Lessons from Aviation

By Rhea Agarwal

Published 11:18 EST, Sat October 23rd, 2021

What is Power Distance?

The concept of power distance was first developed by the Dutch social psychologist, Geert Hofstede; it was one of the first theories of Hofstede’s Cultural Dimension Theory in which Hofstede attempts to quantify the differences in cultural behaviours. Power Distance is a term that expresses the distribution of power in an organization or industry (Kenton, 2021). The Power Distance Index (PDI) is a measure of the power distance in a country; the numbers of a PDI convey the degree to which unequal distribution of power is accepted in a culture or nation. The elucidation of a number on a PDI scale tends to be rooted in cultural norms and legacy (Pettit Whisenant, 2019).

Individuals in an industry demonstrating a high power distance, generally embody people that do not challenge figures of authority and are accepting of hierarchical culture; contrarily, individuals demonstrating a low power distance do not hesitate in questioning figures of authority and expect their views to be holding some weight when making decisions. These behaviours are not only evident within the culture of a nation but also within the culture of certain professions such as aviation and healthcare (Pettit Whisenant, 2019).

Power Distance in Aviation

In the book, Outliers: The Story of Success, author Malcolm Gladwell discusses how a high PDI culture in aviation had severe reverberations on aviation safety (Gladwell, 2009).

In the period 1988 to 1998, Korean Air’s “loss” rate was 4.79 per million departures. An airline’s loss rate is the frequency with which crashes or aviation accidents occur. Relatively, the loss rate for the American carrier United Airlines in the same period was 0.27 per million departures; Korean Air’s record was more than seventeen times higher than that of United Airlines’. However, today Korean Air is a certified 5-star airline and its safety record since 1999 has been immaculate. In recognition of this transformation, Korean Air has received the Phoenix Award in 2006 (Gladwell, 2009).

In retracing Korean Air’s transformation, we see how decreasing a high PDI played a significant role in minimising the airlines’ loss rate and thus ameliorating its reliability and reputation. According to aviation experts, a plane crash is multifactorial and often a culmination of errors that leads to a crash. Astonishingly, these errors are rarely problems of knowledge or flying skill, rather they are errors of teamwork and communication (Gladwell, 2009).

“The whole flight-deck design is intended to be operated by two people, and that operation works best when you have one person checking the other, or both people willing to participate. You will have a safer operation than if you have a single pilot flying the plane and another person who is simply there to take over if the pilot is incapacitated.”

(Earl Weener, Chief Engineer for Safety at Boeing)

In Korean Air, it was the captain on the “flying seat.” The first officer simply worked as a substitute rather than a supplement in the cockpit (Gladwell, 2009).

On August 5, 1997, Korean Air Flight 801 departed for Guam; the flight crashed on August 6, 1997. Among other reasons such as bad weather, the National Transportation Safety Board, nonetheless, cites poor communication between the flight crew and the captain’s poor decision-making skills as the main cause of the crash (Wikipedia, 2021). Upon subsequent inspection of the black box, by psychologists, the most unusual feature of the conversations between the captain, first officer, and first engineer was the lack of explicitness in the language used by the subordinates in informing their captain of an emergency. The speech used by these officers is identified by psychologists as “mitigated speech (Gladwell, 2009).”

Mitigated speech is indirect communication inherent in communication intended to be polite or deferential to authority; it involves implicitly suggesting or referring to something and often uses subtle hints to convey a message. In a critical situation, mitigated speech coming from a subordinate is very likely to be ignored or looked over. The use of mitigated speech by subordinates during this emergency not only demonstrates a high power distance relationship between the captain and the officers but also indicates that such conduct may deeply be entrenched in cultural legacy. Helmreich and Merritt once measured the PDI of pilots from around the world; South Korea ranked second (Gladwell, 2009).

