NINE PRACTICAL ONE HEALTH LEADERSHIP SKILLS
l. Leading with
In dealing with complex situations where collaboration is essential, and cooperation cannot be guaranteed, it is important for leaders to assume a non-authoritarian style of leadership that understands their and other’s responsibilities, roles, and perspectives. As it is in effect a team with many coaches and quarterbacks (depending on the analogy you would like to use), open and transparent information sharing appropriate to the situation is essential. For example, in Canada’s response to the 2009 HI influenza pandemic, provincial and territorial ministers, deputy ministers, and senior public health officials would be advised of what the federal public health agency knew shortly after it was known. No one was told what to say in terms of public messaging, but the key issues were discussed and information shared such that a consensus of best advice and information could be made public. This illustrates the value of intelligent people with accurate information and a common purpose when striving for a reasonable consensus.
2. Getting it right
It is less important “to be right” than it is “to get it right.” It is impossible for any single individual to have all the knowledge and experience to consistently make the best decisions. Even organizations may not have within them all the necessary skill sets. The focus must not be on one’s ability to be right but rather to seek out the needed expertise or other perspectives whether from within or outside the organization, to get it right.
3. Framing issues
It is helpful to be able to understandably frame issues, including the underlying principles on which decisions are based. For example, given the challenges in dealing with complex issues such as climate change, ecosystem preservation, or the determinants of health, it is easy for people to say they cannot do anything meaningful to make things better. What practically can an individual or organization do? One way I found helpful is using the acronym PACEM for different possible types of action.
- • Partner: Finding others of similar interest to work together on those things we can do better together than individually.
- • Advocate: It is not necessarily protesting in the streets, or writing letters, but more so bringing evidence to bear on the debates and discussions.
- • Cheerlead: This may sound trite, but at times it has been felt that for various reasons we are criticizing ourselves more than organizing a common response to address the major issues. For example, in public health, the shifting terminology from health education to health promotion to population health became more a debate about how one concept is superior to the others, rather than how each has something to contribute to our overall understanding.
- • Enabling: What are the things we can do within our own organization or programmes to make them more compatible with the principles we espouse, such as providing service accessibly in the affected community rather than a hospital, or ensuring our own practices have reduced negative environmental impact.
- • Mitigation: This is addressing those things that reduce the impacts of the risk. For example, in northern Saskatchewan, Canada, the problems of poor water quality, sanitation, and overcrowding in housing meant periodic outbreaks of Hepatitis A. While working towards addressing these underlying risks, the use of Hepatitis A vaccine for children and youth in affected communities mitigated the outbreak by lowering the rate of Hepatitis A in children and youth to less than the general population.
- 4. Sometimes it is critical to see for yourself
Getting to know the communities, populations, or systems you are responsible for or involved with can reveal important things otherwise missed. Just reading others’ reports or papers may not be enough. For example, a community outbreak of Giardia was most likely from what the community believed was safe protected spring water source that the community had used for decades. By visiting the site, it was clear that the spring water was actually surface waters coming through the side of the hill. In another case, a community stated that its water treatment plant was functioning normally. A site visit found that the filters were not working, and they mistakenly thought that raising the chlorine level would eliminate any risk, not knowing that Cryptosporidium spp. spores would be resistant to the chlorine. It is critical to talk to those affected to better understand what they view as the issues and what matters. For example, in Amazonia, the government had established a programme to encourage sustainable planting, and not burning, of the rainforest. Participating communities would receive additional funds. One community requested a paved path from the village to the river, which the government administrators thought odd and frivolous. However, when the governor asked the question of why, the community response was that they bathe in the river, but by the time they get back to the village they are dirty from the muddy paths.
