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

This understandinghow self motivating and self

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This understanding—how self-motivating and self-sanctioning behaviours move human action for some, and limit it for others—has implications for health care and behaviour beyond the material resources available to people. The assumption that individuals are always moved by self-interest is itself a cultural prejudice that is overturned each time a human being makes a sacrifice for someone else. It also affects attitudes towards distribution and redistribution of resources and an individual’s ability and willingness to have an effect on local circumstances. In Buddhism, for instance, the worst acts of evil are not those committed by criminals as such, but by those who have had the privilege of learning and now use that knowledge inappropriately. Knowledge comes of experience, and suffering can not only have meaning, but also provide enlightenment. 177 Such a view shows that collective suffering—such as that associated with, for example, the killing fields of Cambodia, Sri Lanka, Indonesia, and, most recently, Burma—can also heal when it is acknowledged. Inequality, then, is only one (even if the most fundamental) part of what limits the capacity of people to control their futures. Identification of socioeconomic inequalities is important. However, inequalities are relative and are not purely financial and economic. Cultural systems of value affect local and worldwide inequalities in much more subtle and complex ways than are often immediately apparent. Care providers, therefore, need to be diligent in recognising how and when they participate in discriminatory practices. Cultural equality—treating others as different but equal—must become a priority when care providers address the most fundamental challenges in care delivery. Otherwise, the desire to be fair in management of human adversity will remain unfulfilled. Techniques of erasure Michel Foucault 178 argued that confinement of prisoners was dehumanising not merely because containment itself is painful. In extreme forms of confinement, prisoners lack the ability to make the most basic eye-to- eye social agreements with those who imprison them. His concern has direct implications for what a focus on structural violence can miss—namely, the effects of erasure of other forms of meaning, and the assumptions that carers make regarding what constitutes a cure. 179 As Laurence Kirmayer writes: “for those others who come from far away, and especially for those escaping extremes of chaos and violence, experience is hard to come by and harder to convey. There may be elements of the random and arbitrary that fall outside the possibility of any conventional account, and challenge our need for order and explanation.” 142 Kirmayer’s point is not that cultural awareness might be unachievable, but rather that what people find credible in stories of suffering is defined for them by personal values that are never neutral. To provide a proper assessment of suffering, practitioners should come to
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