Jan Malcolm
Appearances
Health Chatter
Public Health Leadership
Well, you know, when I said there are so many lessons we need to learn or we must learn, I think, from what we've just been through, there's a lot to unpack in that question of how does the medical care system and public health
Health Chatter
Public Health Leadership
um best interact um you know and i think there's a lot of specific experiences we had through covid that uh that can help us um deepen that understanding i you know quite honestly i think when it came to particular things about the pandemic response our respective roles were not clear Who should do what? Who is in the best position to stand up all that testing and do the mass vacs?
Health Chatter
Public Health Leadership
And, you know, are those the things we typically lean on healthcare for? But healthcare didn't have the capacity to do it, nor, you know, in some respects, did they have the incentives to do it? Crazy as that sounds. So, but we haven't built a public health system to be that safety net when it comes to the delivery of some of those services. So should we?
Health Chatter
Public Health Leadership
You know, and how do we kind of put some surge capacity back into the public health system and into the healthcare system when that's systematically been squeezed out over years and years and years of... of resource constraints and short workforce and all the rest. I think we absolutely learned how interdependent we are on each other.
Health Chatter
Public Health Leadership
I mean, healthcare could not succeed unless public health could succeed in trying to keep as many people from getting sick as possible and to get the the preventive measures in place. Politically, we absolutely needed the healthcare system's support to say, we have got to do some of these things at the community level to try to restrict the spread because we can't handle
Health Chatter
Public Health Leadership
this surge in volume if we just let this thing rip through the society. Certainly, we couldn't succeed in keeping the public healthy if healthcare didn't have the capacity to take care of the people that inevitably were going to end up needing Needing acute care.
Health Chatter
Public Health Leadership
So I mean, to me, this was a wake up call that we better have some deep conversations about what our respective roles are, how we can best support each other. where we need to beef up the resources, because I think we'd be naive at best to think that this was only a once-in-a-hundred-year thing. Correct. No way. We know.
Health Chatter
Public Health Leadership
I mean, the virologists know how much is sort of out there, able to do what COVID did at any given time, just given the globalization of of the economy, of the world. It's a much smaller world than it was in 1918. And climate change is absolutely a driver of what we're seeing with viruses. So we got to be more ready. And I think that takes a deeper conversation about
Health Chatter
Public Health Leadership
what went well, what didn't go well, where did we kind of spend time and lose time trying to negotiate who should do what and figure that out and then support each other. Healthcare needs to show up for public health.
Health Chatter
Public Health Leadership
to say, you know, we need public health to be strong and we need them to have resources and we need them to have authority and we need, you know, they need to see the degree to which our capacity in public health is necessary for them and vice versa. I mean, I think we should be like seriously kind of really pretty concerned about what we've just seen about the fragility of the healthcare system
Health Chatter
Public Health Leadership
um in terms of surge capacity or lack of surge capacity um you know and and the workforce shortages that are popping up all over the place that's a shared problem right but we don't we don't typically you know we typically you know kind of public health's over here and health care's over here and we're looking out for ourselves we gotta look out for each other to a greater you know um
Health Chatter
Public Health Leadership
Yeah, no, I think that's exactly right, and that's one of my biggest worries, actually.
Health Chatter
Public Health Leadership
This was so disruptive, you know, so bad. Everybody just wants... Nobody wants to talk about this except the three of us, maybe. It's like, don't say COVID anymore. And I think... we, we do have a, you know, a window here to try to, I agree while things are still fresh to have some candid conversations, but it's, you know, and I understand why people aren't so very eager to, to go there.
Health Chatter
Public Health Leadership
Cause it's, it is, it's hard. Yeah. We're recovering from it. It's, you know, it brings back some pretty, pretty bad feelings to, to reflect back on it. But, but boy, I sure hope we do.
Health Chatter
Public Health Leadership
Yeah, you know, I really do think that we can use some of the specific things that we saw in COVID to illustrate things we've been talking about for quite some time about, you know, the fundamental need to work on the community conditions that support health or that don't support health, that it isn't all about the biomedical, you know, end of the continuum.
Health Chatter
Public Health Leadership
It's about what really determines health. It's not just can you get to the doctor when you need to, essential as that is. It's about the conditions in your community, about people's economic security, their physical security, housing, the environment, the access to resources.
