1 Frich JC, et al. BMJ Leader March 2021 Vol 5 No 1 Seeing and managing the icebergs Jan C Frich , 1 Dominique Allwood, 2 Anthony Robert Berendt, 3 Pedro Delgado, 4 Rachel Dunscombe , 5 Bob Klaber, 6 Aoife Caitlin Molloy , 7,8 James Mountford, 9,10 Amit Nigam , 11 Catherine Stoddart , 12 Tim Swanwick , 13,14 Indra Joshi 15 “Structural violence is silent, it does not show—it is essentially static, it is the tran- quil waters.”—Johan Galtung 1 The sinking of RMS Titanic on 15 April 1912 has taught us some important lessons about leadership, hubris, safety culture and the importance of accounting for the parts of the iceberg we do not see. Two- thirds of the passengers did not survive the tragic incident, and famously, social class and sex were important determinants of passenger’s chances of surviving. 2 There was more than one iceberg at play. What are the icebergs we should be more aware today of when reflecting on leadership challenges and inequalities in the health services and in health? One challenge that has long hidden in plain sight is the need to better meet the needs of people disadvantaged by race, gender, class or other sources of inequality. In a modern society, interactions with the healthcare system are not optional: people are literally born interacting with it. The system, including hospitals, public health, primary care and community services, is meant to serve all citizens, without regard to gender, social or ethnic background and race. Nevertheless, social determinants have a huge impact on disease burden and mortality. 3 How well do our systems address health disparities? How well do they adapt to the population’s diversity in needs, preferences, health literacy and service utilisation? How can services better target vulnerable groups and those who experience barriers to access? Further, in every country, health and care systems are major employers: to what extent do systems model and promote equity and inclusion in the workforce? The COVID-19 pandemic has called for extraordinary and rapid transformations of service delivery, 4 and creativity and improvisation has played an important role. 5 Nevertheless, this creativity and improvisation have thus far stopped short of mitigating the effects of societal inequalities. The burden of COVID-19 is distributed unevenly among social groups, both in terms of mortality and the finan- cial effects of societal lockdown. Paul Farmer’s observation 20 years ago that in emerging infectious diseases ‘social forces and processes come to be embodied as biological events’ is no less relevant today. 6 In part, these social forces may be so enduring and violent, and rooted in such a diverse set of institutions and cultural or social practices that no health system can fully compensate. In part, however, these societal inequalities may also be a blind spot for many health leaders—part of the iceberg that sits below the water. As a result, they may not always have the priority they merit on every leader- ship agenda, both during the COVID-19 crisis and in normal times. Moreover, the leadership challenges of addressing the socially structured health disparities may not have received the research attention they deserve. Healthcare organisations need leadership that can understand the complex biosocial realities that determines who falls ill and that embraces diversity in the planning and provision of services. A second challenge is the need for healthcare organisations to better develop the leadership potential of all of their staff, 7 regardless of race, gender, class or social background. This challenge likely stems from deeply rooted cultural biases. Our ideas of leaders and leadership are historically and culturally shaped. Even if ‘the great man theory’ is less relevant today, the portrayal of leaders often echoes the notions that people with certain char- acteristics—white men (who are usually also both tall and thin) in North America, the UK, Europe and Australia—are the ones who best fit the job. These social and cultural blind spots can lead people to underestimate the leadership poten- tial of people who do not fit the stereo- types that inform cultural constructions of leaders and leadership. 7 8 Even more insidious, people are often judged nega- tively or penalised for acting in ways that do not conform to socially and culturally defined gendered and racialised roles. For example, a woman can be judged negatively for speaking assertively or for putting herself forward for a promotion or raise, and black women even more so. As a result, a black or Asian female leader can be judged negatively for behaviours that are acceptable or even valued in a white male leader. 8 9 In response to these challenges, we will shine a light on diversity and inclusion and we will broaden and change ideas of leaders and leadership. Nurturing diverse talent, and allowing diverse leaders to act in ways that we hope and expect our leaders to act, then, is an enduring challenge. In a recent article in BMJ Leader, Gilmartin et al focus on diver- sity and gender balance among leaders as an important organisational capacity, and offer tangible advice on how this capacity can be developed. 10 Gender diversity in leadership can be enhanced through the combination of mentor- ship, talent management, training and network opportunities, improvements to advertising, interview panel diversity and succession planning. 8 Talent needs to be nurtured, and organisations need policies for inclusion and talent manage- ment that embraces and promotes diver- sity. Diversity in teams is associated with better results, recruitment and retention. Diversity in leadership can foster flexible and dynamic organisations that adopt to new challenges. As an academic journal focused on disseminating knowledge about leaders and leadership in health and care, BMJ Leader also has its blind spots and chal- lenges. We have a responsibility to publish research and open up other forms of dialogue that can help organisations and leaders better address the health effects of inequity. We also have a responsibility 1 Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway 2 Medical Directors Offce, Imperial College Healthcare NHS Trust, London, UK 3 Department of Continuing Education, University of Oxford, Oxford, UK 4 Institute for Healthcare Improvement, Boston, Massachusetts, USA 5 Institute of Global Health Innovation, Imperial College London, London, UK 6 Imperial College Healthcare NHS Trust, London, UK 7 Quality Strategy Team, NHS England, London, UK 8 The Health Foundation, The Health Foundation, London, UK 9 Royal Free London NHS Foundation Trust, London, UK 10 UCLPartners, London, UK 11 Cass Business School, London, UK 12 Health Department, Northern Territory Department of Health and Families, Casuarina, Australian Capital Territory, Australia 13 People Directorate, NHS England and NHS Improvement, Leeds, UK 14 Faculty of Medical Leadership and Management, London, UK 15 NHS England and NHS Improvement London, London, UK Correspondence to Professor Jan C Frich, Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, 0316 Oslo, Oslo, Norway; jan.frich@medisin.uio.no Editorial on March 24, 2023 by guest. 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