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Public health leadership Research Paper

Public health leadership Research Paper

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Leadership Journal?

One might say that politics is about who gets what and why. As a public health leader, your role is to advance the causes of your organization and ultimately of the community. This role often requires political savvy, or what might be called the ability to deal successfully in the “real world.”

To lead in the real world it certainly helps if you can advocate courageously and persuasively on behalf of public health’s causes, communicate adeptly to a wide range of audiences, and demonstrate healthy business acumen in your operations. But as many leaders attest, leading also requires the recognition that the best solutions are not always easy to discern. Leaders need the ability to deal with ambiguity, to hold seemingly incompatible ideas, values, or truths, even when doing so might make you seem inauthentic to others.

This week you will explore what it means to be able to deal effectively in real life leadership situations. You will also revisit the concept of social justice and propose ways to promote this perspective among those who hold a “market justice” view of society’s obligations to the public’s health needs.

Objectives

Students will:

• Articulate the case for social justice in an individualized market-based society
• Describe strategies for dealing successfully with ambiguity, uncertainty, and other leadership challenges arising in public health

ANSWER THE FOLLOWING QUESTIONS:

1. Reflect on the “real-world” challenges described this week that you have already faced. Have they been to maintaining authenticity? Fairness? Objectivity? Have you experienced a tension between competing values and ambiguity?

2. How do you know when you have compromised too far? When would you choose to quit a job rather than continue and accept compromises, ethically, and morally?

3. List five skills that you learned in this course and explain how you can apply each of them to your leadership life in the next three months.

USE THESE ARTICLES ONLY:

1.Article: Heifetz, R. A., & Linsky, M. (2002). A survival guide for leaders. Harvard Business Review, 80(6), 65-72.
This article addresses how to manage change and the group conflict that results during corporate climate shifts. This reference was adapted from the article “Leadership on the line: Staying alive through the dangers of leading” (Harvard Business School Press, 2002). The techniques listed within address tactical advice about relating to the organization and employees during change, while discussing how to attend to personal needs and vulnerabilities of the manager in charge.

2.Gostin, L., & Powers, M. (2006). What does social justice require for the public’s health? Public health ethics and policy imperatives. Health Affairs, 25(4), 1053-1060.

This article discusses how social justice and attending to the needs of the disadvantage affect moral aspects of the realm of public health. This article provides examples of the kinds of policies that public health agencies utilizes to manage the field, while shedding light on major public health controversies of the field of study. This article stresses the need for justice and fair disbursement of common advantages and the sharing of common burdens.

Please apply the Application Assignment Rubric when writing the Paper.

I. Paper should demonstrate an excellent understanding of all of the concepts and key points presented in the texts.

II. Paper provides significant detail including multiple relevant examples, evidence from the readings and other sources, and discerning ideas.

III. Paper should be well organized, uses scholarly tone, follows APA style, uses original writing and proper paraphrasing, contains very few or no writing and/or spelling errors, and is fully consistent with doctoral level writing style.

IV. Paper should be mostly consistent with doctoral level writing style.

A Survival Guide for Leaders.
Authors: Heifetz, Ronald A.1,2 Linsky, Marty1,2
Source:
Harvard Business Review. Jun2002, Vol. 80 Issue 6, p65-74. 10p. 2 Color Photographs.
Document Type:
Article
Subject Terms:
*ORGANIZATIONAL change
*MANAGEMENT
*LEADERS
*EXECUTIVE ability (Management)
*CORPORATE culture
*CORPORATE reorganizations
*MANAGEMENT research
*LEADERSHIP
*QUALITY of work life
*ORGANIZATIONAL sociology
*SUPERIOR-subordinate relationship
*MANAGEMENT styles
NAICS/Industry Codes:
541612 Human Resources Consulting Services

Abstract: Let’s face it, to lead is to live dangerously. While leadership is often viewed as an exciting and glamorous endeavor, one in which you inspire others to follow you through good times and bad, such a portrayal ignores leadership’s dark side: the inevitable attempts to take you out of the game. This is particularly true when a leader must steer an organization through difficult change. When the status quo is upset, people feel a sense of profound loss and dashed expectations. They may need to undergo a period of feeling incompetent or disloyal. It’s no wonder they resist the change and often try to eliminate its visible agent. This “survival guide” offers a number of techniques–relatively straightforward in concept but difficult to execute–for protecting yourself as you lead such a change initiative. Adapted from the book “Leadership on the Line: Staying Alive Through the Dangers of Leading ” (Harvard Business School Press, 2002), the article has two main parts. The first looks outward, offering tactical advice about relating to your organization and the people in it. It is designed to protect you from those who would push you aside before you complete your initiatives. The second looks inward, focusing on your own needs and vulnerabilities. It is designed to keep you from bringing yourself down. The hard truth is that it is not possible to experience the rewards and joys of leadership without experiencing the pain as well. But staying in the game and bearing that pain is worth it, not only for the positive changes you can make in the lives of others but also for the meaning it gives your own. INSET: Adaptive Versus Technical Change: Whose Problem Is It?. [ABSTRACT FROM PUBLISHER]

Harvard Business Review Notice of Use Restrictions, May 2009Harvard Business Review and Harvard Business Publishing Newsletter content on EBSCOhost is licensed for the private individual use of authorized EBSCOhost users. It is not intended for use as assigned course material in academic institutions nor as corporate learning or training materials in businesses. Academic licensees may not use this content in electronic reserves, electronic course packs, persistent linking from syllabi or by any other means of incorporating the content into course resources. Business licensees may not host this content on learning management systems or use persistent linking or other means to incorporate the content into learning management systems. Harvard Business Publishing will be pleased to grant permission to make this content available through such means. For rates and permission, contact permissions@harvardbusiness.org. (Copyright applies to all Abstracts.)
Author Affiliations:
1John F. Kennedy School of Government, Harvard University
2Partner, Cambridge Leadership Associates
Full Text Word Count:
6783
ISSN:
0017-8012
Accession Number:
6756407
Publisher Logo:

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A Survival Guide for Leaders
Contents
4. A Hostile Environment
5. The Dangers Within
6. Why Lead?

Section:
MANAGING YOURSELF
Steering an organization through times of change can be hazardous, and it has been the ruin of many a leader. To avoid the perils, let a few basic rules govern your actions-and your internal compass
THINK OF THE MANY top executives in recent years who, some times after long periods of considerable success, have crashed and burned. Or think of individuals you have known in less prominent positions, perhaps people spearheading significant change initiatives in their organizations, who have suddenly found themselves out of a job. Think about yourself: In exercising leadership, have you ever been removed or pushed aside?
Let’s face it, to lead is to live dangerously. While leadership is often depicted as an exciting and glamorous endeavor, one in which you inspire others to follow you through good times and bad, such a portrayal ignores leadership’s dark side: the inevitable attempts to take you out of the game.
Those attempts are sometimes justified. People in top positions must often pay the price for a flawed strategy or a series of bad decisions. But frequently, something more is at work. We’re not talking here about conventional office politics; we’re talking about the high-stake risks you face whenever you try to lead an organization through difficult but necessary change. The risks during such times are especially high because change that truly transforms an organization, be it a multibillion-dollar company or a ten-person sales team, demands that people give up things they hold dear: daily habits, loyalties, ways of thinking. In return for these sacrifices, they may be offered nothing more than the possibility of a better future.
We refer to this kind of wrenching organizational transformation as “adaptive change,” something very different from the “technical change” that occupies people in positions of authority on a regular basis. Technical problems, while often challenging, can be solved applying existing know-how and the organization’s current problem-solving processes. Adaptive problems resist these kinds of solutions because they require individuals throughout the organization to alter their ways; as the people themselves are the problem, the solution lies with them. (See the sidebar “Adaptive Versus Technical Change: Whose Problem Is It?”) Responding to an adaptive challenge with a technical fix may have some short-term appeal. But to make real progress, sooner or later those who lead must ask themselves and the people in the organization to face a set of deeper issues-and to accept a solution that may require turning part or all of the organization upside down.
It is at this point that danger lurks. And most people who lead in such a situation-swept up in the action, championing a cause they believe in-are caught unawares. Over and over again, we have seen courageous souls blissfully ignorant of an approaching threat until it was too late to respond.
The hazard can take numerous forms. You may be attacked directly in an attempt to shift the debate to your character and style and avoid discussion of your initiative. You may be marginalized, forced into the position of becoming so identified with one issue that your broad authority is undermined. You may be seduced by your supporters and, fearful of losing their approval and affection, fail to demand they make the sacrifices needed for the initiative to succeed. You may be diverted from your goal by people overwhelming you with the day-to-day details of carrying it out, keeping you busy and preoccupied.
Each one of these thwarting tactics-whether done consciously or not-grows out of people’s aversion to the organizational disequilibrium created by your initiative. By attempting to undercut you, people strive to restore order, maintain what is familiar to them, and protect themselves from the pains of adaptive change. They want to be comfortable again, and you’re in the way.
So how do you protect yourself? Over a combined 50 years of teaching and consulting, we have asked ourselves that question time and again-usually while watching top-notch and well-intentioned folks get taken out of the game. On occasion, the question has become painfully personal; we as individuals have been knocked off course or out of the action more than once in our own leadership efforts. So we are offering what we hope are some pragmatic answers that grow out of these observations and experiences. We should note that while our advice clearly applies to senior executives, it also applies to people trying to lead change initiatives from positions of little or no formal organizational authority.
This “survival guide” has two main parts. The first looks outward, offering tactical advice about relating to your organization and the people in it. It is designed to protect you from those trying to push you aside before you complete your initiative. The second looks inward, focusing on your own human needs and vulnerabilities. It is designed to keep you from bringing yourself down.
A Hostile Environment
Leading major organizational change often involves radically reconfiguring a complex network of people, tasks, and institutions that have achieved a kind of modus vivendi, no matter how dysfunctional it appears to you. When the status quo is upset, people feel a sense of profound loss and dashed expectations. They may go through a period of feeling incompetent or disloyal. It’s no wonder they resist the change or try to eliminate its visible agent. We offer here a number of techniques-relatively straightforward in concept but difficult to execute-for minimizing these external threats.
Operate in and above the fray. The ability to maintain perspective in the midst of action is critical to lowering resistance. Any military officer knows the importance of maintaining the capacity for reflection, especially in the “fog of war.” Great athletes must simultaneously play the game and observe it as a whole. We call this skill “getting off the dance floor and going to the balcony,” an image that captures the mental activity of stepping back from the action and asking, “What’s really going on here?”
Leadership is an improvisational art. You may be guided by an overarching vision, clear values, and a strategic plan, but what you actually do from moment to moment cannot be scripted. You must respond as events unfold. To use our metaphor, you have to move back and forth from the balcony to the dance floor, over and over again throughout the days, weeks, months, and years. While today’s plan may make sense now, tomorrow you’ll discover the unanticipated effects of today’s actions and have to adjust accordingly. Sustaining good leadership, then, requires first and foremost the capacity to see what is happening to you and your initiative as it is happening and to understand how today’s turns in the road will affect tomorrow’s plans.

