What qualities contribute to effective state health officials (SHOs)? Hear from 11 participants in the State Health Officials Career Achievement and Sustainability Evaluation (SHO-CASE) Study who explain their individual experiences as health leaders.
State health officials tell their stories
Nicole Alexander-Scott, MD, MPH
Rhode Island, 2015-current
As the current director of the Rhode Island Department of Health (RIDOH), Nicole Alexander-Scott, MD, MPH, has emerged as a leading voice in Rhode Island and nationally in ensuring that every person has an equal opportunity to be as healthy as possible, no matter their ZIP code of residence, race, ethnicity, sexual orientation, gender identity, level of education, level of income, or insurance status.
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Hugh: Well, let's just start at the very beginning. This is about, how can we help state health officers be successful, so what's your definition of success? What's success in public health for a state health officer?
Nicole: For a state health official, in my view, success means that you're able to bring some of your own skillsets, talents, gifts and abilities to a state public health agency; be able to embed with and add to the expertise that already exists there; and advance that agency to another level prior to leaving. For example, from my perspective, our agency had a real focus on health equity. And my entire career has involved a commitment to eliminating disparities, and achieving health equity, and making sure that there is equitable access to services and care for people. Bringing those together has been a signature goal for me, to be able to make sure that our Health Equity Zones Initiative, that the department had already birthed, that I was able to join with and take to the next level in promoting it at the state level, is successful. We want it to be successful. We want it to be sustained. For me, one of the demonstrations of success will be that by the time I leave the Health Equity Zones Initiative it is not only successful, institutionalized, and well-embedded into our state system with sustainable funding for making the difference that it's intended to, going forward.
Hugh: Don't misunderstand this long pause as anything except I want to be sure that that gets its own independent time on camera. That was a wonderful answer. Think out loud with us about the ingredients of success. You've named your one great success, one key area of success. What are the components of that? What are the key attributes, your own personal attributes and other aspects that you bring to making that a success?
Nicole: From the state health official's standpoint, personally, what that person brings to leading to such success as an outcome really revolves around emotional intelligence. It's interesting how prominent that has become during my time here. It's something that I was always aware of and certainly appreciated having some experience with, but really have acknowledged that key element to engaging with partners. Being able to communicate to your governor, to other legislators as well as to fellow colleagues and directors of other state agencies, and to your staff, in a way that promotes and inspires leadership. Emotional intelligence is something that should not be underestimated. Being able to be self-reflective, understand why you're having certain reactions to certain responses or activities that are going on, and being able to follow with and be responsive to what your agency is saying is needed. The ability to value who has been there in your agency, who has been committed to public health, and to build on that with that element of emotional intelligence, for me, is a key strategy in achieving the success that's needed. It's often times more than actual knowledge about public health. That's certainly a key component. Being quadruple board certified, adult [INAUDIBLE 00:04:14], infectious disease, I'm familiar with the knowledge benefit, but it often times comes down to being able to be in tune with the people around you, sensing what needs to be moved forward, how you can be that strategic health officer and really get your agency to be in a better place by the time your tenure is over.
Hugh: Let me segue to challenges. In addition to this leadership achievement, what is the greatest challenge that you've faced beyond that? Other things, so far, that have got big and taken a lot of your time. What would you name as the biggest challenge?
Nicole: Number one, by far, is human resources. [Laughs] And being able to understand what management skills are also important to have while focusing on being a leader. Understanding how to delegate, as well. And understanding how to motivate your staff, to incentivize those that are doing good and to hold accountable those that are not, all within variety of political environments that exist. Whether labor relations or a more conservative environment or more liberal, navigating all of that with a human resources system that sometimes has been overlooked over the years, because it's easy to eliminate or not invest in when money gets tight, has been one of the bigger challenges that's required the steepest learning curve, and has often times pushed me in terms of that emotional intelligence and being able to better assess: all right, so what's needed in the situation to navigate this barrier? How do we find the best in people to get the outcomes that we want?
Hugh: I love the way you laid that out. You've already talked a bit about this, but I'd like you to think out loud a little bit more about leadership lessons you've learned as you've tried to master HR. It takes leadership.
Hugh: What leadership lessons?
Nicole: Those leadership lessons, for me, connect to what I've mentioned about being in tune with the people around you. Being able to gather the information needed to make a decision expediently, not taking forever to do it but making sure that you have enough information to make a decision. Feeling confident then to be decisive about a decision. And then also have the ability to be humble if there's a need to learn from the good or the not-so-good about that decision and make sure it doesn't happen again. That continuous cycle takes energy, [Laughs] as a leader, to be effective. And there is always that balance of figuring out how to stay attune to what's going on around you from the emotional intelligence standpoint, but then to also not be paralyzed by that and move forward in making a decision. And you just have to go forth in that, be confident in your own experiences and decision making, and then be confident in a team around you that believes in you and can provide feedback and input that will help make the agency successful overall.
Hugh: If that weren't enough? You had a lot of experience with the state health department before you came to work there as the director, but nonetheless, it's different being the director. Was there something you wish you had known on the first day, that you didn't, that came as a surprise when you become director? What do you wish you had known?
Nicole: My biggest surprise probably was the amount of legal involvement in your everyday activities. If you would let me, I could have my chief legal in almost every meeting. [Laughs] He might not appreciate that, but there's always an opportunity to sort of view your risks and benefits, that was more than I had understood the case to be. It really highlighted for me the importance of having your strong operations team around you. Making sure that you have people that you are confident in and who are competent and also have a similar heart and vision as you. Your chief legal counsel for sure, your chief financial officer, your communications director, your legislative liaison, and then your number-two person in command, as well, whether they're referred to as a deputy or a chief of staff or COO. That's a core team. And everyone will have a few differences here or there, but making sure that you have not only those people that you are confident in but also the group who you know you can close the door and they can also tell you the truth about a decision that's made, and what the best decision may be, in a way that you can appreciate and trust that in moving forward.
Hugh: I love truth-telling. I'm so glad you brought that up. In fact, I think you mentioned integrity in your survey and that is so important. If you wanted to actually to use a sentence that used the word "integrity", it wouldn't bother me. Just think out loud about integrity and what that means for a state health officer.
Nicole: Integrity as a state health officer, for me, it's a stabilizer because there are so many moving parts that can occur. So many conversations that you're having in one room, and then going to the other room and having a different angle of that same conversation because of who you're speaking to. Having that element that grounds you in knowing that your heart and intentions are in the right place, to do the right thing to the best of your ability in a way that reflects the integrity that you want to exude, helps kind of rebalance and reground me. I do tend to lean towards that because it can become easy to get swayed in your conversation with the governor's office today, and then with the legislator tomorrow, but with an advocate from the community the day after that. What's the central value and core that is driving you to be able to make the decisions and have the conversations you need to with each of those audience members but in a way that still fulfills the integrity that you always want to maintain?
Hugh: Breathtaking. Thank you. One of the things we're studying is the high turnover among state health officers. What is the impact of having a state health officer leave?
Nicole: It's significant.
Hugh: Would you start that again? Just sort of, what is the impact? Tell me about the impact of a state officer leaving.
Nicole: The impact of a state officer leaving is significant on an agency. You often times, I often times think of the leaders within the agency at the program level that have been committed for years. And prior to starting and prior to my name even being placed in the hat, so to speak, one of those leaders shared with me, we respect who is in that role but at the end of the day, as well, we are the ones who kind of keep the machine going and are critical to be responsive to the different needs of the community. It's key for a state health officer to recognize that, when they're in their position, number one, so that there can continue to be an investment in those people who have been committed—5, 10, 15 years of doing the right thing—so that they can have the leadership development and career development and support that's needed. But then it's also more stabilizing for the agency to not have the change. Human nature, someone new comes in, there's a need to shift or change something. Sometimes you're changing priorities and directions all together because it's also within a new administration; that's disruptive for an agency if it happens too frequently and can hinder the ability of a public health agency in particular, to positively impact the community the way we all intend to do. Having that time to really advance what's needed, institutionalize some of the core values that are key, add some tools that will lead to sustainable funding over time—those are goals, for me, to be able to establish while in the agency. And if I leave too soon, that kind of just goes astray. Unless the next person comes in with it even better, which is always a good thing too.
Hugh: You always hope, don't you?
Hugh: You brought up, and I want you to just think out loud with us about it, the relationship between academia and public health. Particularly for a state health officer, how does a state health officer build relationships with schools of public health and medicine in the community?
Nicole: I can tell you how important I feel the relationship between academia and public health is by sharing that on day one of being a state health officer in Rhode Island I presented to our all-employees staff at our first meeting the creation of the Rhode Island Department of Health Academic Center. And I shared with them that what my vision is for this academic center is to be able to integrate what I had enjoyed doing in the two full-time jobs that I had just before being selected or appointed by the governor into this role. Which was, as a clinical academician, I would see in the academic world new advances, research, latest clinical trials, innovative thought processes with students who were constantly engaged and asking questions. And then I would see in the public health world rich, state-wide-level data connections to the community and seeing the full extent of the needs at that level, and the ability to intervene, for implementation science, so to speak, at the community level. When you can bring those two worlds together, the synergies that result have been monumental. When you see what San Francisco, within the HIV world, for example, has achieved in having the university embedded with the health department there. And that was really the motivator for me.
We're now two and half years in with having the Rhode Island Department of Health Academic Center. We have a focus on promoting workforce and career development for our staff so that they can be engaged in the academic process and really stimulate the research questions that we have. Why are the overdose rates as high as they are in this community? Why isn't this community using SNAP benefits that we have for them? What can we do better about the teen pregnancy rates in this community? And use those questions to lead the partnership with academia, to say, "Your research career is focused on overdose. Let's partner. Help us in answering these questions." And then that can just not only foster innovation but solutions. Together then we can apply for grants and diversify our funding portfolio, which they hear me discuss often. And then bring students through who can get exposed to an entire new world of public health. Not only health students but economists and architects and paralegals and other professional students who can then see what it is to achieve health equity from a public-health perspective.
Hugh: Let's segue to the future. Public health is an extraordinary field, and you obviously love what you do. What do you think the most exciting, greatest opportunity is ahead for us in public health, particularly in state public health leadership?
Nicole: The most exciting opportunity I see for state public health leadership is to really take the role of being a convener to the next level. In order for us to really achieve the ability to say, "Regardless of the zip code you're from, you should have access to living the healthiest life you can live in the healthiest community." It's not going to happen just through a narrow public-health lane. It has to happen with our transportation and our policy and education and child welfare and behavioral health partners together understanding that mindset. Often times they are doing that in their respective worlds but need public health to be able to translate and bring together those languages, so that instead of going off in silos, potentially in two different directions, we can align the paths and the directions that we're going in and help leverage the work that needs to get done. It's a deliberate process and it has to happen at the local, state, and federal level. And as state health officials we have the ability to directly impact both, as well as our own level. The number of times that we talk to our federal partners about thinking proactively of how they can align the grants that SAMHSA is giving us for overdose with the grants that CDC is giving us for overdose, so that we can better leverage the work that we all need to do to address the overdose epidemic. And then, at the local level, how can we share best practices among the various communities to help each of them get up to an equal level of achieving the optimal health outcomes that we know are necessary? If state health leadership can continue to really be focused on that ability to bring together the usual partners, as well as the unusual partners, enjoying connecting better with our commerce secretary in our state, those types of connections can really take us to where we need to be to achieve health equity, which is our goal from a public-health perspective.
Hugh: Great. Last comment. For your last one, think out loud, what do you want to say to the next generation of public health leaders? You have people looking who are students or new state health officers. What do they need to know?
Nicole: For the next generation of public health leaders my message would be, certainly follow your heart, do what you are passionate about. It's absolutely what has led me to this role. But then also think outside the box. Don't consider yourself to be the only one that's thinking that, or start from scratch, but look around you to see how you can leverage the partners who are there, because being effective within public health, the one thing it requires is for you to not do it by yourself. The ability to know how to engage partners, how to speak the language that they speak so that we can get the outcomes, is what I would encourage future public health leaders to focus on so that we can get some new outcomes and better results for the populations that we serve.
Hugh: Dr. Nicole Alexander-Scott, you quite take my breath away. You started off doing two full-time jobs. You clearly do more than that now. As a passionate leader, I bet you do them all better than anybody else ever has. Thank you so much for doing this with us.
Nicole: Thank you for having me. It's important. [Laughs]
John Auerbach, MBA
John Auerbach is president and CEO of the Trust for America’s Health, where he oversees the organization’s work to promote sound public health policy and make disease prevention a national priority. Over the course of a 30-year career, he has held senior public health positions at the federal, state, and local levels.
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Ed: I'm Dr. Ed Baker. Today I'm interviewing Dr. John Auerbach former health director in Massachusetts for a research project that is being led by the Indiana University Fairbanks School of Public Health. The purpose of our research is to explore and better understand what it means to be a success as a state health official. John, thank you for doing this with me today. I'm looking forward to talking with you.
John: My pleasure.
Ed: John, thank you again for doing this conversation with me. Let's start out with success as a state health official. As you look back on your time there, what does success look like to you as you reflect back on your tenure as a state health director?
John: I think that the biggest indicator of success is being able to point to some sign, some concrete sign that health actually improved as a result of actions that I took, or I took in partnership with other people at the department. Ideally, that's improved health and some indication that people were healthier as a result of our policies or our programs. It may be other surrogate markers that are suggestive of success, but I think that would be the gold standard. I'd settle for a silver standard that had to do with improving awareness, knowledge, perhaps attitudes in some measurable way, that were more supportive of public health or of activities that would promote health.
Ed: When you think about that, as you've just described it, what factors in your mind contributed to that success? Not only perhaps your individual activities but activities of others. What were the factors that really contributed to your success?
John: There were a number of factors that contributed to my success in that role. The first I would say is good fortune to work for governors and a secretary who supported public health. I have to also say a state legislature. You can do so much more when you're in an environment where you receive funding for your work and where new and innovative ideas are received openly; if not always accepted, there's an open process for making the case. I don't kid myself. If we had success while I was there, a lot of it had to do with the good fortune of being in the right political environment.
That said, I think another factor was that I had already worked in public health for a long time by the time I was appointed to be a state health commissioner. I'd worked at the state health department for a decade. I was the chief of staff, I was an assistant commissioner, and then I'd left the state health department and worked for almost a decade as a local health officer where I had to address any health issue that arose in the largest city in the state. When I came back to the department as the state health commissioner, I knew the issues, I knew the challenges, I knew many of the key people I was going to need to work with—that was very important. Third, I was very fortunate that I could bring with me a team of people I'd worked with already or that I knew had the skills and experiences that we needed in order to have a successful tenure.
Ed: Wow. You really had a lot of things lining up to help you succeed.
John: I was very fortunate.
Ed: What about, John, challenges? You've mentioned to me a major challenge that you faced during your term as state health director. What would be an example of the most, really, greatest challenges for you during your tenure? And how did you address that?
John: The biggest challenge during my tenure as state health commissioner was a result of the fact that I was appointed right before the recession hit in 2008. That meant that year after year, the entire time I was state health commissioner, we were cutting the budget. In fact, we had eight rounds of layoffs. Eight. And each round of layoffs took months. Almost every single month that I was a state health commissioner, I was in the process of scaling back programs and laying people off. That took a lot of energy, distracted us from the work we wanted to be doing to promote good health. It created problems within the department around the overall morale, so we had to pay a lot of attention to building morale. And it also meant that people needed certain kinds of creative skills to be able to deal with those challenges and still keep their eye on the ball about what were the key public health issues we need to focus on. I would say overall the team of people did an outstanding job, but it wasn't easy.
Ed: Wow. That's a huge challenge. You mentioned coming into the job as state health director with a familiarity with the state health department, and also having been the health director in Boston, you were familiar with the territory, so to speak.
Ed: What do you wish you had known before becoming state health director, that when you got into the job you realized, "Gee, I wish I'd known about this or that"? Was there anything in particular that you said, "Gee, I wish I'd known about this before I became state health director in Massachusetts"?
John: I had been government for a long time, so you would think that I already knew what I needed to know. I would say, though, one thing I wish I'd known, and known in a very deep way, not just known in my head, was that I needed not to take seriously either the good or the negative things people said about me. I think that you have to have a thick skin to do these jobs because you do take heat. You also get a lot of praise when things go well. I think going into these jobs recognizing you're there temporarily. If things go well, people say nice things about you. If they don't go well, they say not-so-nice things about you. It's not personal. It's really about, more than anything it's about being in government just comes at a certain price. I would say that was one of the things that I wish I knew.
I also was coming back to the state government after having worked as a city health commissioner in Boston for almost a decade. When I was a city health commissioner there was one person I needed to pay attention to if I wanted to change a policy or support a program. That was the mayor. As long as I had a good working relationship with the mayor, things clicked. Coming back into the state I was struck by just how many layers I had to work through to accomplish anything. It didn't matter if the secretary, or in many cases the governor, also supported what we needed or wanted in our budget or for policy. We had to work with committees in the legislature. We had to work with so many different interest groups. It was a long, slow, complicated process to get anything done. I think I would have appreciated being reminded of that early on, to be patient, to get used to working through all of those different layers, not to assume that if you get through a few of them, you're home free. You really have to have a strategic perspective about, what does it take to get something done that recognizes its complexity?
Ed: It's a long-term view. It's really having that.
John: It's a long-term view, definitely.
Ed: When you left the position, you were there for a number of years, you transitioned out. We're going to talk in a minute about things you're doing now. Transitions affect organizations differently. The question, really, here has to do with the impact of your departure on the state health department. You were there for a while. You'd been, as you said, in the state health department earlier. What do you perceive was the impact of your leaving on the department itself?
John: Fortunately, I don't think my departure had a significant impact. Let me say that again. Fortunately, I don't think my departure had a significant impact either negatively or, frankly, positively. I was there quite a long time. I was able to bring in a new cohort of leaders that played critical roles in terms of the department, and most of them stayed. The policies and programs that we had put in place when I was commissioner largely stayed in place. The person who took my job after I left was someone I brought into the department and had a very close working relationship with. I would say in general for the department it was a smooth transition.
Ed: You've really answered, I think, my next question, which was how to mitigate any negative effects of transitions. As you know, sometimes in the role as state health director these transitions can be very abrupt, unanticipated. Say a little bit more about what you believe was in place, or maybe that you did, to mitigate the negative effects of transitions, because sometimes those can be, as you know, problematical. Say a little bit more about that, John, if you would.
John: My management approach when I was the state health commissioner was to work as a member of a team and to have a lot of shared responsibilities with the other senior members of the team. I believe that made for a smoother transition when I left. There was no one needed to learn something that they didn't already know. They knew what the issues were. They knew what the relationships were like. They were ready to step into those roles. I would encourage other commissioners to think about developing relationships with others in the department so that they are prepared and comfortable about stepping into the role of commissioner during a transition. I think a part of our role is to be a good mentor and to think about the long-term health of the department, and that really means putting together the team of people who will continue running the department and may be stepping into one's shoes.
Ed: Let's come back, if we could, to something you mentioned earlier, because many state health directors come into a job without understanding, for example, how to work with the governor's office. You mentioned having it take a long time and sometimes there are a lot of different players and actors. Help us understand better what you might call some best practices. You worked hard to develop those relationships with the governors that you served under, with their chiefs of staff, with those people. In just the governor's office now, what could you suggest worked for you, perhaps? What could you suggest might be helpful to other people that want to strengthen their relationship with the governor's office in this job that you had?
John: Over the course of my tenure, both before being the state health commissioner and after, I worked with four governors—two of them Democrat, two of them Republican. They were quite different leaders. One thing I learned was you need to understand who's sitting in that office and what their priorities are what their work style is, and you need to accommodate that. I do appreciate that the governor is the one in charge, and our role needs to be assisting the governor in making the right decisions, being flexible. That is an important part of the job. I've worked for governors, for example, some of whom were micromanagers and others of whom who were libertarian: they felt like they didn't want to get into details, they wanted you to figure things out, they just wanted there to be no negative stories. It was important to adapt accordingly. That was very important.
