Yale School of Public Health, New Haven, Connecticut
Tuesday, May 19, 2020
Hello Graduates of 2020!
This is quite a momentous occasion for me—it was just about 25 years ago when I was sitting where you are now graduating from Yale with a degree in public health. My concentration within the PhD was health economics, and I remember being sort of relieved because a lot of people outside the field did not really know what “public health” meant, but they sure knew what “economics” meant!
How different it is today, on your commencement, with the world facing the worst pandemic since 1918, and forecasts of more pandemics to come with the changing climate, the melting of the Arctic permafrost, and the human encroachment on rainforests and other natural boundaries.
So let’s talk about where we are in terms of public health and its relevance to the roles that you will assume in your life. I often get asked whether my background in public health has helped in my role as president of Vassar—particularly during this pandemic.
My public health background has, in fact, helped—as I understand our epidemiologic data and related biases more easily, have been through medical and public health crises before, have some sense of how the public health system gets mobilized (or not) and have learned (at YSPH) that everything is connected to everything else.
But I also have to confess that public health has let us down in this pandemic. For sure, most of us in leadership with public health backgrounds and many public health experts throughout the country believed that we would follow an accepted template for responding and have testing early—maybe in February or even late January when tests were available globally. So while we were alert and concerned in January, we were secure knowing testing and isolation could contain the virus.
But week after week passed in February and even March without testing; the virus, which we still do not completely understand, and the risks became overwhelming and here we are: in a pandemic.
When it is over—and no one can say when that will be—we in the US will have devoted, and sacrificed, trillions and trillions of dollars and lost maybe as many as 80 thousand lives in the battle. One might say that the US has taken a very “medical” approach to this pandemic—relying ultimately on the development of medications to address what is a public health problem. As has been shown in so many other instances of health threats, overreliance on this reactive medical approach is very expensive, and not that effective.
Time and time again, U.S. health policy decisions have privileged medical care over public health systems and emergency preparedness. The approximately $275 per person per year we spend on public health (2.5 percent of all health care spending) is simply not enough—not enough for the core investments to protect human health in our country or globally. The US health care spending is more than double that of other countries that appear to have weathered this virus much better than we have. How can that be? Shouldn’t greater investment equate to better outcomes and longer lives?
Well, it turns out that we have not always invested in the right things—at least to combat a pandemic. I want to focus on some of the investments we need to make, which are not complex and in fact are nothing more than common sense.
First, we need the brightest and most creative minds in communications and social media to provide a constant flow of engaging information about health risks and opportunities, tailored to different ages and needs. I understand health communication is a renewed focus for the School of Public Health with teaching by YSPH alumnus Dr. James Hamblin, reporter for The Atlantic. I believe this area is wide open for new graduates—who understand how to be influencers on social media. Having better information in real time about health risks and opportunities in formats that are consumed regularly by everyone is key to proactively protecting our health. Transforming rigorous epidemiological data into meaningful tidbits that the general public can consume is a true challenge for our future. You will be competing with misinformation, sometimes coming from what should be reputable sources, with an audience that does not really know who to believe, but your degree has equipped you for that complex world of health communication.
Second, we need the capability to quickly scale up diagnostic testing, ideally home testing, and public health laboratories to make universal and regular testing feasible. I know Professor Albert Ko is co-chairing a group looking for safe ways to re-open Connecticut with adequate testing and follow up. A big part of this is science but it is also logistics and of course community action—to shift expectations and practices of large populations to undergo testing regularly and quickly.
And last, we need coordinated data collection and analysis to enable timely and accurate contact tracing and follow up to contain outbreaks at their source. And I believe Professor Niccolai here at YSPH is working to develop a 100+ person (mostly students) volunteer corps to help do contact tracing on behalf of YaleHealth, Yale-New Haven Hospital, New Haven Department of Health, and the Connecticut Department of Public Health. That is a nice collaboration between academics and city and state public health departments, and such resources should become regularized in our national public health workforce.
These are all the technical investments—health communication, testing and diagnostics, and coordinate workforce for contact tracing and response. They are the bread and butter of public health, and yet tragically underfunded and unappreciated. Whose parents ever say, “We want you to grow up and be a contact tracer? A health communicator?” Not likely—even those these roles protect us all.