Executives leading difficult change initiatives are often blissfully ignorant of an approaching threat until it is too late to respond.
But taking a balcony perspective is extremely tough to do when you’re fiercely engaged down below, being pushed and pulled by the events and people around you- and doing some pushing and pulling of your own. Even if you are able to break away, the practice of stepping back and seeing the big picture is complicated by several factors. For example, when you get some distance, you still must accurately interpret what you see and hear. This is easier said than done. In an attempt to avoid difficult change, people will naturally, even unconsciously, defend their habits and ways of thinking. As you seek input from a broad range of people, you’ll constantly need to be aware of these hidden agendas. You’ll also need to observe your own actions; seeing yourself objectively as you look down from the balcony is perhaps the hardest task of all.
Fortunately, you can learn to be both an observer and a participant at the same time. When you are sitting in a meeting, practice by watching what is happening while it is happening-even as you are part of what is happening. Observe the relationships and see how people’s attention to one another can vary: supporting, thwarting, or listening. Watch people’s body language. When you make a point, resist the instinct to stay perched on the edge of your seat, ready to defend what you said. A technique as simple as pushing your chair a few inches away from the table after you speak may provide the literal as well as metaphorical distance you need to become an observer.
Court the uncommitted. It’s tempting to go it alone when leading a change initiative. There’s no one to dilute your ideas or share the glory, and it’s often just plain exciting. It’s also foolish. You need to recruit partners, people who can help protect you from attacks and who can point out potentially fatal flaws in your strategy or initiative. Moreover, you are far less vulnerable when you are out on the point with a bunch of folks rather than alone. You also need to keep the opposition close. Knowing what your opponents are thinking can help you challenge them more effectively and thwart their attempts to upset your agenda-or allow you to borrow ideas that will improve your initiative. Have coffee once a week with the person most dedicated to seeing you fall.
But while relationships with allies and opponents are essential, the people who will determine your success are often those in the middle, the uncommitted who nonetheless are wary of your plans. They have no substantive stake in your initiative, but they do have a stake in the comfort, stability, and security of the status quo. They’ve seen change agents come and go, and they know that your initiative will disrupt their lives and make their futures uncertain. You want to be sure that this general uneasiness doesn’t evolve into a move to push you aside.
These people will need to see that your intentions are serious- for example, that you are willing to let go of those who can’t make the changes your initiative requires. But people must also see that you understand the loss you are asking them to accept. You need to name the loss, be it a change in time-honored work routines or an overhaul of the company’s core values, and explicitly acknowledge the resulting pain. You might do this through a series of simple statements, but it often requires something more tangible and public-recall Franklin Roosevelt’s radio “fireside chats” during the Great Depression-to convince people that you truly understand.
Beyond a willingness to accept casualties and acknowledge people’s losses, two very personal types of action can defuse potential resistance to you and your initiatives. The first is practicing what you preach. In 1972, Gene Patterson took over as editor of the St. Petersburg Times. His mandate was to take the respected regional newspaper to a higher level, enhancing its reputation for fine writing while becoming a fearless and hard-hitting news source. This would require major changes not only in the way the community viewed the newspaper but also in the way Times reporters thought about themselves and their roles. Because prominent organizations and individuals would no longer be spared warranted criticism, reporters would sometimes be angrily rebuked by the subjects of articles.
Several years after Patterson arrived, he attended a party at the home of the paper’s foreign editor. Driving home, he pulled up to a red light and scraped the car next to him. The police officer called to the scene charged Patterson with driving under the influence. Patterson phoned Bob Haiman, a veteran Times newsman who had just been appointed executive editor, and insisted that a story on his arrest be run. As Haiman recalls, he tried to talk Patterson out of it, arguing that DUI arrests that didn’t involve injuries were rarely reported, even when prominent figures were involved. Patterson was adamant, however, and insisted that the story appear on page one.
Patterson, still viewed as somewhat of an outsider at the paper, knew that if he wanted his employees to follow the highest journalistic standards, he would have to display those standards, even when it hurt. Few leaders are called upon to disgrace themselves on the front page of a newspaper. But adopting the behavior you expect from others – whether it be taking a pay cut in tough times or spending a day working next to employees on a reconfigured production line-can be crucial in getting buy-in from people who might try to undermine your initiative.
The second thing you can do to neutralize potential opposition is to acknowledge your own responsibility for whatever problems the organization currently faces. If you have been with the company for some time, whether in a position of senior authority or not, you’ve likely contributed in some way to the current mess. Even if you are new, you need to identify areas of your own behavior that could stifle the change you hope to make.
In our teaching, training, and consulting, we often ask people to write or talk about a leadership challenge they currently face. Over the years, we have read and heard literally thousands of such challenges. Typically, in the first version of the story, the author is nowhere to be found. The underlying message: “If only other people would shape up, I could make progress here.” But by too readily pointing your finger at others, you risk making yourself a target. Remember, you are asking people to move to a place where they are frightened to go. If at the same time you’re blaming them for having to go there, they will undoubtedly turn against you.
In the early 1990s, Leslie Wexner, founder and CEO of the Limited, realized the need for major changes at the company, including a significant reduction in the workforce. But his consultant told him that something else had to change: long-standing habits that were at the heart of his self-image. In particular, he had to stop treating the company as if it were his family. The indulgent father had to become the chief personnel officer, putting the right people in the right jobs and holding them accountable for their work. “I was an athlete trained to be a baseball player,” Wexner recalled during a recent speech at Harvard’s Kennedy School. “And one day, someone tapped me on the shoulder and said, ‘Football.’ And I said, ‘No, I’m a baseball player.’ And he said, ‘Football.’ And I said, ‘I don’t know how to play football. I’m not 6’4″, and I don’t weigh 300 pounds.’ But if no one values baseball anymore, the baseball player will be out of business. So I looked into the mirror and said, ‘Schlemiel, nobody wants to watch baseball. Make the transformation to football.'” His personal makeover-shedding the role of forgiving father to those widely viewed as not holding their own-helped sway other employees to back a corporate makeover. And his willingness to change helped protect him from attack during the company’s long-and generally successful-turnaround period.
Cook the conflict. Managing conflict is one of the greatest challenges a leader of organizational change faces. The conflict may involve resistance to change, or it may involve clashing viewpoints about how the change should be carried out. Often, it will be latent rather than palpable. That’s because most organizations are allergic to conflict, seeing it primarily as a source of danger, which it certainly can be. But conflict is a necessary part of the change process and, if handled properly, can serve as the engine of progress.
Thus, a key imperative for a leader trying to achieve significant change is to manage people’s passionate differences in a way that diminishes theft destructive potential and constructively harnesses their energy. Two techniques can help you achieve this. First, create a secure place where the conflicts can freely bubble up. Second, control the temperature to ensure that the conflict doesn’t boil over-and burn you in the process.
The vessel in which a conflict is simmered- in which clashing points of view mix, lose some of their sharpness, and ideally blend into consensus- will look and feel quite different in different contexts. It may be a protected physical space, perhaps an off-site location where an outside facilitator helps a group work through its differences. It may be a clear set of rules and processes that give minority voices confidence that they will be heard without having to disrupt the proceedings to gain attention. It may be the shared language and history of an organization that binds people together through trying times. Whatever its form, it is a place or a means to contain the roiling forces unleashed by the threat of major change.
But a vessel can withstand only so much strain before it blows. A huge challenge you face as a leader is keeping your employees’ stress at a productive level. The success of the change effort-as well as your own authority and even survival- requires you to monitor your organization’s tolerance for heat and then regulate the temperature accordingly.
You first need to raise the heat enough that people sit up, pay attention, and deal with the real threats and challenges facing them. After all, without some distress, there’s no incentive to change. You can constructively raise the temperature by focusing people’s attention on the hard issues, by forcing them to take responsibility for tackling and solving those issues, and by bringing conflicts occurring behind closed doors out into the open.
But you have to lower the temperature when necessary to reduce what can be counterproductive turmoil. You can turn down the heat by slowing the pace of change or by tackling some relatively straightforward technical aspect of the problem, thereby reducing people’s anxiety levels and allowing them to get warmed up for bigger challenges. You can provide structure to the problem-solving process, creating work groups with specific assignments, setting time parameters, establishing rules for decision making, and outlining reporting relationships. You can use humor or find an excuse for a break or a party to temporarily ease tensions. You can speak to people’s fears and, more critically, to their hopes for a more promising future. By showing people how the future might look, you come to embody hope rather than fear, and you reduce the likelihood of becoming a lightning rod for the conflict.
The aim of both these tactics is to keep the heat high enough to motivate people but low enough to prevent a disastrous explosion-what we call a “productive range of distress.” Remember, though, that most employees will reflexively want you to turn down the heat; their complaints may in fact indicate that the environment is just right for hard work to get done.
We’ve already mentioned a classic example of managing the distress of fundamental change: Franklin Roosevelt during the first few years of his presidency. When he took office in 1933, the chaos, tension, and anxiety brought on by the Depression ran extremely high. Demagogues stoked class, ethnic, and racial conflict that threatened to tear the nation apart. Individuals feared an uncertain future. So Roosevelt first did what he could to reduce the sense of disorder to a tolerable level. He took decisive and authoritative action- he pushed an extraordinary number of bills through Congress during his fabled first 100 days-and thereby gave Americans a sense of direction and safety, reassuring them that they were in capable hands. In his fireside chats, he spoke to people’s anxiety and anger and laid out a positive vision for the future that made the stress of the current crisis bearable and seem a worthwhile price to pay for progress.
But he knew the problems facing the nation couldn’t be solved from the White House. He needed to mobilize citizens and get them to dream up, try out, fight over, and ultimately own the sometimes painful solutions that would transform the country and move it forward. To do that, he needed to maintain a certain level of fermentation and distress. So, for example, he orchestrated conflicts over public priorities and programs among the large cast of creative people he brought into the government. By giving the same assignment to two different administrators and refusing to clearly define their roles, he got them to generate new and competing ideas. Roosevelt displayed both the acuity to recognize when the tension in the nation had risen too high and the emotional strength to take the heat and permit considerable anxiety to persist.
Place the work where it belongs. Because major change requires people across an entire organization to adapt, you as a leader need to resist the reflex reaction of providing people with the answers. Instead, force yourself to transfer, as Roosevelt did, much of the work and problem solving to others. If you don’t, real and sustainable change won’t occur. In addition, it’s risky on a personal level to continue to hold on to the work that should be done by others.
As a successful executive, you have gained credibility and authority by demonstrating your capacity to solve other people’s problems. This ability can be a virtue, until you find yourself faced with a situation in which you cannot deliver solutions. When this happens, all of your habits, pride, and sense of competence get thrown out of kilter because you must mobilize the work of others rather than find the way yourself. By trying to solve an adaptive challenge for people, at best you will reconfigure it as a technical problem and create some short-term relief. But the issue will not have gone away.
In the 1994 National Basketball Association Eastern Conference semifinals, the Chicago Bulls lost to the New York Knicks in the first two games of the best-of-seven series. Chicago was out to prove that it was more than just a one-man team, that it could win without Michael Jordan, who had retired at the end of the previous season.
In the third game, the score was tied at 102 with less than two seconds left. Chicago had the ball and a time-out to plan a final shot. Coach Phil Jackson called for Scottie Pippen, the Bulls’ star since Jordan had retired, to make the inbound pass to Toni Kukoc for the final shot. As play was about to resume, Jackson noticed Pippen sitting at the far end of the bench. Jackson asked him whether he was in or out. “I’m out,” said Pippen, miffed that he was not tapped to take the final shot. With only four players on the floor, Jackson quickly called another time-out and substituted an excellent passer, the reserve Pete Myers, for Pippen. Myers tossed a perfect pass to Kukoc, who spun around and sank a miraculous shot to win the game.
The Bulls made their way back to the locker room, their euphoria deflated by Pippen’s extraordinary act of insubordination. Jackson recalls that as he entered a silent room, he was uncertain about what to do. Should he punish Pippen? Make him apologize? Pretend the whole thing never happened? All eyes were on him. The coach looked around, meeting the gaze of each player, and said, “What happened has hurt us. Now you have to work this out.”
Jackson knew that if he took action to resolve the immediate crisis, he would have made Pippen’s behavior a matter between coach and player. But he understood that a deeper issue was at the heart of the incident: Who were the Chicago Bulls without Michael Jordan? It wasn’t about who was going to succeed Jordan, because no one was; it was about whether the players could jell as a team where no one person dominated and every player was willing to do whatever it took to help. The issue rested with the players, not him, and only they could resolve it. It did not matter what they decided at that moment; what mattered was that they, not Jackson, did the deciding. What followed was a discussion led by an emotional Bill Cartwright, a team veteran. According to Jackson, the conversation brought the team closer together. The Bulls took the series to a seventh game before succumbing to the Knicks.
Jackson gave the work of addressing both the Pippen and the Jordan issues back to the team for another reason: If he had taken ownership of the problem, he would have become the issue, at least for the moment. In his case, his position as coach probably wouldn’t have been threatened. But in other situations, taking responsibility for resolving a conflict within the organization poses risks. You are likely to find yourself resented by the faction that you decide against and held responsible by nearly everyone for the turmoil your decision generates. In the eyes of many, the only way to neutralize the threat is to get rid of you.

