British Medical Bulletin 69:1-7 (2004)
Oxford University Press
Preface |
Preface
Cultures of health and illness have always been in existence, ever since the first human expressed the first symptoms of illness, and their first companion endeavoured to help or heal them. Groups of people, defined in social or geographical terms, developed patterns and processes of communicating, classifying and treating ill health. An ancient Egyptian had their particular beliefs and practices surrounding health and illness, as did Viking warriors and British Victorian women.
In terms of academic scholarship, the cultural aspects of health and illness were initially investigated by anthropologists, who intrepidly ventured from their ivory towers in the industrial world to observe the cultural practices of ‘primitive’ peoples in ‘exotic’ locations, returning to their colleges to write up their theoretical treatises. ‘Culture’ was from this viewpoint those aspects of different societies that emphasized their otherness from the home society1. This focus on cultural difference—together with sometimes explicit claims regarding the service that an ahistorical understanding of ‘native’ beliefs and customs could provide colonial administration—has led some to characterize early anthropology as an imperial discipline1. A critique of such an approach lies at the heart of contemporary anthropology, as is clear from several of the contributions to this book (see for example chapters by Singer, Dressler and Kirmayer). The contemporary anthropological gaze is as likely to be turned on health professionals and medical power as it is on less powerful ‘others’—see for example Sinclair’s observations on evidence-based medicine in the specialism of psychiatry in Chapter 14.
In the second half of the 20th century, sociologists also took up the theme of health and illness. Their focus can be divided into two historical parts2—the ‘pre-modern’, including studies of the interconnection of health and social problems in western Europe and the United States, and the ‘modern post-war period’ in which medical sociology has established itself as a profession. The remit of medical sociologists now includes the study of the social context of health and illness and also health care and health services (both formal and informal), associated social relations and institutions and the impact of social, economic and cultural factors upon health. Medical sociology has followed the lead of the discipline of sociology in that particular attention is paid to experiences of those seen by some to be on the margins of society—the stigmatized, the mentally ill, people with impairments and therefore experiencing ‘disability’, ethnic minorities, and others (in addition, of course, to the ‘ill’, more generally). In this vein, within this volume two chapters focus on issues pertinent to the health of migrants (see chapters by Maingay and Thomas, and Bhugra) and Geronimus tackles the issue of teenage childbearing.
|
In formal public health disciplines, references to cultural difference have long underlain explanatory models for health disparities between countries, or between ethnic and social class groups within countries. These approaches have been criticized for simultaneously under-appreciating the structural determinants of such health differences, while propagating stereotypical views of supposedly homogeneous and static group characteristics3,4. Alternative accounts of the determinants of population health, focusing on economic change (see chapters by Szreter and Dorling), the social environment (see Kunitz and Charlesworth et al) and political economy (see chapters by Singer and Dorling) avoid both these limitations.
Even more recently within medicine itself, there has been recognition of the existence of the role of ‘culture’ and of its relevance to understanding, and improving, medical practice. A recent key policy document from the General Medical Council in the UK, ‘Tomorrow’s Doctors’ laid out recommendations for the undergraduate medical curriculum and included reference to the social and cultural:
"Graduates must understand the social and cultural environment in which medicine is practised in the UK. They must understand human development and areas of psychology and sociology relevant to medicine ... They must understand a range of social and cultural values, and differing views about healthcare and illness"5.
But what do we mean by ‘culture’? It is culture that is generally considered to set us apart from animals and make us human. When social scientists refer to culture, they mean the way of life and the patterns of behaviour of a society, or of groups within that society. Culture includes such things as how people organize their patterns of work, how they practice religion, customs of marriage and family life, how they prepare and eat their food and so on. Social scientists study the cultural practices of groups of people (social classes, ethnic groups, people at different stages of life), people in different social roles (mothers, carers, the ill) and organizations or institutions (the state, religions, professions).
|
‘Culture’ becomes more apparent when there is contrast or change and when our everyday actions and thoughts are challenged. A range of chapters in this book employ this method. Chapters consider what happens when people move from one culture to another (see chapters by Maingay and Thomas, and Bhugra), the impact of the movement of people (and infection) across time and place (Cliff and Haggett), and the emergence of new cultural forms (see chapter by Wessely and Greenhalgh).
How this volume is organized
The chapters in the volume have been organized into three sections. The first section—cultural and social perspectives on health and illness—includes chapters that address issues of how health and illness are conceptualized, and how a cultural perspective differs from, and enhances, a biomedical view. Here we also cover issues of how health is related to social organization, specifically with respect to the process and implications of social hierarchies, status, and forms of social cohesion and collectivity.
|
First, Merril Singer takes a classic medical anthropological approach, contrasting the biomedical perspective of disease as having a finite and objective reality discoverable through scientific endeavour, to an anthropological approach which recognizes both the social origins of disease and the social processes involved in the labelling of disease by doctors and other health professionals.
William Dressler addresses the social origins of a particular health outcome: raised blood pressure. Hypertension is, indeed, one of the classic ‘diseases of civilization’, with large differences being seen between countries at different levels of economic development in both prevalence of hypertension and the degree to which blood pressure levels increase with age6. Singular hypotheses such as those focusing on sodium intake, or general (indeed inchoate) notions of ‘stress’ have not proved adequate, but Dressler develops a more nuanced view of cultual congruity and the manner through which this influences behavioural and psychological dispositions that could affect blood pressure.
Laurence Kirmayer addresses the cultural diversity of healing across the world. Healing is recognized here as not only a physiological process within the biomedical paradigm, but also as embodying symbolic elements, with physiological, psychological and social effects; participation in specific healing rituals may contribute to individual as well as collective identity.
