Public Health Officials and COVID-19: Leadership, Politics, and the Pandemic

Health Official Roles

Attending the now virtual meetings of the Association of State and Territorial Health Officials (ASTHO) alumni society facilitates seeing old friends and meeting new members. However, attendance at the alumni society also signifies that someone is a former state or territorial health official (STHO). Often, membership in the ASTHO alumni society has occurred as a planned resignation (eg, retirement, new job offer), but recent experiences suggest a trend of health officials at the state, territorial, and local levels stepping down or being involuntarily removed.^1–4

In the current political climate where science in general and public health science in particular has become politicized, the recommendations and decisions of state and local health officials are being scrutinized in the context of public opinion. Most people would agree that public opinion should not influence the interpretation of scientific evidence. However, because public opinion often influences politicians and because health officials commonly serve communities at the pleasure of an elected official, public opinion and politics can unduly influence scientific recommendations. The current COVID-19 pandemic has highlighted numerous instances where this has occurred.^5–8 Public health response activities (eg, contact tracing), as well as recommendations regarding stay-at-home orders, social distancing, wearing masks, and other protective health measures, have all been influenced or scrutinized by public opinion and politics.^9–12 Public health leaders are not exempt from these critiques.

At the August 2020 meeting of the ASTHO alumni society, 5 new members joined the Zoom meeting of dozens of other former STHOs. While recent research shows that on average STHOs have relatively brief tenures (2.5 years) leading state public health agencies,^13,14 many involved in leadership and related research have held the assumption that at least local health officials experience more stability and are thereby able to provide more consistent leadership. Alas, in the current age of a politicized COVID-19 response, it seems that no health officials are assured job security. In fact, according to data collected through personal communications and media reports, since March 2020 when the nation declared a state of emergency due to the COVID-19 pandemic, more than 55 state, territorial, and local health officials have become alumni and members of the group of former health officials. Some of this turnover is the result of planned retirements, but the decisions to step down, move on, or retire during the pandemic may be tied to the intense public scrutiny and literal death threats health officials have been receiving while accruing 70-80 plus weekly hours of nonstop public health response work.^1–4 Mello et al¹⁵ detailed these attacks in their recent commentary, drawing attention to the need to protect public health leaders from violence and harassment. Similarly, this commentary intends to shine a bright light on the intense controversy and conflict public health officials experience in making policy recommendations to elected leaders and the public in the middle of the COVID-19 pandemic.

Turnover During the COVID-19 Pandemic

One of the first triggers that alerted the National Association of County and City Health Officials (NACCHO) that turnover was going to be problematic was when 3 board members turned over within 1 month early in the pandemic. At that point, NACCHO started tracking turnover more closely. ASTHO was doing the same. Since the start of the pandemic, 18 of the collective 59 STHOs have left office, with at least 33% of this turnover attributable to conflicts with elected officials and/or threats of physical harm/harassment from the public (e-mail with Michael Fraser, PhD, CEO of ASTHO, dated Aug. 9, 2020). Similarly, at the local level, of the 37 county/city health officials who have left office during the pandemic, 30% did so because of COVID-19 response conflicts with local politicians or public threats (e-mail with Lori Freeman, MBA, CEO of NACCHO, dated Aug. 24, 2020). This means that many public health agencies responsible for protecting the public's health are experiencing disruptions in leadership during the most challenging public health event of our lifetime.

Leadership turnover is organizationally disruptive to a public health agency during routine operations, but when it occurs during a pandemic it can be especially difficult for the agency's response efforts. Given the many issues leadership turnover creates, it seems prudent that we support health officials staying in their roles as long as possible. Turnover of senior management roles within organizations, especially at the CEO level, is known to have a significantly negative impact on the organization's productivity and effectiveness, and transitions have to be well managed and communicated lest the agency performance deteriorate or stall.

