A World Cup for the ages, with good old fashioned teamwork

Even four days after the best World Cup final I have ever seen, I am still brimming with the euphoria that only seems to accompany el jogo bonito (the beautiful game) in its finest form. What a spectacle it is. Teams from 32 nations around the planet vie for supremacy of being called the world’s best team. Remember that word, T-E-A-M.

Germany’s relatively small-sized but experienced captain, Philipp Lahm, captured it best after the final game against Argentina. “It’s unbelievable what we have achieved,” said the Bayern Munich defender. “Whether we have the best individual player doesn’t matter at all, you just need to have the best team.”

This Tweet was widely re-Tweeted after Germany crushed Brazil 7-1.

This Tweet was widely re-Tweeted after Germany crushed Brazil 7-1.

A great shot published on game day of the victors.

A great shot published on game day of the victors celebrating their win in the biggest sporting event in the world.

I watched more matches than I planned to, and found myself swept away, as always, in the massive melodrama that captures the world’s attention every four years. This year was no exception.

Uruguayan Luis Suarez bit an Italian opponent like a zombie.

The host team lost in the biggest knockout-round blowout ever in the Cup, 7-1, to winners Germany after its star player, Neymar, had his back broken.

One nation, Cameroon, was alleged to have thrown a game. And of course there were countless displays of sheer athletic brilliance like goals scored by Colombia’s James Rodriguez and would-be goals blocked by U.S. keeper Tim Howard.

More than a game … a social media spectacle of historic proportions

An Internet meme beautifully shows how U.S. keeper Tim Howard blocked the goals.

An Internet meme beautifully shows how U.S. keeper Tim Howard blocked the goals against Belgium.

It is estimated the final match that saw Germany top Argentina in a 1-0 nail-biter decided in the 113th minute drew about 26 million viewers in the United States. In Germany, about 35 million fans watched the game on TV, not to mention public viewing areas. Globally, around the world about 1 billion may have watched, but I suspect the number was higher. I doubt they count small bars in rural China and Africa and other remote spots.

Mario Gotze scores the winning goal against Argentina, as shown in possibly the penultimate game photo of the tournament.

Mario Gotze scores the winning goal against Argentina, as shown in possibly the penultimate game photo of the tournament.

And what a great final game it was, with a brilliant end.  Germany’s André Schürrle darted down the sideline and sent a perfect cross to teammate and fellow late-game sub Mario Götze. Super Mario trapped the volley with his chest and blasted the ball to the side of the net. GOOAAAAALLLLLLL!!!!!!!!!

Where I was watching the game in Seattle at a neighborhood center, half the room went nuts, with orgiastic screaming. Half the room cheering for a great Argentina side fell stunned silent. That is pure World Cup emotion, and there is absolutely nothing else like it in the world. Period.

Some researchers have said events like soccer have a hormonal factor in a brain peptide, oxytocin, that research shows promotes positive intersocial relations. It is called the “love hormone” because it makes people like one another, especially in intimate relationships like mother and child. Research shows that players’ exhibitions of emotions like happiness and confidence, as in after a great play or goal, can be contagious, when a person’s excitement  triggers biochemical reactions in onlookers’ brains.

That is precisely what happened at the same moment around the globe when everyone watching the game on TV and giant screens saw the emotions on the German team members’ faces after the goal.

Bam, oxytocin discharge, followed by social media frenzy.

Social media globally turned into a raging wildfire. Twitter sent more than 600,000 Tweets a minute after the match on July 13 and more than 670 million Tweets by the next day, more than ever before in its short history. On Facebook, there were 280 million interactions such as posts, likes, and comments—the most for a sports event.

It was a sports event and a social media happening of historic proportions at the same time. Small wonder German Chancellor Angela Merkel was at the stadium hugging the sweating German team one by one, and even posed for a selfie with starter Lukas Podolski, and soon that Tweet blasted around the world.

Podolski tweeted this selfie of him and the German leader right after the game, in a Tweet seen 'round the world.

Lukas Podolski tweeted this selfie of him and the German leader right after the game, in a Tweet seen ’round the world.

So it is no boast the singularly most important global event of the past month was the Cup, despite all of the raging conflicts that continued during its course. People the world over adore it, and go crazy over it, and weep and moan over like, like the entire 200-million-person host nation of Brazil did after the German team brutalized the host team 7-1 in the semi-final blowout that was a record-breaker of historic proportions.

Why the game is great, and the Cup is greater

Professionally, the game is easy to grasp. It has simple rules, a 100 meter pitch, three referees, and 22 men making up two teams who are fiercely competing for the title of best national team on the planet during Cup time. I love the Cup because it, more than anything else, is a common denominator that I have with someone in remote Greenland; and Munich, Germany; and Kampala, Uganda; and Rio de Janeiro, Brazil. No matter where I go, I can always talk about the Cup, and I will have a well of good feelings and excitement to draw upon.

This is one of the best shots after the game: Lionel Messi of Argentina is consoled by Germany’s Bastian Schweinsteiger.

What I most liked about this year’s final game was the near-perfect match of two really outstanding teams.

On one side, you had the world’s greatest player, forward Lionel Messi of the elite club Barcelona, who was surrounded by a team that got stronger and more cohesive as the tournament progressed. They were matched by Germany, which lacked the flash and brilliance of Messi, but who had perfected what football commentators called a system of teamwork and cohesion. (Granted this system is strongly supported by the nation’s football federation.)

