When Culture Impacts Health: Global Lessons for Effective Health Research

By Stanley Ulijaszek

Bringing the hard-to-quantify aspects of lived experience to analysis, and emphasizing what might be lost in interventions if cultural insights are absent, this book includes case studies from across the Asia and Pacific regions –Bangladesh, Malaysia, New Guinea, Indonesia, Thailand, South Korea, Australia, New Zealand, Tuvalu and the Cook Islands. When Culture Impacts Health offers conceptual, methodological and practical insights into understanding and successfully mediating cultural influences to address old and new public health issues including safe water delivery, leprosy, Attention Deficit Hyperactivity Disorder and body image. It contains useful methodological tools – how to map cultural consensus, measure wealth capital, conduct a cultural economy audit, for example. It provides approaches for discerning between ethnic and racial constructs and for conducting research among indigenous peoples. The book will be indispensible for culture and health researchers in all regions.

• Discusses global application of case descriptions
• Demonstrates how a cultural approach to health research enriches and informs our understanding of intractable public health problems
• Covers methods and measurements applicable to a variety of cultural research approaches as well as actual research results
• Case studies include medical anthropology, cultural epidemiology, cultural history and social medicine perspectives

• Language: English
• Publisher: Academic Press
• Release date: Jan 25, 2013
• ISBN: 9780124159433

Book preview

1

When Culture Impacts Health

Jane Dixon¹, Cathy Banwell¹ and Stanley Ulijaszek², ¹The Australian National University, Canberra, Australia, ²Institute of Social and Cultural Anthropology, University of Oxford, UK

More complete understanding of the range of cultural influences on disease patterning will come as more frequent and profound interactions take place between the disciplines of medical anthropology and epidemiology, among others.

Trostle, 2005, p. 8

Rationale

In a context of growing populations, aging populations, and the rise of diseases of affluence, governments are increasingly concerned that future health care expenditures will be unsustainable. Thus, it is not surprising that disease prevention is high on national agendas. Making the job more difficult is the inevitability that disease control will always be a moving target. Infectious and chronic diseases emerge with changing ecologies, and the latter is an outcome to some extent of interactions between ever-evolving human genes and ever-changing environments. In this dynamic scenario public health leaders are questioning both the adequacy of population health research and the relevance of much of that research for developing effective interventions. As one of the pioneers of social epidemiology, Leonard Syme (2005, p. xi), said:

[In the last twenty years], we epidemiologists have suffered a whole series of embarrassing failures. … Our model is to identify the risk factors and share that information with a waiting public so that they will then rush home and, in the interests of good health, change their behaviours to lower their risk. It is a reasonable model, but it hasn’t worked. In intervention study after intervention study, people have been informed about the things they need to do, and they have failed to follow our advice.

He noted that the exigencies of daily life often hijacked intentions to behave more healthily; and in order to rectify epidemiology’s neglect of the fact that people have priorities in life beyond pursuing good health, Syme called on anthropologists and epidemiologists to collaborate more closely. In a context of the sedimentation of health risks among certain populations—inevitably the least powerful in society—another leading epidemiologist, Nancy Krieger (2001), called on social epidemiology to broaden its focus beyond identifying who is sick, and expend energy on examining who and what is responsible for population patterns of health, disease and well-being. She shared Syme’s concern about the need to understand and act on the pressure points that generate health behaviors.

One such pressure point concerns the genesis of cultural factors: ranging from individual biological traits, social group practices and rules, to globally circulating ideas and discourses. Thus it is timely that renewed attention is being paid to the proposition that culture can be causal, contributory, or protective in relation to ill health (Helman, 2007; Trostle, 2007; Hruschka and Hadley, 2008; Hahn and Inhorn, 2009).

