Lessons From the Trenches: Leading During a Public Health Crisis

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: words of encouragement and strategies for public health leaders tested by the COVID-19 pandemic; and, at the end of the show, an offer from ASTHO alumni to connect and share their experience and perspective informed by the H1N1 crisis.

DR. LEAH DEVLIN:
It's very dramatic. There are unintended consequences, as we're seeing with the economy in free fall. So, I think that this notion that state health officials have a team around them, have resources in different individuals that they can reach out to outside of their system. To me, that is really important, I think, acknowledging that they don't have to have all the answers themselves.

DR. JOSH SHARFSTEIN:
It's too early to say, but I think it is probably a fair prediction that this is going to profoundly reshape the public health system.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today: we focus on leadership during the pandemic; how are public health officials managing during the outbreak; and what strategies might they consider as they face the possibility of engaging COVID-19 over the next several weeks or months.

Our guests are two veterans with decades of experience in managing public health crises.

Dr. Leah Devlin is a professor of health policy and management at the University of North Carolina's Gillings School of Global Public Health. She's along later to talk about the importance of planning, data, and relationships in the community.

But first, we hear from Dr. Josh Sharfstein, vice dean for public health practice and community engagement at the Johns Hopkins Bloomberg School of Public Health in Baltimore, himself a leader during several local state and national crises as former secretary of the Maryland Department of Health and Mental Hygiene, principal deputy commissioner at the FDA, and Baltimore City's commissioner of health.

SHARFSTEIN:
It's pretty intense, and you're usually working very closely with the elected leaders who are doing a lot of the leading: you know, the mayor; the governor, in my case; the HHS secretary; and, ultimately, the president, for H1N1. So, you know, you have a very important job, but you're also within a structure, you know, where you're working with others.

I think that it's very important for people in the field of public health to be the voice of calm reason, evidence, in the midst of what could be very chaotic circumstances. There's always something pushing the whole process sideways, and being very stable, calm figure I think is an important thing to do.

That doesn't mean indecisive, though. I mean, I think there are moments when you have to take a position and explain what that is, but really stick to the fact that you're operating based on a solid understanding of the situation and the best application of the evidence that you have.

JOHNSON:
How easy is it to do that when things are happening quickly?

People's lives are on the line.

SHARFSTEIN:
It can be tricky at different times. And, of course, it gets particularly crazy because there are all kinds of curve balls and, you know, people's grievances over other issues can surface.

You have politics: if there are people who are angry at your elected leader/boss over something, they may attack you; there is the general national political divisiveness. So, all those things are like, you know, winds trying to push you off course.

And you just have to, you know, make the extra mile to say, "You know, we're going to respond to every call, even if they're from people who are not your typical allies. We're going to go out of our way to engage with communities that maybe have been resistant in the past. We're going to really show that this is about the health of people, and not about the politics or the particular confrontation at the moment."

JOHNSON:
You teach a class on this topic there at Johns Hopkins, and you've written a book about it—the issue being how to thrive and lead during a crisis.

Can you share some of your best advice for the people listening to this podcast as they work through COVID-19?

SHARFSTEIN:
Sure.

We organize the course in a few different areas. The first part is the history, the lesson of which is a lot of public health happens in crisis. So, that's a theoretical concept when I teach that usually, but not this year, right?

A lot of public health is happening during crisis: new policies get set; new approaches. So, this is a moment, a real transition. What might've been possible before now might not be possible now; but more importantly, what was impossible before—meaning, well, we could never, you know, get more staff hired for this function—well, actually, you know, the world is completely changed with the coronavirus, so there are real opportunities to do things. People should really recognize that potential there.

We then focus on aspects of management. We talk about identifying a crisis—that's not a hard one in this situation; although, frankly, in some places in the country, they don't think they are having a crisis yet, but they are. And so, really getting people to act like there's a crisis is very important and, right now, the whole country should be acting like there's a crisis.