In fact, the two best teams showed up in the Maracana stadium, and both played great team soccer.

Passing was strong, there were not many dirty tackles, and both sides had great scoring chances, only to see them squandered. Argentina actually blew three golden opportunities, including one by Messi inside the box, with no one close enough to shut him down. With the exception of two horrible concussions during the game, one to each side that later forced commentators to blast FIFA’s system and led to many calling the contest the “Concussion Cup,” the game was without flops or debilitating injuries.

Despite the excesses and corruption of the world football governing body known as FIFA, for me, Brazil’s 2014 Cup was a great reinforcing example of the power of teamwork.

Organizational behavior theorists have long championed Naval researcher Bruce Tuckman’s famous four stages of group performance from his seminal 1965 article (Development Sequence in Small Groups): forming, storming, norming, and performing. When groups are clicking as a unit, they can achieve well above their own individual abilities and, if really good, as in high-stakes activity like conflict and sport, achieve greatness and victory.

As someone who played soccer most of my life from youth to middle-age, I can attest to the power of teamwork and how effectively groups with lesser abilities can overcome better opponents who do not have that cohesion.

The ultimate team player, Miroslav Klose of Germany

Germany had the team magic. It was obvious the whole tournament. There were great plays by the German team stars like Thomas Müller, even very great plays like Götze’s winning blast, but all of the German team members contributed to their success. The perfect example was forward Miroslav Klose, 36, and veteran of four World Cups and likely the most underrated player in the world. He scored two in the Cup, both lovely.

In the victory over Brazil, the “poacher” scored his 16th Cup goal (see all here), more than any other player in the history of the Cup. He did it as he always did, getting great service from his teammate, and always following up when his first shot was blocked.

Klose scores his 16th World Cup goal against Ghana, a record and a lasting tribute to a great team player.

This photo captures a perfect moment: forward Miroslav Klose scores his 16th World Cup goal against Brazil, a record and a lasting tribute to a great team player.

Klose is not pretty. He is not charismatic. He does not smile often, and he is a quiet family guy. In fact, his lack of flash allows defenders not to respect his killer instinct as a finisher. Most of all he has succeeded in making history by being part of a great team that worked relentlessly at being the best at what it did, and then did it in the highest possible stakes game there is in the world.

My hat is off to the German, and Argentinean, teams. Thanks for making this Cup memorable and for showing how two great teams play the best game in the world.

The 10th man, zombie apocalypses, and incorporating contrarian views

I recently saw the Brad Pitt zombie action vehicle, World War Z.

Brad Pitt goes toe-to-toe with the zombies and saves humanity in his public health swashbuckler, World War Z. Way to go, Brad!

Brad Pitt goes toe-to-toe with the zombies and saves humanity in his public health swashbuckler, World War Z. Way to go, Brad!

It is actually not a bad zombie apocalypse movie, as zombie apocalypse movies go. Brad saves earth, and a lot chattering, undead humans get shot and blown up. It also is a fairly straightforward public health film, which foretells horrific calamity to humans because of some possible viral outbreak that could kill much of humanity. (If you are not worried about this, then perhaps read up on the recent Ebola virus outbreak this is causing legitimate fear and even panic in West Africa.)

This narrative, of course, is nothing new. Some great cinematic predecessors include Omega Man, I Am Legend, 28 Days Later, Contagion, The 10 Commandments (assuming the angel of death that passed over the Jews in slavery might have been a killer virus), Children of Men (a personal favorite of mine), The Andromeda Strain, and much more.

Though I have no data to back up this claim, I am guessing more people around the world have learned about viruses and the threats they can pose to population and human health from such films than anything ever produced by a national or government health agency.

I also believe that public health advocates need to fully embrace the “Brad Pitt saves the world from zombies” approach and copy it, and also use such storytelling techniques to mobilize public understanding of public health issues, from the importance of vaccinations to the woeful underfunding of public health in the United States.

Can the 10th man save public health and humanity?

What I most liked about WWZ was its exploration of the concept of the 10th man, which is used by Israel’s security apparatus.

In the film, Israel had prepared for a zombie apocalypse because it had institutionalized a non-consensus decision-making safeguard. A Mossad security official character, Jurgen Warmbrunn, explains to Pitt’s hero that because of Israel’s pre-nationhood and post-nationhood catastrophes, including the Holocaust and the Yom Kippur War, one person in a decision-making group has to take the contrarian view if all nine of the others reach consensus. In Israel’s experience, failure to do so could lead to extinction. Then that person, the 10th man, must put the alternative view forward, with the larger goal of promoting the interests of the organization, country, or collective. That is why Israel in the film was ready for the zombie horde. (Click on the video snapshot below to see the clip on YouTube.)

10th Man Clip

In science, this happens all the time. Scientists and statisticians do this by attacking the null hypothesis that seeks to disprove their theory they believe to be true.

But I am more interested these days in how this may work in organizations outside of intelligence circles and defense, where mistakes can cost many lives and national security, and how organizations can incorporate 10th man decision-making. Can the contrarian view be protected and even respected in organizations that do not allow for rigorous debate about choices that have implications for the public’s well-being?

Kill the messenger and avoid demonstrating leadership?

