Journal of Public Health | Vol. 36, No. 4, pp. 562 –567 | doi:10.1093/pubmed/fdu003 | Advance Access Publication 12 February 2014

Perspectives Mind the public health leadership gap: the opportunities and challenges of engaging high-profile individuals in the public health agenda Darren Shickle1, Matthew Day1, Kevin Smith1, Ken Zakariasen2, Jacob Moskol3, Thomas Oliver4 1

A B S T R AC T Background Public health leadership has been criticized as being ineffective. The public health profession is relatively small. Critics have argued that there is over-emphasis on technical aspects and insufficient use of the ‘community as a source of public health actions’. Methods The paper analyses the resources, motivations and skills utilized by high-profile individuals who have made contributions to the public health agenda. The phenomenon of celebrity diplomacy is critiqued. Two exemplars are discussed: Jamie Oliver and Michael Bloomberg. The risks of involving celebrities are also considered. Results Leaders for public health demonstrate ‘a paradoxical blend of personal humility and professional will’ to make the ‘right decisions happen’. While they may have ego or self-interest, in this context, at least, they channel their ambition for the public health cause, not themselves. Conclusions Leaders from outside public health may have no understanding of what public health is nor consider their work as part of a wider public health agenda. It is important to understand why they become leaders for public health. This will inform a strategy for how others may be encouraged to collaborate for public health causes. Some key points for working with high-profile leaders for public health are identified. Keywords education, employment and skills, management and policy, public health

The need to strengthen public health leadership Public health leaders have been criticized for a lack of courage and purpose.1 Public health needs leaders who not only identify the ‘right decisions’ supported by scientific evidence, but also are effective in policy implementation to ensure that the ‘right decisions happen’. However, public health leaders are concerned about their ability to influence2 and may be illprepared for the challenges of the new era of public health:

infrastructure have been neglected, and training programmes are inadequate’.3 ( p. 2084) The public health workforce is relatively small, particularly in terms of senior leadership. The need to strengthen the public

Darren Shickle, Professor of Public Health Matthew Day, Visiting Research Fellow in Public Health Kevin Smith, Honorary Senior Lecturer in Public Health Ken Zakariasen, Professor of Leadership and Organizational Change

This lack of preparation is partly because the challenges are large and complex, the public-health workforce and

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Jacob Moskol, Assistant Director for Administration Thomas Oliver, Professor of Medicine and Public Health

# The Author 2014. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: [email protected]

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Academic Unit of Public Health, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Leeds, UK Department of Public Health Sciences, University of Alberta, 3-263 Edmonton Clinic Health Academy, Edmonton, Alberta, Canada 3 Global Health Institute, University of Wisconsin, 4256 Health Sciences Learning Center, 750 Highland Avenue, Madison, WI 53705-2221, USA 4 School of Medicine and Public Health, University of Wisconsin, 610 Walnut Street, 760-C WARF, Madison, WI 53726, USA Address correspondence to Darren Shickle, E-mail: [email protected] 2

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health workforce has been recognized in many countries, for example the UK,4 USA,5 Canada6 and Australia.7 Jim Collins identified what he termed ‘Level 5’ leaders, as being key to converting organizations in both the private8 and social sectors9 from being ‘good to great’. Thus, the key to making public health practice great rather than good may be to ensure that we have more Level 5 public health leaders. In 1988, The Institute of Medicine noted that:

While the public health profession has its own ‘superheroes’,11 they may not be able to establish great public health policy and practice on their own. It may be necessary to identify outstanding leaders in other contexts and recruit them for the public health cause, utilizing their expertise, skills, enthusiasm and innovative approaches. The goal, then, would be to develop leaders for public health along with leaders in Public Health. The rationale for recruiting outsiders is as follows. Most initiatives for disease prevention and health promotion face a combination of political indifference, outright resistance and underinvestment. In response to new evidence about the sources and complexity of public health threats, as well as their own limited influence, advocates inside public health have recognized the need to broaden their strategies and recruit new allies from other sectors. They are organizing to change policies, systems and environmental conditions that greatly influence health but are often not in the hands of public health organizations.12

Celebrity diplomacy Cooper13 described the emerging cohort of celebrities working to influence and indeed operating within public policy and political contexts as celebrity diplomats. It is however not a new phenomenon. In the early 1990s, Audrey Hepburn moved beyond the traditional role of a UNICEF ambassador of generating media coverage by visiting famine and war torn areas of the world and took her campaign to Washington, D.C. appearing in front of a committee of the United States Senate. Other celebrity diplomats have followed a similar path. Angelina Jolie started out as a Goodwill Ambassador for the United Nations High Commissioner for Refugees but recognized that ‘as much as I would love to never have to visit Washington, that’s the way to move the ball’.14

