The issue therefore is not inequality but how agency

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for excellence in the face of mediocrity). The issue, therefore, is not inequality, but how agency and advantage is described and understood when managing the unequal opportunities that disadvantage others. Although awareness of the cultural dimensions of one’s own practices and values is diffi cult, culture mediates between agency and the structures that provide or limit wellbeing, healing, and health. To the extent that tension exists between the structurally advantaged and dis- advantaged, culture provides pertinent sites and relevant narratives for contestation of human values. Any social debate about a government’s responsibility for health care will, for example, show not only what is being contested, but also the limits of what is contestable. 112 Because our values are measured against cultural practices that we believe ourselves to share or not share with others, an understanding of the cultural dimensions of our own practices becomes just as important as those of others. We believe that this observation is crucial to health because it emphasises the cultural dimensions of shared moral choices. We do not mean that morality is relative, but that it is always expressed in relative terms. Cultural systems of value are not wholly abstract. They consist of functional ideologies that have moral consequences, especially when otherwise inalienable rights become negotiable. For example, in his work on French asylum policies and immigration, Didier Fassin 122 described precisely this moral variation—how the lives and suffering of others are variably governed and altered by tensions over time between repression and compassion. “Why”, he asks, should there remain “in societies hostile to immigrants and lacking in concern for undesirable others…a sense of common humanity collectively expressed through attention paid to human needs and suffering?” How does a moral economy transform? Does variation in a moral economy also produce, over time, a kind of moral epidemiology? Although the term used in this sense is ours, not Fassin’s, it does capture a crucial point in his work. This point is that it is much easier to claim the moral high ground from the vantage of socioeconomic and hegemonic stability and privilege than to acknowledge how humanitarian societies can become less humanitarian in the face of social stress. Attention to welfare and wellbeing is sadly negotiable, even in states where the rights to health have been foundational. Does a stated concern with structural violence, then, present an incomplete picture of the actual needs of Panel 8: Agency and fourth-world cultures ‘Fourth-world’ cultures include traditional societies whose human rights are at risk because their ways of living may differ from those of dominant populations or nations within whose borders they reside—say, Jews in Europe before World War II, or tribal groups in many parts of Amazonia—but the term also may be used to describe members of indigenous groups who are unfairly used in double-blind clinical trials, or who do not suffi
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  • Summer '18
  • Jeanne Hughes
  • Lancet

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