I'd say another lesson I learned was patience with transition. We went through many different newly-hired people in the governor's office. Not the governors but their staff. It seemed to us every six months there was some new, really young, inexperienced person who would be hired in the governor's office, whoever the governor was, that would call us up with a bunch of ideas and misunderstandings about what we did. When that's happened several times you begin to feel like, do I have to explain this all over again to another new person who's just entered government? What I've learned was you do. You need to be really patient and you need to take that relationship quite seriously and not express any frustration but be well-prepared to do a thorough briefing and accommodate the needs of the governor's staff.
Ed: One other thing you mentioned different from the governor's staff and the governor's office is working with the legislature. That's a whole different world. Say a little bit about your experiences there, because, again, some state health officials have never worked with people who are in elected positions in state government. What was that like? That's different.
John: I enjoyed working with the state legislature. The starting point, though, I would say was that when I worked for different governors they had different approaches to what a department head should be doing in terms of relations with the legislature. Some of the governors encouraged me to reach out to individual legislators and develop relationships and talk about my programs. I worked for a couple of governors who wanted legislative relations to be handled exclusively by the governor's office. So, it was different under different circumstances. I enjoyed working with the legislators. I enjoyed getting to know their staff. Their staff were often the key people that we needed to get to know. We paid a lot of attention to being responsive. If we got a call from a legislator, if they wanted an answer, once we got clearance from the governor's office, we tried to be incredibly helpful to them. We tried to answer quickly and accurately. We followed up with them. We wanted them to believe that we understood that we, in some sense, worked for them and that we were well-trained, smart, and responsible.
Ed: Another key relationship, as you just said. Now, you've moved on. You've transitioned out of that position. You were at CDC for a while and now you've moved into another position. One of the things that you're involved in now, it seems to me, is around this area of thought leadership. You are leading an organization, and you've published and now begun to speak about this concept of the chief health strategist, in other words, someone in a position like the one we've been talking about, serving as a chief health strategist in this new era that people are describing as Public Health 3.0. You've written about this.
Ed: Could you explain a little bit of what is meant by the term "chief health strategist"? If someone were fulfilling that responsibility, what would they do?
John: Sure. The notion of chief health strategist is developed as a result of the need to think about the future. When you're in the role of a state health commissioner many people consider it like drinking from a fire hose. You're essentially dealing with the emergencies of the day, the most urgent matters. You don't have as much of a chance as you might like to think about, where do I need to be in 5 years or 10 years? What's happening in the state over time in terms of some major trends? You can try to do that but it's not easy. The notion of a chief health strategist was a reflection of taking some time to consider those larger trends nationally, and they're reflected in most states. They represent the changes that have taken place with regard to insurance coverage, how health services are paid for. They recognize the changing demographics, the changing environment with a regard to data, and the shrinking of health resources in the public health sector.
So, the vision of a chief health strategist is one that moves away from the historic role of public health as being a safety-net provider, providing really important clinical services, and in general moves more in the direction of being policy-oriented. It moves away from a focus on working with other people in public health or funded organizations that do the bidding of public health towards a partnership relationship with other sectors: the healthcare sector, transportation, education, and such. It creates a role of being a facilitator and a convener that can provide critical information, like data about the health of the population within the municipality, and like the evidence base for effective policy and programmatic activities. But it has an understanding that there are many other people at the table that are going to have their own interests and will be playing a role in terms of creating a healthier environment for the overall community. And public health can have an important role there but it's really a partnership role.
Ed: One thing you mentioned is the need for better information and better data. If someone moves in this direction of being a chief health strategist, there needs to be, I would presume, an infrastructure, information systems, information technology—all those things are trends that are moving rapidly, as you know. What about that aspect of, sort of, the public health of the future is important for people to think about in this age where information is sort of central to this strategic role? What would you say there for state health departments?
John: A state public health department of the future needs to have a different approach to data than we've had in the past, for a number of different reasons. The data that we have historically used is often old, it's often a year or two outdated, sometimes even older than that. It's often at a state level or a county level, not a granular level. Hard sometimes to get subpopulation analysis. And it doesn't include important data sources from other sectors. From housing or from economic information or education information. What we're encouraging people to do as they're thinking about the future is to utilize the best of traditional public health and try as much as possible to have those sources become more timely. We know death data, for instance, is much more timely than it used to be. At the same time, to access new data sources, access data sources from healthcare as a result of electronic medical records, and some possibilities of working with insurers. Working with other sectors that exist that have an impact on health, be they education or economic sectors or ones that are related to transportation or housing. Polling that data to get a fuller picture of what the conditions are in the community that help to shape overall health.
In addition to that, I think we need to be connected to the organizations that work in social media and are involved in our browsers. We need to think creatively about how to tap information that is related to the questions people ask on Google or information that they are putting out to the public on Facebook. There's more and more examples where creatively thinking about that kind of data can also be helpful for a state public health commissioner.
Ed: It's an exciting future. It's an exciting future. My last question, which you've touched on, is advice to those that would serve as a state health director. Final question. What advice would you give to someone that aspires to do the job that you've done as a state health director?
John: I would recommend a few things. One thing I would recommend is recognizing you hold the position for a short period of time, and that you have the potential to make a difference. Pick a few priorities, work on those, and enjoy yourself. The second thing I'd say is have a support system. That can be your family, your friends, it can be your peers through ASTHO, but you need a support system. You need people who are there to help you think things through, to remind you you're a good human being on a really bad day, and also to keep you humble and remind you that if your people are standing up and applauding you, it's really more about the position than you. You need a reality check from people who love you and care about you. Finally, I would say it's good to think about the future. Too many state health officials begin to think about "what next" at the point they're no longer a state health official. It's not easy to think about the future when you're in the midst of such an important role, but it's worthwhile doing that. Again, I think ask ASTHO and former state health officials who've made that transition can be very helpful in terms of helping think about what their transition was like, what the other career possibilities might be. You want to make sure that you're not caught by surprise and find yourself in a difficult situation at the end of your tenure.
Ed: John, great advice. Great talking with you today. Thanks so much for taking time to talk.
John: Thank you. My pleasure.
Georges Benjamin, MD
Washington D.C., 1990-1991 (interim)
Georges Benjamin is one of the nation’s most influential physician leaders. As a testament to his influence, in 2016, President Obama appointed Dr. Benjamin to the National Infrastructure Advisory Council, a council that advises the president on how best to assure the security of the nation’s critical infrastructure. His career contributions speak to the health issues having the most impact on our nation today.
Description of the video:
Baker: I'm Ed Baker, and today I'm talking with Dr. Georges Benjamin on the subject of success as a state health official. He served as a state health director in Maryland. This work today is part of a research project out of Indiana University's Fairbanks School of Public Health led by Dr. Paul Halverson asking questions about what it means to be a successful state health official. Georges, thanks so much for talking with me today.
Benjamin: Ed, I'm glad to be here.
Baker: Georges, thank you for talking with me today. Let's start off with a very fundamental question. You served as a state health official in Maryland. What does success look like to you when you reflect back on your term as the director of the state health department in Maryland?
Benjamin: Well, my goals when I was coming in as a state health official—I had come in as being the Deputy, and I moved to being Secretary—I absolutely wanted to make sure that I had ultimately improved the health of the people in Maryland. That was my ultimate goal. We were really excited, because we actually think we achieved it while I was there.
Baker: What factors do you think that led to your success, the underlying contributing factors, either things that you yourself was responsible for or maybe others, what were those critical success factors that led to those things happening?
Benjamin: I've always said that it's very difficult to go to a state health job if you don't know the politics and the community. Having spent the four years, almost, as Deputy, I had learned the ropes. Of course, I had an amazing boss, Marty Wasserman, who I really learned a lot from. I think the real critical aspects of what we accomplished as a team was one focus. We decided we were going to do a few things very well and deal with the crises as they came along. During my time as Deputy, I really built a really amazing team. I brought that team with me, and then we incorporated the other part of the department as part of that team. It was building the star track team that you bring with you from ship to ship. That was really our success.
Baker: It really mattered to you to understand the department.Getting in there as the Deputy, you had a basic level of understanding, but it sounds like team building was really crucial to your success. Is that what you're saying?
Benjamin: Team building was absolutely crucial to our success in Maryland. We did a lot of retreats; we did a lot of strategic thinking about where we wanted to go, and we brought consensus around what we thought were the most important priorities for the department to accomplish, understanding the governor's priorities, the challenges we thought we had in state, and functionally what we thought we could reasonably accomplish, realizing that these are ten jobs and we had four years.
Baker: You mentioned challenges just now. As you look back, there must have been a very significant, maybe even the most important, challenge that you faced in your time as a state health director. Tell us a little bit about what you think maybe your most important challenge was.
Benjamin: I woke up one morning and discovered that we had really a huge deficit in our Medicaid program, primarily for the mental health side of our program. That was our biggest challenge when I was the state health officer. The real problem with that, of course, was that that had been my program which I had oversight for as the Deputy. The problems that I discovered as Secretary were ones, in many ways, that I created as Deputy. They were political problems, because there was a growing need for mental health services; it was a physical problem, because we had had… We had been blessed almost with six years of really good funding. That's when the economy was churning along. Now the economy was downturning. There was physical pressures, new problems with the Medicaid program primarily on mental health.
Baker: That was a big hit in terms of budget deficits and a big challenge that you faced, in part because of things that happened even before you took the job.
Benjamin: There were challenges, and, of course, like I said, part of that was due to my creating some of the problems. One of the real issues was we had gone to mandatory managed care in Maryland. That was going quite well overall. In fact, that was one of our successes. We carved out the mental health system, and we thought we had done it right. We brought in a consultant. We brought in a private sector person to help us bill. We suddenly discovered that all of these community-based providers really weren't very good at billing and collecting. We all of a sudden found ourselves with bills that suddenly came in as they improved their collection capacity, and we had not budgeted the money to cover them.
Baker: What about this issue which comes up from time to time, that when state health officials enter a position, there's something that they really wish they'd known about before taking the job? In your case, you were a Deputy. You'd come up through the system. You knew the department. You knew the people. Once you became the state health official and once you had that particular position, did you stop and say,"Gee, I wish I had known about this," or "I wish I had known about that," maybe in greater depth or whatever before you took this position?
Benjamin: I understood health care financing reasonably well, but I suddenly discovered that I did not know it well enough. Of course, as Deputy, we had ran 80% of the department with 20% of the money. The rest of the money was all in the Medicaid program, and Medicaid was part of the department. I had a rudimentary understanding of the Medicaid program. I probably should have boned up a lot more on the health care financing side, particularly because we were dealing pretty much with the private sector. That was a very steep learning curve. I was okay. I got through it mostly because I hired the right person as my Medicaid deputy who absolutely understood this thing. I didn't get in her way as she tried to run the program. I just stepped back and was able to steer it. I wish I had learned as much…I knew as much at the end of my term as I needed to know at the beginning.
Baker: Now, you transitioned out of this position. We're going to talk a little bit in a minute about your life after being a state health official. What about the impact of your departure? In some cases, you know state health officials leave on short notice; others, it's a bit more of a planned experience. Say a little bit, if you could, about the impact of your departure on the department itself. How did that play out? What do you see as the impact of your moving on?
Benjamin: The impact of my moving out of this particular position was certainly quite different than my impact on leaving the DC health department when I left the DC health department. I left the DC health department in the classic abrupt mayor wants to make a change. Quite frankly, I went through the traditional grief and loss experience. In Maryland, I personally planned my transition and such recognizing that it was a temp job.Understand, this is an enormous loss of control and influence that you lose when you leave these jobs. I personally went through a planning process to think about that so that I wouldn't go through the really terrible time I did when I left the DC health department. Now, even though this was something much more on my terms, it was still a great loss.
Second thing was I began to prepare my staff for my departure. Inappropriately, it got leaked out early that I was leaving through the press. I spent a lot of time talking to people and talking to them about the accomplishments that we had. Frankly, we ended up having a celebration at the end of it and thinking about the transition. At the end of that, of course, we didn't know at the time, but we changed governors, and we changed parties. There was every likelihood that I was going to be leaving anyway, but the fact that we had thought about our successes, we got them, and we catalogued all our successes, we jointly celebrated it made a big difference when I left.
Baker: Now, you transitioned out of that job into your current position at the American Public Health Association where you're executive director. How did that experience as a state health official prepare you or in some way help support you, in whatever ways, in your current position? How did that play out for you given what you're now doing?
Benjamin: Well, they're two quite different jobs. Certainly, going to the American Public Health Association was a very big difference in budget. I went from managing almost a $5 billion budget to about $12 million. Frankly, APHA, although very complex. So, running the state health department which was a complex entity, going to a membership association which in itself was a complex entity, that helped me with the complexity. Trying to resolve budget issues in a $12 million budget wasn't a big deal for me. What I learned from making that transition was I moved from being the person that was advocated against to the person doing the advocacy. That's been a big transition for me.
Baker: You're on the other side a little bit.
Benjamin: Making the transition from state health official to community advocate and, frankly, running the largest advocacy association for public health in the world was a big switch.
Baker: Let's talk about the future of public health when you think about this a lot. There's now this talk about Public Health 3.0 and the role of something called a chief health strategist,seeing the role of, say, a state health director in a little bit of a different lens. What are your thoughts about where the field is going? Things are changing. There's a lot of change happening in health care delivery, a lot of change in information systems that are needed to support the work. What about the future? How would you describe what you see as the key things for people to focus on now going ahead?
Benjamin: I've always believed that the future of public health is for the health officials to view themselves clearly as their community's chief health strategist. If you're at a federal level, your role is at the national level. If you're local or state, it's at that level. If it hurts people or kills people, it's yours. That means that you may not own it, but it's a matrix management situation where you need to manage up, and down, and sideways, and across sectors. The challenge we have in public health is that we haven't all adopted that mindset. Secondly, we've not built our systems to be able to do that. We historically do what we're funded to do and not necessarily do what we ought to do to achieve a goal whether we have the program or not.
Baker: When you say systems, do you mean things like information systems that really cut across programs, that really support much different kinds of activities? Would that be an example of the kind of systems that are needed?
Benjamin: The systems that I think we need to build an effective public health system is the legal framework, well-trained people properly positioned to do the job, and all of the tools, whether it's electronic surveillance systems, or data registries, or technical knowledge of working with the hospital system, the private sector, and, frankly, a growing understanding of business and how to engage the private business community using the language that they do. Finally, the people in public health we've talked for years. We always talk about how collaborative we are, and yet, frankly, quite often we are the least collaborative of the people in the world. We need to do a much better job of being a collaborator and an influencer over time with people who, frankly, we disagree with.
Baker: You've answered, I think, already in part my last question, but I'll reframe it and just hear what your thoughts are. Your advice to future state health officials, people that are becoming state health directors now and doing a job like you did in Maryland, what advice would you give to them based on your own experiences in public health?
Benjamin: The first thing to remember is these are temp jobs and many things that will come to you that are unanticipated. You need to decide what two or three things that you want to do so that at the end of your tenure, whatever it is, however long or however short it is, that you feel that you've accomplished what you went to do the job for. Recognize that what's going to be layered on top of that is your governor's or your mayor's priorities, depending on where you are, and the stuff that just happens, that the legislature gives you and fate puts in your way. If you focus on the few things you want to do and get your team focused around that, and deal with the mandates that you're given, you'll be quite successful.
Baker: Right. Georges, thank you so much for talking with us today. I really appreciate it.
Benjamin: Ed, I was glad I could be here.
Leah Devlin, DDS, MPH
North Carolina, 2001-2009
Leah Devlin is a professor of health policy and management at the University of North Carolina Gillings School of Global Public Health. In addition, she is a consultant to the Research Triangle Institute, International (RTI). Dr. Devlin has more than 30 years in public health practice in North Carolina including 10 years as the Wake County health director and 10 years as the state health director for North Carolina.
Description of the video:
Baker: Hello, I'm Ed Baker and today I'm talking with Dr. Leah Devlin; a colleague and friend, as part of a research project on success for State Health Officials. This project is led by the Indiana University Fairbanks school of public health, Dr. Paul Halverson, a former State Health Official himself is leading our work. We're sponsored by the de Beaumont foundation and work closely with that. So, Leah it's great talking with you again today.
Devlin: I'm glad to be here with you, Ed.
Baker: Alright, thank you so much. Let's talk first about your experience as a State Health Official and as you think about it, and look back on it, one of our questions is, "What does success look like, what in your mind’s eye does success look like when you think back about your term as a State Health Official?"
Devlin: Well, Ed, when I look back on my years as a State Health Official and think about what success looks like, I remember that we chose a few priorities, because there are so many issues in public health that need to be addressed, and that we're working on. But, I decided what were the things that I wanted to be able to say, "During my time, we made a difference on school health; on preparedness, on disparities, and building the public health infrastructure was another priority, and working on Women and Children's issues." So, we had those five broad priority areas and how do we move policy? Were we able to put new programs or shore up existing services? What were the partnerships we developed, and did we have impact in the end through those different strategies?
Baker: So, what I'm hearing you say in terms of success, you said priorities, and then, in a sense you measured your success based on the programs you developed; the policies you put in place and that's the way you could almost determine whether success happened. Is that a fair way of looking at it from your view?
Devlin: Yeah, I think that's exactly right. You set your priorities. You measure your outcomes and your outcomes can be a range of things. One of the important issues for me was, how visible is public health on an issue? What were our relationships with our partners? Were we creating new partnerships with important players? Or, were we refreshing old partnerships and finding new ways of working together? So, it was how effective are you? How important, do people want to engage with you on these issues? Because, as we know, public health is a team sport and everybody has to be involved. So, it was some of that kind of relationship building, not just whether you decreased teen pregnancy.
Baker: Let's talk a little bit more about those factors you've just touched on the factors and the sort of way you went about being successful. I watched you in action when I worked in North Carolina, and one of the many things you did well was building those partnerships particularly, across non-traditional lines. Like, with the schools; with the general assembly members, with other people in the State. Say a little bit more about how you went about doing some of those things that led to success, like, building partnerships.
Devlin: Well, the first thing about building a partnership is getting to know each other ahead of time, before you need each other. So, I always thought about having a cup of coffee with a key leader in the community or, another part of State Government; Agriculture, we were always picking at Agriculture about tobacco or pesticide exposure. Well, when we became leaders in the World of Preparedness after the Anthrax attacks, that was a new way of working with an old partner. The preparedness opportunities also gave us a new way of working with hospitals. One of the things after the Anthrax attacks that the Federal Government did very well, is they dedicated resources and they got it out the door, they gave us broad goals to develop our capacity around acts of bio-terrorism. But, one of the great strategies they did is they sent the money for the hospital preparedness through the State Public Health agency. So, that drove a new way of working with hospitals. So, we had a lot of partnerships already. North Carolina is a partnership State. I think maybe some of that comes from being a Hurricane state. We work together. We know each other. But, it also, the preparedness brought new partnerships to the table. Like, the National Guard; and the Law enforcement and some of these partnerships endure today with some of the other critical issues that we face. So, the relationship building is essential for going forward and making a difference, and living to fight another day. You need your friends in all aspects of our society.
Baker: Now, you've mentioned to me before that the real challenges around preparedness, you just touched on that being a huge challenge, say a little bit more about if you would, that challenge. What was challenging about it perhaps, and how you really dealt with it? And, you've already touched on it, Leah. But, that was a big challenge for you, because you came into it at a particular point in time. Tell us a little bit about that important challenge for you?
