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Milbank Memorial Fund

Leadership in Public Health


Molly Joel Coye
William H. Foege
William L. Roper

1994

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Table of Contents

Foreword

Acknowledgments

Introduction

   Our Own Worst Enemy: Obstacles to Improving the Health of the Public
   By Molly Joel Coye
      Why Aren't We There Yet?
      The Corporate Culture of Public Health
      The Corporate Structure and Culture of Government
      The Isolation of Public Health
      Conclusion

   Public Health Without the Barriers
   By William H. Foege
      Introduction: Without a Vision, the People Perish
      What If We Could Apply the Science Available?
      What If We Could Speed Up What We Know?
      What if We Could See the Future?

   Why the Problem of Leadership in Public Health
   William L. Roper
      Overview
      Morale
      Skills
      Systems
      What Is to Be Done?

References

About the Authors


Foreword

The Milbank Memorial Fund is an endowed national foundation that supports nonpartisan analysis, study, research, and communication on significant issues in health policy. Most of the Fund's work is collaborative, involving strategic relationships with decision makers in the public and private sectors. The Fund and its partners currently address policy regarding the care of patients, the organization, financing and governance of health services, and policy directed at the health of populations. The Fund's projects are not supported by grants in the traditional sense. The Fund makes available the results of its work in meetings with decision makers, reports, and books, and publishes the Milbank Quarterly, a peer-reviewed journal of public health and health care policy.

The Fund has worked since its inception in 1905 to enhance leadership in public health. In the 1920s, for example, the Fund organized demonstration projects to integrate public and private services for preventing and treating tuberculosis and other diseases. On the recommendation of a group of public health leaders, the Fund established the Milbank Quarterly in 1923 in order to report on the results of these projects. Half a century later, in the mid-1970s, the Fund organized a commission directed by Cecil Shepps that wrote a report on higher education in public health.

These papers by Coye, Foege, and Roper exemplify the current program of the Fund, which emphasizes the connection between analysis and action. Each of the authors has led major public health agencies in difficult times. Each of them has made policy, implemented it, and studied it. To each of them analysis and effective action are inseparable.

Samuel L. Milbank
Chairman

Daniel M. Fox
President


Acknowledgments

These papers were written for a meeting convened by William Roper for the Milbank Memorial Fund. Participants in the meeting, many of whom made helpful comments to the authors of the papers, were:

Lawrence Altman, National Science Writer, The New York Times; Edward Baker, Director, Public Health Practice Program Office, Centers for Disease Control and Prevention; Patricia Buffler, Dean, School of Public Health, University of California at Berkeley; Scott Burris, Professor, School of Law, Temple University; Mark Chassin, Commissioner of Health, New York State Department of Health; William Foege, Executive Director, Task Force for Child Survival and Development, The Carter Center; Adela Gonzalez, Director, Department of Health and Human Services, City of Dallas; Lawrence Gostin, Visiting Professor, Georgetown University Law Center; Margaret Hamburg, Commissioner of Health, New York City Department of Health; George Hardy, Jr., Executive Director, International Life Sciences Institute; Martha Katz, Associate Director for Policy, Planning, and Evaluation, Centers for Disease Control and Prevention; Zita Lazzarini, Harvard Medical School; John Lewin, Director of Health, Hawaii Department of Health; Fitzhugh Mullan, Director, Bureau of Health Professions, Health Resources and Services Administration, Department of Health and Human Services; Gilbert Omenn, Dean and Professor of Medicine and Environmental Health, School of Public Health and Community Medicine, University of Washington; William Roper, President, Prudential Center for Health Care Research; Charlene Rydell, Member, Appropriations Committee, Maine House of Representatives; Nelson Sabatini, Secretary, Department of Health and Mental Hygiene, State of Maryland; Carole Samuelson, Health Officer, Jefferson County Department of Health; Marni Viet, Senior Vice President, Kansas Health Foundation; Bailus Walker, Professor and Dean, College of Public Health, University of Oklahoma; Martin Wasserman, Health Officer, Prince Georges County Health Department.




Introduction

The authors of these papers agree that problems of leadership contribute to the difficulty of making and implementing policy to improve the health of the American public. By leadership they mean the capacity of professionals to work effectively during long careers in a variety of organizations that command resources and favorable attention from elected officials and the general public. The authors, along with many of their colleagues among senior public health professionals, believe that more effective leadership would improve the translation of existing knowledge about the prevention and control of disease into policies that lead to longer and healthier lives.

The authors have firsthand knowledge of the problems of leadership in public health. Each of them has worked to correct the mismatch of scientific knowledge and effective policy. Each has headed agencies that compete for resources with skilled advocates of other pressing public needs. Their collective experience includes leadership in public health in local, state, federal, and international settings.

The resources allocated to public health must be earned in competitive political environments. Admiring legislators who are eager to apply the best science are unlikely simply to bestow more funds and authority on deserving public health agencies and their dedicated staffs. Public health has no stronger claim on scarce resources and attention than, among other matters, medical care, public safety, defense, education, or economic development. What public health does have are compelling claims on resources and public attention that can and should be made more effectively.

These papers began as background for a meeting of public health professionals concerned about problems of leadership. William Roper convened this meeting on behalf of the Milbank Memorial Fund late in 1993. Each author examined an aspect of a broad subject that would be discussed at the meeting. William Foege discussed what the public's health could be if existing knowledge was appropriately applied. William Roper reflected on the challenge of conducting careers in public health. Molly Coye assessed political and organizational barriers to effective leadership.

The public health professionals who were the first audience for these papers agreed to collaborate on several projects. The purpose of these projects is to demonstrate ways to create more stable career paths, to mentor younger colleagues, and to assess innovations in governance that could contribute to more effective policy. The substance of these projects is emerging slowly through conversations among people who are immersed in the practice of their professions. The projects are receiving warm support from leaders of professional associations and public agencies.

The goal of this publication is to inform and enlarge the constituency for enhancing leadership in public health. We hope the issues raised by the three authors will be discussed by public health professionals and will interest some of their colleagues in the legislative and executive branches of government. We welcome expressions of agreement, disagreement, and interest in the work that is going forward to act on the concerns articulated in these papers.

Daniel M. Fox
William L. Roper


Our Own Worst Enemy: Obstacles to Improving the Health of the Public
Molly Joel Coye

As public health professionals, most of us carry a nagging sense of injury, of virtue and dedication unrewarded. The world has not delivered on the promises that we repeated to each other in our youth and worked so earnestly to achieve in our professional careers. The people of the United States are obese, seldom exercise, use tobacco and abuse alcohol, engage in unprotected sex, injure themselves and others, fail to present for prenatal care––and, for their sins, suffer a burden of premature death and functional disability that is extraordinary among industrialized nations. For more than a decade, these patterns and our attempts to improve on them have been tracked in comparison to the National Health Objectives. Using our current science and technology, each objective could be achieved today. Yet, despite real progress in some areas and mixed success in others, the gaps stubbornly persist between what is and what could be.