We know the popular legend of the archetypal messenger who loses his head when he brings bad news to the king. I was a newspaper reporter, and I have lived this in a mild way, having been threatened with a lawsuit by a corrupt community leader and vilified by autocratic public officials who wanted to have their malfeasance remain hidden. A new movie called Kill the Messenger, focusing on drug running by the Nicaraguan Contras during the Reagan presidency, explores this issue in-depth.

Italian physicist and mathematician Galileo was deemed a heretic and tried for his promotion of the Copnernican view that the earth orbits the sun and that the earth is not the center of the universe.

Italian physicist and mathematician Galileo was deemed a heretic and tried for his promotion of the Copnernican or heliocentric view that the earth orbits the sun and that the earth is not the center of the universe.

In fact, the phrase “kill the messenger” is known and understood globally, and for good reason. Many people know that organizations and human nature prevent good people from offering alternative views that challenge authority and orthodoxy. Some like Galileo, who offered a view the earth was not the center of the universe, turned human understanding of man and God on its head, and he was ex-communicated and not forgiven for more than four centuries by the Catholic Church.

So how can organizations, like public agencies such as health departments, create safe environments to allow for alternative views to flourish, for the purpose of improving decision-making internally. This is no easy fit, as these are hierarchical by design, and I have yet to hear how alternative decision-making works in them in a real-word basis.

In organizational theory, Peter Senge’s so-called “learning organizations” may be a model, but that is not really the built-in acceptance of a 10th man contrarian. Of course CEOs, companies, and consultants aplenty try to allow contrarian views because the endgame for them is profit maximization and success of the firm. In the world of intelligence gathering and organizational behavior. failure has been dubbed “group think.”

Getting back to our popular public health film trope, the zombies

Personally, I would love to see public health agencies, top to bottom, hire and fund the bright and brilliant artists who are creating manga comics and who are making manga comic-styled videos. And it is no surprise some manga comic artists have been hired and there are positive results. I have seen one video already, produced by the outfit called the Global Health Media Project. The group published a gritty portrayal of how lethal cholera can be, as a means to promote global education against its spread. You can watch the video below by clicking on the image.

The Story of Cholera

What would a campaign that promoted immunizations and targeted the promoters of anti-vaccination deniers look like if it were entrusted to artists who can tell riveting stories linked to movies, like the three clips below that accompany Will Smith’s I Am Legend zombie apocalypse thriller?

Check them out and see what you think–click on each screen snapshot to see clips on YouTube. Would there need to be a 10th man pitching these ideas inside the proverbial boardroom saying this would be a better investment of prevention dollars than methods that may have yielded no measurable results, ever?

 

I Am Legend Manga Extra 1

I Am Legend Manga Extra 2

I Am Legend Manga Extra 3

A few thoughts on management, leadership, and the greatest of ‘em all, Abe Lincoln

About two years ago, I was tasked with doing a summary of the essential differences between management and leadership. This is one of the great topics in all of management and organizational behavior literature. Walls of books line bookshelves by experts from every field, from sports to defense to business.

This difference impacts all of us, because the effects of good or bad leadership filter down to all of us, either as government policy or work environments, or in extreme cases, life and death outcomes as seen in conflicts raging in Syria, South Sudan, and other troubled areas.

As someone working in public health, I am acutely aware how this woefully underfunded field needs inspirational leaders to tackle the challenges posed by public health threats, but also to inspire and steer public thinking and win support for greater public health funding.

Without strong leaders, from small agencies to leading scientists to figureheads like the U.S. Surgeon General (see my post that touches on how Dr. C. Everett Koop set the standard), the profession may continue to be relegated to third-tier funding status in federal budget priorities and not gain greater acceptance by a wider majority of Americans. (Note to my international readers, I am writing this post with an American context.)

With management and leadership issues very much on mind this past week because of some interesting developments I have observed, I have decided to publish a short summary document I did on this topic two years ago focussing on Abraham Lincoln as an example. He continues to inspire me, even when I hit roadblocks and get discouraged. And isn’t that what good leaders do, inspire?

“Towering genius distains a beaten path. It seeks regions hitherto unexplored.” Abraham Lincoln

Abraham Lincoln is the most written-about American and also considered the greatest citizen this country has ever produced. He exemplified many of the traits that today's theorists consider to be those of a highly inspirational and effective leader.

Abraham Lincoln is the most written-about American and also considered the greatest citizen this country has ever produced. He exemplified many of the traits that today’s theorists consider to be those of a highly inspirational and effective leader.

What Is Management and Who Are Managers:

Management has been defined as “the art of using all available resources to accomplish a given set of tasks in a timely and economical manner.” Management provides the basis for the system of control needed to maintain and operate an organization. It is also about getting things done through others and delegating work. Managers motivate employees to accomplish tasks with a variety of tools (intrinsic or extrinsic awards).

Typical Management Activities:

- Planning, decision-making, organizing, staffing, directing/actuating (the process of leading through teaching), directing, and controlling (determining what the organization does in relation to its mission).

Management Theories:

- “Classic” management theory, dating back to the 1950s and 1960s, suggests managers have to rely less on technical skills and more on conceptual skills the more senior rank they hold. However, in the down economy as our class’s manager interviews found, managers at higher levels in lean organizations still have a lot of technical skills because they are doing a lot of frontline/skills-related activities.

- Classic models: Henry Mintzberg’s “10 managerial roles” (informational, interpersonal, and decision), similar to Robert Katz’s “skills of an effective administrator”  (technical, human, conceptual).