To survive, you need a sanctuary where you can reflect on the previous day’s journey, renew your emotional resources, and recalibrate your moral compass.
Despite that risk, most executives can’t resist the temptation to solve fundamental organizational problems by themselves. People expect you to get right in there and fix things, to take a stand and resolve the problem. After all, that is what top managers are paid to do. When you fulfill those expectations, people will call you admirable and courageous- even a “leader”-and that is flattering. But challenging your employees’ expectations requires greater courage and leadership.
The Dangers Within
We have described a handful of leadership tactics you can use to interact with the people around you, particularly those who might undermine your initiatives. Those tactics can help advance your initiatives and, just as important, ensure that you remain in a position where you can bring them to fruition. But from our own observations and painful personal experiences, we know that one of the surest ways for an organization to bring you down is simply to let you precipitate your own demise.
In the heat of leadership, with the adrenaline pumping, it is easy to convince yourself that you are not subject to the normal human frailties that can defeat ordinary mortals. You begin to act as if you are indestructible. But the intellectual, physical, and emotional challenges of leadership are fierce. So, in addition to getting on the balcony, you need to regularly step into the inner chamber of your being and assess the tolls those challenges are taking. If you don’t, your seemingly indestructible self can self-destruct. This, by the way, is an ideal outcome for your foes-and even friends who oppose your initiative-because no one has to feel responsible for your downfall.
Manage your hungers. We all have hungers, expressions of our normal human needs. But sometimes those hungers disrupt our capacity to act wisely or purposefully. Whether inherited or products of our upbringing, some of these hungers may be so strong that they render us constantly vulnerable. More typically, a stressful situation or setting can exaggerate a normal level of need, amplifying our desires and overwhelming our usual self-discipline. Two of the most common and dangerous hungers are the desire for control and the desire for importance.
Everyone wants to have some measure of control over his or her life. Yet some people’s need for control is disproportionately high. They might have grown up in a household that was either tightly structured or unusually chaotic; in either case, the situation drove them to become masters at taming chaos not only in their own lives but also in their organizations.
That need for control can be a source of vulnerability. Initially, of course, the ability to turn disorder into order may be seen as an attribute. In an organization facing turmoil, you may seem like a godsend if you are able (and desperately want) to step in and take charge. By lowering the distress to a tolerable level, you keep the kettle from boiling over.
But in your desire for order, you can mistake the means for the end. Rather than ensuring that the distress level in an organization remains high enough to mobilize progress on the issues, you focus on maintaining order as an end in itself. Forcing people to make the difficult trade-offs required by fundamental change threatens a return to the disorder you loathe. Your ability to bring the situation under control also suits the people in the organization, who naturally prefer calm to chaos. Unfortunately, this desire for control makes you vulnerable to, and an agent of, the organization’s wish to avoid working through contentious issues. While this may ensure your survival in the short term, ultimately you may find yourself accused, justifiably, of failing to deal with the tough challenges when there was still time to do so.
Most people also have some need to feel important and affirmed by others. The danger here is that you will let this affirmation give you an inflated view of yourself and your cause. A grandiose sense of self-importance often leads to self-deception. In particular, you tend to forget the creative role that doubt-which reveals parts of reality that you wouldn’t otherwise see- plays in getting your organization to improve. The absence of doubt leads you to see only that which confirms your own competence, which will virtually guarantee disastrous missteps.
Another harmful side effect of an inflated sense of self-importance is that you will encourage people in the organization to become dependent on you. The higher the level of distress, the greater their hopes and expectations that you will provide deliverance. This relieves them of any responsibility for moving the organization forward. But their dependence can be detrimental not only to the group but to you personally. Dependence can quickly turn to contempt as your constituents discover your human shortcomings.
Two well-known stories from the computer industry illustrate the perils of dependency-and how to avoid them. Ken Olsen, the founder of Digital Equipment Corporation, built the company into a 120,000-person operation that, at its peak, was the chief rival of IBM. A generous man, he treated his employees extraordinarily well and experimented with personnel policies designed to increase the creativity, teamwork, and satisfaction of his workforce. This, in tandem with the company’s success over the years, led the company’s top management to turn to him as the sole decision maker on all key issues. His decision to shun the personal computer market because of his belief that few people would ever want to own a PC, which seemed reasonable at the time, is generally viewed as the beginning of the end for the company. But that isn’t the point; everyone in business makes bad decisions. The point is, Olsen had fostered such an atmosphere of dependence that his decisions were rarely challenged by colleagues- at least not until it was too late.
Contrast that decision with Bill Gates’s decision some years later to keep Microsoft out of the Internet business. It didn’t take long for him to reverse his stand and launch a corporate overhaul that had Microsoft’s delivery of Internet services as its centerpiece. After watching the rapidly changing computer industry and listening carefully to colleagues, Gates changed his mind with no permanent damage to his sense of pride and an enhanced reputation due to his nimble change of course.
Anchor yourself. To survive the turbulent seas of a change initiative, you need to find ways to steady and stabilize yourself. First, you must establish a safe harbor where each day you can reflect on the previous day’s journey, repair the psychological damage you have incurred, renew your stores of emotional resources, and recalibrate your moral compass. Your haven might be a physical place, such as the kitchen table of a friend’s house, or a regular routine, such as a daily walk through the neighborhood. Whatever the sanctuary, you need to use and protect it. Unfortunately, seeking such respite is often seen as a luxury, making it one of the first things to go when life gets stressful and you become pressed for time.
Second, you need a confidant, someone you can talk to about what’s in your heart and on your mind without fear of being judged or betrayed. Once the undigested mess is on the table, you can begin to separate, with your confidant’s honest input, what is worthwhile from what is simply venting. The confidant, typically not a coworker, can also pump you up when you’re down and pull you back to earth when you start taking praise too seriously. But don’t confuse confidants with allies: Instead of supporting your current initiative, a confidant simply supports you. A common mistake is to seek a confidant among trusted allies, whose personal loyalty may evaporate when a new issue more important to them than you begins to emerge and take center stage.
Perhaps most important, you need to distinguish between your personal self, which can serve as an anchor in stormy weather, and your professional role, which never will. It is easy to mix up the two. And other people only increase the confusion: Colleagues, subordinates, and even bosses often act as if the role you play is the real you. But that is not the case, no matter how much of yourself-your passions, your values, your talents- you genuinely and laudably pour into your professional role. Ask anyone who has experienced the rude awakening that comes when they leave a position of authority and suddenly find that their phone calls aren’t returned as quickly as they used to be.
That harsh lesson holds another important truth that is easily forgotten: When people attack someone in a position of authority, more often than not they are attacking the role, not the person. Even when attacks on you are highly personal, you need to read them primarily as reactions to how you, in your role, are affecting people’s lives. Understanding the criticism for what it is prevents it from undermining your stability and sense of self-worth. And that’s important because when you feel the sting of an attack, you are likely to become defensive and lash out at your critics, which can precipitate your downfall.
We hasten to add that criticism may contain legitimate points about how you are performing your role. For example, you may have been tactless in raising an issue with your organization, or you may have turned the heat up too quickly on a change initiative. But, at its heart, the criticism is usually about the issue, not you. Through the guise of attacking you personally, people often are simply trying to neutralize the threat they perceive in your point of view. Does anyone ever attack you when you hand out big checks or deliver good news? People attack your personality, style, or judgment when they don’t like the message.
When you take “personal” attacks personally, you unwittingly conspire in one of the common ways you can be taken out of action- you make yourself the issue. Contrast the manner in which presidential candidates Gary Hart and Bill Clinton handled charges of philandering. Hart angrily counterattacked, criticizing the scruples of the reporters who had shadowed him. This defensive personal response kept the focus on his behavior. Clinton, on national television, essentially admitted he had strayed, acknowledging his piece of the mess. His strategic handling of the situation allowed him to return the campaign’s focus to policy issues. Though both attacks were extremely personal, only Clinton understood that they were basically attacks on positions he represented and the role he was seeking to play.
Do not underestimate the difficulty of distinguishing self from role and responding coolly to what feels like a personal attack-particularly when the criticism comes, as it will, from people you care about. But disciplining yourself to do so can provide you with an anchor that will keep you from running aground and give you the stability to remain calm, focused, and persistent in engaging people with the tough issues.
Why Lead?
We will have failed if this “survival manual” for avoiding the perils of leadership causes you to become cynical or callous in your leadership effort or to shun the challenges of leadership altogether. We haven’t touched on the thrill of inspiring people to come up with creative solutions that can transform an organization for the better. We hope we have shown that the essence of leadership lies in the capacity to deliver disturbing news and raise difficult questions in a way that moves people to take up the message rather than kill the messenger. But we haven’t talked about the reasons that someone might want to take these risks.
Of course, many people who strive for high-authority positions are attracted to power. But in the end, that isn’t enough to make the high stakes of the game worthwhile. We would argue that, when they look deep within themselves, people grapple with the challenges of leadership in order to make a positive difference in the lives of others.
When corporate presidents and vice presidents reach their late fifties, they often look back on careers devoted to winning in the marketplace. They may have succeeded remarkably, yet some people have difficulty making sense of their lives in light of what they have given up. For too many, their accomplishments seem empty. They question whether they should have been more aggressive in questioning corporate purposes or creating more ambitious visions for their companies.
Our underlying assumption in this article is that you can lead and stay alive -not just register a pulse, but really be alive. But the classic protective devices of a person in authority tend to insulate them from those qualities that foster an acute experience of living. Cynicism, often dressed up as realism, undermines creativity and daring. Arrogance, often posing as authoritative knowledge, snuffs out curiosity and the eagerness to question. Callousness, sometimes portrayed as the thick skin of experience, shuts out compassion for others.
The hard truth is that it is not possible to know the rewards and joys of leadership without experiencing the pain as well. But staying in the game and bearing that pain is worth it, not only for the positive changes you can make in the lives of others but also for the meaning it gives your own.
~~~~~~~~
By Ronald A. Heifetz and Marty Linsky

Ronald A. Heifetz and Marty Linsky teach leadership at the John F. Kennedy School of Government at Harvard University in Cambridge, Massachusetts. They are partners of Cambridge Leadership Associates, a firm that consults to senior executives on the practice of leadership (www.cambridge-leadership.com). They are also the coauthors of Leadership on the Line: Staying Alive Through the Dangers of Leading (Harvard Business School Press, 2002),from which this article is adapted.
Adaptive Versus Technical Change: Whose Problem Is It?
The importance-and difficulty-of distinguishing between adaptive and technical change can be illustrated with an analogy. When your car has problems, you go to a mechanic. Most of the time, the mechanic can fix the car. gut if your car troubles stem from the way a family member drives, the problems are likely to recur. Treating the problems as purely technical ones-taking the car to the mechanic time and again to get it back on the road-masks the real issues. Maybe you need to get your mother to stop drinking and driving, get your grandfather to give up his driver’s license, or get your teenager to be more cautious. Whatever the underlying problems, the mechanic can’t solve them. Instead, changes in the family need to occur, and that won’t be easy. People will resist the moves, even denying that such problems exist. That’s because even those not directly affected by an adaptive change typically experience discomfort when someone upsets a group’s or an organization’s equilibrium.
Such resistance to adaptive change certainly happens in business. Indeed, it’s the classic error: Companies treat adaptive challenges as if they were technical problems. For example, executives attempt to improve the bottom line by cutting costs across the board. Not only does this avoid the need to make tough choices about which areas should be trimmed, it also masks the fact that the company’s real challenge lies in redesigning its strategy.
Treating adaptive challenges as technical ones permits executives to do what they have excelled at throughout their careers: solve other people’s problems. And it allows others in the organization to enjoy the primordial peace of mind that comes from knowing that their commanding officer has a plan to maintain order and stability. After all, the executive doesn’t have to instigate-and the people don’t have to undergo-uncomfortable change. Most people would agree that, despite the selective pain of a cost-cutting exercise, it is less traumatic than reinventing a company.
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What Does SocialJustice Require For The Public’s Health? Public Health Ethics And Policy Imperatives
Social justice demands more than fair distribution of resources in extreme public health emergencies.
by Lawrence 0. Gostin and Madison Powers
ABSTRACT: Justice is so central to the mission of public health that it has been described as the field’s core value. This account of justice stresses the fair disbursement of common advantages and the sharing of common burdens. It captures the twin moral impulses that animate public health: to advance human well-being by improving health and to do so particularly by focusing on the needs of the most disadvantaged. This Commentary explores how social justice sheds light on major ongoing controversies in the field, and it provides examples of the kinds of policies that public health agencies, guided by a robust conception of justice, would adopt. [Health Affairs 25, no. 4 (2006): 1053-1060; 10.1377/hlthaff .25.4.1053]
Justice is viewed as so central to the mission of public health that it
has been described as the field’s core value: “The historic dream of public health…is a dream of social justice,”‘ This Commentary addresses a single question of extraordinary social and political importance: What does social justice re- quire for the public’s health? Our thesis is that justice can be an important organizing principle for public health.

Justice alone cannot determine the “correct” policy or supply an answer to every question regarding the broad direction for public health; neither can any other single organizing principle. However, there are certain core commitments that all who embrace even a modest conception of social justice recognize as important, and those commitments can shed light on the major ongoing controversies in the field: the legitimate scope of public health, the balance between public health and
Larry Gostin (gostin@law.georgetown.edu) is associate dean and aprofessor at the Georgetown University Law Center in Washington, D.C; director of the university’s Centerfor Law and the Public’s Health; and a professor at thefohns Hopkins Bloomberg School of Public Health in Baltimore, Maryland. Madison Powers is director and senior research scholar at the Kennedy Institute of Ethics, Georgetown University, and an associate professor in its Department of Philosophy.
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civil liberties, and the appropriate roles of the federal government and the states. More importantly, this paper shows how public health based on social justice gives rise to important policy imperatives such as improving the public health sys- tem, reducing socioeconomic disparities, addressing health determinants, and planning for health emergencies with an eye on the needs of the most vulnerable. Before examining the major controversies and making policy recommendations, we provide our particular account of justice in public health.
What is ‘Justice,’ And How important is it in Public Health?
Among the most basic and commonly understood meanings of justice is fairness or reasonableness, especially in the way people are treated or decisions are made.-^ Our account of justice stresses the fair disbursement of common advantages and the sharing of common burdens. It captures the twin moral impulses that animate public health: to advance human well-being by improving health and to do so by focusing on the needs of the most disadvantaged. An integral part of bringing good health to all is the task of identifying and ameliorating patterns of systematic dis- advantage that undermine the well-being of people whose prospects for good health are so limited that their life choices are not even remotely like those of others.’ These two aspects of justice—health improvement for the population and fair treatment of the disadvantaged—create a richer understanding of public health.
A core insight of social justice is that there are multiple causal pathways to numerous dimensions of disadvantage. These include poverty, substandard housing, poor education, unhygienic and polluted environments, and social disintegration. These and many other causal agents lead to systematic disadvantage not only in health, but also in nearly every aspect of social, economic, and political life. In- equalities beget other inequalities, and existing inequalities compound, sustain, and reproduce a multitude of deprivations.”*
Our account of social justice is interventionist, not passive or market-driven, vigorously addressing the determinants of health throughout the lifespan. It recognizes that there are multiple causes of ill and good health, that policies and practices affecting health also affect other valued dimensions of life, and that health is intimately connected to many of the important goods in life. Empirical inquiries, therefore, are critical to justice in public health. Data can help determine who are most vulnerable and at greatest risk, how best to reduce the risk or ameliorate the harm, and how to fairly distribute services and benefits.
The Justice Perspective in Public Health
The field of public health is in the midst of a crisis of public confidence. American culture openly tolerates the expression and enjoyment of wealth and privilege and is inclined to view health as a matter of personal responsibility. Meanwhile, the public has become skeptical of government’s ability to ameliorate the harshest consequences of socioeconomic disparities. At its deepest level, some believe that
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government’s purpose should not be to redress economic and social disadvantage, and this may be doubly so for administrative agencies dedicated to public health and the pursuit of science. We believe that it is time to rethink this view, and the justice perspective offers an alternative. Values of socioeconomic fairness are just as important to health as the prevailing values of personal license and free enterprise. The justice perspective offers a different way of seeing problems that have long plagued the field of public health.
• Legitimate scope of the public health enterprise. Perhaps the deepest, most persistent critique of public health is that the field has strayed beyond its natural boundaries. Instead of focusing solely on narrow interventions for discrete injuries and diseases, the field has turned its attention to broader health determinants. It is when public health strays into the social/political sphere in matters of war, violence, poverty, and racism that critics become most upset.
The justice perspective does not provide a definitive defense against claims of overreaching. But social justice does provide a counterweight to the prevailing political view of health as primarily a private matter. The justice perspective shows why health is a matter of public concern, with the state having a role not only in the traditional areas of infectious diseases and sanitation, but also in emerging areas such as chronic diseases caused by diet, lifestyle, and the environment. Public health agencies have an obligation to address the root causes of ill health, even while they recognize that socioeconomic determinants have many causes, and solutions, that are beyond public health’s exclusive expertise.
• Balancing Individual and collective interests. The exercise of the state’s coercive power has been highly contentious throughout U.S. history. When public health officials act, they face troubling conflicts between the collective benefits of population health on the one hand, and personal and economic interests on the other. Public health powers encroach on fundamental civil liberties such as privacy, bodily integrity, and freedom of movement and association. Sanitary regulations similarly intrude on economic liberties such as freedom of contract, pursuit of professional status, and use of personal property. Justice demands that government take actions to safeguard the public’s health, but that it do so with respect for individuals and sensitivity to the needs of the underprivileged.
In the realm of public health and civil liberties, then, both sides claim the mantle of justice. Finding an appropriate balance is not easy and is fraught with controversy. What is most important to justice is abiding by the rule of law, which re- quires modern public health statutes that designate clear authority to act and provide fair processes. Policymakers, therefore, should modernize antiquated public health laws to provide adequate power to reduce major risks to the population but ensure that government power is exercised proportionately and fairly.^ Fairness requires just distributions of burdens and benefits to all, but also procedural due process for people subjected to compulsory interventions.
Certainly, the justice perspective cannot answer many of the most perplexing
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problems at the intersection of public health and civil liberties such as paternalistic interventions (for example, seat belt laws) or the exercise of powers in health emergencies (for example, avian flu or bioterrorism). These and many other problems pose major dilemmas for the field that neither considerations of justice nor traditional arguments based in beneficence can readily resolve. However, a more serious failure of public policy would be a failure to recognize and give great weight to the demands of social justice when faced with such challenges.
• National, state, and local public health functions. The arguments for and against the centralization of political power have remained largely the same over the course of U.S. history and are part of entrenched political ideologies. There is no simple resolution, and initially it might seem that the justice perspective can shed little light on this contentious area. Considerations of social justice do not side with either of the traditional combatants in the federalism debates, as they neither favor federal nor state action. What justice does do is insist that governmental action ad- dress the major causes of ill health, particularly among the disadvantaged; that commitment has major implications for political and social coordination.
The justice perspective’s emphasis on the multicausal and interactive determinants of health suggests that strategic opportunities for prevention and amelioration of ill health arise at every level of governmental interaction. The challenge of combating the threat of systematic disadvantage can be met only with a systematic response among all levels of government. The level of government best situated for dealing with public health threats depends on the evidence identifying the nature and origin of the specific threat, the resources available to each unit for addressing the problem, and the probability of strategic success.
National obligations. The national government has a duty to create the capacity to undertake essential public health services. A national commitment to capacity building is important because public needs for health and wellbeing are universal
and compelling. The federal government should recognize these needs and invest in a strong public health system. Certain problems demand national attention. A health threat, such as epidemic disease or environmental pollution, might span many states, regions, or the whole country. Further, the solution to problems such as those related to foreign or interstate commerce could be beyond the jurisdiction of individual states. Finally, states simply might lack the expertise or resources to mount an effective response in a major public health emergency.
State/local obligations. Armed with sufficient resources and tools, states and localities have an obligation to fulfill core public health functions such as diagnosing
and investigating health threats, informing and educating the public, mobilizing community partnerships, and enforcing state health laws. States and localities are closer to the people and to the problems causing ill health. Delivering public health services requires local knowledge and direct political accountability. States and localities are also often the preferable unit of government when dealing with complex, poorly understood problems. In such cases, the idea of a “laboratory of