Ideologies, economic realities, social habits, and a dozen other forces conspire to frustrate our best intentions and to belie our certain knowledge of how much better the world could be. Is this failure the crushing summation of a thousand individual failures, of public health professionals being less committed, intelligent, or determined than they should have been? Or can the reasons for this failure be uncovered in understanding systems: the structures and supporting beliefs developed long ago to carry out the tasks of public health? It is the task of leaders to diagnose dysfunctional systems and to envision new ones that will reshape their field. In our field of public health, we have a clear vision of the outcomes we want, but very little understanding of the relevant systems––either their current operation or the changes that will be required in them to turn our vision into reality. Perhaps most damningly, we have failed to understand that vision without strategy is of little use. Simply reciting the acceptable levels of mortality and morbidity is not enough––we need to articulate the strategies and systems that are required to reach these improved levels of health.

Part of this task, and my purpose here, is to understand how our current systems are dysfunctional. In one sense, it is a sorry task. There is little pleasure in cataloguing the failings of our life's work, and great risk that in doing so I will be misread as attacking people––and their dreams and intentions––rather than the failing systems. But the need to recast our efforts, and redefine the systems within which we function, is compelling. And for me, in the midst of a transition out of the public sector after 15 years of public service, I find novelty and relief in laying bare these frustrations and searching out their origins.

Why Aren't We There Yet?

If achieving the National Health Objectives is so eminently doable, why haven't we done so? The common wisdom in our field blames our sluggish progress on these undeniable realities: American society is violent, increasingly fragmented, and highly mobile. Addiction to tobacco, alcohol, and illegal substances persists and contributes to a series of other harmful behaviors, including violence and unprotected sexual intercourse. Sexual activity, unprotected from communicable diseases or pregnancy, is initiated early. Americans are ignorant about health promotion and disease prevention, and poorly motivated to change their self-destructive behaviors. Multibillion-dollar industries profit from the promotion of unhealthy behaviors and substantially influence the political process. Protecting the health of the public is correctly perceived as an uphill battle against social patterns and economic forces that frequently outweigh our meager efforts.

Is it possible, however, that this common wisdom is a grave self-deception - that we have translated the necessary targets for our most challenging work into excuses for our lack of progress? And I do mean excuses: reasons why we should not be held accountable for this lack of progress. For example, why have we not been able to control the increase in syphilis? From lowly master's student to state program director, we "know" the reasons: multiple sexual partners, drug use, low rates of condom use, low rates of reporting. To succeed in controlling syphilis, however, these "excuses" are precisely the behavioral patterns that we must target and change.

This is a classic example of public health problems: complex multifactorial patterns, behaviorally mediated, involving social forces well outside the "control" of public health agencies. But our thinking about systems must be challenged. To meet our public health objectives, we will have to change social patterns and forces that lie well outside the circle in the sand that comprises our current public health systems. We will have to challenge the concept of control by entering into partnerships with sectors like corrections, education, law enforcement, and business, and by effecting change through leadership and influence rather than through command and control.

Are we capable of bringing this about? What are the barriers to change, to leadership, and to achieving the vision of a healthy populace described in the National Health Objectives? In this initial foray, I will divide the barriers into roughly two types: those that are internal to public health organizations, both public and private, and those that are external. The external factors-over which we have far less control––are listed first, briefly:

Ideology or Social Attitudes
These restrict the latitude of government to regulate behavior (controlling tobacco use, requiring motorcycle helmets) or to provide services (school clinics, reproductive services).

Resource Constraints
Public health programs are funded from the discretionary budgets of local, state, and federal government. These discretionary budgets have been disastrously eroded by the growth of both entitlement programs, such as Medicare and Medicaid, and quasi-entitlement programs, such as corrections and law enforcement. Whereas short-term crises related to economic cycles are readily understood, this longer-term structural problem of public finance threatens a permanent pattern of steadily diminishing resources for public health. Compounding the impact of governmental resource constraints in this decade is the fact that less than one percent of the total U.S. health care expenditures are devoted to population-based prevention, which falls short of recent Department of Health and Human Services Office of Health Promotion and Disease Prevention estimates of 2.7 percent as a necessary level of investment in prevention.

Economic Interests
Although there is no lobby for measles or drug-resistant tuberculosis, powerful lobbies support alcohol, tobacco, firearms, pesticides, and industries that employ or produce toxic substances.

Conflicting Social Goods
Political and social choices are often complicated by conflicting social goods and further confounded by an overlay of economic interests. For example, gun controls are opposed by gun manufacturers for obvious economic reasons, but other Americans also oppose gun controls because they view access to firearms as a social good.

Leaving behind these and other external barriers to progress in public health, I turn to internal factors, which we can most immediately tackle and which we will have to overcome before we can successfully attack the external ones.

The Corporate Culture of Public Health

There is much to enjoy and be proud of in public health. The tradition and culture of our field incorporates, among other virtues, a strong scientific tradition and great compassion and dedication. My task here, however, is to identify those aspects of our culture that may, despite our best intentions, obstruct or impede our success. These include:

A Culture of Entitlement
We have a strong sense of what the world owes us (or rather, owes our programs, policies, and budgets), of how things "ought" to be, and we are frequently aggrieved because the support we receive does not accord with our expectations. This unattractive trait undercuts our ability to work with legislators, finance directors, and even the press; we frequently come across as "public health whiners" (with apologies to "Saturday Night Live"). Equally important, it impedes our ability to analyze competing policies and programs and to identify new syntheses ("win-win" solutions) or to present more cogent arguments.

Antipathy to Organizational Discipline
For all our tendencies to liberal or progressive politics, public health professionals have an extremely conservative streak of "John Wayne" individualism. Legislators, the executive branch, and even program administrators despair of the "public health cowboys" who end-run organizational strategies and planning. The more critical and important an issue, then, the less likely administrators in public health agencies are to share their strategies or to involve lower-level program staff in decision making.

Resistance to Accountability
Because many public health problems are multifactorial, and are caused or exacerbated by factors outside the traditional boundaries of public health, professionals in the field have come to believe that they should not be held accountable for success or failure in handling these problems. This attitude is supported by the culture of entitlement, which questions the motives of anyone opposed to our demands for resources or policy support and exacerbated by our lack of a data system capable of measuring the impact of our programs. This resistance to accountability is frequently paired with breathtakingly bold and unexamined assertions (e.g., "Public health agency programs are culturally sensitive.").

Scorn for Cost-Effectiveness Considerations
Despite their absurdly meager resources, public health agencies are notorious for their indignant response to requests that they document the cost-effectiveness of their programs or consider alternative methods of achieving program objectives. Traditional approaches become politically correct, such as the requirement that all HIV test counseling be done in person, and cannot be challenged even when service cuts are threatened. Budget cuts rarely provoke productivity increases other than crude speedups in agency staff workload.

Suspicion of the Private Sector
Employment is one of our most powerful preventive health interventions, community development requires businesses and jobs, and many business leaders are genuinely interested in supporting preventive approaches to health; yet we are plagued by a lingering suspicion of the private sector. Systems analyses of public health problems clearly indicate that support and involvement by the private sector are critical to obtaining necessary resources and achieving behavioral changes, but we are scarcely capable of such partnerships now.

