2020-21 Ahead of the Curve Series

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0:10.6 DuBois Bowman: Good afternoon and thank you for joining us for Ahead of the Curve, a new speaker series from the University of Michigan, School of Public Health. I'm delighted that we're joined today by Dr. Joneigh Khaldun, who's the Chief Medical Executive for the State of Michigan, and Chief Deputy Director for Health in the Michigan Department of Health and Human Services or MDHHS. My name is DuBois Bowman, and I serve as Dean of the School of Public Health. This is our third event in the inaugural season of Ahead of the Curve, a new speaker series that focuses on conversations about leadership. Throughout the series, we'll have discussions with contemporary public health leaders spanning many sectors to hear about their insights, their vision and stories of perseverance. Leadership is critical for navigating complex public health challenges and for building a better future through improved health and equity.

01:06.8 Bowman: And so we wanna hear about those important factors that shape great leaders, and we wanna learn how they continue to evolve and grow even in their current leadership roles, and to do so, so that in turn, we can help to think about how to train the next generation of leaders. Public health leadership has been absolutely critical throughout the last year, as we've been living through a public health challenge of historic proportions, the COVID-19 pandemic, and as we've confronted persistent issue of racism and the intersection of these which has given rise to widespread health inequities, across the country. I'm really excited to welcome our guest today because she's been at the forefront of leading the state of Michigan through the pandemic. So Joneigh, welcome and thank you for being here.

01:55.8 Dr. Joneigh Khaldun: Oh, thank you. Thank you for having me. I'm looking forward to our conversation.

01:58.8 Bowman: Absolutely. In her role, Dr. Khaldun provides overall medical guidance for the State of Michigan as a cabinet member for the governor, and she oversees public health programs. Many of you joining us today may be familiar with Dr. Khaldun, because you've seen her during the governor's press conferences or on local news or making other public appearances. It seems as though she's been just about everywhere over the last year. And we're really looking forward to learning more about how Joneigh has been leading with science throughout the pandemic and other important leadership lessons spanning her career. So excited to dive in today. Joneigh, I'd like to begin just by really discussing your personal and career journey that has brought you to this point in your career. So you're from Ann Arbor?

02:49.8 Khaldun: Yes.

0:02:51.3 Bowman: You're an alum of the University of Michigan, and actually a graduate of our school's summer enrichment program. You've had several educational and professional stops along the way, including medical school and dual positions as a practicing physician and leading health departments, and now you're a leader at the Michigan Department of Health and Human Services. And so as you think about that long journey, what do you think about in terms of those factors that have impacted your educational and professional growth?

03:19.8 Khaldun: I think what has really motivated me in my career, I think it really goes to things that I experienced early in my life, and I'm really talking about in my own family even. I told this story before, but my grandmother, may she rest in peace, on my mother's side, she had a lot of health problems when I was growing up. I was very close to her. She lived... My parents are from Detroit, I grew up in Ann Arbor, but my parents are from Detroit. But every weekend I'd be visiting with my grandparents, but my grandmother had a lot of health problems and she also smoked and she smoked a lot. My earliest memories quite frankly, are of me trying to hide her cigarettes, and so literally I'd hide them under the couch.

04:02.9 Khaldun: For me, I was really putting together, there's a habit, there's something going on [chuckle] when it comes to cigarettes, it's making my grandma be sick. So we've gotta do this prevention, we've gotta prevent her from getting sick, and for me that meant hiding her cigarettes, which obviously didn't work. But I think when I tell that story, because I think I've always been committed to really saying that with prevention you can actually improve the health of communities. Again, parents grew up in Detroit, East side of Detroit, and all the things that come with inner city, fewer resources, many medical conditions that are preventable. I think that's something that excited me throughout my early years, and then I just continued to seek out opportunities to grow, to learn, I think I've always followed what my passion was and what I was interested in, and I've also just had a lot of just amazing coaches, mentors, throughout my entire educational and professional career, which I am incredibly grateful for.

05:06.3 Bowman: That's terrific and really fascinating how you've been able to find a career that you're passionate about, really through personal experiences in your life and your family and your community, and ultimately leading you to a way to figure out how to have the biggest impact, and you certainly have been doing that on behalf of all of us in the State of Michigan. And so if I can probe a bit further, thinking about how you approach leadership at this stage, and some of those people who you mentioned who have had a significant impact on your careers, I'm sure many who recognize they have, but maybe many others who haven't, but are there a couple of people or experiences that have really shaped how you approach leadership in your current role?

05:52.7 Khaldun: Oh, absolutely, I'll start with high school. I ran track at Pioneer High School, and my high school track coach, Mr. Bryan Westfield, who many in an Ann Arbor, I think his [chuckle] name is familiar to a lot of folks. When you ran track for Bryan Westfield, it wasn't just about track. He really cared about the entire person. He met with my parents, he cared about what I was doing in class, he knew that I was interested in medicine, he would give me opportunities to explore my options, he would be calling colleges on his lunch break trying to get me more opportunities to go to different schools. And what I really learned from him was just about being a leader, being a coach, being a mentor is just so important, and I really try to emulate that in my life. There's another individual named Richard Schnaut, who I also say is famous in the Ann Arbor community. I had the opportunity when I was in college to work at the University of Michigan Transplant Center as a perfusionist, which basically meant that I traveled around with transplant surgeons, getting organs.

07:01.6 Khaldun: And so I was very young, I didn't have much clinical experience, I was very, I think overwhelmed by the job, but Richard Schnaut took an interest in me in that he thought I had something special, I guess. [chuckle] He thought I had something special, he trained me, still the way I scrub in today in the operating room is because of the way that he taught me. He kind of pushed me and said, "Joneigh, you're gonna go to medical school. You're gonna do great things." And another thing I really learned from Richard Schnaut is I remember walking the halls of the University of Michigan hospitals and Richard would know every person in the hospital. He knew everyone, he knew how they were doing, he knew their children's names. It didn't matter if you were in environmental services or if you were the chair of a department, he knew everyone and he cared and he was quite committed to his job, but also to the people in the community. And those are two people, again going back, that I really think about when I think about my leadership style and how I really try to lead by example, care about people as I'm doing the work that I do.

08:06.3 Bowman: Thank you so much. And it's, I think, a testament to how our experiences really shape who we are and how we approach things, and those experiences are not just from your training, but so many factors, again, in your personal life. I am also from Ann Arbor and knew Mr. Westfield, the person who you mentioned first, in fact, grew up in a neighborhood that he also lived in and used to see him at the park and so much respect for him and what he accomplished over the years. If I can now dig in just to your current role, so COVID response is of course the most visible part of your job right now, but you wear many hats in your role as Chief Medical Executive for the state and Chief Deputy Director for Health for MDHHS. How would you describe all of the hats that you wear in your current position?

08:57.6 Khaldun: I do a lot of different things every day, so, yes, absolutely, I do a lot of public speaking engagements [chuckle] and press conferences, but I also work on a lot of the behind-the-scenes operational details and strategy when it comes to COVID-19. So our vaccination response, our testing response, all of the kind of details that go into the public health response. So that's COVID, but I also oversee large teams that really run everything as it relates to public health in the state, epidemiology, tobacco program. All of those things have budgets, they have staff, they have goals, they have grants that they have to administer. We're always tracking other public health threats, some that are kind of ongoing threats, like our lead program, for example. But also more broadly as the Chief Deputy for the department, our Medicaid program, so how we are working with our Medicaid health plans to be able to make sure people are getting access to care and quality care, our behavioral health system, our state hospitals, there's so much that I'm... Any given day I'm in meetings really talking about strategy, making sure the operational work is going smoothly, understanding how public health, Medicaid, behavioral health, all those systems kind of come together. That's me any given day, it's a lot of public-facing, but also internal-facing things that I'm doing.

10:24.5 Bowman: Terrific, and so that's such a big portfolio, and I'm sure would present challenges to managing in any time, but carrying such an extensive portfolio during a pandemic of historic proportions, I imagine has to be particularly challenging and you're already spread so thin on the COVID front. How do you go about setting priorities, even budgeting your time, leading your team to ensure that you're able to accomplish what you need to on behalf of the people in Michigan?