Then, there's the actual management and how you have to structure your crisis management differently than the day-to-day operations. You can apply the principles of incident management—which most people know—to structure a response, make sure that people are responsible for specific functions, and that people can sub in for them if they are unavailable.

And then, we talk about communication and politics: the importance of consistent, accurate, scientific, and compassionate, empathic communication; and the need to recognize the political factors are swirling around in order to kind of steer that ship I was talking to before.

And then, finally, we talk about the importance of using a crisis—and using may be too strong a word—but basically recognizing that a crisis creates the conditions for some fundamental changes.

You know, one of the challenges everyone in public health knows is that we have been neglected. Our field has been neglected. We don't have the resources that we all wish we had to respond to this pandemic well, or certainly as well as we would like.

We have to be able to take advantage of the new environment to make sure that this sort of thing doesn't happen in the way that it did after the previous investments were made and then were allowed to kind of wither on the vine.

JOHNSON:
It seems crazy to suggest thinking about the future when we're not sure how far into this crisis we actually are—just yet, anyway.

How do you know when it's the right time to begin considering the long view? To talk about policy change, to think about those lasting lessons learned and how to implement them?

SHARFSTEIN:
Yeah, I think that's a great question.

That's actually an entire class in my class. You know, one of the sessions is about when's the right time, and I would tend to agree with you. Right now, we're just actually, in most places, heading into the storm and that isn't necessarily the right time to say, "Maybe I want a different ship next time."

It is most important for public health to be doing a capable job, for delivering everything they can for their communities, and basically to be gaining the credibility so that later, when there is an opportunity to really think through what needs to be changed for next time, people will really listen.

So, I agree with the premise of your question. I don't think this is the time to give a talk about, you know, what the budget needs to look like for the next decade. I think now's the time to do everything possible to address the challenge.

But, you know, when you think about something that could have been put in place to have made this job easier, write it down, because you're going to take that list out some day and hopefully it'll make a difference.

JOHNSON:
That's probably a good idea. Keep note—that way, you won't forget when you are too tired to stand up.

SHARFSTEIN:
I think that's true, and I'm sure there's more than one book out there, among your listeners, that will be very interesting to read for people on the front lines.

JOHNSON:
What are some of the challenges, then, to getting through a crisis like this for public health leaders?

SHARFSTEIN:
Well, I think right now, even in the midst of, you know, the most important public health crisis of certainly my life, public health strategies are not necessarily at the top of everybody's list. In many places, they're resisting the social distancing that's necessary to shut down the spread of the virus, even temporarily.

There's obviously a critical need to focus on the threats to the healthcare system, and we do not want hospitals to be overwhelmed; but the way that hospitals avoid getting overwhelmed is by preventing new cases, it's by public health. There is a focus on building new hospitals, which there should be because we're going to need them, but we can overwhelm even extra hospitals if we don't prevent.

I think one of the most important challenges is for people to make sure that their communities are focused on preventing new cases. That's the core to reducing an epidemic, it's not building more hospital beds. Build them by all means, but do not think that that alone is going to reduce the potential harm here.

We want to both build beds and reduce the number of patients who need those beds. And so, that means a focus on the identification of cases or suspect cases, isolation, quarantine—those are the core things that actually reduce the spread of that disease. And it's very important for public health officials to be thinking, "What does it really take?"

I'll give you a concrete example. People talk about, you know, "Well, this is a challenge for people who are homeless." It's not just a challenge for people who are homeless. If a lot of people who are homeless get COVID and end up in the hospital, that really reduces the hospital capacity for the whole community. The need to prevent cases among the homeless is a need to control the disease for the community.

And so, it's a public health official who can help set up a system that gives them temporary housing or puts them in hotels or puts them in dorms or does something for them that actually is critical to reducing the spread in the community. It's not like sometimes people talk about, like, it's for their benefit—it's for everyone's benefit. It's a core public health issue of prevention.

