InterCultural Perspectives on Individual Health

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Inter-Cultural Perspectives on Individual
Health Public health in Europe

SAT 10th of OCTOBER 2009 seminar on health
determinants
William SHERLAW Direction des Affaires
Internationales Department of Nursing
Paramedical Science EHESP School of Public Health
Rennes France William.Sherlaw_at_ehesp.fr
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 Europe is diverse linguistically socially and
healthwise  

• Linguistically
• Many languages have different words for health
  with Latin Germanic Greek roots
• With both profane/non religious and religious
  connotations
• Diverse Europe  Mapping Social change
  acrossthe EU  Richard Berthoud, Maria Iacovou
  Institute for Economic and Social Research
  University of Essex (ESCR) 2003

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Latin roots of health- In good health / Heal/Cure

• Salere ( in good form) gesund Gesundheit
  Heilund (Cure) Heiland
  (saviour)
• Salvus (intact) holy whole holistic
• Salus (good state) salut
• Sanare (render well) healthy health heal healing
  healer
• Sanascere (heal)
• Sanus (sain) santé sanitaire
• Sanati
• Sanitas (santé) sane sanitary
• système sanitaire
• Valere valid valide evaluate

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In Greek

• Hygie
• Hygieia healthsanté  the state of
  someone who is well in life  Hygiene
• GORGIAS Plato
• Health is the greatest of goods for mortal man
  ,then follows beauty, wealth, and youth
• Europe is also diverse socially

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Fig based on  Diverse Europe  Mapping Social
change across the EU  Richard Berthoud, Maria
Iacovou Institute for Economic and Social
Research University of Essex (ESCR) 2003
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Fig based on  Diverse Europe  Mapping Social
change across the EU  Richard Berthoud, Maria
Iacovou Institute for Economic and Social
Research University of Essex (ESCR) 2003
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And for the elderly

• In Southern Catholic countries like  Ireland,
  Portugal, Spain, Italy and Greece 33 of women
  over the age of 65 live with one or more of their
  children 
• In Northern Central countries like  the UK,
  Belgium, Luxembourg, France, Germany and Austria
  10 live with a child 
• And in Nordic Countries Finland, Sweden, Denmark
  and the Netherlands  only 3 live in the same
  house as one of their their children 
• And Europe is diverse healthwise

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Variation in health matters

• And how long you live and also how long you live
  healthily varies between countries but also
  within countries and even the same city.
• And the number of doctors available to treat
  you...

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International comparisonDoctors
General practitioners
Practising physicians in OCDE countries(density
/1000 inhab.)
Specialists
Grateful thanks to Dr Martine Bellanger Dr
Oliver Grimaud EHESP
Source OCDE Health data 2008
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Not to mention hospital beds
Grateful thanks to Dr Martine Bellanger Dr
Oliver Grimaud EHESP
Source Eco-Santé OCDE 2008 - Version décembre
2008
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If you have a sore throat

• If you go to see a doctor for a sore throat it is
  likely you will get different treatment in
  different places

 In France, North America, or Finland, a
diagnostic test will be performed, and the
treatment will depend on its result. In England,
Scotland, Belgium, or the Netherlands, physicians
will not use a diagnostic test, and the decision
to prescribe penicillin will depend mainly on the
patients illness severity 
J. Matthys et al, Ann Fam Med 20075436-443.
DOI 10.1370/afm.741.
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For the same old shoulder injury

• In France and Germany, doctors prescribe
  physiotherapy.
• In Britain, they tell you to go home.
• In the United States, top orthopedist recommends
  joint-replacement surgery, costing tens of
  thousands of dollars
• And when is early early ?

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Depending on the country the length of time in
maternity clinic is likely to vary

• In Britain you could leave the clinic with your
  baby within 24 hours
• In Denmark probably in 48 hours
• About the same now in Lithuania
• In France may be 3 to 5 days
• Depending on which country you come from you are
  more likely to be able to have a home birth,
  have a Caesarian or breast feed or not

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• Different European countries traditionally have
  different ways of being ill
• e.g. Low blood pressure (Germany), Spasmophilia
  (France)
• Crise de foie (France) Stomach (Bellyache)
  Britain
• Diagnoses of schizophrenia despite International
  Classifications of disease may vary between
  countries e.g. France and Britain (Van Os et al.)
• We care and educate our children with
  disabilities differently too

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Not to mention suppositories and thermometersThe
list could be long

• Although there is considerable variation which is
  interesting in itself and sometimes amusing
• Different health and social protection systems
• Socioeconomic factors
• Medical health professional training
• Cultural religious traditions
• Style of thinking and beliefs about health
• How to manage it deal with it both individually
  and through public health policy.
• There is also great pressure to harmonize
  treatment and prevention strategies

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Many different definitions and ways of looking at
health
Back to health

• Individually
• Population (public health)
• Subjectively
• Objectively
• WHO  utopian  Definition
•  Health is not only an absence of disease or
  disability but is a complete state of physical,
  mental and social well-being 

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Another definition

• Health can be defined as a state of balance that
  individuals establish within themselves and with
  their environment It is the product of a number
  of interrelated dimensions, including mental,
  physical, emotional, social, cultural and
  spiritual dimensions. Sartorius (1998)
• But in reality in the real public health world
  we count