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the states” enables local officials to seek innovative solutions.
Harmonized engagement. Because justice emphasizes the multicausal, interactive character of health threats, a system of overlapping and shared responsibility among federal, state, and local governments will most often be required. Governments at all levels have differing degrees of responsibility. This insight was illustrated poignantly during the response to the Gulf Coast hurricanes. It was not that a particular political unit should have had primacy. Rather, each should have played a unique role in a well-coordinated effort.
The Policy imperatives Of The Justice Perspective
The public health community has not been successful in gaining attention to or resources for its core mission and essential services. Outside of health emergencies, the public does not demonstrate any particular interest in public health as a priority, and this lack of interest shows in chronic underfunding. From a fiscal perspective, only a tiny fraction of health dollars goes to prevention and population-based services.* Even when attention and resources are ample, it is usually in immediate response to some actual or perceived threat. This leads not to core, stable funding and attention but, rather, to a “disease du jour” mentality. This type of response creates silos, disproportionately funds biomedical solutions, and poses a “no-win” situation for public health agencies, which must respond to the latest fashion but seldom gain the kind of ongoing political attention and economic re- sources they need to improve the public’s health.
The justice perspective offers an opportunity to change this dynamic, and the remainder of this Commentary offers concrete proposals based on the imperatives of population improvement and just distribution of benefits.
• The public health system. Justice, with its concern for human well-being, re- quires a serious commitment to the public’s health. It is for that reason that justice demands a tangible, long-term pledge to the public’s health and the needs of the least well-off. Such a commitment, as countless reports have made clear, is lacking.” Funding for prevention and population-based services is inordinately low, and categorical funding for special programs such as bioterrorism and avian flu is limited to a single issue and is time restricted.
To assure that actions can be taken to protect, promote, and provide for the health of the public, there must be a substantial and stable commitment to the public’s health at the federal, state, and local levels. Given the gravity and importance of the situation. Congress and the executive branch should create a Trust Fund for Public Health to provide generous and stable resources to rebuild the eroded public health infrastructure and implement core public health functions. Nongovernmental trust-fund approaches, implemented in other countries, should also be explored. The Public Health Leadership Initiative, established by the Trust for America’s Health (TFAH), recommends annual, sustained spending of $1.5-$2 billion increase to ensure an adequate public health infrastructure.
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• Addressing health determinants. If justice is outcome oriented, then inevitably public health must deal with the underlying causes of poor and good health. The key health determinants include the built environment (for example, transportation and buildings); the natural environment (for example, clean air and water); the in- formational environment (for example, health information and advertising restrictions); the social environment (for example, social networks and support); and the economic environment (socioeconomic status),’ These are all public health problems, but they are not solvable solely by public health agencies. Public health re- searchers and agencies can provide the intellectual tools for understanding the factual basis of the problems policymakers face. They can act directly and as conveners that mobilize and coordinate government agencies, health care institutions, businesses, the media, academia, and the community.
Obesity policy offers an apt illustration of the numerous ways that public health, together with its partners, can act on the root causes of ill health. By a combination of zoning, public construction, taxation, incentives, regulation, and health information, the state could encourage citizens to eat healthier diets and maintain more active lifestyles. This could be accomplished by changing the inner city, for example, to favor supermarkets over fast foods, recreational facilities and green spaces over roads, mass transportation over automobiles, and so forth. It could involve transformation of schools to ensure healthier snacks and lunches, physical activity, and health education. Critics complain that diet and lifestyle are personal choices outside the appropriate realm of government. However, there is nothing inherently wrong with having the state make healthier choices easier for people to make,
• Fair treatment of the disadvantaged. Fair distribution of burdens and benefits, as discussed, is a core attribute of justice. Allocations based on the market or political influence favor the rich, powerful, and socially connected. Even neutral or random allocations can be unjust because they do not benefit those with greatest need. For example, health officials who direct a population to evacuate or shelter in place should foresee that the poor will not have private transportation or the means to stock up on food or supplies. For that reason, justice requires public health officials to devise plans and programs with particular attention to the disadvantaged. Fair distributions should be integral to public health policy and practice, but they take on particular importance when planning for health emergencies or when there is extreme scarcity.
Health emergencies threaten the entire community, but the poor and disabled are at heightened risk. Social justice thus demands more than fair distribution of resources in extreme health emergencies, A failure to act expeditiously and with equal concern for all citizens, including the poor and less powerful, predictably harms the whole community by eroding public trust and undermining social cohesion. It signals to those affected and to everyone else that the basic human needs of some matter less than those of others, and it thereby fails to show the respect
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“The aims of public health deserve a great deal more societal attention and resources than the political community has allowed.”
due to all members of the community. Social justice thus encompasses not only a core commitment to a fair distribution of resources, but it also calls for policies of action that are consistent with the preservation of human dignity and the showing of equal respect for the interests of all members of the community.
• Planning for emergencies involving scarce life-saving resources. Health emergencies pose the potential for mass illness and death, often resulting in extreme scarcity of medical countermeasures, hospital beds, and other essential resources. Rarely will there be sufficient stockpiles or surge capacity to meet mass needs. For example, the U.S. influenza preparedness plan anticipates marked shortages of vaccines, antiviral medications, and medical equipment.
What does justice tell us about how to ration scarce, life-saving resources? In the context of influenza, the United States focuses on key personnel and sectors such as government, biomedical researchers, the pharmaceutical industry, health care professionals, and essential workers or first responders. These apparently neutral categories mask injustice. In each case, people gain access to life-saving technologies based on their often high-status employment. This kind of health planning leaves out, by design, those who are unemployed or in “nonessential” jobs—a proxy for the displaced and devalued members of society. Consequently, public health planning based on pure utility, although understandable, fails to have sufficient regard for the disenfranchised in society.10″
• Fair distribution from a global perspective. Perhaps the most extreme injustices arise in the global allocation of health resources. Developing countries suffer the multiple, compounding burdens of destitution (lack of medical equipment, health professionals, and hospitals), impoverished environments (drought, famine, and contaminated drinking water), and extremely poor health (tuberculosis, malaria, and HIV). They also lack a scientific infrastructure. Realistically, scarce re- sources will go to those countries where products are owned and manufactured. This reality can have devastating consequences for poor countries that cannot compete economically for expensive health resources. Social justice views all lives as having equal value, so there is a moral justification for fair allocation from a global perspective. Even from a less altruistic perspective there are reasons to invest in poor regions. Improved surveillance and response can help in early detection and containment of infectious disease outbreaks, affording universal benefits.
A Policy Landscape informed By Social Justice
What would the policy landscape look like if it were informed by a robust conception of social justice? The political community would embrace, rather than condemn, a wide scope for the public health enterprise; value the public good as
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much as personal and economic liberty; view the public good as involving a commitment to the health and equal worth of all members of the community; and view federalism as a shared responsibility for health improvement rather than an ideological battleground between national power and states rights.
Social justice would spur important policy shifts. Political leaders would create a trust fund allocating funds on a sustained basis sufficient to assure an adequate public health infrastructure; use a variety of tools (such as zoning, taxation, incentives, regulations, and information) to address the determinants of ill health, including reduction of socioeconomic disparities; devise programs and plans to as- sure the health and safety of the most vulnerable, particularly in public health emergencies; and devote substantial resources to meeting global needs for essential public health services. These measures, and many more, would not ensure equality in health but would soften some of the most egregious inequities.
The central claim of this Commentary is that a commitment to social justice lies at the heart of public health. This commitment is to the advancement of human well-being. It aims to lift up the systematically disadvantaged and in so doing further advance the common good by showing equal respect to all individuals and groups who make up the community. Justice in public health is purposeful, positivistic, and humanistic. The aims of public health deserve a great deal more societal attention and resources than the political community has allowed.
The authors thank Benjamin Berkman, Sloan Fellow at the Georgetown University Law Center, for research and editorial assistance
NOTES
1. D.E. Beauchamp, “Public Health as Social Justice,” in New Ethic for the Public’s Health, ed D.E. Beauchamp and B. Steinbock (New York Oxford University Press, 1999), 105-114.
2. J. Rawls, A Theory of justice (Cambridge: Harvard University Press, 1971).

3. M. Powers and R. Faden, Soda/Justice The Moral Foundations of Public Health and Health Policy (New York Ox- ford University Press, 2006).
4. Ibid
5. L.O. Gostin, “Public Health Law in an Age of Terrorism; Rethinking Individual Rights and Common Goods,” Health Affairs 21, no. 6 (2002): 79-9
6. K.W. Ellbert et aL, Measuring Expenditures for Essential Public Health Services (Washington: Public Health Foundation, 1996).

7. See, fore example. Institute of Medicine, The Future of the Public’s Health in the Twenty-first Century (Washington: National Academies Press, 2003).
8. Public Health Leadership Initiative, A Blueprint for Health)/People in Healthy Communities in Twenty-first Century (Washington: Trust for America’s Health, forthcoming).
9. LO. Gostin, J. I. Boufford and R. M. Martinez, “The Future of the Public’s Health: Vision, Values, and Strategies,” Health Affairs 23, no. 4 (2004): 96-107
10. L.O. Gostin, “Medical Counter measures for Pandemic Influenza: Ethics and the Law,” journal of the American
Medical Association 295, no. 5 (2006): 554-55
HLTH 8136 Week 11 Journal & IDP
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Journal & IDP
Leadership Journal?

One might say that politics is about who gets what and why. As a public health leader, your role is to advance the causes of your organization and ultimately of the community. This role often requires political savvy, or what might be called the ability to deal successfully in the “real world.”

To lead in the real world it certainly helps if you can advocate courageously and persuasively on behalf of public health’s causes, communicate adeptly to a wide range of audiences, and demonstrate healthy business acumen in your operations. But as many leaders attest, leading also requires the recognition that the best solutions are not always easy to discern. Leaders need the ability to deal with ambiguity, to hold seemingly incompatible ideas, values, or truths, even when doing so might make you seem inauthentic to others.

This week you will explore what it means to be able to deal effectively in real life leadership situations. You will also revisit the concept of social justice and propose ways to promote this perspective among those who hold a “market justice” view of society’s obligations to the public’s health needs.

Objectives

Students will:

• Articulate the case for social justice in an individualized market-based society
• Describe strategies for dealing successfully with ambiguity, uncertainty, and other leadership challenges arising in public health

ANSWER THE FOLLOWING QUESTIONS:

1. Reflect on the “real-world” challenges described this week that you have already faced. Have they been to maintaining authenticity? Fairness? Objectivity? Have you experienced a tension between competing values and ambiguity?

2. How do you know when you have compromised too far? When would you choose to quit a job rather than continue and accept compromises, ethically, and morally?

3. List five skills that you learned in this course and explain how you can apply each of them to your leadership life in the next three months.

USE THESE ARTICLES ONLY:

1.Article: Heifetz, R. A., & Linsky, M. (2002). A survival guide for leaders. Harvard Business Review, 80(6), 65-72.
This article addresses how to manage change and the group conflict that results during corporate climate shifts. This reference was adapted from the article “Leadership on the line: Staying alive through the dangers of leading” (Harvard Business School Press, 2002). The techniques listed within address tactical advice about relating to the organization and employees during change, while discussing how to attend to personal needs and vulnerabilities of the manager in charge.

2.Gostin, L., & Powers, M. (2006). What does social justice require for the public’s health? Public health ethics and policy imperatives. Health Affairs, 25(4), 1053-1060.

This article discusses how social justice and attending to the needs of the disadvantage affect moral aspects of the realm of public health. This article provides examples of the kinds of policies that public health agencies utilizes to manage the field, while shedding light on major public health controversies of the field of study. This article stresses the need for justice and fair disbursement of common advantages and the sharing of common burdens.

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A Survival Guide for Leaders.
Authors: Heifetz, Ronald A.1,2 Linsky, Marty1,2
Source:
Harvard Business Review. Jun2002, Vol. 80 Issue 6, p65-74. 10p. 2 Color Photographs.
Document Type:
Article
Subject Terms:
*ORGANIZATIONAL change
*MANAGEMENT
*LEADERS
*EXECUTIVE ability (Management)
*CORPORATE culture
*CORPORATE reorganizations
*MANAGEMENT research
*LEADERSHIP
*QUALITY of work life
*ORGANIZATIONAL sociology
*SUPERIOR-subordinate relationship
*MANAGEMENT styles
NAICS/Industry Codes:
541612 Human Resources Consulting Services

Abstract: Let’s face it, to lead is to live dangerously. While leadership is often viewed as an exciting and glamorous endeavor, one in which you inspire others to follow you through good times and bad, such a portrayal ignores leadership’s dark side: the inevitable attempts to take you out of the game. This is particularly true when a leader must steer an organization through difficult change. When the status quo is upset, people feel a sense of profound loss and dashed expectations. They may need to undergo a period of feeling incompetent or disloyal. It’s no wonder they resist the change and often try to eliminate its visible agent. This “survival guide” offers a number of techniques–relatively straightforward in concept but difficult to execute–for protecting yourself as you lead such a change initiative. Adapted from the book “Leadership on the Line: Staying Alive Through the Dangers of Leading ” (Harvard Business School Press, 2002), the article has two main parts. The first looks outward, offering tactical advice about relating to your organization and the people in it. It is designed to protect you from those who would push you aside before you complete your initiatives. The second looks inward, focusing on your own needs and vulnerabilities. It is designed to keep you from bringing yourself down. The hard truth is that it is not possible to experience the rewards and joys of leadership without experiencing the pain as well. But staying in the game and bearing that pain is worth it, not only for the positive changes you can make in the lives of others but also for the meaning it gives your own. INSET: Adaptive Versus Technical Change: Whose Problem Is It?. [ABSTRACT FROM PUBLISHER]

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Author Affiliations:
1John F. Kennedy School of Government, Harvard University
2Partner, Cambridge Leadership Associates
Full Text Word Count:
6783
ISSN:
0017-8012
Accession Number:
6756407
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A Survival Guide for Leaders
Contents
4. A Hostile Environment
5. The Dangers Within
6. Why Lead?

Section:
MANAGING YOURSELF
Steering an organization through times of change can be hazardous, and it has been the ruin of many a leader. To avoid the perils, let a few basic rules govern your actions-and your internal compass
THINK OF THE MANY top executives in recent years who, some times after long periods of considerable success, have crashed and burned. Or think of individuals you have known in less prominent positions, perhaps people spearheading significant change initiatives in their organizations, who have suddenly found themselves out of a job. Think about yourself: In exercising leadership, have you ever been removed or pushed aside?
Let’s face it, to lead is to live dangerously. While leadership is often depicted as an exciting and glamorous endeavor, one in which you inspire others to follow you through good times and bad, such a portrayal ignores leadership’s dark side: the inevitable attempts to take you out of the game.
Those attempts are sometimes justified. People in top positions must often pay the price for a flawed strategy or a series of bad decisions. But frequently, something more is at work. We’re not talking here about conventional office politics; we’re talking about the high-stake risks you face whenever you try to lead an organization through difficult but necessary change. The risks during such times are especially high because change that truly transforms an organization, be it a multibillion-dollar company or a ten-person sales team, demands that people give up things they hold dear: daily habits, loyalties, ways of thinking. In return for these sacrifices, they may be offered nothing more than the possibility of a better future.
We refer to this kind of wrenching organizational transformation as “adaptive change,” something very different from the “technical change” that occupies people in positions of authority on a regular basis. Technical problems, while often challenging, can be solved applying existing know-how and the organization’s current problem-solving processes. Adaptive problems resist these kinds of solutions because they require individuals throughout the organization to alter their ways; as the people themselves are the problem, the solution lies with them. (See the sidebar “Adaptive Versus Technical Change: Whose Problem Is It?”) Responding to an adaptive challenge with a technical fix may have some short-term appeal. But to make real progress, sooner or later those who lead must ask themselves and the people in the organization to face a set of deeper issues-and to accept a solution that may require turning part or all of the organization upside down.
It is at this point that danger lurks. And most people who lead in such a situation-swept up in the action, championing a cause they believe in-are caught unawares. Over and over again, we have seen courageous souls blissfully ignorant of an approaching threat until it was too late to respond.
The hazard can take numerous forms. You may be attacked directly in an attempt to shift the debate to your character and style and avoid discussion of your initiative. You may be marginalized, forced into the position of becoming so identified with one issue that your broad authority is undermined. You may be seduced by your supporters and, fearful of losing their approval and affection, fail to demand they make the sacrifices needed for the initiative to succeed. You may be diverted from your goal by people overwhelming you with the day-to-day details of carrying it out, keeping you busy and preoccupied.
Each one of these thwarting tactics-whether done consciously or not-grows out of people’s aversion to the organizational disequilibrium created by your initiative. By attempting to undercut you, people strive to restore order, maintain what is familiar to them, and protect themselves from the pains of adaptive change. They want to be comfortable again, and you’re in the way.
So how do you protect yourself? Over a combined 50 years of teaching and consulting, we have asked ourselves that question time and again-usually while watching top-notch and well-intentioned folks get taken out of the game. On occasion, the question has become painfully personal; we as individuals have been knocked off course or out of the action more than once in our own leadership efforts. So we are offering what we hope are some pragmatic answers that grow out of these observations and experiences. We should note that while our advice clearly applies to senior executives, it also applies to people trying to lead change initiatives from positions of little or no formal organizational authority.
This “survival guide” has two main parts. The first looks outward, offering tactical advice about relating to your organization and the people in it. It is designed to protect you from those trying to push you aside before you complete your initiative. The second looks inward, focusing on your own human needs and vulnerabilities. It is designed to keep you from bringing yourself down.
A Hostile Environment
Leading major organizational change often involves radically reconfiguring a complex network of people, tasks, and institutions that have achieved a kind of modus vivendi, no matter how dysfunctional it appears to you. When the status quo is upset, people feel a sense of profound loss and dashed expectations. They may go through a period of feeling incompetent or disloyal. It’s no wonder they resist the change or try to eliminate its visible agent. We offer here a number of techniques-relatively straightforward in concept but difficult to execute-for minimizing these external threats.
Operate in and above the fray. The ability to maintain perspective in the midst of action is critical to lowering resistance. Any military officer knows the importance of maintaining the capacity for reflection, especially in the “fog of war.” Great athletes must simultaneously play the game and observe it as a whole. We call this skill “getting off the dance floor and going to the balcony,” an image that captures the mental activity of stepping back from the action and asking, “What’s really going on here?”
Leadership is an improvisational art. You may be guided by an overarching vision, clear values, and a strategic plan, but what you actually do from moment to moment cannot be scripted. You must respond as events unfold. To use our metaphor, you have to move back and forth from the balcony to the dance floor, over and over again throughout the days, weeks, months, and years. While today’s plan may make sense now, tomorrow you’ll discover the unanticipated effects of today’s actions and have to adjust accordingly. Sustaining good leadership, then, requires first and foremost the capacity to see what is happening to you and your initiative as it is happening and to understand how today’s turns in the road will affect tomorrow’s plans.

Executives leading difficult change initiatives are often blissfully ignorant of an approaching threat until it is too late to respond.
But taking a balcony perspective is extremely tough to do when you’re fiercely engaged down below, being pushed and pulled by the events and people around you- and doing some pushing and pulling of your own. Even if you are able to break away, the practice of stepping back and seeing the big picture is complicated by several factors. For example, when you get some distance, you still must accurately interpret what you see and hear. This is easier said than done. In an attempt to avoid difficult change, people will naturally, even unconsciously, defend their habits and ways of thinking. As you seek input from a broad range of people, you’ll constantly need to be aware of these hidden agendas. You’ll also need to observe your own actions; seeing yourself objectively as you look down from the balcony is perhaps the hardest task of all.
Fortunately, you can learn to be both an observer and a participant at the same time. When you are sitting in a meeting, practice by watching what is happening while it is happening-even as you are part of what is happening. Observe the relationships and see how people’s attention to one another can vary: supporting, thwarting, or listening. Watch people’s body language. When you make a point, resist the instinct to stay perched on the edge of your seat, ready to defend what you said. A technique as simple as pushing your chair a few inches away from the table after you speak may provide the literal as well as metaphorical distance you need to become an observer.
Court the uncommitted. It’s tempting to go it alone when leading a change initiative. There’s no one to dilute your ideas or share the glory, and it’s often just plain exciting. It’s also foolish. You need to recruit partners, people who can help protect you from attacks and who can point out potentially fatal flaws in your strategy or initiative. Moreover, you are far less vulnerable when you are out on the point with a bunch of folks rather than alone. You also need to keep the opposition close. Knowing what your opponents are thinking can help you challenge them more effectively and thwart their attempts to upset your agenda-or allow you to borrow ideas that will improve your initiative. Have coffee once a week with the person most dedicated to seeing you fall.
But while relationships with allies and opponents are essential, the people who will determine your success are often those in the middle, the uncommitted who nonetheless are wary of your plans. They have no substantive stake in your initiative, but they do have a stake in the comfort, stability, and security of the status quo. They’ve seen change agents come and go, and they know that your initiative will disrupt their lives and make their futures uncertain. You want to be sure that this general uneasiness doesn’t evolve into a move to push you aside.