10:58.1 Khaldun: Absolutely, so I can say first and foremost, it starts with having a great team. So I mentioned all of those responsibilities, but really we have amazing senior deputies, bureau directors, other senior level career managers in the department who really make sure the minutia details are getting taken care of, and managing programs, so I'm incredibly grateful for all of them who really are the ones who are doing the day-to-day work. But you're absolutely right, with COVID-19, and I remember early on speaking to someone about COVID-19 and what it could be, even in February, I was speaking to someone about what the department could look like as far as staff, and I think at one point I said, "This entire department might be working on COVID-19 [chuckle] any week now," and sure enough, that is what's occurred.

11:50.0 Khaldun: There's been a lot of people, whoever's been able to do work and has a skill set, we've pulled them into COVID-19 often, but I also, from a leadership perspective, I can say, and people who have reported to me in the past know this, I believe in getting a strong team, getting experts around you and then letting them lead. Just because you're not at the top or you don't have a senior position, doesn't mean that you can't lead every day in your particular role. So I really believe in empowering my staff, I believe in any decision that my staff can make on their own that does not need me necessarily to approve it, I really believe in delegating and empowering staff making sure everyone's on the same page. And in my role, often just helping to think about strategy and helping to remove barriers from my team to be able to get their work done.

12:39.6 Bowman: Yeah, it's such a wonderful approach to leadership that allows growth of individuals, but also I think best outcomes because you have contributions from so many different perspectives. And now I'd like to transition and just to ask you about, you've been well known in public health for many years, but since the pandemic, you've been just extremely visible across our state, again at press conferences, on the news, on a nightly or weekly basis, on the national front, names like Fauci are now household names and your work has a national layer but certainly for us here in Michigan, you're a household name. And so I'd just like to ask you just about what that experience has been like for you and to find yourself on stage participating in these national press conferences or other kinds of events?

13:29.1 Khaldun: Yeah, so certainly when I took this job, or even I think about five years ago, when I moved back from the East Coast back home to Michigan, I knew it was to do public health work. And when I asked my husband, who's not from Michigan, here's an opportunity for me to come back home, well he... And I asked him would he come back to Michigan with me? He said, "Absolutely Joneigh, because I know this is your heart when I met you," and I met him back when I was in medical school. And he said, "When I met you," he said, "You were doing all of this work and you wanted to be a doctor, so you could go back home and help the people where you're from," and so the past five years, Detroit, as the Health Director there, and now as the Chief Medical Executive for the state, I'm doing exactly what I think I've always felt that I wanted to do and that I needed to do, and so I'm just incredibly grateful for this opportunity. And even though there's, had no idea there would be a pandemic, I do feel that the stars have aligned and I feel that it's part of my life's work.

14:27.2 Khaldun: I guess I was supposed to be here at this time, and I'm truly trying to give it my all every day. When it comes to the, I guess, the fame. [chuckle] It's taking some getting used to. I'm not really someone who's ever looking for attention really, so it's been somewhat humbling. I'm still quite frankly, trying to get used to it. I'm more than happy to be behind-the-scenes, to be honest, and I can do that too. I will say the one thing that's been the most different is just me being recognized out in public. A couple of months or a month, whatever, into the pandemic, when we'd been doing those, I think at one point daily press conferences or at least three times a week, people really started noticing me, and I have a signature hairstyle, [chuckle] so going to the grocery store, going anywhere just became a thing where people would recognize me, and it has impacted my personal life, not that I go to many places because of the pandemic, but I'm very aware of people recognizing me. Sometimes when I go out, I might have a disguise on, I'll just say that. [laughter] So that people don't notice me and I can just get my groceries and go back home.

15:40.5 Bowman: If I can ask you just to elaborate on the professional aspect of that as you are making remarks. You know every word is going to be heavily scrutinized, and that there may be something in your words that people find encouragement in and something else in your words that someone may take issue with for various reasons. So from a communication perspective, just over the last year any lessons or strategies that you might offer on just generally how to approach that kind of thing for the audience?

16:13.9 Khaldun: Especially as the Director of the Detroit Health Department I've done some press conferences and interacted with the media, but certainly not at this level where you're on TV multiple times a week, or interacting with media, radio, written media multiple times a day. I think I have learned, hopefully, maybe people who were judging me can say I've gotten better [chuckle] over the past year. But I think I have learned, I've watched, I'll be honest with you, I've watched the governor, she's a great role model. In the beginning, I didn't even know how to put my own microphone on for the various [chuckle] events so I had to ask her, but I've learned, I think I've gotten more comfortable with the camera. But I also think part of public health leadership is really communication, and as people are going through their training and understanding and growing into leadership roles, even if they're already in the public health department, I think public health communication is just a really critical skill.

17:12.9 Khaldun: Whether you're communicating with your boss, when I'm communicating with the governor, whether I'm communicating with the media or the general public, it's just really an important skill to be able to communicate facts, communicate them quickly, to let people know that sometimes you don't know everything, which is important to say as well, if you don't know something, and also trying... So what I try to do is just make things very simple, and including... I used to work in the ER, when I'm speaking to my patients, I can't give them all this medical jargon, I try to keep things very simple so people understand the issue, they understand the risk, and they understand what they can do to protect themselves. So that succinct communication, I think is also really important, and again, I hope I've improved throughout the past year.

17:56.5 Bowman: Terrific. So from an observer, you do a terrific job. I tune in [chuckle] whenever I can catch you. And certainly informative for many of us in the state. So there was so much packed into what you said, and I'll come back and maybe try to flesh out some of your remarks a bit more, but now I'm transitioning. You mentioned your role as an ER doctor, you bring perspectives from both public health and as a medical doctor, and I wonder how training in both fields have really been helpful for you in your work and even thinking about young health professionals, what would you say to them just about approaching a career and flexibility, and maybe even how to combine interests in a way that might allow you to have an impact that aligns with your passion.

18:51.5 Khaldun: Yeah, I think, of course, I've got a resume and I've got different jobs, but this wasn't necessarily intentional. I had no idea what a Chief Medical Executive was, even when I moved back home to Michigan, quite frankly, didn't know what the job was or what it did, but I can say, again going back to when I was a young girl, when I decided to become a doctor, I did all kinds of volunteer work in medical school, I was always doing something in the community related to community health, and I think I also noticed pretty quickly in medical school that there's only so much you can do in your individual one-on-one interactions with a patient, and I really saw kinda these systemic changes. Someone having a stroke because they ran out of their medication and they couldn't get to it or they're homeless, all of those kind of things that are really societal issues. We talk about social determinants of health, right? So those things are... They happen outside the walls of a hospital, and I think one thing I've always tried to do is seek places and seek to be engaged in places where I thought I could have an impact and where...

19:58.5 Khaldun: That's the problem. If you fix that problem, that's where you'll be able to have an impact. So I like fixing problems really, really upstream, but I also like fixing problems in the ER where you have that, I don't know, sometimes, if you can, kind of instant gratification, intubating someone, sewing up a laceration, kind of instant ratification things. So I think I just like helping people heal, whether that's individually as my patient or whether it's fixing the entire system. I would encourage people in their professional endeavors to think about not the job title that you want, but the type of work and the type of legacy and the type of impact that you want to have and get engaged in those things immediately. It may be volunteering, I did a lot of volunteering early on. I would just show up and I would be like the only doctor in the room. I was working with a lot of public health folks, and just, and said, "I'm interested in this too." So I think it's just keeping an open mind and not focusing so much on a degree or a title, but the actual work.

21:02.8 Bowman: Absolutely, and those experiences actually helping you to refine what you ultimately wanna do, so I appreciate that really sage guidance, particularly again, for our young public health professionals. Thinking now about the broader landscape of public health, the pandemic has prompted a focus on the field, and it's drawn attention to the state of public health infrastructure in the US, which I would submit was not as strong and sound as we would want it at the outset to be able to face a pandemic. And so I wanna ask you as a public health leader, what do you think should be done to strengthen our local, state and federal public health systems?

21:45.4 Khaldun: I think overall, the United States has struggled with addressing this pandemic for many reasons, but I think the main reason is a lack of public health infrastructure and an investment in that infrastructure, disinvestment in staff, not having enough staff, even in Michigan, there are some health departments don't even have an epidemiologist. I think people now understand how important epidemiologists are, maybe they even know what that is, where they didn't a year and a half ago, but some health departments didn't even have one. Contact tracers, right? We all know what that is now, but some health departments had one for, or don't even have any, for all things infectious disease. So COVID-19, contact tracing isn't new, you do it for COVID-19, but you also do it for other infectious diseases where there might be exposures.

