TM5563: Public Health Leadership and Crisis Management
The key challenges to
providing leadership
during public health
crises.
Assignment One
Samantha Leggett: SN 12494652
9/16/2011
Samantha Leggett: SN 12494652
TM5563 Public Health Leadership and Crisis Management
Assignment One
Introduction
This assignment will define leadership and explore the traits and qualities that are deemed to be
inherent to effective leadership and an explanation given for why leadership matters in times of
crisis. The key challenges to leadership in both sudden and expected crises will be explored and
potential solutions to these key challenges offered. Examples will be provided throughout using
recent public health crises to illustrate.
Leadership can typically be defined by the traits, qualities and behaviours of a leader. It has also
been described as a process with a shifting locus of control in which leaders are not seen as
individuals in charge of followers but as members of a “community of practice” where everyone
involved in the activity is assumed to play an active role in leadership. However, even with an
advanced team, there is still a need for distinct leadership to enable the whole team to be
optimally successful. 1-3
It would appear that there are a number of key traits that good leaders possess, however the
literature provides little concrete agreement on a finite number of these: Kambil et al. (2009)
found that leaders have five key traits: Curiosity; courage - in willingness to face uncertainty and
perhaps danger; perseverance- the willingness to persevere to achieve, a trait found to often be
innate from childhood; confidence and ethical responsibility. Ethical responsibility refers not
only to the leader adopting and demonstrating organisational ethical responsibilities but also
personal ethical responsibility; being willing to take a clear stand when the code of ethics is
challenged; saying what you mean and doing what you say; acting with integrity.4,5
Mostovicz et al. (2009) offer further key traits that they see as essential to effective leadership:
having a deep understanding of one’s emotions, strengths, weaknesses, needs and drives, values
and goals through self awareness; empathy-if leaders are unclear about their own values and
purpose, their ability to empathise with others will be severely constrained; motivation-a
propensity to pursue a goal with energy and persistence.6 It is argued that if a leader’s own
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purpose is unclear, how are they able to pursue their goals? Goldsmith (2001) adds that
flexibility and adaptability are core traits that serve to guide leaders through tragedy.7
Horner (1997) also identifies negative leadership behaviours: arrogance, untrustworthiness,
moodiness, insensitivity, compulsiveness and abrasiveness which, if they emerge, regardless of
the extent to which leaders exhibit positive leadership traits or qualities , will render the leader
less effective with potential failure as a consequence.3
Why does leadership matter in contemporary public health crises?
Disasters have no respect for national borders and never occur at convenient times. The
magnitude of human suffering caused by these events is often unprecedented and many aspects
of people’s lives are affected: health, security, housing, access to food, water and other
commodities. Not to mention the potential for massive loss of life. Emergency plans must be in
place in order that the effects of the disaster can be mitigated and a co-ordinated response must
be launched and led as effectively and efficiently as possible; the aim is to save lives and reduce
suffering.1, 8-10
At times of crisis, when a community experiences a threat to its existence, leaders are needed
who will be visible and serve as guides, ensuring the continuing functioning of the community
and offering its members a sense of security.1, 7, 11 Leaders will be the ones who can function in
an ambiguous arena without clear boundaries and using a chaotic starting point.12
Much of the literature on crisis leadership looks at the wider community: large cities, states and
even entire countries. However, Phillips et al (2008) in considering mass fatality management
after the 2004 Indian Ocean tsunami take more of a grassroots community perspective. Due to
delays in communication and 72 hours of isolation from national emergency relief, local
community leaders had to manage the rapidly unfolding and large-scale disaster. Having
freedom from the usual bureaucratic government decision making procedures gave community
leaders the autonomy to lead as they saw fit and with an understanding of the cultural
permutations of the local communities.13 Boehm et al (2010) support that grassroots leaders may
help to foster a better understanding between formal leaders and community members during the
course of a crisis thus helping their community to cope with anxiety and feelings of panic and
enhance resilience, particularly when there is a very real threat to the lives of the community
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members.1 Pre-existing relationships, networks and prior experience with disasters were seen by
grassroots leaders as critical to successful leadership in crisis situations.13
The key challenges to providing leadership during public health emergencies and crises:
Khodarahmi (2009) believes that there is a right and a wrong way of coping with a crisis;
inappropriate actions can cause even worse consequences.14 However, the inherently unstable
nature of emergencies means that decisions need to be made rapidly and often with limited
information.15
Communication
The one skill that the literature agrees upon as essential to successful leadership is that of
communication. In times of uncertainty, creating a dialogue and hearing other’s points of view
while making decisions is seen as critical. Listening and approachability are seen to foster trust,
and strengthen communications. It is purported that being a good communicator is essential but
that an individual’s core values will help to provide direction for the communications during the
crisis. In a crisis, a true leader will be able to communicate the realities and possibilities of the
situation with complete and unwavering honesty.3, 5, 16, 17
New York mayor Rudy Giuliani demonstrated these key qualities during his first media briefing
in the aftermath of the 9/11 terrorist attacks in New York. He looked emotional and visibly
shaken but spoke in a very natural and honest manner adding a very personal dimension to the
situation. He acknowledged the dead and acts of terrorism but stressed that focus should be
placed upon saving as many lives as possible. When questioned by a reporter on the number of
casualties he answered in a very honest manner saying that at that time speculation wasn’t
appropriate but that ultimately the number of casualties would be “more than any of us can bear”
and then appropriately bought the focus back to saving lives.18 Goldsmith (2001) asserts that in a
crisis, a good leader will explain the challenges faced.7 Communication is the foundation of
crisis leadership and authenticity and influence its pillars. Without them trust will not be earned
and the leader will lack both organisational and public support.5
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Risk Management
Gray and Ropeik (2002) state that among the many lessons learned from the 2001 US terrorist
attacks was that fear has powerful public health implications.19 Risk communication is vital
during crises as it reduces confusion and uncertainty, thus alleviating anxiety.1 Chess & Clarke
(2007) discovered that divergent priorities between agencies due to differences in missions,
procedures and cultures often hindered collaboration and consequently public risk
communication, for example between law enforcement and public health agencies.20 Following
the initial 2001 US terror attacks Gray and Ropeik (2002) report that a public survey found that
48% of Americans would trust the head of the Centres for Disease Control and Prevention as a
source of reliable information in the event of a disease outbreak caused by bioterrorism. As the
anthrax threat was evolving, the head of the FBI and the head of homeland security were the key
public figures chosen to disseminate information, providing, public health leaders felt,
incomplete and inaccurate information to the public; thus maintaining an internal culture of
secrecy from the public and, Gray and Ropeik (2002) believe, impairing effective risk
communication.19
Using the 2001 US terrorist attacks to provide a further example, immediately following the
attacks it was reported that members of the public began choosing to make long journeys by car
instead of flying, thus increasing their risk of injury or death; statistically, driving is significantly
more dangerous than flying. Further, thousands of people took broad spectrum antibiotics to
prevent anthrax infection, potentially accelerating antimicrobial resistance. It is asserted that
these potentially harmful actions were taken because people were afraid and seeking a sense of
safety, an internal locus of control. A greater emphasis is placed upon the importance of risk
communication in order to help people keep their fears in perspective.19 Aids to effective risk
communication will be discussed further in the final section of this assignment.
Preparedness
During the 2004 Indian Ocean tsunami Nagapattinam district in Tamil Nadu, India was one of
the worst affected. The general hospital was located about half a kilometre from the coast and
despite some protection from surrounding walls was hit by a seven foot wall of water that flowed
into all of the 55 buildings which housed 364 patients plus staff. The majority of the buildings
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sustained heavy damage but no lives were lost and this was attributed by staff to not only the
existence of an active hospital disaster management team who practiced drills, but effective
evacuation and survival procedures that were executed in an organised and timely fashion.13
McCaughrin (2003) recognises the importance of disaster planning and regular drills are
highlighted. Drills give staff involved the confidence necessary to act in an efficient and safe
manner with minimal direction.21
Ren (2000) discusses the nature of society: Societies vary greatly in their reaction to and their
capacity to respond to crises. Prior experience of crises, existing infrastructure and health status
play a massive role in a society’s capacity to take action. This stands not only for the public but
for crisis leaders, emergency personnel and other agencies involved in the response.9 The
importance of existing networks to facilitate collaborative working is emphasized particularly in
light of the number of parties that may require co-ordination, for example: local police, fire,
medical, water and sanitation personnel, laypeople/bystanders, national agencies, international
agencies, media and the public.21
A culture of blame
Boin et al (2010) assert that often, while a crisis is still unfolding, the drama of accountability
and apportioning blame begins. Something or somebody must be blamed-for causing the crisis,
failing to prevent it, or to adequately respond to it.22 Governments and their leaders are often
obvious scapegoats. Leaders vary in their responses and responses vary in their blame
management effectiveness.11
Young (2006) points out that during the practice of blaming we have a tendency to see those who
are apportioned blame as guilty of wilful harm. It is argued however, that harm arises more from
thoughtless negligence, sloppiness, indifference, miscommunication, incomplete co-ordination
and the combined and cumulative effects of these individual facets of poor crisis leadership.23
Young (2006) also highlights that general distrust and cynicism can arise as a result of the
‘blame game’ which is wholly counterproductive while a crisis is still unfolding or being
mitigated.23 Effective blame management will be discussed in the final section of this
assignment.
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Ethical considerations
Although India was unprepared for the 2004 tsunami, various localities had significant previous
experience of other types of disasters e.g. earthquake, industrial disaster and cyclone not to
mention disease epidemics. This provided local leaders with the experience to understand the
importance of moving rapidly to either cremate or bury the dead as safely and effectively as the
situation afforded in order to mitigate the possibility of disease epidemics adding to the already
overwhelming disaster. As far as was possible divergent local religious practices (Muslim, Hindu
and Christian) were respected during the disposal of remains and the leaders of each faith were
fully involved.13, 24The local leaders in this particular situation demonstrated cultural, religious
and ethical values that were respected by the entire community, a practice strongly advocated by
Morgan (2004).24
Conversely, following the Union Carbide plant disaster in Bhopal, India in 1984 victims were
buried and cremated en-masse and there remains confusion about the true numbers and identity
of the dead.25-27 It may be surmised that in this instance ethical considerations were not
respected.
Rescue workers may be directly affected by the results of the crisis which may in turn impair
performance, e.g. during the initial local response to the 2004 tsunami in Tamil Nadu, India it
was noted that there wasn’t a single person working in the relief operation who hadn’t
experienced personal tragedy in some way: much of the initial work was search and rescue or
retrieval of dead bodies and many of the rescue workers had lost wives, children or other close
relatives in the disaster.13 In addition to being a challenging ethical issue (for example, are those
affected still expected to work and if they cannot how will they be replaced?) this matter also has
implications in many other areas of crisis leadership challenge.
The increasing complexity of contemporary public health crises
In today’s world of globalization, deregulation, open borders and information and
communication technology the contemporary crisis is increasingly complex: it is not confined by
common boundaries, it entangles rapidly with existing and profound problems and its impact is
often prolonged, intricate and interconnected.11, 28
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Current projections for population growth, climate cycles, impending tectonic activity and
disease proliferation coupled with the progression in current trends in biological/nuclear weapon
development, apparent increase in weapons of mass destruction, human conflict, information
infrastructure growth etc leads Ren (2000) to highlight a growing occurrence of ‘linked crisis
situations’.9 A basic interpretation of this would be that before the impact of an initial crisis has
been resolved, a second or even third crisis occurs. A disaster may therefore include multiple
crises and multiple incidents at the same time; standard emergencies are now exceptions.29
Crisis linkage adds further complexity to leadership during public health crises for example with
regards to areas of expertise of the leader, areas of societal vulnerability exploited and available
recovery resources such as medical supplies, rescue personnel and areas for rapid burial of mass
fatalities.
Some differences in challenges between ongoing/expected public health threats or crises as
compared to an emerging/unexpected threat or crisis.
Kippenberger (1999) asserts that one difference between for example a natural disaster and a
technological disaster is that no one is held responsible for the occurrence of a natural disaster,
only the way that it is dealt with. Conversely, technological disasters are the result of human
failure and blame can be assigned not just to the response but also to the event itself.30
Kippenberger (1999) states that unlike many other forms of crises, natural disasters tend to be
predictable-only their timing and severity remain unknown. As a result- steps that can reduce
vulnerability should have been taken and contingency plans should have been prepared. Natural
disasters can affect everything from telecommunications to power supply, and transport systems
to drinking water supply.30 If precautions are taken, a well prepared and effectively led
community will be able to minimise damage, and will have an increased capacity to cope and an
enhanced recovery time.31 With regard to a sudden and rapid drain of resources-human, transport
or medical for example, a single day’s delay for a critical resource could result in the loss of
thousands of lives.9 If the crisis is ongoing or expected, then response and resources can be
adapted accordingly by the crisis leader.
Ren (2000) argues that the growth of an epidemic is a slower and less intense crisis which gives
leaders the opportunity to shape events more thoughtfully, for example, by influencing
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population mobility and migration patterns. Similarly, in the event of a natural crisis such as a
forest fire, the impact can be redirected away from population centres for example.9
Kippenberger (1999) states that since technological/industrial accidents will inevitably occur,
containment and mitigation of the effects should be seen as an integral component of leadership
responsibility. It is explained that in a technological crisis, early warning can prove difficult due
to ambiguous warning signs or instantaneous and critical failures.30
For example the literature outlines that early warning signs were apparent on the day of the
Union Carbide plant accident in Bhopal, India; shift supervisors and therefore crisis leaders were
not however present. Chouhan (2005) explains that the danger siren at the Union Carbide plant
only sounded loudly enough for a community warning for five minutes as per company policy.
Thereafter only the internal plant siren sounded. It is stated that many of the immediate
community fatalities could have been prevented with a better warning system in place that gave
them longer to evacuate the area. Further, it appears that the evacuation plan in place only
covered the plant personnel and not the local community, thus again greatly increasing the
number of fatalities.25
The Union Carbide incident is widely acknowledged to be the worst industrial disaster in
history27 and Gehlawat (2005) asserts that in cases such as Bhopal, ‘prevention is better than
cure’.26 There were up to 5000 fatalities within 48 hours of the gas leak and an estimated further
20,000 deaths in total since the disaster due to the ongoing effects of the toxic gas. It is also
estimated that around 200,000 people were exposed to the toxic effects of the gas to varying
degrees with 60,000 requiring long term treatment, 50,000 of these being partially or completely
disabled1. Not only this but livestock and hence food security for the survivors was also
compromised.27, 32 It could be challenged that from a crisis leadership perspective, had shift
supervisors been present in the plant, more effective mitigation procedures could have been
implemented.
1
Acute toxicity of methyl isocyanate (MIC) includes difficulty in breathing, eye irritation, corneal damage, vomiting,
unconsciousness, fatigue and death. Longer term complications include reduced lung capacity, psychiatric
disorders, cardiac and immunological problems. Additionally, greater than 40% of women exposed to MIC failed to
deliver live babies (Varma R, Varma DR. The Bhopal disaster of 1984. Bulletin of Science, Technology and Society
2005; 25(1): 37-45.)
