The demands of the health official's job are a bit like the demands of a triathlete. Triathletes must combine outstanding speed and stamina in swimming, biking, and running—sports requiring different skills and strengths. The physical fitness, skill, training, and natural talent that lead to stellar performance in 1 sport do not necessarily translate to the other.
State health officials must excel in both public health science and the multiple social sciences that enable leadership in public health. Chief among these are political science and the sciences underlying management and communications. Success in these realms often draws on very different skills. Many who are attracted to the field of public health value our foundation in science and have less background in administration, politics, and risk communication, all of which are essential to the role of the health official.
Without science, we do not know how to improve health, or even what we need to improve. Public health competes with many other essential areas for resources and limited executive and legislative branch attention. Without engaging in the legislative process with committees, advocates, and stakeholders, we cannot secure and protect the resources and authorities necessary to make a difference. Science and politics do not always point a health official in the same direction, and often negotiations result in a balancing act between the two. If it is not possible to achieve all we want, we must decide whether we can obtain what we need. And we must know when the trade-offs required are too dear and it is time to walk away and wait for another day. Decisions are rarely a simple choice of picking one over the other but rather an effort to drive the public health agenda with the tools and constraints of the political process. At times, this is planned and strategic, at others opportunistic. Sometimes we introduce and promote our plans; at others, we attempt to mitigate or avoid harm.
I have heard it said that the state health official position is a political position and therefore not true public health practice. But this political role—the coordination with the political realm, the translation of public health science for the policy-making audience, the leveraging of policy for public health—has the power to change the health of the public in a way science alone cannot. This political role is integral to improving the public's health. Practitioners in positions who are not politically appointed should strive to improve their skills in the political arena as well.
Individual public health programs need to be firmly rooted in good science and practice. The state health official coordinates across these programs, making sure that the state health agency works as a whole and ensuring that all programs have the foundational infrastructure needed to make their efforts worthwhile. This function is less about the traditional public health sciences of epidemiology, biostatistics, and medicine, and more about the sciences of politics, management, and communications.
The state health official must also collaborate across the governor's cabinet, reaching out to all who have an impact on the social determinants of health: education, economic development, transportation, agriculture, housing, urban planning, and environmental protection. While public health science can be very helpful in demonstrating the relationship between a high school degree and health, or access to fresh fruits and vegetables and health, the state health official must work across agency silos to put that evidence into practice.
Beyond the executive branch, an effective state health official works productively with the state legislature. Again, both science and politics matter in this arena. Lawmakers need to know that a given health problem causes a heavy burden for society, and that the health department has proven ways to decrease that burden. But knowing the legislators and understanding what they need to do for their constituencies may help the public health cause more than the data. Laws and regulations are often inexpensive and very effective ways to improve the health-promoting qualities of the environments in which people live. Missteps with the governor or the legislature can cause penalties far beyond the extra minute a triathlete might have added to his or her time.
State health officials must lead in reaching out beyond state government and engage in cross-sectoral collaboration with private entities in health care, agriculture, education, and other areas. Any business with an impact on the environment or a significant number of employees can be a productive partner for the health agency. This work requires translation skills, as leaders in private industry do not use the same language or even work toward the same basic goals as those of public health practitioners.
A good portion of the state health official's time must be dedicated to interaction with the media. This requires translation of the traditional public health science into terms that will be both comprehensible and compelling for the public. The media is an essential part of the public health system, as it can communicate prevention messages, share important information during an emergency, and frame political debates as well. The media can also be highly critical and personally and professionally challenging. Communications science, training, and highly competent staff are necessary to manage the interface.
This broad engagement across the department, across the executive branch, across the state government, and out to the public by a state health official on behalf of the agency provides leverage needed to achieve great things—measurable improvements in the health of the public. But the opportunity to lead a public health agency also comes with a healthy dose of risk. State health officials generally serve at the pleasure of the governor, taking up to a 60% pay cut over what they may have been earning in the private sector, and enjoy no job security. They are subject to lawsuits that can reach far into their private lives because of actions they or those deep in the agency make. One former health official went to sell her home and learned that a lien had been placed as part of a lawsuit 10 years earlier. For another, it took 4 years after leaving office before a judge finally threw out a “personal capacity” lawsuit related to actions taken by agency staff.
Health officials may be fired for mistakes or missteps or for political expediency. They may be put into a position where resignation is necessary to maintain personal or professional integrity. They may resign to take responsibility for actions they were unaware of but reflect poorly upon the agency and in an attempt to protect the institution of the state health official, the health department, or the governor. One former state health official referred to himself as the governor's heat shield—when the flames got too close, his duty was to burn off.
The intensity of this position—the personal, family and professional demands, risks, and rewards—means that only the most highly motivated individuals tend to be receiving these appointments. They must be willing to make great sacrifices and to be held accountable for a system that is large, complex, and over which no one person can truly have control. If something goes wrong in an obscure program tucked far away from the state health official's daily view, his or her career can take an immediate unexpected turn, with the spotlight of the media shining a light into the dark corners. Like the triathlete, they must put everything they have into the job and may end up injured. But if they can leverage both public health science and our political system, they can make a lasting difference in the lives of their constituents. When we conduct exit interviews with outgoing state health officials, the most common remark we hear is “it was the best job I ever had.”