After experiencing several preventable aircraft accidents, aviation recognized the need for change. Reducing “mitigation” has become one of the greatest crusades that aviation has striven for by changing a bureaucratic culture to one that epitomizes collaboration and safety. Aviation experts contribute the decline in airline accidents to the battle against mitigation (Pettit Whisenant, 2019).

Substantial sociological research on the repercussions of a high power distance in aviation has been performed. However, such research is not as readily available for the medical field. In this article, we attempt to draw similarities in the critical situations of both professions. Thus, just how aviation integrated research results to improve safety, the healthcare profession can draw on tips to do the same. Both of these professions share certain features: high-level thinking and quick decisions with no room for error; mistakes in critical situations can have severe safety repercussions. 

Power Distance in Healthcare

The cockpit, with its intricate manoeuvres, can, to some extent, simulate the exacting environment of an operating room; the two professions share a strong resemblance in their administration. In a healthcare setting, the physician has the authority and the final say in most operations. However, a hospital setting does not only involve physicians –  there are nurses, residents – in – training, and assistants – all of which have received official training. A high PDI invalidates their observations and assessments; a low PDI, however, demands participation from all positions. A low PDI work environment involves communication and the transfer of necessary information among different departmental positions. This makes the system efficient, thus indirectly promoting better health outcomes. Literature confirms that a high power distance culture reduces worker wellbeing and commitment thus negatively impacting a positive work atmosphere (Rafiei & Sadeghi, 2018).

Let’s compare the healthcare systems of Denmark and the US. Denmark’s healthcare system is known to be able to provide its citizens with efficient and low-cost healthcare with better health outcomes than the US. Immediately, one may presume that the Danish government may be having higher funds allocated towards healthcare or may have rolled out better healthcare policies. False! In fact, on a percentage of GDP on a per capita basis, Denmark spends less money on healthcare than the US; also no unique policies have been rolled out which may distinguish one healthcare system from the other. The root of the issue is the culture in the workforce. Denmark has a relatively lower power distance culture than the US  (Matus, 2017).

The diminished bureaucratic system in Denmark’s healthcare system optimizes the capacity of the workforce thus enabling an efficient system to operate; additionally, it recognizes the contribution of all healthcare providers (Matus, 2017).

To conclude, a healthcare system can greatly benefit from dismantling a hierarchical system within its administration thus promoting a positive and efficient workplace environment.

Rhea Agarwal, Youth Medical Journal 2021


There is limited research examining how a high power index affects the healthcare environment. Yet, we can draw parallels between the two industries in the sense that both involve complex procedures with little or no room for error. As one begun its crusade against an entrenched, detrimental cultural behaviour, the other should take lessons to do the same. It is only in this way can healthcare promote active participation from all its constituents, thus ensuring an efficient system with better health outcomes.

“Bureaucracy is the death of all sound work.” ~ Albert Einstein

Rhea Agarwal, Youth Medical Journal 2021


Gladwell , M. (2009). The Ethnic Theory of Plane Crashes . In Outliers: The story of success (pp. 206–261). essay, Back Bay Books/Little, Brown.

Hofstede Insights . (2017). Comparison of Pdi between Denmark and Usa. How does Denmark have better healthcare than the US for less money?

ICSB. (2020). Geert Hofstede . ICSB takes a moment to remember Geert Hofstede.

Kenton, W. (2021, July 14). What is the power Distance Index (PDI)? Investopedia.

Matus , J. C. (2017, December 10). How does Denmark have better healthcare than the us for less money? ScienceNordic.

Meyers – Reuters , M. (2019). The Tragedy of Flight 801.,16641,19970818,00.html.

Pettit Whisenant, D. (2019). Power distance in Healthcare: Learning from aviation to decrease power distance and improve Healthcare Culture.

Rafiei , S., & Sadeghi , P. (2018). Personnel Attitude toward Power Distance in Hospitals Affiliated by Qazvin University of Medical Sciences. Evidence Based Health Policy, Management & Economics.

Wikipedia . (2021, August 7). Korean air flight 801. Wikipedia. 

