COMMENTARY
Lois Joy Armstronga
a BSc, MPHTM, Research Co-ordinator, Epidemiology and Research Dept, Duncan Hospital, Bihar, India
Crossing cultures challenges the way one thinks about health and rights. Cultural anthropology provides a framework that helps clarify these issues by categorising cultures by their dominant method of governing behaviour and maintaining social order: 1. Guilt-Innocence cultures, 2. Honour-Shame cultures, and 3. Fear-Power cultures. Rights do not easily fit in either Honour-Shame cultures or Fear-Power cultures as compared to Guilt-Innocence cultures.
Jesus uses Honour-Shame language in his teachings regarding the care of the poor and neglected, rather than the language of rights. Understanding the culture of the Bible, as well as the culture in which you are working can help provide alternate methods of carrying out health work. Jesus also addresses greed, the deceptive trap of rights, where people always want more. In the book of Revelation, there is one right available to all who have clean robes — the right to the Tree of Life; the leaves of this tree provide healing of for all nations.
Key words: rights, health, culture
As I cross between two cultures, some situations relating to rights are hard to comprehend. Here are three examples.
Living cross culturally for most of the last 18 years has challenged me to think about rights and health and how they fit in different cultures. Then, trying to line this up with Biblical material has resulted in a few struggles in my mind. The Bible talks about our standing up for the poor and marginalised, but at the same time, giving up our own rights as Jesus also did (Phil 2:6–8). Have we no rights? and, My rights, My God were books that early influenced my thinking.1,2 Is it right for me to be telling other people to stand up for their rights when I am called to give up my own? Are these mixed messages?
The English word “right,” has numerous meanings as noun, adjective, and verb. In this setting, we are referring to the noun which includes meanings, such as: entitlement, privilege, due, justification, claim, permission, merit. Two Hebrew words from the Old Testament give this meaning: mishpat and tsedeq/tsedaqah. The greatest number of Old Testament references occur in the Prophets—not surprising as they are calling the people of Israel to live according to the Law, God’s directions to live a just and right life.3 The Psalmist speaks of God standing up for the rights of the poor as does the book of Job.4
Only one Greek word matches this sense of the word, right, in the New Testament, exousia. It is usually translated to ‘power’ or ‘authority’ and only occasionally as ‘right’. These include: the right of those who receive Jesus to become children of God5, the rights of apostles to food and family6, the right to eat sacrificial food7, the right of the potter to do with clay what he likes8, and then, in Revelation, two references to the right to the Tree of Life and one reference to the right to sit on the throne with Jesus.9 Interestingly, all four references from the Johannine writings come with conditions—those who receive Jesus, those who overcome, and those who wash their robes.
None of the references in the previous paragraph comes from the lips of Jesus during his time on earth—those in Revelation come from the ascended Jesus in John’s Patmos vision. However, there are many references to Jesus talking about justice and caring for the neglected and overlooked, such as in the story of the sheep and the goats in Matt 25:31–46. Jesus does not call people to obey the Law like the Old Testament prophets because in the Sermon on the Mount, Jesus explains his teaching is completing, or fulfilling, the Law. The Pharisees who tried so hard to keep the Law ended up being condemned by their actions of injustice. With Jesus expanding the meaning of the Law, it is not surprising that he does not use the language of rights, but he still calls people to care for the poor, the outcast, and those without a voice. Cultural anthropology may provide us with an explanation regarding the way Jesus addresses the issue.
Culture is defined as “learned and shared attitudes, values, and ways of behaving.”10 In 1946, Ruth Benedict described three frameworks which exist to govern behaviour and maintain social order.11 All frameworks can exist in any culture but usually one predominates, and thus, the culture is described by the dominant pattern. These three groups are:
1. Fear-Power Cultures: Here, the world is in the control of gods and spirits. The behaviour of humans is influenced by seeking to appease these capricious powers who govern the good and bad happenings in life. Most commonly, this is described as occurring in animistic, tribal cultures, but it plays a very significant role in folk religions and is a much greater influence in majority world honour-shame cultures than in the West. Health, for people in fear-power cultures, is in the hands of the gods/spirit world. Some will accept this fatalistically, while others will invoke a greater power to overcome the spiritual being responsible for the ill health.
2. Honour-Shame Cultures: In these communal cultures, behaviour is driven by the need to seek honour and avoid shame by adhering to the community standards. These tend to be more hierarchical cultures. In many honour-shame cultures, ill health still falls primarily under the realm of fear-power beliefs. At the same time, some health conditions would be associated with shame, e.g., mental health, epilepsy, disability. Ill health, thus, means exclusion for people with shameful health issues.
