Anthropology studies human health problems and healing systems in their broad social and cultural contexts. A specialised branch of anthropology, i.e, medical anthropology has engage in both basic research into health and healing systems and applied research aimed at the improvement of therapeutic care in clinical settings or community public health programs in prevention and disease control. Drawing from biological and social sciences, as well as clinical sciences, medical anthropologists have contributed significantly to the understanding and improvement of human health and health services worldwide. As a result, the growth of the subdiscipline in recent years as reflected in publications and meetings, training programs, and influence outside of anthropology has been remarkable. Medical anthropology is not characterized by a single theoretical paradigm. For example, ethnographic description and analysis of religion and healing systems are as old as anthropology itself, while new approaches like critical medical anthropology are the product of more recent intellectual trends. This has sometimes led to intense debates within the field such as those between clinically applied medical anthropologists (interested in making cultural knowledge useful to the aims of medical practitioners) and critical medical anthropologists (interested in the phenomenology and political economy of biomedicine). But, even though the scope of intellectual inquiry is very diverse, it is possible to identify five basic approaches: biomedical, ethnomedical, ecological, critical, and applied. These approaches share three fundamental premises:
1. illness and healing are fundamental to the human experience and are best understood holistically in the contexts of human biology and cultural diversity
2. disease represents an aspect of the environment that is both influenced by human behavior and requires biocultural adaptations
3. the cultural aspects of health systems have important pragmatic consequences for the acceptability, effectiveness, and improvement of health care, particularly in multicultural societies
The developed world has transformed from industrialized societies organized around the production of goods by machines into technocracies: societies organized around evolution through the development of sophisticated technologies and the global flow of information through these technologies. Thus, Davis- Floyd has labeled its dominant health care paradigm “the technocratic model of medicine” to highlight biomedicine’s precise reflections of technocratic core values. The technocratic model emphasizes the separation of mind and body and metaphorizes the body as a machine and the patient as an object (“the gall bladder in 212”). The resultant mechanicity and often impersonal nature of biomedical care have been mitigated in recent years by increasing emphasis on humanism within biomedicine. The “humanistic model” stresses the importance of “mind-body connection,” defines the body as an organism, and sees the patient as a relational subject; it views the relationship between patient and practitioner as an essential ingredient of healing. While encompassing the relational values of humanism, most alternative healing methods are ideologically grounded in a third transnational paradigm, the “holistic model of medicine,” which recognizes mind, body, and spirit as a whole, and defines the body as an energy field in constant relation to other energy fields, demanding attention to energy-based healing—a radical departure from the mechanistic approach of biomedicine.
Illness and disease as cultural constructs:
Disease is distinguished from illness, which refers to a person's perceptions and lived experience of being sick or "dis-eased" a socially disvalued state that includes disease but is not limited to it. In recent years, the disease illness distinction has been criticized because the process of separating biological "facts" from cultural constructions falsely suggests the superiority of the non-cultural biomedical model (Hahn 1995). From an anthropological perspective, diseases have played a significant role in the evolution of both human biology and cultural systems. Infectious diseases, for example, represent challenges to survival and therefore act as agents of selection for biological or cultural adaptation. Livingstone's (1976) analysis of the history of the sickle-cell genetic trait in West Africa remains a classic example of this phenomenon. Here the introduction of SWIDDEN horticulture resulted in increased P. falciparum malaria, which, in turn, increased the frequency of the sickle-cell gene that gave resistance to that disease, in spite of the huge costs sickle-cell anemia otherwise exacts on the human body. A cultural-ecological approach to understanding disease emphasizes the fact that the environment and its health risks are largely created by culture (Inhorn & Brown 1997). Culture determines the social-epidemiological distribution of disease in two general ways. From a microsociological perspective, culture shapes individual behaviors (diet, exposure to contaminated water, sexual practices, etc.) that predispose people to certain diseases. From a macrosociological perspective, political-economic forces and cultural practices make people interact with their environment in ways that may affect health either by exacerbating disease problems or protecting people from disease. The building of dams for the intensification of agricultural production, for example, can increase rates of schistosomiasis or malaria.
In epidemiology there is a distinction between epidemic diseases, which occur at greater than expected amounts, often in outbreaks linked by time or place, and endemic diseases, which occur at a more constant rate in a population. Epidemics are usually characterized by high mortality rates and socioeconomic disruptions, and have been very influential in history (McNeil 1976). Endemic diseases, often characterized by high morbidity, can be so commonplace in a population that they are considered normal rather than an illness. Infectious diseases caused by bacteria, viruses, fungi, unicellular parasites, and so on often trigger immunological responses in hosts so that individuals build up a repertoire of immunities to endemic (childhood) diseases. Infectious diseases can also be contrasted with chronic diseases (cardiovascular disease, hypertension, etc.); these are sometimes called the "diseases of civilization" because of their increased prevalence in wealthy populations. Chronic diseases have multifactorial causes, partly linked to diet and exercise patterns. Many anthropologists see the rise of chronic disease as a reflection of the discordance between ancient genes and modern lifestyles (Eaton et al. 1988).