22:32.7 Khaldun: And so just the lack of staff, the lack of investment in IT systems, I think early on in the pandemic and people kinda got used to it, and we started building our data systems. People thought that somehow if you just push two buttons, again, this is my interpretation, I'm simplifying this, but I get the sense that people thought if you just push two buttons you would know where every case was, you would know the exact place where they got the virus, you would know what school they went to, you would know how many people associate with the outbreak, all this detailed data, we don't have that. There are still health departments that are using fax machines. Often our healthcare system, electronic health records don't connect in a robust way to our state health department data systems. We had to use SurveyMonkey to even get information from our local health departments. So those things, the lack of investment in workforce, in infrastructure, in IT, all of those things really had a significant impact in our ability to be able to respond, particularly in the very early days as quickly as we needed to, as we should have.

23:37.5 Bowman: Yeah, and so critical for prevention, containment, mitigation, to have that information and infrastructure that ultimately affect decision-making that allow you to impact and achieve the greatest protection of health of Michiganders. So I now wanna return just to... We talked a little bit just about you on the public stage and the awareness that you're on the public stage. Diving into that a little bit more, public health has been politicized during the pandemic in ways that we haven't really seen before. Public health workers at local, state, and federal levels have had incidents of mistreatment and threatening behavior just for doing their jobs and all with the intent of serving a public good. And we've seen pushback from some about adopting Public Health Guidelines. You've talked about the importance of moving beyond politics and focusing on the policies ultimately that'll help keep people safe and healthy, and so as a leader, I'd like to prompt you to learn about the strategies that you found to be effective in navigating this terrain and re-focusing the conversation on public health policy.

24:48.2 Khaldun: Absolutely, I think, and it goes back to my earlier comments, I'd say even about communication. As a medical doctor, as a public health leader, we are put into our particular positions because of the expertise that we have, and the onus is on us to be able to, one, just know the data, be on top of the data and the science, of course, but also being able to communicate that effectively to people who are not public health professionals, which is very, very important. Words like social determinants of health and mitigation strategy. A lot of people don't understand what that means. A lot of elected officials are not doctors or public health professionals, they may be lawyers, they may be business professionals, they need to understand information, they need to have it presented to them in a succinct way, in a way that helps them see pros, cons of their particular decisions. And they hire us, when we're in these public health roles, they hire us to give public health advice. I am not, and I tell my governor this, I'm not a political advisor, I'm not an economic advisor.

25:55.0 Khaldun: I do, of course, understand that public health and the economy are very intertwined, they don't oppose each other, but I come to work every day doing the best I can to understand the data, understand the science, and make sure the people that I'm working for understand that as well, as they're having to make very tough decisions. In medicine I take care of people who are in the ER perhaps because they were in some type of altercation where perhaps they have been accused of doing something bad. Someone was in an altercation, they shot somebody and somebody shot them or whatever, but when I'm taking care of someone, I don't use that lens, I use the lens of I have a human being in front of me, I have special training to be able to help this human being, and I'm gonna use my special training to make that human being be as healthy as they can. And I really bring that same approach to my role in public health as well.

26:49.5 Bowman: And kind of thinking about your role being grounded in the science, does that help at all to sort of buffer, again, from some of the criticism that comes in living in a divided society, or even outside of the divided society, issues and decisions that people will have different perspectives or opinions about? I'm just wondering if that has allowed you to maintain some conviction in your guidance and to be firm in what you're suggesting?

27:18.5 Khaldun: I think so, some people may disagree, but I don't engage in the political. I know people, I'm obviously an appointee of the governor who is Democratic, but the things that I am recommending and talking about data and science and public health policies, these are for public health regardless of your political affiliation. Obviously, unfortunately, COVID-19 has become very political. Basic things like wearing a mask, even getting a vaccine now. There's some data that shows that maybe there's Republicans who are more likely to not wanna get a vaccine. I think it's unfortunate that basic just us helping each other and helping to get through this pandemic as quickly as possible has become political, but I think I continue to make sure my main goal as the Chief Medical Executive particularly, is to provide guidance to the governor on medical and public health matters, and that is what I stick to every day.

28:13.6 Bowman: Terrific, and some of your earlier remarks relate to something that I've read from you, that you turned multilingualism, and as I think about your work, and part of the challenge is you have to be so effective at working with people from different backgrounds and disciplines, and even spanning to communication effectively with the public in communities. Can you talk about multilingualism and even define it and tell me why it's important for the work that you do?

28:48.2 Khaldun: Sure, yeah. So I wrote about this in an article earlier in the pandemic, this kind of professional multilingualism, and I think it's something that I've certainly learned throughout my career, whereas if you're talking to a physician, for example, you may use all kinds of medical jargon terms, and that's okay, we know what that means, but, and this is what teach my medical students and residents, when you're writing discharge instructions for a patient, don't throw your medical jargon in there. Say things like you came in for stomach pain, say arm, say very basic things that the general public who does not perhaps have medical training would understand. So I think it's the same thing when you are a public health leader, making sure you are saying things in very simple ways where people can understand the issues.

29:40.9 Khaldun: In the very beginning I was giving trainings on, again, what contact tracing means, speaking about things like social determinants of health, people don't understand that term often, and often policy makers who are in control of where dollars go, don't understand what social determinants of health means. But they do understand, if someone's homeless, it's very difficult for them to take their medication and get a job and they may keep coming into the ER and that might increase hospital costs or health plan costs. People understand that, but they may not understand things like upstream social determinants of health. So I think really being able to pivot in whatever environment you're in and being able to almost, I feel like I'm almost translating on a daily basis between my MD, my public health role, speaking to other public health professionals, and then speaking to the general public, and then other political leaders who have to make really tough decisions. I think maybe I enjoy it a little bit, but it is really translating important information to leaders in a way that they can understand and be able to make good decisions.

30:47.8 Bowman: Absolutely, so I'm gonna pick your brain for a moment as we think about the pandemic, the journey that we've experienced and then projecting things forward. So there have been so many twists and turns in the road, if you will, as we think about the pandemic, hard for us to project at any given time what things are gonna look like six months ahead or a year ahead. We're experiencing some of those twists and turns in widespread transmission of new variants, lots of promising progress to date in terms of vaccines, despite some hiccups along the road that happened. And I'd just like to ask you, as you distill all of that, what do you think needs to happen for us to make significant progress toward ending this pandemic?

31:36.4 Khaldun: Yeah, you know, we're all tired. I even sigh a little bit, as I say that, really since January of 2020, public health professionals have been working on this response. And so what do I think we need to do as a society? I think we need to focus in on the things that we know work. Masks, again, people hear this all the time, but I'll just say it again, masks, avoiding large gatherings, washing hands, social distancing, getting a vaccine. It's very simple, actually. These are just the things that we have to do to get out of this pandemic as quickly as we can. And I think it's also important for people to understand vaccines are the way to freedom, if you will. There are so many things, the CDC has come out with some, I'm sure they'll come out with more, about things you can do once you get vaccinated, so gathering in your home with other fully vaccinated people without a mask, not needing to be tested before traveling across the country, not needing to quarantine if you've been exposed and don't have symptoms.

32:35.9 Khaldun: So things that you can do. And quite frankly, even for me, I'm grateful to be fully vaccinated, just traveling, going on about your life without feeling so concerned that you're gonna get COVID and potentially end up in the hospital. Even if you get COVID, if you've been vaccinated and that is a possibility still, it's highly unlikely that you'll be hospitalized or lose your life. So I think, again, it's these basic things, I think we all need to focus on in our personal lives and think about it in the sense of what we do have control over, and the things that we actually can do.

33:09.2 Bowman: Absolutely, and the importance for us to do it collectively as a society, so individual choice matters, but as we think about an infectious disease and population health, that we need to really have buy-in from all. So now I'd like to focus specifically on something that we've experienced in COVID-19, and that's the spotlight that has been shined really on the stark health inequities that we have in this country. That didn't start with COVID, but COVID has certainly shined a light on them. And we have intersecting public health crises of an infectious disease by way of the pandemic and continued manifestations of racism that foster inequity. You've been heavily engaged in furthering efforts to promote health equity in the state, and then recently were appointed, I guess earlier in the year, to a presidential, a task force, and congratulations on that.

34:04.3 Khaldun: Thank you.

34:06.7 Bowman: But I'd like to just ask you for a moment to tell us about some of that work that you've been involved in.

