Health Education Research, Vol. 15, No. 4, 508-510,
August 2000
© 2000 Oxford University Press
Book Review |
Health and Culture: Beyond the Western Paradigm
Professor and Director, Program in Urban Public Health, Hunter College, City University of New York, New York
In a world increasingly knit together by international trade, immigration and electronic communications, patterns of health and disease are shaped by both global and local forces. In order to address these two dimensions of health adequately, health educators must simultaneously acknowledge the distinct cultural characteristics of the populations they serve and the common bonds that link humanity. These two books can help health educators to chart a moral, political and programmatic course between culturally specific and more universal approaches, and to understand better the tensions between them.
Health and Culture by C. O. Airhihenbuwa, Associate Professor at Pennsylvania State University, provides a critique of Eurocentric approaches to culture, health and health promotion. The author argues that European and North American paradigms underestimate the role of culture in health, emphasize an authoritarian style of education which dichotomizes teaching and learning, define development in narrow economic terms, and favor medical rather than public health solutions. These problems, he believes, reflect a colonial or post-colonial world view in which Western hegemony is assumed as the norm.
Based on his experience with African populations in Nigeria and elsewhere, and with African-Americans in the US, Airhihenbuwa proposes that culture should be at the center of health promotion interventions. He suggests a model to help health educators assess and address cultural factors in different circumstances. While acknowledging the role of socioeconomic factors in health, he believes that accentuating the socioeconomic at the expense of culture reduces the impact of health promotion interventions.
Health and Human Rights, edited by the late Jonathan Mann and his colleagues at the Boston University School of Public Health and the Fancois-Xavier Bagnoud Center for Health and Human Rights at Harvard University, seeks to encourage a dialogue between the public health and human rights communities. The editors believe that each has much to learn from the other and a common practice could contribute to improved well-being for the world's most vulnerable populations. The chapters define the scope of these two domains; illustrate common interests in addressing such problems as ethnic cleansing, torture, police brutality, and the rights of indigenous, disabled, HIV-affected and other populations; and discuss a political and ethical framework for an integrated public health and human rights agenda. For most authors, three international documents, the Universal Declaration of Human Rights, the International Covenant on Economic, Social and Cultural Rights, and the International Covenant of Civil and Political Rights, constitute a vision of a universal standard for all societies.
For health educators, these two books highlight some of the dilemmas that will pose ethical, political and programmatic challenges in the coming decades. In theory, universalist and culturally specific approaches to health are not mutually exclusive. Our broad goal should be to maximize both these values. In practice, however, these two strategies can conflict, as the following examples illustrate. Without a moral compass to guide these decisions, health educators may become unnecessarily caught up in controversy.
Many urban neighborhoods in cities in both the North and the South now include multiple ethnic and cultural groups. In some areas of London, Paris, New York City and Los Angeles, for example, more than 10 populations might share the same space, speaking different languages, eating different foods, practicing different religions and using different systems of healing. This diversity contributes to the energy and excitement of cities but creates problems for public health planners. How can they make operational Airhihenbuwa's call to `legitimate and affirm' the different meaning that each culture ascribes to various health issues? Does each group require a separate intervention? What if populations disagree about, for example, core messages on drug use and sexuality? Do public health educators concerned about imposing their own agenda choose the lowest common denominator message so as to offend no one? In a recent community campaign to control asthma in a multiethnic New York City community, one group objected to a brochure that showed young girls involved in a mixed-gender soccer (football) game because such activities violated the group's beliefs about gender roles. Should that image be removed? If so, for all groups or only the objecting one?
Another problem can arise if culturally specific interventions polarize or isolate groups, reducing opportunities for dialogue and developing a shared agenda. In their quest to ensure that each subpopulation had its specific needs related to HIV prevention addressed, members of some state and local HIV Prevention Planning Groups, a mechanism established by the US Centers for Disease Control and Prevention to provide guidance on the distribution of federal funds, missed the opportunity to address underlying causes for the spread of the epidemic.
