Leaders and Leadership in Systemic Approaches to the Challenge Posed by COVID-19

A Reflection by Public Health Leadership Coalition’s Member – Dr. María del Rocío Sáenz Madrigal

A single-cause or opportunistic understanding of health contributes to fragmented and insufficient responses. This also results in a reduction of financial resources earmarked for the assistance of other health problems, as evidenced during the two years of the COVID-19 pandemic. This situation is especially critical in countries with fragmented, segmented and underfunded healthcare systems, which have a high degree of dissatisfaction among both healthcare staff and the population.

Unicausality as an explanatory model of the disease tends to focus attention on the agent rather than on the causes of the events. This approach conditions the analysis of the situation and the identification and implementation of measures, as it focuses on control and containment of the disease instead of effectively and comprehensively impacting the factors that determine it.

Between 2020 and 2021, the difficulty of describing and explaining the complexity of the emergence, spread and severity of a new virus both locally and globally became apparent, as well as a potentially comprehensive and integrated approach was demonstrated.

The prioritisation, excessive in my view, in the preparation for medical assistance of more severely ill people who required specialised care at hospital level, is an example of how the explanatory models of the health-disease process converge in extreme or crisis situations. This gives way to the resurgence of myths and stigmatisation, which are clearly not the product of the virus itself, but of the measures that are implemented.

It is worth mentioning that the failure to prioritise actions aimed at interrupting the transmission of the virus causes hospital collapse, including the phenomenon of burnout mainly among medical and nursing professionals. Furthermore, the fragmentation of healthcare systems and their information systems makes it difficult to collect and generate reliable, trustworthy and real-time data on mortality and morbidity, which constitute hard proof of the effectiveness of protection measures implemented at local, national and global levels.

The pandemic has also brought to light the existing tension between individual, group and global responsibility. In this sense, we can mention the importance of global collaboration around scientific information regarding morbidity and mortality, virus variants, prevention strategies, and the availability of vaccines and medical treatments. In addition, information on healthcare policies restricting movement and managing inequities is considered fundamental at the regional level. At the country level, however, essential information is information relating to the process of preparing healthcare and social security systems, taking into account the populations most at risk. All of the above, mediated by the trust that the population has placed in the governments and country leaders, as well as confidence in their ability to serve their respective communities, is crucial for the adoption of measures such as physical distancing, use of face masks and vaccination and their implementation at the individual but also collective level.

It is precisely systems thinking that allows us to comprehend organisations in the broadest sense, as a set of interrelationships, where their raison d’être and purposes are understood in this articulation. Thus, systemic thinking leads to the recognition of internal and environmental complexity as a binding part of the system, and the multiplicity of actors that make it up as a core part of the response to the health claims from the population.

In this sense, it is urgent to strengthen Health Systems based on Primary Health Care (PHC), with people, families and the community at the centre, because it is at the local level where interrelationships, collaboration and cooperation, solidarity and social justice, synergies and contradictions are settled on and developed.

It is the recognition of a systemic approach to health problems and situations that allows us to understand not only the virus, its environment and the populations it affects but also their interrelationships. At the same time, it allows us to conceive the way in which collaborative, adaptive and multidisciplinary institutional processes can be promoted, with explicit and clearly outlined and delimited future vision, values, principles and frameworks for action. For that purpose, the definition of goals framed in action plans are necessary practices; for example, the protection of everyone, having more and better healthcare, etc. These planning exercises allow, from a broader vision, to trace routes for action in areas such as trend analysis and prospective planning; use of scientific and empirical knowledge in the definition of actions in order to be implemented; coherence, consistency, monitoring and evaluation; confidence building; assessment of multilevel health information recording and analysis; education, training and continuing education to ensure healthcare; recognition and characterisation of system actors; openness to consensus building; multidimensional coordination and articulation; communication according to the various audiences; definition of information flows and decision-making chain and incorporation of technologies, as well as digitisation and artificial intelligence.

