Why Responses to Public Health Emergencies Need to Incorporate a Broader
 Understanding of Culture

Responses to epidemics have shown a lack of cultural and contextual understanding which has led to measures being ineffective and harmful. Given the scope of the current COVID-19 pandemic, lessons learned from previous epidemics need to be integrated into response measures. This paper critically reflects on the lessons learned during the HIV/AIDS and Ebola epidemics and their implementation in response to COVID-19. It argues that there is a need for an increased awareness of cultural complexity when reacting to public health emergencies. Particularly, it stresses the dangers of a one-dimensional understanding of culture. A limited conceptualization that considers culture only in terms of behaviour, can enable stigmatisation and racism and ignores interconnections of culture with inequities in power. It is concluded that awareness of cultural complexity, which comprises flexible visible negative and positive aspects as well as the underlying context, must be integrated for effective and respectful responses to epidemics.


INTRODUCTION
Culture is a significant determinant of health. Culture can have direct effects on health and influence the social determinants of health, such as the circumstances in which people live and work. 1 Cultural effects can therefore have a positive, as well as negative, impact by acting as either a resource or as a risk factor for individuals. For example, culturally shaped gender-inequality can result in adverse health results for women. 2 Furthermore, culture can have a profound influence on the processes of symptom recognition, labelling, help-seeking, and the structure of health systems. 3 For instance, public health measures and the response towards them are shaped by cultural factors, such as social agreements and assumptions; representations of health and sickness; or the religious value of suffering. 4 Thus, awareness for cultural effects is crucial to reduce inequalities and inequities in health; 5 for designing culturally competent health systems; 6 and for effectively approaching health emergencies such as epidemics. 7 The significance of culturally appropriate and acceptable health services is also addressed in the human rights framework. 8 By ratifying the International Covenant on Economic, Social and Cultural Rights states recognize the right to pursue one's cultural development (Article 1) and to enjoy the highest attainable standard of physical and mental health (Article 12). More specifically, in their general comment

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Considering the scope and the possible long-term nature of the current COVID-19 pandemic it is of significance to ensure public health responses respect and integrate cultural aspects. Thus, lessons learned from previous health emergencies need to be critically reviewed and integrated. Despite the novelty of the pandemic, there have already been attempts to discuss the impact of culture on the response to . 16 Yet, these discussions rarely take lessons learned from previous epidemics into account. This article addresses this shortcoming and aims to critically reflect on the integration of cultural considerations in responses to both, previous health emergencies and during the current COVID-19 pandemic.
Therefore, a literature review has been conducted. The major amount of relevant papers was found within anthropological and public health literature.
However, given the novelty of the COVID-19 disease, the amount of scientific literature on the pandemic was limited. Hence, grey literature such as reports by expert associations (e.g. WHO, UNESCO) and newspapers have been extensively searched. When analysing and discussing current strategies and measures it must be noticed that evidence is still scarce and often limited to anecdotal reports.
While the omnipresence of culture and its effects is acknowledged (e.g. organizational culture), the focus of this discussion lies on the culture of communities affected by diseases and the responses towards them and the way cultural aspects are considered, presented, and affected by public health measures. The scope of this discussion does not allow to delve into the implications of public health measures on access to cultural heritage that has been discussed elsewhere. 17 The paper is structured as follows. First, the understanding of culture which is used as a foundation for the discussion in this paper is presented. Second, the lessons learned regarding culture in outbreaks of diseases are identified and discussed using the ongoing HIV/AIDS epidemic in South Africa, and the Ebola outbreak in West  Cross-cultural Human Rights Review | Volume 2 | Issues 2-3, 2020 | Special Issue current response to COVID-19 within frame of two key lessons learned: the need for cultural awareness and the significance of community approaches to health. Finally, this article concludes by arguing that similarly to previous epidemics, the complexity of culture is not sufficiently incorporated in current responses to the COVID-19 crisis.

