the-lancet---culture-and-health.pdf

202 in fact the system worked not only in urban

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202 In fact, the system worked (not only in urban settings, but for the most isolated areas of the UK) for three reasons. First, it embedded and incentivised health-care providers suffi ciently to enable otherwise fragile communities to re-emerge and survive. Second, it increased the status of rural doctors through its inducement practitioners scheme. And third, it enabled doctors to become advocates for the communities they served. These basic strategies should be emulated, and resources should be devoted to understand them better. The designers of the NHS recognised that care is a person-to-person exchange that can be disrupted easily when community is eroded or advocates’ loyalties and aspirations are in conflict. For instance, removal of patients with Alzheimer’s disease from homes to care homes shows that disorientation is a risk factor for vulnerable people irrespective of health status. 203,204 100 years on, those same Scottish communities still consider having a primary care doctor the key to making a community viable. 205 As the world becomes less culturally diverse, fewer models of caring are available. However, much can be learned from traditional cultures about caring, 107 from traditional institutions about innovation to meet essential needs, and from new institutions of care that emerge around diverse cultural values. How different individuals, families, and communities give care should be carefully studied. 107 For example, all societies need to rethink how families can make possible more dignified ways of ageing when increased life expectancy changes populations and social priorities. Furthermore, when necessity demands innovation at the local level, new ways of caring sometimes emerge that can provide promising solutions to otherwise insurmountable needs
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The Lancet Commissions 1628 www.thelancet.com Vol 384 November 1, 2014 elsewhere, making it possible, at times, to build a successful health-care system from an idea generated locally (panel 9). However, in multicultural settings, a special need exists to be open to new models of care; a group’s views of what is feasible can often be limited by what it might already assume to be immutable. If clinical care alone does not sustain health, clinical care embedded in relationships of social meaning does—that is, not only in community in a demographic sense, but as it makes possible face-to-face consensus on suffering, tolerance, altruism, and goodwill. Success demands complex social skills that are not well replaced through technical innovations in communication. 208 The first half, therefore, of creating affective communities of care involves gaining an understanding of a community’s sense of what is feasible. However, socially generated wellbeing is the other half of clinical care that decides a population’s willingness to shoulder social burdens and emerge with dignity and respect for having done so. Wellbeing is about sustainability, trust, and continuity. It is not an indicator to be measured economically, even though some think that public trust is itself measurable.
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