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State of Public Health

Leading in the COVID-19 Crisis: Challenges and Solutions for State Health Leaders

Fraser, Michael R. PhD, MS, CAE, FCPP

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Journal of Public Health Management and Practice: July/August 2020 - Volume 26 - Issue 4 - p 380-383
doi: 10.1097/PHH.0000000000001192
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The COVID-19 pandemic is testing the limits of America's health systems while testing our culture's willingness to sacrifice freedom and mobility for the sake of saving lives. State and territorial health officials—along with their partners at the local, tribal, and federal levels—face unprecedented leadership challenges in their attempt to mitigate the virus's spread.

The spotlight is now on public health leaders. As Baker and colleagues1 presciently highlighted early in the COVID-19 response, the need for adaptive leadership is great. McNulty and Marcus2 similarly highlighted the urgency of leadership, not just management, in responding to the COVID-19 pandemic. This commentary builds on these recent contributions by illustrating 5 challenges COVID-19 presents to public health leaders and discussing approaches to overcome them.

Effectively Communicating in a Crisis

Successful leaders understand the critical role communication plays in their work. The best laid plans and most exquisite strategies will fail if not well communicated by leaders to their followers. As Baker and colleagues state, “Communication has now become the central science/tool of public health practice,”1 and this is absolutely true in the COVID-19 pandemic. A tenet of crisis communications training for leaders is to “Be First, Be Right, and Be Credible,”3 a motto well described by former Virginia Health Commissioner Karen Remley4 in a recent Getting Practical column in this journal. Even in the early days of the COVID-19 pandemic, there were many leaders who were able to communicate effectively because they were first, right, and credible—and some excruciating examples of those who did not.

Communicating effectively in the COVID-19 response requires regular communication both externally with partners and the public and internally within a leader's own organization. Well-planned, high-level daily briefings by governors and health officials can help calm fears, reduce panic, and demonstrate transparency. Many states and territories have successfully implemented daily news conferences, during which leaders brief the public on case counts and actions to mitigate the virus' spread. Health officials are also communicating directly with their entire agency's staff, promoting transparency and information sharing within the agency to assuage their workforce's concerns and fears about COVID-19. These internal communication efforts are vital to keeping responders and supporters motivated for a long-term response to COVID-19.

Decisiveness in the Face of Uncertainty

If a leader's most important task is communication, the second most important is decision making. Clarifying who is responsible for making what decisions, and when, is vital. Because COVID-19 is a novel virus disease, we have little empirical data to support our understanding of the virus. Therefore, decision making in the COVID-19 response is extremely challenging. Sound public health policy is rooted in accurate and comprehensive public health data. The lack of valid data and reliable information from outbreaks overseas, combined with the current limitations of assessing community transmission in the United States, is concerning. When responding to a novel virus, there is always going to be a level of ambiguity and uncertainty,5 and leaders will have to make decisions based on anecdotes, news stories, social media posts, their own intuition, and the experience of trusted advisors. Is the virus spreading presymptomatically or asymptomatically? Are droplet protections enough to protect health care workers, or should aerosolized protections be used? Are travel restrictions effective or ineffective? Should physical distancing be local, statewide, regional, or mixed? How should economic considerations be balanced with public health protective measures? More gravely, who should get a ventilator and who should not? All of these decisions are being made as infections grow exponentially and are met with extreme scrutiny by a public with a declining trust in government.6

In their practical contribution to the literature on decision making, “Who Has the D?” Rogers and Blenko7 describe the perils and pitfalls of organizational decision making and propose a method for making good decisions during routine business operations. Applying their work to COVID-19 response, the writers found that their Recommend-Agree-Perform-Input-Decide (RAPID) decision-making model still works within the context of (ironically) rapid decision making with less-than-complete information.7 The RAPID model does not mean every organization will make the same decision, but it does mean that every jurisdiction can use a similar process for making decisions despite lingering uncertainties. For example, take the decision concerning the “right” number of people to use in limiting mass gatherings. In this pandemic, we have seen prohibitions on gatherings of more than 2 people, 10 people, 50 people, 100 people, 500 people, and 1000 people. State and territorial leaders all had to make decisions based on incomplete data and limited evidence (there is no “right” number consensus yet). However, making a decision to limit gatherings was more important to stopping potential spread than either delaying a decision to get more data, waiting for the Centers for Disease Control and Prevention to decide for the nation, or doing nothing (which is itself a decision). There are countless other decisions to be made in the COVID-19 response, including: Should all businesses close and for how long? Should all schools close and for how long? Who are “essential” versus “nonessential” personnel? Who should enforce what laws? Should we work remotely or not? When can we ease gathering restrictions? The challenge facing public health leaders is using a sound process to assess the best decisions for their jurisdictions, despite the ambiguity, and then make them. In short, when it comes to emergency decision making, public health leaders should pay heed to Voltaire's aphorism and not let “the best [be] the enemy of the good” in crisis decision making.8

