The Influence of Visionary Leadership on Change Management and Implementation

Ipatia Apostolides

April 16, 2020

Chapter 2: Literature Review

Introduction

            The purpose of this literature review was to conduct a meta-analysis of literature on the new coronavirus (COVID-19 virus) with a focus on the leadership of the US and Chinese governments during the time period of Dec. 22, 2019 to March 22, 2020. This quantitative study tries to answer the research question of whether or not timing and transparency by government officials, two independent variables, impact the cases and deaths of the COVID-19. The topics covered in this literature review are: the leadership theories in disease outbreak, the risk communication used in the past for the SARS virus, the World Health Organization’s response to the COVID-19 outbreak (WHO, 2005), as well as data from SARS which is the precursor to the COVID-19 virus, followed by both China and the US on the COVID-19 disease and the governments’ response to the outbreak, and the issues that have arisen during this outbreak. A summary will be presented at the end of this literature review.

Documentation

Table 1

Research Databases Used for Review of Literature

_________________________________________________________

Search Engine                                     Number of Resources Obtained

__________________________________________________________

Ebsco Host                                                                              3

Google Scholar                                                                       9

Researchgate                                                                           1

UC MegaSearch                                                                     3

World Health Organization                                                    1

____________________________________________________________

Leadership Theories

In a disease outbreak, leadership is crucial in its management, and according to Arifah et al., (2018), three leadership theories have been proven to be effective: participative, contingency, and transformational. An article by Wu, Yang, and Wu (2004) showed that in a Taiwan hospital stricken by SARS, about 128 medical staff resigned, and the CEO of the hospital brought in experts from headquarters to help, thus encouraging the staff and exercising the participative leadership approach (as cited in Arifah et al., 2018, p.7). 

The second leadership theory in disease outbreak is the Contingency Theory, and it focuses on the dynamics between the leader and the followers, and uses positional power, leader-member relations, and task structure (Arifah et al., 2018, p. 9). In order for this Contingency Theory to work in a disease outbreak, the successful working relationship between the leader and followers motivates the followers to execute well-defined tasks (p. 10). The ability of organizations and employees to work together in response to change, where employees are not only contributing expert knowledge but are accountable for their performance, explains the ‘leader-member relations’ aspect of the Contingency Theory (Gould et al., 2016, as cited in Arifah et al., 2018). 

The third leadership theory in disease outbreak is the Transformational Theory, and it relies on inspirational motivation, idealized influence, and individualized consideration (Wu et al., 2004, Koteyko & Carter, 2008, Rosewell et al., 2013, & Nyenswah, 2017, as cited in Arifah et al., 2018). The paper by Arifah et al. (2018) recommends that governments, ministries, and public health officials attend World Health Organization (WHO) courses for leadership skills in managing epidemics and pandemics to improve leadership in times of global outbreaks (WHO, 2016, as cited in Arifah et al., 2018, p. 12).

Baekkeskov & Rubin (2017) state that during the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak, China’s secrecy and misinformation along with public officials playing down the risk of the disease had exacerbated the SARS epidemic by delaying control. However, by 2009, China had learned its lesson, that secrecy failed as a blame avoidance strategy in epidemics, and in the case of 2009’s swine influenza epidemic (H1N1), the Chinese official media reported immediately on the H1N1 (p.425). Several political dynamics may make the information dilemma during a crisis important for China’s authoritarian regime: authoritarian regimes often control mass media; growing information demands due to institutional reform; and regime vulnerability to information (Baekkeskov & Rubin, 2017, p. 427). 

In the US, to avoid blame for policy mistakes, democratic politicians have used ‘lightning rods’ or individuals that are responsible for any policy mistakes and take the fall for them (Baekkeskov & Rubin, 2017, p.428).

World Health Organization

In an “Outbreak Communication” report by WHO (2005), disease outbreaks are urgent emergencies and require rapid decisions to bring the outbreak under control; these outbreaks have unique features, like: 

·      “urgent public health emergency

·      unpredictable

·      alarming for the public

·      socially and economically disruptive

·      strong political dimensions

·      spread has behavioral component

·      eminently newsworthy” (p.7)

Risk communication has been widely written about in over 8000 articles, and this is defined as a process of communicating honestly about the risk factors of a disease (Menon, 2006); this requires active communication by officials; including openness and transparency, and demonstrating action, as well as encouraging self-responsibility (p. 362). 

The timing of first official communication about a disease is the most important, according to the report by WHO (2005); and if there is a delay, this gives the impression that officials are concealing information, because they are more concerned about loss of income from trade and the prevention of public anxiety than protecting public health (p. 24). However, before making a disease outbreak announcement by the government to the public, it is necessary to verify it first by public health officials and this usually takes two days whereas significantly important events are verified in less than 24 hours (p.33).

In addition, even before a disease outbreak, trust should already be in place (p.28). If the public becomes suspicious that information about the disease is withheld from the start, the report by WHO (2005) notes that this could damage a country’s leadership (p. 31). 