We say renewed because in the mid-1800s, Rudolf Virchow, doctor, statesman, and anthropologist, proclaimed disease to accompany cultural loss (Virchow, 1848/2006). He argued that epidemics are warning signs against which the progress of states can be judged. More than a century later, and with many of the infectious disease epidemics of Virchow’s time remaining unconquered, lifestyle diseases (obesity, diabetes, lung and diet-related cancers) have joined a lengthy list contributing to the global burden of disease. Disconcertingly, less economically and socially powerful groups are more likely to experience multiple behavioral and disease risk factors (Lynch et al., 1997)—smoking, alcohol and drug abuse, poor nutrition—demanding investments in understanding the determinants that underpin the risks. In the absence of resource redistribution, including cultural capacity, their risk of unequal and unjust health status is also likely to persist across generations (Mackenbach, 2012).

There is widespread agreement that the reasons for inferior health outcomes are complex, involving socioeconomic factors (income, education, occupation), area-based factors (quality of water, sanitation, shelter, transport, nutrition), sociopolitical factors (gender, race, ethnicity), and sociocultural factors (values, rules, beliefs, behaviors). Culture forms part of the multifactorial etiology of disease operating in concert with social, economic, and political factors.

The primary aim of this book is then to encourage more sophisticated research designs, based on the inclusion of culture, however framed, in a range of public health research and intervention approaches in order to better explain and address contextual influences over population health behaviors. We provide researchers with conceptual and measurement tools to gain a more thorough understanding of the way culture helps to produce asymmetries in the abilities of individuals and social groups to define and realise their [health] needs (Johnson, 1986/1987, p. 39). At the same time, we want to avoid the situation where cultural explanations can be misused to blame people for their action or inaction. This situation arises when outsiders consider cultural matters to reflect ignorance or irrationality, rather than trying to understand local rationalities in relation to health and sickness.

Health behavior choices are shaped by belief and action systems, which arise in two ways. In part, they are based on local and historical understandings of disease, as well as the health systems available (e.g., Chinese complementary medicine, Ayurveda). They also result from interactions with environmental, economic, and political conditions, including government policies. Often overlooked are ways in which health policies can provide people with social status and material rewards for adopting certain behaviors (Farmer, 1999). For example, women who are the major food provisioners in many societies are enticed into labor markets through child-care subsidies and lowered benefits for stay-at-home women. While we might personally approve such initiatives, it must be recognized that the government’s actions are not simply economic in nature but also have significant repercussions for many facets of cultural life, whether they involve food, parenting, or gender relationships.

So what are we talking about when we refer to culture? Chapter 2 describes in greater detail how contested the term is within the field of anthropology, and other contributors to this book refer to their own struggles with the term.

Drawing from anthropology and sociology, we understand culture as operating like a blueprint guiding but not dictating what is imaginable, moral, and possible. Ideas, knowledge, language, discourses, and practices constitute a significant part of social activity. This array of different forms of culture does not arise from the ether but is promulgated by a variety of societal institutions, including religious and research bodies; government departments; the legal system; the system of production, exchange, and consumption; the kin, gender, and ethnic systems of authority; and the world of commerce. Individuals and communities also generate culture through initiating and practicing dialects, folk wisdom, and customary approaches to decision making, among other things. The resulting institutions, ideas, and practices that are generated change over time and are variable in their reach and effect depending on a people’s historical experience of new ideas as well as existing belief and local power systems. In short, culture is an ever-evolving guidance system, where the major actors may be in dispute about the legitimacy of what is being said and done.

Second, we understand culture as described above (sets of meaning-laden behaviors, beliefs, artifacts) to produce cultures, or groups of people who carry a common culture. Cultures are found at multiple levels: global, nation state, village/community, social, group, family, and individual levels. At the global level, there are adherents to the global rule of law, trade rules, financial system rules, and environmental treaties along with ideas shared through migration, technology, and the media. At the national level, governments enact societal level laws and policies that are intended to encourage particular behaviors and not others. At the same time, a nation’s citizenry inherits and adapts practices from their forebears while reproducing and incrementally altering their culture through embracing new ideas, practices, and technologies.