34:11.5 Khaldun: Absolutely. So, as you mentioned, it's really no surprise that COVID-19 has impacted communities of color in the way that it has, and if you just think very simply about COVID-19, an infectious disease, a virus that you get if you're exposed to someone else, and you think about the fact that Black and Brown people are more likely to live in poverty because of historical policies and racism and lack of resources in communities, lack of educational opportunities, more likely to live in poverty, which means when a lot of people, a year ago, were able to maybe work from home, they had paid leave, or they had their own individual car, things that really come with wealth and privilege, Black and Brown people were less likely to have that wealth and privilege, which meant that they're more likely to be exposed if you gotta take the bus, if you have to come out working when everyone else who's concerned about getting the virus can be in their home, if you have unstable housing, if you may live in multi-generational housing, all of those things contributed to COVID-19 spreading.

35:17.2 Khaldun: Initially, the CDC guidance says, "If you have COVID-19, isolate and use a separate bathroom," well, everyone doesn't have two, three, four bathrooms in their home to isolate. That is how we ended up seeing these disparities throughout the pandemic. And so one of the first things, one of the rules is, if you don't measure it, you can't identify it and then you can't implement solutions. And so I decided with my epidemiology team, when we're looking at data, and they knew this from before the pandemic, don't show me any data if you haven't looked at it by race and ethnicity the best you can. So sure enough, we were one of the first states to actually look at COVID-19 cases and deaths by race and ethnicity, and we found a stark disparity. African-Americans, 14% of the population, 40% of deaths. We looked at that data, we published it, and then working with the governor and Lieutenant governor, just amazing leaders, they went into action. So we have a race disparities task force that we formed, I'm grateful to be a part of that. And we implemented, brought together community members, which I think is really important to not sit in that bubble in a leadership position, but really engage the community.

36:23.0 Khaldun: We engaged community leaders, implemented policies, put money, resources into communities of color, whether it was mask, testing, communication efforts, so people knew the risks and what to do, and we were able to bring that disparity down. So again, I'm very grateful for the opportunity to be on President Biden's health equity task force, and we are similarly looking at those specific recommendations that if implemented could really impact, not just COVID-19, but other current and future public health challenges.

36:55.8 Bowman: On that note, great suggestions and strategies for tackling some of the inequities that we see and have seen unfolding due to COVID and to try to mitigate them, eliminate them. As we talked about that these inequities didn't arise out of the blue, they were due to existing sort of thought lines, if you will, and so at some point we'll turn the corner from COVID, but there will be future health challenges. How do we as a society and maybe the question is, are you optimistic that we can at least achieve it to actually have some structural change so that in the future as we prevent challenges, we don't see this disproportionate burden of who and how those challenges are experienced?

37:43.0 Khaldun: Absolutely, I am optimistic. I'm optimistic because, one, I think people are paying attention to it now more than they were before COVID-19, including people who are leaders and people who have power to make change, and by power I mean bringing resources, quite frankly, often dollars and changing structures and systems that really are what create these inequities. So I am optimistic. I think that it's still a challenge. These systems have been in place for... You may argue, since the United States came into being. And so what really needs to happen is that at every level of society or of an organization, there needs to be, not just training, so training is one piece, inclusive bias training, I think it's important, I support that, we're doing that at the state, we're mandating it for medical providers as far as a condition of maintaining your license.

38:45.7 Khaldun: With the training, we hope that when people are interacting with someone, for example, in a healthcare environment, they are making decisions about what medications or treatments or tests someone may get, they're seeing past the color of someone's skin or their own biases, and they're giving someone the appropriate treatment, which hopefully, collectively, if everyone does that, we'll start seeing better health outcomes. Leaders in departments who may be able to determine who gets a job or how grants are given to entities, businesses, for example. When you have people in leadership positions who are determining where money goes, how structures are set up, it takes some time, but if you can start changing that now, I'm very hopeful that as years go on, we'll be able to see some of those inequities change. I'm concerned that when COVID-19 goes away, I don't want people to forget the tragedy that we've seen play out with inequities in Black and Brown communities.

39:44.9 Bowman: Absolutely, absolutely, and I view it on the academic side as something that should be embedded in our training, and it has been, but using COVID-19 as a specific example for years to come to underscore that. So let me ask you about crisis leadership. Crisis leadership is a different breed of leadership, if you will, and as I think about it relating to your track background, it feels as though public health leaders over the last year have been running a marathon, but at a sprinter's pace. Are there strategies that you've developed or what are your thoughts about self-care, how you manage your team at moments when there are such urgencies that we have to deliver, but also thinking about overall well-being for members of your team?

40:33.5 Khaldun: Yeah, I was actually just talking to my husband about this. When I was in high school and college, I was a sprinter, long jumper, and hurdler, but I feel like I've been asked to do a marathon and then 10 minutes later start another marathon. It's kind of how I'm feeling right now. But you know, I think for my team and my gosh, I am so grateful for... I know people see me often as the public face of COVID-19 in this state, but we have so many amazing public health leaders. You don't have to be at the top to lead, we have so many amazing public health career professionals, epidemiologists, contact tracers, there's so many people in the department and outside the department as well. Of course, we've had wonderful partnerships with the University of Michigan, School of Public Health and other schools to be able to help get through this pandemic. And people are tired, but there's no question that people are tired. People are retiring, people have needed to take medical leave. As a leader, what I've tried to do is really make sure, again, COVID's been going on, COVID's gonna be here next week, it's important, and even I think some of this comes from my emergency medicine training, while this is absolutely a public health emergency, every single thing we do, every minute of every day is not necessarily an emergency.

41:56.2 Khaldun: So being able to help my team understand and prioritize work, there's so many requests that come down every day, so helping to say, Okay, let's look at your calendar, what are the things that really have to be done today versus next week? I know I asked for this, but it's probably not the thing that has to be done now, so just really being mindful of that as a leader. And also as a leader making sure people know, I don't really expect people to be working through the weekend or into the evening, unless it's absolutely necessary. I always try to cut back on meetings and the timing of meetings, sometimes I figure we still need a meeting so I have to put it back on, but I try to be mindful of that and also encouraging people to take care of themselves. If someone has a doctor's appointment or they have to do something with their child, you don't even have to tell me, I don't even need to know. I just know that you've got life, just like I have a life and I have children, and I'm trying to take care of them as well, I expect people to do that. And I also try to emulate that in my own life.

42:52.9 Bowman: Terrific, do you mind sharing with us an example of one thing you do that serves as an outlet for you?

43:00.0 Khaldun: Yes, so my bike. My husband got me a bike like a year ago, and I do frequent bike rides, and I really enjoy it. Sometimes, especially when it's a particularly stressful day, I might take a 20-minute break in-between meetings and just go on a quick bike ride and it is helpful. Also just taking time to be with my children. Two of my children have been on Zoom school the entire year, including my one that's in elementary school, and that has been a challenge, but I take time. I actually read to his class for reading month, last month, just little things that keep me rounded and dare I say, I know this does not sound like self-care, but working in the ER, actually. It's a little break for me, even as busy as the ERs have been including my shift this past weekend, it's very grounding. The ER is still home, I trained in it, all the staff... When I'm in the ER, I'm not Dr. J, I'm, "Dr. Khaldun, can you order this medication?" [laughter] And I'm just kind of focused on that patient in front of me, so it's grounding and relaxing in many ways for me.

44:12.5 Bowman: Terrific, terrific. Well, continue to exercise self-care, again, you've been delivering so much and I like your analogy of consecutive marathon, so appreciate the tips. I'd like to ask you just about tough leadership moments, and if there are any recent examples of things that you've experienced maybe during this sort of crisis period for us as a nation, as a society, but what leadership lessons have you drawn upon to get you through those tough leadership moments?

44:45.6 Khaldun: Yeah, there's been... I feel like every day is a tough leadership moment, but I think often, just when things happen and so many things seem to happen every day with this COVID response, making sure I'm present for my team, making sure when my team may be getting negative feedback, maybe there's a media story, maybe they made a mistake, I make sure that I let my team know that it's okay, they are human. I try to always bring context to the situation and kind of help ground people and say, "Okay, we have a problem. We have a problem, but here are some specific steps that we're gonna do to get through the problem. It's gonna be bumpy, but I'm here with you and this is what we're gonna do now. This is what we need to do next. And tomorrow will be a new day." To be honest with you the Johnson and Johnson vaccine pause that occurred yesterday, we didn't know that when we went to bed and in the morning we found it out. It was a little hectic yesterday, but we just said, "Okay, this is what we know, this is what we don't know, let's do some communication efforts and move on."