Health Chatter
Public Health Leadership
And I think we saw that in who was disproportionately exposed to COVID and who was disproportionately affected by the severity of it. And so taking some of those just really, you know, practical lessons learned about the importance of the housing conditions, the working conditions. Could you get access to tests or not?
Health Chatter
Public Health Leadership
Did, you know, how did we do at getting, you know, testing, vaccination and therapeutics into the communities that were the hardest hit? You know, I think we've got some really tangible examples, you know, when we kind of talk about the the social and economic determinants of health in a theoretical way, people just don't really quite get what we're talking about. But when we say,
Health Chatter
Public Health Leadership
look at the patterns of how COVID moved and how much that was influenced by things like housing conditions and working conditions and multi-generational families and the lack of good quality ventilation in buildings and all of that stuff. I think we just reflect on, okay, what did we see and how do we talk about that in ways that policymakers and other influencers
Health Chatter
Public Health Leadership
can can see the need to really invest in those community conditions and not just you know as important as it is to say boy we need more nurses and doctors yeah we do and that's not enough right you know we need we need to to pay attention to these community conditions way differently than we have so ask a question let me let me ask you a question because i'm i'm intrigued now by the fact of how you've been responding uh
Health Chatter
Public Health Leadership
Wow. So many inspirations along the way. But, uh, you know, I, I go back to, I mean, many years ago, I was a much younger person, you know, somebody who really inspired me a lot was Dr. David Satcher, former surgeon general of the United States.
Health Chatter
Public Health Leadership
I mean, I can remember him, you know, talking about this, you know, kind of the social determinants of health before very many people were using that terminology. Um, You know, and he would talk about I can remember vividly a speech that he gave. He was talking about how this was in the in the 1990s, talking about how unacceptable infant and maternal mortality rates were back then.
Health Chatter
Public Health Leadership
And he said, you know what the most important factor is for infant and maternal mortality? Maternal income security. I was like, whoa, you know, light bulb just kind of went off. It's not just prenatal care or not. It's that more fundamental, do people have what they need to be safe and healthy? And so he really was, he sort of put that spark in me, you know, early, early on.
Health Chatter
Public Health Leadership
And since then, it's really been, you know, leaders in the community, many of whom were were rightly kind of critical of kind of what we were doing with the response. And this is a dilemma, I'll just call it right out, between focusing on the largest number of people versus focusing on the biggest degree of harm, if you will.
Health Chatter
Public Health Leadership
So the whole tension between how do you deploy the resources from an equity perspective
Health Chatter
Public Health Leadership
Um, you know, whether we're talking about testing or vaccination, you know, how do we, how do we prioritize the populations that, that are at the greatest risk while the, the other side of the coin is saying, but you got to get the countermeasures and, you know, as broadly spread as possible, as fast as possible. And that kind of makes you do these sort of more, more untargeted mass events.
Health Chatter
Public Health Leadership
And, and so that, you know, I, and I, you know, I kept being challenged appropriately. So by leaders in the community saying, this isn't working, you need to do more to get the resources deeper into the community. You know, and, and I mean, the, the, the, I will just call out, you know, kind of the black religious leaders, you know, the, the, the, the churches, the pastors, the,
Health Chatter
Public Health Leadership
You know, and the folks in service organizations like yours, you know, working with communities to try to get communities access to the resources and to get the resources deeper into communities.
Health Chatter
Public Health Leadership
I think we got better as we went, but it was always a challenge to, you know, to get that balance between the big, you know, the big P population and the more targeted communities where the needs were particularly great.
Health Chatter
Public Health Leadership
Well, I think that is, you know, that's a question, that too is a question that really needs a lot deeper discussion. I mean, we've, to your point, public health is hugely underfunded. No matter what part of the public health Absolutely. Infectious disease is underfunded. Emergency preparedness is underfunded. Chronic disease is certainly underfunded.
Health Chatter
Public Health Leadership
You know, analysis and planning is certainly underfunded. So it's it's kind of I think where we in public health are kind of expected to do all of it. But but really without any appreciation of of. what it takes to do it, to do it robustly and well. I can remember you raised tobacco as a great kind of lesson, if you will, of how this works.
