Category Archives: Public Health

In my mind, it is a subset of Global Health, often more locally focused.

The Leadership a-Gender — 1

After competence, are certitudecharisma and chutzpah the 3-Cs of research leadership?

An image encouraging positive thinking to overcome self-doubt. Just make sure there are no large dogs about.

When Rob Moodie was the CEO of the Victorian Health Promotion Foundation (VicHealth) he started a “conversations in leadership” series for the recipients of VicHealth Public Health Research Fellowships. The idea was to begin an explicit process to develop research leadership in public health, drawing us together to think about the qualities that were necessary.

There were ten of us at the first gathering; two men and eight women. Beyond the fact that it was a meeting for “future leaders”, none of us knew what it was all about. Rob went around the table, asking each of us in turn to introduce ourselves; he also asked how we felt about being identified as a future leader in public health research.

The gender divide was immediately and starkly revealed. When Rob asked Paul (the other man in the room) and me how we felt, we gave suitably immodest responses. I can’t remember our precise answers, but they would have reflected in some way on the appropriate recognition of our talent. Then the first woman spoke. She told, hesitantly, of a gnawing fear that she would be “found out”. Someone, probably sometime very soon, would realise that she was a fraud. She had no right to the VicHealth Fellowship, and she had even less claim on being a leader. Paul and I glanced at each other. Who were we to say that she was wrong? And then there was a visible sigh from the other women in the room. Each one, in turn, expressed an almost identical fear of being found out. This is a well-recognised phenomenon in the gender and leadership literature, described as, “imposter syndrome“: the fear of being found out.

Notwithstanding my bravado or Paul’s, I suspect neither of us felt quite as sure of our place as future leaders as we expressed. I know I didn’t. Nor, however, did I fear being found out in quite the same way the women had expressed. I may have worried a little about whether my performance would be good enough (was I leadership material?), but I did not experience the depth of self-doubt expressed by my colleagues. I had been invited into the room and, therefore, I had a right to be there! They received the same invitation but doubted their right.

An article in the Harvard Business Review on overcoming the feelings of inadequacy associated with imposter syndrome described individual, cognitive behavioural techniques (CBT) to help people manage the sense. If these techniques work, that’s great! The solution, however, reveals at least as much about organisational gender bias as it does about ways to overcome it. Underlying the CBT approach is not simply a view that self-doubt is misplaced, but that there is a deficit in the way a person’s brain works if they have that self-doubt. In other words, to succeed in leadership, you need to think more like me! The obverse problem, having an over-inflated and unrealistic view of one’s own excellence, is often rewarded in organisations, and the sufferer (or more likely the insufferable) is never referred to a Psychologist for therapy “because you’re not thinking right”. Having the 3-Cs of certitude,  charisma and chutzpah — typically identified as leadership qualities and never as leadership deficits — means that you are thinking right.

It is worth noting that although the women expressed the fear of being found out, they had all applied for and won highly coveted VicHealth Fellowships, and they were all in that room — even with their doubt.

The researcher, Thomas Chamorro-Premuzic, suggests that many of the 3-C style traits that are traditionally associated with great leaders may in fact be emblematic of leadership weaknesses. Being quieter (a listener), more thoughtful (open to new ideas) and having some self-doubt (seeking out a diversity of expert advice) can be valuable traits in good leadership. These are traits often associated with women who are passed over for leadership positions because they have not yet had their “deficits” corrected.

There are some clearly terrible traits for research leaders to have. Being a bully, mean, harassing staff and being incompetent would be high on that list. In research leadership, raw incompetence would be unusual. The others, sadly, are not. Research organisations need methods for identifying good research leaders that do not fall back on tired tropes, and provide women fair paths of advancements. These are organisational systems issues, not individual deficits to correct. Almost two decades ago, Rob Moodie’s conversations in leadership was a gentle step in that direction: making us all ask the question, what is it to be a great leader? He never said, by I suspect that he hoped we would carry forward some insight into the leadership a-gender.

