What is being asked of public health leadership in this moment?

On exercising leadership in pursuit of a healthier world.

I recently had the privilege of speaking at a European Public Health Leadership Course. I very much enjoyed being among the next generation that will lead public health in future. Most importantly, the event pushed me to pause, to note, through conversations with many in the group, that there is a universality of questions that public health is currently asking, questions like: what is leadership in public health? What are priorities for future leadership in public health? How does public health lead in a way that creates confidence in what we do? These questions are resonant worldwide, and even more so in the US in the aftermath of the national election where these very questions were of central importance to the national conversation and to the forward march of history. We are indeed in a time when leadership in health matters perhaps more than ever. Public health, along with science generally, faces a crisis of trust in the post-COVID moment. Challenges like chronic disease, addiction, gun violence, and persistent inequities continue to hold health back nationally and globally. We are seeing a rethinking of the institutions and social structures which, depending on their alignment, can help the health of the public or hinder it. Our capacity to address these challenges, to engage with this moment, is complicated by shifting political winds and voices from both within and outside the field calling for radical changes to how we do what we do. In such times, it is on all of us to rise to the occasion by showing the leadership the moment demands.

With this in mind, I would like to reflect here on how we can exercise leadership in health in the coming decade. I will start with a basic question: what is leadership? I have always thought leadership was best defined by Alan Keith, who said “Leadership is ultimately about creating a way for people to contribute to making something extraordinary happen.” This is exactly right. We are all leading in our own ways, we are all trying to advance a vision of a healthier world. It is in this spirit that I share these thoughts on leadership, reflecting our collective responsibility to lead in this moment in whatever ways we can, consistent with leadership’s goal of helping us contribute what we can contribute, energized by a feeling of mission and common purpose. My hope is that these thoughts inform a conversation where we all lead on public health ideas going forward. I realize that this runs counter to the more stereotypical view of the leader as a strong, indispensable personality functioning as the glue which holds great endeavors together. Such leadership has its place, but, by and large, it is leadership that empowers others, acting with humility and an eye towards the creation of sustainable systems, that has the broadest applicability across a range of contexts and institutions.

So, how do we ground a discussion of leadership in public health. How can leadership create the conditions that allow others to thrive? How can we show leadership in creating a healthier world in the coming decade? I have drawn on the work of many to organize my thoughts, but focus my thoughts here on inspiration provided by the Milbank Quarterly in its values statement suggesting that leadership for health should be future-oriented, aware of the needs of the many, inquisitive, principled, and pragmatic. I will discuss each of these domains in turn.

First, leadership for health needs to be future-oriented. Leadership is something we practice in the present, but it is not for the present only. We lead because we want to build a future—for ourselves, for our children, for our children’s children. This is a big task, and such tasks are not completed in a day. They are the work of years, often generations. Leadership, then, in the work of building a healthier world must be focused on where we are in the moment but always looking to where we want to go. While there can be a conservative element to leadership in the sense of trying to preserve useful traditions and time-tested best practices, leadership is fundamentally about engaging with the future, about moving the ball down the field. In the context of health, this means asking: what is going to affect health tomorrow? What are the ideas, trends, technologies and social movements that will shape the future of health? These questions are often easier asked than answered. It is hard to tell, in the noise of today, what will be most salient for tomorrow. But it is a responsibility of leadership to try to “separate the signal from the noise” and aspire to a farsightedness that helps us get to the future. This means paying attention to developments likely to shape the future, such as urbanization, migration, global aging, climate change, and new technologies like AI. One is reminded of the show The West Wing, where the fictional President Jed Bartlet’s signature phrase is “What’s next?” This well captures where a leader’s long-term focus should always be: on tomorrow.

Second, leadership should be aware of the needs of the many. Creating a healthier world means creating such a world for all people, not just some. This means embracing a vision of leadership which works to ensure no one is excluded from the conditions that create health. This vision reflects our foundational focus on addressing health inequities. We have committed ourselves to a radical vision that says it is not enough to build a world where 99 percent of the population is healthy. We are not done until everyone can enjoy a rich, full life founded on a basis of health. This is the essence of health equity, the core principle that is at the heart of all we do in public health. This is another principle which is perhaps easier to articulate than to enact. This is particularly the case when we factor in our own biases, which can prevent us from seeing when a policy is not working for everybody. During COVID, for example, public health led the way in pushing for broad society-wide lockdowns. These lockdowns were not terribly onerous for those in higher income brackets who were able to work from home but were a challenge for those not part of “the laptop class” who worked in lower-income professions. This meant that risk of infection was higher during the pandemic for populations with fewer resources and lower for populations with more. Was this an example of leadership being aware of the needs of the many? The facts suggest it was not. It is on all of us who work in health to ensure that, going forward, leadership in health truly means leadership for all people.