Health Chatter
Public Health Leadership
I can remember in my first term at the health department with Governor Ventura, it was right after the tobacco settlement. And, you know, so we had this boatload of money coming from the tobacco settlement with kind of lots of differences of opinion about how that money should be spent. But very little support for spending it on prevention. Oh, let's spend it on cancer treatment.
Health Chatter
Public Health Leadership
Yeah. Let's, yes, exactly. Let's, you know, let's help people stop smoking. Well, yes, let's, but let's. try to work on the prevention side as well. And I think we had some real successes there because with that money and with, frankly, Governor Ventura's support, we were able to get more money put into the prevention side than we ever had before. We went from funding our
Health Chatter
Public Health Leadership
our anti-tobacco efforts at a couple million dollars a year, which was like, if that's all you're going to spend, frankly, why don't you save it? Because it's not going to make a difference. It's not going to move the needle at all if you're battling against all these bigger forces that are much more
Health Chatter
Public Health Leadership
successful in uh in getting people to smoke on the marketing side or use tobacco commercial tobacco but but when we could really appropriately resource it we actually produced some pretty good results it wasn't just the money but it was this multi-layered strategy of understanding oh you got to work at the individual level you got to work at the family the community the policy level
Health Chatter
Public Health Leadership
And we had all these things kind of working in synergy. And we dropped youth smoking by 30 percent in about five years. It was like, wow. And it was a combination of lots of different strategies. So to me, that just sort of says we and I think we did it again in the pandemic with a lot of resources. We moved mountains in a hurry. We can do it.
Health Chatter
Public Health Leadership
But it takes it takes resources that we don't typically have in public health. So in chronic disease, I kind of went off a little bit there on a tangent, other than the point being our role is prevention of chronic disease.
Health Chatter
Public Health Leadership
And that's where, again, I think we need our healthcare colleagues to say, we have to be working at the population level to try to reduce these risk factors overall, because just trying to remediate or treat or cure at the other end is going to overwhelm us.
Health Chatter
Public Health Leadership
And because, you know, people just like, well, you know, if I get diabetes, I'll take the drug, you know, or if I have a heart attack, the hospital will save me. You know, I mean, that's sort of how we think about, you know, kind of our individual perceptions of risk.
Health Chatter
Public Health Leadership
And, you know, and I think a lot of folks in the legislature, for example, think, well, the chronic disease, you know, managing that, that's healthcare's job. We want you public health people to, you know, you do this emergency stuff because we just saw that we really need you to do that. You stop the outbreaks. And healthcare should deal with chronic disease.
Health Chatter
Public Health Leadership
But I don't think healthcare is set up to do that. Not the way healthcare is paid for. So I think a lot of this, I know this is kind of wonky, but so much of this comes back to financial incentives and how the healthcare system is paid and how the public health system is funded or isn't, that we just really need to, you know,
Health Chatter
Public Health Leadership
to have a much more specific question about, and I think we've got good roadmaps from CDC and others about what would it take to fund things at a robust enough level population-wise to to make a difference. There are recommendations about what should public health funding per capita be? No state is close. If we really wanted to intervene on the upstream end, how much more should we
Health Chatter
Public Health Leadership
Should we invest upstream? You know, I mean, it's still, what is, maybe you guys know the current data better than I do, but it's, you know, what is it still like 97, 98% of all the dollars are going into the intervention and a pittance is going into prevention. Well, you know, guess what? Part of the reason that other countries spend less money and get better results than we do.
Health Chatter
Public Health Leadership
They put more money, not only into kind of classic, you know, classic, if you will, public health, but also into what we were talking about earlier, the social determinants of health, the social net is stronger in places that invest more in housing and economic development and, you know, on and on.
Health Chatter
Public Health Leadership
And so I think the economics are actually on our side, but we got to really sharpen our arguments around that and broaden the coalition of people who can see that picture and see how all these things really are so interconnected and start to move more of that money upstream, because we will all suffer from it.
Health Chatter
Public Health Leadership
Great question. Well, I think we need to be partners. And the critiques are a part of that. You know, like to help us understand what isn't working from the community's perspective. But then we also need...