Severe Acute Respiratory Syndrome (SARS)

The SARS virus in 2003, was the first pandemic of the 21^st century, and Singapore rose to the occasion in February 2003, in combatting the disease through quick actions, like amending the Infectious Diseases Act to allow enforcement against quarantine breakers, using electronic tags on the public, having thermal scanners for borders; purchasing mass supplies of personal protection equipment; and contact tracing (Menon, 2006).  They also used every communication tool available, with the help of grassroots leaders and religious groups, websites, advertisements, posters and booklets, and hotlines (p. 364). However, their harsh, authoritarian and draconian preventive measures were criticized by the media (p. 366). 

By July 2003, the SARS global outbreak was contained (Peeri et al., 2020).

Novel Coronavirus (COVID-19) – China

The novel coronavirus (COVID-19), was first identified in Wuhan, China, in December 2019, as a genus betacoronavirus, which causes atypical pneumonia, and is similar to SARS, and Middle East Respiratory Syndrome (MERS) (Peeri et al., 2020; Li et al., 2020; Huang et al., 2020). This novel coronavirus was first identified in 4 patients as a “pneumonia of unknown etiology” (Li et al., 2020, p. 1200). Like the SARS and MERS diseases, it transmits through human-to-human transmission; however, it has surpassed SARS and MERS in the  number of cases and deaths (p.2). The lack of transparency by the Chinese health ministry, along with inadequate risk assessment has hampered efforts to contain the COVID-19 disease, and has been cited as one of the largest contributors to the spread of the disease (p. 2). By not being transparent, the Chinese health ministry’s leadership is weakened and may contribute to trust erosion. In addition, under-reporting in the number of cases of the COVID-19 in China was noted by Zhao et al., (2020). This under-reporting can impede containment and endanger other countries, because as the virus spreads to other countries, their public healthcare system might not be adequately prepared as a result of the lower numbers.

Li et al., (2020) looked at 425 patients in Wuhan, China with confirmed COVID-19; the test was done through a RT-PCR process which tested for the virus’s RNA, and was repeated; if they tested positive for COVID-19 twice, then the disease was confirmed (p. 1201). The authors of this study found that the mean incubation period was 5.2 days, and in its early stages, the epidemic doubled in size every 7.4 days, with human-to-human transmission since the middle of December (p. 1199). Upon graphing the number of cases, the authors concluded that the development of the epidemic follows an exponential growth; their concerns were that a delay in identification or testing and subsequent underreporting would affect the number of cases (p. 1202). Some limitations of this study were the unavailability of tests, and identifying only pneumonia cases which left out certain patients who had gastrointestinal symptoms that were later tested positive.

Chen et al., (2020) conducted a study, from Jan 1 to Jan 20, 2020, that looked at 99 (67 men and 32 women) patients in Wuhan Jinyintan Hospital with COVID-19. Out of these patients, 75% showed bilateral pneumonia, 14% showed multiple mottling and ground-glass opacity, and 1% showed pneumothorax’ also, 11% worsened in a short period of time and died of multiple organ failure (p. 507). From this study, the authors concluded that the COVID-19 infection is more likely to affect older men with comorbidities, and could result in fatal respiratory diseases such as acute respiratory distress syndrome (ARDS); it also stressed that early identification and timely treatment of critical cases of COVID-19 are important in order to reduce the severity of the patient’s condition and prevent the spread of the disease (p. 508).

A study by Sun, Qiu, & Yang (2020) was done on 631 confirmed cases of COVID-19 in Jiangsu, China; and they established an early warning system with a sensitivity of 0.955 (95% Confidence Interval), as well as a multidisciplinary hierarchical management group to provide medical guidance for all COVID-19 patients. The authors believe that the hierarchical management strategy (Fig. 3) and early intervention (Fig. 2) provided effective medical interventions (p. 3). By March 7, 2020, 610 patients were discharged with a cure rate of 96.67% which was better than the 4.34% mortality rate of Hubei, and figured out that critical care-dominated treatment patterns might be the core in reducing mortality (p. 1).

Novel Coronavirus (COVID-19) in US

In the “Morbidity and Mortality Weekly Report” by Jernigan (2020), who is a member of the CDC COVID-19 Response Team, he describes several steps taken by CDC in the US by February 28, 2020; posting travel notices to inform travelers about taking precautions in going to China, Hong Kong, South Korea, and Japan; the screening of 46,016 air travelers at the 11 US airports to which all flights from China had been directed; recognizing persons at risk for COVID-19; and testing for COVID-19 in the CDC laboratories. Also, since Feb. 2, 2020, a presidential proclamation was made to suspend any entry from China to the US, and allowed only US citizens and lawful permanent residents to enter the US; and as of February 23, 2020, out of 11 travelers referred to hospitals, one tested positive for COVID-19 (p. 217). However, what Jernigan (2020) failed to mention were the numerous news reports (New York Times, Forbes.com, MIT Technology Review, Associated Press) about CDC’s botched COVID-19 tests and later, the requirement that all COVID-19 samples be sent to them first to be tested, which caused a bottle-neck in testing, especially with test kits that were old and not working well. This significantly delayed the testing of the COVID-19.