3. Guilt-Innocence Cultures: These cultures have a strong, internal sense of right and wrong, but also have strong legal systems to support right and wrong behaviour. These cultures are predominantly individualistic cultures which value equality and fairness. Much of the responsibility for health in these cultures is put on the individual to maintain healthy lifestyle choices.
Rights, in general, are about individuals and fairness, and are often connected with laws or legal systems and so these sit very comfortably within a guilt-innocence culture. However, rights do not fit so easily within a fear-power culture or an honour-shame culture.
Honour–shame cultures make up the largest part of the non-Western world today, and this is where some of our biggest global health challenges exist. Making laws regarding health in these cultures is unlikely to change behaviour. People will not feel guilty about breaking these laws, but they will feel ashamed when they are caught breaking the law. They are more likely to seek the honour of the community in preference to the law. Laws that cannot be enforced lose their power.
Mortality reporting and surveillance, used to assess health statuses, persistently struggles in honour-shame cultures. Attempts to understand problems in health are seen as shaming the persons, or the country involved. Exposure of poor health outcomes can lead to information being hidden rather than exposed. Is there an alternative way to change behaviour in an honour-shame culture? Does the biblical material give us any clues?
Although Jesus did not use the language of rights, he often used honour-shame language and sometimes used it very strongly. A detailed account is beyond the space available here but includesd words like loyalty, glory, inheritance, humiliation, purity, unclean, and dishonour. Try replacing the word “blessed” by “honoured” in the Beatitudes, e.g., “Honoured are the poor in spirit, for theirs is the kingdom of heaven.”12 A number of New Testament passages make more sense when you read with honour-shame eyes.13 Jesus treated the disadvantaged with respect and care, but he shamed the leaders of the community over the way they treated the poor, widows, and orphans. Jesus gave honour to those who treated children and the “least of these” with respect. This is in line with the writer of Proverbs who wrote, “He who oppresses the poor shows contempt for their Maker, but whoever is kind to the needy, honours God.”14
Patronage is a concept within hierarchical honour-shame cultures with which people from egalitarian cultures are less familiar. Alternate words to “patrons” could be benefactors, supporters, sponsors, investors, backers, donors, champions, guardians, defenders, or advocates. Patrons have a responsibility to care for those in their patronage while the clients are obliged to give their allegiance to the patron.15
In the Old Testament, Israel’s king, a patron, was to keep a copy of the Mosaic law with him as a reminder of how he was to care for his people.16 Both Paul and Peter describe the purpose of governments as being for the good of the people, to bring unity and co-operation by encouraging right behaviour and punishing wrongdoing.17,18 Leaders who fail to care for their sheep and seek their own gain, are reproved in both the Old and New Testaments.19
Working with patrons, or those who have more, may be an important model in improving health outcomes in honour-shame cultures. These leaders need to be taught that they are responsible to use their influence and resources wisely and for the good of the people in their protection. We must train these leaders to realise that their role is to help others. By helping them to see this, they will gain honour when they make improvements to the health of their community and may have more impact than when they shame people with bad outcomes.
It is important to model this in the organisations in which we work as well as seeking to find ways to promote this model in other settings. For example, Dil Se (From the Heart), a program that runs alongside the General Nurse Midwifery program in Emmanuel Hospital Association hospitals, has sought to help nurses become “Christ Centred, Consistently Caring, and Clinically Excellent” (Personal communication, Emmanuel Hospital, 2018). It is important, when mentoring students and junior health professionals, to teach and to display biblical principles of leadership instead of falling prey to existing power systems.
The reason many of us work in global health is our passion to see improvements in health for those overlooked and neglected: poor, women, children, disabled, mentally ill, those suffering from tuberculosis, snakebite victims, etc. My motivation of “to whom much is given, much will be required” is shared by many.20 In this way, we can also become patrons, not in a negative paternalistic sense, but as we bless, shepherd, empower, and provide for the good of others.
When reading the Bible with honour-shame “glasses” on, we find there are two salvation motifs: 1. Inclusion into the community and 2. Status reversal.13 Given the close connection between healing and salvation, especially in Luke, these two motifs are worth considering regarding how we work in global health. Both these motifs are seen in the way Jesus was at work: lepers are healed and sent to the temple for inclusion back in the community;21 the outcast bleeding woman is called “Daughter;”22 the Gadarian demoniac is returned to his community clothed and in his right mind;23 the widow from Nain, whose only son dies, has her world turned right side up again, as her only son is raised from the dead.24
The following is a favourite health-related story of “inclusion into the community.” M, one of the hospital domestic staff, was outside the front gate of the hospital when she noticed an unkempt young woman being teased by a group of young men. Realising that this young woman had a mental health problem, she took her by the arm, leading her away from those taunting her. Those taunters said, “She is not your daughter,” to which M replied, “But she is someone’s daughter,” and she led her into the hospital. This young woman was treated at the hospital’s expense with staff from the community team and the ward caring for her as she had no known relative to care for her. She began to improve and one of the security guards recognised her as someone from his neighbouring village. She was returned to her family and continued to receive follow up care from the Community Mental Health team.
