Stigma discredits individuals and groups, reducing social status and creating ‘spoiled identities’, says Goffman. It’s not a good thing. But hang on a minute – might it have a positive function? Could it actually help in terms of public health? Help by changing behaviour through societal pressure. If so, that would be a good thing, right?
An editorial in the International Journal of Drug Policy tackles the issue. Stigma, say the authors, is already in use in terms of public health. Look at the adverts about binge drinking with teenagers vomiting fish suppers into toilet bowls or having the unpleasant social consequences of drinking. Drink driving campaigns are another case in point. According to this paper, some US states make formerly convicted drink drivers display license plates which proclaim their sin to the world, shaming not just them but their families and friends.
The authors higlight another stigmatising campaign:
But perhaps the most notorious instance of stigma is the international ‘war on drugs’ that, in effect, stigmatises individuals by means of criminal sanction. The counterproductive effects of this approach (Buchanan& Young, 2000) led directly to the UK Drug Policy Commission to call for the removal of legislation that reinforces stigma.
Then there is smoking:
Similarly, legislation has been a key tool in efforts to denormalise smoking, an initiative that operates at an international level, in the policies of the World Health Organization (World Health Organization, 2003), and within particular nation states. This is a strategy to ‘deglamourize’ smoking and to make it socially unacceptable.
Campaigns like this are seen as a ‘public health triumph’, but the authors point out that smoking remains a problem in lower socioeconomic groups. These are ‘already stigmatised’ and ‘stigmatisation adds to their burden.’ The balance with smoking however is perhaps in favour of the legislation and campaigns:
Despite such concerns and the alarm created by alreadysocially marginal groups being further undermined, it has beencontended that the benefits from stigmatising populations andbehaviours may outweigh the costs of (temporarily) increasing thesocial marginalisation of the least well-off in society.
So how do you safeguard vulnerable populations against stigmatisation? The answer, say the authors, is to do with trust. Health promotion encourages people to make healthy choices and informed and supported healthy choices make for healthy communities:
This approach is informed by evidence that active, empowered communities and individuals with reserves of social capital – that is, being part of their wider community, having shared values and support from reciprocal,trusting relationships – are more resilient and fare better.
Involving citizens means getting their trust. Stigmatisation may denigrate trust and make meaningful engagement impossible. Stigma, they argue, erodes social capital. Ultimately, says the editorial, we need to be careful:
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.
The editorial made me think of the stigma that can exist within recovering communities. Drug addicts have been treated with contempt by some AA members at some AA meetings. These are rare incidents locally, but they do happen. Even in therapeutic communities there can be a hierarchy of addictions, with IV heroin addicts on the bottom rung of the recovery ladder.
Then there is the stigmatisation of recovery. When recovery is set out as a political concept, introduced by right wingers, recovery support can be cast as an extreme position; one that is easily mocked. Within treatment services, professionals can view recovering people through jaundiced eyes. At an SMMGP conference only a few years ago in Newcastle, a speaker talked of ‘goose stepping 12-steppers’, something grossly offensive to some service users present, without any challenge.
Deglamorizing smoking is one thing, but the entrenched prejudices that people addicted to illicit drugs have to endure is at a different level. We may not be able to remove stigma, but we can name it when we see it, call it out and refuse to tolerate it. We can turn its own undermining ways back on itself and humiliate stigma and stigmatisers. Wouldn’t it be a delicious irony if stigma became disempowered and was shamed into silence?
Williamson L, Thom B, Stimson GV, & Uhl A (2014). Stigma as a public health tool: implications for health promotion and citizen involvement. The International journal on drug policy, 25 (3), 333-5 PMID: 24810060