The Lancet Commissions

www.thelancet.com Vol *** November 1, 2014 1607

Culture and health

A David Napier, Clyde Ancarno, Beverley Butler, Joseph Calabrese, Angel Chater, Helen Chatterjee, François Guesnet, Robert Horne, Stephen Jacyna, Sushrut Jadhav, Alison Macdonald, Ulrike Neuendorf, Aaron Parkhurst, Rodney Reynolds, Graham Scambler, Sonu Shamdasani, Sonia Zafer Smith, Jakob Stougaard-Nielsen, Linda Thomson, Nick Tyler, Anna-Maria Volkmann, Trinley Walker, Jessica Watson, Amanda C de C Williams, Chris Willott, James Wilson, Katherine Woolf Executive summary

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 scientifi c 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 defi ned by measures of clinical care and disease. Health can be defi ned 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 scientifi c practice to this distinction, esp- ecially for macrocultures and large societies, which defi ne 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 ram- ifi cations 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 fi nancial, 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 bio- medical—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 fi nancial 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

defi ne our understanding of human wellbeing. Where economic limitations dictate what is feasible,

socioeconomic status produces its own cultures of sec- urity and insecurity that cut across nationality, ethnic background, gender orientation, age, and political persuasion. Socio economic status produces new

cultures defi ned 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 con- ditioned by a sense of social security that is only partly fi nancial.

Lancet 2014; 384: 1607–39

Published Online

October 29, 2014

http://dx.doi.org/10.1016/

S0140-6736(14)61603-2

See Editorial page 1549

See Perspectives page 1568

Anthropology (A D Napier PhD,

J Calabrese PhD,

U Neuendorf MSc,

S Zafer Smith MSc,

A Macdonald PhD,

A Parkhurst PhD), Heritage

Studies (B Butler PhD),

Biology and Museums

(H Chatterjee PhD), Hebrew and

Jewish Studies (F Guesnet PhD),

School of Pharmacy

(Prof R Horne PhD), Institute for

Global Health (R Reynolds PhD,

C Willott PhD), Centre for the

History of Medicine

(S Jacyna PhD), Division of

Psychiatry (S Jadhav MD),

Sociology (Prof G Scambler PhD),

School of European Languages,

Culture and Society

(Prof S Shamdasani PhD),

Scandinavian Studies

(J Stougaard-Nielsen PhD),

Museums and Collections

(L Thomson PhD), Civil

Engineering (Prof N Tyler PhD),

Clinical, Educational and Health

Psychology (A-M Volkmann MSc,

A C d C Williams PhD),

Philosophy and Health

(J Wilson PhD), and Medical

School (K Woolf PhD), University

College London, London, UK;

Department of Education,

King’s College London, London,

UK (C Ancarno PhD);

Department of Psychology,

University of Bedfordshire,

Bedfordshire, UK (A Chater PhD);

and International Longevity

Centre, London, UK

(T Walker MSc, J Watson PhD)

Correspondence to:

A David Napier, Anthropology,

University College London,

London WC1E 6BT, UK

ac9vr0@r.postjobfree.com

Systems of value

are political, moral, religious,

economic, or social systems of

meaning, either overtly

expressed or taken for granted.

The Lancet Commissions

1608 www.thelancet.com Vol 384 November 1, 2014

In this Commission, we review health and health

practices as they relate to culture, identify and assess pressing issues, and recommend lines of research that are needed to address those pressing issues and

emerging needs. We examine overlapping domains of

culture and health: cultural competence, health

inequalities, and communities of care. In these three domains, we show how inseparable health is from

culturally aff ected perceptions of wellbeing. After examination of these key domains, we identify

12 fi ndings in need of immediate attention:

• Medicine should accommodate the cultural con-

struction of wellbeing

• Culture should be better defi ned

• Culture should not be neglected in health and

health-care provision

• Culture should become central to care practices

• Clinical cultures should be reshaped

• People who are not healthy should be recapacitated within the culture of biomedicine

• Agency should be better understood with respect to culture

• Training cultures should be better understood

• Competence should be reconsidered across all

cultures and systems of care

• Exported and imported practices and services should be aligned with local cultural meaning

• Building of trust in health care should be prioritised as a cultural value

• New models of wellbeing and care should be identifi ed and nourished across cultures

We believe that these points are imperative to the advancement of health worldwide and are the greatest challenges for health. Together, they constitute an agenda for reversal of the systematic neglect of culture in health, the single biggest barrier to advancement of the highest attainable standard of health worldwide.