Ignorance of the Medical Care Sector
Public health and medicine long ago evolved into two distinct cultures; their differentiation is reinforced by a mutual ignorance that cripples effectiveness on both fronts. The imbalance of resources between the two fields has particularly hurt public health, while the division between public health and medicine has implicitly absolved medicine of responsibility for clinical prevention. Our ignorance of, and separation from, medical care systems is especially perilous in the era of health reform. Important opportunities to integrate our goals into the reform of medical care and insurance may be missed, and we may find ourselves bypassed in the establishment of quality oversight functions.

The Corporate Structure and Culture of Government

We can proceed more quickly, and with fewer apologies, to the dissection of the corporate structure and culture of government. Several years' discussion and increasingly public calls for "reinventing government" have acquainted us with the general charges against federal, state, and local systems. Again, I reiterate that this list ignores the successes and strengths of public agencies: my task is to identify those aspects of government that constitute barriers to progress in public health. Some of these are listed below:

Inability and Slow Response Time to Change in the Environment
Public agencies are "unyielding bureaucracies, clogged with layers of management and supervision, driven by antiquated personnel, procurement, and budget systems that seek to regulate even the smallest decisions." Managers cannot focus group efforts quickly, and they do not control the incentives and rewards to reinforce positive performance. The bureaucracy can wait out or sabotage an executive agenda with which it disagrees, but more important, the processes of government itself can exhaust and defeat even agendas that have full agency support.

Opportunities for productive partnerships and innovation are routinely foregone because the authority and initiative required for effective responses at middle and lower levels of the bureaucracy have been suppressed and atrophied over time. The short tenure of executives and their senior appointees diminishes institutional memory and guarantees that up to two years out of every four will be lost in each transition. Budget processes separate planning from implementation by a minimum of 18 months, and "spend it or lose it" policies ensure that a program efficient enough to save money will squander the savings in the final weeks of the fiscal year. The legal system adds a final layer of delay and uncertainty; a seemingly unimportant case can result in a court decision that throws out a key policy, while "judge shopping" and other strategies often permit special interest groups to create broad new law and policy.

Categorical Approach to Program Design and Implementation
Public health agencies are organized by scientific disciplines, by media of exposure, by disease, by financing source, by legislative authorization––in an historical accretion that owes much to Rube Goldberg and little to strategic planning. Authority over programs is fragmented among agencies within each level of government and diffused across local, state, and federal levels. A typical state agency operates literally dozens of programs, each with separate contracts, billing, eligibility criteria, applications, data collection and reporting requirements, audits, and so on, resulting in a "spaghetti web" of overlapping and contradictory programs that target the same populations. Each categorical program accumulates its own collection of entitled interests, including the program staff itself, to oppose any consolidation or integration of that program.

Inability to Work Across Programs and Agencies
Services or programs that frequently lie outside public health agencies––such as foster care, AFDC, mental health, and early childhood intervention programs––often contribute as much or more than our own programs to community health. Yet genuine collaborative efforts across agencies, and even across program lines within health departments, are still the exception.

Inability to Focus and Prioritize Efforts
In every community, a short list of attributable risks, mostly related to behavior (tobacco, alcohol, violence, diet, and exercise), are responsible for the vast majority of premature deaths and years of potential life lost. Without implying that public health departments should abandon their many complex responsibilities for coping with smaller risks, I believe far too little use is made of the mother science of public health––epidemiology––in determining the allocation of resources and the priorities for public policy. This failure to establish clear priorities, combined with the resistance to accountability that I discussed earlier, weakens public support for our programs because we rarely offer information either to outline our key objectives, or to report our success in meeting them.

A related and painful subject is the politicization of priorities and funding. Because of the detailed extent of executive and, especially, legislative political control over funding decisions at all levels of government, it is difficult for agency administrators to make sensible, outcome-driven decisions about resource allocation and program priorities. This does not mean that I believe politics has no place in public health––in fact, public health exists at the interface of science and politics. The lack of congruence between public health goals and actual program priorities and funding, however, is itself a barrier to public understanding and support for our work, and must be addressed, or at least made explicit.

Erosion of Public Confidence
Against a background of plummeting public confidence in government, public health has fared reasonably well. Nevertheless, the transition from preventing communicable disease to halting or alleviating chronic and behaviorally mediated diseases has eroded the public belief that our policies are science driven. When we stepped beyond the mysteries of germ theory into arenas like seat belts, condom use, and smoking reduction, the public felt more comfortable second-guessing our pronouncements––and this converged with a period in which government is increasingly portrayed as inept, politicized, and intrusive. Moreover, because the processes by which government functions in the public view are intensely political––legislation, regulation, executive order––the public view of government is of a highly politicized (and therefore less science-based) undertaking.

Investment in Current Structures and Systems
Although the public health system represents less than one percent of the national health budget (when clinical preventive services are excluded), this is all we, as public health professionals, have got. Not surprisingly, it is hard for many of us to imagine a fundamental rethinking of our structures and functions. Perhaps the best recent example of this difficulty was the work of the health reform task force in the spring of 1993 in Washington. After recommending that clinical preventive services be included in the basic benefit package, and that a full set of "enabling services" (supplemental services such as transportation and translation) be appended for populations at risk––thereby presumably guaranteeing to everyone access to current program services––the agency representatives hastened to add that the budget would have to include continuation funding for essentially all the functions of the Health Resources and Services Administration, the Centers for Disease Control and Prevention, and the state health departments. This went far beyond ensuing a smooth transition; the task force members simply could not imagine a world that no longer required them to perform their specific functions. It will take courageous and forceful leadership to design and implement a sensible new system.

Inability to Reinvent Itself
Despite President Clinton's desire to reform the federal government, and attempts by many states to undertake some version of reinventing this, surprisingly few examples of extensive, enduring transformations exist. The challenges to public health include:

  • Divesting it of personal health care services (if it has a medical chart, it does not belong to us).
  • Defining the functions of local, state, and federal levels of public health.
  • Sorting out thresholds for basic competence by function and size of population base.
  • Developing models and resource need criteria for core functions.
  • Developing "report cards" for public health programs to increase accountability.
  • Designing strategic partnerships among local, state, and federal agencies so that they share objectives and accountability.
  • Ensuring flexibility at each level for agility, streamlining, integration, and continued adaptability.
  • Preventing legislative micro-management.

This list brings us to the obvious question: Is government the most appropriate and effective sector to deliver public health services? Government certainly has not done a good job of holding itself accountable: it cannot allot money well, its budget decisions are highly political, and, once authorized, stopping or substantially altering its programs is nearly impossible (the "merino wool growers' subsidy" approach to continuity in government programs). There are, in fact, no explicit criteria for determining which public health functions might be better achieved by public or private entities.

Through the Looking-Glass: Community-Based Organizations
Community-based organizations have been funded and awarded quasi-governmental status precisely because of doubts regarding the function of government agencies in public health. Unfortunately, these new agencies have recreated many of the same problems. If nothing else, they have an exquisite sense of entitlement, a resistance to accountability, scorn for cost-effectiveness considerations, categorical structures and identities, suspicion of the private sector, and, often, ignorance of and hostility toward the medical care system.

