On 20 April 2021, one of the authors of this blog, Shehnaz, organised the Sheiham-Sefularo Memorial Lecture on Health Equity on behalf of the Wits School of Public Health. Dr Nobuhle Judy Dlamini, Chancellor of Wits, delivered the keynote address entitled COVID-19 and the social determinants of health inequalities: reflections on ethical leadership for health equity and a socially just recovery.

In her thought provoking keynote address, Dr Dlamini reiterated that COVID-19 has exposed the impact of the intersectionality of race, social class, gender, ageism, disability and geography in health access and health outcomes. She referred to COVID-19 as a syndemic pandemic, as it interacts with and exacerbates existing inequalities in chronic diseases and the social determinants of health. This is particularly true in South Africa, where poverty and inequalities are both multifaceted and multidimensional, and women, especially those who live in deprived neighbourhoods, bear the brunt of both inequality and pandemics. In her reflection on ethical leadership, she called out the unjustified and unethical corruption in government. She stated that unethical leadership within the private sector is the root cause of the untransformed economy that continues to exclude the majority of South Africans on racial and gendered lines.

Ethical leadership is all of our responsibility

Dr Dlamini said, “I believe that if all of us in this lecture, in the country, across sectors, deliberately and consistently try to lead ourselves and others ethically, we would edge closer to a just and equal society. Even better if we collaborate – it would have a multiplier effect and be a catalyst for the desired change, including social cohesion.” Dr Dlamini defined ethical leadership as follows, “ethical leadership is the implicit and explicit pursuit of desired ethical behaviour for oneself and followers through efforts governed by rules and principles that advocate learning motivation, healthy optimism and clarity of purpose to uphold the values of empowerment, service to others, concern for human rights, change for betterment and fulfilling duties towards society, future generations, environment and its sustainability” (Shakeel et al., 2018, p. 9).

She also presented a quote by Raina Fox that we would like to explore:

“if systemic inequalities were built, they can also be unbuilt. And doing so will be better for all of us”

This quote prompted us to think about ethical leadership from a systems lens. Having just participated in the Systems Change and Social Impact short course convened by the Bertha Centre with Shehnaz as a participant and Kentse as a facilitator, we have been thinking a lot about what it means to be an ethical systems leader. Being a systems leader calls on us to move away from thinking in linear & siloed ways and to acknowledge the complexity inherent in the systems that we have built. Dr Dlamini rightly pointed out the pandemic is not just a health crisis; it is a crisis that has exposed our deep historic and systemic inequalities. How then would a systems leader respond to Dr Dlamini’s call to action? That we should all strive to be ethical leaders and that we should not only look to our political leaders to solve our most pressing issues.

Collective leadership & moving away from the lone hero myth

We would argue that Dr Dlamini’s call to action needs to go a step further; it’s simply not enough to swap our leaders at any level if we have not addressed the structural drivers of failing public and private institutions. The current dearth in ethical leadership that we’re experiencing in South Africa, and the world over, speaks profoundly about the mental models that have come to shape the expectations that we have of our leaders. In systems thinking, we use mental models to make sense of values, attitudes, beliefs, morals, and attitudes. The pandemic has illustrated that it is possible for government, civil society, the private sector and communities to come together and provide a different kind of leadership. One that is rooted in community, that is collectivist, empathetic, radical and feminist. The question for any systems leader would be how do we sustain that ethos post the pandemic. Part of the answer to that question lies in gleaning lessons from the various forms of collective leadership that emerged during the pandemic. The C19 People’s Coalition and the rise of Community Action Networks in South Africa, illustrate the value of moving away from structures that are hierarchical and centralised as they are less effective and flexible.

Let’s tell different stories

Ella Salmarshe emphasises that “the work of systems change involves seeing systemically—looking at the elements, interconnections, and wider purposes of systems—and acting systemically. Story plays a vital role in helping us do both of these things”. We use stories to make sense out of our chaotic world. We sense-make, and believe stories to help us feel safe, or stories that fit within our paradigm, even when the stories do not reflect the reality or the story serves to perpetuate systemic oppression such as gender, race and class inequality. Dr Dlamini painted a bleak picture of South Africa, but systems thinking allows us to tell stories that go against the dominant narratives and allow us to seed new ways of working.

Systems leaders can tell the kinds of stories that speak to the complexity of the socio-economic challenges that we’re faced with – there are no silver bullets. Our innovations, policies and interventions tend to focus on single issues or solutions. In order to move beyond that, we need to see the system as a whole and reimagine health policies that cut across education, transport and access to decent housing for example. Systems leaders can tell better stories by bringing in voices that would ordinarily not have a seat at the table. Being able to hear and incorporate different voices means that we can tell layered, multi-dimensional and persuasive stories that move others to action. And by convening different voices, systems leaders can begin to do the difficult work of co-creation. Systems shifts do not happen overnight and often include grappling with difficult issues relating to power, racism, gender inequality, coloniality of power, knowledge and being.

Empathy and Inscaping

Systems thinkers view empathy as foundational to thinking deeply about the world and opening one’s eyes to the complexity that any social change work involves, stretching one’s own understanding to empathy. Building empathy requires us to recognise the power of storytelling, and an invitation to embrace new voices, perspectives, paradigms, and questioning. Building empathy also involves a process of consciously building practices that embody personal self-reflexivity. This requires us to be more aware of how we hold power, exercise power, change the distribution and relation of power. In an earlier IHP blog as part of Africa Health Futures, we called on HPSR scholars to take seriously the call for decolonising the academy, to construct new epistemologies and ontologies that can lead to a socially just and equitable world. Systems thinking stretches this understanding to a systems lens and uses the term “inscaping”, where organisations are expected to reflect on the inner lives of organisational members during their everyday work.

Sitting with the problem

A key learning that came out of the course started with an invitation to be present and brave enough to sit with complex and intractable problems despite an uncertain future. Participants were invited to celebrate and be present in what is called a “festival of problems”. In this process of sitting with complexity for long enough, observing, listening, and being curious to the nature and patterns, cultivating a practice of refusal to “define” or “rush to solutions”, one can begin to recognise the paradigms, mental models, and leverage points where systems leaders can intervene in a system. Even though slowing down and “sitting with the problem” can seem antithetical, it does provide the opportunity to deeply engage with our systems, to understand their purpose and to grapple with the dynamics in a system. Therefore ethical leadership is not a destination that we arrive at miraculously. Systems leadership teaches us that to create the kinds of futures we imagine, we need to confront current ways of working and invest in creating systems that are generative, empathic, resilient, adaptable and committed to social justice

Shehnaz is Research Project Manager of the Sheiham Family/Wits Programme on Social Determinants of Health and Health Inequality and Lecturer based at the Wits School of Public Health

Co-author, Kentse, is a Project Manager at the Bertha Centre and is part of the Systems Change & Social Impact faculty.