Welcome to Week 4. In this session, we're going to discuss Leadership During Outbreaks. The question we must ask is, what makes a leader? I have pictured here a variety of famous leaders, including Abraham Lincoln, Mahatma Gandhi, Nelson Mandela, and Malala Yousafzai. All of them have made a significant contribution to the rights of men and women. Many philosophers throughout history, have described leadership. Including Plato, the ancient Greek Philosopher, Confucius, the ancient Chinese Philosopher, and Machiavelli, the ancient Italian Philosopher. The Three Philosophers described leadership and agreed that it must be a moral ethical person. But it was Professor James MacGregor Burns who really studied leadership. And he said that leadership is one of the most observed, yet least understood phenomenon on our planet. And he wrote the seminal textbook, "Leadership". He defined two types of leadership, transactional and transformational leadership. Transactional leadership is the most common type of leadership. Here, leaders try to exchange goods or services with others. For example, political leaders might seek votes in exchange for jobs. In contrast to transactional leadership, transformational leadership is much more profound and complex. This is when a leader will engage the followers to seek higher levels of morality and motivation and purpose. So for example, political leaders will seek to improve society, improving social justice and freedom and peace. According to Professor James MacGregor Burns, a leader is somebody who can make something happen that would not happen otherwise. In other words, anyone can be a leader. When I was studying for my Masters in Public Policy here at Princeton University, one of the courses I took was Comparative Bureaucracies. Max Weber's readings were a key part of that course. In his essay, Bureaucracy, he discussed the relationship between political leaders and bureaucrats. He predicted an inherent tension between them. Politicians must tap into the bureaucratic leaders' area of expertise while still trying to implement their ideologically based policies. Bureaucrats are highly trained professionals and they might not necessarily agree with the political leaders' ideologically based policies. How might this tension then affect public health? What tension might exist between a political leader and a bureaucratic leader who might be a physician? Reading about the inherent tension between a political leader and a bureaucratic leader, I immediately thought about the situation with US President Ronald Reagan and Surgeon General, Dr. C Everett Koop. Their story was well explained by the journalist, Randy Shiltz in his book, "And the Band Played On". Dr. C Everett Koop was a distinguished pediatric surgeon, and he was also a staunch opponent to abortion. Ronald Reagan appointed him to be the US Surgeon General. During the early years of the AIDS epidemic, President Ronald Reagan prevented Dr. Koop from addressing the crisis. Many of the conservatives in the United States believed that AIDS was punishment for immoral behavior. As the epidemic progressed, Dr. Koop was asked to investigate the problem. And he went around the country interviewing patients, physicians, community activists, and others. And he came to the conclusion that AIDS was a public health crisis and not a moral failure, and that because it was a public health crisis, it should be addressed as such. Dr. Koop printed his findings and recommendations in 20 million reports and distributed them to the public without the White House's approval, and that action very likely might have lost him his job. But nevertheless, Dr. Koop adhered to the Hippocratic Oath, which all physicians recite when they graduate from medical school. So his allegiance was more to the Hippocratic Oath, to do no harm, than to the president, who was his boss. So when we look at the relationship between elected officials or political leaders and their appointees, who are the bureaucratic leaders, we need to investigate, what is their relationship? Now, here in the United States, the chief executive is the US President. And this president can appoint a political leader, Secretary of Health and Human Services. And under the Secretary of Health and Human Services, you have Directors of agencies such as the Centers for Disease Control and Prevention. So in my studies of public health leadership, I developed two models. In the first model, the political elected leader is the primary decision-maker and receives expert advice from the appointed bureaucratic leader. In the second model, the elected official delegates the primary decision-making to the bureaucratic leader and this elected official provides political support. Now, both of these models can work as long as the different people involved understand and agree to their roles. But it requires at least two leaders, the political and the bureaucratic leader. So let's look at the case of the 2001 anthrax letter attacks about one week after the terrorist attacks of 9/11 in 2001. Four letters laced with anthrax spores were mailed from a post office in Trenton, New Jersey. These letters were mailed to both political leaders and media celebrities. In all, a total of 23 people contracted anthrax, 5 people died. The letters were successful in generating widespread fear. When we examine the leadership during the anthrax crisis between the political leader and the bureaucratic leader, the two models appear. For example, Mayor Rudolph Giuliani, who was the mayor of New York City, and at that time, was a respected politician, he preferred to follow model 1, in which he was the decision-maker front and center and received expert advice from his appointee, Dr. Neal Cohen, who was the Commissioner of Health at the time. In contrast to model 1, the Governor of Maryland, Parris Glendening, followed model 2, in which he delegated decision-making to his appointee, Dr. Georges Benjamin, who was the Secretary of Health of Maryland. Governor Glendening, instead, preferred to give his political support as Dr. Benjamin made the decisions. In contrast to the leadership that was exemplified in New York City and in Maryland, the situation that happened in New Jersey illustrated a failed model 2 type leadership. What happened in New Jersey? The perpetrator mailed letters laced with anthrax spores from a mailbox in Princeton. Those letters went to a large distribution facility in Hamilton, New Jersey where they underwent high-speed spinning for sorting. No one in New Jersey knew that the spores could fly out of the gaps in the envelopes. So it wasn't clear if the facility was contaminated or not. Dr. DiFerdinando had to make the difficult decision to close the facility because the postal facility was potentially exposed to anthrax spores. Dr. DiFerdinando