The Isolation of Public Health

The corporate culture of public health and the corporate structure and culture of government present two of the major internal barriers to progress in public health. A third barrier is the relative isolation of public health from the currents of change that are affecting leadership and management in other sectors of the U.S. economy and health system. (A notable exception is the Public Health Leadership Institute established by Bill Roper at the CDC to train state and local health leaders.) It would appear that our suspicion of the private sector has deprived us of promising tools for the task of reinventing ourselves:

Conceptual Reformation
This is the task of rethinking organizations, drawing on the approaches of systems thinking to analyze the structure and function of systems; on visionary and transformational leadership to construct alternative models and strategies for achieving them; on the development of learning organizations to support the ongoing evolution of effective systems; and on the creation of a culture of continuous improvement to ground this transformation in solid data and feedback.

Structural Reformation
This is the reorganization of the work of government, integrating systems within and across agencies, relying on performance budgeting, flattening organizations to provide more room for initiative and responsibility at all levels, and shifting to leaders hip that relies upon coaching and teaching rather than command and control.

Health Systems Reformation
This is the redesign of the health system itself, including medical care and public health, by developing common data systems, applying population-based budgeting and capitation, and establishing accountability for access, quality, and productivity. The development of new systems of accountability, based on data systems that link investment and interventions with outcomes for defined populations, holds the ultimate promise of increasing our investment in population-based prevention. In the context of health reform, we have the opportunity to make the case for increased spending on public health. We will find it difficult to obtain or sustain these resources, however, if we do not address the internal barriers I have described here.

Conclusion

Will public health "miss the train," hunkering down within the politically correct bunkers of our isolated field and failing to grasp the enormous opportunity before us? We have made progress in some critical battles: there is modest but appreciable support for universal coverage, coverage of clinical preventive services, new investments in the public health infrastructure, a common data system, and shared accountability. In the year ahead, we must tackle two further controversial issues in the broader debates over health reform: 1. We have to explain that achieving universal health insurance will not substantially improve the health of the population, and clarify the importance of population-based prevention and the continuing need for local, state, and federal core public health programs. 2. We must insist on linking and integrating the public health system with the reformed medical care delivery system in order to track investments, interventions, and outcomes across all of health care.

More fundamentally, we must begin the process of reinventing ourselves. This will take years to implement fully at all three levels of government, but the rewards will be more immediate. In California, public health officials seized an opportunity to join the Bay Area Business Group on Health (BBGH)––becoming the first state Medicaid program to join a coalition. Representing employers who purchase insurance for approximately 15 million persons each year, the BBGH wrote contract language requiring all HMOs doing business with BBGH employers to provide a basic set of clinical preventive services, and more important, to make information on utilization and outcomes available to each employer and to the BBGH in aggregate. This partnership, which cost us almost nothing except a massive change in our way of thinking and working, has achieved public health objectives that could never have been realized through public financing or regulation. In turn, we have new support for our population-based prevention initiatives from employers who are educated about our core functions.

If we can overcome the obstacles I have outlined, we will have a far better shot at achieving our public health goals. Our key challenges will be to leverage the new logic of population-based budgeting and accountability, and to adopt a more flexible, less orthodox and bureaucratic approach to our tasks. I believe that as a result of these efforts we can and will see the substantial improvements in the health of the public that we have so long desired.

Reference

National Commission on the State and Local Public Service. 1993. Hard Truths / Tough Choices: An Agenda for State and Local Reform. Albany, NY: Nelson A. Rockefeller Institute of Government


Public Health Without the Barriers
William H. Foege

Introduction: Without a Vision, the People Perish

Public health is grounded on the assumption that this is a cause and effect, non-fatalistic world. Actions can be taken that change risks and thereby outcomes. The vehicle for exploiting this cause-and-effect world is epidemiology. Epidemiology becomes the interface between science and public policy as it interprets the science, measures the problem, suggests interventions, assesses what could happen if the interventions were applied, and monitors their effects on the population. Public health is grounded on a second foundation, that the truths of science will be used to benefit everyone. Therefore, the philosophical basis of public health is social justice. A look at "public health without barriers" is best viewed not as the result of a magic wand that could produce miracles, but rather as a look at what could happen if the usual barriers were removed at each step of the process, from discovery to application. What if we had an environment that stressed the best science possible, the best interpretation of that science, the best policies based on those interpretations, the best application of interventions resulting from those policies, full participation of people in reducing their risks, and the best evaluation of results with ongoing corrective actions, all within the context of the best imaginable equity and ethics? To date, successes in public health have always been partial, always relative. With the exception of smallpox eradication, we have never met the potential suggested by science nor the equity required by social justice.

Objectives For The Nation, an advisory document that was first developed in 1978 for the year 1990, and then revised for the year 2000, provides an incredibly exciting step in developing a vision for public health workers. But the objectives fall short of what we could do, because they are tempered by the barriers expected in public health, and they are limited to the United States. What could happen if we pushed our science to the limits, thought globally, and developed policies that combined what we could do with what we should do?

What if We Could Apply the Science Available

In 1984 the Carter Center organized an effort to define the gap between the current health status of the country and the potential health status if we could apply our current skills and knowledge. Thirteen study groups examined particular areas, such as cancer, injury, and diabetes, and made the best estimates possible on morbidity and mortality patterns that would result if each specialty field could apply what it knew. The results were then adjusted to balance all thirteen areas so that summed results would not exceed what is actually possible. The study concluded that, despite a remarkable increase in life expectancy in this country in recent decades, two out of every three deaths in the United States are premature, given our skills and knowledge, and that 8 million of the approximately 12 million years lost annually in the United States before age 65 are unnecessary losses. The study went on to show that a few generic risks, such as tobacco, alcohol, violence, and unintended pregnancy, had an inordinate impact on the burden of disease. What if we revisited the concept of what could happen, both in the United States and the world, if we were suddenly free to apply what we know? What would we actually do?

Principles
We would first develop a set of principles to guide all future public health work. Just as health care delivery discussion has been organized around access, cost, and quality, public health workers would probably organize their new freedom to deliver public health around equity, quality, prevention, and outcomes.

  • Equity. Public health workers would promote the idea that the interrelationships between people, both throughout the world and through time, are such that all decisions must be based on what is best for the greatest number of people over a long period of time; that is, a horizon of centuries rather than years.
  • Quality. The best science, policy, and administration must be brought to bear on public health problems.
  • Prevention. Every condition would be evaluated to see if it could have been prevented, and to identify the steps to prevent similar occurrences in the future.
  • Outcomes. The tool for decision-making in public health should be outcome rather than access, which is only another process measure in the equation. The most important measures would be premature mortality, unnecessary morbidity, and life quality. The first two could be combined to form a measure of disability-adjusted life years (DALY), and efforts would be required to quantify life quality and add it to the equation.