Devlin: So, I did start as a State Health Director in May of 2001. So, the towers came down in September, and then the anthrax index case, the first man that was sick and died from anthrax was actually...was from Florida, but he got sick in North Carolina. So, we and Florida were the epicenter for that very first investigation of an act of bio-terrorism. And so, right out of the box we were going through hospital records and looking for where the exposure might have been, and whether anybody else might have been exposed. So, it was time of high risk; high concern, and we right away knew we had to ramp up not just the investigation, but communication with the public. Making sure that we were communicating in a timely; complete, and accurate way. Every day; every morning, every afternoon there would be a media either press release, a media availability, a press conference where we had all of our partners together, but that public face of, "We've got this." Because, actually, it was a really great opportunity for us to eliminate actually, who we are in Public Health, what our role is. That for 100 years we've been investigation infectious diseases and detecting early and responding rapidly so that we can contain the damage done when there is an infectious disease in the community. Or, food borne outbreak, for example. So, we were able to demonstrate that there is a local health department in every County in our State. This is what they do. This is what we do. Now, it got a twist because it was intentionally delivered, and that's frightening, and brings new partners for us to work with. But, that we have the experts in the Science; the medicine, the epidemiology, we know the community, this is what we do. And that was a really strong and important message for the community, that really thought the Health Department was that clinic on the corner down the street. We were able to say, "No, no. That's important. Some of us do that. Some of us don't." We do it in North Carolina. But, our community health protection role is foundational and we were able to demonstrate that.
Baker: It really opened people’s eyes to a whole different aspect of things.
Devlin: Yes, it did.
Baker: Now, you knew a lot of about the State Health Department before you became The State Health Director. You worked there, you worked in local public health before that. But, when you took the position, I'm wondering is there something that you wish you would have known about the job or what it consisted of? Or, what you needed to do to be successful? That once you earned the position you said, "Gee, I wish I knew about this or that." Was there anything like that that happened for you?
Devlin: So, I had already as you say, been in Public Health in North Carolina for over 20 years. I had been a local health director. I had been at the State for a number of years, so, I knew the public health system in my state. I knew the issues, and I knew the people. So, in looking back, I sort of knew what I was getting into. So, looking back on that time what I might have taken great comfort in and been inspired by is that if I had had more awareness of what a gift it was. To have the opportunity to serve as a State Health Officer in a marvelous State. Many challenges, to work with the team that I had to work with, who were fabulous. I worked with a wonderful secretary, Carmen Hooker Odom, and a great Governor. And just, it was an opportunity to grow; to learn, to meet new people. By getting involved in an organization like ASTHO and some of the affiliates I had the opportunity to engage Nationally. And, that was just really life changing. So, I think going into it knowing that there are going to be good days; bad days, knowing that you're going to have successes and that you're going to mess up. But, the big picture in the art of the long view is, "Wow, not a lot of people get to do this, and how wonderful that was." So, it was a gift.
Baker: Wow, that's great. That's great. Now you had that position for about eight years or so, that's right? And at some point, you transitioned out. You went on to do other things, which we'll talk about in a moment. Say a little bit if you would, Leah, about sort of the impact about your transition and things that you did that sort of effectuate a smooth transition. Things you did to sort of mitigate damage. Sometimes there's a transition that's very abrupt and it's not planned out. But, talk about your transitioning out of the position. What was that like? Particularly, the impact on the organization, and what was done to address that?
Devlin: Well, I left my role as State Health Director after thirty years of Government service. And, was interested in seeing if there were other opportunities to contribute from a different sector. But, the impact on my leaving the organization was I believe minimal because we had a strong team. They had had opportunities to develop their skills as leaders in the State Level Public Health System and in their own National associations as well. They were visible. You know, you're always torn between having a State Health Director as the face of public health that's communicating; that's branding the message, versus, there’s plenty of sunshine let's let these other really amazing experts talk about their issues in the Public eye so that they're not only developed their skills, but they're visible. People know them. People trust them. The elected and appointed officials are invested in them. So, it is a little bit of a planning process. And then, thinking a little bit about when you leave. I thought it was important to leave when the lights were on. When things were going well. We were in good shape. We weren't in crisis mode. The budget hadn't tanked yet. We hadn't had flu, shortly after all that both of those things happened. So, those are the kinds of things that can help with continuity of your own mission, of your own goals, which are so important and you've invested so much in. The other thing that I think has been a really wonderful opportunity for me, and I'm grateful for it is that I have remained close to my colleagues in the division of Public Health. I'm home grown; I'm in the community, I'm still engaged in Public Health just from the academic sector, and they're very generous in allowing me to continue to be a part of their work. Which, is really fabulous.
Baker: So, you’ve really maintained those relationship.
Devlin: Oh, they're very important to me. Very valuable in my life.
Baker: Let's go back to one relationship issue that I think new State officials need to learn more about. You worked very actively with elected officials in the States general assembly. Obviously, there is a Governor’s office, we'll talk about that in a moment. But, can you say a little more about relationship about with people, elected officials, around the Public Health issues. What did you actually do? How did that go? Maybe, you were telling me a story one time about the State lab, and trying to get, you were all driving off on a trip somewhere and you were working with some of these people. But, that part of working with elected officials is not something that I think people who become State Health Officials know about. Tell us about how that worked or you. What were some of the things you did that seemed to work?
Devlin: Well, in my work with elected officials, I always was grateful for their service. They stood for election. They made enormous sacrifices to be there with family and with the other careers. So, the fact that they stood for election was impressive to me. In working with them, I was very respectful of them. I was also very, and still am, very respectful of their role. And what my role is. And I was pretty clear in understanding that my role was to bring the Science on an issue. And, based on that Science, what my recommendation as a Scientist would be, State Health Official. But, recognizing that they have a different job. That they have a different set of factors that they are using to make their decisions. Whether it's constituent based; or the economics of a situation, they have other responsibilities. So, I'm there to give them my best guidance based on Science. When you get off on your Science it's just a greasy slide downwards. So, it's really important to stay there on your facts. And, moving into advocacy is tricky. There are others that can do that for you. So, working in partnership with others that are going in another way, another approach to do your advocacy work, usually that's going to be in my State the local health departments were independent. So, they can do that back home in their constituents, in the community or even in the legislature. The non-profit sector is a very good partner in that way as well. The other thing is, I always took someone there with me. So, you always had someone that made sure that everything was, what you heard when you leave is what you thought you heard. That you're not getting pushed into a deal. You never want to make a deal with a legislature. So, that third person, someone from your team, helps everybody stay on the path you meant to stay on when you went in there. So, it's little tricks like that.
Baker: So, an extra pair of ears there. There's someone else in the room with you that's listening at the same time.
Devlin: Yeah, ensuring you up. And, it's not just about you. It's your team. Your system. I mean, you may take a local health director... When we worked on tobacco issues, we would go in, when we were working on particularly the smoke free bars and restaurants. Our most important partner, when we would go in and see legislatures, was the head of the restaurant association. And, it was interesting because the legislatures, we had been working on tobacco for 30 years or more. They knew what I was going to say and want I thought. But, they in that office wanted to hear what that business guy had to say who was the leader of the restaurants. So, we were there and we were there together, which was really important. We had a piece of legislation about where a legislature was really wanting to reintroduce unpasteurized milk to the food supply. So, you go in with your agricultural commissioner, and that's very powerful too. So, you're careful about not only taking someone, but who you take is important, also.
Baker: Yeah, picking the right person, right. You've been doing a lot of interesting things since you left your position. You're at the public health school there at Chapel Hill. You're on the board of the Robert Wood Johnson foundation, and working with RTI. You've done a number of other things. you've stayed in touch with your colleagues as you mentioned. Say a little bit about how your experience as a State health official really informed you, or informed your work, your perspectives, after you left the job. How has that affected what you've done subsequently?
Devlin: So, I do have a wonderful opportunity to be on the faculty at the University of North Carolina, Gilling’s school of Global Public Health and my role there is to connect the school, which is already very practice focused, as a real commitment of Dean Barbara Ramer. And my job is to increase their connectivity to the community in the State particularly, it's a state agency. So, in the state. And, help our school be a part of solving some of these, what we call the Wicked complex public health issues of our time to be more of a player. The second part of my job is to increase the visibility of the school as a state agency with statewide leaders for what we are doing that makes a difference in our state. That we're not just about research, we're not just about teaching. Both very important, but we are very engaged in service in North Carolina. So, in some ways, the work is the same. It's about building partnerships; developing relationships, connecting dots, being able to step back and see possibilities with really smart faculty and students. Really tough problems and restraints that State government might have. That's particularly true when you work with a partner like RTI which is a private think tank that does a lot of research on a lot of public health issues. They can be more nimble than either of our state agencies, so that's a great partnership. So, in terms of working with the Robert Wood Johnson foundation, which is an amazing institution. The work that they're doing their mission around a culture of health, fits with what I've been about my whole life which is community level engagement. Helping and empowering communities to be engaged in solving their own problems, coalition building, getting everyone to the table. So, that's really central to my life’s work and it's amazing and fabulous to have such an incredible foundation such as the Robert Wood Johnson foundation really making a long-term commitment and focus to that work.
Baker: When you look at sort of the future public health, you've already talked about this, Leah. Looking ahead, state health officials, as you were, would need to have a vision of where public health is headed. Where it needs to go in this next period of time. What are your thoughts there? Based on how you're seeing the public health landscape about the future? And what particularly new health officals might want to focus on.
Devlin: I think it's really important in thinking about the public health system and the future, where we might need to be and how a state health director can help position the organization is, making yourself relevant in the community. What’s going on in the community that's important? Of course, at the State level, it would be the whole state. One of the issues for example, is the big disparities between rural and urban areas and how can we work with our hundreds of public health departments or health departments that cover all 100 counties to truly shore up the capacity there; to bring people together, even the most rural communities have assets. They have schools, they have faith communities, some businesses, elected officials. So, how can you continue to make yourself relevant as a leader all on the issues that are important in that community. Some of it is our time on our work. If you're working on prevention, you're going to be working on preconceptual health and family planning; making sure babies are born into the world healthy and wanted and ready to thrive, develop their brains. We know so much more about brain development and focusing on 0-3. So, it's important for us to stay abreast of the science that's changing and stay focused on the science. It's also important to look for the tables that we need to be at when we're talking about whether it's health care; or environmental issues or chronic disease, leading causes of death and all the behavioral changes that go there. Probably understanding more and more about the science about how you actually motivate behavior change would be huge, right? Because, we know where lots of health comes from is our own choices. The technology age that's out there, I think trying to stay fresh on just not only the technology advancements around communications and social media; how we do communicate with the public. But, also, the new technologies around precision medicine; genomics, the possibility of tailoring prevention messages and preventative behaviors truly to an individual in a broad population approach. Using our phones. Using social media and things like that. I think we need to build on the lessons we've learned. Like preparedness, we've talked about the need for good communications and new partnerships like with Law Enforcement that we've developed. We have an amazing opportunity now to bring those skills to bear on the crisis of our time, the opioid epidemic. That's just one example. It's got the awareness of our elected officials; there's funding there, it's an enormous problem. Everybody has to be engaged. This is work we know how to do. It can be prevented. It can be treated with training and working closely with our health care providers that are partners that we can refresh those relationships. That's one example of an opportunity that's at hand. But, there is the broader picture of being at the tables where important decisions are being made about health and healthcare, as well as looking long chronic disease. We have not finished the book of business on tobacco and we need to do that. I'm very concerned about where we're going with Marijuana in this country. Another inhalant in people’s lungs and the cognitive challenges there. And then early childhood development. A major, major opportunity as we learn more and more about brain development and getting kids ready.
Baker: That’s great. Final question, you're advice to a new State Health Official. I'm sure you've talked to people who are new in the job, or are considering the job. What advice would you give to a person that is a new State Health Official?
Devlin: Some of the advice that I would give to a new state health official is to first of all remember that it's about the issues in the system, it's not about you. So, you know, do your best and sometimes it's going to work, and sometimes it’s not. This is hard work over the long haul. The second is to be transparent in everything you do. Be ready to read about it in the paper tomorrow, or be able to have a conversation about it with your Mom or your Grand-Mom about it. And let that be one of your guides. Surround yourself with good people and be sure that you’re supporting your leadership to the very best extent that you can. Work on your communication skills and build those partnership in the community, along with the team that you have inside. Because, that is how you're going to be able to go forward.
Baker: Leah, thank you so much it's been great talking with you today.
Devlin: Thank you for the opportunity, it's always good to be with you, Ed.
Baker: Great, thanks so much.
Jeffrey Engel, MD
North Carolina, 2009-2012
Dr. Jeffrey Engel, MD has served as the executive director of the Council of State and Territorial Epidemiologists (CTSE) since September 2012. Prior to joining CSTE, Dr. Engel was the North Carolina State health director, managing the Division of Public Health since 2009. He led the state's response to the H1N1 influenza pandemic and secured $23 million in federal funding for preventive health services.
Description of the video:
Hugh Tilson: This is Hugh Tillson, for the Indiana University Fairbanks school of Public Health project on public health, state health, officer success. [INAUDIBLE 0:00:10.4] foundation funded projects, supported strongly by Asta[phonetic], and we have the privilege of talking with state health officers, current and the former, about what the ingredients of success are, and what the impact of turnover in the state health offices might be. I’ve already been having great conversation with you, Jeff[phonetic] Ankle[phonetic], former state health officer for the state of North Carolina. So, let’s get going and find out what you define as success. So, Jeff, thank you so much for doing this. Let’s just start off with your definition of success. What’s a… What is a successful state health, officer?
Jeffrey Engel: Well, I have to look at my environment, which is the state of North Carolina, and, I think, in my state, the Health Director role is, actually, defined in statute, and it has to be a physician licensed in that state. That is, pretty much, it. But, in reality, in my time, I think, the success was a dual role. The Health Director needed to wear the hat of the Surgeon General, that is, the subject matter in the public health science of the state, and the second role, is a leader and manager of a very division, within the department of Health and Human Services, that division being the division of Public Health. So, I think, success was mainly due to wearing those two hats, simultaneously, being that valued, trusted, credible public health scientist, as well as a really good manager leading a very complicated division, and an even more complicated department.
Hugh Tilson: So, let’s peel that onion back one more layer. What are the components of success for a state health officer? What has to be in place?
Jeffrey Engel: Well, I think, it’s beginning to peel that onion, if you would, beginning at the division level, the… public health is, mainly, a science practice. We rely on data, whether it be a wick[phonetic] program that we administered for the USDA, or communicable disease control immunizations. You needed really solid data to do your job.So, we relied, whether it was in women’s and children’s health, or in the epidemiology sections on really good staff, you know, good scientists who knew what they were doing, who could get to the Health Director, the data, in a timely fashion. But, also, bring with that data, the stories that needed to be told about the large state. Also, being a home-role[phonetic] state, North Carolina needed excellent communications, and relationships with local health departments, and if you didn’t have that in place, you were gonna fail, because these health departments are autonomous. They reported to their own local health boards. They got very little, in terms of resources, from the state. Most of their funding was from their own tax base, and what we needed to do with them, was provide them technical assistance and quality assurance, and help lead them to make sure that, all those counties and locals were rising at the same level. And, then, finally… So, I’m painting a picture, here, of leading, across the division, down to the local department, and then, finally, up, which is to the department of Health and Human Services. So, Health Director reports to the secretary, or an undersecretary in my case, and you have to lead in that complicated, political environment.
Hugh Tilson: There were so many opportunities to lead, even into your too-short[phonetic] tenure in North Carolina. Now, choose your favorite, biggest, most dramatic challenge, and just talk about that.
Jeffrey Engel: Well, I had two challenges. One was my biggest and my favorite, as he said. The other was, perhaps, my downfall. The first challenge was the H1N1 pandemic. And, I don’t mean to brag, but I was the right guy for that. Subject matter expert, infectious disease epidemiologist, I wrote the flu response plan. My team did, when I was state epidemiologist. There was no more ready-state health official in the United States. I would argue that I was for the pandemic. As being a recent state epidemiologist, knowing so much, and what my staff had done to put together this very, very robust plan… It was just finished, too. So, it was not on the shelf that long. We had extra-size[phonetic] components of it. So, I was ready to lead through that. The complicated issues of surveillance, the risk communication needed for the public, and at the same time, understanding the Federal asset that was coming down, which was, of course, the counter-measures, in the form of either the strategic national stockpile, which we did not need to tap, but we had our own state stockpile of anti-flu medication. And then, of course, waiting the vaccine, which was gonna take the problem off the table. That was the easy one. The hard one, was the recession. It hit in 2008. I took office in 2009 in March, and the impact on the state budget hit at the same time. We had a brand-new Governor. We’ll talk, maybe, more about that. But, my first instruction was to put together a plan with a 5, 7, and 10 percent cut in our state line. So, the budget is complicated. Our division was, probably, 70 percent Federally-funded, and 30 percent state, and we had to dissect, and say, ‘Well, of those dollars, what was pure state money?” In other words, there was some state money, if we touched, we would lose the Federal drawdown[phonetic]. Like, our Maternal Child Health Block Ram[phonetic], for example. You couldn’t touch that state[phonetic]. So, you had to look at the state dollars that were 100 percent state-funded. We only had a few programs in that category. So, I was going through that, eliminating jobs, and people lost jobs.
Hugh Tilson: The leadership challenges, there, were many. Just, take off some of the leadership challenges that taxed you.
Jeffrey Engel: Well, I said the recession. We put forth our budget proposal to the Governor’s office. Some of it came[phonetic] to reality. But, for your information, there were three large pots of three state dollars. One was in the Children’s Developmental Serv… CDSAs. A lot of them were Federally-funded, but most of those positions[phonetic] were pure state. We had a state-health program, which had regional-state hygienists[phonetic] in the schools, in prevention, and all health. And, the third pot of money was the Office of Minority Health. So, the cuts went forward. Two people lost their job in Minority Health. We eliminated, I believe, ten hygienists. We went after the vacancies, of course. But, a couple of people lost their job. And, at the CDSAs, the Children’s Development Service Agencies, we had… We picked at the vacancies, which is not strategic. But, you do it so you’re not firing people. So, that was the hard part of my job, leading on that horizontal division level. The harder part was leading up, into the Department of Health and Human Services, and reporting to the secretary, and the undersecretary. This undersecretary that I reported to was an awful person. He was mean, he, also, didn’t know what he was doing, and he was insecure about that. And, I didn’t manage that well. I was intimidated by him. And, all my meetings in the department were about our hot-button issues, which were areas of our budget that were losing revenue, not due to any fault of our people. So, our state lab was losing money, and our vinyl[phonetic] records Division was losing money, because they were fee-based, and the fees just weren’t coming in, cause, there was a recession, and, also, the legislature cut the fees to… for people wanting their, you know, birth or death records, whatever they needed. And, they cut it so severely, that it couldn’t cut their own costs. So, that’s all I did, when I went to the department, was talk about our red ink. I was never able to talk about our successes, cause that’s all my… This person wanted to hear about, cause, I guess, that’s all he was responsible for, in the governor’s office.
Hugh Tilson: Let’s talk about, and I think you just answered the next question, which was, even though you were a senior, seasoned state official, were there some things about the director’s job that you didn’t know, that you wish you’d known, on day one.
Jeffrey Engel: Yeah, so I think on day one, and I had leadership training later, was that leading-up piece, into the department of Health and Human Services, and beyond that, the Governor’s office. I didn’t work with the Governor much at all. But, I did with her staff. And, I wish I could have just played the politics better. And, it wasn’t partisan politics. It was, just, understanding the stresses that any elected official is under. In 2010, the legislature just completely flipped, from 150 years of democratic party leadership to Republican leadership, for the first time in 100… I don’t know, 140 years, or whatever it was. So, we had to deal, now, with all-new… A whole-new majority, that was opposite of the party of the Governor, dealing with the recession, and the other thing that you need to be a successful leader, is to have that champion in the legislator, which we lost. So, I was hung out to dry. I had an executive office that I couldn’t trust, because of this mean person that I had to report to, even though I could go to the secretary, and engender his trust, a Governor that was failing, and now a legislator that I didn’t know, and had an agenda.
Hugh Tilson: You know that one of the motivations for this study, is the understanding of turnover. What do you say, publicly, about our turnover?