These people will need to see that your intentions are serious- for example, that you are willing to let go of those who can’t make the changes your initiative requires. But people must also see that you understand the loss you are asking them to accept. You need to name the loss, be it a change in time-honored work routines or an overhaul of the company’s core values, and explicitly acknowledge the resulting pain. You might do this through a series of simple statements, but it often requires something more tangible and public-recall Franklin Roosevelt’s radio “fireside chats” during the Great Depression-to convince people that you truly understand.
Beyond a willingness to accept casualties and acknowledge people’s losses, two very personal types of action can defuse potential resistance to you and your initiatives. The first is practicing what you preach. In 1972, Gene Patterson took over as editor of the St. Petersburg Times. His mandate was to take the respected regional newspaper to a higher level, enhancing its reputation for fine writing while becoming a fearless and hard-hitting news source. This would require major changes not only in the way the community viewed the newspaper but also in the way Times reporters thought about themselves and their roles. Because prominent organizations and individuals would no longer be spared warranted criticism, reporters would sometimes be angrily rebuked by the subjects of articles.
Several years after Patterson arrived, he attended a party at the home of the paper’s foreign editor. Driving home, he pulled up to a red light and scraped the car next to him. The police officer called to the scene charged Patterson with driving under the influence. Patterson phoned Bob Haiman, a veteran Times newsman who had just been appointed executive editor, and insisted that a story on his arrest be run. As Haiman recalls, he tried to talk Patterson out of it, arguing that DUI arrests that didn’t involve injuries were rarely reported, even when prominent figures were involved. Patterson was adamant, however, and insisted that the story appear on page one.
Patterson, still viewed as somewhat of an outsider at the paper, knew that if he wanted his employees to follow the highest journalistic standards, he would have to display those standards, even when it hurt. Few leaders are called upon to disgrace themselves on the front page of a newspaper. But adopting the behavior you expect from others – whether it be taking a pay cut in tough times or spending a day working next to employees on a reconfigured production line-can be crucial in getting buy-in from people who might try to undermine your initiative.
The second thing you can do to neutralize potential opposition is to acknowledge your own responsibility for whatever problems the organization currently faces. If you have been with the company for some time, whether in a position of senior authority or not, you’ve likely contributed in some way to the current mess. Even if you are new, you need to identify areas of your own behavior that could stifle the change you hope to make.
In our teaching, training, and consulting, we often ask people to write or talk about a leadership challenge they currently face. Over the years, we have read and heard literally thousands of such challenges. Typically, in the first version of the story, the author is nowhere to be found. The underlying message: “If only other people would shape up, I could make progress here.” But by too readily pointing your finger at others, you risk making yourself a target. Remember, you are asking people to move to a place where they are frightened to go. If at the same time you’re blaming them for having to go there, they will undoubtedly turn against you.
In the early 1990s, Leslie Wexner, founder and CEO of the Limited, realized the need for major changes at the company, including a significant reduction in the workforce. But his consultant told him that something else had to change: long-standing habits that were at the heart of his self-image. In particular, he had to stop treating the company as if it were his family. The indulgent father had to become the chief personnel officer, putting the right people in the right jobs and holding them accountable for their work. “I was an athlete trained to be a baseball player,” Wexner recalled during a recent speech at Harvard’s Kennedy School. “And one day, someone tapped me on the shoulder and said, ‘Football.’ And I said, ‘No, I’m a baseball player.’ And he said, ‘Football.’ And I said, ‘I don’t know how to play football. I’m not 6’4″, and I don’t weigh 300 pounds.’ But if no one values baseball anymore, the baseball player will be out of business. So I looked into the mirror and said, ‘Schlemiel, nobody wants to watch baseball. Make the transformation to football.'” His personal makeover-shedding the role of forgiving father to those widely viewed as not holding their own-helped sway other employees to back a corporate makeover. And his willingness to change helped protect him from attack during the company’s long-and generally successful-turnaround period.
Cook the conflict. Managing conflict is one of the greatest challenges a leader of organizational change faces. The conflict may involve resistance to change, or it may involve clashing viewpoints about how the change should be carried out. Often, it will be latent rather than palpable. That’s because most organizations are allergic to conflict, seeing it primarily as a source of danger, which it certainly can be. But conflict is a necessary part of the change process and, if handled properly, can serve as the engine of progress.
Thus, a key imperative for a leader trying to achieve significant change is to manage people’s passionate differences in a way that diminishes theft destructive potential and constructively harnesses their energy. Two techniques can help you achieve this. First, create a secure place where the conflicts can freely bubble up. Second, control the temperature to ensure that the conflict doesn’t boil over-and burn you in the process.
The vessel in which a conflict is simmered- in which clashing points of view mix, lose some of their sharpness, and ideally blend into consensus- will look and feel quite different in different contexts. It may be a protected physical space, perhaps an off-site location where an outside facilitator helps a group work through its differences. It may be a clear set of rules and processes that give minority voices confidence that they will be heard without having to disrupt the proceedings to gain attention. It may be the shared language and history of an organization that binds people together through trying times. Whatever its form, it is a place or a means to contain the roiling forces unleashed by the threat of major change.
But a vessel can withstand only so much strain before it blows. A huge challenge you face as a leader is keeping your employees’ stress at a productive level. The success of the change effort-as well as your own authority and even survival- requires you to monitor your organization’s tolerance for heat and then regulate the temperature accordingly.
You first need to raise the heat enough that people sit up, pay attention, and deal with the real threats and challenges facing them. After all, without some distress, there’s no incentive to change. You can constructively raise the temperature by focusing people’s attention on the hard issues, by forcing them to take responsibility for tackling and solving those issues, and by bringing conflicts occurring behind closed doors out into the open.
But you have to lower the temperature when necessary to reduce what can be counterproductive turmoil. You can turn down the heat by slowing the pace of change or by tackling some relatively straightforward technical aspect of the problem, thereby reducing people’s anxiety levels and allowing them to get warmed up for bigger challenges. You can provide structure to the problem-solving process, creating work groups with specific assignments, setting time parameters, establishing rules for decision making, and outlining reporting relationships. You can use humor or find an excuse for a break or a party to temporarily ease tensions. You can speak to people’s fears and, more critically, to their hopes for a more promising future. By showing people how the future might look, you come to embody hope rather than fear, and you reduce the likelihood of becoming a lightning rod for the conflict.
The aim of both these tactics is to keep the heat high enough to motivate people but low enough to prevent a disastrous explosion-what we call a “productive range of distress.” Remember, though, that most employees will reflexively want you to turn down the heat; their complaints may in fact indicate that the environment is just right for hard work to get done.
We’ve already mentioned a classic example of managing the distress of fundamental change: Franklin Roosevelt during the first few years of his presidency. When he took office in 1933, the chaos, tension, and anxiety brought on by the Depression ran extremely high. Demagogues stoked class, ethnic, and racial conflict that threatened to tear the nation apart. Individuals feared an uncertain future. So Roosevelt first did what he could to reduce the sense of disorder to a tolerable level. He took decisive and authoritative action- he pushed an extraordinary number of bills through Congress during his fabled first 100 days-and thereby gave Americans a sense of direction and safety, reassuring them that they were in capable hands. In his fireside chats, he spoke to people’s anxiety and anger and laid out a positive vision for the future that made the stress of the current crisis bearable and seem a worthwhile price to pay for progress.
But he knew the problems facing the nation couldn’t be solved from the White House. He needed to mobilize citizens and get them to dream up, try out, fight over, and ultimately own the sometimes painful solutions that would transform the country and move it forward. To do that, he needed to maintain a certain level of fermentation and distress. So, for example, he orchestrated conflicts over public priorities and programs among the large cast of creative people he brought into the government. By giving the same assignment to two different administrators and refusing to clearly define their roles, he got them to generate new and competing ideas. Roosevelt displayed both the acuity to recognize when the tension in the nation had risen too high and the emotional strength to take the heat and permit considerable anxiety to persist.
Place the work where it belongs. Because major change requires people across an entire organization to adapt, you as a leader need to resist the reflex reaction of providing people with the answers. Instead, force yourself to transfer, as Roosevelt did, much of the work and problem solving to others. If you don’t, real and sustainable change won’t occur. In addition, it’s risky on a personal level to continue to hold on to the work that should be done by others.
As a successful executive, you have gained credibility and authority by demonstrating your capacity to solve other people’s problems. This ability can be a virtue, until you find yourself faced with a situation in which you cannot deliver solutions. When this happens, all of your habits, pride, and sense of competence get thrown out of kilter because you must mobilize the work of others rather than find the way yourself. By trying to solve an adaptive challenge for people, at best you will reconfigure it as a technical problem and create some short-term relief. But the issue will not have gone away.
In the 1994 National Basketball Association Eastern Conference semifinals, the Chicago Bulls lost to the New York Knicks in the first two games of the best-of-seven series. Chicago was out to prove that it was more than just a one-man team, that it could win without Michael Jordan, who had retired at the end of the previous season.
In the third game, the score was tied at 102 with less than two seconds left. Chicago had the ball and a time-out to plan a final shot. Coach Phil Jackson called for Scottie Pippen, the Bulls’ star since Jordan had retired, to make the inbound pass to Toni Kukoc for the final shot. As play was about to resume, Jackson noticed Pippen sitting at the far end of the bench. Jackson asked him whether he was in or out. “I’m out,” said Pippen, miffed that he was not tapped to take the final shot. With only four players on the floor, Jackson quickly called another time-out and substituted an excellent passer, the reserve Pete Myers, for Pippen. Myers tossed a perfect pass to Kukoc, who spun around and sank a miraculous shot to win the game.
The Bulls made their way back to the locker room, their euphoria deflated by Pippen’s extraordinary act of insubordination. Jackson recalls that as he entered a silent room, he was uncertain about what to do. Should he punish Pippen? Make him apologize? Pretend the whole thing never happened? All eyes were on him. The coach looked around, meeting the gaze of each player, and said, “What happened has hurt us. Now you have to work this out.”
Jackson knew that if he took action to resolve the immediate crisis, he would have made Pippen’s behavior a matter between coach and player. But he understood that a deeper issue was at the heart of the incident: Who were the Chicago Bulls without Michael Jordan? It wasn’t about who was going to succeed Jordan, because no one was; it was about whether the players could jell as a team where no one person dominated and every player was willing to do whatever it took to help. The issue rested with the players, not him, and only they could resolve it. It did not matter what they decided at that moment; what mattered was that they, not Jackson, did the deciding. What followed was a discussion led by an emotional Bill Cartwright, a team veteran. According to Jackson, the conversation brought the team closer together. The Bulls took the series to a seventh game before succumbing to the Knicks.
Jackson gave the work of addressing both the Pippen and the Jordan issues back to the team for another reason: If he had taken ownership of the problem, he would have become the issue, at least for the moment. In his case, his position as coach probably wouldn’t have been threatened. But in other situations, taking responsibility for resolving a conflict within the organization poses risks. You are likely to find yourself resented by the faction that you decide against and held responsible by nearly everyone for the turmoil your decision generates. In the eyes of many, the only way to neutralize the threat is to get rid of you.

To survive, you need a sanctuary where you can reflect on the previous day’s journey, renew your emotional resources, and recalibrate your moral compass.
Despite that risk, most executives can’t resist the temptation to solve fundamental organizational problems by themselves. People expect you to get right in there and fix things, to take a stand and resolve the problem. After all, that is what top managers are paid to do. When you fulfill those expectations, people will call you admirable and courageous- even a “leader”-and that is flattering. But challenging your employees’ expectations requires greater courage and leadership.
The Dangers Within
We have described a handful of leadership tactics you can use to interact with the people around you, particularly those who might undermine your initiatives. Those tactics can help advance your initiatives and, just as important, ensure that you remain in a position where you can bring them to fruition. But from our own observations and painful personal experiences, we know that one of the surest ways for an organization to bring you down is simply to let you precipitate your own demise.
In the heat of leadership, with the adrenaline pumping, it is easy to convince yourself that you are not subject to the normal human frailties that can defeat ordinary mortals. You begin to act as if you are indestructible. But the intellectual, physical, and emotional challenges of leadership are fierce. So, in addition to getting on the balcony, you need to regularly step into the inner chamber of your being and assess the tolls those challenges are taking. If you don’t, your seemingly indestructible self can self-destruct. This, by the way, is an ideal outcome for your foes-and even friends who oppose your initiative-because no one has to feel responsible for your downfall.
Manage your hungers. We all have hungers, expressions of our normal human needs. But sometimes those hungers disrupt our capacity to act wisely or purposefully. Whether inherited or products of our upbringing, some of these hungers may be so strong that they render us constantly vulnerable. More typically, a stressful situation or setting can exaggerate a normal level of need, amplifying our desires and overwhelming our usual self-discipline. Two of the most common and dangerous hungers are the desire for control and the desire for importance.
Everyone wants to have some measure of control over his or her life. Yet some people’s need for control is disproportionately high. They might have grown up in a household that was either tightly structured or unusually chaotic; in either case, the situation drove them to become masters at taming chaos not only in their own lives but also in their organizations.
That need for control can be a source of vulnerability. Initially, of course, the ability to turn disorder into order may be seen as an attribute. In an organization facing turmoil, you may seem like a godsend if you are able (and desperately want) to step in and take charge. By lowering the distress to a tolerable level, you keep the kettle from boiling over.
But in your desire for order, you can mistake the means for the end. Rather than ensuring that the distress level in an organization remains high enough to mobilize progress on the issues, you focus on maintaining order as an end in itself. Forcing people to make the difficult trade-offs required by fundamental change threatens a return to the disorder you loathe. Your ability to bring the situation under control also suits the people in the organization, who naturally prefer calm to chaos. Unfortunately, this desire for control makes you vulnerable to, and an agent of, the organization’s wish to avoid working through contentious issues. While this may ensure your survival in the short term, ultimately you may find yourself accused, justifiably, of failing to deal with the tough challenges when there was still time to do so.
Most people also have some need to feel important and affirmed by others. The danger here is that you will let this affirmation give you an inflated view of yourself and your cause. A grandiose sense of self-importance often leads to self-deception. In particular, you tend to forget the creative role that doubt-which reveals parts of reality that you wouldn’t otherwise see- plays in getting your organization to improve. The absence of doubt leads you to see only that which confirms your own competence, which will virtually guarantee disastrous missteps.
Another harmful side effect of an inflated sense of self-importance is that you will encourage people in the organization to become dependent on you. The higher the level of distress, the greater their hopes and expectations that you will provide deliverance. This relieves them of any responsibility for moving the organization forward. But their dependence can be detrimental not only to the group but to you personally. Dependence can quickly turn to contempt as your constituents discover your human shortcomings.
Two well-known stories from the computer industry illustrate the perils of dependency-and how to avoid them. Ken Olsen, the founder of Digital Equipment Corporation, built the company into a 120,000-person operation that, at its peak, was the chief rival of IBM. A generous man, he treated his employees extraordinarily well and experimented with personnel policies designed to increase the creativity, teamwork, and satisfaction of his workforce. This, in tandem with the company’s success over the years, led the company’s top management to turn to him as the sole decision maker on all key issues. His decision to shun the personal computer market because of his belief that few people would ever want to own a PC, which seemed reasonable at the time, is generally viewed as the beginning of the end for the company. But that isn’t the point; everyone in business makes bad decisions. The point is, Olsen had fostered such an atmosphere of dependence that his decisions were rarely challenged by colleagues- at least not until it was too late.
Contrast that decision with Bill Gates’s decision some years later to keep Microsoft out of the Internet business. It didn’t take long for him to reverse his stand and launch a corporate overhaul that had Microsoft’s delivery of Internet services as its centerpiece. After watching the rapidly changing computer industry and listening carefully to colleagues, Gates changed his mind with no permanent damage to his sense of pride and an enhanced reputation due to his nimble change of course.
Anchor yourself. To survive the turbulent seas of a change initiative, you need to find ways to steady and stabilize yourself. First, you must establish a safe harbor where each day you can reflect on the previous day’s journey, repair the psychological damage you have incurred, renew your stores of emotional resources, and recalibrate your moral compass. Your haven might be a physical place, such as the kitchen table of a friend’s house, or a regular routine, such as a daily walk through the neighborhood. Whatever the sanctuary, you need to use and protect it. Unfortunately, seeking such respite is often seen as a luxury, making it one of the first things to go when life gets stressful and you become pressed for time.
Second, you need a confidant, someone you can talk to about what’s in your heart and on your mind without fear of being judged or betrayed. Once the undigested mess is on the table, you can begin to separate, with your confidant’s honest input, what is worthwhile from what is simply venting. The confidant, typically not a coworker, can also pump you up when you’re down and pull you back to earth when you start taking praise too seriously. But don’t confuse confidants with allies: Instead of supporting your current initiative, a confidant simply supports you. A common mistake is to seek a confidant among trusted allies, whose personal loyalty may evaporate when a new issue more important to them than you begins to emerge and take center stage.
Perhaps most important, you need to distinguish between your personal self, which can serve as an anchor in stormy weather, and your professional role, which never will. It is easy to mix up the two. And other people only increase the confusion: Colleagues, subordinates, and even bosses often act as if the role you play is the real you. But that is not the case, no matter how much of yourself-your passions, your values, your talents- you genuinely and laudably pour into your professional role. Ask anyone who has experienced the rude awakening that comes when they leave a position of authority and suddenly find that their phone calls aren’t returned as quickly as they used to be.
That harsh lesson holds another important truth that is easily forgotten: When people attack someone in a position of authority, more often than not they are attacking the role, not the person. Even when attacks on you are highly personal, you need to read them primarily as reactions to how you, in your role, are affecting people’s lives. Understanding the criticism for what it is prevents it from undermining your stability and sense of self-worth. And that’s important because when you feel the sting of an attack, you are likely to become defensive and lash out at your critics, which can precipitate your downfall.
We hasten to add that criticism may contain legitimate points about how you are performing your role. For example, you may have been tactless in raising an issue with your organization, or you may have turned the heat up too quickly on a change initiative. But, at its heart, the criticism is usually about the issue, not you. Through the guise of attacking you personally, people often are simply trying to neutralize the threat they perceive in your point of view. Does anyone ever attack you when you hand out big checks or deliver good news? People attack your personality, style, or judgment when they don’t like the message.
When you take “personal” attacks personally, you unwittingly conspire in one of the common ways you can be taken out of action- you make yourself the issue. Contrast the manner in which presidential candidates Gary Hart and Bill Clinton handled charges of philandering. Hart angrily counterattacked, criticizing the scruples of the reporters who had shadowed him. This defensive personal response kept the focus on his behavior. Clinton, on national television, essentially admitted he had strayed, acknowledging his piece of the mess. His strategic handling of the situation allowed him to return the campaign’s focus to policy issues. Though both attacks were extremely personal, only Clinton understood that they were basically attacks on positions he represented and the role he was seeking to play.
Do not underestimate the difficulty of distinguishing self from role and responding coolly to what feels like a personal attack-particularly when the criticism comes, as it will, from people you care about. But disciplining yourself to do so can provide you with an anchor that will keep you from running aground and give you the stability to remain calm, focused, and persistent in engaging people with the tough issues.
Why Lead?
We will have failed if this “survival manual” for avoiding the perils of leadership causes you to become cynical or callous in your leadership effort or to shun the challenges of leadership altogether. We haven’t touched on the thrill of inspiring people to come up with creative solutions that can transform an organization for the better. We hope we have shown that the essence of leadership lies in the capacity to deliver disturbing news and raise difficult questions in a way that moves people to take up the message rather than kill the messenger. But we haven’t talked about the reasons that someone might want to take these risks.
Of course, many people who strive for high-authority positions are attracted to power. But in the end, that isn’t enough to make the high stakes of the game worthwhile. We would argue that, when they look deep within themselves, people grapple with the challenges of leadership in order to make a positive difference in the lives of others.
When corporate presidents and vice presidents reach their late fifties, they often look back on careers devoted to winning in the marketplace. They may have succeeded remarkably, yet some people have difficulty making sense of their lives in light of what they have given up. For too many, their accomplishments seem empty. They question whether they should have been more aggressive in questioning corporate purposes or creating more ambitious visions for their companies.
Our underlying assumption in this article is that you can lead and stay alive -not just register a pulse, but really be alive. But the classic protective devices of a person in authority tend to insulate them from those qualities that foster an acute experience of living. Cynicism, often dressed up as realism, undermines creativity and daring. Arrogance, often posing as authoritative knowledge, snuffs out curiosity and the eagerness to question. Callousness, sometimes portrayed as the thick skin of experience, shuts out compassion for others.
The hard truth is that it is not possible to know the rewards and joys of leadership without experiencing the pain as well. But staying in the game and bearing that pain is worth it, not only for the positive changes you can make in the lives of others but also for the meaning it gives your own.
~~~~~~~~
By Ronald A. Heifetz and Marty Linsky