45:53.2 Bowman: Absolutely. Part of those challenges stem from just the evolving nature of science, and so I'd like to ask you, as you think about leadership, as you think about science, as you think about your work, how do you try to stay ahead of the curve, and in situations like the Johnson and Johnson story, it's nothing that we can fully anticipate, but being able to stay abreast and manage as promptly as possible.

46:21.8 Khaldun: Some people who are close to me know my brain just works like this. Maybe it's why I'm a good ER doctor or chose to go into emergency medicine, I think I'm probably always anticipating the worst, not assuming that it's going to happen, but anticipating it. And so I think often there are a few things that are surprises, even with the Johnson and Johnson. We know that there's a very robust monitoring process in place for these vaccines, that's why I feel so good about telling people you should get the safe and effective vaccines, robust monitoring system. We knew that there's a process in place where these types of things may happen, and so yesterday it happened, right? We didn't know what it was, we didn't know when, but it happened, and so we identified the issue, we communicated with our teams, with providers who had the vaccine, and now we're moving forward. I think it's about anticipating, it's about thinking, Okay, if this happens, what are the next one or two even steps that we need to think about? What's some worst case scenario situations where we need to just have a little bit of a back-up plan if something happens? My brain tends to think like that, but I think just anticipating a couple of steps ahead can really go a long way.

47:34.3 Bowman: Terrific. Well, we're just about out of time. So first of all, I wanna give my sincere thanks to you, Dr. Joneigh Khaldun, for taking time to be with us today and for sharing some really great insights about leadership and responding to the pandemic, and even learning more just about your personal and professional journey that I think it will inspire me and many other listeners today. Thank you again to all of you for joining us. Be well, stay safe and always go blue.

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0:00:10 DuBois Bowman: Thank you for joining us for Ahead of the Curve, a new speaker series from the University of Michigan School of Public Health. We're looking forward to welcoming a guest who is revered in his work in public health and higher education, Dr. Julio Frenk. My name is DuBois Bowman, and I'm privileged to serve as Dean of the University of Michigan School of Public Health. This is our second event for Ahead of the Curve, it's a speaker series that will focus on conversations about leadership. Leadership is a critical component of navigating complex public health challenges in building a better future through improved health and equity. For about a year, we've been living through a public health challenge of historic proportions and the COVID-19 pandemic, and we've also confronted persistent issues of racism and the intersection really of these two things as we think about the widespread health inequities across the country that we've witnessed due to COVID. As problems become increasingly complex, we must turn our attention and resources to developing leaders, building from the well-known assertion of Warren Bennis a preeminent scholar in the study of leadership, leaders are made rather than born.

0:01:33 Bowman: Regardless of one's inequalities, certainly development is a clear component of leadership. Throughout this series, we will bring contemporary leaders spanning many sectors to share their insights, their vision, and stories really about perseverance. We wanna hear about those important factors that shape great leaders and learn how leaders continue to evolve and grow so that we can help make the next generation of leaders. With that, I'm delighted to welcome Dr. Julio Frenk to Ahead of the Curve. Julio serves as President of the University of Miami and is a proud alumnus of the University of Michigan School of Public Health. Julio, welcome, and thank you for joining us.

0:02:15 Julio Frenk: Thank you very much DuBois.

0:02:18 Bowman: Today's topic is leadership to inspire global change. As we begin 2021 leadership weighs heavily on the minds of many, due in part to national politics, but as we know, leaders are all around us in our immediate environment, influences our daily lives to a high degree, and that includes life on college campus. I anticipate that in today's discussion, there will be important lessons for seasoned leaders, for new leaders, and importantly for future leaders as you reflect upon your future path and find ways to contribute now, even from where you are.

So Julio, I'd like to start by going back just to discuss and hear about your personal and professional leadership journey. And as I think about prominent leaders, the richness is often not fully captured by one's current position. I find it fascinating to hear the arc of one's career and yours has certainly been a remarkable one where you've worn many significant hats in different sectors, in different capacities. So, will you please tell us about your pathway to becoming President of the University of Miami? 

0:03:38 Frenk: Well again, thank you, DuBois. For me it’s always a pleasure to come back to my alma mater. I'm so grateful to everything I received from the University of Michigan and five glorious years, I lived in Ann Arbor, so it's an honor for me to participate in this discussion. I'll be brief and I'm grateful for the question because sometimes it's more important that your CV is your biography, it explains more about who you are and not what you are or what job you have. But I will say it in a minute. My family on my father's side were refugees. They were forced to leave their home country of Germany in the 1930s. They were escaping from the Nazi oppression, and they found a country that was much more, not from an economic and material point view, but a much richer in what matters most and that country was Mexico. My father was six years old and arrived with his parents, my grandparents, and his one sibling, my aunt. And started anew in a county that they didn't know anyone, they didn’t speak the language.

And one of the motivations of my life has been this idea of the generosity of strangers. It's easy to be generous to your family or friends, but the real test of generosity is when you're generous to strangers and Mexico was very generous to my family. They saved their lives and made my own life possible. So to me the overriding concept to me and my siblings and we were brought up with a strong sense of debt of gratitude, and that's been my driving force. How do you give back? How do you reciprocate that generosity of strangers by doing something that's meaningful for people who you may never meet, but where you have the satisfaction of knowing that you're doing something that will help them?

And I have found my vehicle through healthcare and through higher education. Those have been my two avenues to fulfill that dream. I went to medical school. I’m the fourth generation of the Frenk side of physicians. We say medicine is a genetic risk factor. So I went and followed in the footsteps of my father, who has been a great inspiration for me and his father and my great-grandfather. And then when I was in medical school, I decided that I would pursue a career in public health because I still wanted to see patients, but I want a society to be my patient, which is the way I think about public health. And fortunately for me, I found that space at Michigan. As I said I spent four years and one year as faculty, and then although I had, I think, a promising career, it could have been, I was already an assistant professor at UofM. But I was called back to Mexico by an inspirational Minister of Health who was launching a reform, and offering me the opportunity to start what eventually became the National Institute of Poverty Health. And I had the privilege of founding that organization right now, I think the leading institution in higher education and research on public health in any developing country.

0:07:01 Frenk: And then I went to the World Health Organization. I was called back to Mexico to serve as Minister of Health, Secretary of Health at the federal level and a historic moment. I served in that capacity for a full administration of six years. It was very satisfying in that public service. And then I went back to academia. Came back to the United States as Dean of the Harvard School of Public Health and from there I was offered or invited to be considered for the position of President of University of Miami. By then I was very interested in the role of higher education broadly. 

And so my life has asserted between healthcare and higher education, between life in the academy and life in the policy-making world. But the unifying theme, although it appears as a very disparate set of positions, has been this overriding idea of giving back, of serving, of recognizing that I wouldn’t have been alive have it not been for the generosity of people who didn't know me and didn't know my family, but made our lives possible. And that's what I'm trying to pay back.

0:08:15 Bowman: Thank you very much. I think a fascinating story and journey in a very inspiring one for all of us, not only the positions that you've held really what you described for most is like a number of different careers packaged into one, but also some very inspiring messages that I think all of us can borrow from and reflect on those lessons even in our own work. So given the distinct kinds of positions that you've held and the tremendous success that you've had in those positions, you are an alumnus, as you've noted from the School of Public Health at the University of Michigan, what role did your education play and preparing you for the careers and the ability to move through different types of careers?

0:09:14 Frenk: You know, the best decision I ever made was to attend the University of Michigan. I was brought there because I had read the work of Avertis Donabedian, the most outstanding figure in the field of quality care, and I was very interested in issues of healthcare and quality specifically, and I wanted to study with him. Avertis became my mentor. He taught me all the essential things I needed. Avertis was a scholar, a true call. I mean, the breath of his wisdom was amazing. So I know a lot about healthcare, but that's not what I got from my education. To have some factual and foundational knowledge is very important but Avertis taught me how to think in a rigorous, systematic way that includes both rigor in adherence to evidence, but it includes also ethical reason as a way of thinking about healthcare because healthcare is so fraught with ethical questions. And I had other outstanding professors, Rashid Bashshur who is to this day a dear friend. I met some of my long life friends, some of whom unfortunately have passed, but I'm still very close to Hillary Murt who still lives in Ann Arbor and we were classmates. And those are friendships that last for your entire life.