Commentary COVID-19 Health and Disease

The Exoticization of Epidemics

By Rhea Argwal

Published 1:30 EST, Tue August 24, 2021


During an epidemic, scientists tend to search for sources of the outbreak. If the outbreak has foreign origins, scientists often enlist the help of anthropologists to study local practices and customs since cultural awareness is necessary for any public health campaign or outbreak control. However, the role of anthropologists seems to extend further than that. Anthropologists identify ‘risky behaviours’ present within a society which may escalate an outbreak. Yet, these ‘risky behaviours’ always tend to be rooted in cultural contexts. Scholars tend to ignore socioeconomic factors, such as overcrowding, poverty, etc., which may have a greater hand to play in the proliferation of a disease through a population. This instinctive ignorance lets slip the presence of racism and Eurocentric bias in the subconscious beings of scientists and researchers. 

Ebola and Africa [1980s]

The Ebola Virus Disease (EVD), a rare and fatal disease, was first discovered in 1976 in the Democratic Republic of Congo (DRC) (Centers for Disease Control and Prevention , 2021). After an incident on a shipping boat in 1989, Western media’s interest in the virus erupted. Due to its foreign origins, media and Western society linked the source of the outbreak to practices in African culture (Jones, 2011). 

The Ebola virus is a zoonotic disease meaning that the virus had been transferred from animals — specifically nonhuman primates (monkeys, gorillas, and chimpanzees) — to people. Thus, enlightened with this information, scholars proposed the Bushmeat Hypothesis: “hunting, slaughtering, and eating infected gorilla or monkey meat is the primary cause of the virus’s entrance to a new population (Jones, 2011).

This argument became one of the dominant explanations of the Ebola outbreaks as it provided a correlation between cultural practice and a viral outbreak. However, doing so overshadowed other arguments which may have been greater factors at play; factors such as overcrowding, poor sanitation, and inadequate provision of healthcare, exacerbated by a legacy of colonialism were responsible for much of Ebola’s spread. However, cultural factors were emphasised more than sociopolitical and economic factors. Africans were presumed to have beliefs rooted in witchcraft and superstitions which may have hindered efforts by doctors and scientists to control the outbreak (Jones, 2011). Disputing this notion was a Harvard professor and a medical anthropologist, Paul Farmer, who was at the forefront of the Ebola epidemic control. The failure to control the outbreak did not occur due to local customs and traditions but rather due to distrust in the healthcare system and the government. 

People fled the medical system, not because of superstitions, but mostly when the medical system was unable to rescue or treat its patients as constituted.”

(Paul Farmer in an interview with Ashish Jha on Lessons from Ebola)

Due to the lack of adequate hospital infrastructure, doctors had implemented a disease control paradigm that concentrated its efforts on isolating suspected cases and confirmed cases without providing actual care (unlike the current COVID-19 care centres). This approach was rendered ineffective. Distrust in the healthcare system further grew and people started turning to traditional healing systems as a desperate resort. 

The erroneous depictions of the Western media and the presumptions of Western society of the Ebola outbreak reveal the lingering presence of racism in our society and the remnants of colonialism. Additionally, it affirms the presence of bias in biomedical research.

AIDS as a Haitian Disease [the 1980s]

It is the 1980s. Haiti, a Caribbean country, has been receiving widespread publicity as the possible birthplace for AIDS. Acquired Immunodeficiency Virus (AIDS) is a chronic and fatal condition caused by the human immunodeficiency virus (HIV); HIV is a sexually transmitted infection (STI) that weakens one’s immune system. A severely damaged immune system progresses into AIDS as it is unable to protect the body from infections or cancers that a person with a healthy immune system wouldn’t normally acquire (Mayo Clinic, 2020). Upon the emergence of an AIDS epidemic, scientists begin investigating the sources of the outbreak. In an eruption of imagination, Western society and media speculated that voodoo rites, sacrificial practices, the eating of cats, and ritualized homosexuality, were the causes of the epidemic – “a rich panoply of exotica” (Farmer & Kim, Anthropology, Accountability, and the Prevention of AIDS, 1991). The speculations gave rise to stereotypes that were enforced time and time again by the U.S. press. Also notable was the media representation of Haitian-Americans: black, poor, immigrants, and associated with cult-like religious practices. As media sensationalized and misrepresented the Haitian-American community, incidents of harassment began to propagate. People of Haitian origin bore the stigma of a fatal condition. The statement of one Haitian-American physician mirrors this sentiment: 

