IJE Advance Access originally published online on December 8, 2005
International Journal of Epidemiology 2006 35(2):261-263; doi:10.1093/ije/dyi238
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Commentary |
Commentary: ‘Culture’, cultural explanations and causality
Faculty of Health Sciences, Simon Fraser University, Burnaby BC, Canada V5A 1S6. E-mail: cjanes{at}sfu.ca
As a medical anthropologist, and thus representative of a discipline that has since the beginning of the 20th century exercised intellectual dominion over the construct of culture as explanatory of the human condition (writ both large and small), I find much in Eckersley's provocative paper to agree with. I also appreciate his efforts to incorporate cultural explanations into social epidemiology. In so doing he has given the field a needed theoretical push to move beyond a narrow focus on social and economic relationships to consideration of systems of meaning in the causation of disease.
Yet, like many anthropologists these days, I experience considerable intellectual anxiety over the general and uncritical use of culture as an explanatory variable. Empirical work in diverse settings conducted over the past three decades has shown that culture is increasingly hard to define, much less apply, to understanding social practices. The transnational flows of people and ideas that are part and parcel of globalization, the legacies of colonialism and, in consequence, a need to take power into account, have rendered older ideas of culture—as a relatively homogeneous set of understandings shared among a group of socially interacting people—conceptually obsolete.1,2 Thus, as I teach my students, culture should never be used as an explanatory variable, or not, at least, without some very careful unpacking. I suspect that Eckersley's goal3 of moving us towards a culturally-informed epidemiology will not be achieved without some consideration, theoretically and methodologically, of what culture is, exactly, and how it manages to get into the body. It seems to me that the challenges are 3-fold: addressing the role culture plays in human social life; understanding how the ‘stuff’ of culture—ideas, symbols, meanings, shared understandings, morals, values, beliefs—are distributed within and among social groups within larger, complex social systems; and developing the conceptual tools and research methods to apprehend the links between culture as a shared perspective on the world and individual experience.
As a starting point, it is important to avoid the culturalist trap; i.e. seeing culture as a thing in and of itself arising sui generis to govern social life. Culture, in this sense, is viewed as being autonomous, explainable only via reference to the ‘working out of its own internal and particularistic logic’.4 Although anthropologists quibble over the degree to which cultural systems develop independently of other influences, both social and ecological, most would agree that cultural systems are inseparable from fundamental social and political processes that unfold over time, in particular places, and in response to certain problems and challenges. Culture is not in this view independently causal or deterministic. It is highly contingent on the forces of history and especially vulnerable to the applications of social power. To employ the culture concept as an explanatory factor, then, one must also be clear as to the nature of these historical contingencies. Is it Western culture that makes people sick, or certain historical processes—capitalism, for example—that leads to the empowering or salience of certain ideological systems, which are then identified as potentially pathogenic? If so, why not then talk about capitalism and leave culture out of it? Put most directly, what does a cultural explanation add that a more specifically social one does not? Does, as Eckersley argues, ideas about ‘cultural fraud’ or ‘individualism’ offer us much more explanatory power than, say, locating pathogenic processes in consumerism?
Cultural explanations also founder when faced with the facts of social inequality. Individuals, social groups, communities, ethnicities, genders, all stand in unequal relationships to the engines of cultural change. Simply put, some people and some groups have more power over the content of culture than others. This power, often as not implicit to the circulation of ideas, justifies certain principles that are consistent with the social and economic interests of the elite. The issue here epidemiologically seems to be not whether Western culture is broadly pathogenic, but how such cultural ‘risk’ is patterned within a population. Some groups undoubtedly benefit from individualism, for example, and thus probably do not experience its more deleterious effects.
In the same way that culture is not democratically constituted, it is not evenly distributed within a society. Especially in this era of rapid globalization it is very much an open question whether and to what degree different groups come to adopt, aspire to adopt, or reject the systems of meanings that circulate increasingly in the global system. Among the pressing research priorities in modern anthropology is understanding how locals—groups, co-ethnics, communities—construct cultural identities in the context of such transnational flows.5 Adoption, acculturation, assimilation, rejection, resistance, and transformation are all possibilities. In research conducted with Pacific Island migrants to the west coast of the US, for example, I found that cardiovascular risk seemed to correspond not to the adoption of features of American culture, but the struggle to maintain distinctly Samoan cultural practices and identity in a market economy.6 Is Western culture implicated in this process? Yes, but not in as straightforward a way as suggested in Eckersley's essay. If elements of Western culture are indeed pathogenic, then it is clear from an epidemiological viewpoint that understanding the distribution of these elements, and how they are interpreted at the local level is a critically important research question.
Pushing this argument a bit further, it seems relevant to ask, paraphrasing the seminal work of Rose,7 whether elements of culture should be employed to explain the causes of incidence across populations, a cause of cases within populations, or make the difficult attempt to link the two. The idea of a ‘Western’ culture speaks to population-level analysis, but apropos of previous comments, culture is variably distributed within populations, and groups stand in various relationships of consistency, or inconsistency, with dominant cultural systems. To what degree does this influence disease risk either within or between populations? It is this kind of difficult analysis, merging analytical perspectives of structure and agency, which has dominated social science for much of the last three decades.8 In the context of bringing the concept of culture to bear on disease risk, Dressler and his colleagues9–11 have, with some success, attempted to identify cultural models as they are held by groups within complex class societies and to measure the degree to which individuals are consistent in their behaviour with these cultural models affect cardiovascular and mental health. As with the work I did with migrants, the results of this research suggest that what is pathogenic about culture is not only or even necessarily its content, but whether individuals are able given their social and economic situation to act in a fashion consistent with the values and beliefs of the groups to which they belong and with which they identify.
Rose's primary point, of course, was to highlight and critique the different models of prevention predicated on individual vs population perspectives on disease causation. It is abundantly clear that shifting behaviours in a population, while less motivating to individuals and health care providers, is a more radical and potentially more useful approach to prevention. It is worthwhile, then, to ask whether culture is up to explaining the difference in the causes of incidence between populations, and, if so, consider whether it is either possible or practical to change cultural systems. I worry that the idea of ‘culture,’ especially if it is not carefully operationalized, does not in the final analysis contribute to prevention science. Instead, like the popular notion of social capital, the potential for blaming the victim looms large.12,13
Eckersley, to be fair here, anticipates some of these challenges in his analysis. Although he tends to use the term ‘Western culture’ in a somewhat broad and unfocused way, it is clear from his essay that his thinking is directed more precisely to the pathogenic nature of those ideological elements that arose to buttress the growth and development of global capitalism—individualism and consumerism. This work is clearly consistent with emerging work in cultural epidemiology.14,15 The challenge, as I see it, is to move beyond the omnibus use of culture as an explanatory variable, to look more carefully at the specific elements of culture that are of suspected causal importance, examine variability in the adoption of such elements within population groups, and ask whether the degree to which individuals endorse such cultural elements modifies their risk for disease.
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