JOHNSON:
When the crisis is this big, is the challenge then deciding what to do first, second, and third?

SHARFSTEIN:
I think it's important to set up key priorities in different areas and really assign good people to lead those teams and, I think, now, to really reach out to the private sector to get scale.

So, I'll give you an example there around communications. If you're going to have a communications campaign that is going to talk to people about what's going on and urge them to protect themselves, really what people do in their own lives matters a great deal for this epidemic. So, one way to do it would be just write a press release and put it out there. But then you go to the next stage and you're going to have a communications team with a great leader who is going to be thinking creatively about not just one press release, but press releases in multiple languages, setting you up for different interviews, I mean, a whole bunch of things.

Now you want to go to the next level and say, you're going to team up your communications person with a major figure in your community—somebody who could be a former mayor, could be a sports figure—and you're going to team up and you're going to call in all the TV stations, all the radio stations, all the faith organizations, leading community organizations. And you're going to say, "We've got a communications challenge here. If we're not doing these things, we are going to have a terrible suffering in our community."

This is not just a job for our public health effort and our press releases, no matter how good they are. It's everybody's responsibility to get their message out there. So, I think this is going to be an evolution in some ways of public health and what it needs to do, given the scale of the challenge in communities. And so, I would suggest setting up, you know, core objectives and having teams, you know, really working on those and really reaching out to the private sector to get a tremendous scale to them.

JOHNSON:
They don't know how long this will last. We hope that it doesn't last much longer, but that might just be wishful thinking.

How does a public health leader maintain momentum on the team that he or she is leading so that they finish strong?

SHARFSTEIN:
Well, you know, part of this is the personal aspect of leadership and really making sure that you have a little bit of a balance in your life—a little bit, you know, a little bit of downtime, a chance to reflect, not going flat out all the time, if it's possible.

I think that it's important to divide up this incredibly challenging task into manageable goals, like I said, and some of them will have short-term, medium-term, and long-term aspects to them.

And two, you want to really keep people focused—that, you know, we had a goal of getting on every radio station and we got on every radio station, you know. And that's not ending the epidemic, but that's something that people really accomplished and if they hadn't sat down and done that, it wouldn't have happened.

In each of the different areas—if there's an area around the hospital capacity, we got it built, we figured out a strategy for how to get the patients there—and so, you know, I think if you have a plan, there's a sense of momentum. If we have a structure, there's a sense that we're doing the things that we intended to do, and that gives people kind of the strength to keep going.

It's also important to really appreciate other people. I mean, everybody is stressed. Everybody feels like they're at risk personally from this coronavirus. So, there's an aspect to leadership these days, which is really about self-care and really encouraging and thanking people in your team.

JOHNSON:
For those leaders who have now found themselves in a situation that maybe they weren't really that prepared for, is it possible to regroup during the crisis and to get control of the situation?

SHARFSTEIN:
Yes, it definitely is. The structure of the response is very important, really having good people responsible for key functions is very important.

The one thing that can be very hard to bounce back from is not being seen as credible. That really is the long-term view for a leader. It can be easy to say, "I think we're going to be good. I think we'll be open for business in a week. I think we can—you know, we got this, we prepared, we are totally ready." But as soon as those things don't work out, then some people may stop believing you; and then, you have to go for like a month or two months of people not believing you. It can be very, very difficult to lead.

So, you know, truth-telling, not offering over-reassurance when it's not justified—you know, those are really important qualities for the long haul to be really seen as somebody who can be counted on.

JOHNSON:
How about transparency?

SHARFSTEIN:
Transparency is important. Transparency is one of the ways people, you know, believe.

I think there are two major aspects of to communication that are important in this sort of situation: one is transparency—telling people what you know and what you don't, not over-reassuring; and the other is bringing in trusted allies to replicate the message.

