Culture, Structure, and Health

     The term “American Dream” mentioned in Benoit’s article (2005) attracted my attention. The idea of American Dream essentially claims that all human are equal, and everyone can succeed and live a happy life through hard work. However, I think actually the American Dream is not attainable for everyone due to the existing inequality rooted in class, gender, race, age, and religion. But the Dream reflects the ethos of the United States. In American’s culture, personhood is established through individual effort. A morality is playing a role here. Thus illness can be viewed as a moral fault that is resulted by failed self-improvement. It reminded me an interview we conducted. When I asked the participant what influenced her choice of Sugar Sweetened Beverage (SSB), she said she would feel guilty if she consumed SSB. She believed health problems would occur if she consumed too many. In her value system, health is a personal business. The narrative is rooted in the structure of meanings and roles. It is very different from Chinese culture. For example, compare the American Dream with the “Chinese Dream”, the American Dream pursues individual honor, whereas the Chinese Dream aims to achieve country prosperity. The Chinese Dream was created by Chinese dominant power, the Communist Party, who is intended to maintain dominance through control people to strive for community interest, rather than individual benefit. The Chinese Dream is a part of ideology that is instilled into the mind of Chinese people. Powerful actors have the ability to shape the contexts where problems locate and influence people’s behavior. Therefore, the ways in which people in different culture construct the disease meanings are distinct. There is an example in the book “postcolonial disorders”. Chinese provincial government viewed HIV throughout epidemiological categories that associated with group rather than individual risk behaviors to HIV. For instance, the Han, which is the dominant ethnic group in China, believes that the Tai ethnic group has a characteristic of sexual promiscuity, and it result to the Tai group members’ higher risk and susceptibility of sexually transmitted infections. Hence, this interpretation of sexual risk places blame in ethnic groups or marginalized communities. I am thinking whether this is the structure that produces violence through restricting resources to borderlands and “hard-to-reach populations”. In other words, this distinct characteristic of Tai ethnic group, even though it is “perceived” by the dominant group, becomes a source of discrimination, and suffering. Thus I think listening to cultures and the narratives of structural violence could identify resource needs and the cause of suffering in the community, in order to promote social change.

     With regard to the “hard-to-reach populations”, I also was thinking there is a wall between the “reachable populations” and the “hard-to-reach populations”. The reachable populations enjoy most of the basic resources, such as food, money, and materials, but in the meantime, hard-to-reach populations endure pain of inadequacy of resources. Why? It is because they are in the other side of the thick wall, no one sees their situation, and no one hears their voices as well. The wall is built by the structure, the culture, and all of these cause inequality in race, gender, and socio-economic status. Interestingly, I think it is like a vicious circle. Culture is a constructor of meanings, values, and roles within which the community exists, and it also can become a barrier of the existence of the community. The web of violence that is knitted by the structure is covering over the head of the “hard-to-reach populations”. They are suffering, struggling, striving, and hovering. They need support and direction, and their nature of suffering requires to be understood. As mentioned earlier, there is a circle. Cultural difference is a start of meaning making process, and a cause of inequality as well. To jump out of the circle, we need to put culture in the center, recognize the differences the structure leads to, identify effective methodology for resistance the structural violence and make efforts to achieve social change.
     However, how can the "silent" voices be heard? It is indeed a larger question as we discussed. Generally, I think the marginalization is caused by the (1) marginalized communities' ignorance, they have little motive to change their situation and they do not take active action; and (2) intentional discriminate or oppress result from political, economic and cultural factors; and (3)inappropriate or insensitive intervention, their voices are not heard. To change the marginalized community's situation, I assume that the ways may include resisting to discriminate, and develop programs that are sensitive to the experience of the marginalized community. Initially, I am thinking about some potential avenues. First, provide communicative platform for whom need to express their needs; Further, create ethical dialogue by sensitive and respectful identification, in order to urge more willingness among marginalized groups; Third, I think conducting a research itself is also a process of raising their awareness to shout their voices out. The projects can be empowering for the participants, because the research induces them to reflect on and evaluate their experiences.

Culture and Suffering

     Suffering refers to human experience of enduring specific problems, load, and wounds towards the body and mind in different forms (Kleinman, 1997). The aim of healthcare always is to alleviate suffering. Understanding suffering is essential in health care practice. The meanings of suffering are culturally different. I think the reason may be that suffering is an aspect of inner experience, a reaction to misfortune in life. The interaction between individuals and the society is influenced by cultural values, which involves subjective self-consciousness.