Disease patterns change over historical time. Through a process of mutual adaptation of host and pathogen, an epidemic disease can become an endemic one within a single population. Armelagos and Dewey (1970) have identified three "epidemiological transitions" in human history. The first was a general decrease in health and increase in infectious-disease burden associated with the domestication of plants and animals (Neolithic Transition). The second was a decrease in infectious disease and an increase in chronic disease as a result of improved housing, sanitation, diet, and (to a lesser extent) medical care in Europe and the United States at the beginning of the twentieth century. The third epidemiological transition is the rise of antibiotic-resistant pathogens and the emergence of new diseases such as HIV/AIDS or Ebola viruses at the end of the century. These are not isolated phenomena. In 1992, the list of new diseases included 17 forms of bacterium, rickettsia, and chlamydia, 27 forms of virus, and 11 forms of protozoon, helminth, and fungus (Lederberg et al. 1992). In an ecological sense, these new diseases reflect evolutionary processes in which pathogens exploit new ecological niches created by environmental changes.
Scholars like Hruschka (2009) argues that culture is a powerful determinant of health outcomes and disparities. In such accounts, culture can be either a barrier to health or a protective factor, it can stymie health interventions, reinforce and perpetuate behaviors that impinge on well-being and explain otherwise inexplicable population differences in health (Health Canada 1998; Young 1998; Kindig and Stoddart 2003; Eckersley 2006). Yet, among the frequent references to culture as a factor in health disparities, the precise mechanisms by which cultural factors influence health outcomes are rarely clarified, and relatively few empirical studies in the epidemiological literature actually operationalize and measure putative cultural mechanisms in an attempt to assess their plausibility. This mismatch between culture’s assumed role in health disparities and the relative lack of empirical investigation has lead to recent calls for more careful definition and investigation of the pathways by which culture might impinge on health and well-being (Dressler 2006; Janes 2006; Kelly et al. 2006). As a precursor to this goal, this paper systematically reviews how population health scholars use culture as an account for health disparities. To give a background to the culture concept, I briefly trace its history and provide a working definition of the term. Then, using published articles as a lens, I document the historical increase in how epidemiologists (and more recently population health scholars) have used culture as an explanation, and in more detail how they use the term today. Finally, I identify key weaknesses in how culture is currently used by epidemiologists and population health scholars, and describe promising ways to define and evaluate culture’s influence on variations in health. Key points of the review are that:
1. Culture is not self-evident and needs careful definition if it is to be used as a scientific explanation.
2. Culture comprises a number of different mechanisms and pathways that can be hidden if we simply invoke ‘culture’ as an explanation.
3. Cultural explanations are only hypotheses, and they require careful specification and testing against other proposed explanations.
4. Because culture is learned, and can differ arbitrarily between groups, cultural explanations require in-depth study of a particular setting in conjunction with population-based quantitative studies.
The 20th century invasion of academic discourse by ‘culture’ equally affected population health and epidemiology (Trostle 2005). There are several important questions that need to be answered in order to understand the concept of culture in population health. How is culture used as an explanation for health outcomes, health disparities, and the differential success of interventions? How are such claims about culture’s influence evaluated? And to this end, how has culture been measured, how have cultural variables been analyzed, and how has an understanding of cultural pathways been used to improve interventions?
Talcott Parsons (1951:436) described the "four aspects of the institutionalized expectations system relative to the sick role." He argued (in The Social System, 1951) that whilst disease involves bodily dysfunction, being sick—that is, being identified and accepted as ill—is a role governed by social expectations, of which he listed four. First, exemption from normal social role responsibilities: this exemption must be legitimated by some authority, often a medical practitioner. Second, exemption from responsibility for being ill, which means that the sick must be looked after. Third, since sickness is deemed undesirable, the sick are obliged to want to get better; and also, fourthly, to seek technically competent help and co-operate in trying to get better.
The concept draws attention to the social regulation of illness: to the mechanisms that guarantee the compliance of sick persons, help to restore them to health, and ensure that only the genuinely sick are exempt from normal responsibilities. It also provides a means of analysing the motivational factors involved in illness. Indeed, Parsons suggested that because of these motivational components (he was influenced here by Freudian theorizing), illness could be considered a special form of deviance, functional to the social system in directing deviant tendencies away from group formation, solidarity, and successful claims to legitimacy.
