A/HRC/38/42 C. Failure of the medicalization of stigmatization and discrimination Resocializing leprosy-related discrimination 45. The second decade of the twenty-first century was marked by an acknowledgment that the medicalization of stigmatization and discrimination (that is to say, the idea that the availability of medical treatment and the dissemination of medical knowledge about the disease would eliminate stigmatization and discrimination) was not enough to eliminate the historically, socially, politically, economically and culturally entrenched discrimination against persons affected by leprosy. Such discrimination had been systematically reproducing unequal opportunities and access to the goods and services of the State and segregation from community, social and family life, and causing tremendous suffering and distress to persons affected by leprosy. 46. Medicalized interventions on what is narrowly described as health-related stigma are mostly based upon “immodest claims of causality” 40 and not on evidence. They also compartmentalize the problem in a way that fails to grasp its multidimensionality. While the ground-breaking effect of multidrug therapy on the lives of persons affected by leprosy and on the public’s image of the disease cannot be dismissed, discrimination persists. 47. Stigmatization and discrimination on the grounds of leprosy must be resocialized, 41 contextualized and approached as interdependent social, economic, political and cultural issues. Stigmatization and discrimination are mutually reinforcing. Enacted stigmatization produces discrimination, which, in return, reinforces stigmatization, trapping persons affected by leprosy in a spiralling chain of disadvantage. 48. It is necessary to analyse how leprosy intersects with other social vulnerabilities. Leprosy-related stigmatization is only the tip of the iceberg 42 of inequalities and inequities that have historically excluded persons affected by leprosy from participating on equal terms in society. Discrimination on the grounds of leprosy is multiple and directly proportional to social vulnerability. 49. However, and despite the current acknowledgment of the persistence of institutionalized and structural discrimination against persons affected by leprosy and their family members, existing indicators used to assess discrimination are mostly based on the medical model. It is crucial to develop new tools that, in the light of the progress achieved by the social model of disability, may be able to identify how societies erect barriers to the full inclusion of persons affected by leprosy and how those same barriers can be taken down. 50. Discrimination on the grounds of leprosy is institutionalized, public, iatrogenic, affiliated, multilayered and must be understood in its social, economic, political and cultural context. In order to respond to discrimination in an effective way, it is necessary to identify the societal spheres in which it occurs and manifests itself. Discrimination on the grounds of leprosy may be found at the: (a) macrolevel of the State (in laws, jurisprudence and public policies); (b) intermediary level of State goods and services, such as health services, education, work opportunities and regulation; and (c) microlevel of community life and/or the family. Institutionalized and structural discrimination 51. Legal dogmatics alone has failed to acknowledge the gap between written law and the practice of law. Discriminatory laws and policies are not the only reason for the exclusion of persons affected by leprosy, but also the lack of effective implementation of 40 41 42 10 A. Castro and P. Farmer, “Understanding and addressing AIDS-related stigma: from anthropological theory to clinical practice in Haiti”, American Journal of Public Health, vol. 95, No. 1 (2005), pp. 53– 59. Richard Parker and Peter Aggleton, “HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action”, Social Science and Medicine, vol. 57, No. 1 (2003), pp. 13– 24. Castro and Farmer, “Understanding and addressing AIDS-related stigma”, pp. 53–59.