Scott Adams extremely insightful comic strip Dilbert captures an essence of management that likely resonates with millions of workers who find themselves led by those who fall short, very short of is well-document as being a good leader. Go to Adams' web site for more of his great work: http://www.dilbert.com.

Scott Adams’ extremely insightful comic strip Dilbert captures an essence of management that likely resonates with millions of workers who find themselves led by those who fall short, actually very short, of what is well-documented as being a good leader. Go to Adams’ web site for more of his great work: http://www.dilbert.com.

Management vs. Leadership:

Managers marshal resources to achieve the vision of others, and if they are good, help each person cultivate their talents and grow. Leaders are “visionaries, strategic thinkers, activators.” A talented few may excel at both.

Managers: rely on analysis and rationality, stress conformity, more like scientists, project power over people, seek obedience, emulate other successful managers/leaders.

Leaders: envision, rely on intuition, have self-confidence and take risks, project power with people, are creative and spontaneous, emphasize team building, explore new possibilities, inspire people to follow their vision.

Key Characteristic of Great Leaders: Emotional Intelligence (the principal theorist of this theory is Daniel Goleman):

  • Self-Awareness: Ability to recognize one’s emotions and their effects.
  • Self-Regulation: Ability to think before acting and suppress disruptive moods.
  • Motivation: A passion for the work beyond salary or status. Optimism, commitment, drive to do better.
  • Empathy: Ability to understand people’s emotions and treat them accordingly.
  • Social Skill: Good at building relationships and networks, finding common ground.

Leadership: Innate Ability Helpful, Practice Is Essential

Management experts debate if leadership is innate or learned; research suggests the latter. But innate traits such as drive, desire to lead, integrity, intelligence, and skill make it more likely that an individual will become a leader but are not the only factors in play. Research has shown that individuals can develop their leadership skills if they are given the right opportunities and mentored.
- Leadership as Innate: Intelligence and technical skill are key, and both are at least partially determined by genetics. Emotional intelligence—main predictor—tends to run in families and be greatly influenced by personality and childhood experience.
- Leadership as Learned: Businesses believe leaders can be created and invest a lot of time and money to identify and train individuals to assume leadership positions.
Transactional Leaders, focus on meeting organizational goals. Make adjustments as needed to complete tasks for group.
Transformational Leaders use personality/relations with followers to inspire the team to go above and beyond expectations. They are defined by charisma, vision, integrity, symbolism.

Abraham Lincoln, the Embodiment of Strong Leadership:

  • Lincoln Model, Emotional Intelligence: By the time he had become President, Lincoln had mastered his emotions and exercised great control by not sending “hot letters.” When the time came for action, he acted decisively, but only after deep analysis of the full situation. His greatest asset was his astounding empathy to understand his rivals, allies, and especially his opponents, including the slaveholding South. He was also a beloved storyteller and well-liked and admired by his peers. Lincoln also learned from missteps and made amends with opponents when victorious, and he did not carry personal grudges. He was driven to have a life that fulfilled a higher purpose and to preserve the Union—a nation he believed that had great future promise.
  • Lincoln Model, Learned Leadership: With just one year of schooling, Lincoln embodied personal drive and self-learning, as well as integrity. Lincoln spent years practicing his craft, in Whig party politics and then in the Illinois Legislature. He lost to his then-more renown rival Stephen Douglas in a U.S. Senate bid in 1856. He then won a brokered convention of the Republican Party in 1860, held in Chicago, after becoming the foremost speaker on the greatest issue of his day, the expansion of slavery. He credited the assistance of many benefactors and friends for believing in him and helping him rise to political prominence.
  • Lincoln Model, Not One Style of Leadership: Lincoln mixed authoritarianism (suspending the writ of habeas corpus, etc.) as a wartime president, but had a democratic style with his cabinet (his “Team of Rivals,” the most capable politicians of his day he personally recruited). He was transformational; his peers recognized his greatness, inspiring them to work harder.

Policy, systems, and environmental change: the current, faddish, cow-patty flavor of public health

One thing I have never shaken since my days as a rookie reporter is my penchant for calling out the obvious. This is one of the sacred duties of the press: to speak truth to power. This also means calling a spade a spade, and bullshit for what it is, and what it smells like.

Anyone who has ever worked in the business of reporting news and telling facts knows this is one of the press’s sacred trusts—and myths—and the clearer we are in doing that, the better our society is from having that unbiased information.

I captured these various images on Google when I typed in a few keywords, and clearly this concept has a lot of widespread acceptance by people who know a cow patty when they smell one.

I captured these various images on Google when I typed in a few keywords, and clearly this concept has a lot of widespread acceptance by people who know a cow patty when they smell one.

Today, I stumbled on Marcy Wheeler’s blog, the Empty Wheel, which tackles many hot-button policy issues. Last year she blogged about climate change in a piece called “The Cost of Bullshit: Climate Change, National Security, and Inaction.”  She pointed out that the cost for maintaining the status quo was too high, even when major government agencies from the Department of Defense and the Department of State concluded that the issue was a critical concern to U.S. national interests. Yet, no actions were being taken by the government, and all of the reports on the emerging crisis were “mere bullshit—more wasted government employees’ time and taxpayer money.”

Sure easy for a blogger not on the payroll to diss hard-working public workers and policy-makers, right? Or, is Ms. Wheeler simply calling out the obvious, like reporters have always done, or thought they were doing.

