Ethnohydrology Project, Brewis and Wutich argue that how people define what is dirty or disgusting differs across contexts. For instance, in Guatemala, people identify structural problems (like poverty) that drive people to appear dirty. In Fiji, people attribute family neglect. In contrast, in New Zealand and the United States, people attribute being dirty or disgusting to falling on hard luck.

Part II, “Lazy,” tackles the pervasive experience of fat stigma. Describing another collaborative, multi-country study, the authors describe how, in the 10 countries they selected, diverse in geography and political economy, they found universal affliction of fat-negative beliefs. Yet, digging deeper through ethnography, they found that fat stigma existed in the lives of people and communities very differently: In some contexts, people internalized fat as bad and in others fatness was as negative as thinness. Brewis and Wutich argue that myths reinforcing fat stigma harken back to neoliberal and biomedical thinking around individual responsibility. Fat stigma is externalized (clinicians saying: Eat healthier, exercise!) and internalized (self-judgment of weight that prevents one from exercising in the first place). This represents what they call “soft stigma” (p. 120). Moreover, ideas about who is fat and why are then reproduced through media campaigns that act to pack the coffers of big business, from medical and pharmaceutical treatments to fad diets and exercise programs. Instead of using these corporate concoctions to tackle fatness, the authors suggest that interventions that move beyond the body and emphasize sociostructural changes are best: investing in city parks and streets; improving access to reliable safe water for children and families. These will improve people’s lives without stigmatizing fat, which reifies pain and suffering.

Part III, “Crazy,” describes the lapses in social, familial, and structural dimensions of people’s lives that cause those with mental illness to fall through the cracks. The authors emphasize that despite short-term gains via advocacy or public health campaigns, reducing stigma around mental illness largely fails because such campaigns emphasize structural factors. Here, the authors bring to the fore the social nature of stigma surrounding mental illness. In describing the tricky disjuncture between institutionalization and family-based care, Brewis and Wutich suggest that both have benefits, and these differ from place to place. They explain how some of the worst stigma comes from mental health professionals and the institutions built to care for people with mental illness. Instead, the authors show that the best treatment may be encouraging someone with mental illness to meet social role expectations, for example, as productive earners or “good” mothers. But this, too, is not always the case; families that neglect their loved ones with mental illness can also cause undue harm. Brewis and Wutich further describe how depression is linked to food and water scarcity or living in the wrong place, which perpetuates “people’s deep concerns of who they should be in their daily lives” (p. 178). Thus, not meeting social role expectations, or facing compounded stigmas, makes life and self-acceptance much more difficult, fostering distress.

In contrast to recent global health texts focused on the political or structural dimensions that undo health progress, this book’s focus on social undoing will make readers consider new perspectives. Public health students will think critically, for example, about how using social capital to encourage community-building projects for toilets may produce compromising social hierarchies and harmful outcomes. Medical students may rethink the implications of narratives of individual responsibility, especially when interacting with patients struggling with weight loss. Anthropologists will learn how to turn decades worth of large, multi-country, mixed-methods research into a powerfully bundled argument around social power. By highlighting stigma in the shadow of more than a century of intervening in the lives of others, Brewis and Wutich forge a new way of seeing and knowing how outsiders may compromise individuals’ and communities’ health.

Lazy, Crazy, and Disgusting is an impeccably researched, collaborative, thought-provoking, and boundary-breaking book that should be required reading for anyone interested in public health, medicine, and anthropology. It stands as an exemplar for public scholarship among two of our most devoted anthropologists who hug the margins of biological, cultural, and medical anthropology. It would be ideal reading for undergraduate coursework in medical anthropology and critical global health. But it would also be a useful text for graduate students who wish to do anthropology of/in global health. It is also a useful book for anthropologists seeking jobs outside of academe, where evaluations may address the subtler forces that cause interventions to succeed or fail. Finally, Alexandra Brewis and Amber Wutich provide a powerful example for future anthropologists wishing to make a mark: Publish in a diverse array of journals, coauthor with gusto, promote diverse arrangements of authorship and contributions, and write a book deeply engaged with theory, ethnography, and mixed methods for the public.