What qualities contribute to effective state health officials (SHOs)? Public health leadership has been analyzed and written about, but few studies have examined the personal characteristics and experiences of state health leaders and what their leadership looks like in the context of their state. Hear from participants in the State Health Officials Career Acheivement and Sustainability Evaluation (SHO-CASE) Study who explain their individual experiences as health leaders.
The SHO-CASE Study Videos
The SHO-CASE Study participants define success for State Health Officials.
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.
Advice for New State Health Officials
The SHO-CASE Study participants give advice to new State Health Officials.
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 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.