Thomas Sowell (1990) famously observed, culture is not “preserved like a butterfly in amber”. It is alive, dynamic and constantly adapting to the shifting conditions of everyday life. In The Blank Slate: The Modern Denial of Human Nature (2002), Steven Pinker makes a similar point, suggesting that culture moulds human behaviour and thought like silly putty, shaping the ways we speak, interact and interpret the world around us.

We do not have to travel to distant societies to see how dramatically cultures evolve. We can look back in time at our own. As historian Theodore Zeldin notes in The French (1988), cultural practices that seem deeply ingrained today were once unfamiliar or even alien. He notes that, in the 14th century, garlic was largely absent from French cooking, but common in English cuisine. In the 17th century, it was the English and not the French who were considered more tactile, kissing upon greeting, a behaviour now closely associated with la bise in French culture. What is now “typically French” was, in earlier centuries, not French at all. Culture shifts, and quickly.

We can see the strangeness of our own past in the literature and media of earlier eras. The world depicted in Dickens, Molière, Shakespeare, Cervantes, or even any 1970s episode of the UK soap opera Coronation Street, is socially and emotionally remote from ours, even if the language feels familiar. Grimly exotic, yet recognisable. Watch an early James Cagney film like Public Enemy and you will see not just different fashion or slang but an entirely different cultural grammar: gestures, postures, tics and emotional cadences that seem odd now. The changes reflect deeper transformations in values, taboos and ways of relating. Some of these create dissonance, if not disgust: the idea of spittoons being openly used in spaces where food and drink were served is…simply horrible.

And yet, despite the evidence that culture is contextual and fluid, much of the literature on cross-cultural communication, including in healthcare, continues to rely on fixed stereotypes. In business training, for instance, the “British professional” is often imagined as a London-based, privately educated financier. This is an archetype that ignores the rich diversity of Britain itself. A person from Glasgow, Leeds, Cardiff or Newcastle will likely bring very different communication styles, value systems and attitudes to hierarchy, time and authority than a banker from the City of London. Americans love portraying this one-dimensional, upper-crust kind of Brit. An example could be how the British employees were portrayed in the TV series Mad Men. It ain’t me. That is for sure.

This flattening of difference in a lot of cross-cultural literature extends globally. Germans are seen as punctual and efficient. Americans are informal and direct. Japanese are hierarchical and reserved. Even broader generalisations persist for entire regions: “Africans”, “Arabs”, “Latin Americans”, “Indians” or “East Asians” are frequently discussed as if they were culturally uniform blocs. The not insignificant cultural diversity within these regions: linguistic, religious, ethnic and historical, is often overlooked or ignored. A Moroccan Arab and an Iraqi Arab may speak forms of Arabic, but inhabit profoundly different worlds. A Nigerian Yoruba person and a Kenyan Kikuyu person may both be “African” but that label tells you nothing about how they think, live or seek medical care.

This matters immensely in healthcare provision and communication. When culture is treated as a checklist of ethnic-specific traits, we risk misreading patients, misdiagnosing conditions and missing opportunities for trust-building. We also risk pathologising culture itself, by treating difference as a deficiency.

For instance, if a patient from a collectivist background defers medical decision-making to their family, this might be labelled as “passivity” in a Western medical record. However, from the patient’s perspective, it could be a deeply respectful, culturally appropriate response. Similarly, if a patient from a high-context culture avoids direct eye contact or speaks indirectly, this may be misinterpreted as evasiveness or confusion, rather than a sign of deference or humility.

Misunderstandings can also arise in the interpretation of symptoms. In some cultures, mental health distress is expressed somatically, i.e. as physical pain, fatigue or digestive issues. Without cultural context, a clinician might miss the underlying psychological cause, dismissing the symptoms as unrelated or imagining that the patient is exaggerating. In other cases, patients might delay care or seek spiritual or traditional healing first, not because they reject Western medicine, but because they have parallel explanatory models that must be respected and understood.

These are not abstract issues. Research shows that cultural mismatch contributes to disparities in health outcomes, including higher rates of non-adherence to treatment, lower satisfaction with care and poorer chronic disease management among minority and migrant populations. Language barriers, assumptions about pain tolerance and differing norms around consent and privacy all impact whether a patient feels safe, respected and heard.

This is where the concept of cultural humility becomes essential. Unlike “cultural competence”, which implies that one can master another’s culture through training or checklists, cultural humility recognises that understanding culture is an ongoing, relational and deeply personal process. It requires listening without judgment, asking open-ended questions and acknowledging the limits of one’s own worldview.

A patient is never just an “Indian”, a “Somali” or an “American”. Each patient is a constellation of intersecting identities: language, gender, age, class, faith, education, migration history, personal trauma and community experience. A second-generation Somali-American woman raised in California will have a different set of expectations and beliefs to her immigrant grandmother or Somali-born nurse trained in Kenya. It we treat culture as static and pathologised, we miss all of that nuance and, crucially, we miss the person.

Cultural humility also invites reflection on the biases embedded in the healthcare system itself. Western medicine is presented as objective and universal, but it is rooted in cultural assumptions about autonomy, evidence and individualism. These assumptions are not inherently wrong, but neither are they neutral. In cultures where family involvement is expected, or where suffering is interpreted spiritually, these values may clash. If developers or clinical staff are not aware of this, the patient may feel dismissed or disrespected: the COA item does not ‘reach’ them.

Effective health communication must go beyond translation. It needs to be a conceptual translation, making sure that the concepts and ideas contained in the COA, such as informed consent, mental health or quality of life are presented in ways that are culturally resonant. This can happen by co-creating understanding and not simply delivering information.

Culture can offer general guideposts, such as expected behaviours and tendencies that you may encounter when working with people from a particular cultural background. But these are only generalisations, and they should be used like a map and not a mirror. They can help you navigate but not tell you who someone is.

Culture is a conversation, not a category. If we wanted to provide patient-centred care that is sincere and not tokenistic, health providers must approach every encounter with curiosity, respect and humility to recognise what they do not know. People are not stereotypes, but full three-dimensional, walking, talking human beings. Yes, they are shaped by culture, but also by their own individual stories, choices and changes. Assume nothing.

Thank you for reading,

Mark Gibson

Leeds, United Kingdom, May 2025