Structure
What framework would be developed for applying what we know? How could the best science actually get applied? Of the variety of structural changes, three are of special significance:

  • Surveillance systems. Great creativity would be needed to obtain the necessary information on individual and collective health indices in a timely fashion. One possible solution is a tracking system on each person that would begin before birth, and would provide information on risk factors, genetic factors, environmental exposures, illnesses, therapy, and other pertinent data. An ongoing individualized health plan would offer each person guidelines for vaccine due dates, screening needs, and therapy suggestions by that person's private physician. But even the best individual medical record system cannot replace public health measures that, for example, would track individuals in certain programs or offer a public health perspective. The information would, however, become part of a larger public health surveillance system that would add community information and evaluate problems in the aggregate, suggesting both public health and individual interventions.

    The DALY approach, developed by the World Bank, could be incorporated into the surveillance and evaluation systems to measure health problems, to evaluate program impact, and to compare intervention approaches as well as geographic areas. Ongoing analysis of the data collected, projection of future trends, the development of intervention strategies, and the widespread distribution of findings would be an integral part of the surveillance system.

    In Cuba, for example, the family doctor has much of this information and [he or she] is seen as a "guardian" who combines the services of a physician and a social worker, integrating all the information from the patient and delivering suggestions in return. It should be possible to combine the technical abilities of the information highway with humane uses of the information acquired. Public health delivery would be based on the most complete and automatic surveillance systems possible, linking patient, laboratory, medical, environmental, and community information.

  • Policy development. Policies would be based on the possibilities offered by science, the interpretation of that science, evaluations of cost-effectiveness, and the best predictions of their impact. Programs would not be introduced just because there are no barriers to their delivery, but because they make sense, are prudent, and improve the quality of life at a reasonable cost. Interventions that have a positive benefit-cost ratio, such as vaccine prevention programs and tuberculosis treatment, would become entitlements. Programs that improved life quality would qualify based on the cost of recovering a "disability-adjusted life year."

    One way to institutionalize such an approach would be to establish a unit in the Public Health Service that is charged with providing a big picture analysis of policy approaches most likely to improve health, with an analysis of costs and options. Such an analysis would be based on the accumulated information and suggestions coming from all parts of the Public Health Service. A second unit in the Office of Technology Assessment would analyze the actions suggested and make recommendations to Congress.

  • Evaluation. Tied to the surveillance system would be an ongoing evaluation of public health and health care delivery programs. Mid-course corrections would be made as required, but always with full knowledge of outcomes being achieved.

Priorities
The 1984 Carter Center evaluation indicated that the large gap between current and achievable health status was largely attributable to a few generic problems. Program execution would logically emphasize the biggest preventable problems. In the 1990s, for example, a third of all deaths could be delayed by concentrating on only three causes. Tobacco is responsible for an estimated 400,000 deaths, about nineteen percent of the total, diet for about 300,000 deaths, or fourteen percent of the total, and alcohol for 100,000 deaths, or five percent of the total. Straightforward steps could be taken to decrease the use of tobacco, such as increasing taxes and restricting availability to young people. Dietary changes could be encouraged by taxation policies, education, easy-to-read labeling, and stricter requirements placed on companies producing food. Alcohol policy could be rebuilt based on information from around the world on providing reasonable barriers between people and alcohol, such as taxes, hours of availability, and legal restrictions on use.

McGinnis et al. have recently reviewed the generic causes of death in this country, and suggested guidelines for priorities. A similar review of morbidity and quality of life could provide the basis for priority actions. The emphasis would be on a rational approach, based on the burden inflicted by a disease, the known prevention techniques, cost-effectiveness studies, and public health decisions based on these facts, unimpeded by political, business, or special interest considerations.

The World Development Report (WDR) provides clear guidelines on the global programs that deserve support. The effectiveness of immunization, vitamin A delivery, diarrheal disease control, and tuberculosis therapy make it clear that cost effective interventions are now available for a wide variety of conditions. The remaining barriers are in policy development and resource commitments from both developed and developing countries.

Expected Impact
In this country, two out of every three deaths could be delayed. Specifically, eight million years of life could be salvaged annually before age 65. The expected increase in life expectancy can be roughly calculated as the difference between the current mean and the best results achieved in subpopulations. Therefore, an overall increase in life expectancy of five or more years would not be unreasonable. The potential amount of averted morbidity and the improved quality of life have not been calculated using the DALY approach, which offers us a useful way to make future calculations. It is reasonable to assume that interventions would produce significant decreases in crippling injuries, chronic obstructive pulmonary disease, strokes, and other major causes of health expenditures and impaired quality of life.

Globally, the burden of disease is calculated to be 1.2 billion DALYs per year. It should be possible to calculate the percentage that is preventable. Although life expectancy is improving rapidly in developing countries, having gone from 40 years at birth in 1950 to 63 years at birth in 1990, the same reasoning is applicable in the developed world. We could expect to see a similar growth in life expectancy in specific populations that can make use of all preventive and public health measures. Therefore, it is reasonable to expect that life expectancy throughout the world would increase by another 15 plus years if we achieved equity in our use of public health tools.

Costs
Because many of the changes suggested have to do with the way things are done and how decisions are made, they would have only marginal cost implications. However, several items are amenable to costing, although the very rough figures given are more illustrative than factual. The improvement of our country's surveillance, epidemiological analysis, intervention planning, and information distribution requires a stronger system at every level; nation, state, county, and city. If a fraction of one percent of current expenditures were invested in such an information system for public health and public policy, the costs might vary from $1.00 per person, or approximately $250 million per year, to $4.00 per person, or $1 billion per year.

The improvements suggested for policy development involve small changes that are unlikely to cost more than about $10 million per year. Evaluation would require programs based in every state and might require an additional $50 million per year. A large domestic cost would be in the area of health education and health promotion. The use of radio, television, schools, churches, community centers, and other outlets could well involve an additional $1.00 or more per person, or $250 million per year. In any case, the costs are in the range of $600 million to about $1.3 billion per year, modest in comparison to other health care expenditures.

The case for global changes is different. Because of the size of the problem and the interventions currently underutilized, the costs are much higher. UNICEF, for example, has estimated a need for about $25 billion per year to provide basic services to the children of the world. These would include basic primary health services, basic education, family planning, nutrition, and sanitation.

What If We Could Speed Up What We Know?

The research establishment of the world is biased towards the diseases of the developed world. Within the developed world, there is a great deal of rhetoric about the role of the investigator in determining the priorities of research. In fact, most research is dependent on funding priorities, and therefore the problems examined are those of interest to politicians, special interest groups, drug companies, and, to a small extent, academics who explore basic science interests.

If there were fewer barriers, could research be made more rational? Could we improve on the tools available to public health?

One way to do this would be to imitate the World Development Report in its approach to the global burden of disease. First priority would go to studying prevention, measuring our disease problems, and improving the process of public health. For example, research support would be given to improving the efficiency and effectiveness of surveillance, methods of quantifying morbidity, approaches to improving the speed and quality of analysis, ways of improving communication and evaluation, and methods for automating response.

