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July 22, 2020
View from Here
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The practice of public health bumps along in heroic obscurity—its practitioners resigned to a lack of attention and respect compared to their life-rescuing medical care siblings—until suddenly it doesn’t.
A pandemic is one of those times. Now prevention merits attention. Epidemiologists are getting at least as much airtime as emergency room physicians.
In this light, I am reminded of an observation of physician, author, and advocate Fitzhugh Mullan, who is often quoted by my colleague Nick Macchione, director of San Diego County’s Health and Human Services Agency. “Public health leaders,” he says, “have to have three role models to be successful in their work: Robin Hood, Machiavelli, and Don Quixote.” We are seeing those figures’ attributes—charity, guile, and the capacity to dream—in state and county health officers leading efforts to combat COVID, but they are not enough for the particular moment we face.
Nicole Alexander Scott, the health director in Rhode Island, and her boss, Governor Gina Raimondo, were quick to follow the lead of the Sherwood Forest hero and hit up hometown company CVS to set up COVID testing sites in early April, making the Ocean State was an early leader in testing its citizens. When outbreaks of the coronavirus began in densely packed, lower-income neighborhoods, the state made sure that testing sites were available in those areas.
Working in political cultures with a strong emphasis on individual liberties, State Health Officers Thomas Dobbs of Mississippi and Scott Harris of Alabama have to be crafty like Machiavelli as well as thick-skinned. These officials need to promote the collective good while navigating the interests of the elected officials and the public to whom they answer, and the conflicting desires of local jurisdictions for both direction and independence. Describing the essential task of a public health leader, Dobbs diplomatically told National Public Radio: “We are trying to build a coalition of people that follow the evidence and follow science so that we can collectively make the best decisions we can to prevent transmission in a way that people find acceptable and is also sustainable.”
For his part, Harris is not shy. When advocating with legislators for maternal health programs, he has overlaid 19th century maps of Alabama slave populations with 21st century maps of infant mortality rates. And he was willing to go national in his efforts to strengthen the impact of his office’s COVID guidance. Calling out the lack of local support for enforcement of public health measures, Harris told a national reporter: “I think we certainly would prefer to have additional restrictions if we felt like they could be effective, and, frankly…we don’t necessarily get the compliance we would like to see, even with the current orders in place.”
Finally, although lacking a trusty steed and a soundtrack, successful public health leaders have to be motivated by an “Impossible Dream,” just as the Man of La Mancha was. A motivating vision—of evidence-based prevention, mitigation, and control policies, smoothly implemented with universal compliance, resulting in isolation and elimination of the virus—is essential for leaders in a time of pandemic.
The dream requires hope, and occasionally that hope is rewarded, as was the case for Macchione, who was one night away from shutting down testing clinics in San Diego earlier this month when he received an 11th hour phone call from a local company offering needed testing supplies.
Sometimes, though, the dream has to be scaled back, and mere adherence to social isolation practices by political leaders seems a big ask, as was the case for Dobbs when earlier this month he had to announce an outbreak of 41 COVID cases in the Mississippi legislature itself. And sometimes the dream is hard to keep alive. Between April and June, according to the Associated Press and Kaiser Health News, at least 27 state and local public health directors had resigned, retired, or were fired. These leaders were forced out by social media–accelerated threats, harassment, and pressure from public officials and private citizens.
That is why I think Macchione may need a fourth role model for all public leaders, perhaps Franklin Roosevelt. In times of crisis, reliance upon science, evidence, and logic for sound policy is insufficient. Political will is needed. To build it, leaders call on ordinary citizens to personally sacrifice by enlisting their hearts, minds, and bodies in a fight against an unseen enemy for a cause bigger than themselves.
In his 21st fireside chat, five months after the bombing of Pearl Harbor, Roosevelt explained his program to generate resources for the war effort, setting public expectations for the rationing, higher taxes, and wage and price controls that lay ahead for the country:
“…’sacrifice’ is not exactly the proper word with which to describe this program of self-denial. When, at the end of this great struggle we shall have saved our free way of life, we shall have made no ‘sacrifice.’ The price for civilization must be paid in hard work and sorrow and blood. The price is not too high.”
With counsel we sorely need at this juncture he went on:
“This great war effort must be carried through to its victorious conclusion by the indomitable will and determination of the people as one great whole. It must not be impeded by the faint of heart. It must not be impeded by those who put their own selfish interests above the interests of the nation. It must not be impeded by those who pervert honest criticism into falsification of fact. It must not be impeded by self-styled experts…. who know neither true figures nor geography itself. It must not be impeded by a few bogus patriots who use the sacred freedom of the press to echo the sentiments of the propagandists.”
We in the United States now face a similar moment with the coronavirus, and our national leaders are failing us. Waiting for a miracle vaccine, counseling a false balance of public health measures and economic activity, and acquiescing to the noisy few is not leadership. Besides charity, guile, and dreams, we need leaders who will summon “the better angels of our nature” to make the sacrifices necessary for our country and our future.
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