Critics have questioned the universality of Parsons's specification of the expectations governing the sick role, the extent to which illness is motivated, the model's relevance to long-term sickness, and his focus on what is functional for society. None the less, the concept of the sick role has been central to sociological thinking about health and illness, and its importance would be hard to overestimate.
The increasing diversity of the nation brings opportunities and challenges for health care providers, health care systems, and policy makers to create and deliver culturally competent services. Cultural competence is defined as the ability of providers and organizations to effectively deliver health care services that meet the social, cultural, and linguistic needs of patients.(1) A culturally competent health care system can help improve health outcomes and quality of care, and can contribute to the elimination of racial and ethnic health disparities. Examples of strategies to move the health care system towards these goals include providing relevant training on cultural competence and cross-cultural issues to health professionals and creating policies that reduce administrative and linguistic barriers to patient care.
Cultural competence in health care means delivering effective, quality care to patients who have diverse beliefs, attitudes, values, and behaviors. This practice requires systems that can personalize health care according to cultural and linguistic differences. It also requires understanding the potential impact that cultural differences can have on healthcare delivery. For example, race, socioeconomics, health literacy, and other factors can influence: How patients perceive symptoms and health conditions When and how patients seek care Patients’ expectations of care Patients’ preferences regarding procedures or treatments Patients’ willingness to follow doctor recommendations or treatment plans Who patients believe should participate in making healthcare decisions While cultural competence in health care initially referred to meeting the needs of people from distinctive ethnic and racial groups, it now also refers to meeting the needs of people with disabilities, those from diverse socioeconomic backgrounds, and members of the LGBTQ community.
The Need for Cultural Competence in Health Care
Differences between healthcare providers and patients can affect communication. This can, in turn, impact both clinicians’ and patients’ decisions with regard to treatment. For example, a clinician may misinterpret a patient’s silence as a lack of interestin receiving care. As a result, the clinician may not order a diagnostic test, when in fact the patient’s response reflected their notion of respectful behavior.
When healthcare providers fail to recognize the differences between them and their patients, they may inadvertently deliver lower-quality care. Cultivating skills that improve cross-cultural communication can play an important role in delivering equitable care.
Additionally, building teams with healthcare professionals who reflect the diversityof the patient populations served can also improve cross-cultural communication. Diverse teams have a wider cultural knowledge base that they can share with one another. This makes them likely to respond with empathy to the unique cultural needs of patients.
Language accessibility is also key. Language barriers keep patients from accurately describing their symptoms and providers from explaining diagnoses. Language barriers can also create unsafe and inappropriate situations in other ways.
For instance, clinicians may rely on children to serve as interpreters, putting young people in the position of telling a parent they have cancer. As another example, clinicians may rely on abusive spouses to interpret for their battered partners. Both situations pose significant problems.
The need for Cultural Responsiveness in health care:
Cultural responsiveness is a new way of thinking about culture. It means being open to new ideas that may conflict with the ideas, beliefs and values of your own culture, and being able to see these differences as equal. For example, in many cultures spiritual beliefs are an important part of overall wellbeing.
It means being respectful of everyone’s backgrounds, beliefs, values, customs, knowledge, lifestyle and social behaviours. It helps you provide culturally appropriate care and support, so people are empowered to manage their own health.
Cultural responsiveness is important for all social and cultural groups, including:
· Aboriginal and Torres Strait Islander peoples
· people from culturally and linguistically diverse backgrounds
· refugees or displaced migrants
· people at all life stages, including end of life
· people with different abilities, including intellectual and cognitive disabilities
· LGBTIQ people
· people from priority populations and sub-cultures, such as the deaf and vision-impaired community.
Cultural responsiveness involves continuous learning, self-exploration and reflection. It draws on a number of concepts, including cultural awareness, cultural sensitivity, cultural safety and cultural competence
Evidence shows that when there is a lack of cultural responsiveness, health outcomes are much poorer.2 Improving cultural responsiveness can not only remove barriers to accessing healthcare, but may also reduce inequitable health outcomes for marginalised and vulnerable groups.
In Australia, there is a movement towards cultural support planning in health, social and community services.
· language, such as translating and interpreting services
· food preferences
· access to health professionals of the same gender
· religion and spirituality for palliative care and end of life.
Culture as an explanation in population health by DANIEL J. HRUSCHKA, 2009, Annals of Human Biology, MayJune 2009; 36(3): 235247
The Sick Role Concept: Understanding Illness Behavior By Alexander Segall: Journal of Health and Social Behavior, Vol. 17, No. 2 (Jun., 1976), pp. 162-169