Written by Po-Han Lee
Image Credit: 總統府, CC BY 2.0 https://creativecommons.org/licenses/by/2.0, via Wikimedia Commons
Taiwan has taken serious containment measures against COVID-19 for nearly two years, while in mid-2021, community outbreaks hit its health system badly, resulting in tight movement control. There were calls for strengthening epidemic surveillance, including case investigation and contact tracing. Disease control requires a nuanced understanding of human behaviour. However, health behaviour studies in Taiwan have focused on the ethnically Han majority. In contrast, health beliefs and needs among indigenous peoples and migrant workers are rarely explored, not to mention health policy discussion from an intercultural perspective.
Cultural competence, though defined variedly in different professional contexts, can be understood as the ability of individual and institutional providers to understand, appreciate, and interact with people from cultures or belief systems other than one’s own and effectively communicate with and deliver care services in response to the needs of recipients. Cultural competence as a protected factor and the ethical imperative of the human right to health should attend to diverse community needs and unnecessary marginalisation to enhance the effectiveness of risk communication.
Social determinants, culture, and contact tracing
Public health work, especially case investigation and contact tracing that are closely related to people, should emphasise the cultural competence of relevant workers, which is an integral part of cultural appropriateness in the context of the right to health and for improving the accuracy and effectiveness of epidemic control. In addition, cultural appropriateness is one of the indicators of whether health services are delivered ‘acceptably’ under the International Covenant on Economic, Social and Cultural Rights, which bounds Taiwan.
There are different levels of cultural appropriateness – from cultural knowledge, awareness, respect, and sensitivity to cultural competence – all attempting to avoid health ethnocentrism, a self-centred approach to health beliefs and practices, usually where barriers to mutual understanding occur. Cultural appropriateness, not compromising scientific discourse and evidence-based guidance, aims to appreciate the various approaches to the relationships between soul/psyche/mind/brain and the body, different interpretations of disease and illness experiences, and thus diverse ways of healing and recovery.
Considering the ‘cultural factors’ in policymaking and clinical settings is to apply a contextualised method to assess and account for one’s health beliefs and behaviours, living conditions and lifestyles, the socio-political context in which one is situated, and more importantly, the power dynamics between caregivers and patients, between case investigators and the investigated, and between minorities and the dominant group in society. Eventually, relevant personnel and institutions are expected to make decisions and provide care that is culturally compatible with all people of diverse backgrounds to achieve the cultural safety of service recipients.
Taking sexually transmitted diseases as an example, the Australian National University has proposed a framework of ‘Social Determinants, Culture and Contact Tracing’, recommending health professionals:
Acknowledge social and cultural variations between contact tracers and contacts, develop creative solutions for quarantine and isolation that respect the culture and protect individuals and others in the community, consider the values and important relationships within populations, be alert to overt racism in testing and treatment, and recognise the importance of cultural understanding of diseases, illness, prevention, and containment.
When developing an epidemic response plan and programmes, attention should be paid to the mutually reinforcing relationship between the effectiveness of risk communication, community participation, and cultural safety. For another example, the WHO once proposed that the training of case investigators regarding the Ebola epidemic in West Africa in September 2015 should understand in advance the culture of the local community to be equipped to communicate with the persons they were tracing contacts for. In May 2020, the WHO also mentioned that, for COVID-19 surveillance, appropriate cultural literacy is crucial for effective communication about risk and the disease.
Virus sees no differences, but human carriers do
The primary purpose of case investigation and contact tracing, particularly in the early stage of a disease outbreak, is to figure out and block the chain of infection, which paves the way the virus transgresses, lives, and moves away from the body. However, we cannot actually witness and detect the movement of the viruses; we can monitor their potential human carriers, predicted through their travel history, occupation, contact history, and cluster history – so-called TOCC.
Doing so makes contact tracing a very micro-sociological work that inevitably involves physical and symbolic interactions and hence values judgement. In May 2020, the British Medical Journal issued a call for COVID-19 epidemic investigation, contact tracing, screening, vaccine promotion, and so forth to ensure that ethnic minorities are equally aware of and receive relevant services, making ‘hard-to-reach’ groups no longer out of reach. Hostilities and minority members’ distrust of the government often present obstacles to having all communities on the same page regarding disease control.
This situation, not taken seriously enough by the governments (including Taiwan), and the gap in policy communication, have made minority groups (e.g., migrant workers, Indigenous peoples, and people of colour) prone to missing important health information, resulting in a risk perception inconsistent with mainstream society. Furthermore, for a disease like COVID-19, if contract tracing is not efficiently done (say, delaying more than 4-5 days or quarantining less than 60% of contacts), it may not be able to facilitate virus containment. Thus, precise identification of contacts does matter, while unbiased and culturally sensitive communication plays a key role.