Ronald A. Heifetz and Marty Linsky teach leadership at the John F. Kennedy School of Government at Harvard University in Cambridge, Massachusetts. They are partners of Cambridge Leadership Associates, a firm that consults to senior executives on the practice of leadership (www.cambridge-leadership.com). They are also the coauthors of Leadership on the Line: Staying Alive Through the Dangers of Leading (Harvard Business School Press, 2002),from which this article is adapted.
Adaptive Versus Technical Change: Whose Problem Is It?
The importance-and difficulty-of distinguishing between adaptive and technical change can be illustrated with an analogy. When your car has problems, you go to a mechanic. Most of the time, the mechanic can fix the car. gut if your car troubles stem from the way a family member drives, the problems are likely to recur. Treating the problems as purely technical ones-taking the car to the mechanic time and again to get it back on the road-masks the real issues. Maybe you need to get your mother to stop drinking and driving, get your grandfather to give up his driver’s license, or get your teenager to be more cautious. Whatever the underlying problems, the mechanic can’t solve them. Instead, changes in the family need to occur, and that won’t be easy. People will resist the moves, even denying that such problems exist. That’s because even those not directly affected by an adaptive change typically experience discomfort when someone upsets a group’s or an organization’s equilibrium.
Such resistance to adaptive change certainly happens in business. Indeed, it’s the classic error: Companies treat adaptive challenges as if they were technical problems. For example, executives attempt to improve the bottom line by cutting costs across the board. Not only does this avoid the need to make tough choices about which areas should be trimmed, it also masks the fact that the company’s real challenge lies in redesigning its strategy.
Treating adaptive challenges as technical ones permits executives to do what they have excelled at throughout their careers: solve other people’s problems. And it allows others in the organization to enjoy the primordial peace of mind that comes from knowing that their commanding officer has a plan to maintain order and stability. After all, the executive doesn’t have to instigate-and the people don’t have to undergo-uncomfortable change. Most people would agree that, despite the selective pain of a cost-cutting exercise, it is less traumatic than reinventing a company.
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What Does SocialJustice Require For The Public’s Health? Public Health Ethics And Policy Imperatives
Social justice demands more than fair distribution of resources in extreme public health emergencies.
by Lawrence 0. Gostin and Madison Powers
ABSTRACT: Justice is so central to the mission of public health that it has been described as the field’s core value. This account of justice stresses the fair disbursement of common advantages and the sharing of common burdens. It captures the twin moral impulses that animate public health: to advance human well-being by improving health and to do so particularly by focusing on the needs of the most disadvantaged. This Commentary explores how social justice sheds light on major ongoing controversies in the field, and it provides examples of the kinds of policies that public health agencies, guided by a robust conception of justice, would adopt. [Health Affairs 25, no. 4 (2006): 1053-1060; 10.1377/hlthaff .25.4.1053]
Justice is viewed as so central to the mission of public health that it
has been described as the field’s core value: “The historic dream of public health…is a dream of social justice,”‘ This Commentary addresses a single question of extraordinary social and political importance: What does social justice re- quire for the public’s health? Our thesis is that justice can be an important organizing principle for public health.

