The SHO-CASE Study Videos

Experienced state health officials share insight about what it means to be a successful SHO

Description of the video:

Ed:            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.


Hugh:         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.


Ed:              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.


Ed:             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?

Hugh:        Let’s just start off with your definition of success. What’s a… What is a successful state health,                officer?


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:        What is success?


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:        What is your definition of success for a state health officer?


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:        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.


Hugh:       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.


Hugh:       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.


Hugh:       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.


Hugh:    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.





In a snapshot, former and current state health officials share advice with new SHOs

Description of the video:

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.


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.

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.

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.

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.

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.

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 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.

Guiding principles and best practices for working with elected officials

Description of the video:

Baker: 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?

Auerbach: 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.

Baker: 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.

Auerbach: 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.

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.

State health officials share their greatest challenges as SHOs (Part 1)

Description of the video:

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.

Tilson: 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.

Tilson: 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 SHO?

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.

Tilson: 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.

Selecky: 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.

Tilson: 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.

State health officials share their greatest challenges as SHOs (Part 2)

Description of the video:

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: 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?

Auerbach: 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.

Tilson: 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. 

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.

Tilson: That will tax your leadership. Let’s talk about you as a leader. How does a leader confront that kind of situation?

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.

Tilson: 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?

Tilson: Let’s apply it.  Remind us where you were a State Health Officer and what years you served.

Halverson: I was the state health officer in Arkansas from 2005 to 2013.

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?

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.