According to a guideline on contact tracing published by the International Federation of Red Cross and Red Crescent Societies in June 2020, the effectiveness and efficiency of good communication depend on the community’s understanding, trust, and willingness to follow the guidance. Members of a particular community – geographical or cultural – usually link their risk perception about a disease to an assessment of their relationships with ‘contacts’ (e.g., family, cohabitants, and co-workers). This would affect their feelings and ideas about following the official rules, which may not necessarily be deemed more important than the local, even implicit, community norms.
Namely, the cost and benefits of ‘confession’ to the government are weighed differently between communities. The consequences of ‘honesty’ (involving identification) may lead the persons under investigation to refuse to confess. The consequences include, for instance, isolation, losing jobs and income, disruption of education, social networks, and welfare benefits (e.g., domestic violence shelter), and the shame, stigma, guilt, and potential violence induced by certain types of contact (e.g., sexual, and intimate contacts, unpermitted meetings, and reunions).
One nation, one fate, yet experienced differently
In my analysis, I have found a lack of local research on non-Han communities’ health-seeking behaviours (e.g., various Indigenous nations, immigrants, and migrant workers) and a lack of development of knowledge regarding intercultural care, not to mention attentive policy recommendations. Regarding public health education, de-stigmatisation and anti-discrimination are taught for health professionals, but they have little influence on the public. In addition, most health promotion materials for COVID-19 and other diseases rarely accommodate non-Sinitic languages and diverse communication skills and abilities.
In Taiwan, especially during the level-3 alert period, a popular discourse of ‘one nation, one fate’ (#同島一命; tóngdǎo yīmìng) was used to call for a sense of community between all who live in Taiwan, regardless of one’s national and ethnic origins. It also became powerful propaganda by the government to unify the strategic interests of various actors. The One is envisaged based on the ethical principle of solidarity in public health. Yet, in practice, barriers based on differences exist that draw out-group and in-group boundaries.
For example, facing outbreaks in metropolitan areas, despite the government’s caution against stricter restrictions of movement, many indigenous nations decided to practise self-protection by blocking entry into their tribal territories (e.g. Orchid Island). Not only does domestic tourism disregards the differences between Han Chinese and indigenous peoples in terms of lifestyles, but it also fails to demonstrate ‘one nation, one fate’ by ignoring the inequitable distribution of healthcare resources between communities when most Cultural and Health Stations (文化健康站; wénhuà jiànkāng zhàn) based in indigenous communities were closed.
For another example, special training and taskforces for populations who speak non-Sinitic languages (e.g., people on the move such as migrant workers and international students) may be necessary to make sure they are informed and fully understand (not just know) the benefits and risks of (non)compliance with epidemic regulations. Outbreaks within migrant communities were due to inadequate information and unsafe living/working environments. Many, especially those working in the industrial sector, were forced to stay at ‘lockdorms’ even when Taiwan eased restrictions to level-2 alert.
The two examples regarding Indigenous nations and migrant workers show the importance of sociocultural factors, such as language, communication skills, and a good understanding of communal life and social networks. Based on what I have termed ‘solidarity of differences’, such cultural competence accounts for the minority cultures and their intersection with other distinctive features of different professions, working environments, and living conditions of individual members. It is necessary for all types of epidemic response – including contact tracing, screening, testing, quarantine arrangement, and vaccine promotion.
What should be done in public health practices?
The ethical imperative of the human rights-based approach to public health requires the ‘acceptability’ (including cultural appropriateness) of health policymaking, impact assessment, and care services. In this context, Cultural competence in public health practices is concerned with ‘health for all’ through ‘safety for all’. That is, the principle of cultural safety, along with awareness of intersectional marginalisation, is to eliminate health inequities due to systemic racism and eventually decolonise public and global health practices. Related training, thus, may start with recognising diversity, involving the affected communities, strengthening risk communication, and promoting inter-community understanding.
Po-Han Lee (firstname.lastname@example.org) is an Assistant Professor of the Global Health Program and Institute of Health Policy and Management at National Taiwan University. He coordinates the NTU College of Public Health’s InDiE (Inclusion, Diversity, Equality) Project. Recently he edited and published two books, one on Towards Gender Equality in Law: An Analysis of State Failures from a Global Perspective (with Dr Gizem Guney and Dr David Davies) (Palgrave, 2022), and the other on “公民不盲從” (麥田, 2022).
This article was published as part of a special issue on healthcare in Taiwan.