Health and cultural contexts of care: interview with Professor David Napier

Interview with David Napier, Professor of Medical Anthropology at the University College of London, and Director of the UCL Centre for Applied Global Citizenship. Napier’ s special interests in applied research include assessing vulnerability, primary health care delivery, human wellbeing, caring for ethnically diverse population’s, migration and trafficking, homelessness, new and emerging technologies, immunology and creativity in scientific practice.

Q. What is culture?

DN. Culture is both the things that we value and the things we affiliate with and the way we relate to the people. Conventionally, we embody these ideas and concepts; in exemplum, if we are in 1950 in Italy, everybody goes to church. Anthropologists now do not follow only the religious pattern, as someone might believe, like how many people are attending a mosque, but the daily ritual habits and work and practice in our society. Therefore, culture with a holistic approach.

When we decide to stay in our culture, you do what is believed suitable for your group. However, beyond religious culture, there are daily rituals and practices: which side of the road on we drive? This is culture. If we are polite, we might have less problem, well, we assume that these conventions that are creating a better life for ourselves. We could call culture also in another way: simply lifeways which are contextual to a place, community, country. But it is just another label: instead of using the word culture you might use lifeways.

Q. What is the relationship between culture and health?

DN. Culture, and so for the insight on the context of the patients, is coming to enrich, to provide meaning to facts: why the disease occurred, why patient accepts or declines a particular therapy and why a certain illness came. And by context, we can encompass both the population level and the single patient level; culture speaks about our values, and if we are consistent with our existential beliefs, we live better, and we have a scope. The doctor, or another healthcare provider, and patient should align during their encounter, and this is feasible when we can build that intersubjectivity, given by the understanding of the background, the habits, the sphere of family or other relationship.

Consider two patients, both of them are in hospital beds since they have a fracture to the leg, same age and level of severity: however, the first broke his leg to help to save life to a child while he was crossing the street, the second man fell down from a scaffold. Could you imagine the mood of these two men? Totally different! The first one is proud since he was with his gesture a lifesaver, the second is full of anger because that scaffold was not safe enough. The “sacrifice” of the first man had a “meaning”, the accident of the other man was meaningless. Up to now.

Q. Why do you think it is essential that the doctors listen to and observe the context of patients’ living?

DN. Because patients at the beginning are timid and do not want to talk about symptoms or signs; only allowing the doctors to create this affiliation, they open up and start to speak. In the current practice, doctors are judged by the efficiency parameter, as the length of the visit. In the US, where healthcare is based on insurance, a primary care doctor is “good” when the visit lasts no longer than five minutes. This time is ridiculously short for establishing an empathic relationship, and diagnoses are based on expensive tests. We could save a lot of money prolonging the length of visit and avoiding many defensive medicine diagnosis tools.

Q. So, we could propose a bank of time, at least the first visit to know the person, to see if “I’m the right carer”: a first visit could last around 45 minute-1 hour, and then we save time later, and not only time, we save the money of defensive medicine.

DN. Absolutely yes. I bring another example of different use of time and access to visit. In rural zones in the US, but also in Scotland, people go as an average only once-twice a year to the primary-care doctor. Why? Because they live in a small town, everyone knows each other, they do not want to tell their stories of illness to the doctor, it is too intimate. They do not want to know that the friends of the doctor, who might be familiar, know about the fact that one has a specific disease. In a big city as Boston, people go up to six times per year to the doctor: intimacy is preserved, the risk of knowing each other is low, so the patients are more confident, and they open up themselves. This is why we need more time for visits, especially in rural zones, but also add in the city, where the doctor still has five minutes. Tests are necessary, technology is fundamental, but empathy is at least as important, remembering that patient may be in a vulnerable situation and needs time to warm up for transforming the untold in words. Patients often tell the most essential information when they are already with the hand on the handle of the door: they have been the whole time of the visit in silence, probably because of shame and only when they go away, they are able to tell the most important clues to the doctors. Yes, stop this parameter of efficiency and prolong time.

Q. Do you think that this short time and spasmodic focus on efficiency can induce a risk of burn-out in doctors?

DN. Yes, definitely, burn-out is there; doctors, in the average, are not happy. They do not have time to find the meaning of what they are doing.

Q. They lost the meaning of their profession, that one they had chosen when they were young. From the metaphors defining a cardiac disease, such as heart failure, it came out that they see more the threat (a sword of Damocles) or a malignant nature (a snake) than the patient’s body limitations, as described by people living with heart failure as “a car with deflated tires”, or “a tree during fall”. Could these metaphors represent, on one hand, the fact that they do not perceive the body limitation of the patients, but, on the other hand, the fact that the language mirrors their thoughts of threat, the possible burnout, living in survival mode?

DN. Yes, and always living in a survival mode is so stressful and meaningless. On the contrary, patients’ stories could be a remedy for burnout. And, also – I think that as an anthropologist – the learning from other medical systems from so-called traditional societies, or better communities not totally subjected to the biomedical system, could help to redefine the scope, both for the carers and for the patients as well. Here we are in an International Summer School dedicated to public policies, for promotion of health: this is fundamental since access to healthcare is a human right. Everyone should have access to health and care, this is a universal right. And I’m optimistic about the future, despite the current local fights with decision-makers: look here in Rome, doctors and nurses are so interested and so caring of their patients.

Q. I have a question for you: do you think that there is a gender effect between doctors?

DN. Unfortunately, yes. It is still there, and prejudices are strong. Women, who want to become surgeons? “Please, no”. You have to dedicate to husband and children, and if you’re going to become a surgeon, “you have to give up to the family”. Furthermore, as a woman “you will never become as good as a male surgeon”.

Q. What about becoming a paediatrician?

DN. Ye – with a nice ironical smile. This is now culturally accepted.

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Maria Giulia Marini

Epidemiologist and counselor in transactional analysis, thirty years of professional life in health care. I have a classic humanistic background, including the knowledge of Ancient Greek and Latin, which opened me to study languages and arts, becoming an Art Coach. I followed afterward scientific academic studies, in clinical pharmacology with an academic specialization in Epidemiology (University of Milan and Pavia). Past international experiences at the Harvard Medical School and in a pharma company at Mainz in Germany. Currently Director of Innovation in the Health Care Area of Fondazione ISTUD a center for educational and social and health care research. I'm serving as president of EUNAMES- European Narrative Medicine Society, on the board of Italian Society of Narrative Medicine, a tenured professor of Narrative Medicine at La Sapienza, Roma, and teaching narrative medicine in other universities and institutions at a national and international level. In 2016 I was a referee for the World Health Organization- Europen for “Narrative Method of Research in Public Health.” Writer of the books; “Narrative medicine: Bridging the gap between Evidence-Based care and Medical Humanities,” and "Languages of care in Narrative Medicine" edited with Springer, and since 2021 main editor for Springer of the new series "New Paradigms in Health Care."

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