Jeffrey Engel: What I say, publicly, is that the Governor chose to appoint a new Health Director, and that was her priveledge that I wasn’t political boy-me[phonetic], and that’s what happened. That’s what I’d tell the public. And, that’s what happened. What I don’t tell the public, of course, is the backstory, which I, really, don’t know, but I explored as deep as I could, because I was incredibly shocked. If we can take a side-moment, and I’ll let you… I’ll share that with you. It was in 2012, secretary called me into his office, and he did that all the time, so I was out of town, and I made arrangements to go see him right away. I thought it was gonna be something else, because he had announced that he was resigning as secretary, and I thought he was just meeting with his division directors, to tell them personally about his decision, and I thought that’s what I was walking into. So, I came into his office, and he said, “The Governor wants me to remove you from office. She wants to appoint somebody else. I’m sorry.” And, that was it. Talk about being pushed off the cliff. I had a visceral reaction, cause, I wasn’t expecting it. I thought I was doing a really good job. And, I gasped. I looked audibly, like that. I was sitting here, like I am with you, now. That’s how shocked I was. And, he said, he apologized. He told me who my replacement was gonna be, which is another complicated story that’s probably not necessary for this interview. And, I had 90 days. That was typical of, you know, your political appointees, and you will now be a senior advisor in the department of Health and Human Services, and you have 90 days to pack. Good luck. So, you know, I left the office. The first thing I did was call my wife. I was in tears. I had no plan B, which is another lesson learned there we’re gonna get to later in the interview. Always have a plan B if you’re a state health official. And, I can tell you why I didn’t; because, North Carolina, this was, pretty much, a secure job. My predecessor had it for nine years. Her predecessor had it for 17.
Hugh Tilson: You’re aware of what his predecessor experienced, however.
Jeffrey Engel: Yes. Let’s… Yes.
Hugh Tilson: Let’s move on [INAUDIBLE 0:15:31.8] that. One of the things we’re studying, is the adverse impact on the agency of precipitous turnover. What happened to the agency, when you came back and announced that you were leaving?
Jeffrey Engel: Well, I first met with my senior leaders, who were the section chiefs, and I sat them down, and I, you know, I told them how shocked I was. By then, I had recovered emotionally. I had my act together, and I told them who the new Health Director was, and I was gonna be cleaning my office out that weekend, and that she will be starting on Monday. And, they were shocked. And, they came to me, individually, afterwards, and just told me how sorry they were. But, I think the impact on the division, which is 2,000 employees, was one of great insecurity. And, they were saying, “If this could happen with the sitting Governor, what could happen to me? Even though, I’m not a political appointee.” And then, what happened in North Carolina after I left, is that the State Health Director’s position has been a revolving door. Nobody has served longer than a few months, 12, 15 months, since I left. I was there for three years, so I can proudly say I was the last long-term Health Director in North Carolina. So, what professional would want that job? You know? See, when I took it, I had some sense of job security with the predecessors, as I talked to you about. I figured, “I’d have to really mess up to lose this job. And, I’m not gonna do that.” So, now, what professional, in their right mind, would take this job, in North Carolina? That’s been the long-term damage.
Hugh Tilson: Is there anything that you could have done, anything that new-state[phonetic] officers can do, to prepare the agency for this instability. What can we do to, at least, create continuity in the agency?
Jeffrey Engel: Yeah. So, I thin, personally, the State Health Director needs to have that plan B, and say, “I don’t know how long this I gonna last. I hope it lasts the term of the Governor. But, I need to have, what am I g… I don’t know, am I gonna go back to my old job, or I need to prepare for my next step. Some of this may come with very senior leaders. They may say, “Hey, you know, this is gonna be my last real gig anywhere. I’m gonna be retiring, no matter what happens to me.” And, that’s good. But, then that leaves you with a rather limited pool of aging, you know, professionals.
Hugh Tilson: So, how do we prepare the agency for that? Is there something you can do to build a stable agency in the face of that?
Jeffrey Engel: But, that’s what I was getting to. That’s the personal piece, is, just planning for your own succession. But, the agency… Thinking about this is… You should always have a succession plan in mind. I mean, you can be hit by a bus the next day. What would the division do? So, I think a senior deputy is mandatory. I did not have that person. I had a chief operating officer. But, he was not the senior deputy, and I think that would have been a second-half, that person. We could have warned. We could have been a succession… Doing succession planning all the time.
Hugh Tilson: Let’s get cheerful, again. Your subsequent career has been fabulous, of course. One of the good things, is, that you are now a national leader in Epidemiology. Talk about Epidemiology in public health, and specifically, the relationship of state-level epidemiology with national activity. Just, bring us up-to-date on epidemiology.
Jeffrey Engel: Right. So, it’s been a great jump for me, in Atlanta, leading the field of Applied Public Health Epidemiology, as we like to call it, at the counsel state territorial epidemiologist. So, we have job security, because our science is the core of public health. You could argue that the epidemiologist working with the laboratorians, so the lab is the other core piece, forms the foundation for almost everything else, as decisions and policy go up the ladder. So, we have that core science that will always be there. And, I always like to say, if you look at the ten essential services of public health, what’s number one, monitoring the health of the population. Who does the monitoring? The epidemiologists, and their statisticians, and their labs. So, we’re number one, in the essential public health services. What’s going on, now, in the whole framework, nationally, is that our folks are contributing, in terms of the public health response to emergencies, and it’s been the EOC, the CDC has been[phonetic] open for the last three… They’re closing next week for Zica[phonetic], but they were open for Ebola, they’ve been open for Zica[phonetic]. Limited activity around the hurricanes, recently. But the epidemiology capacity-building in public-health-preparedness has been a big, front-and-center, national issue. The other thing, is preparing the epidemiology workforce for the twenty-first century, although, we’re already 17 years into that century, some of our methods are still twentieth-century, such as, just data flow, data management, and our… What we’re really focusing on, now, in the field, is computational science. It’s called Informatics, but it’s, really, computer science, and understanding the data, and how to move it more accurately, more quickly, and just be more-timely.
Hugh Tilson: That segway’s, sort of, end-game of this interview, which is, even more optimist, or maybe not. What do you… What do you see as the greatest opportunities for public health, in the coming years?
Jeffrey Engel: Well, I think, that, public health, if leveraged correctly, and you could call it public health three-point-oh, where the health direct is, also, sort of, the health negotiator for the community. And, it[phonetic] can happen locally, or at the state level, or, certainly, nationally. Public health is, really, the only activity that’s going to bend the health cost curve of this nation. You can talk about payment reform all you want, fee[phonetic] for performance rather than fee for service, people are still gonna get sick, and they’re still gonna need care. Care is expensive. The only group that’s talking about prevention, in particularly, of the high-cost diseases of morbidity, mortality, in the United States, is public health. So, if we could just get a few things done, whether if be in tobacco, or banning trans-fats, or limiting salts, or increasing physical activity in communities, that’s the only thing that I can think of, that’s gonna, really, impact the cost of health care. The ACA, as good as it was for access, really did nothing about the upstream[phonetic] determinance[phonetic], in a big way. There were a few provisions in there, that were helpful. But, for the most part, it was about access, and it fulfilled that promise. So, the opportunity for public health, going forward, is, really, going to be that leader in public health three-point-oh.
Hugh Tilson: How about a pep-talk for astho[phonetic]-alumni? What happens after you’ve been a state health officer, do you stop being a state health officer?
Jeffrey Engel: Well, I tell you what. I always look back in saying, “I loved that job.” And, I think, you will always have it, as that memory. And, it may be the pinnacle of your career. But, we’re all pretty capable people. And, all of us land on our feet. Even the ones, where, it’s the terminal job, that is, they retire after they’re complete. They’re all active active, whether it’s in the alumni society, or they’re doing consulting work, they’re recognized leaders. They’re always the Health Director, or the health official. So, that job instilled that in me, and I was fortunate, I mean, doing this national gig now, at Atlanta, and I love public health. And, I can, really, thank the experience I had as a state health official.
Hugh Tilson: So, your last chance, here, this is your [INAUDIBLE 0:25:08.8] we found at the camera, to talk about… To talk with future shows, people are thinking about being a show, training up, or new shows… What message do you wanna leave them with?
Jeffrey Engel: Again, it depends on your state environment. But, be that subject-matter expert, and be that good manager. But, also, learn how to lead up, whoever you’re reporting to. In my case, it was the secretary, and a big-umbrella agency, called Health and Human Services. You may be reporting directly to the Governor, and maybe, sitting on that Cabinet. To me, that was the hardest, was that leading-up. Understand the politics, know that a politics[phonetic] is more emotion than fact. If you’re not getting along with a leader, as you’re leading up, take that person out to lunch. Get to know them better. That was my mistake. If I could do it over again, that’s what I would have done.
Hugh Tilson: Dear Jeff Ankle[phonetic], one of my state health officers in North Carolina, clearly evidence-based, perfectly qualified, a very model of a modern state health officer, and a great success subsequently. Thank you for this interview, Jeff.
Jeffrey Engel: Thank you, you[phonetic].
Paul K. Halverson, DrPH, FACHE
Paul Halverson is the founding dean of the Indiana University Richard M. Fairbanks School of Public Health in Indianapolis. Dr. Halverson came to Indiana University from the Arkansas Department of Health where he served as state health officer and director. Prior to his appointment as state health officer, Dr. Halverson served in senior management roles at the U.S. Centers for Disease Control and Prevention.
Description of the video:
Hugh Tilson: Hi. This is Hugh Tilson. I’m having an interview and wonderful conversation. This is no interview is it, Paul?
Dr. Halverson: No.
Hugh Tilson: I’m with Dr. Paul Halverson. He’s the new Dean of the new school. No longer new after five years, the Fairbanks School of Public Health Indiana University and the principal investigator for this extraordinary de Beaumont funded ASTHO-supported IU-based study on Public Health success.
Dr. Halverson: Right.
Hugh Tilson: Thank you so much for joining me in this conversation, Paul. In addition to all of your other roles, you are a former State Health Officer.
Dr. Halverson: It has been my honor. That’s right.
Hugh Tilson: Right at the core of our study is this concept of success as a State Health Officer. What is success?
Dr. Halverson: It’s interesting. I’ll answer that question by first telling you a bit of a story. When I first arrived in Arkansas as the State Health Commissioner you may remember it was after the unfortunate and untimely death of Dr. Fay Boozman who was in that role and died in a farm accident. That, in and of itself you know, was a public health issue. When I first came to be in that role, I had a chance to go around to all of our 75 counties and 93 offices. I did that over a year but one of the first trips I made I actually went to a rural part of Arkansas and had a chance to really drive in the neighborhoods in small towns. Usually that meant going on dirt roads. Frequently it meant just trying to get a sense of where people live and what their conditions were that they lived in every day. Inherently, I knew it was different than what I lived at. What I found was and I’ll never get it out of my mind was children playing in a dirty street and there was just something about it. As I talked to people in the community I discovered that many of these kids hadn’t had anything to eat and there really were problems in terms of malnutrition and just not having the sense that they will really have a full meal. Not really having the advantages, I think, that a lot of people. We would all like to say that our kids can grow up and have a carefree life and these kids didn’t. It was interesting to me. It set the stage for what to me is success and that is being able to intervene, to create the conditions under which people really can be healthy. To me, take it another step forward and say it’s really about giving kids hope, right? Not just the kids, but their parents. As we all live together in communities it seems to me that one of the most important things that we could strive for in terms of public health is the success of providing the opportunity for people to have hope that tomorrow will be better than today. That there is reason to believe that because of public health there is a better tomorrow. I’m sorry, maybe it sounds corny. To me, it was a driving force to say, “You know, we can do better than this.” So that has been on my mind along with a number of other things about how I wanted to change the way that we lived, worked, played and worked together as a community.
Hugh Tilson: What a fabulous answer. What are the components of success? How do you get there? What are the factors that you need?
Dr. Halverson: To me, I think it starts with an understanding of public health science. We talk a lot about how public health over time has eroded in many ways. We’ve lost capacity and in some cases I would say we’ve never had that capacity. I think we need to begin our work with the strong foundation, a scientific basis of what we call public health. I guess perhaps one of the reasons why I’m most interested in education. Practical, practice-ready education that focuses not just on theory for theory’s sake but theory to help us better understand what the most effective evidence-based strategies could be and that allows us to better understand to be a critical consumer of that information. Number one, the factor is a strong foundation in public health science. Number two is an understanding of how communities work and that we collectively need to help engage with communities. We need to be trusted sources of information. We need to help communities understand their options and the importance of public health, and why health is at the cornerstone of their economic development and the cultural development of their community. Having that understanding of community and the leadership that it takes to be able to lead from behind, lead in the front, lead in a way that allows people to believe and to really know that we are partnering together to improve their health. Third, I think from a practical perspective, the way we move organizations is having a good, solid understanding of management and leadership. We know that leaders can be taught and my hope is that we in public health will do a much better job of training people to lead well. There is good information out there, it’s available. We just need to use that information. Fourth, the idea here is that we need some zeal, some zip. We need to have hope ourselves that things can get better and that enthusiasm we have, I hope, will spill over to others. That zip, the leadership in management experience and knowledge, the public health science and the leadership within the community, and a real sense of authentic community engagement. I think all four of those things are really important as we think about the factors or the pillars, if you will.
Hugh Tilson: Let’s apply it. Remind us where you were a State Health Officer and what years you served.
Dr. Halverson: I was the state health officer in Arkansas from 2005 to 2013.
Hugh Tilson: During that time you had a lot of challenges, some real doozies. Just drill down on one. What was the biggest challenge, the biggest issue that you faced in that time?
Dr. Halverson: Boy, that’s a really tough question. It seemed like every day was a new challenge. I often said that it was the best job that I ever had. Some days it was both the best and worst day that I’ve ever had. So I don’t know. I suppose that one of the biggest challenges was the challenge of demonstrating to the Governor and to the legislature the importance of public health as its own agency. You may know that when I came as the State Health Officer it was in the waning days of the Arkansas Department of Health and the organization was slated for consolidation to become part of the Department of Health & Human Services. There was this one guy that was the director of what was now the Department of Health & Human Services, John Selig, a terrific guy, a wonderful career person. Had primarily focused on children, Medicaid and it was a huge agency. What happened was that public health became one of 13 divisions within the new Health & Human Services area. Despite all of our great intentions when the Governor says I need to have the top three issues for your agency and if your agency contained health and other things, sometimes it was competition to decide whether you would even get one thing that would be mentioned as a health issue. The idea was to save money by consolidating our Health Department with Human Services and so why wouldn’t we do that. Part of it was I don’t think people really understood the importance of health. So it was a good intention, great people that were trying to make it work, but over a relatively short period of time the legislature and our new Governor decided it was time to reverse course. Health was too important to simply be buried in an umbrella agency that didn’t have as its primary purpose protecting and improving the health of the public. I remember when the Governor, I talked with him and he said, “It’s too important. You need to have a strong voice in supporting public health. I need to hear directly from you. It needn’t be filtered. It’s important enough that in our state health is prominent as its own agency.” That was a challenge not just to me but to public health overall. We were able to convince the Governor and the legislature in a way that was professional and respectful, but the importance of being our own agency. That set the stage then for a number of things that I’m quite proud of, including the passage of the tobacco tax increase which also at the same time occurred with the passage of legislation that substantially created the trauma system for our state. We were, I think, among the last states in the country to have an organized trauma system. A trauma system that included not just the big city of Little Rock, but all of our state. I can’t help but believe that’s one of the most lasting things that occurred was the creation and the number of lives saved by essentially employing what we know about injury prevention and control. A lot of things went on that I’m quite proud of. A lot of work went on by some very talented people. It was my privilege to have worked with and creating an important team. Groups of teams that worked on a lot of different projects. There were a number of challenges but that’s just one.
Hugh Tilson: What I want to hear is what leadership skills it takes for a State Health Officer to lead that kind of change.
Dr. Halverson: I think leadership is important in introducing and sustaining change. I think it’s a different kind of leadership if you think about it. It’s not what you’re selling, it’s what you’re actually able to get people to not just be attracted to the idea but to actually embrace the change as something that is theirs, and they can see the purpose and the benefit to them, to their organization, to their jurisdiction. Whatever the unit might be. I think in the case of public health particularly as we think about State Public Health and large initiatives, take for example tobacco addiction. We know it’s the leading cause of death in all states. Still today, while we have literally millions of people dying of tobacco-related diseases and we know how to deal with it, but we’re not. I would say to you that I think public health’s greatest failing in terms of our leadership is in our inability to take what is incontrovertible evidence, particularly related to tobacco and just employ evidence-based solutions that we know work. We know how to deal with tobacco addiction. Our challenge in public health is convincing others the importance of making a change, creating a political change that will ultimately lead to improved policies that have the greatest likelihood of reducing addiction to tobacco and ultimately improving the health of the population. That’s just one example but to me it’s the complexities of those elements for people to embrace a different way of believing. So if we can’t succeed in that area it’s very difficult to imagine doing all of the other things that we need to do as successfully, as quickly as we need. I think that’s probably the other thing, having both the urgency but also the patience for the long-haul. We do our work every day. It’s hard to get people excited or urgently engaged in policy development and yet we know that’s probably one of the biggest and most direct ways in which to influence the health of the public is through policy-related initiatives. Yet, it takes time and energy, and we need a lot of people to come onboard with us. Again, that’s an important strategy for us as public health leaders. Then again, working with our medical care colleagues is also a critical element. I find one of the most exciting parts of our job is actually working with the medical care system as they begin to define public health. They may call it population health and we know it as public health. There is differences in those terms but at the end of the day when we’re all working together to improve the health of people, that’s what it is all about. To me, building strong relationships, creating win/win situations and incrementally changing our systems really is what will allow us to be successful.
Hugh Tilson: You know our study is all about change and turnover too. Think back to your onboarding. You became a State Health Officer unexpectedly and very quickly.
Dr. Halverson: Yes.
Hugh Tilson: Were there some things about being a State Health Officer that you didn’t know but wished you had when you stepped into those shoes?
Dr. Halverson: Oh my goodness, yes. It’s interesting and you may remember I used to be at the CDC. I spend a lot of time as the Director of the Division of Public Health Systems, Development and Research. I thought I actually knew this job fairly well when I was at the CDC. My entire division was focused on trying to support state and local health departments. I worked very closely with colleagues at ASTHO. Little did I know that I would actually be a State Health Officer and as you know when Dr. Boozman died unexpectedly in a farm accident it kind of got thrust upon me and it was one of the things that was a defining moment for me. I recognized that job would fall to me through Governor Huckabee’s appointment. I thought I knew it and I realized every day that I was in that job I realize I had so much to learn. Through my colleagues at ASTHO and the health officers that I worked with across the country and especially in the surrounding states, I had a chance to learn. If you remember during that period of time our public health laboratory, our very existence was at risk because of some technical violation. Not to diminish it, it was an important issue, but I think I was the first public health laboratory in the country to be shut down. Who knows what that’s all about. All of a sudden even though I understood a little bit about how laboratories were working and certified, and understand it was an important undertaking to be able to get us back in business so that the people in Arkansas would be served by a functioning public health laboratory. That was one issue among many that were initial obstacles. The reality is that every day that you recognize as much as you study the science of public health and the importance of leadership you get a chance every day to try it out again. The other thing is you recognize with nearly 10,000 that were in the employment either as an employee or contractor, that’s a lot of people. Keeping everybody going in the same direction is a real task. Communicating is so important and I perhaps underestimated how complicated and yet how important continuous communication and goal-oriented focus was in terms of communicating what is important and how things are going to change, and how they need to be part of it. It’s a complicate job. It’s a wonderful job, but I credit a lot of the success that we had to the training that I had both at CDC and the State Health Leadership Initiative. A lot of good and important training that came, but also perhaps even more important is the relationships I’ve built with other State Health Officers and our colleagues at ASTHO who collectively created a supportive learning environment that allowed me to be able to take some of this knotty issues, have a conversation and learn from what others had done. I think the worse part of being the State Health Officer would be hunkering down and trying to go it alone without any understanding of your peers, or what others have done before you. For some reason, we in public health believe we have to reinvent everything. The reality is that’s a really big waste of time. We need to learn what has worked, initiate that and customize that if you need to. We need to do a better job of networking and customizing known solutions. I guess that was also an important learning for me.