DISCUSSION
Culture is a complex concept that refers to overt and covert beliefs and practices and "frames our sense of reality." 18 In this sense, culture affects all people by shaping their every-day lives and the frameworks they use for making sense of the world.
According to UNESCO, culture refers to a "set of distinctive spiritual, material, intellectual and emotional features" which encompasses the individual and social way of life of a group of people, value systems, traditions, and beliefs and takes diverse forms across time and space. 19 For example, culture with its norms, values, and traditions can be considered as the foundation of communities and determinants of political ideologies and religious mores. Hence, the term culture commonly refers to the way of life of a group of people that is shared and learned. 20 However, the notion of uniformity and internal coherence within one culture has been challenged. 21 Dynamic and highly flexible concepts have been developed that consider not only the changes over time and space but also the distinctions between individual members of one group of people. Rathje, who has a doctorate in intercultural communication, for example, highlights that individuals tend to belong to more than one collective and suggests understanding culture as a matrix rather than a single definition. 22 Next to the traditional plural perspective, Rathje includes an individual perspective that illustrates the individuality and multicollectivity of people.
18 Napier (n 11) 1. 19  intersections with other sources of identity such as age, gender, sexuality, race and ethnicity, religion, lifestyle, and occupation are easily neglected. 29 Bond and Brough rightly stress the need to engage in more critical reflections on the use of concepts of culture to acknowledge not only the meaning of culture for risk-factor epidemiology but also for the people involved.
For this paper, culture is understood as a complex concept that refers to fluid and changing frames of reality that can be both, shared and individual. This understanding aims to highlight the dynamic and flexible nature of culture and takes the multicollectivity of people into account. It implies the need to assess distinct collectives in which people participate and to recognize the effects culture can have on individuals and the meaning they apply to it. 23 Napier (n 11). 24 ibid. 25 Bond and Brough (n 13). 26 Napier (n 11). 27 Sovran (n 16). 28 Bond and Brough (n 13). 29 ibid.

APPLICATION IN THE RESPONSE TO EBOLA
To illustrate the impact of culture on public health emergencies and the responses towards them, a comparative case study approach was chosen. HIV/AIDS is considered as one of the major public health emergencies within the last decades, 30 with the African region being most severely affected. 31

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It can be argued that culture in terms of social assumptions and agreements, 78 shapes socio-structural factors, such as power structures and political trust. Yet, it also needs to be acknowledged that culture and its effects "are historically located," 79 and act within a context of local and global disparities in wealth and opportunity. 80 In other words, culture is a "dynamic entity that is continually shaping-and shaped by-broader societal structures." 81 Essentially, it should also be considered that, the focus on culture must not come at the "expense of attention to socio-political and economic structures, obscuring the reality that global forces affect epidemics in  99 Sastry and Lovari (n 58). 100 Sastry and Dutta (n 57).

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CDC posts on Facebook shows that international medics were considered heroes and local initiatives were hardly mentioned. 101 Such narratives support colonial-era prejudice by comparing a modern, scientific West to primitive local practices. 102 Overall, the significance of culture and its effects became evident in the response to HIV/AIDS and the Ebola epidemic in 2014. Cultural aspects were integrated into the design of public health measures and there was a shift towards community-based approaches. However, the understanding of culture and its effects were commonly one-sided with a strong emphasis on "risky" behaviour. This interpretation of culture narrated a superficial picture of "African" culture that supported othering, stigmatization, and racism, and neglected socio-economic factors.
The rights to cultural development and cultural-sensitive healthcare seemed to play a minor role, undermining the effectiveness of public health measures, and missing the complexity of culture and its effects. Whilst cultural effects were frequently integrated into response designs in a one-dimensional and biased way, lessons have been learned regarding the significance of integrating the cultural context, for example through the support of community approaches.

COVID-19
Given the scale of the current COVID-19 pandemic, it seems crucial to consider and integrate lessons learned from previous public health emergencies. On January 30 2020, COVID-19 was declared a "public health emergency of international concern" by the WHO. 103

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and the Chinese were othered as authoritarian and backward. 118 For example, the virus was called the "Chinese" virus, and China was blamed for its culture by US-American and European politicians. 119 Potential positive effects of prevalent philosophies and cultures (e.g. Confucianism), on how some Asian peoples coped during lockdowns and quarantine have hardly been acknowledged. 120 This is in line with the history of perceiving and treating Chinese and Asian peoples generally as public health threats due to their cultural behaviours, particularly in the US. 121 Next to fuelling racism, this "otherization" led to a "false sense of security among Americans". 122 Due to the frequent attribution of COVID-19 to Chinese and Asian peoples, some people in the US perceived a very low vulnerability towards the virus.
In this regard, the one-dimensional understanding of culture may have negatively influenced the on-set of the pandemic in the US.
Public health responses regularly disregarded the protective potential of cultural components to act as resources, such as rituals and traditions, in the initial response to the pandemic. Everyday routines, for example going to school or work, have been highly interrupted by policies in response to COVID-19. This might have a severe impact on wellbeing, as routines are a common way to show resilience in times of disasters. 123 For example, Orbann explained why students participated in spring break parties despite COVID-19, by emphasising the need for cultural rituals particularly in chaotic times like this. 124 In addition, it can be argued that the omnipresent use of the term "social distancing" exemplifies the limited awareness of socio-cultural determinants of health. Zaki, a psychologist from Stanford suggested using the terms "physical distancing" and encouraged people to practice "distant socialising". 125 For instance,