At the level of the social group, cultural systems may legitimize/encourage or rule out/constrain decisions about how, when, where, and what health-related actions to take and equally what happens at this level can also change the cultural system. Forty years ago, for example, violence against women was tolerated in many nations. Then the second wave of the women’s movement emerged to demand that the perpetrators of violence become subject to legal and community sanctions. Nevertheless, long-standing cultural norms and values leave women subjected to subtler forms of symbolic violence, such as the portrayal of women in pornography.

At the level of the individual, there is growing interest in the idea of human adaptability, or the ability of populations to adjust biologically, culturally, and behaviorally to environmental conditions. Biocultural anthropology of health and disease acknowledges different cultural models of disease, and although these are influenced by environmental conditions they operate independently as Chapters 16 and 19 in this book make clear. This strand of research has been particularly vibrant in small-scale and sometimes premodern societies that are deeply embedded in, and reliant upon, their physical environment (Maddocks, 1978).

Culture’s importance as a determinant of individual health lies in the way that ideas, discourses, and ways of acting become embodied—a part of the taken-for-granted habitus or the right way of doing things. Until there is a big jolt—an epidemic, or change in life circumstances like marriage breakdown—socialized routines dominate reflexive (self-conscious) approaches. The extent of routinized and novel behaviors typically varies depending on the socioeconomic circumstances of people. Traditional or relatively rigid thoughts and actions may persist among often less powerful groups, those less exposed to novelty, and those who are under threat from ecological collapse or resource scarcity (Gelfand et al., 2011), but this may not be a bad thing because some traditions can protect against health risks (many traditional diets are preferable to the industrial diets implicated in so many chronic diseases). However, the adoption of new ideas and practices can also be health protective, and it is important to identify under what conditions traditional and new behaviors are beneficial.

As important as it is to identify relevant cultural risk factors (ideas, knowledge, or traditions) (operating at each level), it is also important to identify the sociocultural processes that facilitate the transmission of the ideas, discourses, practices, and other material effects of people acting together. So our third understanding of culture is as a process, consisting of a variety of mechanisms to transmit cultural factors, which exposes some in the population and not others. Anthropologists and sociologists have identified key processes of social transmission, including emulation, mimesis, magic, socialization, diffusion of innovations, social network effects, and social status distinction (Rogers, 1962; Bourdieu, 1984; Taussig, 1993; Gerbauer and Wulf, 1995; Bell, 1999; Borch, 2005). Global cultures are becoming more common, enabled by global media, mass migrations, and technologies, which facilitate flows of ideas, norms, and practices from one society to another (Appadurai, 1996).

A primary task for culture-in-health researchers is to identify the pathways by which ideas and practices arise, circulate, and are adopted, transformed, and repudiated.

For example, the logic of infectious disease contagion is now being applied to the spread of chronic disease. In studies of lung cancer, obesity, illicit drug use, and alcohol-related illness there is growing acceptance that health-compromising ideas, emotions, and consumption practices are highly contagious and constitute relevant risk factors (Ferrence, 2001; Pampel, 2005; Christakis and Fowler, 2007; Cockerham, 2007).

With our three-part understanding of culture, we echo Susser’s (2004) call for the development of an eco-epidemiology, which considers multiple levels of causation and risks and exposures across time and space. Figure 1 summarizes our understanding of culture as shared systems of ideas, rules, language, and practices generated and transmitted within and across various levels of social organization, interacting with physical environments and biological status, and along the way influencing health experiences and outcomes.

FIGURE 1.1 The levels at which culture impacts health.

A second aim of this book is to provide greater insight into how public health might more effectively influence culture to diffuse or spread healthy lifestyles. Against a backdrop of policy failures to eradicate major health risks and to close the gap in health disadvantage and inequity, there is a growing push to incorporate insights from all the disciplines critical to understanding complex public health issues, such as epidemiology, anthropology, sociology, history, economics, biology, geography, and the policy sciences (Macintyre, 1994; Porter, 1999; Gesler and Kearns, 2002; Graham, 2002; Williams, 2003; Navarro and Muntaner, 2004; Commission on the Social Determinants of Health, 2008; Fairchild et al., 2010). The smoking epidemic is the most studied of the recent noncommunicable disease risk factors; yet, despite thousands of academic papers on the etiology of smoking and 40 years of state activity to halt cigarette smoking behavior, approximately one in five males continue to smoke in most Organization for Economic Cooperation and Development countries, and in Europe, is at historically high levels (Australian Institute of Health and Welfare, 2008; Gallet et al., 2009; Glover, 2012). There has also been a steady rise in obesity rates, and predictions about obesity-related premature death have been made (Peeters et al., 2003). In many of the world’s poorer countries infectious diseases coexist with growing prevalence of these noncommunicable diseases.

