Barriers to Innovation and Reform: Part 2

In my last posting, I presented three barriers identified by Roberts Gates about why public institutions are failing (1). This posting looks at a fourth, and as with the first three, I relate it to my experience working in governmental public health.


My initial reaction to news about legislators reducing funding for governmental public health is to regard these individuals as dim-witted and short-sighted. But it has been nearly thirty years since the 1988 Institute of Medicine report, The Future of Public Health, called for strengthening the fiscal base of public health practice (2). Three decades should have been enough time for public health practitioners to make a convincing case to legislators about the importance of their work. Yet, public health’s allocation of the nation’s total cost for health care expenditures has dropped since 2002, and that percent is projected to fall to 2.40% over the next seven years (3). As such, we cannot rule out the conclusion that we, public health practitioners, are partly responsible for our discipline’s decline. We cannot keep laying the blame elsewhere. We’ve tried that and it has not improved our status.

One way in which practitioners aid this demise is by not insisting that public health leadership uphold the core values of their agencies. As an example, implicit within Robert Gates’ barrier to reform, bosses measure personal success by the size of their empires, is the lack of integrity and inappropriate stewardship of the public’s money on the part of empire builders and the people who tolerate them. The mismanagement of public resources reflects poorly on an agency. Therefore, it should come as no surprise when legislators, who are aware of an agency’s ongoing internal dysfunction, conclude that the money would be better spent elsewhere. This determination is all the more likely if an agency has little to show for its efforts (i.e., poor health indicator rankings).

Two of the most egregious empire builders I observed in public health shared the following traits:

Both blamed their programs’ poor performance on how much work they had to do and with so little money. They insisted on acquiring more staff, usually at the expense of other teams or programs, but their performance did not improve as their empires grew.

Both were exquisitely sensitive about their public image and, as a result, continually sought out information as to how they were being perceived. This intelligence-gathering behavior was demonstrated through actions such as: directing staff to include them on every email; inserting themselves into other teams’ or programs’ business; and schmoozing with leadership. Their activities in this regard were actually a thing of beauty to watch. These empire builders were like symphony conductors monitoring the flow of information around them, and their ever-present cell phones and iPads were their batons. I often thought that if these individuals applied just a third of the time spent maintaining their image on actual work, their programs might have performed rather well.

Both were bullies. One was a ‘bull in a china shop’ type, who shoved and cursed his way through the work day. The other employed the passive-aggressive victim role.  She was the, ‘Why are you being so mean to me?’ type. Her tears were very effective for conveying to her superiors how much others—namely, those who dared to confront her— misunderstood her.

Both had a great need for control, and one way they filled that need was by hiring people who were unlikely to challenge them. For example, one empire builder employed a preponderance of young graduates under the premise that she was giving youth a start in their careers. (Ageism, anyone?) In actuality, the benefit was that they were less likely to question her actions because of their limited professional experience.

Both hired minimally-qualified employees with whom they had personal relationships. This action might be another expression of their need for control, as mentioned above, but it also seemed as if they enjoyed demonstrating their power and beneficence. They used their governmental positions to run their own welfare programs. Rather than employ talent, who might actually accomplish the agency’s work, these empire builders hired, or arm-twisted others under their influence to hire: buddies who needed a job with health care benefits; former or soon-to-be lovers; and the adult children of close friends.

Why do empire builders persist? I see three main reasons.

  • First, they have an exceptional talent for manipulating their superiors. Empire builders are likely what Adam Grant, an organizational psychologist, calls ‘takers.’ They kiss up to their superiors and kick down subordinates. As a result, their superiors dismissed the concerns of those who question the empire builders’ motives and actions.
  • Second, these individuals have exceptional survival skills because they are extremely motivated to keep their jobs. They know they have limited competence and that it would be difficult for them to find such a sweet position elsewhere. As a result, they will put up the nastiest of fights, and take down anyone, to ensure their survival.
  • Third, empire builders thrive in dysfunctional organizations where leaders are ineffectual, distracted, or have little interest in the inner workings of their agencies. The leaders who tolerate empire builders give only a ‘wink and a nod’ to the values that they trumpet so vociferously through their cheerleading, end-of-week email addresses to agency personnel. They rarely take action about lapses in the agency’s values unless those lapses result in a headline-making scandal. Then they quickly find someone to take the fall.

Empire builders are just one example of the exploitations of power and resources I witnessed in governmental public health agencies. Knowledge of these abuses eventually gets to legislators in one form or another. If public health practitioners want to save their discipline, they need to ask themselves if they have tolerated the misdeeds that reflect so poorly on their agencies. I know from personal experience that managers and administrators are unlikely to listen to a single voice about such abuses, but they (or their political bosses) may be forced to take action if several people stand together and speak out.

Upholding our agencies’ values is not the sole solution to preventing the demise of our discipline. But doing so will likely enhance its image and may also lead to better outcomes for our work, which will make it harder for legislators to dismiss public health as a poor investment. Wouldn’t it be nice if we could prevent politicians from sounding encouraged when a local health department is dismantled (4)?  Public health practitioners need to take action soon because, given the direction of funding, it is unlikely we will be granted another thirty years to prove our discipline’s worth.

Your turn

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  1. Gates, R. A passion for leadership: lessons on change and reform from fifty years of public service. New York, NY: Alfred A. Knopf; 2016.
  2. Institute of Medicine. 1988. The future of public health. Washington, D.C.: The National Academies Press.
  3. Himmelstein D, Woolhandler S. Public health’s falling share of U.S. health spending. Am J Public Health. 2016 Jan; 106(1):56-7.
  4. Gray C. New public health network emerges as Douglas County hands off services. The Lund Report, Oct, 27, 2015. Available at: Accessed Feb. 28, 2016.

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