were from different ethnic groups.
One of the earliest and most significant investigations on the actual influence of culture on sick-role behavior was Mark Zborowski’s (1952, 1969) analysis of cultural differences in responses to pain. Investigating differences among war veterans warded in an American hospital, he observed that the Italian-American and Jewish-American patients differed significantly from the “old American” and Irish-American patients in their expression of pain and description of their symptoms. Zborowski proposed that cultural differences such as socialization, time-orientation, and the array of values outlining what is appropriate behavior in cultural communities explained the differences he observed among the four groups of patients. Similarly, Irving Zola (1966) analyzed how culture shapes the subjective perception of symptoms. His research confirmed Zborowski’s findings on the presence of cultural differences in perception of, and reaction to, symptoms and pain. Zola (1973, 1983) continued his probe into the impact of cultural differences on the doctor–patient relationship, the perception of illness, and the importance given to health matters in different cultural communities. Twaddle (1978) conducted an exploratory replication of Zborowski’s study, comparing 26 American married males who classified themselves as “Italian Catholics,” “Protestants,” and “Jewish.” Twaddle found that Parsons’ configuration of “sick role” varied among these groups. The relevance of cultural differences in responses to pain is well recognized and research on this important dimension continues. Some examples of findings on cultural differences are: Black Caribbean and White British cancer patients (Koffman et al. 2008); Saudi, Swedish and Italian patients with temporomandibular disorder (Al-Harthy et al. 2016); Japanese and British subjects’ pain tolerance (Robertson et al. 2017); and chronic back pain among English-speaking Punjabi and white British people (Singh et al. 2018).
Similarly, studies continue to confirm the impact of culture on the doctor–patient relation and, correspondingly, on patient outcomes. Nitcher (1994) observed the use of the traditional term “mahina ang baga” (weak lungs) by doctors and lay persons in the Philippines. Nitcher found that doctors used the term when diagnosing tuberculosis in an effort to spare the patient the social stigma of the disease. However, “weak lungs” is a very ambiguous term in everyday discourse; thus, the unintended consequence was a negative patient outcome. Nitcher states “the sensitivity of clinicians to [the] social stigma [of tuberculosis] is laudatory.” But he correctly points out that “the use of the term weak lungs has [serious] consequences” for public health because the diagnosis “weak lungs is not deemed as serious as TB” and thus people, especially the poor, do not comply with the prescribed treatment, which is a “six-month course of medication” (Nitcher 1994: 659).
A major direct implication of the concept of role is the symbolic, perceived or actual presence and agency of others. Sick-role behavior implies the presence of the healing expert (irrespective of what healing system is at work). A large body of research findings on the doctor–patient relationship has confirmed the relevance of culture. As expected, cultural similarities, such as physical appearance and language, among other characteristics, between doctor (or healer) and patient facilitate the relationship and increase the possibility of positive patient outcomes (Cockerham 2016:175–205; Kleinman 1980: 203–58). A note of caution, however: Similarities in culture do not secure success in the doctor–patient relationship. Many other aspects come into play, from ecological factors (e.g. Catalano 1989), to the differential understanding of metaphors (e.g. Glennon 1999), and structural features of the dyadic healer–patient relationship. Structural features – such as who is involved and how the interaction is conducted – vary across cultures. Haug and her colleagues (1995) found interesting differences in the manner in which the doctor-patient relationship develops in Japan and the US. Kleinman (1980: 250–310) shows how the direct involvement of the patient’s family transforms that dyadic relationship in some communities. Furthermore, patients’ subjective assessment of their interpersonal relationship with their healer may become as significant as “the technical quality” of the medical care they receive (Haddad et al. 1998).
Following the same premise on the significance of the presence of others, another important aspect of sick-role behavior is the availability of an informal social support network for the sick individual. The emotional, social, and instrumental support received from one’s informal network of family and friends tends to guide the attitudes and actions of the ill person before, during, and after consulting experts. Just as cultural variations are observed among sick people searching for help from healing experts (whether traditional or modern), the seeking of emotional and social support and the presence and quality of informal social support from family and friends also vary across cultures. Some examples are: the comparative study of Asian-American and Anglo-American women’s situations after breast cancer diagnosis (Kagawa-Singer et al. 1997); the systematic review of barriers to mammography screening (Miller et al. 2019); and the utilization of mental health services in Japan (Kikuzawa et al. 2019).
CULTURE AND HEALING SYSTEMS
The options available to people seeking health care vary greatly across countries and cultures. As Cockerham explains (2010: 208), even in a modern, developed country like the US, people may not look at modern medicine as the only or right option. In the discussion of culture and health, reference must be made to the wide range of healing options found in most societies today. For the sake of clarity, let us consider all healing options as falling into three general categories: the modern or Western biomedicine system; traditional medicine systems; and popular medicine. A medical system is understood as “a patterned, interrelated body of values and deliberate practices governed by a single paradigm of the meaning, identification, prevention and treatment of … illness and/or disease” (Press 1980: 47). Traditional medical systems flourished well before Western biomedicine and their history goes back more than one millennium. Three ancient healing traditions are considered to be the most important: the Arabic, Hindu, and Chinese healing traditions (Leslie 1976: 15–7). However, there is a revival of interest in the two best-known traditional medicine systems: traditional Chinese medicine (Unschuld 1985) and Hindu or Ayurvedic medicine (Basham 1976). Popular medicine refers to “those beliefs and practices which, though compatible with the underlying paradigm of a medical system, are materially or behaviorally divergent from official medical practice” (Press 1980:48). Popular medicine is also labeled “complementary” and “alternative” medicine or therapies (Quah 2008; Sharma 1990).
In contrast to the modest attention given by researchers to power and dominance in the traditional healing system, the intense concern with the preponderance and power of Western biomedicine is evident in the work of Foucault (1973) and Goffman (1968a, 1968b), and has been documented and analyzed in detail by Freidson (1970), Starr (1982), and Conrad and Schneider (1992) among others. These authors refer to Western biomedicine as practiced in Western industrialized countries and beyond (Quah 1989b, 2003). Interestingly, in the second decade of the twenty-first century Western biomedicine continues its rapid scientific advance and leads in public health (Quah 2018), but, given increasing costs and the large migration waves of indigent communities across continents, Western biomedicine is less accessible to poor people compared to traditional and other healing systems (Benatar and Ashcroft 2017; Sanders et al. 2017).
Healing systems are constantly evolving and two features of their internal dynamics are relevant here: divergence and pragmatic acculturation. Divergence in a healing system is the emergence of subgroups within the system supporting different interpretations of the system’s core values. The notion of “detached concern” in medical education is a good illustration of cultural divergence. In her comparative study of medical schools, Renée Fox (1976) investigated the assumed resilience of six value-orientations (in Parsons’ sense) at the core of Western biomedicine: rationality, instrumental activism, universalism, individualism, and collectivism, all of which comprise the ethos of science and detached concern, a value she assigned specifically to Western biomedicine practitioners. Fox observed that these values of biomedicine are subject to reinterpretations across cultures. She found “considerable variability in the form and in the degree to which they [the six value-orientations] are institutionalized” (Fox 1976:
