Reflections on leadership during the Covid pandemic

ABSTRACT

Doctors lead, in and out of the clinical environment, from ward to board; their roles will range from dealing with risk and uncertainty, communicating with different audiences and managing crises. At the heart of leadership is the ability to make decisions; which operation to perform or treatment to give or, as during this pandemic, what policy to implement or vaccines to order. If leadership is about making decisions, successful leadership is the ability to make the right decisions. This, after all, is what distinguishes a good leader from a poor one. During this pandemic we have been able to compare different leaders, drawn from across the health, political and other sectors. This article identifies how leaders behaved during this pandemic and importantly what can be learnt from their actions.

KEYWORDS:

• Leadership
• Covid
• doctors
• mental health

Introduction

I got Covid early, a souvenir from an International conference I attended in New York in February 2020. At that time there was an evolving situation as hundreds of tourists were stranded on a cruise ship near the city center. At the time only a handful of people in America had been infected and despite worrying numbers of deaths and infections in countries such as Italy and Spain, many leaders down played the risk in their own countries, even advising against public health measures such as mask wearing. Others acted differently. Even before knowing all the facts or information they would have liked, or what an ‘R’ number was, they took decisive action. For example, the Prime Ministers of New Zealand and Israel adopted the precautionary principle of ‘better safe than sorry’ and favored the ‘go hard, go early’ approach [1]. There were gasps of incredulity as they shut businesses down, instituted shielding and social distancing and made the wearing of masks compulsory.

The initial response of world leaders to the handling of Covid were therefore varied, as were the results, all to evident in the tally of deaths, infections and social disruption. As the devastation inflicted by the pandemic has played out we are able to compare how different leaders reacted and observed the consequences and importantly learn from their varying responses.

Understanding complexity

It’s a truism that we are living in uncertain times. Critical decisions are being made by leaders who have little data, information or experience to rely on. From the start there were more unknowns than knowns. For example, no answers to basic questions such as: Why do some people get infected and others do not? How deadly is the virus or reliable is the information flow or is the modeling too pessimistic or too optimistic?

Early on in the pandemic, as a general practitioner, I had to answer calls from patients asking if they had Covid. At this time there was no available laboratory tests for community use. Diagnosis was a made on clinical criteria which were changing on a daily basis. Initially high temperature and a sustained new cough. Then other symptoms were added; loss of sense of smell, diarrhea, tiredness, headache, muscle pains and even more. In the absence of a test I could not reassure my patients. I could only explain the dilemma I was in, provide safety netting and advice and ask them to follow the news, as I was doing. Put simply, I was honest with them. I shared my uncertainty and did not provide false reassurance. My patients were grateful for this. Unlike normal times, where I would be able to reassure – now we were all working in the dark. Finding a path through what needs to be done when all around is unclear places a heavy and unique burden on leaders. The natural tendency is to provide reassurance and try to contain anxiety by offering simple solutions, and this is what some leaders did. They did their best to construct a convincing narrative for themselves, based on the scant information available. A narrative which provided them with an ‘answer’ which could be stuck to, even if emerging evidence might suggest they were wrong. For example, again, as with The President of the United States, Donald Trump, who said on different occasions. ‘It’s going to disappear. … it’s like a miracle – .’ ‘no one will die’. He peddled Chloroquine or disinfectant as magic cures, and presented myths as facts, reassuring us ‘The coronavirus would weaken when we get into April, in the warmer weather.’ Others such as Nicola Sturgeon shared their uncertainty, and admitted that they might have to change direction as more became known about the crisis we were in [2]. This approach is seemingly more honest and less contrived than those leaders who, despite the enormous unknowns, offered false certainty.

Dispersive leadership

There is a natural tendency for people to crave for an authorative leader – an omnipotent one – especially in times of distress, expecting this individual to solve their problems and to lead them out of danger. However, heroic leadership can be disempowering and creates a dependency culture as Wilfred Bion, the British psychoanalyst and expert in group processes observed. He reflected that with this type of leadership the groups behavior is governed by one question, who or what will save us? [3], a phenomena often played out in the meetings, organizations and teams that we form part. This sort of leadership creates dependency and is typified by the chief executive, working only with his small team, expected to find solutions to wicked problems. Others, wait passively to be rescued. If the leader does not perform sufficiently well (which is nearly always the case), they are attacked, replaced and blamed. However, amidst the uncertainty of Covid some leaders understood that when faced with unfamiliar problems, the more important it was to delegate leadership and empower others. They understood only by dispersing the functions of leadership, moving away from the traditional top down leadership can dependency be avoided, and the best results achieved. This is what happened in the NHS, where responsibilities were delegated to local areas and teams. They were able to make crucial decisions unfettered by layers of bureaucracy and allowing for agility and flexibility, leading to positive results. For example – rapid changes in skill mix to get the best fit for patients. Health care staff allowed to practise at the top of their license (meaning for example for the first-time healthcare assistants were allowed to administer insulin) or true joint working across different health and care organizations in ways that had not been possible for years. In general practice, in the space of one weekend general practitioners moved their 1 million consultations done daily with patients, online. Decades of transformation happening in days. Leadership and authority had been delegated allowing innovation and improving the chances of finding creative solutions to difficult problems. A good leader therefore maximizes the authority of others and minimizes that of themselves. Or more simply good leaders enable others to think.

Follow the science, in part

In 2016, Michael Gove, referring to Brexit, and then the Lord Chancellor, said this country has ‘had enough of experts. This view of ignoring experts changed as the pandemic took hold. From the outset politicians, were invariably seen sandwiched between professionals on every outing. Utterances made at press conferences were preceded by the phrase, “following the expert advice, we are receiving”. During these months, doctors have become household names; The American immunologist and national advisor, Dr Anthony Fauci, has had extremely high national approval ratings and now is a household name with his face depicted on a whole range of memorabilia (tea shirts, mugs, hats) [4]. In the UK, Chris Whitty, the Chief Medical Officer for England has a twitter hashtag #welovechriswhitty hailing him as having superhero powers. Calls were even made on social media for him to be the next James Bond and to lead Brexit negotiations [5]. Similarly, medical experts have been lauded in Spain, Germany, France and many other countries across the world. It stands to reason, that leaders, who listen to experts, are more likely to succeed and, as with Covid, to save lives. However, whilst it is scientists who provide expert advice, this advice is never completely clear cut. Science, by its nature, is uncertain and flawed. It moves forward through constant scrutiny, cooperation and competition. It is not a cogent progression toward unquestionable facts, rather a changing background of ideas, thoughts, beliefs and possibilities brought about by experimentation and scholarship. Scientist can, and should also restrict themselves to their areas of their expertise (for example health policy, infection control, vaccine distribution). As Margaret Thatcher, referring to her economic guru said in 1989 “Advisors advise, but ministers decide.’ Political leaders must be more than the mouthpiece of their medical advisors, as it is governments who decide policies and make laws, ideally built on a culture of openness, information and diversity of opinions. When the policies and practices prove to be wrong (and during the pandemic some have had to be abandoned), politicians must not then deflect the locus of responsibility onto the so-called expert [6]. Predictably, the blame game started early with experts as easy prey. For example with the American Government undermining World Health Organization’s handling of the Covid crisis and removing their funding in the midst of the pandemic – creating damage on a global level. In England the Secretary of State for Health, axed what he called ‘the failing Public Health England”. However, as the President of the Royal Society, Sir Venkatraman Ramakrishnan said in May 2020, ‘whilst questioning scientific evidence is crucial, attacking and criticising scientists is misguided, it can and will destroy trust in both politicians and experts’ [7]. Deflecting criticism by blaming others is common behavior amongst politicians but at times of crisis it is important they (as clinical leaders do in their consulting rooms) take responsibility for their decisions, both good and bad. Good leaders, therefore, have used their own critical reasoning and judgment to make and be responsible for decisions informed by, but not dictated by their expert advisors.

Metaphors matter

When the Prime Minister of New Zealand, Jacinda Ardhern speaks she often does so with clarity, honesty, and importantly, compassion. She acknowledges the sacrifices needed and simply asks that fellow countrymen are ‘strong, kind, and united against Covid-19.’ Her language is empathic and compassionate, with metaphors of caring, concern and love. Others, perhaps inevitably, to deal with the threat we are living with use the metaphor of war. Queen Elizabeth II used the wartime anthem of hope and resilience, ‘we’ll meet again’ when she addressed the Nation on 5 April 2020 [8]. Early in the pandemic, and faced with rapidly rising deaths, the Governor of New York Andrew Cuomo used the war metaphor extensively saying ‘The soldiers in this fight are our health care professionals. It’s the doctors, it’s the nurses, it’s the people who are working in the hospitals, it’s the aids. They are the soldiers who are fighting this battle for us.’ [9] In England, NHS staff were thanked by the Chief Executive for “stepping up to serve in the fight against coronavirus’ [10].

The use of imagery evoking the war is persuasive. It casts the leader in the role of the valiant leader, able to reassure a distressed public. It identifies the virus as the ‘enemy’, needing to be dealt with as such; with front-line soldiers (doctors and nurses), a home-front (those shielding or isolating at home). and even defectors (those not wearing masks, catching the virus or not becoming immunized). It reinforces the urgency needed for drastic policy decisions, appealing to one’s sense of duty and obligation to serve the country in its hour of need [11]. However, whilst appealing as a piece of political rhetoric, the metaphor has problems. The choice of words does not just affect the way we talk about something, it affects how one thinks, feels, and even acts. The metaphor risks normalizing actions only seen in real battles, such as where soldiers, in the course of active service, may have to violate their own moral or ethical code. For doctors, this might mean forcing them to choose which patients live or die, due to lack of intensive care facilities needed to save both. Soldiers and doctors are at risk of developing moral injury – severe psychological distress, with feelings of guilt, shame and disgust [12].

War-like analogies also risks legitimizing the erosion of civil liberties through the use of wartime legislation, leaving the door open to more restrictive laws under the guise of a national emergency such as only one opinion is now required for a compulsory admission under Mental Health Act, rather than two. War by its very nature creates divisions which given the need for shared working on local, national and international scales could delay recovery as we are seeing with the vaccine roll out as richer countries dominate the purchase of vaccines. It is important therefore for leaders to understand the impact of their language, especially where the language has connotations of violence and division. Weaponizing the struggle might have been acceptable in the early days of the pandemic but as time moves on it is time to change the metaphor. The virus is not a sentient being, or an army. Rather than defeating it, we will have to find better ways to live with it. Even with a vaccine there will never be a ‘VC’ day (Victory over Covid) as to date, only small pox vaccination has eradicated this virus completely. Good leaders found a different metaphorical frame, one which promoted civil responsibility and global solidarity.

Caring for oneself

A crisis such as Covid-19 demands an agility and speed of response that public bodies, with their layers of scrutiny are generally not designed to deliver. Add to this that decisions have to be taken on the basis of imperfect information, in an emotionally charged context, by exhausted individuals who are well aware they are dealing with matters of life and death. Add to this, remote working, social distancing, shortages of staff due to shielding, infection or isolating and lack of basic equipment – it is surprising more have not struggled. My main work is leading a confidential service for doctors and dentists with mental illness, NHS Practitioner health (PH). The literature from other pandemics suggest that health professionals bear a major burden of the mental health problems [13]. This appears to be the case with Covid-19, where surveys suggest high rates of mental illness, especially so for intensive care staff finding high rates symptoms of post-traumatic stress disorder [13]. Pre-pandemic, PH was seeing around 60 new referrals per week. After an initial dip at the start of the pandemic, referrals peaked at 120 per week and regularly more than 100 new practitioner-patients present every week. Most presenting with depression, anxiety and symptoms indistinguishable from post-traumatic stress disorder. Others with preexisting trauma reopened by their constant exposure to death and suffering. It is not just those who work in the so called ‘front line’ who have suffered from the consequences of their work. Medical leaders in non-clinical roles have often found themselves in the invidious position of being seen simultaneously as scapegoat and savior: hero and villain. Having to position themselves in the conflicting position of needing to implement on-high orders whilst being attacked by their ‘troops’ as they felt they were being put into dangerous situations – exemplified by asking staff to work without appropriate Personal Protective Equipment or more recently insisting health staff work ahead of receiving their second Covid vaccine. For many this has been the first time they felt compromised by serving two conflicting masters. It was not the first time they faced the challenge of not knowing – after all, medicine is full of uncertainties and ambiguities, but for these leaders this was different as constant change and fear dominated their daily landscape, leading to anxiety. Fatigue exacerbated psychological distress as taking any time out became impossible, compounded by lack of normal spaces and times for relaxation and recuperation [14]. Good leaders, however, must take time out, model self-care to those they lead, recuperate and recover for the next stage, though even for the best ones, this is difficult, and they need to be given permission to rest and recharge their psychological batteries.

Final reflections

Across the world we are learning about the strengths and weaknesses of those tasked with leading us through this crisis. It is fair to say that all have struggled in different ways, some more than others. However, leaders who have excelled are those who have shown compassion, empathy, connectedness and even vulnerability. They have been honest about the challenges and shared with us their uncertainties. Overwhelmingly, they have offered us hope, tempered with realism. In time, we all need to learn the leadership lessons emerging from this pandemic.

Declaration of interest

No potential conflict of interest was reported by the author.

Declaration of financial/other relationships

The contents of the paper and the opinions expressed within are those of the authors, and it was the decision of the authors to submit the manuscript for publication.

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

No funding was received to produce this article