Hugh Tilson: We’re also learning departure and how you can prepare an agency for your leaving. What was your experience in leaving Arkansas? Was the agency prepared? Should you have done something different? How do agencies handle turnover? Yours was not precipitous. Sometimes they are precipitous.
Dr. Halverson: Again, part of the issue is creating an organizational structure that makes sense, that is built upon good organizational design principles and then filling our top leadership positions with people that are both technically knowledgeable and experienced enough to stay the course. I think that we were able to do that at the Arkansas Department of Health by being very selective in our appointments of senior staff. Finding people who were in it for the long haul. I was very fortunate to have an incredible senior staff, terrific people that ultimately succeeded me. I’m pleased to say I think that for the most part the organization went on without too much of a hiccup. First of all, I got more involved in national efforts for ASTHO and had the privilege of being the President of ASTHO for a year, then all of the activities related to being in national office. I had a terrific deputy who ultimately became the State Health Officer. Dr. Nate Smith is a terrific State Health Officer for Arkansas. He has done an incredible job. He was able, I think for the most part, to maintain the structure that we had developed. There wasn’t a major departure strategically from what we had been doing and was able to maintain an important position, and have a continuity of both leadership and strategic initiatives. That doesn’t mean that he hasn’t changed things and he needs to. Organizations always need to change. I believe part of the success of a SHO when he leaves, when he or she leaves, is that the organization needs to be able to move on without you and probably one of the greatest feelings of accomplishment that I had was to see that the organization was able to continue to function very smoothly. It didn’t mean to say people didn’t wish me well and say goodbye, and I had a chance to thank them, but the organization needed to go on for the people in this state and it did. The old adage when you first get this job, keep your resume in the right-hand drawer because you never know when you might need it. People said that, I heard it, but I didn’t believe it. Then you know over the years as I saw others leave pretty quickly after their appointment for various reasons, mostly not their fault, I realized that we’re in a very tenuous situation. Maintaining good relationships and understanding that you are never guaranteed that next day but we need to make the most of every day that we get. For me, when the opportunity came to be the Founding Dean at the Fairbanks School of Public Health, I was excited. I think I was ready and the organization moved on.
Hugh Tilson: Great segue to the next thing we need to talk about. I think you may be the only Dean we’re interviewing in this project. Talk about the relationship between academic public health and practice, particularly State Public Health.
Dr. Halverson: Many would remind me when I was at CDC I railed about the disconnect that occurs and exists generally between academic programs or schools of public health and the practice. Probably the biggest part of the issue is that schools of public health have incredibly dedicated faculty, most of which have never stood in a health department. They had great intention. They may not necessarily know what good public health practice looks like. I’m really pleased to say my school of public health has chosen as its major strategic challenge, they want to be a school that makes a difference. Advances the health of the people, the State of Indiana. That’s a big difference. There are schools, I believe, that just say look, we’re going to do great research and hopefully it will be fun to dwell. We’re going to graduate a lot of students who will serve on committees and isn’t that enough? I say to them, “It is not at all enough.” Because if we don’t focus our attention on ultimately doing good research that is translatable to action, if we don’t train out students that are job ready, if we’re not focused on practice rather than simply serving on committees, then we’re not fully getting what public health is about. So I am a strong believer that public health practice is that common ground between the schools and programs in public health, and the practice of public health demonstrated at a governmental agency, either at the local or state level. That we need to have very explicit common ground and recognize that we’re in a partnership. The state health agency has a responsibility to conduct public health and our job is to help support them and to help lead innovation that would ultimately lead to improved health. We’re never going to have enough money to do all that we believe should be done, but if we are doing our job with our research we can find better and improved ways in which to make a difference. If we continue to work on innovating in our teaching, our new public health officials with their degrees from our schools will do a great job and will help lead public health into the future in the new vistas that we have. You can imagine it is an important partnership and when it’s working it is great. The problem has been a disconnect between our funding in schools of public health and our needs in the practice world. That’s something from a policy perspective that we need to address. I think it takes a concentrated focus by both our Deans and our State Health Officials in particular to focus on what is really important and to find that common ground.
Hugh Tilson: Paul, the future is extraordinary but particularly for state public health there are some great opportunities on the horizon.
Dr. Halverson: I think there is an incredible opportunity as we think about the future. Number one, I think our partners in the medical care system, health care systems are incredibly able and interested partners as we move away from fee for service to a value-based orientation as it is now important to them as it is to us to keep people healthy, to make people healthy, create conditions under which people can be healthy. What has been our raise on that has been now also of interest and more than just a casual interest, but a business necessity for our health systems. We can take advantage of that common interest and move towards a strategy of both integration and deployment of evidence-based strategies to protect and improve human health that we have never been able to do before. We never had the money, we never had the influence, and now we have the opportunity to help drive an important chance in our states. Secondly, I think as it is increasingly the case we’re in the middle of upheaval around health care reform and we need to put health into health care reform. I think again we’re seeing great examples across the country on how public health is able to influence the deployment of a new version of health, especially as we think about Medicaid reform. There isa lot of things that are perhaps challenging within our current health care system, one of which is the differences in our Medicaid program. I believe regardless of what ultimately passes in our health reform legislation that there will be greater demands on our states to do something to customize, if you will, Medicaid to the needs of the people in each state. I think that then creates the opportunity for health departments both local, state and schools of public health in those states to collaboratively work towards trying to better understand what the needs and opportunities are for changing the Medicaid program, which is such a vital and important safety net in our communities to being even better in terms of being able to address health issues for us. The other thing is there is so many different ways in which we collectively need to concentrate our efforts. I would suggest we need to find just two or three things in each of our states, develop coalitions and partnerships to move us towards that. Move and work as hard as we can to really accomplish those things. I’m not convinced there’s nothing we can’t do if we set our mind to it. We have great science, we’ve got terrific leaders. We’ve got great partners. What else do you need?
Hugh Tilson: A couple of second left. First, give a shout out to being a State Health Officer after you no longer are a State Health Officer and that is the alumni.
Dr. Halverson: Yes. There is life after being a SHO. It’s a terrific life. I have had the privilege of serving as the President of the Alumni Association at ASTHO and I have contacts with incredible colleagues and dear friends. That’s the one thing about being a State Health Official that is a little bit different than perhaps another occupation. You are either a State Health Officer or you are a member of the Alumni Association and that’s it, or you’re dead I suppose. That’s the whole strategy of keeping people and moving forward. Yes, there is terrific opportunities after being a State Health Official and I think all of us have in common as alumni members, the importance of holding up, supporting and helping our current SHOs to be as successful as possible. But ultimately, we’re all interested in the long game which is improving and protecting the health of the people of this country.
Hugh Tilson: Finally, this is your bullet pulpit moment, Paul. You are in front of the camera, talking to new SHOs probably. What do you want new SHOs to know?
Dr. Halverson: As a new SHO there is a lot of pressure for you to move forward and I think unfairly you think you have to be perfect, and you’re not. The quicker you get over the idea that everything that you do, whether it’s every decision that you make or every speech that you do, or decision that you move forward on, it’s not going to be perfect. We need to recognize that no matter how smart you are, you don’t know everything. Most importantly, there is just help around the corner. Call on colleagues, other state health officials, ASTHO, members of the Alumni Association. Everyone is here to help. We have a vested interest in your success. As a State Health Official and new State Health Official you are entering a part of your life which I think will be the most exciting, most productive and perhaps in some cases the most frustrating job you’ve ever had. It also is the most rewarding because when you can look in the eye of that child or that dad or mom that didn’t have hope before, that because of something you have done have a new feeling of hope and optimism for their life. Then it’s all worth it.
Hugh Tilson: Paul, it may be true that you aren’t perfect, but you’re mighty darn close.
Dr. Halverson: You’re awfully kind, Dr. Tilson.
Hugh Tilson: This has been a great conversation.
Dr. Halverson: Thank you.
Bob Harmon, MD
Bob Harmon has been with Cerner Corporation since 2013 and currently is a senior physician executive for federal, state and local government clients. He previously served as director of the Duval County Health Department in Jacksonville, FL from 2006 to 2012, including three years overseeing jail healthcare. His health IT activities include serving as a member of the Governing Board and Sustainability Work Group of the Digital Bridge Initiative co-sponsored by the Robert Wood Johnson Foundation, Public Health Informatics Institute and Deloitte.
Description of the video:
Hugh Tilson: Hello. You can tell I’m already having a great conversation with a friend of long-standing. We don’t call each other old friends, Bob, Dr. Bob Harmon. Bob is a member of the ASTHO Alumni Association, former State Health Officer in the State of Missouri.
Dr. Harmon: Right.
Hugh Tilson: He’s going to talk with us, of course, about his vision of what it means to be a successful state health official and what it will take to continue to make you a successful state health official. I can hardly wait for that, Bob. This is part of the de Beaumont funded University of Indiana Fairbanks School of Public Health project on the success of state public health officials with strong ASTHO support. We thank them all and I can hardly wait for this conversation to get going further. Bob, thanks for joining me.
Dr. Harmon: Glad to be here.
Hugh Tilson: So Bob, you’ve been there, done that. What is your definition of success for a state health officer?
Dr. Harmon: I think the first thing is to have a successful relationship with different leadership bodies in the state. The Governor’s Office, the legislature, the local health departments, the non-profits so that you can have a successful agenda with your legislation. Your budget is very important and the different programs. Then with all of that to be able to continue in your job for a reasonable period of time so that you have long enough to bring those programs and initiatives to a successful completion and continuation.
Hugh Tilson: Are there any ingredients for that success in the Agency or in the Governor’s Office that makes for a successful state health official?
Dr. Harmon: It’s hard work. Person-to-person relationships. You have to get out of your office. I believe you need to walk the halls of the legislature, establish good relationships with different legislative leaders, the committees, and so forth. Bipartisan, both parties, as well as the Governor’s Office, whoever you report to. You may not report to the Governor. You may be in a division, so with your boss, with your superiors and then with your constituents. Besides the people of the State, your constituents are often the local health departments and the non-profits. The different organizations, state and local, and the other cabinet directors, the other agencies that you need to partner with, especially Medicaid if it’s not in your agency.
Hugh Tilson: Think back to your days as a state health official and remind us where you served and what years.
Dr. Harmon: Right. Well I was the Director of the New Missouri Department of Health. It had been a division of Public Health and Social Services Agency, so that was one of the exciting things and the drawing cards to take the position. I started in 1986 and finished around 1990, around January, 1990. I left to become the Administrator of Health Resources and Services Administration.
Hugh Tilson: We want to talk more about that in just a few minutes. Let’s just start at the very beginning. Go back to your first day as a SHO. Was there some things you wish you had known that you didn’t?
Dr. Harmon: That was actually in the second survey and it would have been helpful to have known how much of a challenge some of the legislatures would be. I learned that gradually. Some who were quite supportive and then might change, some who were negative and didn’t change. It depended on the issues and often depended on the party. So it would have been helpful to have a heads-up on that, but I learned that quickly enough. Otherwise I felt pretty well-prepared. I had lived in Missouri before. I had gone to Washington U and St. Louis for college and med school. This was Jefferson City, the center of the state, but I felt pretty well-prepared.
Hugh Tilson: Let’s have some fun with your recollections as a state health officer. I want you to choose the toughest, biggest deal challenge as a state health officer. An event, emergency, something that really taxed you and taxed your leadership skills. Talk about that.
Dr. Harmon: Probably my confirmation. In some of the press coverage leading up I said that tobacco control, reducing tobacco use was going to be one of my top priorities and the most powerful lobbyists in the state, in the legislature was the tobacco industry rep who also had other big accounts. Anheuser-Busch Beer, Monsanto Chemicals, so he was by far the most powerful. He objected to taking that on and almost blocked my confirmation.
Hugh Tilson: That will tax your leadership. Let’s talk about you as a leader. How does a leader confront that kind of situation?
Dr. Harmon: Well, I worked closely with the Governor’s Office and with my sponsor, a State Senator for my confirmation and worked through that, and told them I would use a rational approach and not get too carried away. Not try to move too fast and use a science-based approach so that they realized I wasn’t some kind of radical who must be stopped at the beginning. I was confirmed on the last day. They made me sweat.
Hugh Tilson: Talk about integrity and trustworthiness as a leadership skill. Obviously that was the trump card you played. Talk about that.
Dr. Harmon: It’s really important that you have trust and that you do what you say you’ll do. That goes with your own staff, your own agency, with the Governor’s Office, with legislators, with your constituent people and organizations. Its trustworthiness and competence, of course. Do your homework.
Hugh Tilson: Be evidence-based?
Dr. Harmon: The harder I work, the smarter I get, the luckier I get.
Hugh Tilson: One of the things that we’re look at in this study is turnover. Precipitous departures and otherwise for state health officers. Let’s talk about your departure.
Dr. Harmon: Sure. Well, I enjoyed being a state health officer but at some time in my career I wanted to have a chance at a federal public health position. So I was very active in the associations. ASTHO, for example. I had been a County Public Health Director in Maricopa County, Phoenix, Arizona. I was very active in NACCHO. I was the President of NACHO. I had a lot of good contacts including Dr. Jim Mason, who had been the head of the CBC. He was appointed the Assistant Secretary for Health and he was the one who would recommend who the agency heads were when Bush One was elected. I contacted Jim Mason. I said, “Are you interested in people for the agency head jobs?” “Sure,” he said. “Put your name in the ring.” So I did and I eventually heard that I was going to get an interview. So I sort of planned ahead. Not that I wanted to leave the position. The Governor was, at that time, running for re-election. No, he had just been re-elected and asked me to stay on. So I could have stayed on.
Hugh Tilson: One of the things we are looking at is how an agency can be prepared better for the departure of its Director.
Dr. Harmon: Right. Well, one of my top priorities from the beginning was to recruit the best people I could or promote the best people I could to my key appointed positions. These were not political appointments. I was the only political appointee in the new Department of Health. I was able to continue, or promote, or appoint some really top people. My Deputy was there when I got there, Charlie Stokes. A really good Deputy who eventually became head of the CDC Foundation. So I was really lucky to have him and he was a huge asset. He and I worked together for the whole time. I inherited some very good Division Directors, Garland Lan in Health and Vital Statistics, National Leader. John Bagby in Disease Control, a pretty well-known guy. So I recruited some good people as well. Ross Brownson, I promoted and named head of a new division I created named after the CDC Center. It was a division of Chronic Disease Prevention and Health Promotion. He went on to do big things in academia at the St. Louis University School of Public Health when it began and he’s now been recruited over to the new Washington U Institute for Public Health, my alma mater. So that was a good promotion and appointment as well. Then when I left, I believe John Baby became the acting and I had recruited Colleen Kibblehand to be my Medical Director for Maternal and Child Health. She became a future Director. That became a succession plan of sorts.
Hugh Tilson: Let’s talk about life after being a state officer. You’ve had a great after SHO life but the particular area I would like you to talk about is relationships between State Public Health and medical care, and medical insurers. You know something about that.
Dr. Harmon: I do. I put a lot of effort into my relationship with organized medicine. I joined the State Medical Association and spent a lot of time with them, going to their annual conventions. They were a huge ally. I had a Board of Health also and some of their best people agreed to serve. When things got rough I could count on the State Medical Association. I’ve done that my entire public health career and my private sector career. I’ve kept a close relationship to organized medicine, County, State or AMA. Hospital Association, the most powerful trade association in the state. I would go to their conventions. I had a close relationship. You couldn’t be too close because we regulated hospitals, but within the limits I got to know their executive director really well. They generally would be very supportive unless I was trying to do something they didn’t like and then we’d agree to disagree. Then I’m internal medicine as well as public health and preventive medicine, so I kept a close eye on what we were doing clinically as far as evidence-based practice and guidelines. Whether it was MCH, HIV disease control or whatever. I always took a personal interest. I always tried to appoint a really good medical director or physician that I would want to work closely with them clinically as well as administratively.
Hugh Tilson: What about insurers?
Dr. Harmon: Yes, very important. Medicaid was the most important insurer that I dealt with. We didn’t have Medicaid Managed Care much in Missouri back then, but I kept in close touch with the Medicaid Program, the Medicaid Directors. We used them as a pricing model and one of the things I accomplished, we had children with special health care needs, the Missouri Crippled Children Service and we had a crazy fee schedule which was always a headache. I successfully engineered turning to accepting Medicaid fees. The Hospital Association was a big against that because they were lower, but eventually they agreed and it is still the model. My experience with Managed Care took a big leap when I joined United Health Group after HRSA and I was with them for 10 years as the National Medical Director for Optum, so I really got to know how huge the biggest health insurer operates. I was in the Optum Division which is now huge and that was a really interesting experience.
Hugh Tilson: Do State Health Officers get Optum and insurance or should they?
Dr. Harmon: Well, they need a good relationship especially since those insurers now do a lot of Medicaid Managed Care. That’s where you really need the relationships for low income patients that public health tends to serve. So it’s good to have those relationships as well and they have Trade Association, the state equivalent of America’s health insurance plans. It’s good to have that relationship too, especially relative to Medicaid.
Hugh Tilson: Talk about the relationship between State Health Officers and ASTHO.
Dr. Harmon: Yes, ASTHO was a huge resource to me. I immediately became active in ASTHO when I took the Missouri job. I worked my way up, got on the executive committee. Great networking opportunities, lots to learn. The State Health Leadership Program didn’t exist at the time in the late 1980’s but I did take advantage of the Harvard Kennedy School. They had and still have the three-week summer institute for state and local government executives. I went, and I think there were 80 of us. I was one of maybe three or four public health people. Others were state and local elected officials, legislatures, transportation, many different agency heads. That was useful and I really enjoyed that. I’m an alum of the Kennedy School and I served for 10 years on the RWJ Advisory Committee for the State Health Leadership Program. I think it is a wonderful program. I believe it was a one-week long and then a lot of self-study and home study. I think that is a huge resource that every new State Health Officer ought to take advantage of.
Hugh Tilson: Give a shout out to the ASTHO alumni. Once a State Health Officer always a State Health Officer.
Dr. Harmon: It’s a lot of fun. We’re here at the annual meeting, the 75th Anniversary Meeting and there are quite a few alums here, a very active alumni council with officers. Great support from ASTHO staff and we interface with the current State Health Officers and we have a lot we can learn from each other. I’m really enjoying that. That’s a bonus of being a State Health Officer.
Hugh Tilson: One more fun thing for you. Being a State Health Officer is exhilarating. You never aren’t one once you have been one and you are always looking for new challenges. Do a little exhortation of the new State health officers about the future. What big challenges and opportunities do you see ahead for State Public Health?
Dr. Harmon: Well, I think one of the biggest challenges always has been and will be in the future is finding the resources. Public Health is woefully underfunded and I know that because I worked in the insurance sector which is well-funded. Now the tech sector which is also well-funded. Must of that driven by the high prices in medical care and the high prices charged by hospitals and ambulatory practices. Public Health doesn’t benefit enough from that and we have to figure out ways to get some of those funds going into Public Health. Medicaid is the place to look for partnerships and funding opportunities such as the 90% federal, 10% State matching funds for a lot of different things, including health information technology and exchange, and Medicaid-based pricing, special Medicaid reimbursement rates for local public health. But then also, just the hard work of working with your state legislature for a better budget, always making the budget one of your top priorities when you are appointed, and spending a lot of time researching the budget and working with the budget committee or committees to get the most you can out of state general revenues and often the federal funds have to be improved too. Then do not hesitate to work on federal grants. A lot of those are competitive, have a really good grant writing machine in your state health agency and go after as much as makes sense. Get to know the federal agencies where those grants come from. Get a relationship with CDC, with HRSA, so that you maximize your grant income, as well
Hugh Tilson: This has been fun. Think about what you want to leave the viewers with. There is probably going to be incoming SHOs who need to get their brain around what is this challenge, what is it like, how does it feel, what was it for Bob Harmon. Do you have a last word or two for them?
