As public health leaders around the globe work to provide leadership in these challenging times, each day will present new or recurring leadership challenges. Some lessons learned from prior outbreaks may serve as useful guideposts. However, the coronavirus outbreak has, in important respects, presented unprecedented challenges. Therefore, leaders will draw on wisdom from prior experiences while learning, in real time, lessons from today.
In this article, we suggest that, by focusing on a few elements of leadership practice, public health leaders, particularly those in state and local health agencies, may find ways to prioritize actions and thereby better serve those in our communities through a greater clarity of mission and purpose. We also suggest leaders should consider the practices of adaptive leadership as offered by Heifetz and colleagues1 as they deal with challenges that are not clearcut or easy to identify. They offer a set of practices (Table) that may be helpful including "maintaining disciplined attention."
One aspect of adaptive public health leadership is for leaders to focus attention (their own and that of others) on 4 central elements of leadership practice in these times. Although these 4 areas may not include everything to be considered, we submit these as a starting point to be used to structure consideration of a range of issues. These elements are (1) situational awareness, (2) decision making, (3) communication, and (4) energy. In each area, we suggest that leaders should focus on asking the right questions rather than having all the answers.2
Situational Awareness
Public health epidemiologists are schooled in the techniques of monitoring case counts, risk factors, and other aspects of monitoring the course of a disease outbreak. All of this is critical to the process of framing the response. In addition to the epidemiologic approach to situational awareness, there are other components of situational awareness.
First, monitoring the status of the public health system at the local, state, and national levels is critical. For example, the state of laboratory capacity across the nation has received laser-like attention. Other aspects of the public health system that are central to this response include public health agency informatics capacity and communication capacity, particularly at the local and state levels. Thus, situational awareness should include monitoring of key system status indicators, such as the 10 Essential Public Health Services, as a component of situational awareness.
Furthermore, as public health and the health care system work together in these times, public health agencies will need to enhance awareness of the status of capacity in health care facilities. As capacity evolves over coming weeks, public health leaders will be called on to address conditions and concerns regarding health care delivery. Thus, a greater awareness of health care system capacity will be needed.
So, in these times, situational awareness for public health leaders may be enhanced by focusing on a few questions:
1. What is the status of the coronavirus epidemic from an epidemiologic perspective?
2. What is the state of the public health system's capacity and capability to respond to the epidemic?
3. What is the capacity of the health care system (especially at the community level) to provide needed care?
4. In a state or local health agency, what are other state or local government agencies doing?
Decision Making
In times of stress, the process of sound decision making can suffer. A preoccupation with events may lead to a short-term focus and a reactive posture.
All too often the process of decision making may concentrate exclusively on data (which change hourly) and recent events (another type of data). As a result, leaders fail to take a longer view and adopt a broader perspective not only incorporating data, information, and knowledge but also cultivating wisdom.
So, how might public health leaders expand the decision-making process and make wiser decisions? A few questions may be of value:
1. How is our prevailing mind-set interfering with our ability to both question our assumptions and encourage alternative perspectives?
2. In what ways are we fostering systems and procedures to better "look around corners" and anticipate events more effectively?
3. How are we encouraging a few wise individuals to serve as "participant observers" to "get on the balcony" and observe our decision-making processes and provide real-time feedback?
4. How are we seeking to uncover what we do not know and also identify what may be unknowable?
Communication
Communication has now become the central science/tool of public health practice (in contrast to the central role of epidemiology in the past). In these times particularly, local public health leaders serve as a credible and trusted voice to address the needs of the public for meaningful, empathetic, consistent, and factual communications.3 A few questions may be useful:
1. As I communicate with others (my staff, my colleagues, local elected officials, and the public), what do they really need to hear? This question contrasts with the frequent mind-set that asks, "What do I need to say?"
2. Am I then tailoring communication to meet the specific needs of the audience?
3. What is the strategic intent of our communication?
4. How is my communication helping prepare others for what lies ahead?
Energy
In public health emergencies, the collective energy of the public health workforce (along with that of the health care workforce) will be drained and stretched to the limit. As a result, public health leaders will be called on to monitor their own energy level and that of team members. The current situation appears to be "more of a marathon than a sprint." In light of that challenge, public health leaders may want to ask a few questions. We suggest that part of doing so requires the leader to separate out issues into 3 categories: (1) "must do"; (2) "good to do"; and (3) "nice to do."
A few questions related to energy preservation include the following:
1. To what extend am I focusing the finite energy of my team on those "must do" priorities in a daily morning meeting to assemble and plan together?
2. In what ways am I modeling self-care and encouraging others to do so?
3. What systems are in place to monitor burnout and other signs of energy depletion and then to act accordingly?
4. To what extent are we reaching out to those with expertise and experience in dealing with public health crises to supplement staff capacity?
Conclusion
The crucial work of public health is generally conducted in the shadows. The COVID-19 crisis thrusts that work and the public health leaders who guide it into the full light of day. Leaders face increased risks with heightened exposure. But with increased risk comes increased opportunity. By focusing attention on better situational awareness, wise decision making, improved communications, and optimal energy management, public health leaders have the opportunity as rarely before to prevent disease and save lives.
Many of our nation's political and scientific leaders have likened the coronavirus crisis to fighting a war. As Sir Winston Churchill said during a war more than 75 years ago, "Never let a good crisis go to waste."
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