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Emerging crises although not sudden, are no less predictable. The challenge for leaders in this
situation is identifying and piecing together the often disparate clues that a crisis is about to
unfold. If this can be done, then time may be available for crisis leaders to plan and prepare.17
Some potential solutions to the challenges identified
Contemporary crisis leadership presents a paradox: the literature establishes that effective
emergency response requires meticulous organization and planning, but that leadership also
needs to be spontaneous. Leaders must be able to innovate, adapt and improvise because
emergency plans however well researched, documented and practiced, will seldom fit the
circumstances.33
Communication: intra-agency, the media and public relations
Communication would appear to be the most important facet of leadership in a crisis; intraagency, media and public relations are all highlighted. Goldsmith (2001) states that ninety
percent of serious controversies arise from misunderstandings and advises that words and
messages should be carefully chosen.7 Khodarahmi (2009) adds that nothing can replace the need
for strategically planned communications34 but Gray and Ropeik (2002) warn that
communication is effective not only through what is said, but also in actions taken (or not) by
leaders.19
The media have been identified as the most effective tool for communications and must therefore
be made an ally by crisis managers. The information given must be of quality, relevant and
trustworthy; providing timely first hand news will invariably help to strengthen media relations
and can disable speculation and rumour and help to allay public fears and risk misperception.8, 20,
34, 35
Coppola (2005) points to the need to increase responsible reporting by the media; during a crisis
event the media has a responsibility to ensure that public safety information reaches the widest
audience possible in a timely, responsible and accurate manner. A fundamental problem is
identified in this as it is believed that not all media personnel or organisations have received
crisis communications training. The media are seen as a vital component of emergency
management without whom risk communication would be almost impossible.36 This points to a
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need for key media figures to be included in emergency planning and training events and for
crisis communications and risk perception knowledge and skills to be shared across the industry.
Khodarahmi (2009) highlights that communication, public and media relations plans cannot
always guarantee success. However, if in place they can increase the chance of achieving
objectives. Clarity of the message is key as is selecting appropriate media channels.34
With regards to co-ordination and collaboration between agencies to enhance risk
communication effectiveness and intra-agency co-operation, the essential roles of pre-existing
networks are implicated in the solution.8 Frequent interaction among a diverse group of
professionals can serve to produce networks of professionals who trust one another, even if their
respective organizational mandates are sometimes at odds.20
Blame Management
Boin et al (2010) in discussing blame management provide a more politically rather than media
focused solution, but one that is generalisable to leaders at all levels. It is asserted that ducking,
diffusing and deflecting blame is a common but an unwise solution22 which will invariably be
perceived as an admission of guilt17; simply accepting responsibility is advocated as often the
most honourable and effective course of action.22
Crisis Management Planning
Phillips et al (2008) advocate that leadership skills should be integrated into crisis planning in
order to provide a balance between the technical skills needed to manage a crisis event and the
interpersonal skills required to manage it successfully.13 Disaster training and planning should
occur not only within individual organisations but cross-organisationally, and should include
local communities which will not only aid national and regional decision makers to be versed in
local culture and customs but will also strengthen the response capacity of communities at risk.10
Ren (2000) adds that with regards to crisis linkage, strategic planning should include analysis of
varying linked crises and how these may impact leadership during a crisis situation. Training
scenarios for crisis leaders and response personnel should focus on this aspect in order to bring
about a shift in attitudes towards disaster potential.9
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Conclusion
Although the literature doesn’t provide a finite number of essential leadership qualities, what
authors do agree upon is that communication is the key trait to the achievement of effective
leadership. Without it trust will not be earned and the leader will lack both organisational and
public support.
In times of public health crisis strong leadership is essential to guide and reassure communities,
as well as in co-ordinating an effective intra-agency response. Maintaining public and media
relations, quality risk communication and ethical considerations are all important crisis
leadership challenges that are highlighted.
While crisis preparation and planning, including the identification and training of leaders, are
highlighted, the literature recognises that quality crisis leadership can also be accidental. Phillips
et al. (2008) provide the example of grassroots community leaders’ successful response to the
2004 Indian Ocean tsunami. They were unprepared and unsupported, isolated from any formal
disaster response efforts for seventy two hours and yet a whole community response was
orchestrated taking into consideration divergent religious needs and with a recently bereaved
workforce.
It would appear that although a crisis can be prepared for, it is never truly known how it will
unfold. Excellence in crisis leadership in its varying manifestations is therefore implicated as the
key to success.
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