Dr. Harmon: Well, it’s one of the most enjoyable jobs I’ve ever had. It was really fun. It was challenging because of all the politics and the lack of funding, it was a continual effort. It’s like being head of a foundation. You are continually trying to raise money, a non-profit. Use ASTHO, use the resources of ASTHO. It is a great way to learn quickly what lies ahead and the networking opportunities. Get to know the State Health Officers in the neighboring states because you have cross-border issues. Another important one is work closely with your local health department partners. In maybe 10 of the states its unified and the locals are state employees. That’s the way it is in Florida. That makes it easier if you are all in the same agency. In fact, if not, you really need to get to know them. I visited all 112 local public health agencies in Missouri. It took two and a half years, I think. I created a partnership council with three large, three medium, and three small size health department reps. We met monthly or quarterly, I can’t remember, but that’s where we dealt with challenging issues of funding formulas, funding distribution, big priority areas. HIVA was a big one for me back then in the late 1980’s. Then you can count on them as allies instead of opponents. They were independent in Missouri. They have their own relationship with legislators so when I go into town to visit with the local public health agency. I would also visit the local legislator in his or her office locally. I remember one time I was telling the Governor about this, John Ashcroft. I had a very good relationship with John, and I said, “I’m trying to visit all of the local Public Health Agencies in the state.” He looked at me and he said, “What are you running for?” I said, “Well, nothing Governor.” He was joking. Have a good relationship with your Governor if you report directly to him. You may not report to him and if you don’t report to the Governor have a very good relationship with your Agency Secretary or the leader of your Umbrella Agency. Then, if possible, also have a good relationship with legislators or someone in the Governor’s Office.
Hugh Tilson: This is a study about success as a State Health Officer. Bob Harmon, you are the embodiment of success as the State Health Officer. Thank you so much for this conversation. I loved it.
Dr. Harmon: You’re welcome.
Douglas Lloyd, MD, MPH FACPM
Douglas Lloyd retired from the U.S. Department of Health and Human Services in 2007, where he worked for 16 years. He held several key public health positions, namely the director for the Center for Public Health Practice. Dr. Lloyd was the youngest cabinet level state health officer in the country at the age of 34 when he was sworn in as the Connecticut State Health Commissioner, in 1974. At the completion of his 13-year tenure as state health officer, he had been the longest-tenured cabinet level state health officer in the country.
Description of the video:
Tilson: Well, hello. This is Hugh Tilson. I'm here having an unbelievably delightful reunion with a friend and colleague in state level public health of over 40 years—did I say that, Doug?—Dr. Doug Lloyd. You're going to get to…
Lloyd: It was in the late 1800s.
Tilson: It was in the 1800s, I think. Hugh Tilson here for the [inaudible 00:00:18] funded, ASTHO supported, University of Indiana Fairbanks School of Public Health project on public health success and leadership. I can't think of anybody better to talk with about that, Doug. Thanks for joining me.
Lloyd: Thank you, Hugh. Glad to do it.
Tilson: Good. All right, Doug. Thanks so much for doing this. This is good. Let's just start off with some recollection about you as a state health officer. As a state health officer, what does success mean? What is a successful state health officer?
Lloyd: Well, times have changed so much, as you know, Hugh. We have a situation now where most of the health officers are at super agencies. I think one of the greatest parts of being a health officer in Connecticut is I reported directly to the governor, which was Tom Meskill and then Ella Grasso. When she died, that was Bill O'Neill.
Tilson: What was success?
Lloyd: Well, we were very successful in many different ways. First of all, we had the first hospice in the United States in Branford. I've been back to see that several times. I remember the day we got a call on the Lyme arthritis. Annie was my secretary. She said, "There's this woman on the line, and she's nearly hysterical because of these large things on her." It was Lyme arthritis, named for Lyme, Connecticut. We were the second state in the United States to have a rate setting commission. That was back in the days of certificate of need. Of course, they don't do that now; they negotiate with health plans. We were the second state in the country to have an EMS system. Indiana, I think, was the first.
Tilson: Name the ingredients for your success. What was it about you and the setting that made you successful?
Lloyd: Well, it was interesting, because at 33, I was kind of young. I use the word somewhat advisedly. I had a little bit of chutzpah. I wasn't afraid to get out there. One of the things that I think is most important for a health officer, if you can do it—because you pretty near have to get the sign-off of the governor and everybody else—is to use the office of health officer as the bully pulpit, which means you get out there, and you get on television. You're not afraid of TV, and you tell the people in the state what kind of… If it's a national problem, you talk about what's the state implications. I did that quite frequently.
Tilson: Let's talk about the biggest challenge you had. What was the toughest nut to crack as a state health officer, biggest challenge, biggest scandal about this job? What was the…?
Lloyd: I don't know if you really want me to go into that.
Tilson: No, I do.
Lloyd: Okay. You're going to have to cut this one out. I got a call from Jay Jackson, who was in the governor's office. He said, "Doesn't the medical examiner fall under you, Cathy Galvin?" I said, "Well, not really." They had reorganized the Commission on Medicolegal Investigation, because there was not… I was supposed to be ex officio, but because there was not a chair—[inaudible 00:03:45] Harry Goucher had had a heart attack—I became the chairman of the commission. Jay said, "What about Cathy Galvin? Does she report to you?" I said, "No. What's the problem?" He says, "Well, there are people coming in here and saying that her dogs are eating human remains off the autopsy table." My first reaction was, "Oh, that can't be true." I called Cathy up, and I said, "Cathy, it's time for a tenure review." The day that she was supposed to come in and see me she had the flu, and she didn't.
Anyway, we went over… There are no mountains in Connecticut. We went over the other side of the [inaudible 00:04:32] ridge into Avon. We met and we talked about it. That was when some of the comments that came out unfortunately were not leaked to the press, because the guy from Yale said, "Well, if she does her job well, there's enough for the DA and/or the dogs." That's a true quote. Anyway, what we did is we accepted her resignation. Dick Lynch was the district attorney and state's attorney. He said we could accept her resignation, which is what we did. In essence, we fired her. It's interesting that she sued all of us for $10 million, but small state we knew the [inaudible 00:05:28]. My biggest challenge was not strictly the regular public health but a scandal because of her. As recently as a couple weeks ago, I was talking to the guy we put in as medical examiner, Wayne Carver. Wayne Carver was the guy who was my ME who did all the autopsies at Sandy Hook. That's one of the things we talked about here, about gun violence. That's still a problem. It was a problem then; it's a problem now.
Tilson: You learned an awful lot. Remember we're talking to future state health officers. Talk about leadership lessons you learned when you have a scandal.
Lloyd: Well, first of all, I made one big mistake. I was a regular on Channel 3. I had a show called Dr. Doug, which was House Call. I made the mistake of… I had those ear pieces [inaudible 00:06:28]. I made a mistake of taking the first question from Don Larch from Channel 3. The other stations were very competitive in Connecticut. When that happened, the press conference was over, because they knew that I was being Dr. Doug instead of the representative of the governor. I think you always have to be very cognizant of who's in the State House, and you have to work with them. It doesn't hurt any health officer, no matter where you are in the pecking order, to get to know the legislators. They're the ones that make the difference on your budget.
Tilson: Sure are. How old were you when you took your…?
Tilson: What do you wish you had known that first day when you came into the office that you didn't? What surprised you about being a state health officer?
Lloyd: The first day I came in—I remember it very clearly—I walked into the office. They had been withholding food and water from a bunch of nursing home patients. I was asked, "Is that murder or homicide?" I think I said it was homicide. I was very nonplussed by that one. Let's talk about leadership skills. I had gone through, after I was a health officer, late in my career, the Leadership Institute. I wish maybe I'd had that before I started.
Tilson: Let's segue to one of the focuses of our study. We're looking at turnover of health officers who leave prematurely. Now, how do you prepare an agency…? Well, first of all, what was the impact of your departure in Connecticut?
Lloyd: Relief. [laughter] No, actually when Ella died, Ella was being vetted by Jimmy Carter to be Jimmy's vice presidential candidate. She died before that was finished. Consequently, we really didn't have a shakeup. I remember the day that Bill O'Neill took over. He was sweating because we were closing two hospitals, Laurel Heights and Shelton. He kept everybody in that administration in one more term. Then he asked for letters of resignation and, of course, we submitted them. I rambled around for awhile. The first thing I did was clinical trials in Hartford. I had to leave that one because I had worked with a guy… I didn't particularly trust him. He was a doctor. I went ahead, and we were doing a clinical trial on a woman. She had a history of cardiac disease. I said, "You can't put her in this study." He said, "Okay." Unfortunately, he did, and she died.
Tilson: Go back to the agency. What difference does it make to the agency that you left?
Lloyd: Well, fortunately, I had some very good people that were working with me that were able to take over the agency. I think the agency—and from what I've seen since I've gone back several times—fared very well without my leadership.
Tilson: Is there anything you can do to prepare an agency for health officers leaving? You know they're leaving with very short tenure these days?
Lloyd: Oh, yeah. I lasted 13 years. It was a record at the time. Well, I think the thing that you have to do is you have to look at who your chief lieutenants are. Who are the people that are going to assume the responsibility for your agency? You have to be sure that they're well-trained, that they know about leadership, that they know about being able to approach whoever's the head of the agency and bring anything that is going to end up in the front pages but especially anything that's going to be a health hazard to the people of the state.
Tilson: Great answer. You went on to do some federal work, I understand.
Lloyd: Yes, I did.
Tilson: What did you do?
Lloyd: Well, after the clinical trials, I set up a course for judges to learn risk assessment. That time was the time of the Delaney clause, which said if you find any cancer in laboratory animals, you have to ban it. I set up an organization called the International Life Sciences Institute, which still exists here. Then after that, we had [inaudible 00:11:19] and we set up the panel for judges, because we found out that federal judges didn't know anything about risk assessment. Then after that, I ran into Bob Harmon who I'd known as a health officer. He offered me a job with HRSA, and I went to HRSA. I was there until I retired in 2007.
Tilson: I remember it as though it were yesterday, Doug. What I want you to talk with me about is the relationship between the state health officer and federal agencies, particularly your perspective on HRSA. What was the relationship with [inaudible 00:12:01]? What do we need to do to help that?
Lloyd: Well, I think the relationship between a state health officer and the federal people is usually pretty good. I don't know what they do now, but in our days, we could get an EIS officer assigned to the agency, and it was no question. You might have a state epidemiologist, but the EIS officer… That's the one that went out when we had the case of Lyme arthritis was the EIS officer. I think the relationship with the federal agencies is extremely important, especially with the CDC.
Tilson: Thinking back to your time as a state health officer, was there anything that the federal agencies should have done to help you better?
Lloyd: Well, there was a discussion at the time that's not relevant any more. One of the problems with being a state health officer and having such rapid turnover is you don't really ever seem to get vested in a system. I don't know if that's been solved since then, but there needs to be some system whereby a health officer gets vested in some system. Very often, as you know, we go from state to state. I did not. Otherwise, you're left without a pension. I think that's something that has to be addressed.
Tilson: Let's try to wind this interview down with some futurizing. You've been around a long time. What do you think the greatest challenges are for public health today? That is, the new state health officers, what are they facing and greatest opportunities?
Lloyd: Well, the greatest challenge, I think, is that you have to be fast on your feet, that you have to be current with… If you're not current with the literature, you've got to have somebody in your agency that's current with the literature. You've got to know what the next… You've got to be able to look into your crystal ball and predict the possibility of your next big problem. It probably also is a very good idea to get around the state, as I did, and meet with the people. Talk to the people out there and say, "What do you think the problem is?" That way you learn something that you don't really necessarily get when you're insular within the agency.
Tilson: Hold on just a second while that siren goes by. Okay, he's not coming our way. What about opportunities? Is there a big opportunity for public health these days? If so, what do you think it is?
Lloyd: Oh, there's no question. After all, the name, it's the public's health, and the public is always going to need assistance. Now, we can't guarantee health. We can tell the people that we preach to sometimes what healthy habits are. We have to understand that people eventually have to take control of their own health. What they really need a lot of help with nowadays is learning about the health care field, where we have so many different insurance plans, and questions of affordable care, and things of that nature. When the public wants to know more about that, the health officer should probably be involved.
Tilson: Is there anything else you…? What do you want to say to the next generation of state health officers? [inaudible 00:15:23] They're going to be watching this interview. What message do you want to leave them with?
Lloyd: It is, without a question, one of the most exciting, rewarding jobs that you could have. Personally, you get a sense of satisfaction. You get the slings and arrows. Sometimes you get the arrows, especially when you do things that they consider maybe a little bit out of the ordinary, but what you do is you get the satisfaction of serving the public. To me, I'm not being patriotic, but I happen to think that's a very high calling.
Tilson: I want you to think about gun control.
Lloyd: Oh, boy, gun control. Well, gun control is something that I feel very strongly about for a reason. I was a state health officer in Connecticut when Sandy Hook happened. My medical examiner, Wayne Carver, was the one that went down and did the autopsies on all those kids and the teachers. Gun violence is still a problem. I brought that up down in a session earlier today. There are 350 million guns in this country. That's more than one gun for every man, woman, and child. Now, I'm not anti-gun. My brother's got a Glock. I went out and fired it with him. Part of the problem is the guns get in the hands of the wrong people. We need to vet people much more closely before they get a license to carry a firearm. Right there is… I hate to say 007, but with a hand gun, it's a license to kill. You and I both know of our colleagues who think very strongly that gun violence is a major issue, and it still is. Maybe it won't immediately get there, but it will continue to come up.
Tilson: What do we say to the people who get righteously indignant, indeed, furious, with public health people when we bring it up? Think out loud about the challenge to public health…
Lloyd: I've done that in my own family. My brother carries a Glock. He tells me to mind my own business on it and so does his friends. You try desperately to show them the statistics, and you try to show them that it is a problem. It's not a problem with guns. We don't have a problem with a hunter. We don't have a problem with the person who goes out and does target shooting. We have a problem with the guns in the hands of the wrong people. With 350 million guns out there, you can almost guarantee that there will be another Columbine, or Sandy Hook, or whatever.
Tilson: What do we do?
Lloyd: Well, first of all, I don't think we… We don't let our vigilance drop for a second. We continue at it. There was a gentleman who recently spoke here at our meeting. He talked about what he was doing at his state, meeting with various gun groups and getting them to talk about lock boxes and things like that. There's a lot of things that we can do. I don't think in the next five… With the power of the NRA and the people from Congress would take the money out of the CDC budget, I don't think we're going to get a… The second amendment was passed, not that everybody could have a gun. The second amendment was passed so that states could organize militias and not that everybody could carry a gun. That's why we have a second amendment. Now, Wayne LaPierre of the NRA happens to think different about that. I don't think we can let it off our radar screen. The other thing—we can keep statistics at the state level on gun violence. It's just that the CDC can't keep statistics.
Tilson: Any word of wisdom for the ASTHO alumni? What difference can former state health officers make?
Lloyd: First of all, I don't think we should, as former health officers, as former [inaudible 00:19:56], we should ever forget the amount… Albert Einstein once said, "There is no such thing as knowledge; there is only experience." We have had the experience—at least, I have—since the early 1970s of an enormous amount of information. We can be helpful. The one thing that I learned this last year is that you may forget something for a little while, but if you see something, it triggers another memory, and then another memory, and then you remember about it. I call it the [inaudible 00:20:30] factor, because I remember about the [inaudible 00:20:32] when I was going to have a cardiac MRI. You're always going to be helpful. Even if it's pro bono, you ought to let yourself be known to your local, state, or county health officer that you're available. Work in the legislature. We all have had experiences doing that. We can help. If we're from out of state and we're new, like I am in Texas right now, maybe it's limited, but we can give the advice to the health officer. We don't have to be the guy out there, but we can give the advice to the health officer of how we would have handled it had we had the opportunity.
Tilson: Dr. Doug Lloyd, the voice of experience, always willing to help and, obviously, still a great help. Thank you for joining me, Doug.
Lloyd: Thank you, sir.
John Lumpkin, MD
John Lumpkin is the senior vice president of programs at the Robert Wood Johnson Foundation. He is responsible for the Robert Wood Johnson Foundation’s efforts aimed at transforming health and health care systems, ensuring that everyone has access to stable and affordable health care coverage, building leadership, and engaging business toward building a culture of health in the United States.
Description of the video:
Interviewer: Hi and welcome to this interview that I’m having – a continuous conversation is what it is, John – with Dr. John Lumpkin from the State Health Office of the state of Illinois with an illustrious career since then. We’re going to have a chance to learn a lot about that and his definitions of success for the Health State Office because this is part of a series of interviews that we’re doing for the University of Indiana, Fairbanks School of Public Health, about public health leadership and success and the ingredients that make it so. This is a de Beaumont-sponsored project and we thank de Beaumont for that and an ASTHO-supported project as well. We couldn’t do without ASTHO and of course, we couldn’t without state public health leaders like you, John. Thank you for joining me today!
Lumpkin: Great! Thank you! It’s a pleasure to be here!
Interviewer: So, John, this is a study of success factors for State Public Health Officers, so let’s just start at the beginning. What’s your definition of success as a State Health Officer? What is that?
Lumpkin: I think success of a Public Health Officer at the state level is threefold to the extent that they create the conditions in which local public health can be successful. Health and public health occurs at the local level where people live, learn, work and play. The State Health Agency’s primary job is to make sure that that happens at the local level and that could occur through working through local health agencies or through direct action by the State Health Agency itself. The second measure of success is to the extent in which the broader health context is addressed. That means initially working with other state agencies whose primary purpose may not be health, but who have a direct impact upon the health of the people in that state. That includes the Department of Education, Department of Transportation, as well as others that are more likely suspects like Human Services. Then, the third measure of success is the extent in which the Public Health Director, the Public Health Official improves the functioning of their agency through adoption of quality-improvement methods, through the focus on innovation and a persistence of focus upon the workforce to help improve the qualifications and capacity of that workforce to be able to carry out our continuing public health mission.
Interviewer: I love that answer and it doesn’t surprise me a bit that you’ve given all the leadership of yours over the years, subsequently as well that you had come down there.Help people who are a little new in state public health to understand the ingredients of that success. What does it take within the agency or the context to create the success that you’ve talked about?
Lumpkin: It’s critical for the Lead Public Health Official of the state to be the health leader and that means not just coming up with great ideas – that’s important – but also interfacing and working with the people throughout the state who are engaged in it. First measure of success – creating the conditions in which local public health agencies can be successful. That means working with Public Health Directors, that means working with individual communities and so, just focusing on what happens at the state capital or within the offices of the Public Health Agency isn’t enough. It means building that network. Sometimes, it means interfacing. During my career, we had at some point a major schism between small local health departments and the larger local health departments. It probably wouldn’t surprise you that the biggest part of that was about money. Where were the resources going? It’s important for a Public Health Director, for an Agency Lead, to understand not only the conditions in urban communities, but also the conditions in rural communities because we find as a nation that if we want to improve health, we have to reduce disparities and the disparities that exist within urban communities are equally as great as the disparities that exist between urban and rural. The second area of success – and the skill that’s required – is reaching out to other agencies and other forces. That means understanding the importance of coalitions – what they now call“collective action” – of bringing together unusual suspects, unusual bedfellows, people who don’t know normally work together. For that, let me give an example of what I think may be the biggest increase improvement that we can do in health as a nation. It’s surprising to come from somebody in public health, but I would say that that could be something like universal pre-k. You just sort of follow the logic chain through. Children who participate in pre-k have better socio-emotional skills, they always make some better citizens, but they’re also more likely to finish high school. At the age of 25, someone who has not finished high school, when you compare them to somebody who’s graduated from college, the difference in life expectancy is nine years. When you think about an intervention that could have an impact of nine years of life expectancy, you’ve got to talk to the folks in education and public health leaders need to see that broader context and bring people into the room, not to do public health work, not to bring them in the room and talk about restaurant inspections, but to talk about how if they do their job related to enhancing education, it has an impact upon health, how transportation and the ability of people to get to appointments, to be able to work, has an impact upon health. All of those within that broad concept is what a public health leader or the health leader for the state – that’s how they can have an impact. The third area that I talked about is building the agency. We live in a time where the best days for funding for public health agencies may be behind us. We can do one of two things. We could lament the fact that our budgets aren’t as big as they have been – certainly, if you figure out in present dollars – or we can figure out how to deliver public health services with the resources that we have. There is an assumption that because we’ve always done it this way that that means that’s the most effective and efficient way. I think we have to give into the modern era and think about comparative effectiveness of public health interventions, of increasing the effect of this and efficiency of the public health dollars. If we do that, we can enhance the functioning of our agency. We also need to think about our personnel. We need individuals, we need to build partners with the Schools of Public Health so that the graduates from schools of public health actually think about going into Government or Public Health and we need to think about ways to hire them because too many of those graduates who have the skills we need leave school and they can’t find a job. So, developing that linkage is how you build the public health workforce within your agency.