What is the optimal number of broken jaws?

I was chatting with a friend recently about the COVID-19 response in different countries. Reflecting on her own country, she said, “It is so hard to know what is right!”; that is, it is so hard to know what the right response to COVID-19 should be.

The variation, for instance, in countries’ lockdown responses is substantial, but which country is doing the right thing? In some countries, there has been no lockdown. The government asked the people to be sensible. In other countries, the government legally confined people to their homes — only one person was allowed out at very specific (restricted) times to buy essentials. Given these two policy extremes (be sensible and house arrest), which one is the right one, and how do you know?

An economist, I have forgotten who once asked tongue-in-cheek, what is the optimal number of dead babies? The very purpose of such a crass question is to make you stop and think. What tradeoffs are you prepared to make to save the lives of babies? Sure, you could be lazy, condemn the questioner as immoral (for even asking you to think), and declare zero dead babies to be the right number. As a simple policy proposition, if zero dead babies is the right number, then all the resources of society should be aimed at preventing neonatal deaths. ALL RESOURCES! Until the policy goal has been achieved, there is more work to be done to reduce the number. One dead baby is too many!!! Farmers may farm, but only to produce the food that supports the workforce that is striving to reduce baby deaths to zero. Teachers may teach, but only to educate the people to fill the jobs to support the policy goal to reduce baby deaths to zero. There is very limited use for art, music, cinema, sport, fashion, restaurants, etc. They will all have to go! If five-year-old deaths increase, that is something to live with, just as long as we can save another baby.

At this point, you’re probably thinking, well that’s stupid. That’s not what I meant when I said the optimal number of dead babies is zero. What I meant was something more along the lines of, “In an ideal world there would be zero dead babies”. Equally, if you were asked about poverty or crime, or amazing works of art, you presumably would have stated the ideals in terms of zero poverty, zero crime, and lots more wonderful art. And this is quite a different proposition. An ideal world is not ideal in virtue of its achievement of a single goal. It is ideal in having achieved all sorts of different outcomes. And that is why the real and the ideal do not intersect. In the real world, we do not achieve the ideal anything. We seek to achieve many ideals, and realistically, we hope to make progress against them, knowing that there is always more to be done. In striving to improve the societal position against a basket of goals, we allocate limited resources and make trade-offs.

This is one part of the COVID-19 problem, and, as my friend observed, why it is so hard to know what is right. What is the right number of COVID-19 deaths? There are lots of important, rational debates to be had around this topic because it is about the tradeoffs we are prepared to make against a basket of societal goals against the myopic achievement of one. Muscular public health responses — effective house arrest — are very good at reducing the number of new COVID-19 cases. They are also very effective at increasing domestic violence, increasing depression, lowering child immunisation rates, degrading child education, increasing poverty and increasing unemployment. If the societal goal should be zero COVID-19 deaths, what is the optimal number of broken jaws, suicide attempts, measles encephalitis cases, illiterate and enumerate children, beggars, and soup kitchens?

All these issues, under normal circumstances, are things of concern to Public Health and maybe, one day, they will be again.

Another part of the COVID-19 problem is that, whether a government “did the right thing” will be determined in hindsight, and by making (inadequate) historical comparisons between the outcomes across countries’. In democracies, at least in the short-term, “did the government do the right thing?” will often be decided at the ballot box. This will surely get the answer wrong. In less-than-democracies, astute rulers will write the history books themselves ensuring that, without regard to the outcome, the government did the right thing.

One of the main reasons that “it is so hard to know what is right!” is that we rarely have a societal view about the long term goals we wish to achieve and the tradeoffs we are prepared to make. Furthermore, we are reluctant to accept the fact that one can do the right thing and still fail. We assume that the right course of action will, by definition, result in success. We are prospective Kantians and retrospective Utilitarians.

