In the United States, federal and state initiatives to revitalize public health agencies have focused primarily on hiring and training frontline personnel, such as community health workers, epidemiologists, and microbiologists. The Covid-19 pandemic also exposed a need to improve leadership skills of executives of public health agencies.
During the pandemic, there was a massive turnover of public health agency leadership, with many state and local public health officials being fired or resigning due to public abuse, disputes with elected officials, exhaustion, or public controversies. A New York Times investigation published in mid-October found that “more than 500 top health officials …left their jobs” during the pandemic in what has been called “the largest exodus of public health leaders in American history.”
While many people have the technical qualifications to fill these newly vacant positions, they also require key leadership skills. Many programs provide leadership training and coaching for business and government, but few address the unique cognitive and management skills that are needed to lead public health agencies, particularly during infectious disease epidemics. Based on our experience leading the Covid-19 response in New York City, we believe that public health leaders require five essential skills to effectively manage the next pandemic.
Skill #1: Translate Science
Public health leaders are expected to not just be managers and spokespersons for their organizations but also subject matter experts for complex issues that cross multiple disciplines, including epidemiology, microbiology, and medicine. They must be able to rapidly assess new scientific information and synthesize the key points for different audiences, including policymakers, health care professionals, and the public.
During the pandemic, maintaining subject matter expertise became substantially more challenging than during other recent high-profile emerging infectious disease threats, such as Ebola or Zika viruses, because the volume and velocity of scientific information increased dramatically. Many studies of public health importance were reported first in popular or social media without a peer review process to ensure the methodology and accuracy of the research and without a lag time to carefully consider its implications.
For example, in February 2021, The New York Times ran a front-page story about a new variant in New York City that could “dodge the immune system” and, therefore, make vaccinations less protective. Upon receiving the study manuscript, we had to drop everything we were doing that day — including running the largest vaccine campaign in the city’s history — to analyze the study carefully, integrate it with our own internal data, present the implications to New York City Mayor Bill de Blasio and other city government leaders, and make a public announcement about what this meant for the health of the city’s 8.8 million residents.
Why not just rely on our staff or outside experts to summarize the findings for us? Because with information coming out so fast, there was often not time for outside experts to come to consensus. We, therefore, had to go to the primary source and, in real time, make the best interpretation of the data.
We also uniformly found that our statements had more force, both during internal deliberations and during news conferences, when we could say, “I read this study, and this is what I concluded,” rather than “my staff or the experts concluded this about the study, so that’s what I think.”
Skill #2: Frame How You Move from Evidence to Decision
Public health leaders need to be able to rapidly and thoroughly make policy recommendations, using a structured evidence-to-decision rubric, and then frame that recommendation clearly for the public and other leaders.
While physicians and epidemiologists receive extensive training in school and on the job in how to evaluate scientific evidence, this training can also handicap them during policy discussions. During the Covid-19 pandemic, we observed three related challenges.
First, there was difficulty moving from uncertainty to action. All executives, regardless of field, recognize that emergencies demand thinking in probabilities, not certainties, and that a decision not to act can be as damaging as a decision to act. Public health professionals, however, are uniquely susceptible to being weighed down by an anchor of certainty, because scientific training teaches us to demand proof for every assertion, find flaws in every attempted proof, and use cautious language and multiple caveats when summarizing any study.
Second, many excellent scientists focus almost entirely on assessing the quality of evidence and do not follow a structured process of thoroughly assessing and weighing other essential considerations in policymaking: e.g., benefits, harms, feasibility, acceptability, costs, and alignment with values.
Third, even when scientists know how to assess and weigh these considerations, their cognitive biases may affect their actions and cause them, for instance, to estimate the harms to one group but not another. We encountered these cognitive biases among staff at multiple levels, most notably during debates about protocols for in-person school during the 2020-21 year. Those protocols were particularly challenging to develop because we had to make policies for quarantine, masking, physical distancing, ventilation, and testing with limited scientific data, and decision-making required considering not just the harms of getting infected with Covid-19 but also the less-easily-measured social, emotional, and educational harms of students missing in-person school.
Skill #3: Think Big
Public health leaders don’t need their agencies to do it all themselves; sometimes what’s needed is the boldness to make the big asks.
In our experience working locally, nationally, and globally, one of the most persistent constraints on public health thinking is the scarcity mindset. Public health agencies uniformly receive substantially less funding than other public safety agencies and even less than health agencies focused on research and treatment. Just compare the pre-pandemic annual budget of the Centers for Disease Control and Prevention (CDC) to those of the National Institutes of Health (NIH) or the Centers for Medicare and Medicaid Services (CMS). And, when they first start out, many public health personnel learn the dictum that disease-control programs are always eliminated long before diseases themselves are eliminated.
The result is that many public health personnel learn to think only in terms of what’s immediately feasible given current resources. In March 2020, at the height of the first and most deadly Covid-19 wave in New York City, public health leaders struggled to offer Covid-19 testing even to those with symptoms. Based on prior pandemic planning, the federal government was expected to provide the guidance and resources, which did not sufficiently come. At all times, public health leaders must be able to think both narrowly (“What do I do now with the resources with I have?”) and expansively (“How do I get the resources to do what’s right?”).