While we can predict different subpopulation’s relative vulnerability in terms of socioeconomic factors, these factors do not completely account for or explain people’s health behaviors. According to Thomas et al. (2004, p. 2050), [t]here is credible evidence suggesting that cultural norms within Western societies contribute to lifestyles and behaviours associated with risk factors of chronic diseases. This also applies to non-Western societies.

If cultural norms are contributing to the rise in health risks such as obesity and the persistence of smoking, then it follows that cultural forces need to be unleashed to counteract their present trajectories. Cultural processes are observable in the here and now as well as through the historical record. Understanding the history of the evolution of ideas and practices shows culture to be a battleground of contestations over what is imaginable and possible, with some societies having more mutable systems of belief and actions than others. Cultural history analysis provide valuable insights into cultural pressure points, including which groups will resist change.

It is important to recognize that producing evidence of cultural pressure points is often not a sufficient reason for action. The problem with cultural interventions is their propensity to become highly politicized; think the Nanny State discourse. While citizens rarely question the need for government to shape the economy, even if they disagree over specific interventions, many feel governments should not intervene in culture because matters of taste, religion, and everyday values are private matters. These arguments overlook the ways that, historically, the economic and cultural spheres intertwine. Governments cannot avoid intervening in culture when they introduce labor market policies, for example. Elaborating on this example we would argue that under the pressures of global economic agencies, national governments profoundly affect household cultural activities through their labor market policies. Different employment policies require different allocations of time and temporal rhythms, which then influence who is working, when and where, which in turn influences the cultural realm of eating. With long work hours or unsociable shifts, solo eating and eating convenience foods on the run become normalized or the new eating routine for busy working people. This particular style of eating is often framed as a modern social trend; however, equally it can be viewed as a modern instance of Virchow’s cultural disturbance that is contributing to weight gain because there is some evidence suggesting that eating together has health protective effects (Fischler, 2011). The disturbance in shared eating practices is an unintended outcome of government labor market policy, but is becoming part of the contemporary cultural context into which new generations are socialized.

Just as governments can unwittingly contribute to chronic disease risks, they can mitigate risks through regulations that foster a cultural change in attitudes and practices. In Australia bans on public smoking have contributed to an attitudinal change where most people (including smokers) find smoking in enclosed public spaces unthinkable. In another instance of the positive cultural shifts that can be unleashed by governments, we can point to equal opportunity legislation that regulates the most extreme forms of discriminatory practice toward women and ethnic minorities. In addition to governments, commercial firms, political parties, religious institutions, and social movements all contribute to the ideas and practices that constitute the cultural environment that individuals inhabit. In a previous book, The Seven Deadly Sins of Obesity, we reported on public health successes that have involved cultural shifts beginning in civil society prior to government intervention (Dixon and Broom, 2007). Examples include the gay community’s leadership on safe sex in response to HIV and AIDS, Mothers Against Drunk Driving and road rules in the United States, and the health community’s actions to the SIDS epidemiology. In each instance these groups intervened in the cultural realm to reinstate earlier safe health behaviors or to encourage the adoption of new behaviors.

The Book’s Orientation

This book is animated by a desire for greater public health effectiveness in relation to chronic and infectious disease risks, which are engulfing all nations. We hope to demonstrate how cultural perspectives enrich and inform understandings of intractable public health problems. In this way, we anticipate that there are lessons for nongovernment and government agencies as they grapple to design effective interventions to improve public health. In particular, the book reinforces the argument that understanding the complex array of social forces responsible for health and illness requires a true collaboration between disciplines to be successful (Janes et al., 1986; DiGiacomo, 1999; Weiss, 2001; Trostle, 2005; Hahn and Inhorn, 2009). The range of material in this book will be useful for expanding the repertoire of both medical anthropologists and social epidemiologists. Indeed, it has great potential to provide the theoretical background linking medical anthropology to social epidemiology and public health.

