The classic definition of culture, written in 1871 by Edward Burnett Tylor, states that "culture … is that complex whole which includes knowledge, belief, art, morals, law, customs, and any other capabilities and habits acquired by man as a member of society" (Primitive Culture ). In 1952, Kroeber and Kluckhohn cited 164 definitions of culture, ranging from "learned behavior" to "ideas in the mind." Culture depends upon an ability, possessed by humans alone, called symboling, which consists of "assigning to things and events certain meanings that cannot be grasped with the senses alone." (Encyclopaedia Britannica 1997, p. 847). Language is an example of symboling.
CULTURAL DIVERSITY IN THE UNITED STATES
For more than two hundred years, the United States has been the most culturally diverse country in the world. At the beginning of the twenty-first century, this diversity grew with the influx of more and more cultures from around the globe. Racial and ethnic minorities have been the fastest-growing segments of the U.S. population, making up almost 23 percent of the total population in 1990 and 25 percent of the population in 2000. Non-white children accounted for one-third of all children under nineteen in the United States in the year 2000.
Culture can affect how chronic and disabling conditions are defined and treated. For example, white Americans typically emphasize physical survival and functional capacity, and they therefore tend to battle against chronic conditions and disabilities that they see as being inflicted on them. In contrast, many Asian cultures emphasize living in harmony with nature; a chronic condition is therefore seen as part of the normal cycle of life. A person's culturally based health beliefs and practices determine what problems are recognized as needing traditional Western medical care, and whether someone will follow through with prescribed treatment, change lifestyle behaviors, or reduce exposure to environmental factors associated with an illness. Because of historic inequalities and racism in the health care system, many African Americans delay seeking health care. Beliefs about health and illness also influence community responses to health communication messages designed to promote health and prevent disease. Language and cultural differences often hinder communication between public health professionals and members of minority populations.
To understand cultural identity in the context of public health it is important to focus on the worldviews of the communities and people in need of health services. The meaning of words used to describe disease and adaptive behaviors needed to maintain good health must be examined in the light of a diverse cultural environment. People live their lives as simultaneous members and participants in a multiplicity of social contexts. An individual's cultural identity can be shaped not only by race and ethnicity, but also by age, gender, family configuration, religion, socioeconomic status, education, occupation, sexual orientation, political ideology stage of acculturation, and place of upbringing (rural, urban, or suburban).
Epidemiology enables public health professionals to systematically assess the health status of various populations. However, when morbidity and mortality data is used without an appreciation for the social context, unintended consequences can result. For example, it is not uncommon to use surveillance data to describe populations as "intravenous drug users," "homeless," "high risk," and "hard to reach." While such catergorization enables public health professionals to focus scarce resources where the need is greatest, it also stigmatizes the very people in greatest need of assistance. Ethnic and racial minority populations have historically suffered from the way in which public health data is presented to the policy makers and the general public. A prominent example of this is the figures regarding "crack mothers" and "crack babies" made prevalent by the media in the 1990s.
DISPARITIES IN HEALTH STATUS
The disparity in health status between black and white Americans was not new when it was documented in the Report of the Secretary's Task Force on Black and Minority Health (U.S. Department of Health and Human Services, 1985). This task force identified the six leading causes of preventable excess death for minority populations as cancer, cardiovascular disease, diabetes, infant mortality, chemical dependency, and homicide/unintentional injury. The report developed the descriptive term excess death, which was defined as the difference between number of deaths in minority populations and what would be expected in the majority population; by this standard, blacks experienced 42 percent excess mortality compared to whites. In 1985 these findings led to the creation of the Office of Minority Health within the U.S. Department of Health and Human Services.
In 1998, President Bill Clinton announced a new initiative that set a national goal of eliminating longstanding racial and ethnic disparities in health status by the year 2010. The president announced that the federal government would, for the first time, set high national health goals for all Americans, ending a practice of separate, lower goals for the racial and ethnic minorities. To help reach these ambitious targets, a five-step plan was put in place to mobilize the resources and expertise of the federal government, the private sector, and local communities to eliminate disparities that had long been treated as intractable.
Since culture influences how communities view and take action on disease conditions, public health professionals will increasingly need to understand the cultural context in which disease prevention and health promotion strategies are delivered. The fear and mistrust that shape the behavior and attitudes of many people of color must be addressed if disparities in health care delivery are to be eliminated.
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