Culture and Health

Applying Medical Anthropology

Michael Winkelman

• Publisher: Jossey-Bass
• Year: 2008
• ISBN:
  9780470462614
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Culture and Health offers an overview of different areas of culture and health, building on foundations of medical anthropology and health behavior theory. It shows how to address the challenges of cross-cultural medicine through interdisciplinary cultural-ecological models and personal and institutional developmental approaches to cross-cultural adaptation and competency. The book addresses the perspectives of clinically applied anthropology, trans-cultural psychiatry and the medical ecology, critical medical anthropology and symbolic paradigms as frameworks for enhanced comprehension of health and the medical encounter. Includes cultural case studies, applied vignettes, and self-assessments.

CHAPTER 1

APPLIED MEDICAL ANTHROPOLOGY AND HEALTH CARE

In improving patient satisfaction . . . administrators’ attention
is being directed to the impact of culture—of organization, roles,
and values—upon overall quality of care and outcomes

—PRESS, 1997, P. 6

LEARNING OBJECTIVES

• Introduce how culture affects health

• Illustrate how anthropological perspectives can facilitate effective health care

• Introduce the nature of cultural competence in health care

• Illustrate medical anthropology’s major applications in addressing cultures’ impacts on health

• Illustrate the broad range of concerns people have with respect to their health

• Introduce the biopsychosocial framework for understanding diverse effects on health

• Present a cultural systems model for addressing factors that affect health

• Illustrate principal mechanisms of culture’s effects on health

CULTURE AND HEALTH

Have you ever felt when you went to the doctor that your problem wasn’t understood or that your treatment was not relevant to your health problem? Cultural differences between physicians and their diverse clients make cross-cultural misunderstandings inevitable. Culture affects patients’ and providers’ perceptions of health conditions and appropriate treatments. Culture also affects behaviors that expose us to disease and the reasons prompting us to seek care, how we describe our symptoms, and our compliance with treatments. This makes culture central to diagnosis and an important issue for all of the health professions.

Patients and providers need knowledge of the relationships of culture to health because culture is the foundation of everyone’s health concerns and practices. Improving health care requires attention to cultural influences on health concerns, conditions, beliefs, and practices. People’s health occurs within cultural systems that are concerned with broader issues of well-being than addressed by physicians’ concerns with disease and injury; we are also concerned with psychological, social, emotional, mental, and spiritual well-being. As biomedicine turns from a disease-focused approach to concepts with health and well-being, cultural perspectives and cultural competency emerge as central frameworks for improving care.

Medical anthropology is the primary discipline addressing the interfaces of medicine, culture, and health behavior and incorporating cultural perspectives into clinical settings and public health programs. Health professionals need knowledge of culture and cross-cultural relationship skills because health services are more effective when responsive to cultural needs. Cross-cultural skills also are important in relationships among providers of different cultures when, for example, African American and Filipino nurses interact with each other or with Anglo, Hispanic, or Hindu physicians. A knowledge of culture is also necessary for work in community settings, such as collaborating with diverse groups and organizations to develop culturally relevant public health programs. Health care providers and patients are more effective in managing their health and care with cultural awareness and the ability to manage the numerous factors that affect well-being.

What do health professionals—providers, researchers, social service personnel, educators, and other “helping professionals”—need to know about the effects of culture on health? They all need systematic ways of studying cultural effects on health and developing cultural competence. Cultural responsiveness is necessary for providers, researchers, and educators if they are to be effective in relating to others across the barriers of cultural differences. The cultural perspectives of medical anthropology are essential for providing competent care, effective community health programs, and patient education. For biomedicine to be effective, providers need to know whether a patient views the physician as believable and trustworthy, the diagnosis as acceptable, the symptoms as problematic, and the treatment as accessible and effective.

The concept of culture is fundamental to understanding health and medicine because personal health behaviors and professional practices of medicine are deeply influenced by culture. Culture involves the learned patterns of shared group behavior. These learned shared behaviors are the framework for understanding and explaining all human behavior. This includes health behaviors, particularly intergroup differences in health behaviors and beliefs. Culture is a principal determinant of health conditions, particularly in exposing us to or protecting us from diseases through structuring our interactions with the physical and social environments: for example, through producing environmental contamination, work activities, contact with animals, sexual practices, diet, clothing, hygienic practices, and others. Culture also defines the kinds of health problems that exist and the resources for responding to health concerns, defining our perceptions, and producing the resources for responding to them.

Cultural knowledge is also essential for addressing public health mandates to assess communities’ health needs, develop appropriate health policies and programs, and ensure adequate and culturally competent health services. The health needs of communities vary widely, requiring an understanding of each community’s perceptions of health and illness to develop appropriate services. Public health initiatives require knowledge of culture to change the behaviors and lifestyles associated with an increased incidence of disease. Addressing the effects of culture on health is an important issue for everyone, not just physicians, because disease in any group impacts society as a whole. According to Durch, Bailey, and Stoto (1997), “Improving health is a shared responsibility of health care providers, public health officials, and a variety of other actors in the community.” This requires people with an ability to engage communities in a culturally appropriate manner and understanding of their cultural systems, health beliefs, and practices.

Perspectives for addressing culture and health relations are provided by medical anthropology and the cultural systems models used within nursing, public health, and medicine to understand systemic ecological and social effects on health. The foci on principal factors affecting health reflect the major traditions of medical anthropology:

• Medical ecology, which examines culture’s mediation of health through the physical, biological, and material relationships with the environment

• Political economy and critical approaches that address how health is affected by economic resources, power, and social activities that produce risks and distribute resources

• Symbolic approaches that examine how cultural meanings create the socially legitimated healing processes and link beliefs to physiological processes

This book helps you understand how cultural effects occur across a wide range of health concerns, ranging from clinical care to prevention programs and the funding priorities of health care. Hundreds of factors can have effects on our health, ranging from social conditions producing or reducing exposures to germs and noxious agents to the cultural, economic, and political factors that enable a person’s access to quality care.

CASE STUDY

Cultural Conflicts in Health Care

The potentially tragic consequences of confl icts between biomedical culture and the culture of patients became more widely known to providers and the general public through the accounts provided by Anne Fadiman (1997) in The Spirit Catches You and You Fall Down. Numerous factors produced a disastrous outcome in infant Lia Lee’s interaction with her doctors, factors that derived as much from the Hmong culture as from that of biomedicine and its efforts to control the Hmong and ignore their beliefs. The result was a brain-dead child; physicians blamed the parents and their failure to adhere to the prescribed medications.

In trying to explain why Hmong patients did not accept the physician’s point of view, Fadiman recounts the Hmong history of resistance to the Chinese and other outside invaders and authorities: fi ghting rather than surrendering and standing up to intimidation. Fadiman suggests that their history of resistance is the root of their opposition to the doctor’s orders. But the Hmong are not some static culture caught in the past; rather, they have continually adapted and changed in the face of many dominant cultural groups that have attempted to control, tax, assimilate, militarize, and profi t from them. The Hmong have changed in many ways, adopting infl uences from other cultures that have served them well. This is manifested in their Christianization, U.S. military service, education, and acculturation.

Lia’s family had undergone acculturation and accepted the value of biomedicine, taking her repeatedly to emergency departments and doctors’ appointments. Nevertheless, they often resisted visiting hospitals, which they believed were haunted by spirits of the dead. And they resisted treatments imposed by physicians, viewing them as coercion rather than gifts of healing. The Hmong view of health was a mixture of religion, economics, lost souls, and spirits, a balance of virtually all aspects of life. To the Hmong, many basic aspects of medicine were taboo or horrifying—blood specimens for tests, autopsies to study diseased organs, and invasive procedures including spinal taps, surgery, and vaginal exams. Their doctor’s orders for the constant drawing of blood, sometimes as often as three times a week for Lia, increased her parents’ concern about the vital fl uids being taken from their child. Experimental procedures and treatments unrelated to her complaints reinforced many of the Hmong’s worst fears: that doctors would eat the liver, kidneys, and brains of their patients. They had seen the doctor’s offi ces with body pieces cut up and stored in jars, preserved like food.