Interviewer: Great and specific and I thank you! Let’s get even more specific. Remind us what years you were in service as a State Health Officer.
Lumpkin: I was first appointed in 1990 and I left in 2003.
Interviewer: During that time, you had so many challenges. Just name one issue that was among the most challenging, most exciting that you had to confront and talk about leadership lessons you’ve learnt in confronting it. Would you give us a specific of your experience as a show?
Lumpkin: My guess is that every State Health Official who was a State Health Official in 2001 would say that the events that happened on September 11th and actually, subsequently in October with anthrax, was a wake-up moment. For me, it really was a culmination of the work that we had begun in the agency many years prior to that and it was sort of a validation of an approach. It was our major challenge. It’s hard to describe the environment when those first anthrax cases were reported, where we were getting calls from day-care centers. They were talking about, “Oh, we’ve discovered a white powder by the changing table.” Well, was anybody using baby powder? Someone got a letter full of white powder and we said, “Where did it come from?” “It came from my daughter.” “Did you ask her if she sent it?” “Oh…” When we went back, “Yes, she actually thought I didn’t have any baking powder, so she sent the recipe with the baking powder in the envelope.” There was a mass hysteria around this, but part of what our response was building upon the partnerships that we had built. Partnerships with the State Police who worked very closely with us around all the reports of white powder so that our laboratories were not overwhelmed, the ability of our laboratories to do the kinds of molecular biology to test whether or not these samples actually might have anthrax. All of that was based upon prior work and the ability to work with our Emergency Management Agency. That all put in place our ability to respond to this challenge by some of the work that we had done prior. For example, about three years before that, we had an activation of our State Emergency Operation Center. It was about 11 o’clock at night and we’re sitting in the center because there was a report of a laboratory that was found in one of the western suburbs of Chicago. It appeared to be a bio level four laboratory. We were sitting there with the Director of Emergency Operations Center, we had one of our employees who was trained because he had come in from a police background, a military background and how to use biohazard suits and they were entering the laboratory to try to determine what exactly was going on. We had the FBI on the launch pad at Quantico ready to come in and help out if we could in fact determine that this was a risk. As we were getting the description from our staff who was in there with signs on the wall that said, “Go! Bugs grow!” All of a sudden, something clicked in my mind. It had been an earlier investigation about fraud and it turns out that this actually had been a case that the Attorney General was investigating because they had a simulated bio level four lab and they were bringing in potential investors in this new innovation. When I brought those together and brought it to the Emergency Management Agency at one o’clock in the morning and the Head of the State Police at one o’clock in the morning, they began to realize. In fact, the Head of the Emergency Management Agency said that every disaster has a public health component. A week after September 11th, we began to respond and I was sitting in the Emergency Operation Center. We knew each other’s names. You never want to get into a disaster situation and exchange business cards. You want to work with people you’ve worked with and solve things through. The second thing that we had done to prepare for that was recognize the importance of bio terrorism as a public health challenge, much as current public health officials or state health officials in 2017 have identified ahead of time the challenge of the opioid epidemic and to make plans in place and to recognize that you can’t always get funded when you think you have a need, but if you explore and put plans in place, when there’s an opportunity, you can actually get funded. We had wanted to expand our laboratory to include molecular biology and we had put it in our budget and the Bureau of the Budget said no and the Governor’s Office said no, and we put it in the budget the next year and the same answers. Then, there was an outbreak of invasive group A strep, also called “flesh-eating bacteria”, and it was in a small town in central Illinois and at that point, there were a lot of news and the Governor’s Office and the Bureau of Budget said, “What’s going to be our response?” My response was, “We need to expand our laboratory.” Half a million dollars immediately became available. We built in that molecular biology capacity. If I hadn’t been ready for that answer and I couldn’t say, “This is exactly how we spend it,” it would’ve been a missed opportunity and we would not have been available in 2001 to have that laboratory enable us to respond to the thousands white powder evaluations we had to do. It’s identifying where the challenges are, looking at opportunities and then, taking that opportunity when it presents itself to move forward the public health agenda.
Interviewer: I wasn’t about to step on that line. One of the things we’re looking at in our study is how the agency or people recruiting the new show can help state health officers to be successful early or fast. Are there some things you wish you would’ve known when you became a State Health Official?
Lumpkin: I was in a somewhat different position than a number of shows. I had been in the agency for five years before I was appointed State Health Director and I was very familiar with a number of the people both in the legislature, but also within the agency. The challenge of coming in as a new state health official, particularly if you haven’t been in the department, is you have to know the people in your agency and you have to know who is good and you have to know who is not good. That becomes really important because coming into an agency, you sometimes don’t appreciate the dedication of state employees and also, the difficulty in recruiting people with certain credentials. One of the things I had done – and it took me a while – is I was able to recruit a PhD epidemiologist to head up our epidemiology section. It took me years to find this individual. My successor, when they came in, thought that was someone who was part of the old administration and pushed him out of the agency and the agency still does not have a PhD epidemiologist. It’s coming into the position and knowing the importance of certain skill sets to be able to carry out the public health mission is one important thing. For me, personally, the one thing I wish I had known more about was the public health service core. I came into public health out of the field of emergency medicine. I wasn’t really familiar with the core and I think that that is a critical national resource. I think I would’ve either personally thought about being involved in the core or getting those officers in the core more involved in the work with the agency because times change, leadership changes, but the core has a certain amount of consistency that I think you can provide at the state level, that it currently provides at the national level.
Interviewer: Great idea! Thanks for planting it! Let’s talk about your departure. Agencies experience departures of state health officers, sometimes precipitous, sometimes planned. What’s the impact of turnover, of departure of the State Health Officer on the agency and its ability to continue?
Lumpkin: When I think about turnover within agencies and turnover in leadership, sometimes that’s something that’s very difficult to plan for and figure out how to do in a good way. When I came into the agency, I followed Bernard Turnock. He was our State Health Director, he had brought me into the agency and I learnt a lot of things and what to do. In fact, the transition was a little bit strange. I was State Health Director for about four or five months and I was down in southern Illinois and we were doing a visit with the Regional Office and I was talking about how we were following through on Barney Turnock’s initiatives and one of the regional health officers said, “You know, you can do your own initiatives, too.” I was doing them, but it really put it in a different context that now, I was the leader. Alternatively, other transitions that I’ve seen where I left, the new administration came in, not just at the State Health Department, but in the Governor’s Office and throughout State Government saying, “We’re throwing the bums out and we’re going to do everything different.” Somewhere in there needs to be a middle ground and I think transitions help best if the new person coming in recognizes what was positive about the other agency and at the same times, begins to implement their own ideas.
Interviewer: Are there some things agencies can do to prepare for departure, particularly for some of the more precipitous ones or short-term state health officers? Is there something we can do to shore up the agency’s resiliency to handle top-level turnover?
Lumpkin: Agencies have a role to play in thinking about how to manage turnover and the lead person, the state health official. Some of the things that they can do is think about their operations, clearly document everything that you’re doing in the sense that the manuals, should someone new come in,is not something that you have to do. You do that during transition. You develop a transition report when you have a new governor. Why not have it as an ongoing document so you’re ready in case there was a transition in state health official? If there isn’t, you’re still ready if you to do a transition report for a new governor anyway, so it helps you get that process. The second – and this is really critical for the role of the state health official – they are not all of the show. That is an important thing to remember. If you don’t function in such a way that you’re delegating authority and not just delegating authority to your tight circle most of whom serve it well, but also delegating authority throughout the agency so that if there is a change at the top, you’ve got policies, procedures and ways of operating where people feel they have the autonomy and the ability to make good choices, to carry out innovation. At that point, you begin to protect the agency from changes in leadership because you build in that resilience through a strong infrastructure.
Interviewer: Let’s talk about life as a former show. You’ve done quite well. Maybe we should talk about relationships between state public health and philanthropies, maybe using your experience with RWJ. How can shows work well with philanthropies?
Lumpkin: Let me talk about the questions of how state health agencies can work with philanthropies. It’s critical for a state health official to recognize that there are many types of philanthropies. First, there is a tendency to look at larger organizations like the one I worked for – the Robert Wood Johnson Foundation – and say, “How do I build a relationship with them?” That’s not really the most critical. Every state, every region has regional philanthropies. In Missouri, there is the Missouri Health Foundation. In New York State, there is the New York State Health Foundation. These regional philanthropies, many of which were formed as a conversion from a not for-profit to a for-profit hospital or healthcare system or insurance company, have significant resources and they tend not to have a relationship with the health department, but my guess is predominantly because the health department has never come to talk to them. Seek out those philanthropies. In some locations, particularly large cities, they have funder collaboratives. Seek out those collaboratives and talk about the priorities of the state health department. You may not get interest immediately, but if you begin to talk about the broader context of health, you may find that these philanthropies become critical partners and they will be very interested not in funding the state health department, but funding your initiatives and funding your initiatives at the community level. That’s a partnership I didn’t really appreciate when I was State Health Official that I’ve seen now from the other side and said, “That’s a critical approach to take in thinking about engagement between state health officers, state health agencies and philanthropy.”
Interviewer: Give me a pep talk for people who are former state health officials about ASTHO and ASTHO alumni. What difference could we make?
Lumpkin: One of the important questions for state health officials as they are thinking about the end of their term is to think about the broader health context and how you are positioning yourselves. Just as I talked about the role of the state health department is to create the conditions in which local health departments can be successful, in many ways, I look upon that as the role of the CDC and other federal agencies in creating the conditions in which state and local health departments can be successful. They don’t always get it. Part of the role of the state health official is to not only work within the state, but to think about the broader national context and to be engaged not only with things within your state, but also nationally and that means in a couple of ways. One is by working with ASTHO. ASTHO is a critical organization because it’s the voice of State Public Health throughout the nation and most importantly, it’s the voice of State Public Health in Washington. Get engaged with agencies of the Department of Health in Human Services or Agriculture or WIC because it’s important for the voice of state public health to be heard there. It’s also critical to do those things as part of your own personal transition planning. When you think about your next step, the first thing people do is begin to network and it’s very similar to the situation in a disaster. A disaster is not the time to share business cards and when you’re looking for a job because there’s a change in administration or because there’s been some disaster that it’s time for you to leave, that’s not the time to begin to exchange business cards and think about your next job. Carrying out your job as a state health official, networking with in-state, but across the nation, also positions you to have an environment in which you can begin to network and think about your next position.
Interviewer: Once you’re in the next position, can you continue to advance the cause of state public health?
Lumpkin: I think it’s really critical for state health officials. Once they’ve left their positions as former state health officials, I think it’s absolutely critical to not give up the fight. What you’ve experienced is something that only a small number of people have experienced. It gives you an insight that only a small number of people have and it is your responsibility to carry that insight with you into your next position and the position after that. That means thinking about, whether you’re working in a healthcare entity or a government agency or even in philanthropy, how you can carry forward what you’ve learnt and continue to build the public health mission. Public health cannot be successful solely by itself. It can only be successful building those partnerships and once you leave that role as a state health official, you can help build those partnerships in your other position. Finally, it’s absolutely critical – I found one of the things that have been most rewarding –is working in the ASTHO Alumni Association and having the ability to continue to interface with my colleagues in current shows made me more successful in my job, but it’s also been more fulfilling because again, it’s a club with very small membership and not everyone understands what you’ve gone through, but they do.
Interviewer: I’m having a great conversation! John, thanks for taking the time. I didn’t want to miss the opportunity to hear your vision of what’s next on the horizon, next exciting challenge or opportunity for public health.
Lumpkin: When I think about the next exciting challenge for public health, I’m really struck by what we’re doing at the Robert Wood Johnson Foundation and the concept of building a culture of health. That has really been exciting for us, but I think it should be exciting for public health at large, but also for state public health agencies. It begins to put in the context of what we do in public health. Every time I work on this, I think back to 1996. We were involved Illinois in an initiative related to reducing infant mortality in Grand Boulevard. It’s a very poor community in the south side of Chicago. At the time, 60% of the people living in that community lived in large conjugate public housing and we went to talk to them about infant mortality. They wanted to talk about economic development. We said, “We’re the Public Health Agency. We don’t do economic development. We do infant mortality.” We went round and round and all of a sudden, it was this “aha” moment. The leading risk factor for infant mortality is poverty and we were not listening. I once had a professor when I was training in emergency medicine who said, “If you listen to the patient long enough, they will tell you what’s wrong with them.” In public health, if we listen to the communities long enough, they will actually tell us what needs to be done. So, we took that program and infant mortality and we hired peer case managers – people from the community to be case managers. We set up a WIC program where we went away from the normal WIC stores where there was fraud and abuse and we set up system where people could go in there with WIC coupons and we hired people from the community to run these WIC-only stores. We set up arrangements whereby once they were trained by the WIC-only store, they would then be hired by the large chains. We merged and used our public health dollars as part of economic development in the community. It’s this broader concept, the broader way of thinking about how we in public health can engage this broader concept. That is really where excitement comes. We think about health-impact assessments and we think about working with businesses and transportation and all of a sudden, that public health vision becomes so much closer than it’s ever been. If that isn’t exciting, I don’t know what is!
Interviewer: I’m with you, John! Anything else you want to say to particularly a group of new or incoming shows because this video will be viewed by them? Any last words of wisdom for the new class of shows?
Lumpkin: If I were to give a message to someone who is a new state health official, having told them how they need to work with other agencies, how they need to work within the agencies, how their funds are going to be restricted, this is the best job in the world. This will be some of the best times of your life. Take time to pause, to enjoy the moment, to recognize the importance of what you’re doing and how rewarding this can be because it’s too easy to focus on the challenges and too easy to focus on the problems and that center who’s been giving you grief, but think about what you’ve been doing and what you can do. That, I think, is really the joy of this position.
Interviewer: I conclude that your professor of emergency medicine was right. If you listen to John Lumpkin long enough, you’ll get an insight into what you need to do. Thank you, John! This was just wonderful!
Lumpkin: Thank you!
Judith Monroe, MD
Judith Monroe’s professional focus has centered on the intersection of primary care and public health. Her career has taken her from private medical practice to academia, hospital administration, and public health protection. In February 2016, Monroe was named president and CEO of the CDC Foundation. Prior to joining the CDC Foundation, Monroe worked for six years as a CDC deputy director and served as director of the Office for State, Tribal, Local and Territorial Support (OSTLTS).
Description of the video:
Tilson: Hi, I'm Hugh Tilson, on the faculty of the Fairbanks School of Public Health and here for a project that Fairbanks, Indiana, School of Public Health is doing thanks to the funding from the de Beaumont Foundation and strong support from ASTHO. I'm here talking with you, Judy Monroe. It's wonderful to see you, as always. Thank you for joining us. The subject here is how to be successful as a state health officer. I can't think of anybody better to talk with, with that, than you, former state health officer for the state of Indiana.
Monroe: Thank you. Good to be with you.
Tilson: Glad you're here. Judy, let's start at the beginning. The subject is successful state health officers. What is your definition of a successful state health officer?
Monroe: I have to tell you, Hugh, my definition of a successful state health officer is someone, to be honest, first and foremost, that enjoys the job and enjoys engaging with the public, and with the legislators, and with their governor and all the stakeholders, because I think that's one of the keys to success. Going from there, if you get those relationships well established and you're enjoying it, then you can take on the challenges. Honestly, as a state health officer you do want to see some policy advance. So that's one of the successes is if you've advanced really good public health policy in your state, which is not an easy thing to accomplish, by the way. If you get the stakeholders and the coalitions, begin to build coalitions or promote coalitions that have already been established that are actually doing good work, I think that's another characteristic of a successful state health officer.
Tilson: Let's talk about the ingredients of that success, then. What are the attributes of a successful health officer? Describe one for me.
Monroe: I think the first attribute is actually listening. When I was state health officer I found that regardless of whether it was the governor, the legislators or the constituents that would come with their issue that they wanted me to help advance, I would start by listening and trying to understand. I think then from there, when you're communicating as a state health officer, the ability to tell a good story. Story telling is honesetly, it's gold, regardless of which audience that you're speaking with, and marrying that with data. And making sure that as a state health officer, and this is something I did right of the gate, I made sure that all my audiences knew that I would be data-driven and that I would be seeking the best data available for the day, regardless of what the issue was. But if I really wanted to capture the imagination of any audience, I had to have a story. That's the way we've learned as human beings for a long time, and it makes a big difference.
Tilson: Let's talk about challenges. You were state health officer in Indiana during a time when there were a lot of challenges in public health. Do you want to name one of your favorite challenge and talk about it a little bit?
Monroe: Well, I would tell you, on the national scale, as well as state and local, was H1N1. I was president of ASTHO, and I was state health officer, during the H1N1 pandemic. I found myself in a leadership role on multiple levels. We had a lot of challenges during H1N1. You know, the vaccine was supposed to be available at a certain time. Everyone had been assured. And then it was delayed. Messaging that was a major challenge. Getting folks to comply in the early days, before we had a vaccine. How do you get your public to begin to wash their hands and stay home when they're sick and use their sleeve to cough into? Communications, again, is just one of the things that was really needed to be able to overcome those challenges. Convincing the governor to stockpile, to mobilize resources.
At that time, we were talking about antivirals, and you have a strategic national stockpile on the national level, but there was opportunity for states to stockpile further for their amounts for their population. And I can remember having the conversation with the governor about mobilizing resources; in my case, a conservative state. But that happened, because at that time, that's what we felt like was one of the better things to do. School closings, oh my, that was a real challenge because there was, quite frankly, there was some delay in getting the guidance out from CDC, and you had all the school superintendents, I can remember there being some pretty tense moments, especially when in some jurisdictions there were reports of either teachers or students that were quite ill or deaths that were occurring during H1N1. There were challenges on multiple levels. And coordinating between the local communities, the state, and the federal is obviously something that needs to happen, but it happens many times behind closed doors.
I can remember one time with the school closings I had to make sure that the local health officer and the local school superintendent was aligned with the state and the governor and so forth. And we had multiple phone calls, for hours, the evening before, the morning before, to gain consensus. But when we all stood up shoulder to shoulder at the press conference, about two o'clock in the afternoon the next day, we were all aligned. And we got so much praise from the public because everyone saw that we were all on the same page and giving the same message.
Tilson: I wasn't about to step on that message. What a great story. Judy, translate that into leadership lessons that you've learned. That, as you were a leader, you were thrust into a real leadership position. For future state health officers that are going to be facing these same sorts of challenges, what leadership skills do you bring to that leadership?
Monroe: I think the leadership skills, we could talk a long time about leadership skills because there are many. I think in being a good leader, part of it is reading the room or reading the situation, because there are times that humility is what is needed, there are other times when folks really need to see someone stand up and be a really strong leader, grounded in the data, and have a forceful message and using the bully pulpit. As state health officer there were times, especially during H1N1 or other outbreaks, when I would go in front of the cameras or go in front of audiences and I was very clear in my message. Other times, you need to step back, listen, and again have that humility.
Being able to lead different groups is quite a challenge for a state health officer, because in many ways you're trying to influence and convince your governor or your legislators of certain things that need to be done. And the next day you may find yourself in a small community meeting in a small town, in a rural community, that type of thing, so I do think it takes some flexibility. And reading the room would be one of the things. Good listening, good communication, strong communication so that it's very clear. Willingness to learn, I think that's a strong characteristic. A characteristic of a strong leader is being always willing to learn because there's always something new coming around. Even though you may have thought you had the answer, new data or new information may come in that actually there's maybe a better way to go about it.
