In discussions of health and healthcare, culture is often reduced to the visible, the exotic and the cosmetic: the colourful tapestry of traditions, clothing, music and cuisine. In contemporary British society, ‘culture’ is reduced to lazy and tokenistic celebrations of saris and samosas, steelbands and street food, i.e. the visible facets of transplanted cultures that have been cherry-picked and presented as perfect compliments to the mainstream culture. But this surface-level view captures only a fraction of the picture. Beneath these outward expressions lies a deeper, more intricate layer of culture, less visible but profoundly influential. It is in this hidden realm that culture silently shapes how people perceive health, interpret illness and seek healing. Are these ever captured in Patient-Reported Outcomes?

The iceberg metaphor is a powerful framework to understand culture’s true role in health. Above the waterline are the visible, easily recognisable manifestations of culture: food, music, language, celebrations. While these are important, they only represent a small fraction of a culture’s influence. The majority of this is far below the surface, submerged and often unexamined. This is where values lie, as well as norms, beliefs, assumptions and worldviews. The hidden dimensions dictate how people conceptualise health, how they make sense of illness, how they interact with healthcare providers and how they engage with treatments. It is this submerged cultural space that is likely to clash with the Western biomedical model and health provision.

In these depths of cultural influence resides what philosophers and artists have long described as “the sublime”. This is the awe-inspiring, the overwhelming, the inexpressible. The sublime is the emotional reaction we have when faced with something vast, beyond our grasp and could effortlessly engulf us: the infinite ocean, the towering mountain, a sky full of stars. The philosophical notion of the sublime, articulated by thinkers like Edmund Burke and Immanuel Kant, emphasised how the unknowable and the overwhelming stir us to both fear and fascination. I have definitely experienced this, and I describe the sublime as a kind of respectful, cautious fear, fear of the sheer power of something much bigger than me, such as the sea.

“A beauty impossible to define

A beauty impossible to believe

A beauty impossible to endure”

Culture is sublime. In healthcare, the sublimity of culture is not always acknowledged. Yet, it is deeply present in the quiet hesitations of a patient, in the silent logic behind treatment choices and in the unspoken rule that shape behaviours around health. The vastness of what lies under the waterline – the submerged iceberg – which are the unarticulated assumptions that people carry, can create a chasm between healthcare systems and the communities they serve. Often, the sublimity of culture can clash with these institutions of Western biomedicine. Navigating this space requires sensitivity, curiosity and a willingness to venture beyond the cosmetic and tokenistic efforts to account for culture. These could include having Urdu or Bengali leaflets in a GP waiting room that tell readers not to cook in ghee and that have been there for years, never so much as noticed by anybody, let alone read. And take the cultural adaptation of Clinical Outcome Assessments, for example. When do they ever move beyond the tip of the iceberg – the easy stuff, such as finding appropriate equivalents of words and phrases?

What Lies Beneath

Culture does not stand still. It grows, adapts and redefines itself through everyday life. Anthropologist Clifford Geertz described culture as a “web of meaning” spun from lived experience, not a list of traits that remain forever static. A Somali family living in London will have a very different experience from one in Malmö and different still to Somalis living in Mogadishu. Culture, ethnicity, religion and social class intersect dynamically. Overgeneralisation leads to dangerous assumptions in medicine, such as assuming that only African-Caribbean people can have sickle cell disease, ignoring others with ancestral risk (because they might look white to the treating doctor). Cultural humility, by contrast, urges healthcare professionals to treat identity as dynamic, rooted in migration.

So, what lies beneath the visible part of the iceberg?

·       Beliefs about illness and health: many cultures conceptualise health holistically, blending physical, spiritual, emotional and social well-being. Illness is not just germs and malfunction of the body but may be seen as the result of spiritual imbalance, moral failing or ancestral displeasure.

·       Approaches to healing: in some traditions, healing practices include rituals, prayers, herbal remedies or communal ceremonies. These approaches may coexist with, or even take precedence over, biomedical treatments.

·       Attitudes toward healthcare providers: In certain cultures, doctors are viewed as unquestionable authority figures, while in others, decision-making is collective, involving family and community leaders.

·       Communication patterns: directness versus indirectness, expressions of pain and even body language can vary widely across cultures. What might seem evasive to one clinician could be a culturally appropriate way of showing respect or avoiding shame.

·       Perceptions of time and urgency: some cultures prioritise present-moment relational harmony over rigid punctuality, potentially clashing with the time-sensitive demands of Western healthcare systems.

The Sublime in Clinical Encounters

When healthcare professionals focus solely on the visible tip of the iceberg, consisting of tokenistic nods to cultural diversity, such as handing out leaflets in 10 languages without checking for understanding, displaying flags in the waiting room or acknowledging cultural awareness days in staff newsletters, they risk mistaking token gestures for true cultural understanding. Beneath the surface lie far more consequential forces: differing beliefs about illness and treatment, mistrust rooted in historical injustice, unspoken stigma or the navigation of complex family roles. When these deeper layers are overlooked, the result is often miscommunication, mistrust and unmet health needs.

Consider a patient from a culture where mental health issues carry stigma and are viewed as a family disgrace. That patient might present physical symptoms, such as fatigue, headaches or stomach issues, that mask underlying depression or anxiety. A clinician who fails to recognise the submerged cultural dynamics may miss the real diagnosis.

Or consider a patient who hesitates to undergo surgery because they believe their condition stems from a spiritual imbalance that requires ritual intervention first. Without understanding this belief system, a practitioner might interpret the delay as non-compliance, overlooking the profound cultural logic guiding the patient’s decision.

The sublime undercurrents of culture make themselves known in these moments, not as towering waves but as quiet, unseen tides pulling below the surface. The clinician may feel a subtle discomfort, an unease, as though facing a vast and unknowable ocean. This is the sublime at work, the recognition that there is something vast, complex and deeply human at play, something that cannot be reduced to simple checklists or cultural competency workshops.

To practise healthcare with integrity is to recognise that culture is not an accessory to clinical care but woven through every aspect of it, often invisibly. And in acknowledging this depth and sublimity, health providers begin not only to understand patients better, but to meet them with the humility and reverence their humanity deserves.

Thank you for reading,

Mark Gibson

Leeds, United Kingdom, May 2025

References:

Brompton Oratory, Nick Cave and the Bad Seeds, 1997