For their part, the historical inequalities within and between countries in the Americas region were revealed to the whole world throughout these two years of the pandemic. They filled the world with suffering, desolation and uncertainty about the future, not only because of the pandemic itself, but also because of the awareness of these inequalities. In most cases, inequalities have been exacerbated in the context of COVID-19, which is why it was generally observed how the population silently claimed a comprehensive approach to the crisis.

In our region and in the specific case of Costa Rica, leadership in health was characterised by harmonising a multilevel, inter-sectoral health response with an emphasis on institutional and hospital epidemiological preparedness. However, it was striking – not only in the Costa Rican scenario – that there was little emphasis on linking local governments and organised community groups from a logic of co-responsibility, self-management and co-management, but rather with restrictive and somewhat blaming messages about getting sick or making other people sick. This approach brought to the local and global imaginary the paradigm of unicausality, which leads to focused, monothematic and partial social responses to the complexity that we have experienced in recent years; with indirect effects on the suspension of care for chronic diseases and routine procedures; physical and emotional overload on hospital teams, the population’s fear of being infected in health facilities and, in the worst cases, people’s fear of dying alone or with strangers.

Taking all this into account, being a leader entails in the first instance the ability to have the social, legal and capacity legitimisation to:

1. Identify the magnitude, severity and complexity of the situation.
2. Organise the response and the projection of organisational adjustments to processes. For example, design interventions based on equity and justice (lest the measures to be implemented increase inequalities, make certain groups of the population vulnerable, victimise or even harm them.
3. Recover the scientific and empirical evidence underpinning the actions. As well as adaptation and flexibility according to the evidence.
4. Establish priorities.
5. Protect the most vulnerable people and populations.
6. Promote the empowerment of people and organised groups, developing in them not only awareness and a sense of responsibility, but also capacities for self-management and co-management.
7. Communicate assertively and have risk communication skills.
8. Build consensus with diverse actors in the public, private, national, civil society, local and global spheres.
9. Have systems for transparency, effective use of resources and strengthening democratic mechanisms for accountability to citizens.

The experience of the region in the wake of the COVID-19 pandemic taught us that leadership in health must include equity in the design and implementation of actions, otherwise the results will be partial, insufficient, and will perpetuate and exacerbate inequality gaps.

WFPHA Has Joined Health Professionals to Call for Fossil Fuel Non-Proliferation Treaty

The message is clear; to prevent exceeding 1.5ºC of warming and to protect the health and lives of present and future generations, we need a rapid, equitable phase-out of fossil fuels globally.

The WFPHA joins health professionals and organizations to call on governments around the world to develop and implement a Fossil Fuel Non-Proliferation Treaty, laying out a legally binding global plan to:

1. End expansion of any new fossil fuel infrastructure and production
2. Phase out existing production and use of fossil fuels in a fair and equitable manner
3. Fast-track real solutions and ensure a just transition

Similar to the Framework Convention on Tobacco Control, the proposed Fossil Fuel Non-Proliferation Treaty would be an evidence-based international agreement to control a category of substances well-known to be harmful to human health.

We see serious global health risks posed by the continued extraction and use of fossil fuels. We see people suffering from health impacts of climate change, fossil fuel production, and air pollution. To protect the health and lives of current and future generations, now and in the future, the WFPHA joins the call for a global Fossil Fuel Non-Proliferation Treaty.

Largest Continued Backslide in Vaccinations in 3 Decades

On 15 July 2022, the World Health Organization (WHO) and the United Nations International Children’s Emergency Fund (UNICEF) published new data showing the largest sustained decline in childhood vaccinations in approximately 30 years.

The decline is due to multiple factors including conflict, under-investment in national immunization programs, misinformation, and COVID-19.

“This is a red alert for child health. We are witnessing the largest sustained drop in childhood immunization in a generation. The consequences will be measured in lives,” said Catherine Russell, UNICEF Executive Director.