Es ist ernst! [It is serious]

Chancellor Angela Merkel, 2019 (source: wikimedia)

There are truly great, rousing political speeches. President John F Kennedy’s Inaugural Address on 29 January 1961 comes to mind: “ask not what your country can do for you — ask what you can do for your country.” Prime Minister Winston Churchill’s, “We shall fight them on the beaches” speech, during World War II.

The defining political speech of the COVID-age will surely be that of the German Chancellor, Angela Merkel: “Es is ernst!” It’s in German. There are subtitles. Watch it!!

The power of the speech lies in no single phrase and no single idea. The power lies in the gestalt. It lies in the thoughtful, measured, and compassionate speech to a nation from someone who holds the idea of democracy dearly, and needs to ask 83.1 Million people for patience, sacrifice, and forbearance; for a great community good — because no one is expendable.

In her speech, brilliantly, she thanks the forgotten cash register staff and shelf packers for their tireless efforts, as well as the easily remembered healthcare and public health workforce for theirs. She suggests that people might even consider writing a letter to a friend or loved one because, of course, the German postal service continues to work. She constantly plays between the culture of the German people (what it is to be a German), their expectations of Government, and the task of managing SARS-CoV-2.

Like many countries, Germany has instituted measures that are anathema to democracy, but necessary to slow the spread of the virus. As she explains, all we are doing now is buying time. Stretching it out. The longer we stretch it out, the more time researchers and healthcare workers have to find measures of prevention, management, and cure. The longer we stretch it out, the more person-ventilator-time (PVT) and person-ICU-time (PICUT) there will be to allocate. If you are acutely ill, PVT and PICUT are the most precious commodities available at the moment (excepting toilet paper), and the best way to make more of this commodity is to stretch out the length of the pandemic.

Do not watch or listen to the blather and buffoonery of the likes of Trump and Johnson. Whether they do not understand or do not care is irrelevant. Their “ideas”, their politics and their speeches will be lost in the waste-paper basket of history, to be picked over by pimply, undergraduate students in response to the essay topic: “Political leadership is important in times of crisis. Discuss”

Merkel’s speech is the most hopeful, rational and caring political message I have heard since the outbreak of the SARS-CoV-2 pandemic. Sitting at my desk in Dhaka, I found it enormously comforting to know that there was leadership like Angela Merkel’s out there. There has been considerable discussion about the lack of global political leadership. It is there. Turn your eyes and face the light.

This is serious.

Covid Economics

“Governments will not be able to minimise both deaths from coronavirus disease 2019 (COVID-19) and the economic impact of viral spread.” [Anderson et al.]

A soup kitchen during the Great Depression. Apparently it was only men who were hungry

It is easy to see that the economies of the world are being affected by the COVID-19 pandemic. Share-markets have tumbled. Airlines are flying empty. Except for bizarre panic buying of toilet paper, malls and shops are more deserted. And if you have an employer with a large cash reserve and a bit of heart, you will be OK. There are many companies, however, that are at the margins and they are already failing because of the impact of COVID-19. Households are hunkering down: not spending, not going out.

These are the consequences of containment.

Now think about the daily wagers and piece workers, the sex workers, couriers, garbage pickers, rickshaw drivers and maids. Who will pay their bills, put food on their tables and ensure the same for their children?

Workplaces are instituting attendance rules based on health guidelines. Fevers, coughs, headaches and myalgia? Stay home! Recently been with someone who tested positive. Stay home! Etcetera.  That’s fine for me. I will apply for sick leave. In all countries, but disproportionately in Low- and Middle-Income Countries, large numbers of people in the workforce are in the informal sector. They are vulnerable. Even in the formal sector, many workers have no financial protection.

Think again about the daily wagers and piece workers, the sex workers and couriers. Their capacity to pay the bills and keep food on the table is proportional to their capacity to keep working. No matter what.

Death is not everything.

The obligation of countries who have committed to sustainable development goals is to “leave no one behind”. Governments should implement their public health measures to limit the effects of the COVID-19 pandemic, but the poor should not have to carry an unfair burden.

A street sweeper in Mokhali