Two chapters then address issues central to current controversies in the field of social epidemiology. Simon Charlesworth and colleagues address polarizing health inequalities in life expectancy by social class in Britain by examining the social and psychosocial consequences of economic change. Theirs is an in-depth study of the interpersonal experience of class, how it feels to be constantly socially degraded, excluded and disrespected. Similarly, Kunitz examines a mechanism linking individual sense of self to broader social (and biological) consequences—the concept of social capital. This is one of the most fashionable current concepts in social epidemiology, yet there is no agreed definition of what social capital is, or indeed of whether it should even be talked of as an entity. Kunitz addresses the historical specificity of the concept and provides a powerful complementary approach to that provided by Simon Szreter and Michael Woolcock in their recent authoritative interpretation of the appropriate role of social capital in health discourse7.
In the second section of the book, authors explore historical and geographical perspectives on health and illness. Simon Szreter explores the central issue of how industrialization influences health. The historical picture has usually—but not always—been of initial worsening of health followed by long-term improvements. He develops the notion that appropriate political processes could lead to the avoidance of what he refers to as the four Ds of rapid economic growth—disruption, deprivation, disease and death—and produce ‘gain without pain’ as far as health outcomes are concerned. Cliff and Haggett include a spatial dimension in their historical analysis. They consider the effective ‘collapse’ of geographical space over the last two centuries—brought about by technological developments in transportation and the resulting profound effects on the circulation of human populations and on the transfer of infectious diseases.
Approaches to spatial differences in health in social epidemiology have increasingly focused on methodology—in particular multilevel modelling8—and attempts to demonstrate that there are contextual influences of the small areas where people live over and above the compositional aspects of the characteristics of the people who live within these areas9. Dorling spectacularly spins the microscope around and looks through the other end at the big picture of geographical differences (and similarities) in health, based around considerations of power as the major differentiating force. Continuing the geographical theme but with a more specific focus, Maingay and Thomas consider the health effects for displaced persons and Bhugra considers a battery of concepts which can be used to understand the mental distress of migrants.
The third section of the volume we have called ‘contemporary topics and new horizons’. Here there are chapters which address issues that have aroused recent attention as health issues—MMR, teenage childbearing and lead poisoning in children. Mike Fitzpatrick provides a fascinating account of the recent MMR controversy, using the concepts of risk, choice and chance as a framework for unpacking recent events, reactions and actions. Arline Geronimus tackles the issue of teenage childbearing in the US context in a fine example of sociological critical analysis. She points out that patterns of fertility-timing are culturally and historically variable and asserts that postponing childbearing beyond the teenage years is now adaptive practice for European Americans, whereas early fertility-timing patterns may constitute adaptive practice for African American residents of high-poverty urban areas. Didier Fassin takes as his subject the culture of public health as a human activity which transforms natural phenomena into cultural facts, using the history of lead poisoning in France as a case-study.
In this last section, there are also chapters looking with a fresh perspective on the culture of medical professionals—the emergence of evidence-based medicine in medical teaching—and a particular cultural expression amongst those who make use of the services of the medical profession. Simon Sinclair views the training of doctors in what is appropriate evidence on which to base medical therapeutics as a ritualized process, aimed at recuperating what could be a challenge to clinical practice. The replacement of the (singular and concrete) patient by the (multiple and abstract) research report as the focus of postgraduate medical education may on the surface be apparently revolutionary, but, Sinclair demonstrates, is easily incorporated into conventional (Western) medical thought with little foundational threat. Wessely and Greenhalgh alternatively consider the context of primary care, and the GP confronted by the emerging socio-cultural phenomena of what they term ‘healthism’—the beliefs, behaviour and expectations of the articulate, health-aware, and information-rich middle-classes.
Finally, we close with a chapter by Fatimah Jackson on genetic variation and health, a topic that will no doubt be much discussed as genetic technologies develop, but which is also a prime example of the way in which culture, health and medicine are intimately and intricately connected. Jackson suggests that a historical view of population formation is required, rather than a static and ultimately unsupportable view of ‘racial’ groups with different genetic makeup contributing to health disparities.
In producing this volume, we hope that we have succeeded in bringing together a diverse (and occasionally divergent) range of essays, each presenting their own means of exploring issues of culture and health. We have not aimed to produce a comprehensive overview of current themes and perspectives, but rather we have aimed to reflect some central issues and key debates. We hope that by providing examples of critical thinking around cultures of health and cultures of illness that understanding of medical practice, and perhaps practice itself, may be in some way enhanced.
References
- Stauder J. The "relevance" of anthropology to colonialism and imperialism. Rad Sci J 1974; 1: 51–70
- Bloom S. The Word as Scalpel: A History of Medical Sociology. Oxford; Oxford University Press, 2002
- Davison C, Frankel S, Davey Smith G. The limits of lifestyle: re-assessing "fatalism" in the popular culture of illness prevention. Soc Sci Med 1992; 34: 675–85[CrossRef][Web of Science][Medline]
- Lambert H, Sevak L. Is "cultural difference" a useful concept? In: Kelleher D, Hillier S (eds) Researching Cultural Differences in Health. London: Routledge, 1996
- Tomorrow’s doctors: recommendations on undergraduate medical education. General Medical Council. April 2003. http://www.gmc-uk.org/med_ed/tomdoc.pdf
- Eyer J. Hypertension as a disease of modern society. Int J Health Serv 1975; 5: 539–58[Web of Science][Medline]
- Szreter S, Woolcock M. Health by association. Social capital, social theory and the political economy of public health. Int J Epidemiol 2004, in press
- Gatrell A, Loytonen M. GIS and Health. London: Taylor and Francis, 1998
- Macintyre S, MacIver S, Sooman A. Area, class and health: should we be focusing on places or people? J Soc Policy 1993; 22: 213–34[Web of Science]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||