“After all the wild theories of voodoo rites and genetic predisposition were aired and dispelled, and the slip-shod scientific investigation was brought to light, the public perception of the problem remained the same that if Haitians have AIDS, it is very simple because they are Haitians (Farmer & Kim, Anthropology, Accountability, and the Prevention of AIDS, 1991).”

However, none of the speculations and gossip surrounding the epidemic had any epidemiological research to back them up.  As a matter of fact, declarations of plausible theories of the sources of the outbreak by scientific researchers had slowly begun unravelling the lies illustrated by the press. On December 1, 1982, the following statement was made: 

“Homosexuals in New York take vacations in Haiti, and we suspect that this may be an epidemic Haitian virus that was brought back to the homosexual population in the United States.” 

(Dr. Bruce Chabner of the National Cancer Institute, 1982) 

At the 1988 conferences of the American Anthropological Association, researchers congregated to discuss “Ethical Considerations in Anthropological Research.” The focal point of the meetings was the failure to lighten the burden of stigma on the Haitian-American community, aggravated by the spread of misinformation. Further addressed was the economic damage of Haitian businesses, which were boycotted by tourists and investors, and the rise in unemployment within the Haitian-American community. Nevertheless, in February 1990, the Food and Drug Administration (FDA) ruled that no person of Haitian origin will be allowed to donate blood (Farmer & Kim, Anthropology, Accountability, and the Prevention of AIDS, 1991). The incessant discrimination against the community, not only resulted in economic damage but also a decline in the mental and emotional health of members of the ethnicity. All this, due to the deep-rooted racism in a system that embraced popular societal opinion rather than verified scientific research. 

SARS – CoV – 2 (COVID-19) Pandemic [2020]: Hate Crimes Against South East Asians

SARS-CoV-2, colloquially known as COVID-19, originated in Wuhan, the capital city of the Hubei province, China. The virus evidently has zoonotic origins (similarly to Ebola) with genetic similarities to bat genomes. The COVID-19 virus first caused a viral outbreak in the Hubei province region, soon spread to surrounding provinces and all over China. In China, it has declared an epidemic. Subsequently, the virus infiltrated borders and crossed seas through international travel and infected millions of people; On March 11, 2020, the World Health Organization (WHO) had declared the COVID-19 viral outbreak, a pandemic (World Health Organization, 2020). 

Proclaimed as a zoonotic disease, researchers began investigating the source of the animal-to-human transfer and traced it back to the Wuhan Southern China Seafood Market where wild animals were being sold. The bushmeat theory, first proposed during the Ebola outbreak, found new ground almost 40 years later in the SARS-CoV-2 epidemic. However, the magnitude of this viral outbreak significantly surpassed the Ebola epidemic; millions, if not billions, of lives, have been affected around the world; trillions of dollars are being spent on reviving an economy that has seen its deepest slump since the Great Depression. Now, at a very vulnerable state, with dear lives lost, people need someone to take blame and responsibility. Hate incidents and crimes against the Chinese and Asian communities increased. The pandemic had given rise to stigma and discrimination. News media picked up on this sentiment and began referring to the SARS-CoV-2 virus as the “Chinese virus,” or the “Wuhan virus.” Associations of such may have provoked people to detest a community that was struggling with an outbreak, too (Xu, et al., 2021). 