So that was part of my experience, but having a mentor in those formative years is absolutely crucial. And that has guided me to one of the great strengths of Michigan, which was the flexibility. I ended up doing a joint PhD, it was called then, I don't know if it's still called the individual departmental degree program in the department of what was then called Medical Organization (the successor department now is the Health Services Management and Policy) and the Department of Sociology in Literature, Science, and the Arts. And that duality was incredibly enriching. It was truly an experience that was tailored to my need, my interest, and that has allowed me to do everything I have done, including that career plasticity, I call it, where because I didn't become a narrow specialist, but rather I had this training in how to think about problems and how to address them, that I've been able to move from the world of policy to the world of academia and academic administration.

So I have many degrees. I got three degrees from Michigan: my master of public health, my master of arts, and my joint PhD between the School of Public Health and the Department of Sociology. And then I was very honored to receive an honorary doctorate. So someone told me that I had more degrees from Michigan than a thermometer. And I’m very proud of those degrees and very grateful for the superb education I received.

0:12:42 Bowman: Terrific. Again, a wonderful story. And the message really I think is more timely than ever, as I think about the world, how rapidly it changes and what our graduates will have to face throughout their careers. And pulling from a phrase that I've heard you use before, this idea of career plasticity, which is so important as we think about preparing the next generation of leaders. So I'd like to transition into a set of questions that really focus on your position in higher ed, but really it's your unique position in higher ed as someone with the public health background. And so you lead an institution during a time of intersecting public health crises of racism and COVID-19 and with your background as a public health professional and also a physician, how has your public health training informed your leadership over the last year at the University of Miami?

0:13:53 Frenk: Well, you know, if there was the time to have the training I’ve had, that's been it. My education at Michigan has helped me not only during the pandemic, because of that issue of career plasticity, and I do think for the students who are watching us, I think my career path was a bit exceptional when I went through that, but I think it's the dominant pattern today. No longer do we have fixed lanes in our career path. I think we need to have that flexibility, that creativity to seek opportunities and take advantage of them. And I think career plasticity is going to be the dominant feature as our graduates are facing the most dynamic labor marketing history and that kind of critical thinking, ethical reasoning, ability to communicate persuasively, teamwork, and it was those themes that actually attracted me a lot to become a university president. I think we're at the threshold of an educational revolution, and already the education I received in the 1980s at the University of Michigan really was ahead of its time because it prepared me exactly for the type of reality, Back then, may be my experience was exceptional, but today, I think it's going to be more of the career path of current graduates, graduating into this very dynamic labor market where conditions are changing all the time because of automation and artificial intelligence.

0:15:30 Frenk: So it's helped me a lot even before, but this year because of the pandemic it’s been absolutely crucial. My public health training of thinking about populations, of thinking dynamically, understanding the fundamentals of epidemiology has just been very, very, very important. And I would highlight, when we were trying to decide to have in person instruction or continue online, I did a very rigorous comparative risk analysis. I tried to compare the risks to our students of either having classes on campus or not allowing them, and it was my ability to look at data, to understand patterns, to know that whatever I was looking at today in terms of number of cases was reflecting patterns and decisions that had been made two weeks before, that I needed to understand what had happened before to understand where we were and to project where we're going, and public health gives you exactly that way of thinking. It’s thinking in a dynamic way so that you understand that your current circumstances are determined by events in the past and will shape what comes ahead. So it allows you to do this sort of prospective planning and that has been the key. I believe in public health. I decided that there was a risk in re-opening for sure, but that if we follow the science, we could do so safely.

0:16:59 Frenk: So we invested a lot of money in reconfiguring spaces and changing filtration systems. We produced very rigorous protocols of mandatory use of face coverings, regular testing, and contact tracing. Applying everything we know. And we were able actually to have a very successful, most in-person, we gave a choice to students or students didn’t have a choice because they had an underlying medical condition or there were international students who just could get to the United States, but for about 75% of the students who did show up, we were able to have a healthy, secure, successful semester, with cases but with a very robust system for testing and tracing. And it just reaffirmed that science does work, public health does work when you adhere to that and you avoid the politicization of some of the measures, which has been one of the sad parts of the way the larger society has handled it. But we managed to do that.

And then as you say, it's been a unique year because it's been that public health crisis, but that has triggered an economic crisis and it has also brought to light a social crisis stemming from deep inequalities and racial injustice. So handling all of that has required a lot of very focused leadership and certainly my experience at Michigan has helped me enormously to do so.

0:18:32 DuBois: Terrific. Thank you so much for that. And I'd like to ask, maybe for you to expand a little bit. You alluded to it really in your comments, and you talked about your public health approach as a university leader to think about concrete and safe plans for reopening. But of course, as university presidents or other administrators across the country face this challenge, it's really not a challenge in isolation, it's really the balancing of safety on the one hand, but then really the precious part of our mission in terms of fulfillment of education. And so I'm wondering for you how you thought about the coupling of those two things as you approached the last fall semester and now moving into the spring semester at University of Miami.

0:19:31 Frenk: No, that is exactly right. One of the attributes of leadership, I think, is to try to strike the adequate balances, understand that there are no perfect solutions when you're dealing with a complex situation, and that it's never an all or nothing situation. For example, a lot of the discussion as we were considering our plans for the fall, having like every university we pivoted in the Spring of 2020 at the beginning of the pandemic where there was so much we didn't know, we did what every university did. We pivoted quickly to finish the Spring of 2020, the early months of 2020, fully online. But then came the dilemma, what to do after the summer. And the idea was exactly to balance the richness of an in-person instruction with the risks. But a lot of the discussion seemed to suggest that all the risk was concentrated on opening up for welcoming students back on campus, as if letting students stay at home, not allowing them on campus, was a risk-free alternative. And I spent countless hours, literally of the day and the night thinking about this, and I concluded that there was also a risk in not welcoming students back. As it turns out, our students, like many students, here I’m talking about mostly our undergraduates and I appreciate that the School of Public Health is mostly a graduate school, but for the younger students on our campus, it’s a moment they've been waiting, it's a moment when they leave their parents home. So a lot of the students have literally moved to Miami and they had rented apartments literally across the street. And so as I thought this carefully, I realized what we were trying to avoid where the more of the social interactions where there was risk and exposure to the virus, but keeping the students outside, although it was an easier solution for us, didn’t mean that they would be risk-free. And in the end I concluded in that balance of risks, that offering the opportunity with very careful protocols, where a quarter to a third of our students were not going to be on campus, so we were able to de-densify, where we were going to introduce rigorous testing, we also started like Michigan, a program of Public Health Ambassadors, peer students who were trained to respectfully but firmly provide positive peer pressure to other students so that they comply with what we were doing, and then millions of dollars invested in rearranging spaces and filtering. We also, like Michigan which has a superb program in music, we have a school of music. That's a high risk, especially wind instruments. Well, we changed all the air handling systems.

0:22:52 Frenk: And the idea was, if you do this the right way, and it is a message for the larger society. The problem is we've been in a full dilemma between protecting people's health or reactivating the economy. Those two objectives go in synergy. You have to think about them, and if you do the things the right way, you can re-open safely. The problem is we open too soon and too carelessly without instituting the necessary protocols. Where I felt that in a more controlled environment we could do that, not carelessly, but carefully, very carefully and very cautiously. And we were able to do it. We did have cases, of course, we knew we would have cases, but we were never overwhelmed. And we had zero cases, we couldn’t document a single case of classroom transmissions. All transmission happened in the dorms, most infections occurring outside of campus, and the vast majority of students actually complied. By that, I mean literally 98%. Now, with that 2% with a virus that's highly contagious, is very dangerous. But the other thing I thought about the last thing I'll tell you is, if we had just decided to keep our doors closed, which probably would have been an easier solution, first of all, I wasn’t denying my belief in science and in public health. Because I had to say, “Well, if I believe in public health, we apply the science, we've gotta be able to do this safely”, but most importantly I thought that giving up sent a terrible message. And the message was that we couldn't trust students in that generation, students 18 to 24 years. If you think historically, that's the age group of students that have fought almost all wars, that have been the leaders of social movements, activists who risked their lives for civil rights, for equality, for many other causes, and we're saying that we can’t trust young people to sacrifice the social aspect of their education, which is the sacrifice because it's an important part of college experience, but we're asking them to sacrifice for a higher objective, which is the rest of the educational experience. And saying that we cannot trust would have meant giving up on your people, and I thought that was just not right.

