On Culture and Health.

The Robert Wood Johnson Foundation (RWJF) recently unveiled a forward-looking agenda that frames the foundation’s efforts as an effort to foster a culture of health. This agenda includes outcomes designed to assess culture around health and a comprehensive action portfolio that aims to foster a culture of health. There is much that is interesting and commendable about the foundation’s efforts, and much about the approach that echoes our own school conversations around influencing the conditions that make people healthy. Inspired by the foundation’s focus on culture and health, I wanted to reflect here a bit on what we might mean by the notion of culture, what it might mean for population health, and what implications this has for our work in public health.

First, what do we mean by “culture”? That question has fueled countless academic discussions. In 1952, anthropologists Alfred Kroeber and Clyde Kluckhohn compiled a list of 164 definitions of culture, with this list expanded on to more than 300 definitions in Redefining Culture: Perspectives across the Disciplines. In 1976, the Welsh Marxist academic Raymond Williams suggested that culture is “one of the two or three most complicated words in the English language” but broadly suggested three predominant meanings of culture as being 1.) the symbols that inform our intellectual and spiritual development; 2.) our specific ways of life; and 3.) artistic activity. The latter is the most common use of for the term, though perhaps not the most relevant use for public health purposes. Despite more than 60 years of lexical analysis, the word retains much recent currency. In 2014, Merriam-Webster announced “culture” as the word of the year, noting that “culture is a word that we seem to be relying on more and more.” Such anointment of the word was followed, perhaps inevitably, by more social comment.

Perhaps more directly relevant to public health is a definition from the United Nations Educational, Scientific, and Cultural Organizations (UNESCO) seeing culture as “that complex whole which includes knowledge, beliefs, arts, morals, laws, customs, and any other capabilities and habits acquired by [a human] as a member of society.”

Given the ubiquity these definitions suggest for the role culture plays, it would be surprising if culture were not important as a driver of health. Indeed, at a simple level, a body of empiric work in population health science has directly grappled with the role that changing culture can play in shaping health. For example, a study in the UK concluded that conduct problems increased significantly in the last 25 years of the 20th century among both male and female adolescents from all social groups and family types. Another study looking at the cultural correlates of youth suicide found a strong positive correlation between male youth suicide rates and indices of individualism such as personal freedom and control, and argued that the increase in suicide rates can be explained by a shift towards individualism in western nations. In our own work, we have considered how norms around drinking shape population problems with alcohol use.

More impressive examples emerge when one thinks about how changing culture have promoted change and influenced health. The most readily accessible example is smoking. The national, and emerging global, decline in smoking has been clearly linked to the growing public appreciation of the dangers of smoking, policy started actions around smoking, and a slow but inexorable change in the perception of—the culture around—smoking, with the glamour and ubiquity of smoking that existed in the ‘50s and ‘60s giving way to stigma around smoking in many sectors of American society. Leaving aside, for a moment, the potential harms associated with the latter, there is little question that the ubiquitous behaviors, symbols, and way of life around smoking—a culture of smoking—changed, to the benefit of public health. This provides much hope.

The recognition, then, that culture is centrally linked to the health of the public calls for the question: Can we change culture around other dimensions to improve population health, or in the words of the discourse started by RWJF, can we create a culture of, perhaps “for,” health?

What would a culture of health look like domestically? A culture of health must definitionally promote population health as an overriding value, making the promotion of health central to societal decisions about the conditions that shape how we live. In some respects, we are living in a culture that far undervalues health, most readily evidenced, perhaps, by our absence of a national health insurance that covers all Americans. As articulated by Richard Wilkinson, elements of our culture suggest that a “culture of inequality” informs many of the inequities that continue to color our health indicators and our accepting of wide health gaps between groups. Wilkinson and colleagues have shown that societies with more inequality have less trust as well as worse health indicators, with the US at the top of this list. Income inequality can stem from cultural ideas of wealth, social mobility, the “American dream,” and “pulling oneself up by the bootstraps,” all of which may seem deeply ingrained in a particular American way of thinking but which may be linked to health inexorably and unavoidably. A culture change, a culture of health, would help recalibrate our values and priorities, to create a culture that encourages societal investments in the resources that indeed promote population health and narrow health gaps.

Although much of this discussion has taken a domestic focus, promoting a culture of health in global health has an important, urgently needed space. By way of one example, female genital mutilation (FGM), or the practice of partially or fully removing external female genitalia, is often carried out on young girls in the Middle East and African countries for a range of cultural reasons, including encouraging femininity, modesty, decreased libido to encourage virginity and fidelity, a moral upbringing, social conventions, and power structures. More than 125 million women are alive today who have experienced FGM, and about 3 million girls are at risk each year. There are no health benefits to the practice, and risks of the procedure can be devastating, including urinary tract infections, hemorrhage, anemia, HIV, birth complications, infertility, and later surgery. And yet the practice is deeply embedded in cultural practices as a symbol and marker of age transitions. The global community, including WHO, UNICEF, and UNFPA, have explicitly aimed to change culture to end the practice. Many of the initiatives to end FGM, such as the UNICEF and UNFPA joint program to accelerate the abandonment of the practice, focus on community empowerment and involvement to change the culture around FGM. The UN General Assembly adopted a resolution on the elimination of female genital mutilation at the end of 2012. This movement has seen growing political support, including laws against FGM in 25 African countries. This would indeed be a positive change in culture to the betterment of millions worldwide.

Perhaps an important concluding question, given the potential centrality of culture in any real consideration of promotion of population health, is why has culture not had a greater and more systematic role in our population health thinking until relatively recently? To this point, a few years ago, Richard Eckersley contributed a chapter on culture for my book Macrosocial Determinants of Population Health, arguing that different disciplines have contrasting positions on culture, limiting our consideration of culture as a determinant of health. Relevant to public health, he suggests that its quantitative core, epidemiology, is mainly concerned with “subcultures and differences,” with a focus on individuals rather than on a higher level of complexity. Thomas Glass agrees, noting, somewhat dyspeptically: “Like the pre-20th century idea of the luminiferous ether in physics, culture has no place in a Newtonian vision of cause and effect. With few exceptions (think of herd immunity) epidemiology has great difficulty incorporating aggregate-level phenomena that exist in larger dimensional space beyond what touches or invades the individual.” Eckersley offers a useful explanation why we may underestimate or ignore the effects of culture of health. He argues that culture is often invisible to those living within it, that we tend to recognize cultural influences only when viewed in unfamiliar societies, and that specific factors such as personal circumstances affect the influence of culture on people. Therefore, put another way, culture is ubiquitous and yet experienced differently, posing substantial challenges to a social determinant of health framework that has broadly found acceptance as a guide to our public health thinking.

In sum, it seems to me that culture is a ubiquitous social determinant, shaping our values, expectations, norms, priorities, and behaviors, all of which in turn influence the health of populations and the health gaps within populations. To that end, the promotion of a culture for healthier populations seems to be an unavoidable part of the business of creating population health. As such, culture should be a central concern for those of us responsible for generating knowledge about the production of health in populations, for teaching that to our students, and for translating it to inform those who can make change happen on a global scale.

I hope everyone has a terrific week. Until next week.

Warm regards,

Sandro

Sandro Galea, MD, DrPH
Dean and Professor, Boston University School of Public Health
Twitter: @sandrogalea

Acknowledgement: I am grateful for the contributions of Laura Sampson and Salma MH Abdalla MBBS, to this Dean’s Note.

Previous Dean’s Notes are archived at: https://www.bu.edu/sph/category/news/deans-notes/