Culture and health

Introduction

On Feb 6, 2013, a crowd gathered outside London’s

Queen Elizabeth II Conference Centre across from

Westminster Abbey. They were there to hear the verdict of the Mid Staff ordshire NHS Foundation Trust

commission that investigated the causes of hundreds of preventable patient deaths in just one NHS hospital system in the West Midlands between 2005 and 2009. On the day of the announcement of the commission’s

fi ndings, aggrieved families, policy makers, and mem- bers of the press assembled to hear the results. They all wanted to know on whose shoulders the blame for this travesty could be placed. As the crowd listened, the commission’s lead attorney, Robert Francis, announced that no specifi c group or person could be held accountable for such malpractice. The real villain was culture—culture caused these crimes of neglect to occur, and the culture of the UK’s NHS was responsible.

As one newspaper put it: “The victims and their

families were not happy. The culture of the NHS is not something that can apologise and try to atone. The culture of the NHS cannot be punished for its misdeeds. They wanted to see someone held to account. But the verdict was clear. ‘It was’, Francis announced, ‘not possible to castigate: failings on the part of one or even a group of individuals’. There was no point in looking for ‘scapegoats’. The guilty party was the ‘culture of the NHS’. It was the culture that had ignored ‘the priority that should have been given to the protection of

patients’. It was the culture that ‘too often did not consider properly the impact on patients of actions being taken’.”2

However, members of the Care Quality Commission,

the group that oversees health quality in the UK, were subsequently charged with participating in a “tick-box culture”, “presiding over a dysfunctional organisation” with a “closed culture”,3 and were themselves partly held responsible for the failings of the Mid Staff ordshire Trust. Culture, here, supersedes direct actions of nurses and doctors, hospital boards, local and regional health regulators, health policy makers, local and national politicians, and even referring family doctors as sources of blame. Indeed, responsibility is extended to the culture of the very commission established to regulate the eff ect of cultures of practice on health.

Nowadays, in assessments of health and health-care provision, to blame culture, however defi ned, is not uncommon. Culture, as this example shows, cannot be merely equated with ethnic group or national

allegiance. We all participate in locally defi ned forms of behaviour that not only produce social cohesion, but that limit our ability to see the subjective nature of our values, our perceived responsibilities, and our

assumptions about objective knowledge. In this

context, the responsibilities of doctors and health sys- tems, and the priorities of policy makers and

researchers, are also collective behaviours based on social agreements and assumptions—ie, on culture.

Such examples show the degree to which culture

cannot be ignored by science-oriented clinicians, disease specialists, and policy makers, making clear the need to understand the eff ect of culture, however defi ned, on care for one another in the 21st century. To understand culture and what it means is crucial to improvement of health, which is why disciplines that once focused solely on the study of other societies are, now, central to our future health and wellbeing. Today, anthropological and medical humanities approaches to health and wellbeing are necessary to reshape our under standing of how we conceptualise health and what makes us healthy.

What is culture?

The anthropologist Robert Redfi eld once elegantly defi ned culture as “conventional understandings, mani- fest in act and artefact”.4 This defi nition is useful because Cultural competence

is defi ned as awareness of the

cultural factors that infl uence

another’s views and attitudes, and

an assimilation of that awareness

into professional practice

The Lancet Commissions

www.thelancet.com Vol 384 November 1, 2014 1609

it focuses not only on shared understandings, but also on practices that are based on those under standings and that make sense of beliefs held in common with others. Culture, therefore, does not equate solely with ethnic identity, nor does it merely refer to groups of people who share the same racial heritage.

