Culture and health

Abstract

Planned and unplanned migrations, diverse social practices, and emerging disease vectors transform how health and wellbeing are understood and negotiated. Simultaneously, familiar illnesses-both communicable and non-communicable-continue to aff ect individual health and household, community, and state economies. Together, these forces shape medical knowledge and how it is understood, how it comes to be valued, and when and how it is adopted and applied. Perceptions of physical and psychological wellbeing diff er substantially across and within societies. Although cultures often merge and change, human diversity assures that diff erent lifestyles and beliefs will persist so that systems of value remain autonomous and distinct. In this sense, culture can be understood as not only habits and beliefs about perceived wellbeing, but also political, economic, legal, ethical, and moral practices and values. Although culture can be considered as a set of subjective values that oppose scientific objectivity, we challenge this view in this Commission by claiming that all people have systems of value that are unexamined. Such systems are, at times, diff use, and often taken for granted, but are always dynamic and changing. They produce novel and sometimes perplexing needs, to which established caregiving practices often adjust slowly. Ideas about health are, therefore, cultural. They vary widely across societies and should not merely be defined by measures of clinical care and disease. Health can be defined in worldwide terms or quite local and familiar ones. Yet, in clinical settings, a tendency to standardise human nature can be, paradoxically, driven by both an absence of awareness of the diversity with which wellbeing is contextualised and a commitment to express both patient needs and caregiver obligations in universally understandable terms. We believe, therefore, that the perceived distinction between the objectivity of science and the subjectivity of culture is itself a social fact (a common perception). We attribute the absence of awareness of the cultural dimensions of scientific practice to this distinction, especially for macrocultures and large societies, which define only small-scale, microcultures as cultural. We recommend a broad view of culture that embraces not only social systems of belief as cultural, but also presumptions of objectivity that permeate views of local and global health, health care, and health-care delivery. If the role of cultural systems of value in health is ignored, biological wellness can be focused on as the sole measure of wellbeing, and the potential for culture to become a key component in health maintenance and promotion can be eroded. This erosion is especially true where resources are scarce or absent. Under restricted and pressured conditions, behavioural variables that aff ect biological outcomes are dismissed as merely sociocultural, rather than medical. Especially when money is short, or when institutions claim to have discharged fully their public health obligations, blame for ill health can be projected onto those who are already disadvantaged. As a result, many thinkers in health-care provision across disciplines attribute poor health-care outcomes to factors that are beyond the control of care providers-namely, on peculiar, individual, or largely inaccessible cultural systems of value. Others, having witnessed the ramifications of such thinking, argue that all health-care provision should, rather, be made more culturally sensitive. Yet others declare merely that multiculturalism has failed and the concept should be abandoned, citing its divisive potential.1 Irrespective of who is blamed, failure to recognise the intersection of culture with other structural and societal factors creates and compounds poor health outcomes, multiplying financial, intellectual, and humanitarian costs. However, the eff ect of cultural systems of values on health outcomes is huge, within and across cultures, in multicultural settings, and even within the cultures of institutions established to advance health. In all cultural settings-local, national, worldwide, and even biomedical-the need to understand the relation between culture and health, especially the cultural factors that aff ect health-improving behaviours, is now crucial. In view of the financial fragility of so many systems of care around the world, and the wastefulness of so much of health-care spending, a line can no longer be drawn between biomedical care and systems of value that define our understanding of human wellbeing. Where economic limitations dictate what is feasible, socioeconomic status produces its own cultures of security and insecurity that cut across nationality, ethnic background, gender orientation, age, and political persuasion. Socio economic status produces new cultures defined by degrees of social security and limitations on choice that privilege some people and disadvantage others. Financial equity is, therefore, a very large part of the cultural picture; but it is not the entire picture. The capacity to attend to adversity- to believe that one can aff ect one's own future-is conditioned by a sense of social security that is only partly financial.