So, if you're a health official and you say, "We really do need to close the bars and restaurants," you can say that as well as you can. You can say it transparently, you can say it standing on your head. But if you're sitting there with the head of the emergency departments of the major hospitals saying that they're being overwhelmed with patients or they're worried about being overwhelmed with patients, and they know how hard this is, but on behalf of their health systems, this is a life saver right now—it's just going to go a lot better. People sometimes take too much of the burden of communication for themselves. So, I think it's transparency, it's also being with trusted advisors.

One other note about transparency is I think it's important to set up rules about transparency. So, I remember during the Ebola epidemic in West Africa—when people were very anxious in the United States, which during that time I was a health secretary, you know—for a while, we were telling the media when we had suspect cases, and that just drove the media into a frenzy. They would be like, "Here we are, it's 12 o'clock, we think the patient's in the emergency department. We don't know more, but we're standing by." And then everyone in the hospital gets stressed out, everyone gets stressed out, and then the test would be a negative.

And so, finally, we said like, "Look, we're not going to tell you right when it's happening. It may sound like it's a little bit less transparent, but it's literally driving everyone crazy and interrupting the response, and we put out a policy that we're not going to do that." You know, and people said they understood. We will tell you if there's a positive case, you know?

So, I think like if there's an issue of people really demanding information, think about what's a reasonable amount of information to give, put it out as a policy, defend it, explain it. And, you know, it doesn't necessarily have to be every minute, every day, everything that you're doing is public; but it has to be enough information—the important information—when people need to know on a regular basis.

JOHNSON:
You know, after 9/11, an entire government infrastructure was created to respond to threats of terrorism against the United States.

Do you see a similar response growing out of what's happening with COVID-19?

SHARFSTEIN:
It's too early to say, but I think it is probably a fair prediction that this is going to profoundly reshape the public health system. How that happens is anybody's guess at this point. There's a lot—you know, we are still heading into the storm right now.

But the global public health system, the national public health system, and the state and local public health system are going to get a massive amount of renewed—and I think deservedly so—and I think that there will be a moment in the future when public health is going to have to have a loud voice saying, "Here's what we really need in order to protect the public as well as possible."

JOHNSON:
Dr. Leah Devlin was a local health department leader in North Carolina in the early 1980s during the HIV epidemic, going on to lead campaigns against West Nile virus and SARS, among others.

With us, Devlin discusses the importance of leaders making full use of their teams and their contacts in the community.

DEVLIN:
I think we have to come to grips with the fact, that at some point, you as the leader of the public health system are going to own the messaging. You may have to own the final decision. So, there is that. You have to show the flag for the workforce, reassuring the public.

So, there is a special role for the leader, you know, as a state health official. So, along while you're still making those decisions within the context of the situational awareness, the data of the science you have, and the experts that are helping you with that information—but at the end, you're the one that does have to step out there.

It doesn't feel lonely—it can feel exciting, it can feel a little intimidating—but I've never felt alone, that's for sure.

JOHNSON:
How did you make sure that you never felt alone?

DEVLIN:
So, in order not to feel alone, the strategies that I used were to have regular meetings—predictable meetings—with the experts on the public health team; to also be available at any time; to also have a ways to communicate regularly with the public in a crisis.

So, there is the importance of having a plan ahead of time; and we have done a lot of planning in states over the past 20 years, and we have more readiness than we ever have had before.

So, having that plan is part of not being alone; and then executing that plan and modifying that plan as you move through a crisis are really important in making sure you aren't alone.

JOHNSON:
Anything else other than planning?

DEVLIN:
Well, we have adequate planning for a crisis and how you're going to manage that, not only within public health but with all the different partners that are part of your response.

But you also exercise this plan. So, you do tabletop exercises: you have smaller outbreaks that you're managing in real time and you learn from different experiences. And what we typically do is create an after-action report that goes back to look at what went well, what didn't go so well, how do we amend our plans for this exercise again with our new thoughts and our new place of learning from our experience.

