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

Often use their their own agency to deny themselves

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often use their their own agency to deny themselves what is otherwise accessible (food, water, and protection from the elements) when they put aside their own needs in favour of those of their families and friends. Agency is inevitably structured, although not always structurally established. People’s everyday lives and the restrictions on their decision making are, in part, shaped for them by external and internal structures. Because structures can remain hidden (eg, when culturally driven ideas are assumed within a group holding them to be universal, or when people working to abate inequality themselves subscribe to their own prestige hierarchies), education should be the means to increase awareness of those structures and their effects. Pioneer 19th-century thinkers about health and its maldistribution, such as Engels 169 and Virchow, 170 regarded those who defended or promoted structures that systematically worked to their advantage and to the disadvantage of others as murderers (eg, for Engels, the Manchester factory owner murdered his employees by exploiting them to the point of making them sick and so shortening their lives). 171 This kind of structural violence is not as controversial if acknowledged in the past or in distant places. However, it clearly applies no less to contemporary financial, business, political, and other elites than it did to Engels’ factory owners. To put this point another way, people’s lives are structured by social mechanisms that they are often largely unable to affect, the elucidation of which is opposed by the advantaged. 23 Caste, class, status, sex, ethnic group, age, and gender preference are all examples where hiding difference also involves hiding inequality. In India, the so-called Scheduled Castes (or Untouchables) who make up about 15% of the pop- ulation continue to be subjected to systematic structural violence, 172 despite the fact that the Indian constitution explicitly prohibits discrimination based on the now- abolished caste system. For example, findings from a field study showed that 10 years after the reforms began in 1951, only 6% of formerly Untouchable families had been able to purchase land compared with 55% of high- caste Hindus and 66% of intermediate-caste Hindus and Muslims. 173 Libertarians often argue that agency is available to all—a thing we earn through hard work—and some Panel 7: Cultural genocide of indigenous groups Samoan Airlines has announced that it will introduce extra-wide seats to accommodate the increasing need for such seating by obese passengers. 165 Three-quarters of deaths in the Pacifi c Island Countries and Territories are caused by non-communicable diseases. 166 According to a WHO report, 166 60–90% of people aged 25–64 years are overweight in some regions of the Pacifi c, where diabetes occurs in up to 40% of some populations. Although genetics are important, much of the disproportionate non-communicable disease burden of Pacifi c Island people is the outcome of cultural disadvantage. Although high rates of non-insulin-dependent
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