Health Chatter
Public Health Leadership
for community organizations, community leaders, community members to kind of embrace their role in changing some of the conditions so that it's not all like, you know, you out there, you government people, you need to fix this. It's like, how do we fix it together? You know, how do we
Health Chatter
Public Health Leadership
how do we get the community the resources and the support, but also look to the community to lead and to learn how to Let me take that back. It's not about learning how to take responsibility, because I think community knows that a lot, but how to exercise some of the The muscles, if you will.
Health Chatter
Public Health Leadership
I am so glad you did. I think you said it way better than I did. I was kind of trying to get at the same point, I think, that We have to support communities to be able to be more responsible and to create those expectations. Absolutely. You know, you're right about that. I think we need to be more explicit.
Health Chatter
Public Health Leadership
The expectations shouldn't be lowered for, you know, investing in the capacity of more community-based organizations to take more charge. But they also need to then, you know, be able to to deliver, as you say, and that's not a one way street.
Health Chatter
Public Health Leadership
So I love what you said about, you know, let's let's set the expectations higher and then let's have a dialogue about, you know, what is needed to be able to fulfill those expectations and get, you know, get the get the outside in, you know, perspective switched to the other way.
Health Chatter
Public Health Leadership
You know, I'm not sure I'm in a great position to answer that just because the last three years, as you said earlier, were hijacked by everything. So I don't have a great answer to that question, but I do think. that we need to do a better job of lining up our state priorities with the national.
Health Chatter
Public Health Leadership
And we've spent a lot of time writing plans, and I'm not always sure that we're using the plans that already exist well enough to save the resources. I did want to, if it's okay, Stan, I know Clarence was trying to make another point there before. I know we're getting close on time, but I just wanted to turn it back to Clarence and see if he had another comment that he wanted to make.
Health Chatter
Public Health Leadership
Well, I think there's often not a lot of time for that. And I'm so proud of Commissioner Cunningham and the work that she has been doing and will be doing on equity and so many other things. The job is like you're in the deep end of the pool right away and having to juggle a million things and there's not as much time for that sort of
Health Chatter
Public Health Leadership
reflection and bigger picture conversation that things tend to be more like, how do I handle this thing? And anything a former colleague can do to help their successor. I think there certainly is a willingness. I know I'm part a member of the Alumni Society of the Association of State and Territorial Health Officers. And we talk about that a lot.
Health Chatter
Public Health Leadership
It's like, how do we make this easier for the folks who've been around the block a few times to be helpful to the people who are in the hot seat now? Because it's just The pace of the work doesn't really allow that as much as you would wish. How do we build more time into the jobs of leaders at any level for this kind of continual learning and reflection and improvement?
Health Chatter
Public Health Leadership
We don't do a very good job of saying how much of the leader's job is that.
Health Chatter
Public Health Leadership
That's very kind of you, Stan. And I think that that is, again, kind of what I love about public health, the people in public health.
Health Chatter
Public Health Leadership
We don't always do it perfectly, but we get it that, you know, this is a team effort. It's not just individuals working really hard. It's the collective impact of people knowing how to work together and how to support each other. So I think that's a great note to end on. Thank you.
Health Chatter
Public Health Leadership
Well, first of all, thank you for inviting me to join you and Clarence in this conversation. I think it's a critically important topic, leadership in general, but leadership in health, leadership in public health, particularly now, given what we've just been through and the time that we're in, there is so much we need to learn.
Health Chatter
Public Health Leadership
from what we've just been through and figure out how to take those very hard won lessons through the COVID-19 pandemic and apply them not only to being more ready for the next health emergency, but how do we improve what we do every day to serve the people that we serve, which is everybody.
Health Chatter
Public Health Leadership
And I think too, that, you know, the one thing I know for sure is that it is not true that leaders are born and not made. I think there needs to be intentionality to to thinking about what is leadership? How do you get better at it? Nobody just, you know, kind of comes fully formed as a leader, no matter your training or your experience. I think there are always ways to get better.
Health Chatter
Public Health Leadership
I do think that there are certain characteristics that help one to be a better leader, but the characteristics alone don't make you a good leader. And by characteristics, I guess I mean things like, I think actually there are values and there are personality traits, if you will, or styles, and then there are skills. And I think those are three different things.
