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Health, Illness and Identity: The Chinese Community in England
From: London School of Economics and Political Science
| By:
Marie-Claude Gervais |
EDITOR'S INTRODUCTION |
 The Chinese community in England appears to exhibit more diversity than coherence. Yet identity is too slippery a concept to be attributed merely to national or cultural origins. The health beliefs of the Chinese community in England provide a crucial locus for cultural identity. In this interview, Marie-Claude Gervais, lecturer in social psychology at the London School of Economics and Political Science, discusses the relationships governing health, illness and identity among the Chinese community in England. |
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| Identity and illness: the Chinese community in England | |
Fathom: What was the general context and ultimate purpose of your research on the health beliefs of the Chinese community in England? |
Marie-Claude Gervais: The study was commissioned by the Health Education Authority (HEA), which is now dismantled but was a national organisation commissioning and conducting research at the national level into health promotion and health education. The HEA was also in charge of distributing public health information to doctors, GPs and nurses. |
The person in charge of ethnic minority health at the HEA realised that they had very little knowledge of how Chinese people experienced questions of health and illness, how that affected their use of the health services, what their needs were and how to contribute to improving their health status. What they knew from isolated, quite sporadic research was that Chinese people in England tended to underutilise health services and health resources. The HEA had no idea whether this was because they were healthier than other ethnic groups or than the general population or whether there were other factors that contributed to this state of affairs. So my colleague Sandra Jovchelovitch and I were commissioned to conduct a small-scale qualitative research, which was going to be the basis for a very broad-ranging quantitative study at a national level into the health status of the Chinese people. It was a preliminary qualitative analysis, but it also, I hope, stands and is interesting in its own right. |
We had three objectives in this research. The first was to describe the nature, the structure and the function of Chinese health beliefs and how that impacts on the use of health services. The second was to assess what the consequences of living by certain health beliefs might be in terms of acquiring new biomedical information. Because the study was commissioned by the HEA, whose mandate was to educate, they needed to know how people from ethnic minority groups were going to relate to the body of knowledge which they, as a national organisation, intended to communicate. The third aim was to assess what problems Chinese people experienced using existing health resources, specifically the National Health Service (NHS), but also whether they were drawing on other resources such as folk healers or traditional, classically trained medical doctors. |
The overall aim of this research was to find answers to these three main questions. To go about it, we first conducted interviews with "experts" on the Chinese community. Now, "expert" is a very loose term, but these were basically people who, by virtue of their occupation, had "meta-knowledge" of the Chinese community, people who could think about the community: doctors, people working in different organisations that help in caring for the Chinese community, representatives in one form or another. We also interviewed lay Chinese people, sampled mainly in London and Greater Manchester, because this is where the population is most concentrated. Otherwise, the Chinese community is geographically a very widely dispersed community, because it used to be involved in the catering industry, and you needed to be working in isolation in order to be able to make a profit out of your trade. The third method which we used was focus groups with lay members of the community. Focus groups are particularly useful to prompt participants in the group to think about aspects of their lives--in this case, health and illness--which they might take for granted, which they might not think were particularly interesting or meaningful. Focus groups were used as a way of tapping into the collective knowledge which Chinese people possess about health and illness. |
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| Marie-Claude Gervais discusses the different perspectives on the Chinese community | |
Fathom: What is the best way of defining and characterising the Chinese community in England? |
Gervais: There are so many different perspectives on the Chinese community. If you look at census data, for instance, the image that emerges is that the Chinese community is more educated than the white population, that they are economically successful, that they are doing well in just about every respect. However, if you presented that image of the community to a number of community members, they would just shrug their shoulders and look sideways and wonder where that came from, because it just doesn't seem to tally with their reality. |