But now, there is something more—also lacking in our current public health and medical care system is leadership. Here I want to reflect on an innovative study led by Professor Leslie Curry (the Faculty Marshall today at these ceremonies) called Leadership Saves Lives. The hypothesis going into the study was that leadership capacity within hospitals could be prospectively improved and would be associated with reductions in risk-standardized mortality rates.
This mixed methods study was a two-year follow up study and had interesting results. Four out of the ten hospitals exposed to the intervention—which included in-depth training and development sessions and team building work—made marked improvements in their leadership and organizational culture. And these hospitals saw significant reductions in risk-standardized mortality rates.
In the hospitals that successfully reduced mortality rates, staff talked about how they had unearthed new skills on the team they never knew were present (e.g., physicians recognizing the value of EKG techs, nurses and technologists seeing their distinct roles as complementary not competitive). Additionally, the successful hospitals found ways to encourage staff from different disciplines to participate fully and authentically in the quality improvement efforts—allowing lower power staff to feel more secure providing critique or creative ideas to the group. And last, staff at the successful hospitals learned how to manage conflict effectively. It was funny; staff at the poorly performing hospitals noted feeling “bored” by or “withdrawn” from the quality improvement project team. And if not bored or withdrawn, they were slightly irritated or angry—blaming someone or being blamed. This was quite a contrast at the successful hospitals where staff talked about having errors that got analyzed in ways that uncovered systems and structures they could improve for next time.
Why is leadership important to today’s struggle with the pandemic and to your commencing into the field of public health?
Although I argued that the calamity of COVID-19 is due to inadequate intelligence about the virus and its spread, as well deficient testing—the current mess is also so much a function of ineffective leadership. Let’s go back to the evidence about leadership efforts that save lives: convening groups of different disciplines, ensuring each is comfortable participating fully (even to speak truth to power), and resolving conflict in ways that are analytic, focused on discovery of mis-designed systems and structures, and keeping people engaged—not in blaming others but in collaborating with others to improve.
To prevent and mitigate the devastating effects of pandemic threats, agencies such as the CDC, FDA, and HHS (to name a few) need to work together, guided by accurate and real-time data, and without blame. There is no room for “othering;” there is no room for ego and bragging rights—there is only room for evidence-based, painstakingly careful analysis and strategy, and strong leadership to keep teams of people pulling in the same direction. We see these capacities in some states (I am proud to be from NY today), but not enough at all levels of government.
The leadership I have been talking about is not the traditional leadership model we often have in our heads based upon cultural norms in the United States. The research did not find a “great person” who led the hospital with intelligence and charm to successfully change its systems to save lives. Rather, the research found people from all parts of the organization who were inclusive, who sought ideas from every area, who developed trust and transparency, and who shared power among the team.
Many of these ideas about leadership were informed by the global health work I have done around the globe with very few resources. I know Yale is celebrating 50 years of women this year, and so I will plug in particular how women around the globe have demonstrated new norms of leadership. Many are women who had seen suffering and disease in their communities and had concluded that they could not accept things as they are. Health extension workers in Ethiopia and community health workers in Rwanda who could no longer accept that women died from what should be routine births, women in rural China who believed with basic hygiene, hospital infection rates could be reduced, and women in Ghana who refused to accept the lack of treatment and stigma for people living with mental illness and advocated for a state-of-the-art national mental health policy.
And now to you. You might not fashion yourself to be “a leader,” but you have leadership in you because, like my colleagues around the world, with this public health degree you have taken the step to say: “There is unnecessary suffering and disease, and I will do something about it.” You know the power of working in groups. To the degree that leadership is a property of a system not an individual, you can be part of the leadership capacity of any organization, community effort, or agency you join. Remembering to focus on attracting a diverse group of people and roles with complementary skills to the table, ensuring the working atmosphere is one in which even low-power roles feel they can speak up and participate, and learning to resolve conflicts in ways that deepen engagement and help uncover paths to improvement. All this is leadership and all this saves lives—at the micro scale of a hospital or the macro scale of a country facing the threat of pandemic. Given our shared field of public health, no matter our role in it, we are all called to such leadership.
You have chosen to pursue one of the most important fields for our time. To graduate from Yale with a degree in public health in the middle of a pandemic is an enormous achievement—for you and all the family and friends who have gotten you to this place. We are not physically together, so I cannot ask you to look around at all your peers and supporters in the room and say thank you. But let’s take a quiet moment and think of all those who have carried you to this place.
What a wonderful day! CONGRATULATIONS Class of 2020!
—Elizabeth H. Bradley, President, Vassar College