Leading Population Health
Transforming self, people, systems and cultures towarding equitable, sustainable results
Tomás J. Aragón
In December, 2010, I was appointed the health officer of the City and County of San Francisco, and the director of the Population Health Division1 at the San Francisco Department of Public Health (SFDPH). As health officer I exercised leadership and legal authority to protect and promote health and health equity. For the Population Health Division I directed public health services.
Prior to SFDPH I trained in primary care internal medicine, clinical infectious diseases, and epidemiology. Since 1996, I worked as a deputy health officer in various capacities, focusing primarily on communicable disease control, community health epidemiology (including chronic diseases, cancer, and environmental health), and public health emergency preparedness. For more than seven years I directed a Centers for Disease Control and Prevention (CDC) public health preparedness training center and systems research center at the University of California, Berkeley School of Public Health. In spite of my diverse training, technical expertise, and practice experiences I was not sufficiently prepared for the health officer and division leadership roles—and I recognized this going into my new job.
The breadth and depth of public health is too large for anyone to master. I was surrounded by technical experts in their fields. I could never hope to master each field sufficiently to guide them technically. Any technical contribution from me would add marginal value at best. I wanted to add real value to the organization, to mobilize and align our enormous talent, and to create a learning organization. When I was running a research center I strove to be an academic thought leader.2 In my new role I needed to become an organizational leader. I believed that if I could meaningfully contribute to developing a high-performing, learning organization, then the staff—collectively—would accomplish much more that I could ever hope to accomplish in my lifetime.
My goal, then, was to become an effective organizational leader. I immediately applied for health leadership fellowships. This would be the quickest path to developing the leadership skills to lead my organization. I completed leadership fellowships with the California Healthcare Foundation / Healthforce Center UCSF Leadership Program,3 the National Association of County and City Health Officials’ “Survive and Thrive” Program,4 the Center for Health Leadership and Practice’s Leadership Academy for the Public’s Health,5 the Kresge Foundation Emerging Leaders in Public Health Program,6 and Rise Together Bay Area’s Leadership for Equity and Opportunity.7
These leadership programs were outstanding! I learned a tremendous amount, and each contributed uniquely to my leadership development. I learned foundational themes, unique and innovative approaches, but I also observed variation, gaps, and room for improvement. I supplemented the trainings with reading, reflection, and on-the-job action learning. I sought out selected mentors to soak up their wisdom. I learned that the best mentors (who share their experiences and wisdom) and coaches (who bring out the best in you) are not necessarily in high profile health leadership positions.
In spite of numerous leadership roles, I am early in my leadership development journey. However, I feel that I have learned enough of value to share with you. I realize that not everyone has the “bandwidth” for another leadership development book. Who has the time to train, read, reflect, and improve in all the important things that we must do? We must be selective. By sharing some of what I have learned I hope to improve the efficiency of your leadership development. And when you do read books or participate in trainings you do so with an informed and intentional mindset.
The purpose of this book is to share one roadmap for developing practical skills for leading organizations engaged in improving population health. The skills are foundational, necessary, but not sufficient to continously improve your leadership in population health practice. They are not sufficient because you must ultimately experiment and adapt what works for you, your teams, your organization, and your communities. The content is not original: I synthesize ideas, concepts, and skills from other sources, and for the content I cannot cover I provide selective resources. The leadership development roadmap I promote has practical skills for transforming
- self and interpersonal relationships;
- teams, groups, and collaboratives; and
- organizations and communities.
At every level—micro, meso, and macro—our teams, organizations, communities, and societies are socioecological, complex adaptive systems. The work of population health is about transforming complex socioecological systems. Specifically, we define population health as a systems framework for studying and improving the health of populations through collective action and learning. I assert that the essential goals of population health must include:
- protecting and promoting equity and health,
- transforming people and place,
- ensuring a healthy planet, and
- achieving health equity.
By people I mean ourselves, teams, organizations, collaboratives, communities, and—ultimately—society. Transforming the complex social systems in which we are embedded is central to population health improvement. If we cannot transform ourselves, our teams, and our organizations, then how do we expect to partner with communities to support their transformations? It is very unlikely that we will have the knowledge, skills, abilities, social relationships, and postive influence to engage and mobilize stakeholders in our collective purpose. Therefore, we must start with personal and team transformation and continuous improvement. This means understanding and improving core human processes like how we make choices, build and restore trust, practice humility and courage, vigorously debate sensitive topics, ensure individual and team accountability, ensure team consensus, inspire commitment, and support passion, creativity, and innovation.
Health equity is the attainment of the highest level of health for all people by ensuring that all people have full and equal access to opportunities that enable them to lead healthy lives. Health inequities are health differences that are avoidable, unfair, and unjust. Health inequities are affected by social, economic, and environmental conditions.8.
Finally, we are in unprecedented times. While the world becomes more complex and connected, we have become more interdependent, polarized and vulnerable. Income inequality and wealth concentration continues unabated. Automation, machine learning, and articifial intelligence should free humans to develop socially and culturally. While we have made some advancements (e.g., marriage equality and the election of an African American president), in the United States we have epidemics of obesity, opioid addiction and deaths, housing insecurity and homelessness, depression, suicides, and food insecurity. Industries leverage advances in neuroscience and behavioral economics to addict us to their products (opioids, alcohol, sugar, soda, gambling, etc.). Universal health care access—a basic human right in every developed nation—eludes us because of political ideologies and industry greed. Leading population health improvement requires being, designing, and leading change from the universal values of humility, compassion, equity, and dignity to transform self, people, systems, and cultures towards equitable, sustainable results.
At the time it was called “Population Health and Prevention,” and previous to that “Community Health and Safety.”↩
Through teaching, conducting research, and publishing scientific papers.↩