Cultural factors

Culture encompasses the set of beliefs, moral values, traditions, language, and laws (or rules of
behavior) held in common by a nation, a community, or other defined group of people. Culturally
determined characteristics include: the language spoken at home; religious observances; customs
(including marriage customs that often accompany religious and other beliefs); acceptable
gender roles and occupations; dietary practices; intellectual, artistic, and leisure-time pursuits;
and other aspects of behavior. In the United States, and in other nations with large immigrant
populations, there is a wide range of cultural diversity, religious beliefs, customs, and values,
reflecting the scattered origins of the people. The "melting-pot" concept of nationality reduces
this diversity with successive generations, but considerable variation remainsdistinguishing
rural from urban, African American from European, East Asian from South Asian, religious
believers from secularists.
Anthropologists and epidemiologists have identified many associations between culture,
customs, and risks to health. Those who, for religious reasons, abstain from tea, coffee, alcohol,
and tobacco have smaller risks of getting cancer of the gastrointestinal or respiratory tract than
others of similar social, economic, and residential background. Seventh-day Adventists, who are
strict vegetarians and are very health conscious have low death rates from coronary heart disease
when compared to neighbors of similar socioeconomic backgrounds. Though often called
"lifestyle factors," in such cases these differences are culturally determined because the related
behaviors are associated with religious beliefs and practices. Jews who practice circumcision
have lower incidence and death rates than gentiles from cancer of the male genital tract, perhaps
related to sexual hygiene and reduced risk of infection with carcinogenic viruses.
Many cultural characteristics, and the health states related to them, are associated with education,
occupation, income, and social status. These factors influence one's awareness of the world, and
whether one will seek improvement or accept things as they are. Well-educated white-collar
workers may be more aware of the benefits of exercise than those lacking educationthey are
more likely to play than watch sports, and are more likely to have better-paying jobs that enable
them to afford sporting equipment. Values related to these perceptions also shape the relative
priority accorded to intellectual versus athletic pursuits, motivating some working-class parents
to encourage their children to study and remain in school in hopes of a better life for the children

than the parents have had. The clash of competing values between environmental sustainability
and economic development also has a cultural component. Appreciation of the fact that health is
ultimately dependent on the integrity of the earth's life-supporting ecosystems is part of a value
system. Such values may sometimes be over-ridden by short-term priorities such as job security
or financial gain.
Much can be learned about the linkages between culture and health by studying migrant
populations, whose culture of origin is often very different from the culture into which they
migrate. Japanese migrants to California and Hawaii were found to have higher rates of coronary
artery disease than their counterparts in Japan. Part of this difference could be attributed to
changes in risk factors such as diet, weight, and cholesterol levels. However, loss of a stable,
cohesive social environment also appears to have contributed to the rise in prevalence of
coronary artery disease in the migrant groups. In another study, blood pressure values among
African Americans from the southern United States who migrated to an urban environment were
compared with that of urbanborn African Americans. The longer the period of city life, the higher
was their blood pressure. Many studies have shown that immigrants have higher rates of mental
illness, probably due to the tremendous stresses of living in a new cultural environment. Cultural
groups that have a strong group identity and cohesion seem to be somewhat protected against
this type of stress.
Culturally shaped illnesses are disorders that reflect the social, political, and moral worlds of the
patient. They also often represent ways in which deep cultural messages are transmitted through
the medium of the human body. For example, among Latino populations in Central America and
the United States, anthropologists describe "ataques de nervios," an illness characterized by
symptoms such as shaking, a feeling of heat in the chest, difficulty in moving the limbs, and
parasthesias. Among Latino immigrants in the United States, anthropologists have linked the
illness to the sense of social and political disempowerment that these people experience. Other
culturally shaped illnesses include: "heart distress" in Iran; "semen loss" in South Asia; and
"susto" in Latin America. Anthropologists study the symbolic meaning of symptoms within
specific cultural contexts in order to understand the cultural messages these illnesses express.
Cultural context can profoundly affect the transmission of disease. A tragic example is the spread
of HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome),
particularly in Africa, where economic necessity shapes choices that are often hazardous to

