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

Indeed exclusion of outsiders in moments of perceived

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Indeed, exclusion of outsiders in moments of perceived duress is not limited to nations and majority groups—the same tendency to discriminate is equally evident when health-care workers discriminate against other kinds of health work as less important; when health authorities perceive non-biological interventions as expendable; and when advocates of global health criticise local practices as insuffi cient or unprofessional. To perceive different cultural practices as sources of trouble occurs especially when those who represent dominant forms of care provision feel threatened and vulnerable. In these circumstances, the biomedical validity of other cultural practices (and notions of health and wellbeing) can be challenged outright (panel 3). However, although contemporary biomedicine is quick to see itself as universal, 126 in some countries as much as 85% of a population self-medicates without the benefi t of biomedical care—ie, do not participate directly on a daily basis in worldwide biomedical culture and the professional networks of biomedical practitioners. 127 Indeed, most people choose their own forms of medical treatments because biomedical provision is absent. 128,129 Although this majority might rely on local, indigenous remedies, inauthentic and out-of-date pharmaceuticals, or products and inter- ventions that have unknown eff ects, it nonetheless can be made up of individuals who have strong views about wellbeing and health. The idea that biomedicine is able to address the ills of the world is therefore a fundamentally cultural notion. An under standing, then, of how culture plays out in disadvantaged societies and groups can enable people to go beyond simplistic arguments that focus exclusively on the benefi ts of worldwide fi nancial equality, while also holding impor- tant answers to overwhelming health-care delivery challenges (panel 4). In a healthy society, both outsiders and upwardly mobile professional achievers can nourish, inform, and Panel 3: Multiculturalism and the limits of governance In May, 2012, a regional court in Cologne in Germany defi ned male circumcision on religious grounds and without medical indication or legally valid consent of the circumcised as bodily harm and thus liable to prosecution. 123 The ruling outlawed a religious ritual central to Jewish and Muslim faith communities on the grounds that state law needed to protect the basic right of children to physical integrity. By doing so, the Cologne court made a continuation of Jewish and Muslim religious life impossible. In the ensuing debate, health-care professionals argued both for and against the ruling. Mathias Franz (University of Düsseldorf, Germany) claimed that the damage inflicted on the body and the long-term psychotraumatic effects of circumcision outweighed their religious significance. The German Academy for Paediatrics avoided a clear statement, but pleaded in favour of new legal provisions respecting both a child’s physical integrity and the religious sensitivities of their parents. The highly respected Deutscher Ethikrat, a committee advising
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