Crises feature severe threats, urgency, and uncertainty.1 While there are varying definitions for a public health crisis, a public health emergency has been defined as “an occurrence or imminent threat of an illness or health condition, caused by bio-terrorism, epidemic or pandemic disease, or (a) novel or highly fatal infectious agent or biological toxin, that poses a substantial risk of a significant number of human fatalities or incidents of permanent or long-term disability”.2
Public health emergencies may originate from natural disasters. Since 1990, natural disasters have affected approximately 217 million people per year globally. These natural disasters may be biological, geophysical or climate-related.3 In the 21st century, with global interconnectedness through transnational trade and travel, public health crises are increasingly complex and often have international ramifications.
Advances in humanitarian public health responses have been made over the past 40 years.4 These advances have come as a result of an expanding use of epidemiological methods and logistical frameworks in public health crises. In addition to these advances, there has been an increased focus on prevention of public health crises. 5
This essay will examine the challenges to providing leadership during a public health crisis, the contrast between facing an unexpected public health threat versus an anticipated and ongoing public health threat, and discuss potential solutions to the challenges identified.
Theories and challenges of leadership
Leadership is paramount in public health crises. The public experience of crisis is marked by threat and uncertainty and the natural response of the public in times of distress is to look to leaders to act. In response to a crisis situation, leaders are expected to take control, mitigate the fallout, respond with vision and decisiveness, protect the public from additional risk and, ultimately, resolve the crisis.6 When crisis leadership brings about reduced stress and a return to normality, the public heralds their leaders. The converse is also true.7
From an Australian perspective, we expect our leaders to demonstrate participative, humane, and performance-orientated leadership.8 Specific to crisis leadership in public health, there are six desirable attributes that a public health crisis leader should possess. These are: competence in public health science; decisiveness; situational awareness; coordination skills; communication skills; and the ability to inspire trust.9
Crisis leadership involves engaging followers to seek higher levels of motivation, morality and/or immediate purpose. This type of leadership is especially important in acute and time-dependent public health crises where an immediate response is needed. 10 In the aftermath of an acute crisis or in public health crises that play out over longer periods of time, the challenge is to maintain the impetus required to address the issues, receive expert advice, evaluate new risks, provide direction, and enable co-ordination across organisations and jurisdictions. 7
A central and ever-present challenge of public health crisis leadership is providing clear communication and maintaining control over the key messages – often in situations where ambiguity exists. While uncertainty is inherent in unanticipated crises, it should be clarified and communicated appropriately with the public. Uncertainty may be characterised as a fault of leadership if it is not communicated in a way that meets community expectation. Also, without this communication, the information gap between what is known and what the public would like to know may be filled by commentators within the media, or other actors looking to further their own agenda. It is therefore incumbent on an effective leader to ensure a clear, consistent, and accurate message is disseminated to the public.10
Developments in information technology have magnified the impact of uncertainty as a distorting force in public health crises. In the 2009 influenza A (H1N1) pandemic, delays in production of a vaccine and a lack of full disclosure by the United States Government led to increased public scepticism and a loss of credibility for those in power. In lieu of complete information provided by the Government, the internet and electronic social media filled the gap, enabling dissemination of incomplete information and misinformation.11
During public health crises, perceptions of risk are largely framed by media communication. This perception is instrumental in influencing the public response and compliance with public health interventions. This effect was demonstrated in a recent study comparing the uptake of immunisation in Australia versus Sweden in the wake of the 2009 influenza pandemic. While the risk of H1N1 was communicated similarly in both countries, there were major differences in how the media framed the pandemic. In Sweden, where the media focused on the community’s responsibility to protect public health, immunisation rates were 42% higher.12
Risk communication is based on four theoretical models – risk perception; mental noise; negative dominance; and trust determination. These describe how risk information is processed, how risk perceptions are formed, and how risk decisions are made.13
The risk perception model is concerned with the factors that are associated with, and contribute to, an individual’s appraisal and recognition of risk. The perception of risk is vitally important in understanding why the public becomes more or less upset by events. There are several perception or “fright” factors that have been identified to have direct relevance to risk communication.14 Levels of public concern tend to be highest when the risk is perceived as involuntary, inequitable, not beneficial, not under one’s personal control, associated with untrustworthy individuals or organisations, or associated with averse and irreversible outcomes.15 This was exemplified in the 2011 Fukushima nuclear incident, where the risk from the radiation fallout was involuntary, not beneficial, not under personal control, and known to cause dreaded diseases such as cancer.16
The mental noise model focuses on how people process information under stressful conditions and how changes in the way information is processed affect communications. Evidence suggests that that when the public is alarmed by what they perceive to be a significant threat, their capacity to understand information is severely impaired.13 Clear communication, utilising simple and consistent terminology, assists in delivering a message that the public can comprehend.17
The negative dominance model posits that when the public is experiencing high levels of stress, negative cognitions predominate. The relationship between negative and positive information is asymmetrical, and the public places greater value on losses rather than on gains.13