health. The combination of limited education, migratory labor that separates men from their
wives and families, and the breakdown of traditional family networks creates a context in which
men may seek multiple sexual partners. Women often lack the social power to negotiate condom
use, and their need for economic and social survival outweighs the risk that they know they are
taking by having unprotected intercourse. In Thailand, where culturally condoned intravenous
drug use is widespread among the large population of sex workers, HIV/AIDS and other bloodborne viral diseases became epidemic in the 1990s, creating a national public health emergency.
The health of girls and women is particularly sensitive to cultural influences. In societies where
women are able to make decisions for themselves, especially about their education and their
reproductive choices, have longer life expectancy, lower fertility rates, and better overall health.
When political totalitarianism and religious zealotry flourish, women usually suffer oppression
disproportionately compared to men, and this can adversely affect their health and longevity.
Patriachal values can also be harmful to the health of girls and women. Such values have a
pervasive influence in many settings, mainly in traditional agricultural societies, but also in some
urbanized economies. In some strict Islamic societies where girls and women are segregated and
allowed to appear in public only if totally covered from head to toe, deprivation of sunlight can
impair the cutaneous synthesis of vitamin D, causing a deficiency of this vitamin and putting the
women at risk for rickets or osteomalacia.
Another cultural practice with severe health consequences is female genital mutilation, which is
performed on young girls in many African and Middle Eastern nations. In its most extreme form,
the procedure can be life threatening. It deprives women of sexual fulfillment and makes
childbirth a hazardous process for both mother and infant. While performed in many
predominantly Islamic countries, this procedure is not a religious ritual, and is not condoned by
any Islamic scripture. Anthropologists have described the complex cultural meanings of ritual
purity associated with female genital mutilation that serve to perpetuate this practice despite its
serious adverse effects on health. The majority of women and men in cultures that perform
genital mutilation support the continuation of the practice which makes change all the more
difficult. Both international and national efforts are underway to stop or change this practice,
with some of the most promising initiatives coming from within the cultures themselves. Female
genital mutilation was banned in the United States in 1995, and is also outlawed in Britain,
France, Canada, Sweden, Switzerland, and some African countries.

In Western societies the female body is often altered for cultural reasons. Women in the
nineteenth century constricted their waists and compressed their breasts with rigid corsets. Many
women today wear high heels and tight shoes that deform their feet, with painful consequences
in old age. Some undergo painful cosmetic surgery in the quest for an idealized physical form,
with reshaped ears, eyes, and nose; facelifts; liposuction; and breast implants. Some girls and
women strive to achieve a very low body weight, a modern, culturally shaped notion of beauty
that has supplanted the former "ideal"the plump female form depicted in the paintings of
Rubens and Renoir. The pursuit of very low body weight may be associated with the
development of anorexia nervosa, an illness that can be fatal. Men in Western society in the late
twentieth century also began seeking an "improved" body image by taking muscle-enhancing
steroids or having muscle grafts to enlarge pectoral and calf muscles.
In modern industrial societies an adolescent culture has developed. This culture often fosters
rebelliousness and defiance of adult authority figures, leading some young people to smoke, take
drugs, and expose themselves to dangerous and unhealthy practices. Such actions have,
unfortunately, often been encouraged by the tobacco industry and advertisers of beer and other
alcoholic drinks. The pervasive influence of the media, especially television, in almost all
contemporary societies projects cultural values and behavior that emanate from the American
entertainment industry. Many of these messages, such as encouraging the use of mood-altering
substances and sexual promiscuity, are potentially harmful to health.
Public health specialists must be aware of these and other cultural trends, and they must
endeavor to mobilize beneficial cultural influences while discouraging unhealthy ones. The task
of public health professionals is particularly challenging when influential and economically
motivated interests glorify aspects of culture that are harmful to health.