Successfully Leading Up, Down, and Across

Leading up, down, and across is a challenge for any leader but made more acute in an emergency. Over the last few weeks of the COVID-19 response, we have seen many state and territorial health officials sharing the podium with their governors during press conferences and briefings. Likewise, local health officials have been supported by elected leadership, often acting as spokespeople for mayors and county officials. Effective working relationships between public health leaders and their elected or appointed leadership were most likely formed well before COVID-19 appeared.

Leading “down”—the way leaders lead the rank and file staff in their agency—can be challenging in an emergency response. Because leading “up” can be all-consuming, especially with a daily tempo of press briefings and meetings, public health leaders may be less present in their agency and may appear less in touch with the organization's needs. McNulty and Marcus2 warn leaders to remember “the human factors” in an emergency and to lead with a “clearly articulated mission” that focuses on the organization's shared purpose. Creating a shared purpose can be difficult when team members may be in emergency operations centers, working from home due to physical distancing measures or their own health concerns, or are deployed to other agencies as part of the response. Successful leaders continue to care for their people during an emergency, remembering that their own success as a leader is inextricably tied to the coordinated activities of the entire agency's staff. They also realize that even in an emergency, command decisions should be made sparingly. Instead, leaders should rely on their staff to competently manage the incident, involving themselves only to set and share direction and priorities, fill gaps, and move issues up and across as needed.

Leading “across” is an often-unanticipated leadership challenge, as it addresses the way a leader collaborates with peers and partners. In government, these collaborations generally include other agency heads and important stakeholder groups. If leaders establish positive working relationships with other cabinet agencies prior to an emergency, they can build upon those relationships in the response. For example, efforts to establish telehealth visits for COVID-19 patients may require close collaboration between the leadership of the state's Medicaid agency, the state public health agency, hospitals, and physician leaders. Health officials' prior engagement with their state emergency management agency is important to strengthening those relationships during the COVID-19 emergency, especially as many state and territorial emergency management agencies transition to leading the COVID-19 response. Leading across can be obstructed by turf wars and silos, a leader's need for control, or the need to “overcentralize” the response.2 Instead, effective leaders know they cannot control everything and seek to coach and contribute as a peer, mentor, or friend when working horizontally between organizations.

Planning for What's Next, Not Just Responding to What Is

Strategic foresight and planning are also closely tied to leadership decision making. Baker and colleagues1 describe the adaptive leadership strategy of moving beyond day-to-day operations on the “field of action”9 toward a vantage point from the “balcony.”9 This balcony view provides the perspective a leader needs to identify patterns, examine interdependencies, and view agency activities within an entire system. McNulty and Marcus suggest that every crisis, including COVID-19, unfolds “over an arc of time with a beginning, middle, and end.”2 The leader's job is to think across this arc, considering how the future may unfold and what new issues will present themselves over time.

New York Governor Andrew Cuomo has skillfully led his state's response to the COVID-19 outbreak with his state health commissioner, Howard Zucker, and other state leaders by his side. In what will surely become a mantra for future public health responses, Cuomo stated in a recent press conference that “you don't win on defense, you win on offense.”10 While many are critical of the aggressive and unprecedented steps New York has taken to prevent infection—which have created a budget deficit of more than $10 billion and counting—the governor's daily briefing is a reminder that the state's planning assumptions are modeled not on what is happening today but on what they predict may happen tomorrow, over the next several days, and in the weeks and months ahead. Cuomo's focus on what “will be”2 is precisely the mind-set public health leaders should adopt, despite the constant distraction of “what is,”2 or what Hummel aptly calls the “tyranny of the urgent.”11 Similarly, Baker and colleagues remind leaders that “a preoccupation with events may lead to short-term focus and a reactive posture,”1 at a time when proactive posturing is needed to creatively plan and iterate response tactics for an uncertain future.

