Educating Future Public Health Leaders

As public health schools and programs prepare for the future, they can also serve as a natural training ground for leadership. Many schools have already begun to launch innovations in this arena. Students who aspire to be leaders can learn skills to face the inevitable challenges involved in navigating the dynamic milieu of our field. This involves staying true to their goals for the future while remaining flexible within the constraints of the present. As part of this process, students can improve their comprehension of the “what” and “when” of leadership while navigating the “who” through the “7 P’s of public health.” Then they can explore the “how” by embracing the ambiguous, cultivating interdependence, building better systems for health, and “encouraging the heart.”

To begin, public health educational programs can boost the many who enter our field with high ideals and great passion. Students often enter public health absolutely hungry to change the status quo for the better. They traditionally learn concepts in key areas such as epidemiology, biostatistics, environmental health, behavioral health, among others. And in doing so, they usually spend much time sitting and listening in lecture halls, trying desperately to absorb as much knowledge as they can.

But preparing leaders means going beyond such traditional educational approaches. We can begin now to entertain additional innovative ways to teach leadership skills. Through such learning, students can explore an inner journey of personal development that helps them prepare for the outside world. They will need both the will and the skill to face the inevitable challenges involved in achieving their mission. Navigating the journey requires perseverance and the capacity to deal with often unpredictable twists and turns.¹ Future public health leaders can prepare for a career of constant negotiation, understanding that only great interpersonal skill can move their purpose forward. They must learn to choose their battles while striving for excellence, not perfection. And they must be willing to endure the most humbling and searing of experiences in the name of service.^2,3

Flexibility is key to adapting to the creative tensions of the present while staying true to dreams for the future. Leaders need to accept that the needs always seem infinite while the resources are always finite. They must learn to tolerate high levels of uncertainty and conflict. They must fully understand that public health is not simply about the body and the mind, but most importantly, about the spirit. And they can recognize, as some have said, that “the strongest steel goes through the hottest fire” and that good leadership sometimes requires “absorbing the punishment without surrendering your soul.”⁴

Fully grasping these themes requires constant attention not only to the science of public health but also to political science. Some have defined politics as “the art of the possible.” Political scientist Harold Laswell describes the essence of politics simply as “who gets what, when and how.”^5(p3),6(p20) Schools traditionally teach the “what” and “when” of public health. But to truly arm students for the future, pupils can better understand that the “what” often arises from forces that often have nothing to do with medicine or science. More often, the “what” is fundamentally shaped by the forces of the “who” and the “how.”

CURRENT CONTEXT OF THE “WHAT” AND “WHEN”

Students can begin their leadership journey by standing for something bigger than themselves.¹ The World Health Organization (WHO) broadly defines health as a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”⁷ The WHO also articulates the vision of having all people reach “the highest attainable standard of health.”

Leaders can concretize this vision by setting explicit goals and targets that serve as a roadmap and a compass for the future. Several years ago, I had the privilege of unveiling Healthy People targets for the decade leading up to 2020, continuing a tradition of national goal-setting that extends back to 1979. For Healthy People 2020, the vision for a healthier nation includes overarching goals of improving length of life and quality of life, eliminating health disparities, taking a lifespan approach for health, and creating cultures where the healthier choice can be the easier choice.⁸ As a nation, we can focus particular attention to Healthy People 2020 Leading Health Indicators, which encompass 26 indicators in 12 key topic areas where national action could substantially improve public health.⁹ The Affordable Care Act, which offers the broad promise of better insurance, better care and better public health, could also help accelerate progress in many of these indicators.

However, reaching such lofty goals may be more challenging today than ever before. Life expectancy at birth in the United States has increased to an average age of 78 years, compared with that of about 45 years at the turn of the 20th century. Although life expectancy at birth has increased, upholding quality of life represents a growing challenge. So many live longer but are burdened with an array of emotional and physical disabilities; two thirds of Medicare beneficiaries, for example, have multiple chronic conditions.¹⁰

We also need to serve a country that is growing ever more diverse. By 2050, the United States will be a “majority minority” society, with most people coming from racial/ethnic minority backgrounds. And of course, our country’s diversity grows even broader when dimensions of geography, level of disability, sexual orientation, and gender identity are also considered.¹¹

UNDERSTANDING THE “WHO”

In public health, the power to resolve any challenge usually falls well beyond the control of any single authority.³ Hence, leaders need skills to interact with a vast array of stakeholders: the “who.” Each stakeholder group usually has a passionate view on what should be done in any given situation. Students need a better understanding of what motivates each group and how to align them all, if possible, to find common ground. Every public health issue features arguments and counterarguments, advocates and opponents, and dissenting voices. Future leaders need to be ready to face this panoply of opinion in any and every area.