Justice alone cannot determine the “correct” policy or supply an answer to every question regarding the broad direction for public health; neither can any other single organizing principle. However, there are certain core commitments that all who embrace even a modest conception of social justice recognize as important, and those commitments can shed light on the major ongoing controversies in the field: the legitimate scope of public health, the balance between public health and
Larry Gostin (gostin@law.georgetown.edu) is associate dean and aprofessor at the Georgetown University Law Center in Washington, D.C; director ofthe university’s Centerfor Law and the Public’s Health; and a professor at thefohns Hopkins Bloomberg School of Public Health in Baltimore, Maryland. Madison Powers is director and senior research scholar at the Kennedy Institute of Ethics, Georgetown University, and an associate professor in its Department of-philosophy.
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civil liberties, and the appropriate roles of the federal government and the states. More importantly, this paper shows how public health based on social justice gives rise to important policy imperatives such as improving the public health sys- tem, reducing socioeconomic disparities, addressing health determinants, and planning for health emergencies with an eye on the needs of the most vulnerable. Before examining the major controversies and making policy recommendations, we provide our particular account of justice in public health.
What is ‘Justice,’ And How important is it in Public Health?
Among the most basic and commonly understood meanings of justice is fairness or reasonableness, especially in the way people are treated or decisions are made.-^ Our account of justice stresses the fair disbursement of common advantages and the sharing of common burdens. It captures the twin moral impulses that animate public health: to advance human well-being by improving health and to do so by focusing on the needs of the most disadvantaged. An integral part of bringing good health to all is the task of identifying and ameliorating patterns of systematic dis- advantage that undermine the well-being of people whose prospects for good health are so limited that their life choices are not even remotely like those of others.’ These two aspects of justice—health improvement for the population and fair treatment of the disadvantaged—create a richer understanding of public health.
A core insight of social justice is that there are multiple causal pathways to numerous dimensions of disadvantage. These include poverty, substandard housing, poor education, unhygienic and polluted environments, and social disintegration. These and many other causal agents lead to systematic disadvantage not only in health, but also in nearly every aspect of social, economic, and political life. In- equalities beget other inequalities, and existing inequalities compound, sustain, and reproduce a multitude of deprivations.”*
Our account of social justice is interventionist, not passive or market-driven, vigorously addressing the determinants of health throughout the lifespan. It recognizes that there are multiple causes of ill and good health, that policies and practices affecting health also affect other valued dimensions of life, and that health is intimately connected to many of the important goods in life. Empirical inquiries, therefore, are critical to justice in public health. Data can help determine who are most vulnerable and at greatest risk, how best to reduce the risk or ameliorate the harm, and how to fairly distribute services and benefits.
The Justice Perspective in Public Health
The field of public health is in the midst of a crisis of public confidence. American culture openly tolerates the expression and enjoyment of wealth and privilege and is inclined to view health as a matter of personal responsibility. Meanwhile, the public has become skeptical of government’s ability to ameliorate the harshest consequences of socioeconomic disparities. At its deepest level, some believe that
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government’s purpose should not be to redress economic and social disadvantage, and this may be doubly so for administrative agencies dedicated to public health and the pursuit of science. We believe that it is time to rethink this view, and the justice perspective offers an alternative. Values of socioeconomic fairness are just as important to health as the prevailing values of personal license and free enterprise. The justice perspective offers a different way of seeing problems that have long plagued the field of public health.
• Legitimate scope of the public health enterprise. Perhaps the deepest, most persistent critique of public health is that the field has strayed beyond its natural boundaries. Instead of focusing solely on narrow interventions for discrete injuries and diseases, the field has turned its attention to broader health determinants. It is when public health strays into the social/political sphere in matters of war, violence, poverty, and racism that critics become most upset.
The justice perspective does not provide a definitive defense against claims of overreaching. But social justice does provide a counterweight to the prevailing political view of health as primarily a private matter. The justice perspective shows why health is a matter of public concern, with the state having a role not only in the traditional areas of infectious diseases and sanitation, but also in emerging areas such as chronic diseases caused by diet, lifestyle, and the environment. Public health agencies have an obligation to address the root causes of ill health, even while they recognize that socioeconomic determinants have many causes, and solutions, that are beyond public health’s exclusive expertise.
• Balancing Individual and collective interests. The exercise of the state’s coercive power has been highly contentious throughout U.S. history. When public health officials act, they face troubling conflicts between the collective benefits of population health on the one hand, and personal and economic interests on the other. Public health powers encroach on fundamental civil liberties such as privacy, bodily integrity, and freedom of movement and association. Sanitary regulations similarly intrude on economic liberties such as freedom of contract, pursuit of professional status, and use of personal property. Justice demands that government take actions to safeguard the public’s health, but that it do so with respect for individuals and sensitivity to the needs of the underprivileged.
In the realm of public health and civil liberties, then, both sides claim the mantle of justice. Finding an appropriate balance is not easy and is fraught with controversy. What is most important to justice is abiding by the rule of law, which re- quires modern public health statutes that designate clear authority to act and provide fair processes. Policymakers, therefore, should modernize antiquated public health laws to provide adequate power to reduce major risks to the population but ensure that government power is exercised proportionately and fairly.^ Fairness requires just distributions of burdens and benefits to all, but also procedural due process for people subjected to compulsory interventions.
Certainly, the justice perspective cannot answer many of the most perplexing
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problems at the intersection of public health and civil liberties such as paternalistic interventions (for example, seat belt laws) or the exercise of powers in health emergencies (for example, avian flu or bioterrorism). These and many other problems pose major dilemmas for the field that neither considerations of justice nor traditional arguments based in beneficence can readily resolve. However, a more serious failure of public policy would be a failure to recognize and give great weight to the demands of social justice when faced with such challenges.
• National, state, and local public health functions. The arguments for and against the centralization of political power have remained largely the same over the course of U.S. history and are part of entrenched political ideologies. There is no simple resolution, and initially it might seem that the justice perspective can shed little light on this contentious area. Considerations of social justice do not side with either of the traditional combatants in the federalism debates, as they neither favor federal nor state action. What justice does do is insist that governmental action ad- dress the major causes of ill health, particularly among the disadvantaged; that commitment has major implications for political and social coordination.
The justice perspective’s emphasis on the multicausal and interactive determinants of health suggests that strategic opportunities for prevention and amelioration of ill health arise at every level of governmental interaction. The challenge of combating the threat of systematic disadvantage can be met only with a systematic response among all levels of government. The level of government best situated for dealing with public health threats depends on the evidence identifying the nature and origin of the specific threat, the resources available to each unit for addressing the problem, and the probability of strategic success.
National obligations. The national government has a duty to create the capacity to undertake essential public health services. A national commitment to capacity building is important because public needs for health and wellbeing are universal
and compelling. The federal government should recognize these needs and invest in a strong public health system. Certain problems demand national attention. A health threat, such as epidemic disease or environmental pollution, might span many states, regions, or the whole country. Further, the solution to problems such as those related to foreign or interstate commerce could be beyond the jurisdiction of individual states. Finally, states simply might lack the expertise or resources to mount an effective response in a major public health emergency.
State/local obligations. Armed with sufficient resources and tools, states and localities have an obligation to fulfill core public health functions such as diagnosing
and investigating health threats, informing and educating the public, mobilizing community partnerships, and enforcing state health laws. States and localities are closer to the people and to the problems causing ill health. Delivering public health services requires local knowledge and direct political accountability. States and localities are also often the preferable unit of government when dealing with complex, poorly understood problems. In such cases, the idea of a “laboratory of
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the states” enables local officials to seek innovative solutions.
Harmonized engagement. Because justice emphasizes the multicausal, interactive character of health threats, a system of overlapping and shared responsibility among federal, state, and local governments will most often be required. Governments at all levels have differing degrees of responsibility. This insight was illustrated poignantly during the response to the Gulf Coast hurricanes. It was not that a particular political unit should have had primacy. Rather, each should have played a unique role in a well-coordinated effort.
The Policy imperatives Of The Justice Perspective
The public health community has not been successful in gaining attention to or resources for its core mission and essential services. Outside of health emergencies, the public does not demonstrate any particular interest in public health as a priority, and this lack of interest shows in chronic underfunding. From a fiscal perspective, only a tiny fraction of health dollars goes to prevention and population-based services.* Even when attention and resources are ample, it is usually in immediate response to some actual or perceived threat. This leads not to core, stable funding and attention but, rather, to a “disease du jour” mentality. This type of response creates silos, disproportionately funds biomedical solutions, and poses a “no-win” situation for public health agencies, which must respond to the latest fashion but seldom gain the kind of ongoing political attention and economic re- sources they need to improve the public’s health.
The justice perspective offers an opportunity to change this dynamic, and the remainder of this Commentary offers concrete proposals based on the imperatives of population improvement and just distribution of benefits.
• The public health system. Justice, with its concern for human well-being, re- quires a serious commitment to the public’s health. It is for that reason that justice demands a tangible, long-term pledge to the public’s health and the needs of the least well-off. Such a commitment, as countless reports have made clear, is lacking.” Funding for prevention and population-based services is inordinately low, and categorical funding for special programs such as bioterrorism and avian flu is limited to a single issue and is time restricted.
To assure that actions can be taken to protect, promote, and provide for the health of the public, there must be a substantial and stable commitment to the public’s health at the federal, state, and local levels. Given the gravity and importance of the situation. Congress and the executive branch should create a Trust Fund for Public Health to provide generous and stable resources to rebuild the eroded public health infrastructure and implement core public health functions. Nongovernmental trust-fund approaches, implemented in other countries, should also be explored. The Public Health Leadership Initiative, established by the Trust for America’s Health (TFAH), recommends annual, sustained spending of $1.5-$2 billion increase to ensure an adequate public health infrastructure.
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• Addressing health determinants. If justice is outcome oriented, then inevitably public health must deal with the underlying causes of poor and good health. The key health determinants include the built environment (for example, transportation and buildings); the natural environment (for example, clean air and water); the in- formational environment (for example, health information and advertising restrictions); the social environment (for example, social networks and support); and the economic environment (socioeconomic status),’ These are all public health problems, but they are not solvable solely by public health agencies. Public health re- searchers and agencies can provide the intellectual tools for understanding the factual basis of the problems policymakers face. They can act directly and as conveners that mobilize and coordinate government agencies, health care institutions, businesses, the media, academia, and the community.
Obesity policy offers an apt illustration of the numerous ways that public health, together with its partners, can act on the root causes of ill health. By a combination of zoning, public construction, taxation, incentives, regulation, and health information, the state could encourage citizens to eat healthier diets and maintain more active lifestyles. This could be accomplished by changing the inner city, for example, to favor supermarkets over fast foods, recreational facilities and green spaces over roads, mass transportation over automobiles, and so forth. It could involve transformation of schools to ensure healthier snacks and lunches, physical activity, and health education. Critics complain that diet and lifestyle are personal choices outside the appropriate realm of government. However, there is nothing inherently wrong with having the state make healthier choices easier for people to make,
• Fair treatment of the disadvantaged. Fair distribution of burdens and benefits, as discussed, is a core attribute of justice. Allocations based on the market or political influence favor the rich, powerful, and socially connected. Even neutral or random allocations can be unjust because they do not benefit those with greatest need. For example, health officials who direct a population to evacuate or shelter in place should foresee that the poor will not have private transportation or the means to stock up on food or supplies. For that reason, justice requires public health officials to devise plans and programs with particular attention to the disadvantaged. Fair distributions should be integral to public health policy and practice, but they take on particular importance when planning for health emergencies or when there is extreme scarcity.
Health emergencies threaten the entire community, but the poor and disabled are at heightened risk. Social justice thus demands more than fair distribution of resources in extreme health emergencies, A failure to act expeditiously and with equal concern for all citizens, including the poor and less powerful, predictably harms the whole community by eroding public trust and undermining social cohesion. It signals to those affected and to everyone else that the basic human needs of some matter less than those of others, and it thereby fails to show the respect
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“The aims of public health deserve a great deal more societal attention and resources than the political community has allowed.”
due to all members of the community. Social justice thus encompasses not only a core commitment to a fair distribution of resources, but it also calls for policies of action that are consistent with the preservation of human dignity and the showing of equal respect for the interests of all members of the community.
• Planning for emergencies involving scarce life-saving resources. Health emergencies pose the potential for mass illness and death, often resulting in extreme scarcity of medical countermeasures, hospital beds, and other essential resources. Rarely will there be sufficient stockpiles or surge capacity to meet mass needs. For example, the U.S. influenza preparedness plan anticipates marked shortages of vaccines, antiviral medications, and medical equipment.
What does justice tell us about how to ration scarce, life-saving resources? In the context of influenza, the United States focuses on key personnel and sectors such as government, biomedical researchers, the pharmaceutical industry, health care professionals, and essential workers or first responders. These apparently neutral categories mask injustice. In each case, people gain access to life-saving technologies based on their often high-status employment. This kind of health planning leaves out, by design, those who are unemployed or in “nonessential” jobs—a proxy for the displaced and devalued members of society. Consequently, public health planning based on pure utility, although understandable, fails to have sufficient regard for the disenfranchised in society.10″
• Fair distribution from a global perspective. Perhaps the most extreme injustices arise in the global allocation of health resources. Developing countries suffer the multiple, compounding burdens of destitution (lack of medical equipment, health professionals, and hospitals), impoverished environments (drought, famine, and contaminated drinking water), and extremely poor health (tuberculosis, malaria, and HIV). They also lack a scientific infrastructure. Realistically, scarce re- sources will go to those countries where products are owned and manufactured. This reality can have devastating consequences for poor countries that cannot compete economically for expensive health resources. Social justice views all lives as having equal value, so there is a moral justification for fair allocation from a global perspective. Even from a less altruistic perspective there are reasons to invest in poor regions. Improved surveillance and response can help in early detection and containment of infectious disease outbreaks, affording universal benefits.
A Policy Landscape informed By Social Justice
What would the policy landscape look like if it were informed by a robust conception of social justice? The political community would embrace, rather than condemn, a wide scope for the public health enterprise; value the public good as
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much as personal and economic liberty; view the public good as involving a commitment to the health and equal worth of all members of the community; and view federalism as a shared responsibility for health improvement rather than an ideological battleground between national power and states rights.
Social justice would spur important policy shifts. Political leaders would create a trust fund allocating funds on a sustained basis sufficient to assure an adequate public health infrastructure; use a variety of tools (such as zoning, taxation, incentives, regulations, and information) to address the determinants of ill health, including reduction of socioeconomic disparities; devise programs and plans to as- sure the health and safety of the most vulnerable, particularly in public health emergencies; and devote substantial resources to meeting global needs for essential public health services. These measures, and many more, would not ensure equality in health but would soften some of the most egregious inequities.
The central claim of this Commentary is that a commitment to social justice lies at the heart of public health. This commitment is to the advancement of human well-being. It aims to lift up the systematically disadvantaged and in so doing further advance the common good by showing equal respect to all individuals and groups who make up the community. Justice in public health is purposeful, positivistic, and humanistic. The aims of public health deserve a great deal more societal attention and resources than the political community has allowed.
The authors thank Benjamin Berkman, Sloan Fellow at the Georgetown University Law Center, for research and editorial assistance
NOTES
1. D.E. Beauchamp, “Public Health as Social Justice,” in New Ethic for the Public’s Health, ed D.E. Beauchamp and B. Steinbock (New York Oxford University Press, 1999), 105-114.
2. J. Rawls, A Theory of justice (Cambridge: Harvard University Press, 1971).