Lia’s family had undergone acculturation and accepted the value of biomedicine, taking her repeatedly to emergency departments and doctors’ appointments. Nevertheless, they often resisted visiting hospitals, which they believed were haunted by spirits of the dead. And they resisted treatments imposed by physicians, viewing them as coercion rather than gifts of healing. The Hmong view of health was a mixture of religion, economics, lost souls, and spirits, a balance of virtually all aspects of life. To the Hmong, many basic aspects of medicine were taboo or horrifying—blood specimens for tests, autopsies to study diseased organs, and invasive procedures including spinal taps, surgery, and vaginal exams. Their doctor’s orders for the constant drawing of blood, sometimes as often as three times a week for Lia, increased her parents’ concern about the vital fl uids being taken from their child. Experimental procedures and treatments unrelated to her complaints reinforced many of the Hmong’s worst fears: that doctors would eat the liver, kidneys, and brains of their patients. They had seen the doctor’s offi ces with body pieces cut up and stored in jars, preserved like food.

CULTURE, ETHNOMEDICINES, AND BIOMEDICINE

Culture is at the foundation of all medicine, the biomedicine of physicians (M.D.s) as well as all other ethnomedicines, the health care practices of a culture. Medical systems are intimately intertwined with a culture’s economic, social, political, and philosophical systems; this is illustrated in the United States in biomedicine’s control of governmental resources, its successful lobbying in Congress, and its powerful economic position in society, including government.

Culture affects health behavior in many ways:

• Conceptualizing health maladies (disease, illness, and sickness) and their significance

• Affecting the distribution of causes of disease and illness

• Creating risk behaviors and disease exposure

• Informing symptom recognition and care-seeking behavior

• Creating health providers’ and their institutions’ responses to health care needs

• Shaping utilization of the popular, folk, and professional sectors of health care

• Producing social, economic, and political impacts on health and health care

• Creating emotional and psychodynamic influences on health and well-being

• Providing psychodynamic, symbolic, and social mechanisms of healing relationships

Culture mediates our responses to health maladies through ethnomedicines, cultural practices for addressing health problems. The term ethnomedicine typically distinguishes other cultures’ health practices from biomedicine, the dominant ethnomedical system of the United States, which is also referred to as Western medicine, scientific medicine, and allopathic medicine. Biomedicine is also an ethnomedicine, reflecting the culture where it is practiced (see Chapter Five).

Ethnomedical studies (see Bannerman, Burton, and Wen-Chieh, 1983) reveal that health problems and treatments are conceptualized within cultural frameworks. Culture directly affects the manifestations of conditions, their assessment and social implications, and processes of treatment. Ethnomedical analyses show the importance of understanding healing from the cultural perspective of the group, their social dynamics, the social roles of healers, and the conceptual and cosmological systems (Rubel and Hass, 1990).

Many contemporary U.S. health issues illustrate underlying cultural dynamics:

• Death due to lifestyle (e.g., poor diet and alcohol and cigarette use)

• Political decisions that leave major segments of the population without health services

• The spread of infectious diseases through immigration and lifestyles

• Pharmaceutical companies and physicians’ groups lobbying Congress for legislation to deny U.S. citizens access to foreign medicines

Health co...

Table of contents

• Title Page
• Copyright Page
• Table of Figures
• List of Tables
• Table of Exhibits
• PREFACE
• Dedication
• THE AUTHOR
• Acknowledgements
• CHAPTER 1 - APPLIED MEDICAL ANTHROPOLOGY AND HEALTH CARE
• CHAPTER 2 - DISEASE, ILLNESS, SICKNESS, AND THE SICK ROLE
• CHAPTER 3 - CULTURAL COMPETENCE IN HEALTH CARE
• CHAPTER 4 - CULTURAL SYSTEMS MODELS
• CHAPTER 5 - ETHNOMEDICAL SYSTEMS AND HEALTH CARE SECTORS
• CHAPTER 6 - TRANSCULTURAL PSYCHIATRY AND INDIGENOUS PSYCHOLOGY
• CHAPTER 7 - MEDICAL-ECOLOGICAL APPROACHES TO HEALTH
• CHAPTER 8 - POLITICAL ECONOMY AND CRITICAL MEDICAL ANTHROPOLOGY
• CHAPTER 9 - PSYCHOBIOLOGICAL DYNAMICS OF HEALTH
• CHAPTER 10 - THE SHAMANIC PARADIGM OF ETHNOMEDICINE
• GLOSSARY
• REFERENCES
• NAME INDEX
• SUBJECT INDEX