Redfi eld’s defi nition is also helpful because it does not imply that all members of a group that share

languages, practices, and overt expressions of belief automatically share a given value, nor that local ideas can be readily translated across or even within a given group. For example, we can say that a particular society has con ventional knowledge about medicinal plants, but clearly this fact does not imply that such knowledge is evenly distributed between all members of that

society. Further more, local healers could hold specialist knowledge, but the benefi ts of that knowledge would be available to anyone who visits them for assistance. Moreover, the eff ects of that knowledge could vary widely across encounters with those healers, and what that knowledge suggests could also vary between

various healers themselves when, say, they question a fi nding or diagnosis. The same applies, of course, to surgeons, nurses, and dentists, and so on. Their

practices and values vary broadly, even in western Europe and the USA, where biomedicine is sometimes thought to be uniformly practised. Germans might

defi ne low blood pressure as an illness as much as a health benefi t; North Americans might use antibiotics to excess; and French people might spend government health funds on spas and homoeopathy.5

To say that culture is about shared conventional

understanding does not, however, imply that the cultural dimensions of the behaviours of any group of people are always subscribed to or overtly understood from within. For example, a group may perceive itself to care for the elderly while failing to address the actual needs of ageing. Moreover, members can regularly—and

wrongly—assume that their own practices are universal, rather than particular. Monotheists, for instance, might customarily think of religion as a belief in God, whereas for many people, religion is not the belief in any single, omniscient being at all. This example is a social

convention—something widely evidenced (even ass-

umed to be universal), but not often consciously

questioned or critically examined. Cultural systems might, therefore, not be overtly expressed, but their eff ects can be ubiquitous, including in daily scientifi c practices. Not only hospitals, but universities, scientifi c laboratories, global health charities, and government agencies all have their own cultures, although they might seem less obviously cultural than the kinds of cultures anthro pologists traditionally study. However, because they are sometimes more covert, their un-

examined eff ects might actually be greater.

More than a century ago, the sociologist Émile

Durkheim separated empirical facts (what we see and evidence) from social facts (what we assume when

our beliefs remain unchallenged).6 For Durkheim, the things we take for granted are founda tional to our existence, even if, or perhaps because, we do not always recognise them. They transcend our capacity for self- criticism, yet exercise a continuing eff ect on us that is inversely proportional to our awareness of them. Indeed, groups of people rarely believe that their moral

perspectives are relative, and their awareness of how much their values are cultural only becomes clear when those values diverge from, or are in confl ict with, other values that they do not agree with.

The eff ect of culture might therefore seem overt

when a clinician attempts to care for someone from another society, but when we think of how culture

aff ects behav iours in a hospital, we might not view such activities as cultural in nature. When we speak of, for example, the silent majority, we are referring to shared values and categories of thought that survive in a largely uncritical manner; this silent majority is made up of the beliefs, habits, ways of life, ideas, and values of a majority that might not feel the need to express these values overtly because they are not overtly

challenged. For this reason, cultural values can become more obvious when members of a group are faced with practices and beliefs that vary substantially from their own. Culture is made up of not merely those variable behaviours and practices that a group understands

itself to possess and articulate daily, but those that are covert and taken for granted. Accord ingly,

anthropologist Fredrik Barth once meta phorically

called culture an empty vessel—ie, a concept defi ned at its peripheries.7 The vessel’s walls are tangible—they separate inside and out, and give shape to contents that might be less easily defi ned.

Most importantly, culture is a dynamic concept—

sometimes overtly expressed, sometimes not openly

defi ned. For example, citizens might rally around national identity in times of confl ict, but happily return fl ags to their cupboards in times of peace. Likewise, they might fundamentally believe in human equality, but participate actively in prestige hierarchies in their places of work. Because it is often taken for granted, culture as a category of inquiry is crucial to the experience of health and wellbeing, and the provision of health care.

Culture, then, can be thought of as a set of practices and behaviours defi ned by customs, habits, language, and geography that groups of individuals share. As the UN Educational, Scientifi c, and Cultural Organization

(UNESCO) affi rms8 in its adoption of anthropologist Edward Burnett Tylor’s 1870 defi nition of culture,9 we need to fi nd ways to develop a complex understanding of how customs, moral values, and belief systems manifest themselves in particular settings over time. Here, part- icularly, a medical humanities approach could be used to reshape medicine and health care.