On the other hand, as Airhihenbuwa observes, imposing one group's values on another rarely leads to sustainable changes in health. The universalist aspirations of the United Nations covenants on human rights fail to acknowledge the differing resources that societies bring to meeting the needs of their populations, differences dictated in part by the history of colonialism and Western exploitation. Both the new government of South Africa and the State of New York recognize a legal right to shelter, for example, yet the two governments have very different resources to apply to improved housing. What are appropriate standards in these two situations and what common and differing strategies do public health advocates employ to improve housing in Soweto and the South Bronx? For that matter, what obligations does the developed world have to the developing world, a particularly salient question as the global HIV epidemic consumes the health resources of some nations?
The two books define the culturally specific and universalist approaches to health promotion, and help to identify the questions that health educators must address if they are to integrate these two approaches successfully. However, it is the reader who must provide the answers for neither book defines the resolution of this tension as a central goal. I suggest the following generalizations to assist in that effort.
First, as the history of the last decade illustrates, no nation, region or culture has a monopoly on virtue. From the police precincts of Los Angeles and New York to the streets of Kigali, Sao Paulo, Grozny, Pristina and Kabul, governments and their agents have demonstrated an unquenchable capacity for torture, brutality, prejudice and inhumanity. Developing new standards for universal human rights must be an international effort and no nation is immune from criticism. Both the developing world view that human rights standards are an imposition of Western values and the developed world position that human rights are at risk only in poor nations deserve critical scrutiny. Public health workers may be able to play a useful role in moving from sanctimonious statements to a new practice that promotes health and rights at both the local and global levels.
Second, public health is not well served by presenting itself as a value-free profession that seeks to respect all cultures, no matter what their beliefs or practices. We risk either becoming tools of those in power, imposing their self-interested agenda, or apologists for sub-populations with discriminatory practices. Rather, by articulating our own values as a profession, we create the opportunity to engage in a respectful dialogue with our constituencies to define goals and objectives that all parties can live with. Both books emphasize the importance of this open dialogue. As an example, by asking participants in their programs to examine the impact of culturally assigned gender roles on health and disease (e.g. in HIV prevention, family nutrition, birth control and elder care), health educators can help populations to strengthen cultural beliefs and practices that promote health, and to change those that damage health. In this view, the task of the health educator is not to support culture (a passive role) but rather to encourage critical reflection, a more active role.
Another rationale for playing a more active role is that no community or culture is homogeneous. By drawing out the differences within a culture, health educators can encourage rather than impose critical dialogue. For example, many observers note that patriarchy and machismo are key elements of Hispanic (as well as other) cultures. It is also true that Hispanic cultures have a tradition of strong women, taking care of themselves and their families and speaking out against injustice. By exploring the tensions in these two traditions, health educators can contribute to changes that improve well-being.
Third, global changes require us to re-think the meaning of culture and therefore its impact on health. Just as human biologists are now questioning the meaning of the concept of `race', in part because inter-racial mixing has all but eliminated biologically distinct groups, unique cultures may also be mutating and blending before our eyes. The mixing of cultures due to migration and immigration, always a factor in world history, is now proceeding at warp speed. The creation of a world culture, dominated by multinational corporations who seek to profit by spreading consumerism across the globe, influences the desires and values of almost everyone. We can approve or disapprove of these trends, but not deny their existence.
In reality, we all belong to many cultures: of our parents, peers, partners and neighbors; those with whom we worship, work and vote; and of our media market and socioeconomic class. These differing cultures may overlap but global trends suggest they will become more heterogeneous, not more similar. At any moment, one of our cultural identities may be more salient or influence health behavior more directly, but to envision individuals as having a single fixed cultural identity is no longer viable. Thus, health educators face an even more complex task of eliciting the multiple cultural identities within a defined population, assessing their relevance to health and designing appropriate interventions. To master this complexity will require enlisting all sectors of the population in the development of interventions, again a strategy that both Airhihenbuwa and Mann et al. encourage.
In summary, Health and Culture and Health and Human Rights offer health educators clear expositions of two dominant trends in public health practice and theory. By familiarizing themselves with the strengths and limitations of these two approaches, and by forging a new synthesis, readers can contribute to creating a health education practice for the new century.
Notes
C. O. Airhihenbuwa, Sage, Thousand Oaks, CA, 1995, 152 pp. ISBN 0-8039-7157-5
Health and Human Rights: A Reader
J. M. Mann, S. Gruskin, M. A. Grodin and G. J. Annas (eds), Routledge, New York, 1999, 448 pp. ISBN 0-415-92102-3
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||