5. Building plans and relationships before a crisis
Eisenhower would say: “Peace-time plans are of no particular value, but peace time planning is indispensable.” The reality is that emergencies by their nature are full of surprises. Thus, it is important to plan for the knowable possibilities and build the relationships with needed partners in advance, so that time is not wasted in trying to build trust amid a crisis. Energy can then be focused on solving the unanticipated. Understanding the governance and organization of your emergency response team ahead of time can clarify roles and responsibilities and ensure a more coordinated and effective response. For example, it is wise to have one team focused on operations and another to focus on strategic aspects of the response. Establishing the role of collaborating agencies and how communications will occur within and across response teams is an essential pre-emergency activity. This can help avoid miscommunication and help each partner to better understand the other’s situation.
6. Think vertically and horizontally at the same time
Many of our most important issues or problems occur at the margins, or intersections that require multisectoral, multidisciplinary, and multijuris- dictional approaches. Often, however, our assessments tend to be linear in trying to understand that x causes y, or we give up as the issues are beyond our individual control. In complex systems, such as nature and human interactions, the solutions are also more complex and rarely linear, let alone having a single cause. Variation and connectivity are hallmarks of biology, whether in genetics, immunity, exposure, dose, social structure, or other influencing factors and differences. When trying to understand causes in the hope to intervene, limiting our thinking to linear solutions risks serious untoward effects or unintended consequences. More details on complex systems and unintended consequences can be found in Chapter 13. The dynamic nature of these relations requires solutions to change over time. For example, waste and pollution management through dilution was feasible when human populations were small, but not feasible as populations grew and additional harms reduced the capacity of the receiving environment to cope with our wastes.
7. Working through decisions
There are two principles that I believe are essential in seeking the best, safest, and most appropriate options whether in clinical, programme, or policy spheres. The first is “first do no harm.” The principle is that the essential obligation is to not make things worse. And while there is always the potential for unwanted side effects or adverse outcomes, the primary consideration is a focus on improving health or reducing disability or their correlates in other sectors. The second principle is “do what is the least intrusive, most effective with the fewest side effects.” It is an additional ethical and practical view that interventions always have risks, but these can be minimized by utilizing those that are less invasive or violating. We should always aim for the best possible outcome and in order to do so, seek options shown or likely to be most effective. Respecting the concept of “first do no harm” requires us to seek options with the least side effects. These principles are particularly important in facing problems that are less than catastrophic or fatal, and are as important in designing an environmental, social, or economic policy as they are in deciding on a clinical course.
8. Working with coalitions
There are some key principles that help to make effective coalitions,
It is difficult to influence who or what we do not respect. We need not like them or want to socialize with them, but we must respect who they are, the role they play, and that they have a perspective that we need to understand, even if we do not agree. I have yet to see where a harangue has successfully changed a person’s long-held perspective. Rather it may entrench their views, or at the very least cause them to disengage, awaiting a chance to escape the encounter.
ii. Make it practical
Great ideals without substance or do-ability only tend to frustrate. For policymakers or others, there is always a long line of advocates, academics, or others happy to point out the problems, and the need for someone to do something. The challenge is finding practical, acceptable, and achievable solutions that help to move us in that direction. It is particularly well received if they also help meet objectives that the decision-maker values.
iii. Rule of three
Committees, coalitions, or negotiations often bog dowm around things that different governments, disciplines, or individuals will never agree on. Yet given they are at the table, there are likely far more issues that they might agree on. As such, I try to break down issues into three categories. Those we can agree with we should just do. Those solutions that we may not have perfect agreement on but could live with, we also do. Then, those few that we will never agree on, while not ignoring them completely, we do not waste all our time trying to convince others of what is unlikely to change for jurisdictional, situational, or any number of reasons. The nice irony is that when we successfully tackle the first two categories together, it is easier at times to find some accommodation or agreement on the third.
iv. “Having something to offer”
Many good ideas flounder as they are passed from department to department or organization to organization because no one has the authority, mandate, or capacity to take it all on. However, if we have something we can offer, or if the other organizations could contribute another part, sometimes that logjam can be broken. For example, wanting to have health and social impacts included in environmental assessments was seen by colleagues in environment as one more complication for which they did not have the expertise or capacity. However, by offering to collaborate and take on responsibility for that aspect of the work, the conversation changed.