Health Chatter
Public Health Leadership
But how you marry them together, how you take advantage of any, how you, first of all, I think it's a lot easier to lead and to lead authentically, which is a key word, I think, authentic leadership. People can sense it if it's there and if it's not. But what makes an authentic leader, I think, is somebody whose work is aligned with their values.
Health Chatter
Public Health Leadership
And who who kind of is intentional about how you how you use the traits that you either naturally have or that you learn over time and then being being really attentive to where, you know, where your skills are the strongest and where they're not. So I think, you know, kind of on that front of values to me and I feel so lucky to have had a career in health policy and public health.
Health Chatter
Public Health Leadership
because that is just an exceptionally well aligned with my personal values, especially the field of public health, what we're all about really just resonates with me and makes it easy to love this field and the people in it because we do share this deep values connection about social justice, about thinking at a very kind of ethically driven
Health Chatter
Public Health Leadership
equity-driven look at how society is either helping or harming people's ability to be healthy. I just have always felt so at home, actually, in this field and with these incredible colleagues that I've had. I think some of the traits that are important, again, I think top of my list is authenticity
Health Chatter
Public Health Leadership
and empathy, really genuinely caring about the work that you're doing and the people that you're doing it for and the people you're doing it with. And I think another trait that I would call out, probably especially from the last few years, is persistence. Because nothing that we do in public health is necessarily easy.
Health Chatter
Public Health Leadership
And nothing, I think we've learned this the hard way, even when we make great progress, that progress isn't, it's not a given that that's always going to last. You sort of have to keep remaking the progress and building on it. So I could go on and on about values and about traits, and we can go any way you want on that.
Health Chatter
Public Health Leadership
I'm not going to try to make a comprehensive list, but just wanted to kind of get across the point that I think it's helpful to be cognizant of You know what are the values are they aligned, what are some of the traits that you can draw on which might be different in different circumstances, and then the skills question and maybe we'll we'll go into that you know, through this conversation.
Health Chatter
Public Health Leadership
you know, but certainly communication, coalition building, kind of political acumen. I think, you know, we could go on and on. I think skills around emergency preparedness, oh my heaven, have we just learned, you know, how important that is, not just to read the book, but to, you know, practice that, I think, in a much more robust way than we've ever done before. So,
Health Chatter
Public Health Leadership
You asked me a really open-ended question, and I could go on the whole novel with that, but let me stop there.
Health Chatter
Public Health Leadership
Well, yeah, thanks, Clarence. You know, I think in a crisis in particular, communication is essential. That was probably the main job that I, as the leader of the state health department, had was to try to keep the lines of communication flowing between the scientists and the policymakers, between the quote-unquote experts and the public, with the media, with the legislators.
Health Chatter
Public Health Leadership
And to Stan's point, being able to not just say, here's my speech, I have to deliver these facts, to listen to people, to listen to the community. As I know you know, Clarence, this has been a devastating pandemic in many ways, but it absolutely further kind of illuminated and exacerbated, I would say, all the flaws in the system.
Health Chatter
Public Health Leadership
And so that people who've been disadvantaged and experienced inequities for so long on so many different fronts, it happened again with COVID. And so, understanding and listening to the community about what about our response? As hard as we were working and trying, what about it wasn't working for the communities that were at some of the greatest risk?
Health Chatter
Public Health Leadership
And to be not in denial about that and to really seek out honest conversations
Health Chatter
Public Health Leadership
with communities who were disproportionately affected, and then to Stan's point, on the other end of the continuum perhaps, the folks who really were having a hard time believing that COVID was as big a deal as we were saying, whether those were folks in the business community or folks who were just very concerned about the role of government in all of this, hearing that incredible,
Health Chatter
Public Health Leadership
variety of experiences and perspectives and being able to try to navigate your way through how do you effectively communicate with folks who are in such different places in terms of how this is affecting them, what the reality is of their point of view and their circumstances. So You know, there's many more things, obviously, about kind of keeping a cool head and trying to help keep people going.
Health Chatter
Public Health Leadership
You know, so many people worked their hearts out for so long and how to support them, how to encourage them. But I would say, you know, kind of that trying to help people keep it together from an organizational health perspective. And then... this multifaceted communication challenge, those would be probably the two things I'd call out.