Will a public health fad meaningfully address the main killers of Americans?

The cost of bullshit has been on my mind late, particularly regarding public health jargon that inflates busy-looking arm-waving, but does not change reality.

For me, one of the most frustrating aspects of working in the public health is the field’s faddish way it labels its collective actions to address chronic disease issues, such as obesity, using fancy sounding concepts like “policy, systems, and environmental change.” Mon dieu, what big words, what big ideas.

This is an expression coming from the top, from the venerable U.S. Centers and Disease Control (CDC), to explain national efforts to tackle the monster that is chronic disease—the leading causes of death in our ever-fattening and ever growing income-unequal country.

These diseases kill seven in 10 Americans, and of the CDC’s meager budget of under $7 billion for our national public health effort is a mere drop in the bucket compared to other priorities of the $1.2 trillion national budget that is so-called “non-discretionary spending.”

The Congressional Budget Office released this info graphic on government spending and revenues for 2013. Go here for original: http://www.cbo.gov/publication/45278.

The Congressional Budget Office released this infographic on government spending and revenues for 2013. Go here for original: http://www.cbo.gov/publication/45278.

The CDC still estimates 18% of U.S. GDP spending is on healthcare, and a third of it at the place where the most outrageously overpriced and at the same time least effective primary care interventions can take place—hospitals.

So what do public health officials do, when faced with a handful of breadcrumbs thrown to them from Congress? They invent concepts that make it appear that public health is doing something, when there is little or no clear evidence population benefits are accruing based on investments at this level in the large ocean. Yes, I am taking about the catchy and jargon-laden ideas like “policy, systems, and environmental change.”

This is a hodge-podge of activities that encompass everything from starting farmers markets to promoting smoke-free buildings. Here are a couple of definitions I randomly found from some online sources:

  • State of Mississippi: “Our environment and the policies and systems in it shape the pattern of our everyday lives and have a profound influence on our health. The design and walkability of communities, the availability of low-cost fruits and vegetables, and the smoking policies in our workplaces have a direct impact on our physical activity, diet and health.”
  • State of Maryland: “Policy, systems, and environmental change (PSE change) refers to public health interventions that modify environments to provide healthy options and make healthy choices easy for everyone.”
  • Fairfax County Virginia: “Policy, systems and environmental change is a way of modifying the environment to make healthy choices practical and available to all community members. By changing laws and shaping physical landscapes, a big impact can be made with little time and resources. By changing policies, systems and/or environments, communities can help tackle health issues like obesity, diabetes, cancer and other chronic diseases.”

Budgets for this kind of intervention exist in most public health jurisdictions, and public health leaders are doing to the talk, because they have so few funds to do the walk. But public health experts end up playing in a small sandbox when these investments are measured against other spending, and then we spend a lot of time trying to convince ourselves through published papers, webinars, conferences, and the like that this is working. The illusion is powerful, like the illusory power of the Iron Throne in the Game of Thrones, except the shadow from a fad still does not make meaningful change when the numbers are crunched and the costs are calculated regarding chronic disease.

From the Game of Thrones, a lecture on power and illusion, for Westeros and beyond.

From the Game of Thrones, a lecture on power and illusion, for Westeros and beyond.

Public health departments who get funding through competitive grants from the CDC spearhead these efforts and then spend extensive amounts of time documenting their work trying to prove the bread crumbs made a difference to the overall health crisis facing Americans.

About $200 million was doled out from 2011 and 2012 through an effort called Communities Putting Prevention to Work (the amount initially announced in 2010 was about $380 million). In one case, Public Health-Seattle & King County published findings that show its CPPW-grant-funded efforts in schools cut youth obesity in specific schools by 17 points. Great job, except the funding was not permanent and it was not renewed when the grant ran out. The program is now in the past tense.

In 2014, public health professionals learned another funding source, the Community Transformation Grants, which also promote the policy, systems, and environmental work, is being cut too. Some can argue the money is being allocated to other programs that tackle chronic disease, focusing on heart disease and diabetes.

More musical chairs without really changing the big picture again?

I do not mean to belittle the work of public health people doing this work. They are my colleagues. I respect them. And the work being done, like promoting activities to reduce tobacco use and get more people eating healthy food, should be continued.

But as a field, I am convinced this type of work is self-delusional because it hides the nasty realities of how much larger issues shape the public’s health, such as how transportation budgets are allocated, how cheap petro-based energy is spurring obesity in measurable ways, how legislation is crafted by special interests at the state and federal level, and how the principle of health care is considered a privilege not a right in the United States. (In Denmark, by contrast, the public funds about 85% of all health care through taxes, and the system is rooted in both law and a social contract that is premised on system where all citizens are provided free and equal access to quality health care.)

Emilia Clark, mother of dragons in the smash HBO TV series Game of Thrones, is a good visual metaphor of what public health is not in the bruising world of budget appropriations at the state and federal levels of government.

Emilia Clark, mother of dragons in the smash HBO TV series Game of Thrones, is a good visual metaphor of what public health is not in the bruising world of budget appropriations at the state and federal levels of government.

The nasty realities we do not want to think about, using a contemporary TV metaphor, would be what happens when the violent kings of Westeros cut deals and cut heads, to maintain order in that mythical, lovable place with White Walkers, a giant ice wall, and fire-breathing critters. Mother of Dragons, public health is not, that is for sure!