Tilson: I think I know too much about you.
Tilson: But I'd like you to talk out loud about integrity, trustworthiness.
Monroe: I think as a leader trust is fundamental. When you are authentic and people trust you, you do get a lot more done. I found myself many times almost being surprised at some of the success, and what would come back to me would be messages that, no, the legislators trusted me, therefore they would allocate funding for whatever I was asking for or they would...it was helpful for passing certain laws, or the trust of the governor, the trust of the communities, the academic communities. That's the other thing as a state health officer, you need to have that trust at so many levels and so many audiences that are looking at you through a different lens. So, having integrity and building trust is key to the success of a state health officer.
Tilson: You hadn't had prior experience in government when you started off as a state health officer, so let's scroll back to day one. What do you wish you had known on day one that you had to learn the hard way?
Monroe: I did not have any experience in government prior to becoming state health officer. In fact, when the governor asked me would I consider being the state health officer, I had to go quickly and do some reading and talking to people to find out exactly what a state health officer did. I mean, what in fact was the job of the state health officer? I think coming in it would have been nice to have actually had a better and deeper understanding of the political process and just government in general. I had a basic understanding, but I certainly learned by fire very quickly.
Luckily, I also had legislators that took me under their wing. They made it clear to me that I was now in politics [Laughs] and that they were there to help and guide me, which I think actually paved the way for even more success because I was willing to be a good student of those that wanted to teach me.
Tilson: Were there other aspects of the onboarding that were particularly useful to you or that you wish people had done but didn't? What do we need to tell people who are bringing new health officers on board about how to increase their likelihood of success?
Monroe: When I think about my onboarding, coming in without having that prior experience in state government or even at the local level, I just really valued the outreach that I had from ASTHO. I think that mentoring relationship just is invaluable. I had been told by the individual that I came in behind, the person that I succeeded told me, "Make sure you get involved with ASTHO very quickly." And that was the best advice, probably, I was given on day one in the job. I can remember thinking that the current state health officers that I started to meet in meetings or that I would hear on telephones, I thought, these people are brilliant, unbelievable the knowledge that they seem to have, because I was so new to the whole aspect of being a state health officer. But people reached to me. I had private phone calls. I had visits. That was probably the most valuable because, to be honest with you, there were very few people in the state that could help me—former state health officers. Some of them had approached the job differently than I wanted to. And so that was the other thing, too, I think knowing yourself. And I would put that high on the list for a leader, above all, know thyself and follow your own North Star, just be authentic. In doing that I started seeking out other state health officers that I would see characteristics in them that I wanted to be like or that I could see some of myself in.
The other things I looked for were, what were the priorities for my governor, what were the priorities for my state legislature? And then looking to state health officers that maybe had advanced those issues. Who'd been successful and how did they do it? I was very curious about the how. The other thing I would tell you is the State Health Leadership Initiative, that week of being with state health officers and being able to be in a learning environment with my new state health officers, my colleagues, was also an invaluable early experience that just served me...it serves me still today. I think back to the lessons I learned that week.
Tilson: One of the things we're looking at in our study is the high turnover of state health officers, too many leaving too fast. Talk about your departure and what the experience with that was. You left fairly precipitously because you got a great job offer.
Monroe: I did.
Tilson: What did that do to the agency?
Monroe: When I started as state health officer, I was there for five years which was a long enough tenure that I had really put my mark on both the State Health Department as well as the public health system in the state of Indiana. When I got this job offer and left to go to CDC, it was pretty abrupt. Surprised the governor, surprised the public health community that I was often running. With that I had put together certain structures that, after I left, some of those fell apart, quite frankly. Now there are some things I'd put in place that are still there today, and people remind me and that's celebrated. The one thing in government that is a bit distressing for me is that you don't really have the advantage to select your successor, so succession planning within the state is challenging in government. There were, especially for local public health departments, I think they felt my departure pretty acutely, and I heard that a lot. Part of that was just someone coming in behind me took a different approach, and I don't know that they felt as valued or heard the way they did when I established my relationship with them.
Tilson: Advise new health officers about how to protect their agencies against the pain of turnover, in case they don't last five years.
Monroe: Again, I think when new health officers come in they do need to take some time, and do it quickly, to listen to the various stakeholders, to find out what was valued and what worked, and to see if it's still politically viable. Because if you come out too quickly with messages to, say, your local health department, the local health officers, or it could be to the academic community or so forth, you may find yourself having a troubled start because the person that preceded you may have put some things in place that have a high value. Now, you need to make them your own. And that's one of the challenges of the job, you want to put your own stamp on things and make them your own, but don't throw the baby out with the bath water. That happened for a couple of things after I left, which I did hear quite a bit about.
Tilson: Can you insulate the agency against that kind of turnover trauma? Particularly for the short tenure health officers, the ones who only make it two and half years, say, what can they do?
Monroe: That's a great question and it's one that I think we all need to give a lot of thought to. Part of that can be done by having a strong executive team, I think, at the health department. I think the deputies play an incredible role, as well as the others that might be on that executive team. Anyone that may come in and know that they're going to be there for a short time, and a longer term as well, but especially the short term, they do need to be conscious of that, that there needs to be some sustainability and buffering the agency against the trauma of them leaving. I think I'd turn to my deputies.
Tilson: I don't want to miss the chance to talk particularly with you about the relationship between state health officers and the CDC. Help our SHO's to understand how to use the CDC, and maybe vice versa.
Monroe: First of all, when I came in as state health officer, to be honest, I was pretty wowed that I got to work with CDC. It's such a great brand, both domestically and worldwide. I had been a practicing physician, so coming in it was like, this is really cool, I get to work to CDC. As I started to work with the CDC, though, I found that I wasn't always getting what I needed directly from CDC. In my case, I was asked to go to CDC to establish an office of state, tribal, local and territorial support, OSTLTS. That is your home at CDC. Any new state health officer, not only would I advise quickly getting involved with ASTHO but you want to be known by OSTLTS also, because OSTLTS is the inside game at CDC, and we really built that office to be the home for state health officers, as well as locals that come in, as well, but especially for the state health officers. That means establishing a relationship with the director, currently José Montero, but there's a tremendous staff there.
What we did when state health officers would have a particular need, whether that was trying to advance policy or whether that was data needs or whether that was just they needed the experience or they needed...maybe things weren't working as well in a particular program that they needed some support, they can call OSTLTS and OSTLTS will help navigate either connecting them to the right people, problem solving, what have you. We did a number of things on behalf of the state health officers. It's a really important relationship. State health officers and CDC need one another, and they need to learn, they need to continually learn from one another, as well.
Tilson: You bring another... You have so many things to bring to this table. We don't have all day but just in the next exchange, please think out loud about the relationship between public health and private medicine.
Monroe: The relationship between public health and private medicine is one that quite frankly has intrigued me my entire career. I think we miss opportunities all the time with private medicine and public health. That's, when we think about the leadership of state health officers and what they can bring to the table, is forging a strong relationship with the Hospital Association at the state level and then with CEO's.
A quick story. I was state health officer. Had been state health officer in Indiana two or three years by this point. There was something I had a question about, and I started calling CEO's of hospitals. And I called one particular CEO in a moderate-sized town who'd been the CEO of this hospital for 30 years, and he said, "This is the first time a state health officer has ever picked up the phone to talk to me," and he was thrilled. He was thrilled with the call. We ended up probably talking an hour. We covered all kinds of issues. He became one of the greatest advocates for public health during my tenure and after. Picking up the phone, talking at that top leader, the state health officer, the beauty—and I love this part of the job—was that quite frankly anybody would take my phone call. CEO's of companies, CEO's of hospitals, it didn't matter, as the state health officer, folks would take your call because they knew you worked for the governor and they had an interest in that. Use that wisely because we need to forge more relationships. And then if it's starting at the top, then you can engage the local health officer to work with the local hospitals and with the medical staff.
One of the things I did as state health officer is I started very strategic communications out to all licenses professionals. And it would depend, sometimes it would only be to the physicians, sometimes it would be to the pharmacists, nurses and so forth. Some other state health officers have followed suit with that. That's another bully pulpit opportunity that state health officers have. If new state health officers are coming into the job and that's not established in your state, seize that opportunity, but be strategic about it. You don't want to overwhelm the practicing physicians with communications.
Actually, we started a medicine and public health day. It was the Indiana...it was the commissioner's public health and medicine day. I actually got the residency programs to close down for the day, have the faculty cover their patients, and we'd bring residents in to highlight all the things that had happened in public health in Indiana for a year. Looking back in the year before, what were the issues that medicine should care about, that public health had been managing, and those kinds of things. It was a really robust and fun day. So, you can be creative with it.
Tilson: Let's do one more of those exchanges. Let's now blue sky. Public health is an extraordinary field. Things are changing rapidly. What do you think the greatest opportunity looking forward is? Where are we going here that public health needs to embrace?
Monroe: If I get blue sky about where public health needs to go, I'm going to put on my current hat, because I'm now president and CEO of the CDC Foundation, and I've spent the last year and a half working with large companies and large associations that I'd never even heard of before, that are in various industries. When I think about the entrepreneurs and the new technologies and all of these things that are emerging, we need those folks to be champions of public health. We need to be more innovative in public health, and to do that we need to talk to people who are innovators. I will tell you, there are communities out there that think differently, that would serve us well both ways. So, I'm beginning to do some of that in my role at the foundation, and I think there's huge opportunity there.
Tilson: And then finally, speak to the alumni. What can ASTHLO alumni do to help public health?
Monroe: ASTHO alumni are, what a treasure. They have gone... Life after being a state health officer takes so many shapes and forms. I've talked to fellow alumni that have gone into pharmaceutical companies and philanthropy and various businesses, it's very cool. I think the alumni need to be a strong force. They can be a voice, they've got the freedom now. Most of them have the freedom to speak up. They can write op-eds, they can be on the Hill, they can get with their legislators in their own state or jurisdictions to help carry the message. They can be incredible mentors to those coming up through the ranks. I would call on all alumni to be incredible active and use their talents and their experience to advance public health.
Tilson: Unbelievable how quickly the time flies, Judy. You also have the bully pulpit here with the microphone and the camera.
Tilson: Is there anything you want to say to ASTHO or your fellow state health officers?
Monroe: Just a huge thank you. I just give a huge shout out to ASTHO for all that they've done for 75 years. They've been quite a force, and they need to continue to grow and even be stronger. My colleagues across the field at all levels, I've had such a privilege of meeting so many remarkable people, and it's just a big thank you from me.
Tilson: Judy Monroe meets remarkable people because she is a remarkable person. Thank you so much for doing this for us, Judy. Appreciate your coming.
Mary Selecky served as Washington State secretary of health from 1998 until April 2013. As one of the nation’s longest serving secretaries of health, she served three governors – Locke, Gregoire and Inslee. Prior to that, she worked in local government in one of Washington’s most rural areas – Ferry, Pend Oreille and Stevens Counties - where she had been a local public health administrator for 20 years.
Description of the video:
Hugh: Hello and welcome to this set of interviews. I'm having a great conversation with you, Mary Selecky, former state health officer for the State of Washington. We'll have lots to talk about, but I wanted to first of all say that this is a study of the factors of success for state health officers, sponsored by the de Beaumont Foundation, supported by the Association of State Territorial Health Officials and run by the Fairbanks School of Public Health in Indianapolis. Thanks for joining me.
Mary: Oh, you're welcome.
Hugh: Mary, you know that our focus is on success of state health officers. I'd love to hear your definition of success from your own experience and maybe a few of the factors that you think made you successful.
Mary: Approaching that term "success" is very interesting when you're at the state level because, depending on the issue, it might be a very quick issue with a quick turnaround, and what you're hoping is that you're really going to have a longer-term impact on the population in your state. As I think about success it's always wonderful to have hindsight and to look back and say, what was that thing that really made a difference? I was very fortunate that I got to serve multiple governors for a number of years. And a big issue for us was tobacco prevention, for example, but it took 10 years to see what difference that made. We did get a smoke-free state, and you see that pretty quickly. You do get some numbers that tell you kids are starting to smoke less. But you're looking for, what's that health impact? And as we got more adults to quit we actually saw a reduction in respiratory diseases showing up in hospitals. Success can look like an epidemiology curve. Success can be a good headline that thanks the department of health for doing something very well. Success can also be an okay nod from a governor giving you an attagirl or an attaboy for following through on something that was very tough.
Hugh: You know, it doesn't matter how you define it. You also know yourself and know what factors you brought to the job that made you a success. Talk a little bit about what made you successful.
Mary: When I became a state health official I had had 20 years of experience at the local level. Not everybody gets that opportunity. I felt like, at least I knew the players, I knew the issues from the local level, and I was able to take that kind of local voice to the state level. However, the state is a very different arena than working in local public health. I don't care what state you're in. Because when you do that change to the state level you have to have a perspective that's much broader, you've got to look at the issues from many angles. Now, all of a sudden, you're the regulator instead of the regulated. Coming to the job of state health official gave me a little bit of a start at least in knowing the issues but how complex they were I didn't have a clue. That was a major learning curve for me in my first year.
Hugh: I think you actually answered the third question while you were answering the second but let me just drill down. Is there something you wish you had known on your first day, that you didn't, that maybe we could have given you?
Mary: When I walked into state service I thought I understood state government. I did not. And I do have to credit the leadership institute that we had at the time, and I was in the inaugural class, about talking about much broader policy issues, about looking at how we would look at it from a different set of lenses. Initially, I was feeling very good about taking my local public health experience to the state level, but my learning curve about looking at it from a state policy level, a state system level, and a state impact level was a very high learning curve.
Hugh: I wish we had time to talk about the dirty dozen. Maybe a little later we can do that. To focus on the most important challenge, give me just one most important challenge you faced in your time as state health officer, and then talk about leadership lessons learned and leadership you had to exert.
Mary: Challenges come in many different shapes and forms. One of those challenges is a very large-print headline in the very important newspaper of the biggest town talking about the department of health as licensed to harm. I happened to have the responsibility to license all the state health officials, and there were some things that we didn't do well. That's a very humbling pill to swallow. To make sure that you've prepared the governor for that kind of headline was going to come, and hope that the governor would stick with you to go through the improvements that were needed. So that kind of challenge of managing the media, making sure the staff didn't lose their confidence in what we were doing, and then leading through the improvements that needed to go on was a huge, huge challenge.
Another one of the kinds of challenges is certainly everything that we faced after September 11th, 2001. We were not prepared as a system, and we will be better prepared every day that we work on it. But the coming together of state health officials across this nation and learning from our colleagues in the eastern states and Washington DC. Even though Seattle and Washington state were far away, we needed to be ready for things that we couldn't anticipate. Whether it was the H1N1 flu epidemic, we used the skills that we learned in preparedness. Whether it was when Fukushima blew up in Japan, and while it didn't impact the United States, the amount of fear that people had about radiation impacting them used every skill of risk communication, giving the public the kind of information they needed so that they would feel comfortable in trusting you that their health was okay. Those are challenges that are not easily defined, and you've got to have skill building and leadership building prior to that, to get through those challenges.
Hugh: I wasn't about to step on that line. Great. Even longstanding health officers eventually have to leave. How did you prepare your agency for your departure and what was the impact of your departure, do you think?
Mary: I had some very interesting experiences as state health official who'd been in the office through three governors. And probably the toughest learning was how you transitioned from one governor to another governor, not knowing the outcome of an election, not knowing whether the new governor would ask you to stay, whether you would fit in a new administration or the new administration would be taking some direction that perhaps you didn't agree with. Those are all unknowns and only you can share them with another state health official because they go through the same kind of path. Nobody else can help prepare you. The best advice I got was the way you keep your job is to do your job. That's one.
Two, don't count on anybody's word saying, "Oh, they'll keep you," or, "Oh, you'll be able to stay," until it's that governor who says to you, "I want you." I think that's an important piece, but also preparing the agency for a transition that could come. Being prepared for someone who's new going to come in. Even though it might be you, or you want it to be you, it still is a new administration. And I think that's an important thing for those of us who have been there through a governor’s term.
Now, there are also times I think when folks have to prepare for an issue they didn't expect, the headline they didn't expect, and a governor saying farewell. And that's a sudden departure. None of us ever want to wish that on anybody. For me personally, I was looking at a time in my life, I was approaching 66, is this a time for me to commit four more years to a governor? And if I couldn't commit four, why would I? No, I have no idea what his plan might have been, the new governor, but I needed to prepare the agency for saying farewell and that you'll be in good hands with the next leader. And indeed, I was very lucky that my successor was just prepared like he was for the job.
Hugh: Help us with some messaging for the short-term precipitous to partners and how they can prepare their agency for the unexpected. A lot of them are coming in and won't be here more than two and half years, as we now know.
Mary: Right. A number of my colleagues were not as fortunate as I to serve, and maybe they didn't want to serve, as long. What we needed to as state health officials was support one another. By supporting one another you also could remind them that when they're going through the bad time, do they have a deputy who's ready to step in? Do they have an administrative team that would be able to make sure that the agency kept humming, that their senior leadership in their agency was ready to handle situations when you weren't there? Because none of us can predict whether we're there tomorrow or not by either life or by our appointment by our governor. Your job could be gone at any time. Our job was really to build a foundation for which the agency could succeed, not just us.
Hugh: Mary your experience of course is like mine. You were a local health officer and a successful local health officer before you became state health officer. Help our SHO's, particularly those who weren't local health officers, to understand the unique relationship between the state and localities.
Mary: We have 50 states, the territories and Washington DC as members of this very exclusive club called ASTHO. One of the things that quickly I learned was to listen to my fellow colleagues about how different their state might have been than mine and not anticipate that it was the same. Every state, regardless of whether you are a state that runs the local health departments, whether you're in a state that has local health departments with law jurisdiction that gives them the authority at the local level, you have to have a relationship. And relationships are everything, all else is derivative. As a new state health official, paying attention to what's going on in the far corners of your state, listening to those folks who are in the communities, is as important as listening to the governor, the governor's policy person, the legislature, because without those relationships at the community level you can't get much done.
Hugh: One of the most exciting things about being a former state health officer is we don't stop serving. You see these opportunities now emerging for us going forward. Can you put your finger on what you think is the greatest opportunity for public health in the near future, where we might be able to put our stake?
Mary: Healthcare in these days is changing so rapidly. I know as a long-term public health professional when I hear a hospital system talking about population health, on the one hand you want to say, "Excuse me, I've been doing that for a long time," on the other hand you have to appreciate, how are they looking at population health? Is it in a way that enhances the public's health overall or the population that they serve that isn't the population overall? I think those of us who are looking at communities and saying, okay, there are healthcare providers, there are hospitals, there are local docs offices, the community clinics, whatever the case is; do they have the eyes of the whole community? Because public health has to have the eyes of the whole community. As we look forward it's important for us to have a voice in those tables, to be at those tables, and to serve when you're done being a state health official in your community in some kind of capacity.
Hugh: You have the eyes and the ears of the public health and state health leadership on tape right now Mary. What do you want to say to them as sort of a final bon mot?
Mary: Your opportunity when you're a state health official is something that not very many people share, so reach out to your colleagues, number one. Create whatever friendships it is that you will create but use them to help you through the tough times. Secondly, relationships are everything, all else is derivative. Whether it's with your governor's staff, whether it's with the legislature and the legislative staff, or the congressional staff in Washington DC, we have to have those relationships in order to have the policy discussions that we need to have when we're the state health official. And the other one is to pay attention to your workforce. Give them a good place to work. If they're not in great buildings, help them get into great buildings. If they need infrastructure updates, whether it's your IT department or whatever the case is, give them good tools to work with. But also provide the kind of leadership that helps them thrive and create a learning opportunity for them all the time and be a lifelong learning organization.
Hugh: Mary Selecky born a leader but never stops learning. And Mary, you never stop teaching me either. Thank you so much for doing this.
Mary: Oh, you're welcome. And good luck with this project.