The entire process would then be used to develop both applied and basic research priorities. For example, twenty-four conditions each account for more than one percent of the global burden of disease. Collectively, these twenty-four conditions account for sixty-five percent of the total burden of disease in the world. It is possible to categorize these conditions into three groups: (1) Conditions for which our interventions are adequate, such as poliomyelitis eradication, where we can simply apply what we know. (2) Conditions for which good interventions are available but, for some reason, are difficult to apply. In this case applied research is required in order to take advantage of the scientific possibilities. (3) Conditions that result in a significant burden of disease and where our intervention techniques are grossly inadequate. Basic research would be indicated for this group.

Funding decisions for global research could be based on the importance of the problem and the best judgment of the scientists regarding the possibility of a breakthrough.

Without the usual barriers, one can envision major breakthroughs in respiratory infections by means of vaccines, better detection, rapid field diagnostic techniques, appropriate therapy, and supervision. Likewise, a variety of vaccines could be available within decades for other infectious diseases if such a priority would be selected. Public health needs would be more adequately addressed by the research establishment, and within public health, priorities would be established on a rational basis of need.

Within this scenario, violence would be a major recipient of research resources. Five separate areas of violence each account for more than one percent of the total burden of disease in the world (automobile injuries, falls, homicide, suicide, and war). When violence is aggregated, it represents the largest cause for the world's burden of disease. The rapid fall in automobile mortality in the United States, the strides made in injury control in the past decade, and the pervasiveness of this problem in all geographic areas of the world gives hope that basic and applied research is not only likely to be productive but that the reduction in DALYs could be substantial.

What if We Could See the Future?

What do we wish reasonable people had done in the past? When we look at our current conditions of rapid population expansion, environmental degradation, low birth weights, drug use, violence, and a multitude of medical and social problems, we are tempted to wish that public health people of the past had acted differently.

For example, what if public health people had taken a strong stand on tobacco when it first became obvious that this was a health problem? Ochsner identified this as a health problem in the 1930s. Even if we had waited until 1964, when the Surgeon General's report outlined strong proof regarding the role of tobacco in disease, 30 years of sustained effort would put us in a situation quite different from the one we now find ourselves. Imagine what could have happened if decision-making had been based on public health evaluation, without the barriers of political decisions. What if we now took a coordinated stand on the export of tobacco?

Likewise, we have always suffered in the long run when public health officials took a provincial view of problems. Repeatedly we are reminded that we must take a global perspective, that all things are interrelated, and that health must be seen to involve all areas of life.

What if, on the basis of this experience, we agreed that all future public health activities would be based on the following:

  1. Programs would be planned from a global viewpoint, with the goal of providing what is best for the largest number of people.
  2. Programs would be planned with the longest time span possible. What would the impact of a program be on persons living hundreds of years in the future?
  3. What is the level of impact? For example, an episode of diarrhea in an adult, while extremely annoying, may have no long-term impact, whereas such an occurrence in a young child may be the pivotal event leading to death; the child's illness thus would assume greater priority. To take another case, vitamin A deficiency may lead to lifetime blindness, whereas the lack of education may lead to lifetime bondage; therefore, both must be viewed as being of concern. Rubella may actually penetrate to the next generation, and thereby gains greater priority. However, some problems have a "Humpty Dumpty" impact in the sense that they can never be repaired. Population growth, the destruction of rain forests, and depletion of ozone are examples of conditions that must be attended to no matter what the cost.

The bottom line is that, while it would be great to see into the future, a rational step can be taken by looking at what was neglected in the past, to our current regret, and making sure that these problems are not shared by the future. Population programs, anti-tobacco programs, alcohol control programs, the reduction of global weapons, the reduction of violence, adequate nutrition and primary education for all children, but especially for females, programs to reduce poverty, and to control sexually transmitted diseases and other infectious diseases would be paramount.

It is possible to provide a new vision for public health, where truth and equity propel the decisions, and common sense frames the priorities. Health would be seen to involve all aspects of the world. Interventions would benefit this generation as well as those to follow. We could be ideal ancestors while making relatively few changes in the way we operate.

References

McGinnis, U.M., and Foege, W.H. 1993 Actual Causes of Death in the United States. JAMA 270(18):2207-2212

World Development Report. 1993. Investing in Health. New York: Published for the World Bank by Oxford University Press


Why the Problem of Leadership in Public Health?
William L. Roper

Over the past decade and more, leadership in public health has been a major concern. A study by the Institute of Medicine, entitled The Future of Public Health, and a series of examinations of the problems in general government have highlighted the need to enhance leadership and to better equip leaders. Despite ongoing attention to the issue, we continue to have a serious national problem. Although there are large numbers of dedicated, hard-working, and able workers in the public health community, we are suffering from a grave shortage of leaders to deal with the magnitude of the threat to health that we now face, and to cultivate the real potential for substantial progress that exists for dealing with these threats.

This shortage of leaders with relevant skills will not be remedied simply. What is needed is not a modest increase in the number of willing and able leaders for the field of public health, but rather a giant pool of qualified leaders from which to draw. The next generation of public health leaders should be readily visible among our younger colleagues today.

For purposes of this discussion, leadership positions in public health are the senior appointed positions in official public health agencies at the local, state, and federal level. These include agency heads and other top staff, including the heads of the major agency components––bureaus, divisions, centers, and so on. These positions are optimally filled by persons who have had similar experience, usually at a lower level, in the same or another organization. For example, my service as director of a county health department and as assistant director of a state public health agency was very helpful when I became director of first one and then another federal health agency.

Overview

Public health leaders must understand and deal with the multidimensional public health problems of today and the future. Some of the straightforward challenges of the past (an uncomplicated infectious disease, for example) were amenable to straightforward solutions (produce a vaccine and deliver it to all who are potentially susceptible). Today, many problems (such as teen pregnancy, drug abuse, and sexually transmitted diseases) are intertwined with seemingly intractable social and economic ills. These issues demand that leaders in public health be equipped differently than the leaders of yesterday. Even active professionals, who have been working in the field for some time, are not prepared for the current and future challenges facing public health.

Public health leadership today suffers from problems of morale, skills, and systems. A significant improvement in any or all of these areas would be in the public interest. In this paper, I seek to describe these problems in detail and to suggest promising areas for future work.

Morale

Why do public health workers have a morale problem? Low morale begins with the lack of respect accorded the field of public health. It continues with the paucity of resources and attention given to its issues. It is perpetuated by the low level of reward to workers in the field.

The public at large views public health as dirty and unpleasant work, removed from the concerns of the broad spectrum of society, especially the world of the power elites. Official public health agencies are commonly viewed, by the public and by the people trying to improve them, as encrusted bureaucratic systems, largely devoid of positive leadership role models. And despite laudable dedication, it is seen by its own workers as an underfunded, overwhelmed field, especially compared with the realm of medical care. The facts of generally low pay and meager benefits add to the difficulty of recruiting and retaining effective leaders.

