Serving the public as a health official is an amazing opportunity. I am privileged to have had the opportunity to support more than 175 state and territorial health officials as the Association of State and Territorial Health Officials' (ASTHO's) executive director for almost a decade. During this time, I partnered closely with 3 National Association of County & City Health Officials executive directors and many ASTHO-affiliated organizations as well as 2 federal administrations. Prior to that, I had the opportunity to be a health official in Vermont for 3 years and to serve on ASTHO's board during that time. As I now transition to a leadership position with the March of Dimes, I wanted to share my parting thoughts on how to be effective and have a rewarding experience in the challenging role as state health director.
During these years, I have learned that to promote and protect the health of the people we serve, health officials must understand the context in which they work, the role they play, and the rules of the game. Public health professionals often refer to public health science, such as epidemiology or environmental health, as true public health. A line is sometimes drawn excluding the role of the health official as somehow political and therefore not true public health. Skillful engagement with the political leaders and systems, however, is an essential part of public health, without which public health agencies would lack legal authorities and resources to carry out the agency's mission. Securing these authorities and obtaining these resources are indispensable elements of public health and reside with the health official.
A fundamental skill of the state and local public health officials must be to translate good science and policy into good politics aimed to benefit the health of the community. It can be a rude awakening to learn that science alone often does not carry the argument. Politics, power, and money are the currency of the political system. Elected leaders must make complex calculations based upon how an action will further the interests of their constituents and supporters without alienating a critical interest group or competing with established priorities. In the resource-constrained environment we operate in, the better an idea is, the more it competes with others' good ideas.
The ability of the health official to negotiate this system and avoid unforeseen pitfalls determines success or failure. We often enter the system with a good idea of what is scientifically sound policy. Success, however, is rarely, if ever, 100%. At what point do we agree that we have enough of the critical needs met to be effective? 50%? 75%? At what point do we back off realizing that what we were able to negotiate is no longer in the interest of public health? How then do we maintain confidences as we explain to our department scientists that we could only obtain the bare minimum of what they asked for?
At the same time, science to guide decisions is frequently limited in complex systems. If an elected official must make a decision to close a school, or cancel a sporting event, it is unacceptable to respond that the public health evidence is unclear and a decision cannot be recommended. The health official must commit to a course of action using his or her best judgment even in the absence of compelling evidence. It is essential to recognize that the elected official to whom the health official reports has a greater purview and makes or approves any final decision before it is carried out. The public health official is unelected and does not have independent power or ultimate authority. His or her power is referred power derived from the elected official who is the appointing authority. The power of the public health director is related to the perception of how close his or her relationship is to the elected official. Forgetting this can result is being fired for doing the right thing for public health in the wrong way or at the wrong time-a not uncommon event.
Some of the most common pitfalls for health officials involve this intersection between science and politics. Health officials need to remember that expressing their personal opinions is not in the job description. You cannot de-role as a public figure.
Health officials express the opinions of the governor, the county executive, or the board for whom they work. There are no off-the-record conversations-one should always assume every conversation is on the record and could appear on tomorrow's front page. If their opinions or values conflict substantially with those of their employers, they have no independent power to pursue their own personal agenda. Those serving as health officials are stewards of an esteemed position. They have been entrusted with a powerful platform to serve and promote the health of their jurisdiction. During this time, they have a responsibility to build the credibility and capacity of the position and the agency. If they are put in a position requiring compromise of their personal integrity or that of the position or the agency, it is time to resign with honor.
Public health agencies are large and complex organizations. Health officials are also tasked with becoming excellent organizational leaders and executives. This can be a challenging transition from practice, academia, or other career paths. The transparency of government leadership and processes is also often a shock to those coming from the private sector.
Health officials must quickly build a diverse and loyal team, adding complementary skills and perspectives. The necessity of a diverse leadership team cannot be overemphasized. The team needs to include people who will tell you what you need to hear, not what you want to hear. They need to know they have permission to critique the health official's leadership and be rewarded for constructively doing so.
Perhaps, one of the most important adaptations is the perspective of one's own role. The job is no longer to dive in and complete a good day's work as one might do as a clinician or academic. Rather, it is to support hundreds or thousands of staff in achieving their highest level of individual and collective work. Getting overinvolved in decisions or tasks is not sustainable across the body of an agency work. It takes skill to know when and where only the health official can accomplish something and when to stay out of the way.
Another first order of business for new health officials is to pick 3 to 5 priorities for his or her tenure. Relentlessly returning to a limited number of priorities requires discipline, as the urgent problem du jour can easily steal the spotlight from the important goals of the department. But staying focused on these priorities is essential, as it will allow the health official to weigh the importance of opportunities. It is important to steward the resources of the office to make significant advances in the public's health and not be caught in an endless cycle of crises.
Understanding the underlying values of potential partners and potential opponents is a key strategy. If a health official understands others' values and can communicate his or her priorities in relation to those values, he or she can increase the commitment of a partner or decrease the antagonism of an opponent. Seeking a diversity of perspectives is important. Cross-sectoral leadership is essential to transforming the health of the public. Health officials must not only take the time to understand the values of their partners but also learn to speak their language.
While a health official may only serve for the few short years of an administration, stewardship extends far into future decades. The leadership responsibility includes advancing the field and the agency to meet the health needs of tomorrow. We face exciting opportunities in public health today for which we must prepare. Public health and health care have potential to align in achieving improved population health through integration and differentiation of our roles. Like health care, we in public health must transform ourselves to accomplish this. Among the most important and daunting challenges we face are creation and financing of a public health community platform to streamline our data systems and create an accessible interface between public health and clinical data.
As a field, we increasingly recognize the need to engage with other sectors and take a "Health in All Policies" approach. This will again require a transformation for public health. We must develop the workforce with expertise to meaningfully engage with other sectors on their terms. Few of us could hold our own in a conversation with financial institutions about the community reinvestment act. Second, we must develop a financial model to support cross-sectoral engagement. Our funding is largely categorical by disease or condition. It is not oriented toward education, housing, transportation, etc. Finally, we must develop "legitimacy" for public health to be engaged with these other sectors. Today, despite our rhetoric, cross-sectoral engagement is not a core function of public health agencies.
Perhaps, the most important development for public health is to measure everything that we do in terms of both "goodness," the overall population outcome, and "fairness," the equity in outcomes between groups within the population. Our degree of resolution must increase substantially so that we can target interventions in a culturally appropriate way to those most impacted. It is simply unacceptable to allow the continuation of health disparities in areas such as infant mortality, cardiovascular disease, and many other fields. Health disparities, related to the social determinants of health, including historic and structural racism, are our greatest challenge for the future.
During the 12 years I have served on the board or as executive director of ASTHO, I have learned that to further the health of the people, health officials must understand the context in which they work and the rules of the game. Politics is a critical part of public health, determining both the authority and resources that can be leveraged in the interest of health.