“Culture eats strategy for breakfast.” (Peter Drucker)
In the book “Blink”, Malcolm Gladwell argues that many plane accidents result mainly from human communication failures. “One driver knows something important and somehow doesn’t communicate it to the other.”
Enomoto and Geisler (2017) decided to test Gladwell’s hypothesis that the vast majority of failures in commercial flights are cultural and not technical. In the study of 68 countries, covering air accidents between 1970 and 2012, they controlled obvious variables such as GDP per capita, weather conditions and number of flights. And cultural differences made all the difference.
The central characteristic that determined greater or lesser risk of accident was what Geert Hofstede called Power Distance Index (PDI), the index measures the degree of acceptance of differences in power and hierarchy in social relationships.
Hofstede studied different cultures over five decades and demonstrated that many socioeconomic differences can be explained by cultural differences alone.
In the case of the aviation study, high PDI remained significantly associated with a greater number of accidents. Countries with a high PDI fly more frequently in the risk zone – not because of a lack of technology, but because of an excess of silent hierarchy.
The mechanism is simple and frightening: in high-PDI cultures, the copilot who notices a captain’s error faces an immense psychic cost in speaking out. And uses what was called mitigated speech (“softened communication”, used to avoid confronting authority). This type of communication dilutes the message until it becomes ineffective.
Replace “pilot” with “team leader” and “copilot” with “nurse” or “resident” and you will have a scenario common to countless Brazilian health institutions.
Brazil is among the countries with a high PDI, with 69 on the Hofstede scale, alongside Mexico, Türkiye and Greece. These are exactly the countries that a 2020 study by Braithwaite and other authors grouped into the cluster called Collective-Pyramidal (Hierarchical and Collective Pyramid), which means more hierarchy and social status, cultural cohesion and respect for authority.
This grouping presented the worst health performance indicators among the 35 countries of the Organization for Economic Co-operation and Development (OECD), evaluated by 57 indicators covering mortality, quality of care, access and resources.
Different cultures and performances
Braithwaite’s study has been called the “black box” of the global health system. By crossing Hofstede’s cultural dimensions with the study data, Health at a Glance of the OECD and the indicators of the UN Sustainable Development Goals, three groups emerged with surgical clarity.
O cluster Collaborative-Networked (Collaborative Network Culture) — encompassing the United Kingdom, Canada, Australia, USA and Nordic countries — has low PDI, low uncertainty avoidance and values of individualism and openness. Result: 83% of the countries in this group achieved the UN sustainable health goals.
O cluster Orderly-Future Oriented — comprising countries such as Germany, Japan and France — was in the middle. And the Collective-Pyramidal, where Brazil fits culturally, did not even have a country achieving the UN objectives. None.
Culture is not just the “way of being” of a people. It is an independent predictor of health outcomes, even when adjusting the system for income and local infrastructure.
The normalization of deviation: when error becomes routine
There is a concept developed by the American sociologist Diane Vaughan after the Challenger space shuttle disaster in 1986, which deserves to be urgently incorporated into the vocabulary of health management: the normalization of deviance. Vaughan described how clearly unsafe practices become culturally accepted when they do not produce immediate consequences.
At NASA, leaking sealing rings, one of the causes of the tragedy, had been known for years. However, as previous missions were successful, this risk became normal until the day Challenger crashed into pieces in the sky.
In aviation, this manifests itself in incomplete checklists, crew fatigue accepted as “normal” and minor incidents never reported. In health, it appears in safe surgery checklists that have been completed “proforma”, critical communications omitted to avoid hierarchical confrontation, adverse events underreported for fear of punishment, long shifts frequently repeated.
In a study I worked on, published in 2025 in JCO Global Oncology, we identified similar patterns in oncology centers around the world: cultures with high PDI tend to centralize decisions, inhibit open communication and compromise the psychological safety of teams and patients.
In the Indian subcontinent, for example, hierarchical rigidity in Kashmir has been directly associated with underreporting and poor care in prostate cancer. In Finland—a low-PDI country—professionals were frustrated by exactly the dearth of interprofessional collaboration they had come to expect as the norm.
The answer aviation found and healthcare is still learning
After a series of accidents attributed to communication failures in cockpits hierarchical, large airlines developed Crew Resource Management (CRM), a training program focused not on technical skills, but on effective communication, distributed leadership, shared decision making and threat and error management.
CRM starts from a radical premise for high PDI cultures: the copilot has a duty to question the captain – not just the right. There is hierarchy, but it cannot silence security.
A 2016 study shows that implementing CRM-based programs reduced standardized mortality rates and improved the safety climate in an intensive care unit, according to Haerkens.
This is what Amy Edmondson calls “psychological safety,” the collective belief that it is safe to take interpersonal risks, to talk about mistakes, to raise concerns without fear of humiliation or punishment.
In our study, we proposed that programs such as the Quality Oncology Practice Initiative (QOPI), from the American Society of Clinical Oncology (ASCO), integrate psychological safety training as culturally sensitive strategies to overcome the barriers of high PDI in countries such as Brazil and Mexico.
Edmondson’s recommendation is simple in form and difficult in practice:
- Define the context and environment (clarify purpose and tolerate errors);
- Invite everyone to participate by demonstrating humility, saying “I don’t know”, practicing active listening;
- Respond productively to problems by being grateful, destigmatizing failure, and not tolerating clear violations.
Change requires leaders who say “I don’t know”, who thank those who point out mistakes, who transform the adverse event into collective learning instead of individual judgment. These are small gestures with a huge systemic effect. Every leader who breaks the cycle of hierarchical silence is literally saving lives.
Peter Drucker said that culture eats strategy for breakfast. However, what the aviation data, the clusters from the OECD and our own studies in oncology show us something more precise and urgent: culture can put the lives of our patients at risk.
Health professionals who do not speak up when faced with obvious errors in operating rooms are not negligent by nature — they act rationally within a system that punishes voice and rewards silence.
In both healthcare and aviation, this silence can be fatal. We need to treat our psychological safety indicators with the same severity as we treat our hospital infection rates.