Caring for Yourself so You Can Care for Others

High-performing leaders often obtain their positions through countless hours of dedication and a commitment to mastering their profession, frequently at the cost of forgoing social events or denying themselves exercise and recreation. Physicians train for years, enduring grueling call schedules and residency appointments that may inadvertently reinforce the impulse to sacrifice one's own health for the health of others. These rites of passage may be part of professional development for many, but they have the unfortunate consequence of associating success with a failure to rest, recharge, and refresh. The tempo of emergency response requires a 24/7 response, but that in no way implies a leader need stay around or awake for all of it.

German pastor and theologian Martin Luther is quoted as saying, “I have so much to do that I shall spend the first three hours in prayer.”12 This seemingly contradictory statement is sound advice for a leader challenged by the demands of an emergency response: take the time you need for self-care and be mindful of what you need to stay the course with the COVID-19 response. Baker and colleagues1 rightly suggest that in the COVID-19 response—and any sustained public health emergency—leaders can prioritize their demands by sorting them into 3 categories: what is a “must do,” what is a “good to do,” and what is a “nice to do.” This straightforward and elegant 3-question framework may help many leaders effectively manage their time and energy. Author and motivational speaker Simon Sinek's13 recent book, Leaders Eat Last, and Greenleaf and Spears'14 classic, Servant Leadership, emphasize that leaders must exercise humility—not self-denial. No one leads well when they are hungry, scared, sleep-deprived, burned out, or sick. While this challenge is the last of the 5 listed in this commentary, it may in fact be the most important to the overall success of our nation's COVID-19 response.

COVID-19 Response: New and Old Leadership Challenges

There is much we do not know about COVID-19. This makes the task of leading the public health response all the more complicated. However, many of the challenges COVID-19 presents to public health leaders are not new. These include communicating in a crisis; making decisions with incomplete information available; effectively leading up, down, and across; taking an offensive versus a defensive posture; and taking the time to care for one's self. What is different is the size and scale of the COVID-19 response, combined with the real-time scrutiny of public health decisions by social media and global connectedness. The spotlight is indeed on public health leaders, but leaders must use that spotlight to skillfully address these challenges and competently lead up, down, and across to protect the public's health.


1. Baker EL, Irwin R, Matthews G. Thoughts on adaptive leadership during the COVID-19 pandemic. JPHMP Direct. Published March 19, 2020. Accessed March 30, 2020.
2. McNulty EJ, Marcus L. Are you leading through the crisis ... or managing the response? Harv Bus Rev. Published March 25, 2020. Accessed March 30, 2020.
3. US Centers for Disease Control and Prevention. Crisis & Emergency Risk Communication Manual (CERC). Published January 23, 2018. Accessed March 30, 2020.
4. Remley K. Be first, be right, and be credible. J Public Health Manag Pract. 2019;25(2):208–209.
5. Kupferschmidt K. Study claiming new coronavirus can be transmitted by people without symptoms was flawed. Science. Published February 4, 2020. Accessed March 30, 2020.
6. Pew Research Center. Public trust in government: 1958-2019. U.S. Politics & Policy. Published January 4, 2020. Accessed March 30, 2020.
7. Rogers P, Blenko MW. Who has the D? How clear decision roles enhance organizational performance. Harv Bus Revi. Published January 2006. Accessed March 30, 2020.
8. Voltaire. Dictionnaire philosophique. Cited in Wikipedia. Published March 17, 2020. Accessed March 30, 2020.
9. Heifetz RA, Laurie DL. The work of leadership. Harv Bus Rev. December 2001:1–13. Reprint #R0111K.
10. Littleton C. How the Coronavirus crisis turned Governor Andrew Cuomo into a TV sensation (Column). Variety. Published March 28, 2020. Accessed March 30, 2020.
11. Hummel CE. Tyranny of the Urgent. Westmont, IL: Intervarsity Press; 1999.
12. A quote by Martin Luther. Accessed March 30, 2020.
13. Sinek S. Leaders Eat Last: Why Some Teams Pull Together and Others Don't. New York, NY: Penguin Group; 2019.
14. Greenleaf RK, Spears LC. Servant Leadership: A Journey Into the Nature of Legitimate Power and Greatness. New York, NY: Paulist Press; 2002.
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