“Pandemics do not materialise in isolation. They are part and parcel of capitalism and colonisation. The countries that struggled to contain and control major epidemics in the recent past, from Haiti to Sierra, had deficient public health systems prior to these crises, partially as a result of their colonial histories. Moreover, products of capitalism – from war to migration to mass production and increased travel – contribute massively to the proliferation of diseases.”

(Edna Bonhomme, Postdoctoral Fellow at the Max Planck Institute for the History of Science in Berlin, on the topic of COVID-19 and Inequality (Bonhomme, 2020))

In the three occurrences discussed above, there seems to also be three recurrent themes. Firstly, the sudden media interest in the three cases amplified the racialization of these epidemics. Arguably, the media played the biggest role in the dramatization of the epidemic’s events. Unexpectedly, scholars often also shared the view proposed by the popular press. The prejudices and biases present in these scholars subconsciously affected their judgements in an epidemic control centre or a research centre, thus adversely influencing the healthcare quality available in these countries. Additionally, in the media frenzy, the western way of living was enforced as the norm, painting foreign cultures as exotic. This is where the remnants of colonialism become apparent once again. Lastly, through analysis of media reports and scholarly articles or journals, one can understand that some researchers subliminally undermine indigenous knowledge and accept biomedical research as the divine truth. 

Media Manipulation: Sensationalism 

Western media portrayals in each of the three case studies seem to have subconsciously depicted Western ways of living as norms by contrasting them with the ways of living of other ethnic communities. This juxtaposition depicts the complex and vibrant cultures of various ethnic groups around the world as simply exotic. Exotic, meaning interesting, different, and ‘other’. The exoticization of an ethnic community and its practices alienates its members, thus leaving them more susceptible to racial discrimination. This dramatization is not only demeaning for an ethnic community but also an exploitation of the credibility the masses of people associate with news media reporting. 

Systematic Racism, Stigma, & Discrimination

The existence of systematic racism, ingrained within institutions — in the laws, policies, and decisions — are mainly what hinders the provision of healthcare in epidemic control centres; it is what distorts epidemiological research. The erroneous conclusions of such scientific and anthropological research attribute the causes of an epidemic to local practices, traditions, and customs of an ethnic community while hardly considering sociopolitical or economic factors. This, in addition to media sensationalism, places a degrading spotlight on a community that may be suffering as well. Stemming from such situations is stigma and racial discrimination. At a moment when people are at their most vulnerable state, systematic racism and media sensationalism give rise to hate crimes as currently seen occurring against the South East Asian community due to the COVID-19 pandemic. 

Worth Found in Indigenous Knowledge 

When planning epidemic centre controls in different countries, scientists and anthropologists often study the local practices, customs, and traditions — indigenous knowledge. However, the lens with which this body of knowledge is viewed indicates that scholars believe indigenous knowledge serves to hinder the provision of healthcare rather than aid its use. Subliminally, all scholars undermine indigenous knowledge and regard it as ‘backwards’. Associated with many of these communities is a cumulative body of knowledge and know-how honed through years of observations, experiments, and reflections. Although these practices have been developed through years of observations, it is not possible to ascertain their reliability or accuracy since they have not been assessed by the wider intellectual community as of now due to there being notions that indigenous knowledge is retrogressive and anti-development. If we aspire to put in the effort to inspect the accuracy of indigenous knowledge, we may be able to verify that the majority of their claims may be accurate and, in fact, useful in developing future theories or innovations, instead of labelling them as regressive. 


In conclusion, the notion that any ethnic community’s customs or traditions hamper epidemic control efforts should be challenged. Publishing unverified scientific information that may be linking the source and spread of an outbreak to an ethnic community can prove to be very degrading and even detrimental for members of a community, leaving them predisposed to scorn and resentment. Although our world has come a long way from its colonizing history, the legacy and remnants of it can still be seen today in the form of the exoticization of ethnic practices through systematic racism. 

Rhea Agarwal, Youth Medical Journal, 2021 


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