v. Coalitions and collaborations form and reform as needed Organizations or individuals need not agree on everything to work together on the things upon which they do agree.
vi. Other expertise or perspective
There is always a tendency to consult with "the usual suspects,” so we develop blind spots to both problems and potential. Many organizations, including governments, will w'ork away internally to figure out how to address an issue, then when it is finally public get defensive against all the other perspectives or alternate suggestions that present. It is possible to explore options without tipping one’s hand or betraying government secrets in order to ensure that things are considered more fully by the time decisions need to be made. There will be items that must be done in secret, but that excuse may be overextended into areas that would do better with transparency. For example, the many advisors I had assisting with the Annual Reports on the State of Public Health when I was Canada’s Chief Public Health Officer (which always were in the context of the complex relationships of Determinants of Health and One Health perspectives) were initially required to not only sign confidentiality agreements but also to return any numbered drafts upon which they commented. I was eventually able to get that changed as the purpose of these reports to parliament were to provide the best understanding of the issues and possible solutions, which required hearing from multiple perspectives and expertise, and were not a matter of national security. One of the nice things about working in Public Health and on One Health or Health Determinants issues is that the more people know and understand what makes a difference to human and animal health, the environment, the economy, and what we can do about it, the better.
9. Crisis communications
There is much that has been studied and written on risk management and crisis communications. While there may be many nuanced differences in situations and the appropriate response, the five core messages below must always be kept in mind and articulated clearly. Too often I hear officials and others responsible for communicating messages miss the point by effectively dismissing the fears or concerns of the public by only eating a hamburger to declare it safe from BSE, attending a restaurant during SARS in Toronto, drinking a glass of water to demonstrate safety, or simply saying something is safe, or the risk is low. The challenge for the hearer is what does that mean? How low? You may eat that one burger, but I have been eating that meat or drinking that water daily for weeks or months.
There are five core messages that need to be part of crisis communication:
- • What we know
- • What we don’t know
- • What we are doing to find out
- • What we are doing to address the issue
- • What you can do to protect yourself and others
These five core messages in and of themselves do not make up crisis communication, but they are critical to helping people understand the real nature of risk. No matter what else is said, and whenever possible, it is essential to offer people something that they can do to protect themselves and others. It was striking as part of the response to the 2009 HI influenza pandemic that people took personal action. I am told you could identify Canadians in international airports because they were the ones that would cough or sneeze into a tissue or their arm rather than contaminating their hands. This is something I had advocated early, and it was reinforced in diverse settings from schools to television comedy skits. In the most remote parts of the country I travelled, there were sanitizing gels in shops and public places. People increased the washing of hands, avoided others if ill, had antivirals readily available should they become ill in pregnancy, and almost half the population was immunized in the autumn, sufficient to stop the pandemic in Canada before Christmas. Thus, for the first time in history, the course of an influenza pandemic was fundamentally and positively altered. At the same time, food establishments and hospitals increased their focus on hygiene, hand washing, and cleanliness, dramatically diminishing the usual hospital-acquired infections and food-borne outbreaks.
Dealing with the wicked problems we face in One Health requires a broad range of disciplines, sciences, evidence, expertise, sectors, organizations, and disciplines. It demands a different kind of leadership than the typical approaches and structures when a leader has some measure of control over those in their company, military, government, or organization. It is less about power or command and more about influence, persuasion, collaboration, and modelling of effective strategies.
There is not as much written about this type of leadership, perhaps as it is less certain, and more working in the grey area of motivation. And yet much can be effectively accomplished, with experience and practice being reinforcing. It can be very satisfying to see positive change effected whether one’s personal leadership in it is recognized or not, for it is a team sport. I am regularly reminded of the quote by Samuel Johnson paraphrased as, “It is amazing what can be accomplished when no one has to assume the credit.”