Learning Leadership — A Key Component of Public Health Education

I started my Doctor of Public Health (DrPH) program reluctantly with a course on leadership in the summer of 2017. As I sat in the opening lecture, I was impatient to get to the quantitative classes, like biostatistics, epidemiology, and demography. I believed, at the time, that developing my technical and research skills were all I needed to advance my public health career. Leadership training was not part of my plans.

Just a year and a half after graduating, I know now that I was completely wrong. My leadership training has been instrumental in my current role as a Tribal Public Health Officer for a small American Indian Reservation in California. I would argue it has even been more valuable than the quantitative classes that I eventually took in my DrPH program. As public health practice looks to recover from COVID-19, I hope to see a larger role for leadership training in public health education.

My initial doubts about leadership training began with the pedagogy. From years of previous schooling, I knew how technical topics would be taught. There would be lectures, problem sets, papers and exams. But how would leadership be brought into a classroom? Would there be “leadership” problem sets? What would a lecture on “leadership” be like? I felt the topic was subjective, ambiguous, and amorphous – making teaching nearly impossible.

This concern was quickly disabused by my professors, who made leadership imminently teachable. They used various approaches, such as case studies, interviews, personal reflection exercises and the rich, academic literature on leadership. Assignments included personal reflections, as well as analyses of situations, decisions, and responses. While grading may have been more subjective, the courses were more about what I got out of it than my marks.

Over the next few months, I took multiple leadership courses. A key early lesson was the idea of adaptive and technical challenges, from Ronald Heifetz, a Harvard Professor on leadership. According to Heifetz, a technical challenge is a clearly defined problem that can be solved with existing know-how and expertise, like running a regression model to estimate a correlation. An adaptive challenge, on the other hand, is not clearly defined and usually involves many people changing behavior. Solutions will often require group learning to collectively develop new options, making individual technical expertise insufficient. In other words, adaptive challenges require leadership.

I refer to this lesson often in my current role as a Tribal Public Health Officer. When I face a new challenge, I try to classify it as technical or adaptive. For example, we needed a standard way to report our number of COVID-19 cases and contacts to the community early in the pandemic. I saw this challenge as technical and used my quantitative training to develop a situational report that was easily understood.

Other times, there have been adaptive challenges underlying technical ones, like when we considered updating our isolation protocols during last winter’s case surge. We had belatedly changed from a symptomatic to a testing approach to clear individuals from COVID-19 isolation. Soon after this update, CDC shortened their recommendations for the timeframe of isolation, making our orders a few days longer. Seen as a technical challenge, we should have updated our orders immediately to follow CDC’s best practices.

However, I felt there were deeper issues at play. I thought back to my leadership training where we diagnosed problems in case studies. We learned that people’s emotions and beliefs usually outweighed data. In the current situation, I knew that community members were very concerned about the recent rise in cases and were already confused by the current orders. Therefore, I felt that a change in our orders would lead to fear, confusion, and noncompliance. I recommended we wait till after the case surge to update our protocols to keep the community safer. The Tribe ultimately kept the orders in place for a few more weeks, until cases declined.

Despite over 30 years of calls for leadership in public health, I see confusion between adaptive and technical challenges in other areas of the COVID-19 response. A prime example is the CDC’s masking update this past May. While the latest scientific research supported not requiring vaccinated people to wear masks, making it technically correct, the CDC decision to lift mask wearing for vaccinated individuals did not foresee the adaptive impact, which included many areas lifting all mask mandates. There was a deeper, emotional interpretation, the “song beneath the words,” of a relaxing in mask policy that they did not account for. Though the CDC ultimately reverted the mask guidance back, an adaptive perspective from the outset may have accounted for this visceral response.

To improve public health leadership, we must ensure that the next generation of leaders have leadership training. An encouraging sign is the growth in DrPH programs. According to the Council on Education in Public Health, the accrediting body for public health education in the US, leadership is a core component of DrPH curriculum. Between 2010 and 2019, there were nearly 20,000 applications to DrPH programs in the US and graduates nearly doubled. I expect more interest in the DrPH due to the pandemic. There have already been several new DrPH programs within the past year alone, such as New York University, Rutgers University, and the University of Toronto.

Leadership training, especially in DrPH programs, can improve leadership in public health. The challenges ahead of us – recovering from COVID-19, adequately addressing climate change, and eliminating the unjust and immoral health inequities – will not be solved by technical solutions alone. Future public health leaders will need both technical and leadership skills. Leadership training will be essential to ensure that our leaders have the adaptive skillset to solve them.

Author Profile

Eric Coles
Eric Coles is the President of the DrPH Coalition and the Tribal Public Health Officer for the Tule River Indian Reservation.

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