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More to an obelisk than meets the eye !
After Davey-Smith
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We nearly always define health through disease
and death

• Deaths (mortality) and number of people who have
  a disease (morbidity) We calculate life
  expectancy and years of life lost and adjust if
  for disability And then we say the population is
  healthier or less healthy
• Why ? It is easier to count
• It is more objective.
• In demography and epidemiology everyone is equal
  and counts as one but

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But we think about health from the negative pole

• We are always on the look out for disease,
  talking of disability, avoiding risk,
• Do you remember Dr Knock ? (Jules Romains)  In
  every well man their is a potential patient in
  the waiting 
• If you look hard enough youll find something
• The public health river and people drowning
  parable
• Some even have suggested that if in the past we
  invented drugs to treat disease
• Now we invent disease to make and sell drugs
• (Blech) Viagra 150-200 million euros/year in
  Germany alone (2005).
• Not to mention Hyperactivity and attention
  deficit disorder Ritalin among others Low
  blood pressure becomes high

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So we define health through disease/maladie

• We do this both individually and in public health
• In the past you could be
• well in good health
• Ill or have a disease
• Dead
• But its not so simple now

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For the Individual

• When you are feel ill you complain of symptoms
  this gives your doctor an idea of whats wrong
  diagnosis
• But you can feel well but have signs of disease
  which tells your doctor that you will probably be
  ill
• But the signs now often come from biological
  tests. You get normal values or abnormal values.
  But these come from gathering data from many
  cases

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Fixing what is normal

• This data fixes what is normal and abnormal
• So there is constant influence of public health
  data on individual health and vice-versa
• So now based on epidemiology we have invented a
  new category neither ill nor well people at
  risk or at risk groups. e.g. smokers, drinkers,
  obese, drug users etc. So if you have a high
  blood pressure highish level of cholesterol

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Consequences

• We offer advice to people to adopt or change
  lifestyles in order to diminish risk.
• But the problem is we can predict how many people
  will die or commit suicide or contract a disease
  or shoot people for instance but not precisely
  who
• Consider the following two graphs

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The sociocultural economic political context
matters
After Michael Marmot Understanding social
determinants in Berkmann Kawachi Social
Epidemiology OxfordOxford University Press
2000 Citing
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The sociocultural economic political context
matters
After Michael Marmot Understanding social
determinants in Berkmann Kawachi Social
Epidemiology OxfordOxford University Press 2000
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Different questions and different answers

• Why do some individuals murder people and some do
  not ?
• Why is there such a big difference between
  Chicago and England and Wales ?
• This gives rise to two sorts of prevention
  health promotion policy
• A) Individual
• B) Environmental and Community

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Whose responsibility ?

• In public health we can broadly divide
  interventions into two sorts. Those that
• Involve the responsibility of the individual for
  his or her health
• Let us remind us of one definition of Individual
  health Health is a state of balance between the
  self, others and the environment
• Involve the responsibility of the social and
  political institutions

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Responsibility of the individual for his or her
health -

• GIVING ADVICE
• Scientific Knowledge becomes information and
  information becomes advice and advice may
  possibly become appropriated knowledge.
• 3 KINDS OF ADVICE
• Prudential how to do something in order to
  satisfy the recipients own wishes desires)
  Good advice results in What one wants WANTS
  give up smoking
• Beneficial What best for the person It
  does not take its advisees wants and desires as
  fixed givens. What should the person (if
  sensible) want given the nature of their best
  interests Good advice results in what is good
  for ones best interest INTERESTS
• Moral advice geared to what one ought to do.
  Good advice results in protection of the interest
  of others OBLIGATIONS passive smoking
• Giving advice is relatively ineffective. It is
  difficult to induce change in lifestyles.
• Probably works better in a climate of trust and
  privileged relationships

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Responsibility of the social and political
institutions

• Reducing unemployment, improving schooling and
  housing, increase public transport, reduce stigma
  and discrimination, changing norms, enforcing
  speed limits
• Key agents Politicians, Educators, NGOS
• But its much more difficult to do due to vested
  interests or sacred traditions
• And so its easier to offer individual advice
  (rather than change the housing, the working
  conditions, the price of fresh fruit and
  vegetables, adding chocolate sugar to muesli,
  ban guns in the US)
• Dangers of an inherent moralism

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There are interesting deep-running cultural
parallels between religion health (Laplantine
1986)
TRANSGRESSION OBEDIENCE
By your good works

• In the christian religion

Sinners
Saved
Grace (Chosen)
Damned
Follow the health advice Accept the medical creed
If follow advice but Fall ill and die early
Scandal (Unlucky)
Health as a just reward
In the health religion Information
knowledge Transformative Power Money
Illness as a sanction
Fall ill
Medical Might Genetics
Due to ignorance Carelessness Irrational
behaviour OR Deliberate disregard of advice
If you live long in good health Scandal No
justice
If you are ill die ( Not surprising)

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This takes us back to health and real culture and
lifes

• Health is not all ! People live possible lives
  (LeCorps) People might have more important
  things to think about and do Too much health is
  unhealthy ! too much worry --- little joie de
  vivre Fugelli (2006)
• Two ways of looking at it
• Health as a good in its own right
• Health as a means of favouring choices we have
  reason to value (Amartya SEN)

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Can you guess what these tables refer to ?
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GRAZIE MERCI THANKS