I imagine a new fad will emerge in public health in the next three years, like it does in management. We might change the concept, but we likely may even have a smaller piece of the government pies.

No, public health jurisdictions cannot stop working until we see changes on these fronts. But the more we in public health delude ourselves that we are making a difference with scraps from the table, the more easily we are duped into accepting that the larger model is as it should be, and how it shall always be.

We will continue kvetching about farmers markets and soda machines, but not moving in a rigorous way upstream, where budget deals are made with transportation dollars, for starters. And I think we have to start being honest with ourselves about what we are accomplishing in the sandbox and whether this is the best use of our meager and diminishing resources.

Greenwashing or great brand marketing?

The Rainforest Alliance‘s Follow the Frog viral video now boats more than 3.8 million views. If you have not seen it, the now-viral video is a made-for-YouTube brand promotion for the organization’s efforts to save the rainforest through preservation and collaboration with corporate partners, who put a cute little frog logo on their products.  (The organization’s actual mission statement is here; and wow, they publish slick annual reports too.)

The video itself mocks what I could only presume to be do-good, liberal-guilt-drenched, white, middle-class YouTube users that direct action, person-to-person contact with other cultures, and global-minded activism are failed and meaningless strategies for dupes like the star of this video. The moral? Why quit your job? Why learn about things first hand and be involved in meaningful efforts overseas? Most importantly, why stop shopping? Instead, sit back, relax, and buy more stuff with a little frog. And, by doing that, you can save the forest ecosystems and those charismatic critters and natives you care so passionately about.

That, in a nutshell, is the storyline. Oh, and if you do participate in failed efforts abroad, your wife might leave you for another man who is, yes, not white. (No, I am not making this up. This race element is integral to the “follow the Kermit” story. Please tell me this was not intentional, please, OK?)

Nazi filmmaker Leni Riefenstahl at work with the Nazis during the making of Triumph of the WIll.

Nazi filmmaker Leni Riefenstahl at work with the Nazis during the making of Triumph of the WIll.

Clearly, the Rainforest Alliance’s brand managers and media team hit pay dirt with this one. Be one of us, sport tattoos, be cool, and be a froggy consumer. (These brand managers need to consult in public health, which lacks a hip frog right now.)

Does that mean they are not just, as some critics claim, “greenwashing” consumerism? This creepily somewhat reminds me of the wildly successful Kony 2012 phenomenon, itself the artistic step-child of Nazi propagandist Leni Riefenstahl’s seductive 1934 film Triumph of the Will. That acclaimed masterpiece of filmmaking, by nearly all metrics, ultimately celebrates the virtues of the National Socialist Party led by dictator Adolf Hitler, a year after he peacefully seized control of the German state.

A scene of the Nazis during a rally filmed by Leni Riefenstahl for Triumph of the Will, one the most successful propaganda films ever.

A scene of the Nazis during a rally filmed by Leni Riefenstahl for Triumph of the Will, one the most successful propaganda films ever.

Do not get me wrong. I buy certified organic coffee. I love cat videos and Jimmy Kimmel’s infamous twerking video as much as the next YouTube user. But, ouh la la, there really is nothing more powerful than a good story, a clever media product, and the right artist to sell just about anything, from armchair activism to strong-arm fascism.

Sadly, I do not think you can teach this stuff. The best and the brightest will inevitably also work with the nastiest, wealthiest, and the worst, sometimes more than with the “virtuous.”

So, what do you think about following the frog? Good for forests? Or, something completely different?

Can innovation thrive in the culture of U.S. public health systems

Amazon, despite its critics, has been an innovator in the private sector.

Amazon, despite its critics, has been an innovator in the private sector.

The business press and the communications teams in the private sector work hard to show that innovation mingles in the air like oxygen  at successful businesses. The theory goes, innovation breeds success, which creates profits, which spurs new products and services and wealth, which of course is good for the economy and thus all of us.

Forbes, for instance, showcases business innovators, like Starbucks and Amazon, by highlighting metrics that the magazine considers to be markers of innovation. According to the Forbes’ Sept. 2, 2013, piece on innovation, Amazon’s CEO Jeff Bezos says he looks for traits in innovators in his company and allows for innovation to occur three ways:

  • Rewarding innovators who are relentless in their on their vision but flexible on the details of how to get there.
  • Fostering a decentralized work culture for new products or services, so that the majority of employees feel like it is expected of them (Amazon’s now famous “two-pizza teams”). 
  • Third, teaching teams how to experiment their way to innovations.

But once we start talking about government, talk of innovation gets tossed out the door. In fact, the prevailing wisdom among many in the private sector, and likely in the public sector too, is that government is the ultimate death machine to innovation.

Not only does innovation die still-borne in public agencies, government regulations themselves kill innovation in the private sector, many writers and politicians claim ad infinitum.

Do any public agencies have capacity to innovate?

Government still funds innovation and research and development, particularly in defense and health care. But as a culture, government is not the incubator, goes prevailing wisdom. One global survey completed this year puts trust in government around the world below 50%, behind trust in business at about 58%, for its ability to demonstrate change and new leadership.

Public health, as a public endeavor in the United States, is by definition a public undertaking. Thus it remains government-funded, government-run, and thus, be default, the inheritor of government’s best and worst traits.

As someone who has now worked at the international, state, and local levels of government, including in public health, I can attest to government bureaucracies’ failure in many instances to embrace change, inability to stimulate ideas, and poor track record in adopting new ideas to improve how government does business.

