1. Beitsch, Leslie M. MD, JD

Article Content

As a former (and still recovering) public health practitioner, it pleases me immensely to cheer from the sidelines as fellow public health system researchers bolster the previously limited data regarding state health officials (SHOs) with 4 articles published in this issue of the Journal.1-4 The roles assumed by SHOs are critically important senior leadership positions providing oversight of large and highly complex organizations. The significance of a steady guiding hand cannot be overstated for these CEOs who protect and promote health in the face of challenges as diverse as natural and man-made disasters, outbreaks of diseases both acute and chronic, climate change, and health inequities-all within a political context. SHOs become the face for public health in their state and must be masters of succinct mass media and risk communication. Seldom do we task private sector leaders with such daunting tasks, while offering them so little preparation and limited resources. Nonetheless, my informal poll of former SHOs bears repeating. Little surprise, most found being an SHO to be their most fulfilling (yes, challenging, too) professional role.


Admittedly, I feel a personal stake in this sentinel work, having previously served as both an SHO and senior deputy, who also participated in the underlying study itself. It is comforting that authors in this issue dispel certain ancient myths regarding the appointed state senior public health leader.1-4 We now have a solid basis to conclude that the majority of appointed SHOs came to their roles with public health experience, most of it recent, nearly two-thirds are physicians, and that almost half hold degrees in public health.3 The methodical assembly of solid data by the research team, with assistance and support from the Association of State and Territorial Health Officials (ASTHO) and the de Beaumont Foundation, assures us that a rich core for a substantive evidence base has been developed (SHO-CASE).1 Moreover, nurtured and shared with other investigators, it provides an excellent point of departure going forward to conduct further research that delves into other critical questions that determines whether SHOs survive and flourish.


So what exactly did we learn from SHO-CASE? Harvesting only the most salient points, we know that SHOs have relatively brief tenures, with a downward trend line; comparisons with industry underscore the brevity of service.4 Greater gender diversity is entering the SHO ranks, as more women are appointed recently, although racial and ethnic diversity lags.3 Those best positioned to judge, senior public health deputies, noted strong SHO relationships with governors and key staff presaged lengthier incumbency.2 This was triangulated with the finding by Menachemi et al4 that governor-appointed SHOs tended to remain on the job longer. Deputies also identified personal characteristics we would like to think matter influenced the success of SHOs: being excellent listeners, taking an evidence-based approach to solving public health problems, and having a credible voice.2 In contrast, having previous management or law degrees was associated with a more abbreviated leadership.4


Despite our quantum leap in knowledge about senior state public health leadership, more study is warranted to answer other critical questions. With the median tenure of 4 years, and declining, how do we reduce the extreme learning curve for SHOs, even those assuming the helm with considerable public health and leadership experience? My guesstimate is that mastering the skill sets to be successful requires roughly 2 years, meaning the typical SHO departure comes just as they are reaching their leadership potential. Alternatively, how do we extend the life cycle? Public health, like medicine, is a team sport. Surrounding the new SHO with an experienced and dedicated team may buffer the turbulence of learning on the job in a hyperpolitical environment. However, data from PHWINS offer the frightening scenario of senior executives who support SHOs planning to retire disproportionally over the next several years.5 What approaches might be taken to keep them engaged, motivated, and ready to mentor the next new SHO? Although SHO tenure is abbreviated versus industry, how does it compare with other state-level human services leadership-in other words is this a state government "problem" or a public health problem?


My personal observation is that even after a decade-long recovery post-Great Recession, public health remains a fragile enterprise-literally one budget cycle from irrelevancy at a time when scientific expertise in government is enduring ever greater disrespect. The demand for strong leadership is its greatest during such times of extreme duress. How then does a discipline such as our own attract the "best and the brightest" when the apparent tangible rewards may appear fleeting? Rewards are in fact an issue. The SHO-CASE study tells us the majority of SHOs are physicians; how does the salary gap between public health and clinical medicine further exacerbate the difficulty attracting the most capable candidates? Moreover, with longer tenure the cumulative pay gradient grows larger.


Although the efforts of Halverson et al1 were not intended to answer every conceivable question that could be raised, they have provided a solid starting point. Importantly, with the benefit of the SHO-CASE data, it is possible to compile the qualitative and quantitative findings and begin the synthesis of competencies and associated skill sets that may be related to successful SHO terms.1 Governors and transition teams, ASTHO, as well as senior deputies will want to be equipped with the products of this emerging intelligence. Just as with PHAB accreditation, once an evidence base is established, it is possible to move beyond the old adage about every health department being unique (when you have seen one health department, you have seen one health department). We now know there is far more similarity in the DNA base pairs among all health departments than difference. The studies appearing in this issue are beginning to define some of those same commonalities across senior leadership of state public health agencies. Viewed collectively, this is groundbreaking conceptually, revealing that principles of management and organizational science apply equally to public health. How appropriate that this content should appear in the Journal of Public Health Management & Practice, a journal created for precisely this purpose.




1. Halverson PK, Yeager VA, Menachemi N, et al State health official career advancement and sustainability evaluation-description of the methods used in the SHO-CASE Study. J Public Health Manag Pract. 2020;26(1):5-8. [Context Link]


2. Boedigheimer SF, Yeager VA, Chapple-McGruder T, Moffatt S, Halverson PK; SHO-CASE Steering Committee. Public health senior deputy's perceptions of state health officials' success factors: professional characteristics, personal attributes, and signs of derailment. J Public Health Manag Pract. 2020;26(1):16-22. [Context Link]


3. Yeager VA, Menachemi N, Jacinto CM, et al State health officials: backgrounds and qualifications. J Public Health Manag Pract. 2020;26(1):9-15. [Context Link]


4. Menachemi N, Danielson EC, Tilson HA, et al Tenure and turnover among state health officials from the SHO-CASE survey: correlates and consequences of changing leadership. J Public Health Manag Pract. 2020;26(1):23-31. [Context Link]


5. Beitsch LM, Yeager VA, Leider JP, Erwin PC. Mass exodus of state health department deputies/senior management threatens institutional stability. Am J Public Health. 2019;109:681-683. [Context Link]