Culture and Health

We hear a lot these days about cultural bariers to good health, with a strong tendency to blame victims themselves for their illnesses. "There, it's because of their culture," the term culture almost meant to be synonymous to ignorance.

The UNFPA's latest yearbook, State of World Population 2008, was launched Wednesday with the theme "Reaching Common Ground: Culture, Gender and Human Rights," discussing how important culture is for the whole range of reproductive health, from the care of pregnant women to family planning, the prevention of domestic violence and tackling HIV and sexually-transmitted diseases.

For several years now, a team of faculty from the UP Diliman anthropology department, myself included, has been assisting UP and Ateneo's medical schools, as well as Ateneo's MBA (master's of business administration) program for doctors and health professionals, to link culture and health. As I read through the UNFPA yearbook, I made a note to make the yearbook recommended reading for the medical students and required reading for the doctors taking MBA.

There is so much in the report that is useful, not just for health professionals but for policymakers, legislators and development NGOs. For today's column, I want to focus on two issues--cultural fluency and cultural politics--to encourage readers to get the report themselves, which they can download for free from unfpa.org/swp.

Engaging culture
UNFPA says it is important to start with what people already know, and with their existing norms and values. The UNFPA also uses the term "cultural sensitivity" but I feel sensitivity can sometimes take on a token quality, meaning we look at other people and say we respect their culture, but we do so in a detached way, remaining distant.

At UP and Ateneo's medical schools, our team of anthropologists uses the term "cultural competence," a somewhat more modest term than "cultural fluency." Competence and fluency can come only from a more engaged immersion--doctors taking time, for example, to understand where a patient is coming from because of sex, ethnicity, religion, class or other social circumstances.

Cultural competence and fluency go beyond the "what" of culture, which often results in a list of quaint beliefs and practices. Instead, we probe and ask why people have these perceptions and concepts.

There are many examples from family planning. All it takes is one negative experience of a couple with a particular method--"natural" or "artificial"--to convince the entire barangay to avoid using it.

Power
The other important concept to pick up from UNFPA's yearbook is cultural politics, which recognizes that cultures are not static givens. Cultural meanings and norms are often formulated and imposed by people with power.

I particularly appreciate the way UNFPA identifies different types of power, including the most insidious one, which is hidden and non-coercive, so much so that the oppressed themselves become the most ardent defenders of the status quo.

For some time now, I have been asked why the Philippines can seem so progressive in terms of gender equality, even ranking sixth globally and first among developing countries, in the World Economic Forum's annual survey on gender equality. The latest survey was released on Wednesday, and the press releases note that this was the third year in a row where the Philippines has held that ranking.

The indicators are clear, showing we rank high in terms of women's education, women's access to high positions in the academe, private corporations, and government with two women presidents. Yet when it comes to reproductive health, one where women's empowerment is so crucial, we fare poorly, with continuing high maternal death rates and low family planning usage.

Why this paradoxical situation? The answer may come from cultural politics: the way women and men have internalized repressive cultural traditions. In the Philippine context, cultural conditioning has made us fear the freedom that comes with gender equality. It's not surprising that the word "liberated," which should be very positive, has very negative connotations, mainly sexual promiscuity, when used to describe a woman in the Philippines. Women know that, too, and so they "embody" this fear of liberation, becoming careful about every body movement, every word said about sex.

This embodied oppression finds its way to other aspects of our lives: the way we raise our children, the way we talk (or don't talk) about sex, even the way we respond to injustices. The UNFPA report refers to a little known fact in the Philippines: rapes in Basilan escalated between 2000 and 2003 because of armed conflict. Rather than sympathizing with the raped women, the communities discriminated against them, labeling them as "dirty." Even worse, some of the women were forced to marry the soldiers.

The cultural politics here is blatant: If women are made "dirty" by the men through rape, it is only these rapists who can make them "clean" again by marrying them. Repulsive? Our laws actually absolve rapists of criminal liability if they marry the woman they raped.

UNFPA reminds us that people are not always passive victims. Cultural politics means that dominant meanings and practices are constantly being contested and challenged by people who work on a rights framework. Put simply, a woman gets to the point where she's had enough and decides she has rights, and will fight for those rights.

An excellent example of cultural politics in the Philippine setting is the recent statement of 14 Ateneo professors (joined later by 55 more), expressing their support for the Reproductive Health Bill, even as they assert that this is not in contradiction with their Catholic faith. A particular passage highlights the negotiations around culture:

"We respect the consciences of our bishops when they promote natural family planning as the only moral means of contraception. . . In turn, we ask our bishops to respect the one in three (35.6%) married Filipino women who, in their ‘most secret core and sanctuary' or conscience, have decided that their and their family's interests would best be served by using a modern artificial means of contraception. Is it not possible that these women and their spouses were obeying their well-informed and well-formed consciences when they opted to use an artificial contraceptive?"

Sensitivity, dialogue, negotiations. UNFPA synthesizes its discussions around culture quite elegantly when it points out how culture presents us with infinite choices: "From within the same cultural matrix we can extract arguments and strategies for the degradation or ennoblement of our species, for its enslavement or liberation, for the suppression of its productive potential or its enhancement."

More than a simple declaration, that passage should be taken as a challenge to Filipinos and people throughout the world to take culture and health seriously.


By Michael Tan
Philippine Daily Inquirer
11/14/2008