In particular, this book offers a companion text or reader for those keen to go beyond risk factor epidemiology, sometimes known as black box epidemiology with its narrow interpretation of what constitutes good research based on an understanding of causality. One of the critics of this type of epidemiology, E. Susser (2004), has called on health researchers to adopt a wider and richer framework. Part of the richer framework involves generating detailed insights into the contextual determinants of risk behaviors. Traditionally the terrain of medical anthropology and social medicine, a wider group of disciplines has been contributing to this endeavor of late, including social epidemiology, life course epidemiology, medical geography, health sociology, bio-anthropology, and public health history. Since the late 1980s, this multidisciplinary cast has:

• Greatly enhanced insights into the embodiment of social structure: how social status hierarchies, for example, create psychosocial stresses that are unhealthy

• Shown how risks can accumulate due to repeated and successive physical and social environmental exposures, and how risks change according to life stages

• Indicated the genetic influence over behavioral dispositions, and the dissonance between behavioral dispositions acquired over millennia and contemporary human environments

• Widened the appreciation of the transmission of culture through the application of social network theories

• Revealed how public health interventions can fail because the incentives for behavior change are at odds with prevailing cultural systems

The Book’s Structure

Section A, Research Approaches, contains four chapters from leading international authorities in their respective fields: health sociology, medical and bio-anthropology, cultural anthropology, and field-based epidemiology. They set out their perspectives on the history and role of culture-in-health research, pointing to a century’s worth of attempts to bring the hard-to-quantify aspects of lived experience to the analysis of health and illness. They also reveal what is lost in interventions if cultural insights are absent.

Section B, Local Tales, contains 15 chapters that bring together elements of one or more of the intellectual currents described above. Each case study articulates its methods and many reflect critically on any deficits. Part 1 provides examples from industrial and postindustrial societies, which are among the more wealthy nations on earth: Australia, New Zealand, and South Korea. These case studies focus on marginalized and disadvantaged populations and attribute part of the marginal status and poor health outcomes to culturally insensitive medical and social systems. Part 2 focuses on economically transitioning societies in South East Asia and the Pacific: Indonesia, Malaysia, Bangladesh, Papua New Guinea, the Cook Islands, and Tuvalu. These case studies shine a particular focus on human society—physical environment interactions and cultural struggles around long-standing versus modern ways of living. The chapters in Parts 1 and 2 highlight the effects of the ongoing process of the medicalization of societies, and detail the effects of maintaining lay knowledge in the face of dominant medical knowledge. The chapters in this section reveal a diversity of cultural factors, actors, and processes.

Several chapters showcase the importance of anthropological approaches to improving the efficacy of interventions. Again a critical approach is adopted, where failures as well as successes are noted. This section advances the intellectual rationale for teams of epidemiologists and social researchers, including anthropologists, to work together from the beginning on any public health research.

Section C, Methodological Lessons, contains eight chapters that address in greater detail the methods used by Section B authors as well as introduce some additional tools. Among the research approaches included are the interrogation of epidemiology datasets by relevant sociocultural theories, cultural economy audits of social trends that are plausibly linked to health trends, ethnographic approaches to longitudinal studies of health and well-being, cultural consensus modeling to determine the extent of common values, and elite interviewing as a basis for social network mapping and for gathering the cultural history of a health policy or intervention. Two chapters detail the highly important and sensitive issues of ethnic identification and respect for alternative practices that arise when research is conducted among first people in postcolonial western societies such as Australia and New Zealand. The section concludes with a chapter describing multidisciplinary team work.

The Conclusion section provides a synthesis of the conceptual, methodological, and intervention lessons that emerge across the book. These are lessons that apply to a vast array of settings in which culture-in-health research is required.