This short report on COVID-19 cases in the US by Burke et al., (2020) is linked to the CDC website and focuses on 10 travel-related COVID-19 cases as of February 26, 2020, who had close contact with 445 persons in the US on or after the onset of the patients’ symptoms; this could be family contact, community contact, or healthcare personnel (p. 245). Symptom monitoring of the 455 close contacts for 14 days, consisted of daily telephone, text, or in person inquiries and revealed that 12% of the close contacts developed symptoms of COVID-19 (p. 246).

In another report by the CDC COVID-19 Response Team, as of March 16, a total of 4,226 COVID-19 cases had been reported in the US (Pilishvili et al., 2020). Limitations to the findings in the report were: data were missing for 9%-53% of the cases, including hospitalizations, ICU admissions, and death; further time was needed to determine outcomes; initial approach to testing was to identify only persons with travel histories; data on underlying health conditions were unavailable at the time of this report; and finally, limited testing underscores the importance of ongoing surveillance of COVID-19 cases (p. 344-345). The report concluded that social distancing is recommended for all ages to slow the spread of the virus, protect the health system, and help protect vulnerable older patients (p. 345).

It has taken over two months for the CDC to launch studies to detect COVID-19 cases, and will include the following three studies: looking at blood samples from people never diagnosed; national survey will be conducted to sample different parts of the US; and the third study will look at the health care workers and how widely the virus has spread within them (Branswell, 2020).

Issues in Reporting COVID-19

Some issues have been raised by Kobayashi et al., (2020) in appropriately measuring the risk of death in COVID-19, and these include: delay in time from onset of illness to death; observed data of reported cases represent a portion of all infected individuals, as many are never diagnosed; using shorter virus detection windows and less sensitive diagnostic lab tests would bias the ascertainment and risk of death among all those infected. Kobayashi et al., (2020) believe that if a patient has mild symptoms and never goes to the doctor to get diagnosed, they will fall outside of the number of cases reported; in addition, the perceived severity of the COVID-19 epidemic is directly influenced by the absolute number of deaths (p. 2). Knowing when to test for the virus is important because it is not always detectable, and also the accuracy of the diagnostic RT-PCR tests range from 44% - 80% (p. 4) which sometimes give false results. Another issue is the underreporting of COVID-19 cases (Zhao et al., 2020; Pilishvili et al., 2020). Therefore, these are issues to take into consideration when working with data from the COVID-19 outbreak.

According to Gostin, Hoge, & Wiley (2020), more aggressive measures have been taken by other countries than the US for the COVID-19 outbreak, such as guarding areas where individuals may not enter or leave, and ordering individuals to remain in their homes at all times. In response to the COVID-19 outbreak, three national emergencies by the US federal government have occurred: on January 31, 2020, the US Secretary of Health and Human Services (HHS) issued a public health emergency, authorizing funds for diagnostic tests, antiviral drugs, and vaccines; on March 13, 2020, six weeks later, the president declared a national emergency, facilitating telemedicine and increasing hospital capacity; and the president also declared an emergency under the Stafford Disaster Relief Fund and Emergency Assistance Act, using the services of the Federal Emergency Management Agency (FEMA) (p. 1). Although Gostin, Hodge, & Wiley (2020) state that there must be a careful balance between public health and individual rights, the number of COVID-19 in the US as of April 5, 2020 has reached 332,283 cases with 9,507 deaths (Coronavirus Cases, 2020), and the numbers have not reached their apex yet. This balance between public health and individual rights might be causing more cases and deaths as a result and needs to be investigated more.

Summary

            Several theories abound on leadership in the time of a disease outbreak (Arifah et al., 2018). However, it is difficult to pinpoint one exact leadership theory that can be used when different leaders are acting at different levels of an organization. In the Chinese (CCP) government, which is authoritarian, it leads several levels of subordinate organizations in the fight of the disease, while the US government, which is democratic, relies on the Centers for Disease and Control Prevention (CDC) and emergency measures (Gostin, Hoge, & Wiley, 2020) as well as the states’ governors to lead the fight against the disease outbreak. Also, the reporting of the disease outbreak, if not transparent, leads to data misinformation, as seen in China’s reporting (Li et al., 2020). This makes for the measurement of timing in response of the disease difficult to assess. 

In addition, not enough data has been made available of cases and deaths during this COVID-19 outbreak in the US and China to be able to get an accurate comparison between the timing and transparency of these two governments during December 22, 2019 to March 22, 2020 (Pilishvili et al., 2020; Zhao et al., 2020). More research is needed in this area.

References

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Baekkeskov, E., & Rubin, O. (2017). Information dilemmas and blame avoidance strategies: From secrecy to lightning rods in Chinese health crises. Governance: An International Journal of Policy, Administration, and Institutions,30(3), 425-443. https://doi.org/10.1111/gove.12244

Branswell, H. (2020). CDC launches studies to get more precise count of undetected COVID-19 cases. Statnews.com website. https://www.statnews.com/2020/04/04/CDC-launches-studies-to-get-more-precise-count-of-undetected-COVID-19

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