“Planning and tackling COVID-19 should also go hand-in-hand with vaccinating for killer diseases like measles, pneumonia and diarrhea,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “It’s not a question of either/or, it’s possible to do both”.

WHO and UNICEF are working with Gavi, the Vaccine Alliance and other partners to deliver the global Immunization Agenda 2030 (IA2030). The IA2030 partners call on governments and relevant actors to take several actions including intensifying efforts for catch-up vaccination, implementing strategies to build trust in vaccines and immunization, ensuring political commitment from national governments to strengthen and sustain immunization, and many more.

Letter to President of the Government of Spain

Spain was among the most progressive nations in the world in 2010 with the passage of Law 42/2010, which banned smoking in all enclosed public locations, including hospitality venues. It was in accordance with the World Health Organization Framework Convention on Tobacco Control (WHO FCTC).

The WFPHA understands that the Government of Spain has prepared an advanced Comprehensive Smoking Prevention Plan, which is great news. However, Spanish public health professionals and their associations are disappointed to see the initiative stalled.

The policies that the Government of Spain has designed and, as far as the WFPHA knows, are ready to be launched, are the most sensible public health policies that can be implemented. With Spain holding the presidency of the European Union next year, is an opportunity to lead progress in such an important area of European health policy.

The WFPHA sends a letter to Mr. Pedro Sánchez Pérez-Castejón, President of the Government of Spain, to express its full support for tobacco prevention measures.

Could Leadership still Avert Catastrophe?

A Reflection by Public Health Leadership Coalition’s Member – Dr. Alejandro R. Jadad

I gave them blind hope… and so turned away their eyes from the doom of death. – Aeschylus1

For more than 1200 years, the word “leader” has been used to describe someone with the ability to persuade others to travel toward a given place or to pursue a goal, together. When the destination is perceived as much better than the starting point, and the journey is believed to be safe, leading is easy. The true test of leadership is convincing people to embark on a dangerous journey toward a destination where they could end up being worse off, and to remain unflinching in the moments of greatest peril and hardship. At a time when we all face a grim outlook caused by multiple existential threats, nobody seems willing to take this test. Instead, we seem to be stuck, reliving a psychopathic recurring pattern. Those in positions of political leadership are presented with updated reports that paint a worse picture than what was described in previous versions. Consistently, they state that there is still hope for change, even though the window of time for an effective response keeps narrowing. The reports then call for urgent action by governments, corporations and the public at large. With uncanny consistency, these documents are then discussed at large-scale international summits that end with high-profile announcements and commitments to fix the problem. What makes this cycle so psychopathic is that the date for meaningful action is conveniently set so far into the future that those making the pronouncements will be long gone by then, and essentially escape any accountability. Sometimes there is a minor variation: the goals that are set are pathetic and practically useless. In either case, the official statements are always followed by short-lived outpourings of disappointment and anger by a few advocacy groups, with ephemeral coverage by a complicit media, and complete apathy by the public. Then, once again, it is time for yet another set of reports to be released. All along, those who profit from the status quo take the spoils, with intentional inaction and complete disregard for the impact on future generations.

We have gone through this complacent flow of events so often that it feels like the right time to ask and answer a few uncomfortable questions:

Is there any other way for political leaders to react to the growing evidence of worsening existential crises? Can they, or any other group of leaders for that matter, really do anything to revert what might be an inexorable trend toward self-destruction? If so, what needs to be done and by whom?

This may also be the best moment to understand ‘existential hope’ better. Could its advocates be right in thinking that there is “a chance of something extremely good happening”? If so, is there any role for leadership, of any kind, to increase such a chance?

What we really want to know is: Is it too much to ask from leaders to put in place mechanisms to prepare for the worst case scenario, even if it is just in case?

If the answers reflect more of the same, then maybe it is time to accept the possibility that we are “a dead species walking”.

1. Aeschylus. Prometheus Bound; ca. 430 BCE