Prestige hierarchies

are hierarchies created by real or

perceived diff erences in status

and authority, and acted out in a

defi ned environment, such as a

clinic or hospital

The Lancet Commissions

1610 www.thelancet.com Vol 384 November 1, 2014

However, the diffi culty of acknowledging the impor- tance of culture does not alone enable us to recognise our own cultural assumptions. Indeed, the hardest thing to know in a relative and comparative sense might be one’s own culture: what anthropologists call the

anthropological paradox. On the one hand, we believe that it takes one to know one; whereas, on the other, we acknowledge that the hardest thing to know is one’s own culture—ie, to critique objectively the subjective nature of our own practices.10,11 This diffi culty accounts for why culture remains, for many, a vague concept. By

defi nition, being immersed within a culture can be hard to recognise.

This dimension of culture is seen in the initial NHS example, and is crucial to our major claim: the systematic neglect of culture in health and health care is the single biggest barrier to the advancement of the highest

standard of health worldwide. Although we accept, along with the Francis Commission,12 the accountability of culture for clinical malpractice, we also suggest that examination of culture holds the key to good practice. Not only are the things we fi nd most diffi cult to examine the things we take for granted.When a society’s own objectivity is compromised by local practices and covert understandings, we begin to understand why culture matters in ways that aff ect us all.

We believe the time has come to revise common views of culture as overtly shared and largely un scientifi c ideas and practices. Culture can as much concern what we take for granted and do not critique—what we

assume is universal—as what we understand at the level of social diversity. We therefore recommend the

following defi nition of culture:

The shared, overt and covert understandings that

constitute conventions and practices, and the ideas, symbols, and concrete artifacts that sustain conventions and practices, and make them meaningful.

Why culture matters

In 1952, the French anthropologist Claude Lévi-Strauss led a study13 commissioned by UNESCO to address the issue of racism and the threat that it posed to world peace and stability. In the period after World War 2, when colonial values were still common, the project provided a direct attack on ethnocentrism and its assumptions about the superiority of one society over another. Lévi-Strauss

“warns against genetic determinism, reveals the fallacies of ethnocentrism and facile cultural evolu tionism, defends the rights of small societies to cultural survival, and revels in the intricacies of the symbolic systems of societies to most of his readers”.13,14 Embedding these concerns into a key UNESCO document by a leading

anthropologist assured that the idea of culture would inform contemporary views of multiculturalism, cultural competence, and the value of social diversity. UNESCO’s perspective on cultural rights became the foundation of how health rights are now defi ned multiculturally. But to defend local cultures, and especially to appreciate how culture aff ects local ideas about health and related health outcomes, is not always easy. Since Lévi-Strauss’ report, UNESCO has struggled to mediate between the need for universal human equality and the right to harbour diverse worldviews, and it has been criticised for its perceived ambivalence. Indeed, its policies (embodied in its 1995 report)15 reignited the right-to-culture debate by promoting “a relativistic view of development and a universalist view of ethics”.14–16 In short, the diffi culty with respecting local diff erences while promoting health universalism is that under such conditions, culture can be used “to legitimise not just exclusiveness, but exc- lusion as well”.14 Apartheid, for instance, is an intolerable form of multiculturalism—separate but unjust, rather than separate and just.17

Although Lévi-Strauss’ document13 provided a basis for decision making about culture, no-one knew at that time how globalisation would aff ect the dissolution of cultural diversity. The 1950s was the era of salvage anthropology, in which anthropologists were charged to record dying cultures and their local social practices. At that time, people needed to recognise the benefi ts of indigenous knowledge—of how surgical practices, for instance, might be advanced through understanding the Amazonian use of curare to paralyse muscle tissue.

But as globalisation continues, cultural diversity decreases, denying us not only the benefi ts of genuine diff erences, but also the diff erent kinds of knowledge that characterised humanity in former times. Many of the estimated 6000 languages still spoken across the world are rapidly disappearing. Many are now only spoken by a handful of people, and a unique mother tongue dies every two weeks.18 The failure to preserve cultural diversity might not only be incalculable, but also rob humanity of the very alternatives it so desperately needs—not only from the standpoint of indigenous knowledge about the natural world and the cures such knowledge might hold, but also in terms of models of cooperation and trust that have been lost on modernity. As cultural diversity and biodiversity give way to global homogeny, both other ways of thinking and potentially important ethnopharmacological resources are jeopardised.

