By Nathan Douthit
“People who are excluded…are not ‘just like’ the rest of the poor, only poorer. They are also disadvantaged by who they are or where they live, and as a result, are locked out of the benefits of development.”
In ‘HIV-associated dementia in the Dominican Republic: a consequence of stigma, domestic abuse and limited health literacy,’ Santoso et al describe the case of a woman living with uncontrolled HIV for 14 years. She did not report it for fear of abuse and stigmatization in society. She also was found to have significant psychiatric disease, but when referred to a specialist, “She insisted that she was not ‘crazy’.”
Stigma can be a major factor in the progression of disease and the decision to seek care. The authors of this case describe the barriers to HIV care,
“People living with HIV/AIDS in the Dominican Republic experience social devaluing as their illness is commonly associated with marginalised groups such as sex workers, the lesbian, gay, bisexual, and transgender (LGBT) community and drug users. Additionally, they are subjected to institutionalised discrimination, including denial of medical services or jobs. Fear of discrimination likely played a significant role in this patient’s avoidance of treatment.”
And the reluctance to receive treatment for her psychiatric problems with,
“Although the patient voiced suicidal intent, she was reluctant to see the psychologist for fear of being labelled as a ‘loca’ (crazy person). Locas are rejected in Dominican society for being perceived as being out-of-control, unpredictable and unable to fulfill expected gender roles.”
Stigma from mental health can have, “significant social and economic deprivation…as a consequence.” This problem is not only neglected but, in some ways, exacerbated by the global health community. While the burden of depression exceeds malaria in low-income countries, the amount of awareness, fundraising and innovative treatments for the latter far exceed the former. It has been shown that physicians educated in low-income countries may worsen stigma by attributing mental illness to supernatural forces; a problem that persists even after psychiatric training.
Stigma from HIV is well described by the authors above. In many countries, there is legislation in place that enforces stigma and economic deprivation for those infected by HIV. The social stigma in place also effects the livelihood of patients.
Global health professionals engaged in the care of individual patients must work to ensure that discrimination and stigma are eliminated as barriers to care. This can be done by intentionally working with high-risk or stigmatised groups, education of local communities and advocacy for change in harmful policies. All stake-holders must realize that disease stigma causes increased morbidity and mortality and has no place in society.
In light of this, BMJ Case Reports invites authors to publish cases regarding stigma in global health and methods used to overcome this barrier. Global health case reports can emphasize:
-the devastating effects of stigma worsening disease
-diseases that are uniquely stigmatised in individual cultures
-innovative methods to overcome stigma
-the stigma created and perpetuated by the healthcare system
Read more about stigma and disease at BMJCR:
Read more about stigma and disease from other sources:
-World Health Organization. Mental health and development: targeting people with mental health conditions as a vulnerable group. World Health Organization; 2010.
-Ngui EM, Khasakhala L, Ndetei D, Roberts LW. Mental disorders, health inequalities and ethics: a global perspective. International Review of Psychiatry. 2010 Jun 1;22(3):235-44.
-Joint United Nations Programme on HIV/AIDS. Global AIDS update 2016. Geneva: UNAIDS. 2016.
 Reducing poverty by tackling social exclusion: a DFID policy paper. United Kingdom, Department for International Development, September 2005 (http://www.d d.gov.uk/Documents/publications/ social-exclusion.pdf, accessed 29 December 2009).
 World Health Organization. Mental health and development: targeting people with mental health conditions as a vulnerable group. World Health Organization; 2010.
 Ngui EM, Khasakhala L, Ndetei D, Roberts LW. Mental disorders, health inequalities and ethics: a global perspective. International Review of Psychiatry. 2010 Jun 1;22(3):235-44.
 Joint United Nations Programme on HIV/AIDS. Global AIDS update 2016. Geneva: UNAIDS. 2016.