JOHNSON:
Planning is intended to help you prepare for the unexpected.

What if you find yourself in one of those situations? How do you cope with that situation? What is the strategy there?

DEVLIN:
So, I think the first strategy is always making sure that you have the best science available, making sure that you stick with the science for public health in every instance when you're making recommendations or designing strategy. If you don't stick with the science that is available, then it's a greasy slide downwards—there's no toe hold there. I think that's particularly important in a crisis.

If you don't have the information and if you don't know, I think it's important to say that you don't know and being transparent about that, but that you are working on it, that you have scientists doing research. You're working with major organizations like the CDC and the WHO, being informed by academic partners that are doing great research, and what other states are learning and doing as well.

So, having the data, having the situational awareness about what it is going on in communities—that's the first step.

We've already talked about partnerships. Closely related to that is having relationships with people, and you've probably already said that a crisis is not the time to be handing out your business cards. We need that relationship ahead of time. Well, that is absolutely true. When you get in a crisis like this one, which is unprecedented, those relationships are also being built and strengthened with new and different partners because of the overwhelming nature. It's almost like agency issues go to the side, turf goes to the side, we are all goals—to keep people well, support the sick, keep society functioning as best we can.

So, I think that relationships can be built in crisis as well as the better opportunity, of course, that building in before, and I think communication is central in every way. We always have a commitment to giving the public, partners, the information in a timely, accurate, and predictable fashion. So, we would decide, "Okay, we're going to be doing our availability at 9 and at 4 every day, every other day. We're going to do press releases once a week," depending on how a crisis is unfolding.

Now, these decisions—this is now, and has been for some time, much bigger than public health. We are driving, in public health, a lot of the recommendations. Some of the issues around communications, of course, now are coming from the governor's office, for example.

You know, at different stages of a crisis, public health may be the lead and the decider; but as it moves into such a massive response, we become an advisor, a facilitator—sometimes still the top person, but a lot of times we are in support of elected officials that the public wants to see out there. They don't want to know that those elected officials were supported by health professionals in sound science, but it is elected officials that are a lot of times the messengers.

JOHNSON:
How important is communications in a crisis?

DEVLIN:
I think we always underestimate how much information the public wants and needs. And so, that underpins everything.

I think that operating in an environment where you have a trusted messenger is essential, and they are able to provide the health information in a credible timely, complete, accurate, very transparent manner on a consistent basis is really one of the most important things that can be done.

In my experience, sometimes there were multiple spokesperson and multiple messages coming from different spots, and I think we're seeing some of that now in this current outbreak. So, the more you can be consistent with your messaging, the better you are going to be able to handle crisis.

JOHNSON:
Do you ever seek outside help or advice from colleagues, or stakeholders, or even people that you knew who were knowledgeable about these very same issues?

DEVLIN:
So, we have a number of occasions, sought out academic partners for their expertise.

Sometimes—particularly in an environmental crisis, which we're not in right now, but with an environmental crisis like the most recent PFAST contamination in drinking water, or cancer clusters is another example—we reach out to a third party so that we are not just standing alone as the government experts, that we are validated by other stakeholders from other sectors.

When we were working on our pandemic flu planning, we also would reach out to experts in different sectors of society. I remember a Supreme Court justice came to me actually and wanted to know how could she develop her plan for pandemic flu. The secretary of state reached out to the statewide Bankers' Association here in North Carolina so they provide their leadership all over their banks.

So, I think when you can also find that champion within a sector to work with you, to take the message to their membership, that's also another really good, important strategy.

JOHNSON:
Because, again, the idea here is you don't have to go it alone.

There are so many different places you can go to get support, to get feedback, to get expertise.

You shouldn't leave any of those sources unchecked.

DEVLIN:
I think that's exactly why, personally, as a state health official, I did have other colleagues in other states that I could get on the phone with and talk about what they were doing. I did have a mentor assigned to me from Washington State, also had been a local health director and very wise individual, and she was my formally assigned mentor. So, we had relationships like that.