The trust determination model positions the goal of risk communication as gaining trust and credibility. Only once trust has been established can education and consensus building be achieved. To establish and maintain trust, one must demonstrate the following values: caring and empathy; dedication and commitment; competence and expertise; and honesty and openness. 13 Trust is an essential factor in gathering community support for public health interventions during crises.18
A heuristic tool to examine risk perception has been proposed by Peter Sandman. He states that risk is the sum of hazard and outrage, where the former is defined as the perception of danger posed by a crisis. He posits that public health experts frequently focus on the hazard and ignore the outrage, thereby systematically overestimating the risk when the hazard is high and outrage is low, and systematically underestimating the risk when the hazard is low and outrage is high.19, 20
Models of leadership
Utilising knowledge about risk communication is essential in managing public health crises. Two predominant leadership models exist, both underpinned by the United States’ Centre for Disease Control (CDC) six principles of effective crisis and risk communication. These are: be first; be right; be credible; express empathy; promote action; and show respect.21
One example is the “Giuliani model”. This was based on the behaviour of former New York Mayor Rudy Giuliani following the 2001 anthrax attacks. In this model, the elected official takes the lead by making key decisions, underpinned by advice from experts. Following these episodes of bioterrorism, in an already uneasy post September 11 climate, Giuliani made key decisions, and conveyed empathy and compassion. He utilised the expertise of bureaucrats, each speaking to his or her specific area of responsibility. Here, Giuliani demonstrated key aspects of the trust determination model, including concern, empathy, honesty and the principle of trust transference. Trust transference underpins situations whereby the credibility of the highest trusted source on an issue (often scientific experts) is adopted and conveyed.22, 23 A higher level of trust in the Government is associated with a greater intention amongst the public to adopt protective measures in public health crises.24
The alternative example is the “Glendening model”, based on the behaviour of former Maryland Governor Parris Glendening. In this model, the bureaucratic leader takes the lead, by making key decisions with political support from the elected official.10 While there is evidence supporting both models, analysis of levels of trust in the United States during the 2009 influenza pandemic found that public health professionals received the highest level of trust. 25 This may offer some support for the Glendening model, at least within the United States.
Practical solutions to public health crises
In responding to a public health crisis, a leader must demonstrate knowledge, accountability and the ability to act. In a practical sense, this can be delivered by an initial assessment of the magnitude of the crises and a commensurate response based on initial expert opinion, with frequent updates and education on the evolution of risk assessment provided by experts and conveyed to the public. In the initial phase of a crisis, the focus is on conveying empathy and reassurance, designating crisis or agency spokespersons, and establishing a general and broad-based understanding of the crisis circumstances, consequences and anticipated outcomes based on available information. Following the initial response, the focus shifts to the provision of updates on progress and further background information, as well as gathering feedback, maintaining systems of accountability, and correcting misunderstanding. In the resolution phase of a crisis, further education on remediation, recovery, and rebuilding is required, as is a frank discussion about causes and blame, and the promotion of measures to prevent re-occurrence.21
In the evaluation phase, leaders must discuss the lessons learned, and evaluate the performance of communication and action throughout the crisis. They must also look to the horizon and anticipate further potential crises. Here, assessing the structural elements of preparedness, including public health laws and regional support networks, is necessary. In addition, implementing sustained funding for public health preparedness is essential to develop infrastructure, attract innovative minds to the area of public health, and maintain the existing workforce.26, 27
There are distinct differences between an acute, unanticipated and sudden crisis versus an ongoing, anticipated and smoldering crisis. In sudden crises, there is limited warning and urgent action is necessary, whereas in smoldering crises, there are often warnings, the issues are protracted and ongoing and concerted action is necessary. In sudden crises, leaders are typically not blamed. In smoldering crises, leaders can be blamed for inaction or lack of foresight in managing the precipitating issues. In both cases, the same principles of leadership remain. However, in smoldering crises, considerably more effort is needed to establish trust with the public and garner support and eliciting followership and compliance.28
One of the primary roles of political and public health leaders is communicating with the media. It has been argued that this is perhaps the most important role of the leader, as this is the conduit through which they deliver their message to the public. In effectively utilising the media in a public health crisis, a leader must appreciate the time constraints at play, and provide access to resources and technical expertise to journalists. The provision of pre-prepared resources is an effective method of early intervention in dissemination of a message through the media, while an appeal to the ethical values of the media can encourage the framing of information to benefit public health.29
It is important that competent public relations are supported by action on the ground. These actions should be dictated by honest goals, measurement of progress, and regular communication and updates on steps towards resolution.30
Another role of the public health leader is in capacity building. Preparedness is essential in crisis management. In the United States, community-based disaster coalitions have been developed, with recommendations to introduce this program into other countries. The benefit of involving the public in disaster preparedness and crisis management is twofold. Firstly, it allows the public to feel empowered in situations that are often typified by powerlessness. Secondly, it enhances both the skill set of the public and their knowledge about crisis management.31, 32
Evidence from Australia has found that, at present, the public is not sufficiently prepared for an unanticipated disaster.33 The onus of public preparedness rests on Australia’s public health leaders and government officials. As with communicating during a crisis, communication in preparation for a crisis is a significant task. Effective communication to engage the public but avoid alarm is imperative.