In New York City, we set making testing universally available as our target and received support from Mayor de Blasio for a multi-pronged approach to achieve the goal that drew resources from across New York City government. It included: the mayor making prominent public demands for the federal government to activate the Defense Production Act; the mayor appointing a city-wide testing czar; city agencies awarding contracts to additional laboratories and private urgent care clinics; the city’s public hospital system establishing de novo community testing sites and modified testing protocols that reduced some supply constraints and increased testing capacity by the city’s public hospital system; and the city’s Economic Development Corporation creating a public-private partnership to launch a new private lab. As a result, New York City was able to offer testing to all who wanted it, regardless of symptoms or exposures, beginning in June 2020.
The natural tension between making immediate decisions when you are under constraints and building toward the attainment of a more optimum goal, such as making testing universally available, is challenging. But public health leaders must be able to plan and execute both in parallel.
Public health leaders are also often wary of “the big ask” because they fear losing complete control over a program. But we found that asking for help from New York City government executives often led to better outcomes such as the establishment of interagency command centers for testing and tracing in public schools and for vaccine delivery.
The scale of our historic vaccination campaign, with more than 12.5 million doses administered thus far, was such that it required a whole-of-government approach. While the city’s public health agency coordinated the overall strategy, we partnered with city government technology colleagues for appointment scheduling, economic development colleagues for various vaccine incentive programs, community relations colleagues to enhance our outreach efforts, and the entire city government workforce when more hands were needed at our mass vaccination sites and for door-to-door canvassing.
Skill #4: Spend Your Political Capital Wisely
Public health leaders must understand when to spend their political capital and when to save it for a future issue that they think is even more critical.
In policy debates among New York City’s leaders during the pandemic, we served as the primary advocates for strict control measures and caution when relaxing existing measures. Consequently, we were characterized as “Drs. Doom” by some city government leaders who were focused on the potential economic, political, or social harms of interventions we proposed and positioned themselves as voices of moderation.
To counter such friction or head it off before it emerged, we found it beneficial to proactively acknowledge our biases and explicitly name trade-offs to position ourselves as the builders of consensus across policymakers. In doing so, we preserved our political capital so we had some to spend in circumstances where we felt no compromises were possible.
When the 2021 summer surge in Delta variant infections began, we discussed extensively whether to institute requirements for mask wearing, vaccination, or both. Beyond the effectiveness of these measures, we had to factor in their acceptability by businesses and the public and the feasibility of issuing such requirements given the limits of city inspection personnel to inspect, cite, and reinspect tens of thousands of facilities for compliance.
While a strict approach rooted in public health evidence would say to do both, we prioritized vaccine mandates while strongly recommending (but not requiring) mask wearing in most indoor settings. We chose to invest our political capital in the intervention with the most durable and effective reduction in the spread of Covid-19, recognizing the tradeoffs in implementing all evidence-based interventions at once.
Skill #5: Think Like a Lawyer
The Covid-19 pandemic did not create a critical need just for epidemiologists but also for lawyers. Controlling a highly contagious airborne virus requires restrictions on individual or group liberties, which invariably triggers lawsuits challenging their necessity, scope, and legality. Consequently, whether the measure being considered was mandatory testing in schools, restrictions on indoor fitness and/or dining, or vaccine mandates, we spent considerable time discussing each extensively with lawyers before enacting them and even more time writing affidavits to defend these measures.
Public health personnel are used to thinking through issues with nuance and considering exceptions to every rule. While restricting civil liberties to protect the public’s health has a strong legal basis, that basis weakens considerably when exceptions to a rule do not have a firm grounding in science or when exceptions are made for some individuals or groups but not others. We spent countless hours, for example, trying to clearly and consistently define “outdoor dining” or “indoor group fitness.”
The U.S. Supreme Court specifically highlighted the challenge of consistency when it ruled, for example, that New York State’s Covid-19 restrictions on capacity at houses of worship can be no stricter than those imposed on commercial settings. Public health leaders need to understand how to think like a lawyer from the outset — for example, understanding concepts such as “undue burden,” “arbitrary and capricious” regulation, and “the takings clause” — to ensure that whatever policies they seek to implement will withstand scrutiny.
Earlier tensions between New York State and New York City government officials only increased the difficulty of addressing these challenges. First, a February 2020 executive order by Governor Andrew Cuomo suspended New York City’s traditional legal powers to regulate public health threats and gave broad powers to the governor and state health commissioner. Second, the state’s leadership did not routinely coordinate policy and regulatory decisions with the city.
The Training Imperative
In the United States, public health agencies are at a critical juncture with substantial new resources being made available for additional personnel while many leadership positions are vacant. Filling the deficit in public health leadership will require multiple initiatives.
First, the CDC and graduate schools of public health, public policy, and management should develop training specifically tailored to public health leaders. While standard components of leadership training remain critical, these courses need to build competency in the unique skills we have highlighted above, and training should be encouraged both for public health executives and talented personnel who may become leaders in the next few years.
Second, government and academic entities hosting pandemic response exercises (e.g., so-called “tabletop” exercises) should ensure that these go beyond exploring how leaders manage technical or logistical challenges, such as a new virus or the shortage of a specific supply, and should include scenarios in which there is rampant misinformation, tradeoffs between perceived threats to freedoms and public health actions, and lawsuits challenging public health actions.
Third, public health leaders should bolster their communications and policy analysis staff and use them regularly during emergencies to test different ways to frame recommendations and explain complex information.
It is widely recognized that another pandemic is inevitable. We should start taking steps immediately to ensure that public health officials have the leadership skills required to stop them.
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5 Skills Public Health Officials Need to Combat the Next Pandemic - Harvard Business Review
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