Third, leadership should be inquisitive. By this I mean we should be willing to ask difficult questions which may have uncomfortable answers. The way we view the world is often flawed, incomplete. When we understand this, we can see the value in continually asking questions, in interrogating our assumptions, in wondering, always, if there is something we might be missing and working to find what that may be. When we are not inquisitive, when we avoid difficult questions and those who pose them, we risk falling into groupthink and developing the kind of blind spots that can lead to truly significant errors. Remaining inquisitive can also help us to identify new approaches, new ways of thinking that can improve our ability to do what we do. There is always more to learn, room to improve. One is reminded of what the great film director Akira Kurosawa said when, at the age of 80, he accepted an honorary Academy Award for his legendary career:

“I’m a little worried because I don’t feel that I understand cinema yet. I really don’t feel that I have yet grasped the essence of cinema. Cinema is a marvelous thing, but to grasp its true essence is very, very difficult. But what I promise you is that from now on I will work as hard as I can at making movies, and maybe by following this path I will achieve an understanding of the true essence of cinema and earn this award.”

When Kurosawa said this, most of his career was behind him and he had already created some of the most influential and lauded films of all time, making him a leader in his field. Yet he was still approaching his work from a place of inquisitiveness and humility, an outlook which allowed him to remain artistically vital to the end. We should be equally humble in our approach, open to learning more about the world and about how to become ever better at making it healthier. This includes having the humility to ask questions even when the answers run counter to what we think, or hope, to be true. Showing leadership means engaging with difficult questions despite the challenge of doing so. Ignaz Semmelweis’s curiosity about the causes of maternal mortality led him to recommend handwashing in hospitals—truly a groundbreaking suggestion. This sparked fierce opposition from many doctors, who resented the implication that their hands were unclean. But Semmelweis persisted, showing leadership which was not appreciated in his lifetime. But the fruits of his inquisitiveness would lead to a healthier world as handwashing was eventually embraced, saving many lives. We should learn from such examples by having the courage to ask questions and reckon with the full implications of their answers, mindful that this is the only way a field truly moves forward.

Fourth, leadership should be principled. This means leadership should be committed to a radical vision of the future that is founded on principles of equality, justice, and inclusivity. Keeping this commitment calls on us to engage with elements of our society and history which may be harming health, even when addressing them is uncomfortable. In the US, for example, this means addressing the history of racism and injustice that contributes to deep health gaps between black and white populations. It also means being willing to call out our own field when we stray from our foundational principles. There are times when we have not lived up to our ideals, when we have been complicit in injustice or the persistence of an unhealthy status quo. Leadership means acknowledging this and trying to do better, working to instill principle in all we do.

Finally, and balancing principle, leadership should be pragmatic. By pragmatic, I mean able to pursue a radical vision practically, incrementally, with the understanding that it is possible, even necessary, to make tactical compromises without compromising on a long-term strategic vision of a healthier world. Such pragmatism can sometimes seem at odds with principle, seeming like a betrayal of the radical vision that guides our efforts. But principle alone is not enough to change the world, and neither is pragmatism. It is only when principle and pragmatism work together that we have a viable path toward creating a healthier world. This is the case in considering a phrase which became famous during the COVID years, “Follow the science.” On the surface this seems simple enough, suggesting that science can point us towards ineluctable truths which, once known, should be as a North Star guiding our efforts. Yet this vision is incomplete. Science is just one aspect of public health decision-making, a process which also includes a range of social and political considerations. The science, for example, says clearly that we could greatly reduce deaths in car accidents by dramatically lowering speed limits. But we do not do so. Why? Because while we value safety, we also value other considerations, including the convenience of quickly getting where we want to go and the enjoyment of driving fast. So, we have adopted pragmatic limits which are sensible in the context of these considerations when they are taken together. And there is nothing wrong with this. Leadership for health should aspire, always, to strike such a balance, informed by the science, adhering to our principles, while working pragmatically towards what is best for health in the moment. We arguably did not do this enough during COVID, when a principled vision of safeguarding health caused us to sometimes act unpragmatically, as we pushed for lockdowns without giving due consideration to the costs of these polices—in mental health challenges, in educational disruption, in drug overdose. We cannot afford to make such a mistake again. Leadership in this moment means making compromises, being pragmatic, having a vision but being willing to do what it takes—reasonably, responsibly, mindful of the world as it is—to get to where we want to go.

In articulating these principles, I do not mean to suggest that they capture everything about the leadership that is being called on for health in the coming decade, only that they may serve as helpful guideposts for our thinking about how to exercise leadership that does right by this moment. Thank you to the many who have shown leadership—both within the field of health and outside of it—in pursuit of a better world. As we navigate the coming years, such leadership will be needed more than ever to ensure that we are indeed laying the groundwork for a healthier future.

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Also this week

ICYMI, recent thoughts with Dr. Mohammed Abba-Aji, in JAMA Health Forum, on the future of population health science and scholarship.

New in Observing Science, with Michael Stein, a reflection on the link between science and art and the values that sustain both.

It was a privilege to participate in a conversation about the new book, “Ripples of Hope in the Mississippi Delta: Charting the Health Equity Policy Agenda,” by our late colleague, David Jones. A recording of the event will be posted here.