One recent research paper by British researchers Geoff Mulgan and David Albury on the lack of innovation in the public sector noted: “Most service managers and professionals spend the overwhelming proportion of their time dealing with the day-to-day pressures of delivering services, running their organisations [sic] and reporting to senior managers, political leaders, agencies and inspectorates [sic]. They have very little space to think about doing things differently or delivering services in ways which would alleviate the pressures and burdens.” In short, government culture lacks innovation.

The pair argue that innovation should be a core activity of the public sector. They claim this helps public services improve performance and public value, respond better to the public’s needs, boost efficiency, and cut costs.

Geoff Mulgan and David Albury 's diagram how public bodies do no innovate.

Geoff Mulgan and David Albury ‘s diagram how public bodies do not innovate.

What are people saying about innovation in public health and health care

In Europe, in 2010, the Association of Schools for Public Health in the European Region’s Task Force on Innovation/Good Practice in Public Health Teaching developed a plan that called for seven action items, two of which focused on innovation:

  • Developing more coherence between policies in the fields of education, research and innovation.
  • Measures to develop an innovation culture in universities.

Back on this side of the pond, the Harvard Business School held a conference on innovation in the massive health care sector in October 2012, and then published a study in February 2013 on how innovation was seen as critical to health care and health education, which includes public health.

The report found that 59 of the CEOs of the world’s largest and most innovative health-sector organizations most frequently used the word “innovation.” According to the discussion of the attendees, innovation in its broadest sense was even seen as the “only way that change will happen and that creative solutions will be found for our current problems in health care.”

The most important characteristic for a company according to leading health care CEOs is innovation.

The most important characteristic for a company according to leading health care CEOs is innovation.

Recent evidence shows that innovation can lead to better outcomes. A 2013 study  published in the Journal of Multidisciplinary Healthcare, on technological innovation and its effect on public health in the United States, found a correlation regionally in parts of the country where it was perceived that technological innovation was occurring. The study reported that “relationships between the technological innovation indicators and public health indicators were quantified,” and it was found “that technological innovation and public health share a fairly strong relationship.”

Will innovation remain a dirty word in public health departments at all levels of government?

But does anyone working in a local health jurisdiction, hard-strapped for cash in the post-Great Recession era of downsizing, see innovation taking place in their work environments? As hierarchical bodies, modeled originally after the military since their original inception in the United States, public health bodies are seldom discussed in organizational behavior literature as “innovative.” They are organized hierarchically and often divided by departments with no interchange, and their managers may be unable to allow for information sharing and promote collaboration seen in many for-profit firms.

Yes public health jurisdictions, to win much-coveted accreditation by the national Public Health Accreditation Board, must prove they are committed to quality improvement and a competent workforce. But this by no means is the same as encouraging a culture of innovation to adapt to tremendous change, particularly financial downturns and the challenges posed by chronic disease and the increasing wealth disparity among the top wage earners and the majority at the bottom, which is leading to great health disparities.

One local health jurisdiction that is trying to innovate, the Spokane Regional Health District, developed a strategic plan that calls out as its top two strategic priorities: increasing awareness about the role of public health and securing more stable funding. I think these are spot on and demonstrate how this agency has moved its focus upstream and is adapting itself to succeed in that bruising political arena.

innovation not

More of Tom Fishburne’s artwork can be found on the web site: http://tomfishburne.com/.

But my own sense of public health jurisdictions, small and large in the Pacific Northwest at least, is that other jurisdictions may not wish to emulate Spokane because of agency rivalries and personal jealousies among upper management. I would love for one day to learn that some of the traits of private sector organizational behavior practices, such as rewarding innovators, promoting a culture of innovation, and teaching workers how to innovate take root. Right now, I’m not seeing that within the sector, and the talk is not matching the walk.

How the 10 essential public health services handicap a weakened profession

Public health, as a profession and system to improve population health, continues to fall short in the United States.

Since the start of the Great Recession, nearly a quarter of all employees working for local health jurisdictions have been downsized or laid off because of funding cuts to already meager budgets. The National Association of County and City Health Officials pegs the attrition at nearly 44,000 workers–a fact reported on this blog before.

Proportional changes in inflation adjusted spending for public health (CDC) versus health care spending in the United States.

Proportional changes in inflation adjusted spending for public health (CDC) versus health care spending in the United States.

Today, most Americans have little idea what public health does, why it matters, and why its funding is critical to improving health outcomes at the population level. For that matter, half of all Americans cannot even identify what the core elements of health insurance plans are. 

From its start as a profession in the United States in the early 1900s, public health was deemed to have a political-activist function. In fact, noted public health pioneer C.E.A. Winslow, Yale’s first chair of public health, promoted universal medical care in the 1920s as a principle of sound public health policy, backed later by other public health practitioners in the next two decades who unsuccessfully called for a form of universal health care.

Winslow’s often-quoted definition of public health called for the “development of the social machinery which will insure to every individual in the community a standard of living adequate for the maintenance of health.” Such efforts were overt and unashamed calls for political action and advocacy, the likes of which are mostly not heard today from the profession.

10 essential public health services: a recipe for political impotence?

Since 1994, the U.S. Centers of Disease Control has pushed the “10 essential public health services” model as the gold standard for defining public health’s realm of practice. As far back as 1999, the CDC claimed, “The overall goal for public health’s infrastructure is to have every health department fully prepared with capacity to fulfill the Ten Essential Public Health Services and every community better protected by an efficacious public health system.”

