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When we think of how we respond to outbreaks, we often think of physical things like vaccines or medicines, but there is another factor that is just as critical to understand: culture! Culture determines how we collaborate and use the resources at our disposal in the face of an outbreak. So in this episode of Crash Course Outbreak Science, we'll look at the ways culture impacts our outbreak response, and in turn how outbreaks can change our cultures.

This episode of Crash Course Outbreak Science was produced by Complexly in partnership with Operation Outbreak and the Sabeti Lab at the Broad Institute of MIT and Harvard—with generous support from the Gordon and Betty Moore Foundation.

Music:
Sad Trio by Kevin MacLeod
Link: https://incompetech.filmmusic.io/song/4314-sad-trio
License: https://filmmusic.io/standard-license

Sources:
https://www.euro.who.int/__data/assets/pdf_file/0009/334269/14780_World-Health-Organisation_Context-of-Health_TEXT-AW-WEB.pdf
https://link.springer.com/chapter/10.1007/978-3-030-15346-5_5
https://www.researchgate.net/profile/Giovanni-Travaglino/publication/341659861_Explaining_Compliance_with_Social_Distancing_Norms_during_the_COVID-19_Pandemic_The_Roles_of_Cultural_Orientations_Trust_and_Self-Conscious_Emotions_in_the_US_Italy_and_South_Korea/links/5ed4c8c6299bf1c67d32251d/Explaining-Compliance-with-Social-Distancing-Norms-during-the-COVID-19-Pandemic-The-Roles-of-Cultural-Orientations-Trust-and-Self-Conscious-Emotions-in-the-US-Italy-and-South-Korea.pdf
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0239795
https://gh.bmj.com/content/5/7/e002732
https://www.cambridge.org/core/journals/irish-journal-of-psychological-medicine/article/culture-counts-the-diverse-effects-of-culture-and-society-on-mental-health-amidst-covid19-outbreak-in-australia/18E900AC207F81535F8DF0EA6F31347C
https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/rp/rp9899/99Rp27
https://www.sciencedirect.com/science/article/pii/S0165032720326392?casa_token=Rs1EtVPXR1oAAAAA:ULic-Jn669YcT80_7nxnF9hGoEyrsy6HPUdWv8UaQpiDqUlXnQlIc6h8V7aCIK-95RiRkFUmlhk
https://www.cdc.gov/globalhealth/stories/cdc-trained-disease.html
https://www.cdc.gov/tuskegee/timeline.htm
https://pubs.ciphi.ca/doi/full/10.5864/d2020-009
https://www.csmonitor.com/World/Africa/2015/0913/In-aftermath-of-Ebola-Sierra-Leone-finds-forgiveness-is-a-powerful-resource
https://fambultok.org/about/our-story

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In this series, we've studied outbreaks.

Not just because they are fascinating but because we wanna know how they can affect us, how we can stop them, and how our lives can change because of them. These motivations are linked to what matters to us, how we participate in wider society, and how we learn.

Like, say by watching Crash Course. In other words, they reflect our cultures. The cultures and social behaviors we share are just as critical for dealing with outbreaks as physical things, like vaccines and medicines, because they determine how we use the resources at our disposal.

Like whether we work together to do so. and like most things we've explored so far, the relationship between cultures and outbreaks is a two-way street. Cultures affect how we deal with outbreaks but outbreaks are also pressure-filled environments that can change a culture for better or worse. It's a complicated issue.

In fact, I've written a whole book about it! But today we'll take a brief look at the relationship between cultures and outbreaks. I'm Pardis Sabeti, and this is Crash Course Outbreak Science. *Theme Music* As part of our discussion on the communities, culture, and behavior in the context of outbreaks, in this episode, we'll be covering death, grief, and trauma.

While it's not always easy or comfortable to hear about topics like these, we want to clearly acknowledge the difficulties that individuals and communities face during outbreaks so that we can learn from them and take steps towards addressing them. Culture is a little tricky to define since it's a hidden factor in many different parts of our lives. On the surface, it's made up of things like age-old mannerisms, such as whether we shake hands or bow, and our expressed values and preferences, like whether we're fans of or horrified by pineapple on pizza.

