Institute of Medicine

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. Public health is grounded on a second foundation, that the truths of science will be used to benefit everyone. 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.

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. • 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. • Structure

• Surveillance systems. 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 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. The entire process of improving on the public health sector would then be used to develop both applied and basic research priorities.

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. 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.

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. 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 Ancona D: in praise of the incomplete leader. 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. 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. 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 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 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. 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. 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. 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 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. 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. 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. 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. 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.

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.

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 assignment also requires a comparison of the contents of the three articles chosen. The following is a brief comparison of the three. a) The first article, Goleman D: leadership that gets results dwells more looking at the causes of the problems that have plagued the public health sector. The author attributes most of them to the humans in charge.

He particularly pinpoints economic hardships as a factor that has hindered progress in public health management. At one point he also says that the incompetency of those in office is also pointing a blaming finger at given that they have contributed to the detriment of the service delivery. b) In the second article, Collins J, level 5 leadership, the author concentrates his efforts in attributing the current mess to science and its effects. On a positive note he also concurs that the same science can be used to rectify the situation and make the whole place a better place in terms of public health.

c) The third person on the spotlight is one, which entails his research work on condemning the fact that although the country has a huge population, not many are qualified to occupy public office and indeed deliver quality services to the people in their jurisdiction. He at one point tries to highlight the problems that have plagued the leaders in these offices. One in morale to undertake the obligations entitled to their offices. References Ancona, D, 2007. In praise of the incomplete leader Harvard Business school Collins J. 2005. level5 leadership.

The triumph of humility and fierce resolve, Harvard business school Goleman, D. 2000. Leadership that gets results, Harvard business school McGinnis, U. M. , and Foege, W. H. 1993 Actual Causes of Death in the United States. JAMA 270(18):2207-2212 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 World Development Report. 1993. Investing in Health. New York: Published for the World Bank by Oxford University Press

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