THE SEVEN P’S OF PUBLIC HEALTH

Students should broaden their ability to entertain opinions different than their own, be able to identify the range of stakeholders involved in any public health decision and navigate the “7 P’s of public health”:

Policymakers in Government

Policymakers impact health in major ways. It has been said government is the only entity that must care for all the people all the time. But as part of that process of decision-making, policymakers always feel the pull and tug of hundreds of constituencies. Understanding this dynamic process is critical to public health success. Students could learn more by spending at least some time working in government at the local, state, federal or global levels.¹²

Purchasers

Public health involves the purchase of a wide range of health-related commodities: health plans, hospitals and hospital systems, clinics, health insurance, mental health services, preventive services, medications, and devices, just to name a few. The interplay of public and private purchasers has never been more dynamic. In the insurance arena, for example, public coverage now reaches millions in the United States through Medicare, Medicaid and Children’s Health Insurance Program. In the era of health reform, state-based or federally facilitated marketplaces in all 50 states are now offering new coverage options for many more. Increasing attention has focused on value-based purchasing, not just volume-based purchasing, as a means of improving quality.

Penurious Budget Officials

In public health, inadequate budgets are usually the norm. In pursuing improved funding for any area, one will always meet the budget official who says “no.” Understanding how budgets are crafted, negotiated, finalized, and implemented is a critical part of appreciating how the system works.

Providers

The traditional definition of providers in health and health care has rapidly extended beyond doctors and nurses to include social workers, therapists, navigators, pharmacists, community health workers, promotores, and many others. They all can contribute to improved team-based approaches to care in the future.

Passionate Advocates

Every public health controversy is accompanied by passionate advocates. There is good news and bad news about them. The good news is that they are absolutely passionate about what they believe and they will not rest until everyone else agrees with them. The bad news is that they are absolutely passionate about what they believe and they will not rest until everyone else agrees with them. Many of us entered public health because of our own advocacy on some issue or another. But few schools currently address, or even acknowledge, the lessons and principles of successful advocacy. Students need to appreciate and respect the power of advocacy, and learn how to work with advocate leaders to promote health.

The Press

Public health leaders need to learn the essentials of interacting with the media whose job may not necessarily be to make you feel comfortable. To reach audiences unfamiliar with health, students need to make their communication understandable, memorable, and succinct enough to convey the heart of an argument in a line or two. Schools can teach media skills, for example, through mock press conferences to give students a “feel” of such settings.

The Public

Our work is always on a public stage—that’s why it’s called public health. And as leadership expert Warren Bennis once wrote,

You have to learn how to do the job in public, subjected to unsettling scrutiny of your every word and act, a situation that is profoundly unnerving. . . . Like it or not, as a new leader, you are always on stage, and everything about you is fair game for comment, criticism, and interpretation (or misinterpretation).^13(p49)

Schools need to prepare students to understand that leadership positions inherently come with public scrutiny.

DISCOVERING THE “HOW”

Students can develop their own unique ways of discovering the “how” of leadership. Future leaders need to find their own unique ways to discover their own paths to “mobilizing others to want to struggle for shared aspirations.”¹⁴ New leaders can craft their own ways of interacting with others to reach the highest attainable standard of health for all. This can involve the following:

Committing to Building Better Systems

Good leaders create structures that will live on and leave some kind of legacy. Assuring such sustainability requires attention not just for managing crises for the present but also for having the foresight to create better systems for the future.

Embracing the Ambiguous

Leaders must be willing to push themselves out of their comfort zones and stretch to find new solutions. This often requires stepping into situations where solutions seem elusive and ambiguous. Here, the flexibility and adaptability themes are crucial.

Cultivating Interdependence

Public health requires a deep and authentic commitment to team-based approaches. Our field requires a profound understanding that we are all interdependent and interconnected, and we all have promises to keep.

Encouraging the Heart

Ultimately, leaders succeed when they bring out the best in others.^14,15 Leadership experts advise to “encourage the heart.”^14(p15) The best leaders encourage the contributions of others, are willing to make the extra effort to connect with people, can build nontraditional alliances, and view each person as a potential partner in the public health journey. Doing so not only builds connections but renews a sense of community that brings meaning and value to our work even in the most difficult of circumstances.

CONCLUSIONS

To visualize the “who” and the “how,” imagine the public health leader as the orchestra conductor, setting the tone, pace and tempo. The conductor selects the soloists (and supports the many others who want to be soloists), encourages the piccolos to play with more confidence, and coaxes the drums to play at a steadier rhythm. He leads practice after practice to balance the tones and guide the transition from cacophony to harmony. When the curtain goes up, the product is then widely available for both applause and criticism. And while conductors often receive great attention, it’s better when the audience forgets that they were ever there at all.