For my part, I'm team... sure, why not? It also incorporates our lifestyle choices, the media we consume, the architecture we live in, our traditions, and more. Overall, a culture is a bunch of characteristics that help distinguish societies and social groups.

Because they're present across much of our lives, it's natural that our cultures affect our beliefs and actions during an outbreak. Our cultures impact everything from how we take care of the sick, to how we define "being sick" in the first place- when you zoom out, there's no one perspective that's always true. We can clearly see the influence culture has on our actions when we consider public health measures like social distancing, where people limit their physical meetings with one another to slow the spread of disease.

Social distancing is one of the most crucial tools for turning the tide against an outbreak, and it depends on our individual behaviors, which are influenced by culture and the communities we're a part of. If social distancing is needed in response to an outbreak, public health organizations and community health groups need to make sure people know to do it! In other words, they help us become culturally aware of the situation facing us.

Then, values we hold, like our sense of belonging to a community and protecting those close to us, might make us responsive to those messages. We could feel encouraged to socially distance and report cases of disease to public health bodies. But sometimes, people can also feel ashamed if they do end up getting sick, or worry about the stigma they'll face if they get sick and transmit a disease to others.

People may feel like they've done something wrong by getting sick, or that they'll be judged by others. In the US and Western Europe, while everyone reacts differently, people who worry about this kind of shame tend to be less likely to comply with social distancing measures. They're also more likely to hide the fact that they have the disease responsible for the outbreaks, from both public health organizations and their friends and family, to avoid being stigmatized.

Naturally, that increases the risks of transmitting the disease. So our beliefs, like how we think others will see us, play an important role in how we act during an outbreak. And the way we see others matters too.

For example, one of the reasons people give for not following social distancing orders is that they see other people in their neighborhoods who don't appear to be following them. And more broadly, our perceptions of trust and fairness towards other people influence whether we'll be willing to participate in public health interventions. For instance, when people don't have trust in governments and public health bodies, they're naturally less likely to follow the guidance given by those groups.

Many marginalized communities have been mistreated by government interventions unrelated to outbreaks. For instance, during the Tuskegee syphilis study, Black American communities were lied to by medical and public health authorities. Four hundred black men were recruited into a study without being told it was looking at what would happen in syphilis went untreated in that group.

In the middle of the study, penicillin had become available as a treatment against syphilis but none of the participants were told about it or offered it, since it would have cured them of syphilis, and thus interfered with the study results. Even more shocking, this study went on for 25 years, and only stopped when details of the study were leaked to the press. That's one of the sadly too many reasons why, today, Black American communities hold lower trust in medical authorities and have a greater mistrust of programs like flu vaccination.

In general, mistreatment can make members of a community less trusting of government messages about social distancing during an outbreak, since they believe the government doesn't always act in their best interests. And even when governments do act in their people's best interests, if they aren't transparent about their actions with the communities they intend to help, it can end badly. For example, during outbreaks of Ebola in parts of West Aftica, healthcare treatment centers were set up for sick patients.

But, since authorities didn't always explain the treatment centers' purpose, in certain instances, it seemed like people in hazmat suits came along, took a community's sick relatives to a mysterious place, and a few days later told them their loved one had died. Unsurprisingly, without being able to monitor the conditions of their loved ones, families were confused and perplexed, and sometimes took caring for infected people into their own hands as a response. This lack of transparency had serious consequences: without guidance and resources from healthcare centers,  the caregivers often exposed themselves to greater risks of transmitting Ebola.

In fact, caregiving is one of the biggest challenges during an outbreak. At the very moment where many of us feel a desire to be close and comforting to others, we may be told that keeping our distance is the best way to collectively protect ourselves. But the balance between caring and distancing can be really difficult, particularly when healthcare systems are unable to provide or we feel unable to trust them. so instead of broad advice telling people to simply stay away from each other, or one-size-fits all treatment options, it's important for public health agencies and governments to address outbreaks in individual communities in ways that focus on their particular need and cultural norms, like how to care for a person with an illness when there's no other option.

As well as considering how those in caregiving roles take care of sick people, it's important to pay attention to how they take care of themselves more generally, particularly when dealing with grief. The way we process the loss of loved ones is an important part of many cultures, including how communities handle the bodies of those who have passed away and how we gather to mourn the dead. But during an outbreak, some of these mourning behaviors could increase the spread of disease.

