(Illustration by Caroline Gamon)
On an unassuming corner in central London sits the Broad Street pump, where in 1854, physician John Snow hypothesized that it might be the source of a cholera outbreak ravaging the city. His insight inadvertently launched the modern field of epidemiology.
Today epidemiology is a cornerstone of public health education. It has contributed to the extraordinary success of the field in preventing and combating disease. However, the traditional competencies taught in public health schools, such as biostatistics and health services administration, can only help so much to address the threat of new pathogens, the impact of climate change on health, and the role of global corporations in affecting our health. As in Snow’s time, an expanded set of skills are needed for public health leaders.
Consider the threats they confront today. First, they face a triple burden of growing noncommunicable diseases, the emergence of new infectious diseases, and the magnification of public health problems due to climate change. This triple burden greatly increases the complexity of health system design and reform.
Second, public health leaders confront an intersectoral challenge of how to align social forces to improve human well-being. While social determinants of health, including education, housing, and macroeconomic policies, have always played a significant role in individual and population health, our understanding of them has expanded in recent decades. The COVID-19 pandemic in particular revealed how employment, education, housing, childcare, global trade, and the economy influence, and are affected by, health. Today, health must increasingly be understood as part of a wider nexus of well-being and human security.
The intersectoral challenge, in turn, presents governance challenges. An ever-widening web of agents affect systems that shape public health. In democratic states, governments must collaborate with nongovernmental actors to implement health policies. At the international level, sovereign states must collaborate to solve domestic health problems. These issues are made more difficult in an era of internet-driven misinformation, where confidence in institutions is declining; trust in science is challenged; and internet, social media, and the rise of new technologies including AI blur our understanding of truth. For public health, a discipline driven by evidence and expertise, the misinformation problem has proven especially difficult.
The challenges facing public health leaders have changed dramatically since Snow’s discovery. Drawing on our teaching of public health leaders, our research on health systems, and our leadership practice, we believe that public health education and practice must be reformed to help its leaders respond to an increasingly complex era.
Mindset Shifts
Public health is typically defined by its level of analysis. Unlike medicine, which focuses on the individual, public health is interested in the population. Nevertheless, the public health field, at least in the United States, remains dominated by medical doctors trained to think at the individual, rather than the population, level. At the US Centers for Disease Control and Prevention, for example, all directors but one received their initial training in medicine. While these leaders have many other forms of diversity and experience, the common source of training risks driving an emphasis of the field on biomedical and lifestyle risk factors, rather than the broader social drivers of health and diseases.
Furthermore, public health professionals typically struggle with the role of politics in public policy. In contrast with other public policy actors, who may consider it part of their jobs, public health professionals are often ambivalent about engaging in politically charged processes, rightfully worried it may alter their science-based legitimacy. This tension creates a legitimacy trap: Focusing on science alone may undermine public health’s impact on vital public problems, but focusing on the politics as well may cost the field its scientific credibility.
To tackle these issues, the public health field must adopt three shifts in mindset. The first is a shift toward multidisciplinary, multilevel analysis, to better grasp the complex and cross-sector nature of public health challenges today. The second is to widen its outlook from piecemeal policy design to broader system design across government, nonprofit, and private sectors. The third shift is a heightened focus on policy implementation, including how to identify potential collaborators in implementing policy and how to support stakeholders who may be negatively affected by the change.
New Competencies
To develop and further these shifts in outlook, public health educators should seek to instill an expanded set of competencies in their students. Institutions and governments should also provide the right governance structures and incentives for public health professionals to exercise those competencies.
Societal responsibility | First, leaders must embrace their widening societal responsibility and commit to tackling public health influences beyond their immediate purview. For example, advocating for policies focused on animal health could be decisive in the fight against human microbial resistance, as most antibiotic use is found in animals, not humans. Public health leaders can have a broader impact in the long term by expanding their sphere of concern.
Intersectoral vision | Public health leaders increasingly need to look beyond their scope of formal responsibility to see interconnections across systems. This ability requires knowledge of how other sectors operate, the role they play in advancing public health, and how to appeal to leaders within those sectors to act in support of shared interests. How many public health leaders today, for example, have an operational understanding of the key tenets of urbanism, agriculture, trade, or big data—which are essential to designing policies that address air pollution, tackle obesity, or combat vaccine hesitancy?
Systemic wisdom | Intersectoral leadership requires an understanding of how systems work to inform how to align them with policy goals. Governance models can be designed to incentivize such wisdom. Take, for example, road traffic fatalities, a problem that requires inputs from multiple sectors, including health, transportation, urbanism, and law enforcement. To cut across silos, some countries have adopted a “peer among equals” model in which one ministry or government agency is tasked with facilitating collaboration with other institutions. A systems view shows how each sector affects the core concerns of other sectors, such as how education and stable housing support public health, and how health, in turn, enables people to learn, work, and maintain housing.
Comfort with uncertainty | Recent epidemics, including Zika, mpox, and COVID-19, have shown that consequential decisions often need to be made under conditions of uncertainty. Public health leaders advise on questions such as whether to roll out vaccines or wait for additional safety data, whether to urge the public to use masks or maintain mask mandates for health professionals alone, and whether to test the entire population for infection or only those most at risk. Public leaders often face difficult decisions with limited scientific evidence.
One promising approach is to use analytic tools based on the concept of deep uncertainty. These tools focus on developing policies that are robust and adaptable, ensuring that they can perform well regardless of how the future unfolds. Alternatives such as capabilities-based planning, expansive exploratory modeling, and robust decision-making (RDM), which prepares for a wide range of possible futures rather than optimizing for a narrow set of possibilities, are more critical than ever in our era of constant surprises.
Mastery of change management | With intersectoral challenges, public health leaders need to understand how to identify important stakeholders and those in positions of authority to take necessary actions, as well as how to appeal to them to advance policies of shared interest. Increased spending on health services, for example, may lead to greater participation in the economy, thus aligning the interests of both medical and economic leaders. Another skill for leaders is helping others manage loss. Take, for example, alcohol: Reducing alcohol consumption will improve people’s health but also affect small alcohol producers and distributors, potentially destabilizing local economies.
Focus on implementation | Finally, public health leaders need to maintain their drive all the way from policy ideas to impact, including through the monotony of implementation. Findings from implementation science, and toolkits focused on implementation methods such as the World Health Organization’s Implementation Playbook or Harvard Kennedy School’s Problem Driven Iterative Adaptation (PDIA) Toolkit, can provide a systematic approach to drive implementation of complex issues.
These competencies can be nurtured in emerging and established public health leaders. Examples are sprouting up around the world. In Europe, the Sciana Network for health leaders explicitly focuses on systems thinking and interdisciplinary work. In the United States, the Harvard T. H. Chan School of Public Health has led with a DrPH curriculum positioning leadership at the center. In Latin America, centers focused on implementation of health policies have opened in Argentina and Mexico.
Epidemiology is important, but changing people’s minds and hearts is also essential to public health. After all, John Snow didn’t just show officials where cholera originated—he also had to persuade public officials and the population to change their perspective on the drivers of the epidemic. The public health leaders of tomorrow must look beyond their areas of expertise, engage with others, and take risks to tackle complex, but vital, challenges to move the world forward.
Read more stories by Claire Chaumont & Tim McDonald.