wanted to prescribe to the 1000 postal workers antibiotics in case they were exposed. This would be for preventive or for prophylactic purposes. The CDC was stretched, however, they were dealing with cases in Florida and New York. So they sent an inexperienced team to New Jersey. The leader of the inexperienced team refused to release antibiotics from the National Emergency stockpile. Dr. DiFerdinando then had no choice, but to tell the postal workers on TV to get antibiotics from their private physicians. His announcement was made on a Friday night when physicians' offices were closing and pharmacies quickly ran out of the antibiotics. That's when panic ensued. This situation occurred because Donald DeFrancesco, who was the Acting Governor of New Jersey delegated leadership to his political appointee, Dr. George DiFerdinando, who was the Acting Health Commissioner. Dr. DiFerdinando had to make difficult decisions without political support from the acting governor. In other words, they did not have time to develop a relationship to understand how each other would work because before they were both placed into office, the Governor, Christine Todd Whitman, had left to become Head of the Environmental Protection Agency. And so you had an unfortunate situation, where you had an acting governor and an acting Health Commissioner working without really establishing a relationship. This situation exemplifies model 2 leadership with difficulties. At the same time, the mayor of Hamilton Township, Glenn Gilmore had to deal with a contaminated post office. And before the crisis even happened, he very presciently established an emergency task force. But nevertheless, he expected the the federal government to assume leadership when, in fact, that's not their role. What is the role of the federal government during a public health crisis? This is a timeline of the development of Public Health in the United States. But in contrast to National Security, Public Health, which was in its infancy, was made a state and local responsibility. To understand the role of Public Health in the United States, we need to look at the US Constitution which was signed in the late 18th Century. Now, the Constitution provides for a common defense and it provides a right to a lawyer, but it does not provide for a right to a doctor and does not even mention Public Health. Now, as I mentioned previously, Public Health was in its infancy, 18th century medicine was primitive at best. The only treatment that doctors could result to were bleeding using lancets or scarification, and they were more likely to cause harm or even death than cure. Let's look at poor George Washington, the first President. At the age of 67, he had been healthy and was even horseback riding, but he became sick while riding in a storm. George Washington is pictured here, lying in his deathbed surrounded by his doctors and his family. Three doctors bled him multiple times, and he lost approximately five pints of blood. And he died shortly thereafter. I would argue that his doctors most likely hastened his death rather than helped him. As I mentioned, 18th Century medicine was primitive at best. They were following Hippocratic medicine, which lasted over 2000 years, pure quackery focusing on the four humors. They believed that humoral imbalances caused illness. Advances in science and technology in the late 19th Century led to a revolution in Public Health and medicine. But the US Constitution has not been upgraded to follow those changes. According to the Tenth Amendment of the Constitution, the powers that are not delegated to the federal government are relegated to the state and local government by default. Therefore, public health is a state and local responsibility. As a result, each state has developed its own public health laws. And the United States is now a patchwork of antiquated public health laws across the country. The role of the federal government therefore, is purely advisory and supportive. Since the anthrax letters were a form of terrorism, they threaten the nation's national security, therefore, it was a federal responsibility. On the other hand, they were also generating a public health crisis and that made it also a state and local responsibility. So then the question everyone asked is, well, who's in charge? Well, the elected officials are in charge. They are legally responsible for the health, safety, security, and well-being of their constituents. It is up to the electorate to vote into office the most competent individuals to assume leadership. You want somebody who has your best interest at heart, and not their own. You don't want somebody who is corrupt, who is going to make decisions to only benefit themselves. And you want somebody who's going to appoint qualified competent people to be the bureaucratic leaders during any kind of crisis. Because your life can be at stake depending on who's in charge. Honesty and trust are key components of any crisis response. And the leaders must be honest with the public if they want the public to accept their policies during a crisis. Political leaders, bureaucratic leaders, must be highly ethical and moral if they want the public to believe them and to trust them and to follow their recommended policies. During the COVID-19 pandemic President Donald Trump made many mistakes. He downplayed the severity of the crisis, he gave false reassurances, and he did not accept expert advice. He preferred to keep his own counsel and he wanted to be in front of the press' cameras as much as possible. His chain of command started with himself and then went to Alex Azar, the Health and Human Services Secretary, and then down to Dr. Robert Redfield, the director of The Centers for Disease Control and Prevention. Neither Dr. Redfield nor Mr. Azar were prominent during the pandemic and indeed, while Dr. Redfield was supposed to be in front of the cameras, he was virtually invisible. Instead, Dr. Anthony Fauci, who was not part of the official chain of command, but instead was the director of the National Institutes for Allergy and Infectious Diseases, became the most trusted science advisor for the public. So the questions for this session include, what are the two types of leadership? Why is one more powerful than the other? What is James MacGregor Burns' definition of a leader? Why might there be an inherent tension between political leaders and bureaucrats, particularly if the bureaucratic leader is a physician? What are the two models of public health leadership? What might happen when leaders haven't developed a working relationship? Why isn't public health or the right to a doctor written in the US Constitution? Finally, who is legally in charge during a public health crisis in the United States? And with that, I'd like to thank you for your time and attention.