Another aspect of this morale problem is the scarcity of public resources devoted to pressing public health matters. From my perspective, as a White House official watching the budgetary process, and subsequently as head first of a health care financing agency and then of a public health agency, I was continually amazed to watch as billions of dollars were allocated to financing medical care with little discussion, whereas endless arguments ensued over a few millions for community prevention programs. The sums that were the basis for prolonged, and often futile, budget fights in public health were treated as rounding errors in the Medicare budget.

This dichotomy arises principally because prevention spending is discretionary, whereas medical care is almost exclusively entitlement driven. It also stems from the lack of clear-cut evidence for the effectiveness of preventive interventions, and the demand by budgeteers that prevention programs be shown to return value. Of course, no such test has been applied in the medical care field.

This bias toward medical care and away from public health has an effect: people working in public health feel constantly shortchanged. And because they think that the public does not care, they become discouraged.

The general difficulty of capturing the attention of political leadership on health issues adds to the morale problem in public health. I have had the experience of working with elected and senior appointed political officials in local, state, and federal government. I cannot recall a single example of being asked to do or say something that I strongly disagreed with––but there were many times when I questioned the wisdom of the decisions made by these officials. Most often, these were occasions when I wanted to get something done, and I was faced with people up the line who disagreed with my recommendations, or at least did not share my sense of urgency.

Probably the most prominent example of this difficulty was my effort to persuade the Bush Administration to undertake seriously the issue of health reform in 1989. I was privileged to serve as President Bush's deputy domestic policy advisor during the first year of his term. I was convinced that the issue was ripe for major progress, and that Bush could steal the issue from the Democrats, under whom most health legislation had passed previously. However, despite my efforts to interest others in and mobilize them to take on the issue, it was rejected as too costly and difficult. Unfortunately, when the administration did turn to the matter in 1992, it was too late.

I reacted to "my issue" not being championed in 1989 by deciding to turn my attention elsewhere, and, to my very good fortune, I was quickly offered the opportunity to go to Atlanta to head the Centers for Disease Control and Prevention (CDC). The question of how aggressively to push for policies one believes in is a constant issue for public health leaders––and lack of success can adversely affect morale.

A further factor that can hurt morale is the increasingly obvious problem of the vulnerability of top leaders in the field of public health, a point was brought clearly home to me in 1992 at the first CDC Public Health Leadership Institute. This gathering of a select group of fifty state and local public health officials included several who had lost their jobs in the six months since they had been chosen for the Institute. They seemed devastated by their terminations, and were struggling with the fact that "politics" had taken their jobs away. They seemed to be groping to find an alternative explanation, asking themselves whether they had committed a grievous error that had led to their being fired. The remaining members of the group appeared to be shaken by their colleagues' fate.

The willingness to take and accept risks is one of the chief attributes of a leader. Although mitigating part of the risk for some key jobs in public health is possible, as I will discuss below, part of our effort must go toward assisting people in the very top positions to deal with the inevitable risks that accompany such jobs.

Skills

What skills are needed to prepare leaders in public health? The business community and academia have moved increasingly into the study and teaching of leadership, and away from the more technical discipline of management, a trend that is taking hold in the public health sector as well.

Leadership includes skills like the ability to see the big picture, to think and plan strategically, to share a vision with others, and to marshal constituencies and coalitions for action. The CDC Public Health Leadership Institute is one attempt to teach these and other leadership skills to senior public health officials at the state and local level.

One reason for providing these training programs is that many senior executives in public health come into their positions with no formal training or real experience in leadership. My own career is surely an example of this phenomenon. I was named county health director in my home of Birmingham, Alabama, at the age of 28. Before assuming the title of chief executive of this urban public health agency with 800 employees, the largest group of people I had ever supervised consisted of two interns and two medical students when I was a resident. I had the good fortune of seeing the bright potential for public health early in my education. When I was a sophomore medical student, the local county health department director was a guest lecturer for our class. He was a young, articulate, interesting, and able leader. In that one-hour lecture, I saw the possibility of combining my interest in politics and public affairs with my upcoming career in medicine: a combination that is called public health. I can point directly to that experience as a turning point in my career path.

Most medical students (and other young persons generally) are not as fortunate as I was. Either they have no introduction at all to the ideas of community preventive services and of public health, or they have a negative experience with boring lectures and tired role models for public health leadership by people who either cannot or choose not to work with dedication and vigor.

I would be hard pressed to point to my own career path as a model for raising up leaders for public health. Furthermore, when I pursued a formal degree in public health, taking one course a term to complete the degree over three years, I graduated without ever entering a class in management or leadership. My formal preparation for my job then, and for my subsequent ones, was almost zero.

Because many persons who are placed in top public health positions are physicians (indeed, a medical degree is a legal requirement for many such positions), an obvious potential source of leadership building for the future of public health is a collaboration between schools of medicine and schools of public health to offer more young physicians-in-training first insight into public health (as I was fortunate to receive) and then leadership instruction. This could be done formally or informally. Unfortunately, in many academic health centers, the great gulf between the medical school and the school of public health seems impossible to cross.

Furthermore, the problem is compounded because medical schools are no more explicit than public health schools about the qualities of leadership and how to achieve them. Academic physicians, like their colleagues in public health, often seem to equate leadership with facility in science and technology.

Senior executives in the field of public health are daily called on to interact with political leaders (elected and appointed) and the media, usually without any training or experience with these unique sectors of society. Efforts to provide assistance to public health agencies in the areas of public affairs, communications techniques, and legislative affairs are all too often viewed by elected officials and budgeteers as either superfluous or expendable in tight budget times.

It is especially important today to understand thoroughly the interplay between science and politics in developing and implementing public health policy. It is often said that, in the past, persons trained only in the science of epidemiology were successful as senior public health officials. Most likely this was as untrue then as it is today. However, given the much more complicated public health problems of today, science alone is surely not sufficient for current and future leaders.

During my time in government, and especially during my three and one-half years at the CDC, I was often exhorted to "keep politics out of public health" and to be guided only by science. Persons on all sides of the many very polarized HIV controversies, for example, regularly repeated these words. At a time when science is still venerated by most of American society while politics and politicians appear to be despised by almost everyone, it sounds like a worthy admonition.

Like many things today, however, it is too simple. Scientists have a notion that politics is dirty, and politicians, on their side, consider science, by its continual qualifications and equivocations, to be irrelevant. Some politicians also describe scientists as self-serving and internally contradictory, as well as being obsessed with uncertainty. I believe we must deal with both elements of this mutual distrust. Within our public health system we need science to discover new knowledge and to guide policy formulation and implementation, and we need the political process to reach governmental decisions and to implement them through programs.

Possibly there is no issue in recent years that has been more hotly debated in public health than the question of infected health care workers. First HIV-infected workers, and later multidrug-resistant, TB-infected workers (and those with both infections) have raised issues that have severely tested public health agencies like the CDC and have stressed the broader public health community.

People on one or another side of these debates often said (or shouted) that science alone should guide public health policy on these issues, and that politics should play no role. The central importance of public opinion, and the role of elected officials at every level of government, is basic to an understanding of how such a complex issue is handled in our democracy. Science must inform public opinion, but doing so effectively requires clear thinking and clear speaking by public health scientists.

