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

What has happened during the subsequent 30 years

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What has happened during the subsequent 30 years? Despite this longstanding awareness and many regulations, discrimination remains almost unchecked. Blacks outnumber other racial groups by as much as 3:1 in some UK psychiatric intensive care units. 162 Similar findings from a study of life expectancy of black Americans showed that racial disparities in the delivery of heath care have not decreased substantially, leaving them to live, on average, 6 years less than white Americans. 163 Decades of work have “documented that whether bounded by ethnic or racial identities, immigrant status, English language fl uency, educational attainment, poverty, low socioeconomic status, or urban/rural residence,
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The Lancet Commissions Vol 384 November 1, 2014 1623 minorities and the poor receive less care and poorer quality care than their middle class and educated compatriots”. 163 Type 2 diabetes is so common in indigenous communities (more than 50% of men older than 50 years of age for some Native American groups) that local leaders openly describe the sequestration of indigenous people into reservation social housing as a form of cultural genocide. In the Pacifi c Island Countries and Territories, the situation is particularly worrying, especially when considered against the background of groups in which this illness was once virtually unknown 164 (panel 7). Although measurement of differences in treatment according to race is still important, the eff ects of interventions need to be gauged as they relate to the ability of people being treated to make their own decisions. “Unless differences in medical care according to race refl ect the quality of care and meaningfully aff ect patients’ survival or quality of life, the existence of racial disparities will remain of far greater interest to social scientists than to policy makers and physicians.” 167 If freedom to make decisions is limited by race, then racial disparities should fi rst be addressed and controlled for before disease can be examined racially. In too many instances, racial factors are assumed relevant to disease without controlling for social inequality and its eff ects on an individual’s capability and opportunity. Despite debate about their meanings and relation to one another, the ideas of agency and social structure are still used in many disciplines to highlight the relation between individual decisions and a person’s sense of what is feasible. At an individual level, obtaining and maintaining a minimum degree of agency—that is, an individual’s capacity to act on the world—might, in fact, be as or more important than relative status in any given society because perceptions of inequality are always relative and, in unstable contexts, exaggerated in unexpected ways. Many social scientists agree, therefore, that if the aim is to grant every human being a sense of agency, then the expression and exercise of will needs always to be locally contextualised. After all, people will
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