Rather than giving one single answer, I think a better way of presenting the community is to say that there are three generational groups and that each of these generational groups maps onto different patterns of migration, different levels of integration into the mainstream community and different levels in the ability to use the English language. So, for instance, the older age group, which we have called the "settlers," are usually from rural Hong Kong, have lived under very deprived conditions and are generally illiterate in their own language as well as in English. They are very isolated, tend to have very serious health problems and rely on the Chinese community for support. They engage very little with the main population and underutilise the National Health Service. |
Then there is the middle generation, people aged roughly between 30 and 60. Professionals, people who have trained as doctors, nurses, lawyers, very well educated--they have no problem whatsoever integrating into English society and participating as full members of that society. But, in terms of their identity, they feel hybrid, they are mixed. They know the ways of the Malaysian culture they come from, the Chinese culture they come from, the Vietnamese culture they come from, the country they left before they came here, and they are still very much emotionally attached to the culture they were raised in--that is their way of being. But you also have in that middle generation people who are really not very well integrated at all. These people often come from Vietnam, they might have arrived here as political refugees via Hong Kong and they are involved in the catering industry, in the main, with pretty appalling working conditions. Here again, in the middle generation you have a great mixture of life experiences. |
Then there is the younger generation, which is again a mixture of people. We have those who are born in the UK; they are known as the BBCs--the British-born Chinese, or the "bananas," which is quite an interesting term. "Bananas" because they are yellow on the outside and white on the inside. This of course does not capture the whole complexity of their experience. One is never just "white" on the inside, if only because one has yellow skin and therefore one is not allowed to engage with the mainstream society in the same way as a white person would be. Finally, there is a very large body of students from Chinese cultures that come here to study and then either decide to stay or leave. Arriving here as adults, they have been socialised in a different context. They will tend to stay with Chinese people rather than really participate with a culture which is unfamiliar. |
So you can begin to imagine that there are different identity struggles that are related to these waves of migration and different patterns of participating in mainstream British society. |
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| Marie-Claude Gervais talks about the cohesiveness of the Chinese community | |
Fathom: Considering this diversity, are there ways in which the Chinese community is cohesive? |
Gervais: The Chinese community is both very diverse, in terms of generation, language, country of origin, use of NHS resources (because this is what is at stake in the current research), and very homogenous, at a deep cultural level. Attachment to and pride in Chinese culture are very important sources of a common identity for the Chinese people living in England. Within this broad Chinese culture, the major factor of cohesiveness is really the fundamental value attributed to the family as the basic unit of social life. The community shares in what has been described as a collectivist ethos, whereby you put collective goals above your private ambitions and desires. So it creates a lot of problems when Chinese people raised in that collectivist culture then have to live in deeply individualistic cultures such as the British culture. |
In terms of factors of cohesiveness, there is this collectivist ethos and the importance of the family in people's lives. There is also a sense of hierarchy and power-distance in the ways in which people engage with others. In the Western world, we tend to assume that social relations are based on some kind of egalitarian principle, which is completely different from the traditional Chinese way of relating to other people. Both at home and in the public sphere, there are very different ways of relating to others that are structured in terms of generation, age and gender, and that sense of hierarchy seems to be shared across the Chinese community. There is also a strong emphasis placed on morality and self-restraint: being controlled and not going beyond the boundaries of decency. The Chinese community is recognised by most commentators, in the UK at least, as being a law-abiding, problem-free community. So, cutting across these very diverse groups within the Chinese community, there are factors of cohesiveness. It is both diverse and homogenous. |
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| Marie-Claude Gervais reflects on the problems of integrating into an alien culture. | |
Fathom: What kind of problems, if any, did you find the Chinese community encountered with integrating into the host British culture? |
Gervais: When we talked to people, we found that they had generally struggled a lot to integrate. We had a very small sample size, so it is not easy to see how widespread this pattern is. Interestingly, women tended to be much more reflexive about their experience. They tended to questions themselves in much more radical, profound and problematic ways, perhaps because they are more in contact with the white population through their children who go to school and who come back with these Western ideas. It is their mothers who have to somehow reconcile that with the values they try to pass on. |