For example, in many cultures, the rituals after death include physically touching to body of the deceased, such as bathing them by hand, or dressing them in a favorite outfit. Combined with the fact that many people gather for wakes, processions, and funerals, practices like these can increase the risk of transmission during an outbreak, particularly for diseases passed through bodily fluids like Ebola. At the same time, the outbreaks themselves can interrupt traditional funeral practices.

Whether it's Ebola and Covid-19 in the twenty-first century or the Black Death in the fourteenth, serious outbreaks can overwhelm a community's burial infrastructure, making it more difficult to gather and mourn or bury a loved one. It might seem easy to suggest that we should halt these traditions to keep each other safe during an outbreak, but it's not that simple. Sudden, harsh measures meant to alter a cultural practice can subject families and communities to enormous psychological and emotional tolls during an already difficult time and affect them well after an outbreak has ended.

So, public health interventions need to take into account customs surrounding death and funerals in different regions during outbreaks, working with religious and community leaders to find ways for people to deal with loss a greif that minimizes the risks of infection and trauma. In other words, like lots of other difficulties we face in life, we can get through them more easily when we're mindful, attentive and supportive of each other. These same practices can help when people from more than one culture come together to address the fallout of an outbreak--or a war.

In 2007, a Sierra Leonean human rights activist and two American collaborators created the US-based organization Fambul Tok. Fambul Tok, which means "Family Talk" in Krio, a common language in Sierra Leone, is a tradition of resolving issues within a community through a group discussion. The organization expanded this practice to different parts of the country, and many communities in Sierra Leone used Fambul Tok as truth and reconciliation forums after the country's civil war.

To see how Fambul Tok works in the context of wars and outbreaks, let's go to the Thought Bubble. During a postwar forum, victims could describe the atrocities committed against them and perpetrators could listen and ask for forgiveness. The whole community would then hold a cleansing ceremony, and the perpetrator would compensate the victim with a small token, so both sides could be reconciled and move forwards from what had happened.

In many ways, the environment an outbreak creates is like war. Like war, outbreaks can tear apart communities and families, leaving them with anger, fear, resentment, suspicion and mistrust. And from practices like Fambul Tok, we know that people and places most affected by disruptions like wars and outbreaks can also be the ost powerful resources in the work of healing and rebuilding communities.

For instance, as we mentioned before, many families felt wronged when loved ones were taken away to healthcare facilities during Ebola outbreaks, and so may have resented contact-tracers who called ambulances for the sick and the health care workers who took them to hospitals. Similarly, community members may have resented neighbors who had been infected and gone on to transmit Ebola to others, causing other people to fall sick and die. So, like the time after the civil war in Sierra Leone, Fambul Tok was a vital part of many communities rebuilding after Ebols outbreaks in West Africa.

They helped absolve guilt in previously infected survivors and community members who hurt each other when acting out of fear during the outbreaks. They were especially helpful for those who didn't trust foreign responders and health care workers who carried out public health interventions during the outbreak to reconcile and understand each other's well-meaning intentions during the outbreak. Respecting traditional cultural practices and the way communities already operated helped repair some of the trust that had been lost when other traditions weren't upheld.

Thanks, Thought Bubble! Honest personal accounts like those shared by communities in West Aftica could help everyone affected by an outbreak come to terms with their experience.  Outbreaks change our way of life, sometimes temporarily, sometimes forever. Coming together to forgive and heal can promote a more compassionate culture.

Next episode, we'll keep talking about rebuilding after and outbreak ends, when we look at vaccines and recovery. We at Crash Course and our partners Operation Outbreak and the Sabeti Lab at the broad Institute at MIT and Harvard want to acknowledge the Indigenous people native to the land we live and work on, and their traditional and ongoing relationship with this land. we encourage you to learn about the history of the place you call home through resources like native-land.ca and by engaging with your local Indigenous and Aboriginal nations through the websites and resources they provide. Thanks for watching this episode of Crash Course Outbreak Science, which was produced by Complexly in partnership with Operation Outbreak and the Sabeti Lab at the broad Institute at MIT and Harvard with generous support from the Gordon and Betty Moore Foundation.

If you want to help keep Crash Course free for everyone, forever, you can join our community on Patreon.