     I was impressed with the assumption in Dickson’s article (2003) that Korean culture affects the way in which people respond to pain, as well as face suffering. It is true, at least according to my own experience that Korean women have unusual pressure in Korean society which is male-dominated, because they are expected to look after all the families, including three generations in some cases. In addition, older age in Korean culture means respectable states and honor. All of these distinct meanings make Korean women perceive pain differently. Sometimes pain and illness become their secret, which are hided in front of their families. What’s more, they would experience through the process of struggling, striving to decrease pain, and then tolerating the pain by themselves, because they view pain as an inevitable part of aged life. In this way, physicians could improve healthcare and pain management through considering patients’ cultural beliefs.

     I also was reminded that there is a question of balance between time and effectiveness. How could healthcare practitioners provide effective service within limited time and resource? They usually have inadequate time, or money to explore the cultural characteristics of the patients. In my opinion, it is essential, at least, for health care providers to keep the culturally sensitive perception in mind. It means physicians should notice patients’ cultural background and take it into account in diagnosis and therapy.

     Human life is filled with suffering and desire, pain and joy. Suffering is unendurable since it conflicts with the desire of goodness. Thus human are usually fighting with good and evil. It is a process of resistance, bearing and struggling with the distress of pain of body and spirit. Therefore, I am thinking whether suffering could be a power that inspires people to seek human’s desire. When people are suffering a certain kind of pain or sickness, they usually struggle to reduce the pain, to pursue “good” states that is consistent with their expectation.

     Then, I was enlightened by the point that to prevent this resistance, political violence is used to create hopelessness through suffering. Undoubtedly, dominant power needs to suppress criticism in order to maintain the domination. As we mentioned earlier, suffering can produce energy to resist, as well as sense of helplessness which result in silence. That is also the way in which dominant system keeps power and control. Human trauma can lead to silence of people. Silencing exists in the context of access to power. The dominant social actors have more chance to construct the priorities of the healthcare system. On the other hand, the voices of marginalized communities always are mute, who are hard to access to the health care resources and basic materials of life. They have no access to express their voices, and as time goes by, they lose the hope and desire to shout their voices out. They are numb, and physicians and policy maker as well. However, the voices of marginalization should be heard and represented in policy to accomplish social change.

     It also reminded me that in a society which is controlled by absolute dominant actors, it is more difficult to find out and address the challenging that marginalized people encounter. Sometimes dominant power creates a “safe” atmosphere on the surface and ignores the voice of marginalization. I am thinking the problem in China. It is likely that people who are marginalized believe no one can help except themselves. What they can do is to “climb up” to “dominant society” and gain the power to change their life through higher education and all the efforts, despite many people still are struggling in the dark. Unfortunately, little research and attentions are paid in suffering of marginalized communities. It is partly caused by abnormal state of the society. The society is supposed to be “in harmony”. The poorer and marginalized people are victim of sacrifice. What do we researchers do in the context? To heal it, I think, is to figure out a balance between the center of power and marginalized individuals. What it means is to explore how the dominant policy systems influence suffering and lead to further change through the research of culture. 

Culture, Health, & Pain

     I am enlightened by the assumption that pain is a universal experience, as well as an inner experience, which means although all people experience pain similarly, there are differences in people’s perception of pain and expectation of how others respond to their pain. That is because pain is not only understood in biological aspect but also it is sensitive, emotional, and cognitive (Kleinman et al., 1992). Biological, psychological, and social factors intertwine in the response, expression and management of pain. It reminds me the influence of culture on pain experience.

     Culture difference in pain-related behavior, I think, is likely to derive from social contexts, since the way that an individual interpret and understand pain depends on his or her past experience. The relation between pain and culture combines science and philosophy together. Pain is defined differently using their own languages and idioms in various cultural groups. For example, to patients from Asian cultures, they are often stoic facing pain. Why people in Asian cultures have high pain tolerance? It is probably linked to cultural beliefs of self-management. Even though an individual feels pain, it is a habit to make it unobvious and hide it. Asian patients view it as an improper social manner to complain pain openly. I think this cultural value arises from traditional Asian cultures which assert that harmony in interpersonal communication is important.