It could also be that, because women traditionally have a less powerful position within the family and within society, they are more able to question their cultural heritage. Whatever the explanation, it seems to be very difficult to maintain a sense of pride, to maintain in your heart the value of your culture. It is difficult. At the same time you want to integrate, the last thing you want is to isolate your children from mainstream culture. You want them to be successful, but what defines success might be valid only in your own terms. |
What tends to happen is that there is a lot of shame from the perspective of parents, because they feel that they don't manage to raise their children in the way they would like to raise them. And there is a lot of guilt on the part of the children, because they don't live up to their parents' expectations, which they recognise as being legitimate but also as not mapping onto their own life experience and reality. It is difficult and fraught with tensions, and I don't know the extent to which that is specific to the Chinese community. I expect that in most uprooted and displaced communities, very similar processes are at stake. |
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| Marie-Claude Gervais on the forces that shape perceptions of health | |
Fathom: Can you explain how perceptions of health and illness are influenced by social environment and cultural background? |
Gervais: Every system of knowledge is a cultural system of knowledge and biomedicine. Our cherished system of beliefs and institutions about medicine is no exception. I wouldn't want to portray Chinese health beliefs as an exotic set of beliefs while we in the West have this grand universal knowledge. I would not want to overplay this dichotomy. On the contrary. |
However, the content and the ways in which health beliefs function vary in each culture, and this specificity also needs to be described and explained. In the case of Chinese health beliefs, notions of health and illness are rooted in Confucian philosophy, which is a worldview that organises, amongst other things, ideas about health and illness. As many people know, Confucian philosophy sees the universe as being ordered by the complementary and antagonistic forces of yin and yang. These complementary and antagonistic forces structure what happens at the level of the individual, at the level of social relations, what happens in the realm of what we call nature--but also cosmic forces, or the realm of the supernatural. |
Health is conceived as the harmonious balance between the forces of yin and yang, between these opposite and complementary forces, not only at the level of the individual organism, the biological individual, which is what biomedicine would focus on, but at the level of the individual as a social being embedded in a network of very complex social relations in a natural environment and always within cosmic forces. Illness then becomes a disruption of that balance, that harmonious relation. |
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| Marie-Claude Gervais on the health beliefs of the British-born Chinese | |
Fathom: How does the level of integration into British society affect beliefs and practices with regard to health and illness? |
Gervais: Based on common sense, one would expect a straightforward relationship according to which people who have lived here longer should also participate more in Western society and no longer think of themselves as primarily "Chinese" people. When people are more educated and they live in urban centres, we tend to assume that they should become more modern, more Western, less Chinese. To some extent, this is a pattern that we do find in our data. However, we also find more subtle and complicated ways of relating to what may be described as the mainstream, English or "host" culture. The "bananas," those who are yellow on the outside and white on the inside, the British-born Chinese, the BBCs, if you will, sometimes desperately want to think of themselves as British. They are BBCs and they have no other home to go back to. This is their culture, this is their world. But they face discrimination, they face barriers to social integration, institutional discrimination and individual bigoted worldviews, and this reminds them that they are not British in a fundamental way. No matter how much they would want to integrate and participate, there will be barriers because they don't look like "one of us." |
Those who you would expect to be the most integrated and the most unproblematically participating in mainstream British society often return to their Chinese roots as a way of restoring some kind of dignity, some kind of cultural identity. And so they, more than the middle generation, would believe in traditional Chinese medicine, turn to folk healers, use acupuncture, consult bone-setters and eat pigs' brains in order to deal with their migraine. They would resort to very traditional ways of managing ill health. This provides them with some existential grounding. For a naive observer, this may seem strange. I think most people--lay and professional--would expect young, urban, educated Chinese people to make full and exclusive use of NHS services. After all, they don't have language barriers and there are no obvious reasons why they should not make use of these good and free health resources. But this is to seriously underestimate the need which most people have to belong, to be recognised, to find some sense of rootedness in the world. In this sense, health beliefs and practices are not just about keeping well and curing diseases. They are about being Chinese or not. And they tell us much about how culture is not just a variable "out there" but a reality "in here." Culture is at the very heart of our sense of ourselves, and this has implications for our every thought and action. |
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