3. M. Powers and R. Faden, Soda/Justice The Moral Foundations of Public Health and Health Policy (New York Ox- ford University Press, 2006).
4. Ibid
5. L.O. Gostin, “Public Health Law in an Age of Terrorism; Rethinking Individual Rights and Common Goods,” Health Affairs 21, no. 6 (2002): 79-9
6. K.W. Ellbert et aL, Measuring Expenditures for Essential Public Health Services (Washington: Public Health Foundation, 1996).

7. See, fore example. Institute of Medicine, The Future of the Public’s Health in the Twenty-first Century (Washington: National Academies Press, 2003).
8. Public Health Leadership Initiative, A Blueprint for Health)/People in Healthy Communities in Twenty-first Century (Washington: Trust for America’s Health, forthcoming).
9. LO. Gostin, J. I. Boufford and R. M. Martinez, “The Future of the Public’s Health: Vision, Values, and Strategies,” Health Affairs 23, no. 4 (2004): 96-107
10. L.O. Gostin, “Medical Counter measures for Pandemic Influenza: Ethics and the Law,” journal of the American
Medical Association 295, no. 5 (2006): 554-55

SAMPLE ANSWER

Social Justice in public health

Obesity has been associated with increased multiple pathophysiological disorders such as cardiovascular diseases, diabetes, and asthma. Obese children have also been found to be less successful into adults. This has spawned into a vicious cycle where poverty begets obesity; leading to increased poverty. Very few stakeholders seem to be bothered; and this gap must be filled to ensure that the timing bomb problem is circumvented before it explodes. Managing of organization conflict is one of the most social justice issues. These conflicts could be associated with institutional change resistance, and or clashing view point.  Institutional conflicts are essential stage in change process and could serve as the progress engine when handled carefully. It is important for a leader to manage the differences between workmates in a manner that it reduces all destructive forces and harness the workforce energy constructively (Heifetz & Linsky, 2002).

This is challenging especially for the leader because the conflict temperature could boil over and burn them in the process. Issues associated with cultural competences and weight issues are the most common social justice concerns in the public health sector. This is especially so with the increased wave of obesity in underprivileged communities. Self-awareness is one of the skills emphasized in this course.  Responding to interpersonal and group issues is associated such as addressing inequitable representations dynamics and developing an inclusive cultural society is also emphasized. Other skills enhanced includes skills  which will ensure effective transformation  such  critical analyzer,  and effective leadership to spearhead  implementation of  institutional norms  and policies which are all inclusive and equitable.  The most important skill gained is that of collaborating with other disciplinary to foster societal changes (Gostin &Powers, 2006).

References

Gostin, L., & Powers, M. (2006). What does social justice require for the public’s health? Public health ethics and policy imperatives. Health Affairs, 25(4), 1053-1060

Heifetz, R. A., & Linsky, M. (2002). A survival guide for leaders. Harvard Business Review, 80(6), 65-72.

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