So we trusted, we tried to inspire students to do the right thing, we used positive peer pressure, and for the minority that did not follow the rules, we did institute sanctions including expulsion or losing the right to be on campus if you couldn't live up to the trust that was deposited in you. But by and large it was a good experience and was driven by all of those considerations. All of that, driven by a public health mindset, I would say.

0:25:51 Bowman: Yeah, and the University of Miami is certainly very fortunate to have your leadership, with your public health background, your medical background, and commitment to education. Expanding, one of the things that has played out even more broadly in society during the COVID pandemic is this tension between individual interests or even liberties and contributions to the collective good. And drawing parallels in higher education and other sectors, the most effective leaders are ones who are able to motivate and inspire individuals toward a shared vision or goal, and I'm wondering if you can share with us at any point in your career, whether related to COVID or not, an example where it was important to align people and comment maybe on the strategies that you used to do it.

0:26:48 Frenk: Absolutely. I mean, in every position I’ve had, articulating not the what but the why, why are we doing this, is a fundamental element of the communication that has to proceed any proposal for action. And that requires identifying a goal that's worth pursuing, and almost all goals that are worth pursuing involve other people. It's very hard, unless you're an incredibly self-centred person, just to think about your own goals. Your own goals are important as well and you certainly need to take care of yourself as an individual, but it's when we as humans connect to something that transcends us, that we really fulfill our sense of mission and a sense of legacy of leaving something behind, because we're all here for just a limited period of time. And to me, the idea of legacy is the cornerstone of leadership. It's thinking rigorously, what do I want to live behind when I am gone? And being gone means, you can be gone from a job, we have terms. I had six years to be Secretary of Health in Mexico. I started thinking on day one, how am I going to make sure that if I survive the six years (with politics you never have that guaranteed, but I did last the six years) how do I assure that I leave things behind better than the way I received them? And being purposeful and understanding that legacy is fundamental and we always build those legacies with others. So to me, that's a central attribute of leadership and being able to communicate persuasively about that is critical.

0:28:47 Frenk: Coming to the case of the pandemic, since it’s the topic the absorbs us now, one of the striking features is the huge variation in the way that countries at the same level of economic development, how widely differing the effectiveness of their responses has been. These are countries of equal level of development, it's the same virus, it's the same human species, and yet some countries have been able to control the virus very effectively, and others have had a very poor performance in dealing with the virus. And when you look at that comparison, what you find is that it's in the countries where leaders had set to unify people around managing the pandemic and have convincingly persuaded everyone that their own individual wellbeing is depending on the collective wellbeing, those are the ones that have done best. The countries where they have done the worst, far from that have politicized the response to the pandemic. And a consistent pattern around the world is that around the worst performances, you have countries led by populist leaders, and I'm not just talking about the United States, because I do not want to politicize this statement, but this is around the globe. Whether it's Russia or Turkey or Hungary or India or Mexico, my country now with a populist leader, or Brazil, it is a uniform element because part of the essential logic of populism is to divide people, to identify people that are defined as others, and then quickly blame them for whatever it's going on, include a pandemic. And part of that is translated into politicizing some public health measures. The most sad of them was the face covering and this should have never been allowed to happen if you explain that wearing a face cover certainly protects you but most importantly it protects others. And by thinking or framing that as an issue of individual freedom without understanding the element of neutrality and reciprocity that is signified by using a face cover, I think perverted the whole debate.

This is the exact same reason why we do not allow people who are intoxicated, for example, with alcohol to drive. It protects them, but it protects other people who would otherwise be innocent victims of drunk driving and we don't question that. But somehow in those countries that have not done well, we fail to put some of these public health measures in the same line. And we're paying a big price for that. I think if there's one lesson, it’s that we need to be able to persuasively connect people to something that's bigger. And then it also happens to be the best way to protect themselves, then again, that becomes a false dilemma. My own health is hugely dependent on what I do for other people's health, and nowhere is this more obvious than with infectious diseases. So if we can align enlightened self-interest with generosity and compassion, then you have a very powerful, a very powerful formula to address a crisis.

0:32:49 Bowman: Very profound statements, ones that we could probably spend substantial time digging into but thank you for sharing those remarks. Referring back to something that you alluded to earlier, illuminating health inequities will undoubtedly be a legacy of the pandemic. The pandemic has also revealed inequities in many other areas, including education, thinking about the rapid change that you mentioned back in March, the rapid pivot to remote education and the circumstances and conditions that people return to. As we start 2021, how should we focus our efforts as a field from a public health perspective, but even more broadly in thinking about higher ed, to address these inequities.

0:33:47 Frenk: Yeah. It's that confluence of the three crises and they interact. The trigger was a pandemic, but the economic crisis has not affected everyone. The iniquity starts there. Not everyone has the ability to work from home. There's people who I live literally day-by-day. Most of the essential workers, the so called essential workers, were out there risking their lives being more exposed to the virus, we’re also the poorest members, members of minorities, people who suffer racial injustice. And then on top of that, we had the events in the summer leading to a reactivation of the cry for racial justice. And it's been all of this against the backdrop of a very serious polarization...exactly what you don't need in an emergency, which is divisiveness.

So, I think universities have a huge role in continuing to address this confluence of crisis. Now, the public health crisis is the one where I think we can see an end to that because I think thanks to the brightest element of this pandemic which has been the unprecedented level of cooperation among scientists to produce a vaccine in record time, a safe and effective vaccine in record time, that has to stand as an incredible achievement. We now need to match our distribution and logistics to the scientific feat of developing a vaccine, but we can see now there is light at the end of the tunnel of the pandemic, but we're still in the middle of that tunnel.

0:35:32 Frenk: And we're still, in the middle of that tunnel, there's the other crisis. And we can not just come out and think that the pandemic is over and we can go back to where we were before. Because the economic and especially the social crisis are not going. They’re going to outlive the pandemic for many, many years to come. This is an opportunity, because the pandemic has brought out to light some of those fundamental inequities, to really, really commit ourselves to addressing their root classes. And that's another element of public health. We're not content with dealing with the symptoms or the manifestations of a health problem, we dig deeply into the roots, and that includes the social determinant of poor health. And among them, racial discrimination, anti-Black discrimination, in the United States and other countries is a fundamental root cause.

I strongly believe and one of my motivations to work in the university is that universities have to serve as exemplary institutions. This is a very old idea, the idea that this community of scholars and students, who are united by the thirst for knowledge and learning, can develop a set of values, adhere to those values and a set of behaviors that serves as an example for the larger society of which they're a part. And if there ever was a time to serve as exemplary institutions, it is now. We need to model for the world out there this sense of, first of all, that we value diversity. It's not tolerance, it's embrace of difference. The difference makes us stronger, that diversity is not just the right thing to pursue from an ethical point of view, which it is, it’s also the smart thing to do because different allows difference of perspectives. We need to embrace the balance of freedom of inquiry and speech and model our ability to disagree respectfully. And then show that at a time when civil interactions, civil discourse has rapidly deteriorated and we don't listen to what other people are saying, we just dismiss them ahead of time if it happens to not coincide with our views. So allowing ourselves to show and demonstrate respectful disagreement, the ability to debate ideas, use reason, we commit ourselves to truth. Understanding that the pursuit of truth is contradictory, dynamic, it's constantly changing, but we gotta say it is not okay to say whatever you want, especially in the public arena and lie, and say that's okay. It’s not okay. We do have standards to judge the truth content of a statement. We need to show that’s our core actually. We are here in the pursuit of truth. We need to show and redouble that commitment and show that it is possible. Truth may not be absolute but there are standards to judge the truth content of statements. Bring back stability, ability to interact to disagree, celebration of difference, inclusiveness, and the relentless pursuit of equality of opportunity, which is at the root of the ideals of higher dictation. If we do that, not only will we be out of the pandemic, but we will get over the economic crisis, and we may make momentous progress like what we haven't seen since the civil rights movement on addressing the racial justice crisis.

0:39:16 Bowman: Thank you very much. And I go into 2021 with a sense of optimism of the role that institutions of higher ed can play in really facilitating much of the change that you just referenced. So the last question I'd like to ask just in terms of the COVID pandemic and your role as University President, for many leaders, the pandemic has brought a relentless pace of very complex and challenging work activity, and I can only imagine how busy your schedule has been over the last several months, and I'd like to just prompt you to comment on any lessons that you've learned about the importance of self-care or care for other leaders in your organization or other members, including students at your university.