Our culture surely affects how each of us views these questions––not only the culture at large, but also that of our particular subgroup, whether that subgroup be coworkers in a public health agency, or friends in the gay community, or fellow believers in a conservative religious community. The challenge is not to deny these cultural forces, but to be aware of our own personal values, preconceptions, and biases––our culture––as we approach scientific and public policy questions.

Finally, the debates about infected health care workers have been filled with questions about the freedom of individual workers to do their jobs unhampered by an obtrusive, interventionist government––and the right of uninfected individuals to be free of unreasonable threats to their health and welfare.

These issues are surely not fully settled, but matters of democracy, culture, and freedom play important roles in what some described as purely scientific issues.

Short-changing the skills of public health leaders compounds the problems of morale and contributes to the difficulty in attracting and retaining the best and brightest to the field.

Systems

What practical steps might improve working conditions for public health leaders? A recurring theme is the need for a general overhaul of personnel systems, to give more flexibility in the management of complex institutions in the public sector. My experience has convinced me that the frequent caricature of an encrusted bureaucracy accurately reflects the true situation.

My worst personnel mistake in government service was first hiring, and then retaining beyond the probationary period, a person about whom I had grave doubts from the beginning. I made the hiring decision because I had no other options in the civil service system. Its cumbersome rules and procedures prevented me from hiring anyone else. Once it became clear that I had made a major mistake, those same regulations prevented the employee's removal. This is but one example from one person's experience. The lost productivity and resulting frustration across the public sector caused by this problem are monumental.

Another often-mentioned need is for a "portable pension" system that would allow movement among levels and jurisdictions without sacrificing retirement benefits. The analogy to the TIAA-CREF system for educators has been drawn. My personal experience illustrates this matter. I recently left government service for the private sector, after 16 years in local, state, and federal public health agencies. My retirement benefits for this entire period are precisely zero. Because I did not serve long enough in any of the retirement systems to vest for pension purposes, I am now in my mid-forties facing the need to compensate for many years without a good retirement plan.

Although my case is near and dear to my wife and me, I do not think it is unique. This same problem is faced by large numbers of persons in the field. The growing number of senior public health officials who are moving to positions in health care delivery firms is a reflection of the opportunities in the health care sector, but I believe it is also the result of these persons' desire to offset years of service in a field that makes retirement planning difficult. Instead of moving to other leadership opportunities in public health, perhaps even choosing to teach the discipline in an academic setting, they often opt to move from public health to health care. One virtue of this phenomenon is the resulting numbers of persons in health care organizations who are inclined to take a public health perspective on medical care issues.

Finally, an issue I noted above is the political vulnerability of senior appointees in public health. Positions that have often been viewed in the past as professional or technical are now viewed as political, with the resulting lack of security that this implies. This can result in persons facing the choice either not to accept the more senior positions, in order to stay in "safer" second-tier slots, or to come to terms with the likelihood of frequent career moves, almost regardless of performance.

Again, my own experience colors my thinking in this area. Despite being warned a decade ago by colleagues that taking a job in the White House might well return to haunt me, I chose to make the most of that and other opportunities. I have no regrets about those choices, and feel extremely fortunate to have been given the chance to make them. Nevertheless, my career illustrates the issue of lack of security, which is compounded by the retirement pension problems discussed earlier.

I believe the insecurity of top public health positions leads many to avoid these roles. The tenure of the average state health director today is less than two years. It is becoming increasingly difficult to persuade qualified people from across the country to move themselves and their families for such tenuous jobs. Unfortunately, one response now is to appoint someone from within the state who may well not be prepared for the complex challenges of leading a modern public health agency.

The establishment of a professional corps of public health leaders serving state and local agencies, rather like the Commissioned Corps of the U.S. Public Health Service at the federal level, might permit greater stability of many persons in these positions. Perhaps the Commissioned Corps itself could be used for this purpose, through greater reliance of intergovernmental personnel assignments.

It should be noted that, at the highest levels of public health agencies, persons who are not themselves health professionals have served with distinction. The set of skills required for leading large agencies, and especially for relating directly to elected officials, does not necessarily include a health professional degree

What Is to Be Done

A significant improvement in any or all of these areas would be in the public interest. However, tackling these and related issues will not be easy. If there were simple solutions, they would have been implemented long ago. At a time when our national leaders have become enthusiastic champions of "reinventing government," however, perhaps we need to make a major attempt to reinvent public health.

These three impediments to leadership in public health, if properly assessed and acted upon, could become three areas of progress. But substantial change is impeded by acceptance of the status quo and a lack of willingness to push hard for improvement. Low morale has been so commonplace that it is difficult to imagine another arrangement, at least as a permanent phenomenon. Similarly, training public health leaders in totally different ways and radically reforming governmental systems appear to be unthinkable.

In this era of possible health reform, a significant opportunity lies in drawing the fields of public health and health care delivery closer together. A significant step toward achieving this goal would be building cooperative linkages between schools of medicine and schools of public health. The academic institutions that are training future leaders for medical care and for public health must collaborate to produce both physicians who are equipped to deal with the health problems of populations and public health workers who understand the medical care system. Indeed, over the long term, we can aspire to having a "health system" that does not involve constant discussion of this matter of two separate and different worlds.

The major progress in public health leadership that I am calling for will require entirely new and different efforts. We need not simply minor, or even modest, adjustments, but rather major shifts. It is with a view to such a quantum leap that the Milbank Memorial Fund convened the meeting on public health leadership in November 1993, which was designed to foster innovative thinking about these problems and to search for creative solutions.

The opportunities for progress in public health have never been greater, despite the complexity of the issues we face. If we can just assemble a large enough group of leaders who are equipped to deal with these matters, and if we can alter their working environment to remove the bigger obstacles in the system, then morale problems will take care of themselves. The single greatest difficulty facing us is a general unwillingness to confront the lack of leadership in public health and then allot the necessary time and resources to deal with it. It is time to set aside this reluctance and tackle the task.

Reference

Institute of Medicine, Committee for the Study of the Future of Public Health. 1988. The Future of Public Health. Washington: National Academy Press


About the Authors

Molly Joel Coye is the director of the West Coast Office for The Lewin Group, a health care strategic planning, policy, research and management consulting firm. She was previously executive vice president for strategic development at HealthDesk Corporation, a developer of online consumer health information and communication systems. She has also served as senior vice president for the Good Samaritan Health System, commissioner of health for the state of New Jersey, and head of the Division of Public Health at the Johns Hopkins School of Hygiene and Public Health.

William H. Foege is the Presidential Distinguished Professor of International Health at Emory University. He is also the executive director of the Task Force for Child Survival and Development. Previously, Foege was the director of The Carter Center and the Centers for Disease Control and Prevention.

William L. Roper is dean of the School of Public Health, The University of North Carolina at Chapel Hill. He was senior vice president of Prudential HealthCare. He also served as the director of the Centers for Disease Control and Prevention, the director of the White House Office of Policy Development, as the head of the Health Care Financing Administration, and as a county and then state health officer in Alabama.


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