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Part A

Research Approaches

Chapter 2 Antecedents of Culture-in-Health Research

Chapter 3 Biological and Biocultural Anthropology

Chapter 4 Toward Cultural Epidemiology: Beyond Epistemological Hegemony

Chapter 5 The Cultural Anthropological Contribution to Communicable Disease Epidemiology

Chapter 2

Antecedents of Culture-in-Health Research

Dorothy Broom¹, Cathy Banwell¹ and Don Gardner¹, ², ¹The Australian National University, Canberra, Australia, ²Universitaet Luzern/University of Lucerne, Switzerland

Introduction

Scholarly and practical interest in the relationship between the health of populations, variously defined and contested, and the sociocultural realm has a long and distinguished history, under such headings as social medicine, community health, medical anthropology, medical sociology, sociology of health and illness, and social and cultural epidemiology. The boundaries between these various categories are blurred at many points, and observers often use the terms interchangeably. This brief discussion is designed to highlight the characteristic emphasis of each rather than to define clear distinctions. The comments that follow sketch activity during the twentieth century, although theoretical and applied origins could be traced across hundreds of years.

Social Medicine

The origins of this enterprise are often attributed to Rudolf Virchow, a nineteenth century Prussian pathologist and clinical researcher who famously stated that

Medicine is a social science, and politics is nothing else but medicine on a large scale. Medicine, as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution: the politician, the practical anthropologist, must find the means for their actual solution.

Virchow, nd

Virchow’s clarion call to doctors to become the natural attorneys of the poor was taken up with great commitment in the early decades of the twentieth century by doctors in southern Africa, several of whom founded the Pholela Health Centre in KwaZulu Natal in 1940. Emily and Sidney Kark, Sidney and Gwen Sax (later significant influences on the Australian community health movement), John Cassel, and Mervyn Susser played a range of roles in the foundation and development of the visionary holistic service for southern Africa’s most vulnerable population, combining primary medical and a wide range of other health and social services under one roof.

The distinctive focus on the links between society and health were articulated by the UK Society for Social Medicine (founded in 1950) who define social medicine on their Web site as

… the study of health in its widest sense. It recognizes the broad determinants of health— income and poverty, education, environmental factors such as housing and transport—as well as health care and genetic influences.

… The nature of social medicine requires a multi-disciplinary approach to the development of scientific knowledge. The disciplines involved include medicine, epidemiology, statistics, economics, social science and many others.

Much like the World Health Organization (WHO) Commission on the Social Determinants of Health decades later, social medicine is positioned at the intersection between scholarly research and practical application, and makes no claim to value neutrality or disciplinary separation. Instead, it articulates fundamental principles:

• Social and economic conditions profoundly impact health, disease, and the practice of medicine.

• The health of the population is a matter of social concern.

• Society should promote health through both individual and social means (Rosen, 1974).

These perspectives continue to be expressed in the work of famous institutions and researchers, including the Department of Global Health and Social Medicine in the Harvard Medical School whose Web page explains that it applies social science and humanities research to constantly improve the practice of medicine, the delivery of treatment, and the development of health care policies locally and worldwide.

Medical Anthropology

Contributing substantially to social medicine, medical anthropology emerged initially from ethnographic research, often in less developed nations or among aboriginal inhabitants of colonized nations. The American Anthropological Association’s Society for Medical Anthropology Web page defines their enterprise (in 2010) as:

… a subfield of anthropology that draws upon social, cultural, biological, and linguistic anthropology to better understand those factors which influence health and well being, … the experience and distribution of illness, the prevention and treatment of sickness, healing processes, the social relations of therapy management, and the cultural importance and utilization of pluralistic medical systems.

As part of this enterprise, medical anthropology includes, among other things, the study of health disorders that may be self-defined or community-defined, including those not validated as real by biomedical epistemology. This often raises questions about biomedicine’s claim to ultimate authority on the nature of disease. It also critiques medical research and practice for being largely free of theoretical commitments, and often turns its research gaze back onto medicine