The 10 essential public health services is the U.S. model, not a global model, for defining the profession.

The 10 essential public health services is the U.S. model, not a global model, for defining the public health profession’s realm of practice.

This model has rippled outward to every public health agency, every school of public health, and all professionals in the field as the benchmark to measure quality and effectiveness. Logic models have been developed to see how well health departments were doing according to this standard.  Anyone who works in the field is told that these services define who we are and what we do.

All the while, public health budgets have been slashed nationally, and at the state and local level, workers have fled or were pushed out of the profession. Still the field of public health continues to push its competent but still toothless model for what is considered a best practice—the 10 essential services.

While evidence-based and certainly valid, this 10-step model is also a self-defeating set of quasi-religious commandments that fails to address the harsh political realities related to developing legislation and orchestrating fights over budget appropriations. It also fails to call for advocacy and political activity, which can and have pushed public health efforts far greater than these prescribed activities.

Politics, money, and real power

For-profit entities working in the health sector thrive because advocacy and political engagement are fundamental to their business models and bottom lines, unlike the model of inefficacy promoted for the public health profession.

For instance, pharmaceutical powerhouse Pfizer unabashedly states, “We believe that public policy engagement is an important and appropriate role for companies in open societies, when conducted in a legal and transparent manner. … The Pfizer Political Action Committee makes contributions to candidates for federal office, and fully discloses its contributions on a regular basis to the Federal Election Commission.”

Pfizer, multinational pharmaceutical firm, published its political spending activities in the United States for the first half of 2013.

Pfizer, the multinational pharmaceutical firm, published its political spending activities in the United States for the first half of 2013.

While for-profit health interests march forward, with ever more dollars and clout, public health continues to retreat. The President’s budget request in 2014 for the CDC, the agency charged with protecting America’s health, is a measly $6.6 billion (for its program level expenditures)—a drop of $270 million over 2012.

This dip likely reflects pushback by GOP lawmakers in the current Congress, who view CDC’s public health activities as synonymous with overt advocacy. Language in funding measures, in the current session of Congress, has attempted to limit federal dollars for grassroots efforts by public health practitioners to lobby on behalf of specific legislation, particularly on efforts to address chronic disease and obesity.

Generally, public health advocacy is not lobbying, which is prohibited when it involves federal or earmarked funds. Exceptions include study or research and discussions of broad social problems.

So it is not surprising that government-funded public health bodies have been generally shy, and in the case of firearms legislation, nearly totally muzzled, from discussing firearms deaths since congressional language banned funding of firearms research starting in 1996. (In my opinion there has been a failure of leadership in public health when such leadership was needed on the issue of firearms violence, which is a legitimate public health concern.)

But should bans on using public funds for lobbying mute the profession from pushing for advocacy approaches and political engagement?

Daniel Callahan and Bruce Jennings’ 2002 article in the American Journal of Public Health examined the ethics of public health advocacy. They noted, “Politics is a necessary component of public health, moreover, precisely in order to achieve public health policies and practices consistent with American traditions and values. Politics is the messy arena in which ultimate questions of the public good are worked out.”

Public health’s failures in the political mosh pit

A perfect example of what happens when public health was not fighting tooth and nail was President Obama’s Affordable Care Act of 2009, which ultimately squashed efforts for a single payer system—the long-held dream of public health advocates from the 20th century—and advanced a health insurance industry, market-based model for “health care” reform.

All told, advocacy groups in 2009 spent $3.47 billion for D.C.-based lobbyists to parse out issues, according to left-leaning Center for Responsive Politics. Not surprisingly, the lion’s share of that spending went to fight the health reform battle. Businesses and organizations that lobbied on “health reform” spent more than $1.2 billion on their overall advocacy efforts.

APHA lobbying 2013

Source: The Center for Responsive Politics

For its part, the American Public Health Association (APHA) spent less than $500,000 annually on lobbying at last count in 2013. (See spending chart for lobbying expenditures by APHA from 1998 to 2013.)

The good news is that this marked a jump of more than 300 percent from what APHA spent in 2012. It would appear that some in the field are waking up to the realities of fighting for public health where the most meaningful impacts can be achieved – through policy and legislation.

By comparison, just one big pharma company, Pfizer, spent more than $800,000 in the first six months of 2013, from local to congressional candidates and political parties nationwide (see chart above).

What is most discouraging is that future leaders entering the profession continue to be shortchanged by graduate programs that do not know how to prepare practitioners to win in the bruising political environment known as “upstream.” This is my general assessment of not just my graduate MPH program, but of the field that I still see through its obsessive and yet parochial obsession with the 10 essential public health services.

The CDC's 10 essential public health services.

The CDC’s 10 essential public health services.

A very smart resource guide developed by the California Endowment sharply noted: “… many public health faculty do not possess the skills or experience to teach advocacy effectively. Faculty surveys show, for example, that despite advocacy for health being recognized as an ethical responsibility and required competency of health educators, many health education faculty do not see themselves as competent for teaching advocacy and lack instructional materials to do so. Degree-granting programs in public health need to provide systematic training in social advocacy. In the absence of formal training in social change, public health graduates must learn this information and develop these skills on a catch-as-catch-can basis. Working in this way means that some will be less effective than they otherwise could be in advancing the health of the public.”