The success or failure of public health responses depends largely on the capacity and preparedness of services already in place.34 In the United States, the Center for Public Health Preparedness (CPHP) has been tasked with the role of meeting these challenges. Over the past ten years, this centre has provided preparedness training to approximately 10,000 public health officials. 35 Evidence suggests that ongoing training and longitudinal reinforcement is necessary to maintain preparedness behaviours and attitudes. 36
At present, there does not exist an organisation equivalent in size to the CPHP providing preparedness training in Australia. However, Australia does have a National Strategy for Disaster Resilience and an Australian Emergency Management Knowledge Hub, which are positive steps in preparing for a large scale public health crisis.37 Some professions have formulated, or taken steps to formulate, frameworks and advocacy for training in disaster preparedness, including nurses38, general practitioners,39 and emergency physicians. 40 Additionally, a national framework for disaster health education has been proposed. This framework identifies seven education levels along with educational outcomes for each level, with a view to provide greater consistency in language and operational approach in disaster management.41
In a study of emergency preparedness within United States public health departments, it was found that a number of equally efficient models exist. One essential theme across all models was strong leadership. Within public health departments, the most effective leaders were found to be those who fostered respect and co-operation, had extensive public health experience, had an ability to influence and persuade, possessed strong negotiation and diplomatic skills, and were adept at achieving reciprocal factors within their organisation. Leadership training programs have a role in creating effective leaders.42
In Australia, The Minster for Justice is responsible for national emergency management and disaster resilience. In the case of pandemics, there are highly complex arrangements in place, with a number of management plans available. Across the Australian federation, there are at least 18 primary plans; 27 subplans, appendices or annexes and 11 guidelines or other minor planning documents. These numbers do not include numerous websites containing various advice and guidance documents. There also exist overarching guidelines provided by the World Health Organisation. Navigating such a complex system can lead to confusion, and exemplifies the key role of a leader in coordinating the response to a crisis.43
There are additional global challenges that countries face. In the case of pandemics, global public health laws such as the International Health Regulations (IHR) exist to provide a framework for controlling the international spread of infectious diseases and specifying the measures that can be undertaken by countries in response to disease outbreaks in other countries. The IHR allow each country to construct its response in line with its cultural values, but these regulations are now dated and have limited effect in the 21st century. In addition, these regulations do not prevent countries from acting unilaterally in response to domestic issues, which may not aid international efforts. Global leadership is required to foster consistency, and the World Health Organisation has a key role here.27
Leadership skills can, and should, be taught to all people in positions of authority within the public health sphere. Capacity building and preparedness are essential components in enabling an efficient response to a public health crisis. Leadership, as described in this essay, is paramount in all stages of a crisis, as well as in the development preparedness.
In the aftermath of Hurricane Katrina, a White House official observed, “At all levels of government, we must build a leadership corps that is fully educated, trained and … populated by leaders who are prepared to exhibit innovation and take the initiation during extremely trying circumstances.”44 This statement encapsulates both the challenges faced and goals desirable to prepare nations and the world for future public health crises.
Dr Malcolm Forbes
Medical Registrar, Royal Australasian College of Physicians
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The Royal Australasian College of Medical Administrators
Dr Malcolm Forbes, , p707