The Stigmatization of Illness


From OpEd News .  I so agree with many of Dr. Bramhall’s comments. While I have no experience with most of the issues he cites, I do have with the way we “treat” depression and anxiety as many of my clients come with those issues. They almost always experience discrimination.

Of course, my agreement or disagreement is somewhat irrelevant. His comments stand on their own. We have a long history of stigmatizing victims, blaming them for their victimization. The woman who was raped is blamed for wearing “provocative” clothing. The person who has lost her job, struggles daily to find another but in this economy (Five applicants for every position, even at the flippin’ burgers level) has been trying for 15 months, is not trying hard enough. The kid who is obese just eats too much; its his fault. (Ignore that his parents have been “treating” him to MacDonalds several times a week, and that he is surrounded by fast food joints, and that in many schools the same kind of food is served, and that peer pressure is most effective, and . . .)

Useless Eaters: the Stigmatization of Illness

By Dr Stuart Jeanne Bramhall

As a psychiatrist battling the stigma of mental illness for more than 30 years, I am gratified by growing public awareness that schizophrenia, depression and bipolar disorder run in families and are, at least partly, biologically determined. Thankfully the days when it was socially acceptable to blame depressives for being lazy or not doing enough to help themselves are long gone.

I wish I could say the same of physical illness which, after all, is basic to human existence. The US, unquestionably, has the most reactionary and punitive attitude towards illness in the world. It comes out in all manner of regressive and inhumane government policy: the federal government’s absolute refusal to make sick and parental leave mandatory (as it is in all other industrialized societies), the pressure for long term recipients of Social Security disability benefits to undergo continual review and mandatory treatment (which most have no way of paying for, as doctors have stopped accepting Medicare and Medicaid), as well strong pressure on doctors to declare them well enough to work; and now a proposal to change eligibility for Social Security retirement to make the elderly “prove” they are too sick to work.

The Growing Attack on Entitlements

In the growing attack by Republicans and Democrats on entitlements, there are always assertions either direct or implied that sick people are somehow responsible for the problems that make them unable to work. However what troubles me even more is the way so many Americans have internalized these attitudes how ready they are blame people who get sick on eating the wrong food, not exercising or not managing stress properly. Epidemiological studies show clearly this is not the case lifestyle factors only account for 10 percent of what causes us to become ill.

There is no question that the US has parted company with the rest of the world on this. I think it’s important to ask why. Quite frankly I hear a lot of discussion that is ominously reminiscent of Hitler’s “useless eaters” initiative. And I think it’s time to ask whether this is simply “coincidence” an accident of history or if there are more sinister reasons why this might be.

The Long Shadow of Joseph Goebbels

Hitler’s adopted his “useless eaters” policy in the early thirties at the very beginning of his regime. It was a utilitarian approach to social welfare consistent with the role the Nazi state played in serving the German and American corporate elite who put them in power. And Hitler enforced it vigorously, carting tens of thousands of elderly, handicapped, chronically ill and mentally ill and retarded individuals off to execution centers (long before the communists, Jews, gypsies and other undesirables) because of their inability to contribute “productively” to society.

American attitudes, not just around health, but around all spheres of human activity, are far more reactionary than the rest of the “free” world. And I think it’s high time to ask ourselves why. With new information surfacing over some of the Nazi connections of CIA founder Allen Dulles, I am increasingly skeptical this is either coincidental or down to a handful of right wing think tanks. Dulles’ high regard for Hitler’s chief propagandist Joseph Goebbels is a matter of public record. As is the fact that Dulles incorporated Hitler’s entire eastern European spy network into the CIA after World War II. And the long, cozy relationship between the CIA Office of Public Information and many US newspapers, news magazines and publishing houses. (see excellent article by Daniel Brandt at http://tinyurl.com/244m25v, along with two dozen references, including Carl Bernstein’s 1977 Rolling Stone article)

If the CIA, as it appears, has direct influence over media content, I think it’s reasonable to ask whether this plays a role in shaping how we think. I believe it does.

What I find most troubling about the reactionary “useless eater” mentality pushed by policy and opinion makers is the way Americans have internalized the belief that it’s their own fault if they become ill. In fact much of the US population seems more freaked out about getting sick than dying. I can’t say I blame them, as so many American workers have no sick leave and lose a day’s pay every time they are ill.

Americans also spend billions of dollars on alternative health care and vitamin supplements and other non-prescription remedies. And many are practically obsessed with healthy eating, only drinking bottled or filtered water, compulsive exercise routines and meditation, yoga and other stress reduction techniques to keep their massive job stress from making them sick (at present those who still have jobs do the work of 1.5 to 2 people on average).

The media compounds the problem by promoting a variety of cough and cold remedies and caffeine and mega B vitamin “boost” drinks to enable people to attend work when they have colds or even quite serious illnesses, such as bronchitis and the “flu.”

Medicating Kids

Parallel to this pressure for adults to be healthy, is immense pressure for children to be “normal.” While parents seem to be appropriately skeptical about taking unnecessary drugs themselves, they seem far too eager to and medicate children with behavior problems. As a child and adolescent psychiatrist, I am well aware that ADHD is a genuine disorder affecting 1-2% of children (but not childhood bipolar disorder this is a diagnosis heavily marketed by drug companies and totally unsupported by developmental or epidemiological research).