     Undoubtedly, it is essential to deliver culturally competent care. However, how do clinicians measure patients’ pain, in order to conduct appropriate health care? What about self-report? But different words are used to describe pain in different culture, and many of them are too abstract to understand. Language is limited in conveying pain experience. And how do clinicians understand patients’ narratives about personal pain experience? There is neither easy way, nor assured way, I am afraid. In addition, it is not necessarily true that everyone from a culture will perform the “typical” or expected behavior in this culture when suffering pain. Thus developing a critical reflexive awareness is needed in health care. Still, we should keep in mind that culture is a framework that directs patients’ behavior. An individual’s experience of pain may rely on his or her cultural belief, past experience, and unique characteristics. Every patient is a unique unity. By careful listening and probing each patient’s feeling and experience, health care providers may discover what is happening.

     In many cultures, interestingly, people often believe illness and pain are caused by evil spirit or punishment from a higher power such as God. In this case, patients might refuse pain medication because they think it is God’s desire and God will help him to bear it. Additionally, it is a common saying in Chinese culture, that as long as you can suffer the pain that you encounter, you will obtain spiritual growth. Hence for health care professionals it may be not wise to judge their beliefs. Conversely, they need to anticipate patients’ needs and values, and initiate conversation with patients, to negotiate an appropriate treatment for patients within their cultural and religions contexts. Never take for granted, and be rigorous when exploring deeper origins. 

"The Name of the Disease"

    The documentary "The Name of the Disease" opens another window to me, narrating the voices of patients who have less power in the poor region of rural Rajasthan, India. It is fantastic to touch a picture of another world. In this world, patients and their family believe the disease is due to evil spirit; in this world, “doctors” can heal every disease, and anyone can be a “doctor”; in this world, the name of the disease is “who knows”. I don’t know why I am sick, what the name of the sick is, and how to cure the sick. “I don’t know what to believe” may be meaning “I have to believe everything I hear”. Thus no matter bhopa, or official doctor, no matter science, or ghost, as long as I can access it, as long as I can afford it, I need to have a try. The people here have the original desire – to be alive. How do they live without resource, without knowledge, without support? They are struggling within the poverty, inequality, and hopelessness. Honestly, while watching this documentary, I don’t feel anything except empathy. I hope it is a good start to be a good researcher.

Culture, Modernist Paradigm, and Health

    The individual is a cell of society. The whole atmosphere of society may influence what an individual think, what an individual do. With regard to the influence of social force on individual health behavior, the instance of sati highly impressed me. The symbolic meanings of sati in a culture could “persuade” or restrain a widow’s self-destruction unconsciously. In some cultures, sati is symbolized as a representation of dignity, loyalty and purity of women. What does a widow do when she is suffering from the depression due to her husband’s death in such an atmosphere? Sometimes women are pushed to step on the way of sati by social power. As modern society changes, on the other hand, what if sati is considered as an irresponsible and hasty behavior?

    As Nandy (1988) claimed, people keep their social and political dominance through making themselves rational in social change. Human learn from the patterns, cause, and rules of nature to understand how to dominate it. Culture of a group, a community, a region, and a country is reinforced by social power. Social force can push people to perform a certain behavior by building rational environment. “Rationality” would change across different social contexts and cultures. Rationality gives people reasons to believe, to act. Rational behavior in a culture is one that is not just reasoned, but also is aimed to achieve a goal. However, it varies as the context varies. One “rational” behavior may be “irrational” in another culture. Religious practice may be one kind of manifestation.

    Thus, every behavior has its reason to exist. So does health-related behavior. Patient-centered communication therefore plays a vital role in understanding patients’ social contexts among diverse groups. Physicians need to elicit what patients are thinking, what is their expectation, all of which are depending upon their cultural identities. It is required for physicians to be sensitive to recognize patients’ problems, their misunderstanding caused by patient-physician cultural differences. Besides, in order to engage with the patient, I think the attitude of empathy is a core element in patient-physician communication. Empathy is a process of understanding and anticipating the feelings and experiences of another. Physician puts himself in patient’s places, giving him cues of what he should do in a certain setting. It enables the physician to accurately fulfill patients’ needs. Specifically, the patients are willing to talk more about their concerns and symptoms, helping the physician get known more information about their physical and psychological states and respond to patients’ need appropriately. It leads to more accurate diagnosis.