ASTHO has been a great organization for not only supporting current SHOs [Ed. note: state health officials] but also provide a mechanism for alumni state health officials to stay engaged with ASTHO so, that we could be of assistance, whether it's mentoring or during an interview like this when the current SHOs are so overwhelmed with their current responsibilities and many other ideas. So, I want to acknowledge that important work that ASTHO's been doing for all the states.

JOHNSON:
And it's important to reinforce the idea that, as crazy as it is right now for every one of the state and territorial health officials, if they need someone to talk to who was in a similar leadership position, those opportunities are available.

There are alums just like you willing to listen or to respond and help them through that so that, when they go back to work tomorrow, maybe they have a new idea, a new perspective, or just a little more energy.

DEVLIN:
I think that it's really important for the state health officials to be able to go to the distance.

They are working very long days, their teams are working long days, they are under a lot of stress. They're being asked to make decisions, oftentimes without as much data as they would like. They're doing a lot of modeling—this particular pandemic is moving very quickly, and many of the non-pharmaceutical interventions are being implemented for the first time.

It's been very dramatic. There are unintended consequences, as we're seeing with the economy in freefall. So, I think that this notion that state health officials have a team around them, have resources in different individuals that they can reach out to outside of their system if they need that, is really important. I think acknowledging that they don't have to have all the answers themselves, they are not the only one that is accountable in these situations, is really important.

And also acknowledging that not everything is as equally important, that some things are going to fall by the wayside while this particular crisis is underway. So, how do you figure out what you gotta do, what you'd like to do, and what things can absolutely be done later is not a bad idea.

But, taking time to make sure you're taking care of yourself so you can go to the distance.

JOHNSON:
What else should our public health leaders keep in mind?

DEVLIN:
So, when the response gets as overwhelming as this particular one is, and public health is front and center on recommendations around protecting help, there are other factors that come into play in what maybe the governor, or the mayor, or county commissioners ultimately decide that they're going to step into with policy—that's okay, because each person has their role to play in coming to the best solution for their community—in this case, their states.

So, I think it's important for state health officials to remember, and I know they do, that when they make their recommendations based on health and based on science, they've done their job. It may be that another decision is made, but they have done their job when they put forward their best guide and recommendations. So, that's one thing.

The second thing, is in terms of supporting their own workforce—if there are small things they can do to communicate with their teams over emails, little good mornings, thank yous, it's another day that we're going to do our back for the people of North Carolina or South Dakota, and hats off to all of you for the work that you're doing—if there's just small things you can do to create positive energy and just representing your agency well—in the emergency operation center, in press events, and communicating back with your staff, giving them feedback on how things are going, how the public health messaging is going, the role that they're playing, and the good work that they are doing—is very helpful for the whole workforce.

JOHNSON:
Final words of advice for state health officers and their teams who might have a few minutes to listen to this while they're doing all of this work across the country?

DEVLIN:
What I would like to say to the public health workforce and the state health officials that are leading the efforts in the COVID response is how proud I am of the work that they're doing.

This is a very unprecedented time, and public health is standing tall and the expertise that we bring to the table, the experiences that we have had throughout the workforce, the team work that we display, we bring together all types of expertise from the lab to the workforce, environmental, nursing, nutrition—everybody is coming to the table with their ability to participate, and we can be proud that our governors and mayors and commissioners are relying on the sound science and expertise that public health leaders bring to the table.

JOHNSON:
If you're a health official looking for another perspective on the COVID-19 pandemic, ASTHO is here to help. We've compiled a list of former health officials who have experienced and led response efforts during the H1N1 outbreak, each of them willing to connect with you to provide their thoughts as you engage this novel coronavirus. A list of these alumni is included in ASTHO’S COVID-19 daily brief. A link is in the show notes for this episode.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

And if you have comments or questions, we'd like to hear from you. Email us pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.