Dilemma of cultural determinants of health

Sir,

I have read with interest the editorial by Chaturvedi et al1 on cultural determinants. There is no denying that cultural practices cast an important influence on the health of the people and as such the study of these influences deserves greater seriousness. However, we also need to address the question - ‘What creates or constructs the cultural moorings of the people?’ Can there be a conceptualization of culture devoid of the economic, social and political structure of the society? We know that the culture of a slave society was much different from that of a feudal society and development of human civilization to the capitalist and socialist societies opened up vast possibilities for cultural advancement of the people. Central to this was the change in the forces of production, the relations of production they enforced, leading to a economic, social and political structuring of the society that was suitable to the requirements of a production system and a culture that rationalized such structuring of society. At no point in time and at no place were such momentous changes affected by a primary change in culture of the people. For example, most of the issues pertaining to women's health in countries like India are invariably a result of the lingering feudal attitudes towards women and sexuality. Even in the advanced capitalist societies, most of the problems of the women accrue from inferior position accorded to her in the production and property relations.

Another very important caution that one must exercise in the study of cultural determinants is that we move from the macro (societal) levels to the micro (community and individual) level factors. The macro provides the context in which micro is to be analyzed. For example, any comment on the social acceptance or the propagation of the culture of drinking is meaningless unless we see it in the context of the political economy of liquor industry. There is also a class orientation to the whole issue; socially speaking this problem is reflected in a much uglier way among the labouring masses, than among the well to do, and yet the tool to understand this phenomenon is the political economy and not culture per se.

I agree that most of the studies of the social determinants of health do not go beyond correlating the health outcomes with the social and economic parameters, or elaborating upon the pathways by which these parameters impact on the health outcomes, but without questioning the structural causes of the broader socio-economic realities. This however, does not mean that stand alone epidemiological study of cultural determinants will provide the missing answers. One inadvertent result of this can certainly be that our health planners will promptly wield the stick of culture to browbeat the people, without reflecting upon the mess that they have otherwise created. During campaigns on the issue of user charges in different hospitals of Delhi, we often came across the refrain from many doctors - “if they have the money for drinking liquor and bidis, they might as well pay for their health.”

The question is not of Social Determinants vs Cultural Determinants but of studying the composite whole, and studying it with the honesty; not in a circumscribed manner that suits the convenience of the rulers.