In a recent study, where former STHOs were asked to reflect on what would have helped them be more successful in their leadership roles, they reported needing a better understanding of the political process and how to relate to the governor's office before taking the job.¹⁶ Former STHOs also highlighted a need to better understand state government overall. The collective skill set of political astuteness appears to be critical for public health leader success, not just in retaining their jobs but also in tackling public health problems from a systems perspective and challenging policy failures and developing new policy approaches as a result.¹⁷ Findings from a qualitative study that assessed the perceptions of senior public health agency deputies (eg, those directly reporting to STHOs) suggested that being able to manage and meet gubernatorial expectations was a key characteristic of STHO success.¹⁸ However, many in health officer roles have no prior experience in politics and often come from clinical practice, academia, corporate settings, and organizations whose decision making is not determined by legislatures or chief elected officials.

Making Improvements to Health Official Positions

In an examination of the training and experiences of current and former STHOs, findings indicate that the majority (64.6%) are medical doctors. Approximately half of STHOs have public health degrees (48.3%), but only 21.8% have formal academic training in management or administration.¹⁹ While understanding public health issues is important, it is now increasingly clear that health officials require a skill set in operational management, strategic thinking, and change management. These are topics not traditionally covered in medical school, nor always consistent with health officials' expectations before taking the job.²⁰ In fact, common reasons why STHOs reported they were involuntarily removed from their positions include difficulties in managing a situation or because they failed to understand or adequately manage the expectations of elected leadership.

With turnover so common and the job so difficult, one has to wonder: who wants to be a health official? Fortunately, for the public's health, there are still individuals who seek the opportunity to serve their community and improve the health and well-being of the public. Given the recent turnover among health officials and experience of leading in a global pandemic, we suggest that now is the time to reach consensus on what success as a health official looks like. Having clear priorities and expectations can also facilitate the development of job descriptions that explicitly clarify what “good” means and how governors or mayors define “success” for their health official appointee.²¹ Perspectives of success may vary, but the skills necessary include being able to navigate conflict, managing partnerships, communicating effectively in crisis, and having political acumen. Could it be time to establish contracts, including assured term lengths and even severance arrangements for health officers, similar to those that exist for other public sector leaders such as school superintendents, university presidents, and other federal executive roles such as the surgeon general or the FBI (Federal Bureau of Investigation) director? Given the importance of this role, and the expertise needed, it seems unfair to require health officials to put their career and safety at risk every time they have to make tough decisions as part of their job without some protections for doing so.

Leading the Way Out of the Pandemic

The pandemic has caused a uniquely stressful and sobering time for our nation. In addition to division and unrest stemming from the pandemic, we have unprecedented attention on racism and an urgent need to recognize structural racism as a public health issue.^22–26 We are also planning for unprecedented vaccine administration challenges, concurrently during continuing efforts to mitigate COVID-19, and addressing other public health challenges such as drug addiction and suicide that have amplified during the pandemic. State and local health department staff are working nonstop assignments without a light at the end of the tunnel. As many on the front lines of health care and public health response can attest, it is hard to sprint a marathon.

To combat the fatigue and to ensure that the essential public health services can be seamlessly provided, agencies should consider crisis management strategies that manage COVID-19 operations separately but in consort with day-to-day agency activities by designating and authorizing a senior deputy to handle routine operations and give top leaders some breathing space. Such alternative “B-team” strategies, although not frequently seen in public health, are an example of an adaptive complex organizational strategy. Leaders can also benefit from leaning on each other and seeking help and advice from people who have done similar work before them, such as STHO alumni. Leadership, especially during a pandemic, can be lonely and difficult work, and no one leader has all of the answers. We need to work together and share ideas and resources and look to our national associations such as ASTHO, NACCHO, and the Big Cities Health Coalition for collective strength. Finally, there is no better time than now to unite the polarities of science and politics. We cannot easily end this pandemic if we do not follow science and allow scientific principles to guide and inform the path forward, while acknowledging the inevitable political pressures of the job. While politics and science often conflict, effective leadership should be supported and sustained in the best interests of health officials and, even more importantly, the communities they serve.