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.