Nowadays, issues not recognised when Lévi-Strauss

wrote for UNESCO13 aff ect how we see the benefi ts of diversity. There was, for instance, no way of knowing how indigenous rights issues would come to be legally tied to court cases involving the return of indigenous property,19 or of anticipating how new defi nitions of culture would encourage racial use of biological markers to establish indigeneity,20 or of predicting how both would contribute to contemporary stereotyping of health-related behaviours by well-intentioned clinicians and culture mediators working to improve clinical competence.21,22 Because of these complex diffi culties, many people now maintain that we no longer need Lévi-Strauss’ form of structural anthropology, nor the idea of autonomous The Lancet Commissions

www.thelancet.com Vol 384 November 1, 2014 1611

cultures, to understand, account for, and acknowledge how meaning is constructed locally.23,24 After all, how do we engender the moral trust needed to cross ideological boundaries, if not by faith in what the Brundtland report in 1987 called “our common future”—ie, by a focus on our uniformity rather than our diversity?25 Furthermore, what constitutes culture in a globalised world where diff erences are often only annoyances to be ameliorated and levelled?

For many people concerned about global health,

culture is less important than addressing political and socioeconomic inequality, even perhaps a thing best de-emphasised, if not wholly forgotten. We completely disagree. Worldwide equality can only be achieved by recognising cultural systems of value and countering the idea that local cultures are obstacles to worldwide equality. Indeed, a failure to acknowledge culture leaves its negative eff ects unaddressed and its positive potential for providing new models of thinking unrealised.

Ignoring culture prevents each person from feeling like he or she belongs to a local moral world.

Culture in itself is neither good nor bad. Thinking about cultural systems of value often helps, but

sometimes hinders, the amelioration of diff erences between people. When culture works unchecked to

exclude and discriminate, an eff ort should be made to uncover practices that are taken for granted so that they can be changed. When culture creates moral bonds that increase commitment and empathy, endeavours should be made to understand how those bonds improve

wellbeing and health, and how they might provide future models of care.

To dismiss, however, that culture is ever-present—for example, that the universalism of science can be

opposed to the local prejudices of culture, or that worldwide goals should take priority over local ones—is to blind us to our own vanity and the exclusionary ways in which even the best-intentioned individual can

unknowingly behave. In times of social dysfunction, people with a public voice might come to share more with one another as an emerging culture of worldwide elites (irrespective of their views) than with the incapacitated others with whom they might otherwise share an ethnic, religious, or racial heritage, or with whom they identify morally.

Although suff ering and compassion are often dis-

cussed, if carers are ignorant of what brings value and meaning to another’s life, it becomes diffi cult to make life better when illness undermines health. For example, irregular antenatal visits and reluctance to attend common screening tests are well-known issues across the world, adversely aff ecting maternal and infant health. Findings from a study26 of south Asian women done in the UK showed that, contrary to health

professionals’ beliefs, non-adherence to these visits and tests had little to do with negative attitudes towards antenatal care. Instead, the women merely lacked

informed choice. By contrast, fi ndings from another study27 in Nigeria showed that women booked their fi rst appointments too late because all clinical care was deemed curative and seemed to off er no advantages for a healthy mother. Here, participation in health care was mediated by ideas about the cultural meaning of care. Finally, in a study28 of use of folic acid supplements during pregnancy in Arab and Turkish ethnic pop-

ulations, underuse was associated with economic

pressures on pregnant women rather than because

participants were neglectful or lacked information. These are just a few instances of how the investigation of stereotypical views of—wrongly presumed—culturally infl uenced behaviours can have a real and lasting eff ect on clinical encounters. Unless we address local models of wellbeing that might diff er from what we assume to be universal, we have no way of understanding the day- to-day behaviours on which good health and well being depend.

It is important, then, to understand how wellbeing is socioculturally generated and understood, and how

cultural systems of value relate or not to notions of health and to systems of care delivery. Because wellbeing is increasingly recognised as both biological and social, health-care providers can only improve outcomes if

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