A majority of the world is made up of predominately honour-shame cultures, but the influence of the fear-power culture is much greater than in Western countries.13 As mentioned previously, much of the understanding about health in honour-shame cultures lies within the framework of the fear-power culture. If health or ill health is in the hand of the gods, what right does one have to health?
The power concepts carry over into regular health systems in many cultures. When a new medicine or a new health service arrives, people from fear-power cultures are likely to see the new medicine, treatment, or the new doctor, as the greater power. If that power fails to bring healing, then they run to a more prestigious and expensive health facility because these are seen to be more powerful. In chronic diseases, this is particularly a problem as cure is not possible. People waste endless amounts of time and money seeking help at bigger and better health services. A poster advertising a new super-speciality hospital in a rural town has as its motto, “The power to heal.”
There is a great need for humility as we introduce ourselves as health workers, as servants of the Great Healer. He is omnipotent, but we need to be careful not to portray ourselves as all powerful. We need to make a special effort to make sure we care for the fearful and powerless who often “melt away” unseen in our health facilities.25 “One number-one voice,” has become the surveillance motto for our local epidemiology team. Making sure cases are counted in surveillance gives a voice to many who might go unnoticed. This “behind the scenes,” part of health care can be a powerful tool in speaking up for the powerless.
Luke 12:13–15 is a challenging introduction to the story of the rich man who builds bigger barns to hold his expanding wealth. It begins by a man in the crowd asking Jesus to tell his brother to give him his fair share of the inheritance. Jesus tells the man he does not think it is his place to make the judgement. Then Jesus turns to the crowd and says, “Take care! Protect yourself against the least bit of greed. Life is not defined by what we have, even when you have a lot.”26 Here is a man standing up for his inheritance rights and Jesus turns around to the crowd and raises the issue of greed. Jesus has identified the trap that exists in asking for our rights, the trap to always want more. Staff from our community health team tell me how some of the lowest caste people are always looking for someone lower than themselves who they can lord it over. This very same issue of greed was identified by a scientist as the problem in environmental issues.
I used to think that top environmental problems were biodiversity loss, ecosystem collapse and climate change. I thought that thirty years of good science could address these problems. I was wrong. The top environmental problems are selfishness, greed and apathy, and to deal with these we need a cultural and spiritual transformation.27
The direction of rights being exercised is important. We are told to stand up for the rights of others, especially the disadvantaged, but we are warned of the potential problem of standing up for our own rights. Would it be better if we teach, even the most disadvantaged, that it is honourable if they stand up for the rights of others? This would then mean teaching the same message to all. When we tell people to stand up for their rights, are we mixing our messages and creating more problems? Creating a culture of thankfulness and respect for others and loving our neighbour as ourselves may be less likely to promulgate the abuse that grasping after rights can bring.
It has been suggested that in the West, the guilt-innocence culture is being eroded by a pain-pleasure culture.28 In this setting, people aim to avoid pain and seek what brings them pleasure. Where do rights fit in this culture? As this framework is driven by what people feel, the standard for the feeling is, not the god’s, the community, or the law, but self. It might be argued that an individual’s rights in this culture is what they feel is right for them. This would explain the plethora of rights appearing in the West, both in health and other areas of rights.
The language of rights may not be appropriate towards improving health in all cultures. What might seem good can become an insatiable grasping for more. Using the idea of patronage to train leaders who care for and empower those in their circle of influence can be one alternate way of working; using project designs that develop inclusion of outsiders into community can be powerful; avoiding being caught up into existing power systems; helping people who are overlooked and neglected towards a status where they are valued by themselves and others, can also bring improvement in health. Teaching all people to value and care for others is important.
Amazingly, the Bible speaks to people from all cultures. It also requires culturally sensitive skills on our part to communicate the Message, in word and deed, enabled by the Holy Spirit.29 The leaves of the Tree of Life are for the healing of the nations.30 The right to the Tree of Life is available to those who have washed their robes.31 This right, in all its fullness, is available to people from all cultures.