Being a Good Follower

In 1988, the Institute of Medicine (IOM) released its seminal report The Future of Public Health, which defined public health as “what we, as a society, do collectively to assure the conditions in which people can be healthy.” For leaders in public health, The Future of Public Health was a wake-up call and a guidepost for those of us interested in measuring the progress of our efforts. For me, perhaps the most memorable passage of the 1988 report was its description of the activities of public health professionals:

Public health officials appear defensive and self-serving when they attempt to answer the criticisms of legislators or mobilize needed resources. Yet many public health professionals who talked with us seemed to regard politics as a contaminant of an ideally rational decision-making process rather than as an essential element of democratic governance. We saw much evidence of isolation and little evidence of constituency building, citizen participation, or continuing (as opposed to crisis-driven) communications with elected officials or with the community at large. ¹

The report made the case for a leadership deficit and the need for better leadership in governmental public health. It recommended the skills and backgrounds needed for public health professionals to lead and manage public health agencies. But it also made what was, for me, a more important observation: that the training of public health leaders must be accelerated and must encompass more than formal educational programs. Reflecting insights from interviews with health officials, the report underscored the importance of strengthening public health leadership. Since the 1988 IOM report, several organizations have designed and implemented training programs for that very purpose. ^{2 –5}

In 2003, 15 years after releasing The Future of Public Health, the IOM published The Future of the Public’s Health in the 21st Century, which again recognized the leadership deficit. The report recommended that “leadership training, support and development be a high priority for governmental public health agencies and other organizations in the public health system and for schools of public health that supply the public health infrastructure with its professionals and leaders.” ⁶

I understand the wisdom of that recommendation. Early in my career, I worked at a community primary care site that received government grants. Although I appreciated the grant programs that public health leaders designed to promote health equity and lower the burden of chronic disease, I came to feel that these programs were only minimally effective, largely because they did not often incorporate community participation and constituency building. My experience at the community primary care site inspired me to pursue a career in public service and help lead efforts to bring more community input into prevention initiatives.

Today, the leadership deficit persists despite the great work of organizations such as the Association of State and Territorial Health Officials and the National Association of County and City Health Officials. ⁷ One cause of the deficit is the high rate of turnover in public health leadership positions. According to the Association of State and Territorial Health Officials’ 2014 Profile of State Leadership, state health officials have an average tenure of fewer than 4 years. ⁶ Many of these officials hold gubernatorial appointments and know that they might be just 1 election away from leaving their positions. This uncertainty can lead to a short-term leadership style among officials who—compelled by a passion for their work and the pressure to rapidly demonstrate their competence to survive a change in political leadership—resort to programs that are not best suited to solving public health problems in the long term.

In the past few decades, we have come to realize, albeit slowly, how right the IOM was in 1988 when it recognized as a major leadership problem the isolation of public health officials and the uneven routine communication with elected officials. Public health officials must avoid these pitfalls. But that is not enough—effective leadership also must include another increasingly important function: convening the expertise and efforts of people from different parts of society, public and private. Without this convening function, it will be increasingly difficult to support the crucial infrastructure needed to maintain public health systems. By recognizing the paramount role of the social determinants of health and their connection to health disparities, today’s public health leaders need to be mobilizers of collective social action across many areas of human enterprise. Leadership, it could be said, now resides less in charismatic leaders and more in an apparatus of many people, private interests, and government bodies and authorities working together. Let me extend that even further. In the 21st century, a good public health leader must know how to be good follower.

Effective public health leaders must be able to outline a vision and stir people to action. But they must also be able to relinquish the driver’s seat—the spot usually assigned to them in a traditional governmental hierarchy—and support the ideas and work of diverse partners from other sectors, such as other government agencies, the private sector, local communities, and the health care system, as well as the less obvious partners in education, transportation, criminal justice, and environmental protection. Sometimes, paying attention to the connections and the interstices among efforts can make the difference. Sometimes leading is what is needed, but, increasingly, it is following.

We have learned that the health of the public relies on far more than public health workers, departments, and health care providers. Just imagine either the mother who wants to get immunizations for her children but has no way to transport them across town to the clinic, or the child with recurrent severe asthma who needs to live in a different kind of housing. The examples are endless. In cases such as these, public health leaders can sometimes lead best by embracing and supporting the efforts of people who work outside public health or even outside health care. A public health leader can lend his or her authority to health improvements afforded by a healthy home program, for example. Being a follower and supporter works better.

But isn’t this obvious? The answer is no, not always. In her book Followership, Barbara Kellerman, founding executive director of the Center for Public Leadership at Harvard Kennedy School, reminds us that leaders need followers. She asserts that, despite our tendency to view them as subordinates, followers are just as important as leaders. We cannot escape the natural human tendency to assume rank and authority. Kellerman notes, “The dynamics of power, authority and influence are endemic to the human condition.” ^8,9 The more we recognize that being a follower is not a flaw and that, increasingly, it is the followers rather than the traditional leaders who make things happen in today’s society, the more we can use that knowledge to public health’s advantage. Assuming a follower role among colleagues does not necessarily diminish stature. It can raise it, and it does.

This new followership idea might not be well accepted by every public health leader. Many traditional leaders might feel that assuming their places in front of the pack is the only way to reverse the many problems facing health departments, including workforce reductions, declining budgets, and low appreciation of the importance of public health despite the remarkable gains it produced during the 20th century. Increasingly, though, as we recognize the crucial connections between the status of the public’s health and so many aspects of human life, for public health to “get its mojo back,” ² its leaders must assume their places among allies rather than in front of them.

Leaders can find strong guidance in the Public Health Leadership Forum’s description of a new vision of governmental public health, which positions the health department as home to the community’s chief health strategist. ¹⁰ A chief strategist is a leader who, by definition, takes the long view of his or her role and the welfare of the public at large. As we continue to face national health challenges caused by the increasing burden of chronic diseases and their shared risk factors, we will rely more on such health strategists to recognize that efficiency and effectiveness require new approaches and that collaboration and integration must come before short-term gains.

The 7 practices laid out by the Public Health Leadership Forum are instructive: (1) addressing the causes of disease, premature mortality, and injury; (2) identifying and developing solutions for emerging health threats; (3) maximizing the use of big, real-time data; (4) collaborating with a wide, diverse set of allies within and outside the health sector; (5) modernizing organizational business practices; (6) leveraging collaboration with federal partners to address community health needs; and (7) partnering with health care entities to create a system for health. ¹⁰ For each step, leading might mean understanding when and how to be a chief among chiefs and when to be a good follower and collaborator. The skill of following, if thoughtfully and studiously applied, can make our ultimate goal of stronger, healthier communities easier to attain.