At the same time I see absolutely no reason why American children should be three times as likely to be diagnosed and treated for ADHD than children in other parts of the world. In my work, I come across psychiatrists from all over the world. Based on their input, I can safely asserted that the eagerness of US doctors (at the behest of drug companies) to prescribe psychotropic medication for children is an international scandal that casts the standard of American pediatric and psychiatric care in a very bad light.

Sending Sick Kids to School and Day Care

However I am even more concerned about the number of kids who have to go to school or day care when they’re sick because their working parents can’t afford to stay home and have nowhere else to send them. In doing so, they will also expose all their child’s classmates. Who, because their immune system is still forming, are very likely to develop the illness themselves and expose other children. Over the past decade, I have seen many children who suffer 12 or more serious (requiring antibiotics) throat, ear, sinus or chest infections a year.

This is a major public health problem, especially now that asthma (often triggered by chest infections), is reaching epidemic proportions among American children. Allowing children to suffer one respiratory infection after another can have permanent lifelong health consequences.

The reality is that illness both acute and chronic is fundamental to the human condition. In my experience, people willing to allow themselves to be ill and take time off to get well recover faster and cope better with other life stresses better.

Obviously adults have the choice whether or not they want to work when there are sick. Parents with sick children must make that decision for them. They are also entrusted with that child’s future health and welfare. And I think they need to weigh that responsibility carefully in deciding to send a sick child to school or daycare.

The Myth That Lifestyle Factors Cause Illness

Good health is elusive. In general we have a very limited ability to stay well by eating right, exercising and reducing stress. Epidemiological studies show that only 10% of illness is accounted for by lifestyle factors (including smoking).

The University of Washington epidemiologist Dr Stephen Bezruchka has been writing and speaking for nearly two decades on the real cause of illness and poor health. As he repeatedly points out, lifestyle factors (including smoking) only account for ten percent of the causation of illness. According to Bezruchka, the single most important determinant of adult health status and life expectancy is your mother’s income and social status during pregnancy and the first three years of life.

Although more than fifty years of epidemiological studies bear this out, it is only in the last decade scientists could explain why this is thanks to the new science of epigenetics. While the early Freudians used to make similar claims about unfavorable “psychological” influences on infants and young children, it is now clear the effect is biological rather than psychological. That it relates to “epigenetics” a term referring to changes in gene expression caused by mechanisms other than the underlying DNA sequence.

Numerous studies show that environmental stress and hormones (particularly stress hormones) produced during pregnancy can cause genetic code to be transcripted (into proteins and enzymes) in such a way to negatively affect the development of the immune system in addition to predisposing the fetus to biochemically based mental illnesses.

The Link Between Income Inequality and Poor Health

However the most important epidemiological finding, according to Bezruchka, is that the effect of low income status on health is much more pronounced in societies with extreme income inequality. Study after study bears this out. In other words, a poor person’s adult status and life expectancy will be worse if he is born into a country with big gap between the economic status of its rich and poor residents (such as the US where 10 percent of the population controls 71 percent of the wealth). In fact the US is near the bottom of the charts if you look at statistical indicators that measure the overall health of a country. In life expectancy it rates 38th, just behind Cuba. In infant mortality it rates 30th, just above Slovakia.

These findings also belie the efforts of policy and opinion makers to convince us that class differences have disappeared in the US. For example, it’s extremely rare to see working class families depicted on American TV. In fact some Republican commentators accuse their opponent of “class warfare” for even mentioning the existence of an underclass. Nevertheless with a double dip recession on the horizon, in the face of healthy corporate profits and CEO bonuses, American’s class divide is receiving more and more attention.

A Mindset Driven By Social Service Cuts

Dr Susan Rosenthal, in Sick and Sicker, also points out that it’s only in the last thirty years that politicians and policymakers on both sides of the aisle have made sick people responsible for their own illness. Epidemiological studies as long as scientists have been doing them have always shown that poor health correlates directly with low income and social status. Rosenthal notes that even in Dicken’s time it was taken for granted that the poor undernourished and living in cold, damp, overcrowded tenements were far more prone to illness than their middle class counterparts. In her mind this shift to a new “blame the victim” mentality has been deliberate to justify aggressive social service cutbacks (by both Republicans and Democrats) that became fashionable with the election of Ronald Reagan in 1980.

The Role of Oppression and Exploitation in Illness

Although the data establishing the link between income inequality and poor health is unequivocal, epidemiologists are still at a loss to explain why poor people have poorer health in countries with more income inequality. Bezruchka relates it to the fact that people in more egalitarian societies look after each other more. I like Rosenthal’s explanation better. She relates it to the extremely high level of oppression and exploitation in societies with extreme income disparity.

She points out that minimum wage workers aren’t just poor. They also work in exploitive, arbitrary and often punitive job settings that they feel powerless to change. The immense stress of confronting this massive stress on a daily basis takes an enormous toll on both the human body and psyche.

Ironically her view is born out by studies showing that American life expectancy increased by 6.2 years during the Depression when 20-25 percent of Americans were out of work (see http://www.sciencedaily.com/releases/2009/09/090928172530.htm)

Dr Susan Rosanthal’s website: http://susanrosenthal.com/

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