0:40:09 Frenk: Yes, it's crucial to understand that this is a marathon and not a sprint. That we need, especially when you're a leader you have a special responsibility to remain healthy because you're not healthy enough to fulfil your duties you put others at even higher risk. So it's a tough one because we're all very driven people, and we tend to work long hours. One liberation here has been the inability to travel and I'm not going back to my travel schedule from before the pandemic. That's one of the lessons. There's so much that we can do more productively using some of this technology. Some travel is essential and I do look forward to many in-person encounters once we are out of that, but that has liberated a reservoir of time that I don't know how I would have done without that. But being mindful is important. I try probably not enough as I should to take care and to be mindful about my own health, being introspective, being self-aware, understanding when you're reaching a limit and then protecting also the team. Leadership is never solitary, even though there are moments of great loneliness when you need to make a decision that's very involved and you own it. You cannot tell anyone that it's the team, that's you. It's not withstanding those elements. It is a team effort and making sure you take care of the team in the service of the larger community is absolutely critical. And so I try to take up a few moments in the day for deliberate exercise in mindfulness, in understanding my own, being aware of my own sensations, where I am, being aware of my surroundings. And trying simply to take, sometimes it's a 5-minute or a 10-minute break of focusing on the moment and trying not to be consumed by the anxiety of the uncertainty. 

Pandemics are defined by uncertainty. It’s the first time we're encountering that particular pathogen. There's a lot we don't know. You have to be very thoughtful about mastering the anxiety that unavoidably accompanies uncertainty and not let that get the best of you. And that requires a lot of focus on what you have at hand, understanding the various elements that you need to master in that moment. Even as I was saying before, you're taking into account what happened before to understand the present and you are projecting towards the future. I use models extensively. But once you understand that dynamic, part of taking care of yourself is mastering the uncertainty and being very self-aware about your own feelings and accepting your own vulnerability. We're not called to be...let me tell you this. It's related to the resistance of some political leaders, mostly these populist leaders I was talking about to wear a face covering. It’s a false idea of leaders being strong, and I see this most in men. Because the other interesting pattern is, among the best performing countries you have an over-representation of countries where the leaders are women: New Zealand, Taiwan, Germany, Denmark, Norway. You have this over-representation. And instead in the worst places, some of these populist leaders like to portray themselves as strong men, and that false idea of strength.

0:44:21 Frenk: When I wear a mask, I'm not showing weakness, I’m showing the strength of caring for others. Because a mask is not so much “I'm so strong because I'll be vulnerable and I'm not gonna get sick” it's, “I am strong to care for you, to think about you”. And re-thinking what strengths means as a leader, it's not the alpha male mindset. That's a common stereotype of leadership. It's actually your ability to think about others and care about others that actually provides you with the inner drive to then take care of yourself because there's something higher that's calling to service. So service, along with the send of legacy, is the other overriding attribute I think of a good leadership. And in my case, it comes back to the story I told at the beginning. The idea that you're giving back, that you're serving, and that actually is what builds in legacy.

0:45:23 Bowman: Excellent. You've touched on the impact of politics and the context of politics, as I think about your career, there's a clear global component. And you've held leadership positions in Mexico, the World Health Organization, different regions of the United States, how does national or regional culture, possibly politics, impact or affect how you lead or how individuals expect for you to lead?

0:45:57 Frenk: Well, there's a lot of cultural specificity. This thing about what is a strong leader, it's very cultural, and you will find other societies where it's not like that. And there is this gender consideration that I described. I do hope they're one of the big lessons of the pandemic, one of the positive outcomes of the pandemic is we put to rest forever the idea that women cannot be effective political leaders because they have been the best leaders in managing this emergency. So there's a lot of specificity. But look, I like to make a distinction between politics and politicking. Politicking is the usual almost caricature of back-stabbing and lying at convenience. To me politics, non-corrupt politics is the art and science of reaching agreement for valued and shared goals. You can articulate a goal that’s shared and valued and then you reach compromise and agreement. That is good politics, and it's unavoidable whether...I was asked to serve in the cabinet when I was minister or Secretary Health in Mexico, not because I was a politician, I did not belong then and I still don’t belong to any political party, but I was brought as an expert. What a crazy idea, right? Bring an expert to the cabinet.

0:47:33 Frenk. But the President then, President Fox had that idea that not for all positions in cabinet, but those that had a strong technical core, like health, environment, education, those secretaries, members of the cabinet, we were all people who were not appointed because we were politicians. But I always understood that this was a political job. I used to say, I am not a professional politician in a health job, I am a health professional in a political job. You need to understand that it is a political job, and it goes from government, but also you can’t be dean or a president if you don't understand the politics of universities, of faculties, of student life. But it's turning politics into that positive exercise, and again, I hope we rescue that concept of the art and science of reaching agreement through compromise, through respectful disagreement, through finding common ground, in order to pursue shared and valued goals. And if we do that the other thing we might come out of is healing the political landscape, which is so fractured and so much the opposite of what I just described. It’s much more politicking than politics. And the key here is not to confuse the ends and the means. Politics becomes corrupted when power becomes the end and service the means. If you oppose that and power, having some power, some control over resource of decision becomes the means to a higher end, which is to serve people, then politics is a dignified activity.

0:49:24 Frenk: And you need for that to have a strong sense of integrity. You don't do things that your ethical code of conduct doesn’t allow you. I, when I was in the cabinet, I walked with a letter of resignation in my pocket and the President knew it. And if he asked me to do something that I didn't believe in, I would put it out. You need to be able to do that and you need to be able to communicate that you will behave with integrity. And again integrity is core to honest politics. So yeah, I was in the political job, I'm still in a political job. But if you understand that your ultimate goal is service, serving others, and you act with integrity, then you can make that a very dignified part of your job as a leader.

0:50:14 Bowman: Excellent. I'd like to ask one final question, and this is a light question, but it'll play on actually the name of this leadership speaker series Ahead of the Curve. Is there anything that you'd wanna say to the audience about how you as a leader stay ahead of the curve?

0:50:32 Frenk: Yeah, I love this title. Because the key with this pandemic has always been to say ahead of the curve. But generally, that’s an enormously valued proposition. Look, the first thing I would say is to cultivate diversity of thought. We need to cultivate diversity in every dimension, but that includes purposely surrounding yourself with people who think differently than you, and identifying your own weaknesses and recruiting a team that complements and compensates even for some of your own weaknesses. Self-awareness and the ability to say “I don't know everything, I have my own blind spots, I need to build a team that's diverse in every dimension, racial, gender, national origin, sexual orientation, and diversity of thought”. Because as I was saying, diversity is not just the right thing to do ethically, which it is, it’s also the smart thing to do. And if you have that diversity of perspectives, you are much more likely to get ahead of the curve because whatever bias any one member of the team, including yourself has, and we all have biases, they will be neutralized by other people. Encouraging disagreement and you know, very often, people will start when we have regular, almost every day meetings to see how we're doing with managing the pandemic on campus, and very often, I see a colleague say “with all due respect” when they’re going to say something that disagrees with me, and I say “Please understand, I don't interpret disagreement a disrespect. It's good for us to disagree.” Those are elements of staying ahead of the curve. Because the curve, if you take it, it's very hard to see what's on the other side of the curve, and the way you lift yourself is when you stand on the shoulders of a large group of people who think differently and figuratively they allow you to see beyond the curve, so you can stay ahead of the curve.

So those are elements that I would bring and then integrity, rethinking what it is to be strong. So integrity, community, team-building and be driven by evidence, not by prejudice, listening to the science, and mix evidence that is science driven with experience-based intuition. Also trust your intuition when you have experience, that's another thing, and I know at some points when the evidence was not that clear, I drew into my reservoir of experience to try to say what makes sense to me. Some of the things I was saying before about the relative risk of keeping students outside or allowing them into the campus, that was more intuitive, but it was based on experience. And getting that balance, always use the evidence you have available, but also rely on your experience and not just yours, but the team. That's where the diversity of perspectives is so, so valuable. If you do that, I think you have a good chance of staying ahead of the curve.

0:53:58 Bowman: Absolutely. We're just about out of time now, but I can't think of a better way to end than on those very insightful remarks. I've certainly enjoyed a lot myself, and it's always a pleasure to have an opportunity to sit down and speak with you. And I'm sure our listeners have benefited a great deal as well. So I'd like to thank Dr. Julio Frank for giving of his time and insights into leadership and current events, and even ideas just about handling leadership through challenges and risk-taking. So thank you all again for joining us. Thank you to Dr. Frenk. Be well, stay safe, and Go Blue.