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public health experts highlighted that social isolation bears high mental and physical health risks particularly, for the elderly and children. 126 While some authors and institutions pointed to the drawbacks of physical distancing early on, 127 middle-and long-term outcomes of quarantine and lockdown measures are yet to be evaluated.
However, some governments in Europe have acknowledged the risks of social isolation and the need for rituals and social contact during "the second wave." For instance, a "soft lockdown" was announced in Germany for November 2020, emphasising the need to avoid complete social isolation of risk groups; and with the aim to lift restrictions during Christmas. 128  high-risk groups but to foster collective agency. 151 The significance of shared awareness and collaboration beyond communities and countries has been highlighted by European politicians and international associations and sometimes led to collective action. 152 For example, it is argued that the Norwegian call to join the effort in fighting COVID-19 led to a strong team-spirit. 153 Also, mandatory mask-wearing was found to reduce stigmatization in Germany. 154

CONCLUSION
This discussion has illustrated the significance of culture and its effects in response to public health emergencies. It has also underlined the need for an increased awareness of cultural aspects. The shift towards a cultural approach can be considered as a major lesson learned within the HIV/AIDS response. 161 This change stressed the need to engage anthropologists and local communities in public health responses around the world to "produce comparative understanding" 162 , and investigate how culture matters for the people concerned and how diseases affect these cultures. Yet, while positive changes have taken place, the response to the Ebola epidemic and the current COVID-19 pandemic highlight persistent challenges in integrating cultural aspects. 163 Particularly, there are three shortcomings in the considerations of culture that have been evident in the public health emergencies discussed: 1) reducing culture to behaviour that is considered negative, 2) enabling stigmatisation and a language of racism, and 3) ignoring interconnections of culture with inequities in power. These drawbacks not only decrease the effectiveness of public health measures but may pose a threat to health and wellbeing in themselves.
One-dimensional understandings of culture neglect underlying beliefs and values. The response to the Ebola crisis has highlighted that cultural practices cannot 158 BBC, 'Birthday Honours 2020: The drivers, volunteers, and the quizmaster' BBC News (10 October 2020). 159 Jude Stansfield, Tom Mapplethorpe and Jane South, 'The community response to coronavirus

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be changed without considering their underlying meanings, traditions, and beliefs.
Rather, approaches which failed to respect local cultures increased violence and harm. 164 Furthermore, by framing culture or cultural effects as a risk factor, the integral significance of cultural aspects and their potential to act as a resource, particularly in times of disasters, are ignored. The WHO Europe rightly states that "allowing for careful considerations of cultural differences in health-care interventions means recognizing culture as an enabling factor for sustainable development and health-care systems that leave no one behind". 165 Yet, during the initial response to COVID-19, cultural factors were merely acknowledged and even less supported as a resource for individual and social well-being. Given the potential of the pandemic to last for another few months or even years, it is of importance to acknowledge the role of culture and strengthen its positive effects.
Public health measures and media discourses on public health emergencies have in some instances enabled othering, stigmatization, and racism. In response to the Ebola and HIV/AIDS epidemics, colonial prejudice and superficial narratives about the "African culture" led to an othering of affected people and a loss of empathy.
COVID-19 affected the global community, however again stigma and discrimination were prevalent and sometimes supported within public health measures. As discussed above, particularly racism against people of Asian descent and 'appearance' had increased. 166 While it has been argued that a universal approach to culture can lead to the "neglect of the radical differences (in experience and interpretation) that accommodations conceal", 167 culture must not be considered as the foundation for othering and discrimination. Therefore, this article argued that public health responses need to be sensitive to discriminatory and racist language and avoid measures that can support stigmatization.
Furthermore, there needs to be an awareness of socio-structural interlinkages with culture in the design and implementation of responses to public health emergencies. Socioeconomic factors can be highly interrelated with cultural effects, such as gender norms. Public health measures might lead to negative implications by 164 Maxmen (n 48). 165 WHO Europe (n 32). 166 Human Rights Watch, 'Covid-19 Fueling Anti-Asian Racism and Xenophobia Worldwide' (2020).