Cooper13 ascribed the following characteristics to such individuals: † Active on the world stage, emphasizing global reach in terms of problem solving; † Limited or no formal training in academia, politics, etc.; † Use colloquial or sometimes undiplomatic language; † Frame message to connect with both general public and social elite; † Utilize a wide cross section of new and media, rather than traditional diplomatic channels; † Unlike politicians, they cannot easily claim that they have a democratic mandate or speak for a defined constituency; † Balance ‘megaphone diplomacy’ with face-to-face engagement with officials and politicians at a range of levels; † Push hard against the constraints of the status quo and the usual way of doing things They blend ‘enthusiasm’ with ‘outrage’ to cajole and embarrass politicians and officials to do more. Bob Geldof (a rock musician in the late 1970s and 1980s) is probably the best exemplar of this, a maverick who in some ways was an extreme anti-diplomat, but he both embraced and was embraced by the political elite, who like to use celebrities to boost their own credibility. There is a key difference between celebrity diplomats and celebrity activists who use their public persona to attract media coverage and to add weight to a campaign. While both have an activist zeal from a particular social background or set of influences, celebrity diplomats go on to develop links with formalized institutional structures and organizations. Bono (another rock musician of the 1980s and 1990s) utilized his personality and sense of purpose but also his skill set and persistence, and established his own organization (with the support of Bill and Melinda Gates and George Soros) called DATA (Debt, AIDS, Trade, Africa) to provide a hub through which other individuals and activities could be networked. Thus celebrity diplomats recruit friends to endorse the campaign, but they can also recruit non-governmental organizations and experts to provide the evidence of the things they believe need to happen. While many celebrity diplomats come from acting and the worlds of television and film, Cooper13 identified others, usually with an entrepreneurial background: for example Richard Branson (the founder of the Virgin Group), Bill Gates (the founder of Microsoft) and George Soros (financier and investor). Cooper13 excluded celebrities who achieved elected office from his definition: for example Glenda Jackson who became a Member of the UK Parliament, Arnold Schwarzenegger who became Governor of California or Ronald Reagan who became a Governor and President of

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Effective public health action for many problems requires organizing the interest groups, not just assessing a problem and determining a line of action based on top-down authority . . . This capability requires appropriate leadership skills and techniques, as well as an attitude that the community itself is a source of public health actions’.10 ( p. 122)

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Two exemplars as leaders for public health Jamie Oliver is a British chef, restaurateur and television personality. In addition to television programmes relating to food, he has presented television series on social issues and public health. In Jamie’s School Dinners (2005) and Jamie’s Return to School Dinners (2006) Oliver took responsibility for running the kitchen meals in schools. Concerned about the unhealthy food served to schoolchildren, Oliver led a 271 677 signature petition to improve school meals. In Jamie’s Ministry of Food (2008) Oliver encouraged the inhabitants of a deprived Northern England town to learn how to cook fresh food. The Pass It On campaign taught people recipes and were encouraged to pass it on to family members and friends. In Jamie Oliver’s Food Revolution (2010 – 2011) he visited some of the unhealthiest cities in the USA to try to improve its residents’ eating habits. Oliver has received awards for his sociopolitical campaigning, including his contribution to public health, for example, from the Faculty of Public Health of the Royal Colleges of the UK, and the Harvard School of Public health. Oliver has been commended for doing ‘more for the public health of our children than a corduroy army of health promotion workers or a £100 million Saatchi and Saatchi campaign’.15 A Lancet editorial16 entitled ‘Jamie Oliver for Chief Medical Officer?’ stated that ‘it is a sad indictment of public health in the UK that it took a television programme hosted by a celebrity chef to make the government realize that radical changes are needed in the way we feed our children’. The direct outcome of Oliver’s 2005 campaign was a Government pledge to spend £280 million on school dinners in England, spread over 3 years. However, given that as of January 2012, there were around 6 million children aged 5 –14 in England, this increased spending would have limited impact on the quality of an individual school meal. The longer term and indirect impact of Oliver’s campaigns are

more difficult to assess. Food-based and nutrient-based standards for school lunches in England came into force in primary schools in 2008 and secondary schools in 2009.17 In 2013, the Government announced that free school meals would be extended to all children aged five to seven in England, irrespective of household income. Whether Oliver was a sufficient or even a necessary catalyst for these policy developments, he was an important contributory cause. More recently two less high-profile chefs, Henry Dimbleby and John Vincent, have taken up the school meal agenda via their School Food Plan.18 Jamie Oliver may have first got involved in the school dinner campaign because a television executive approached him with an idea for a new television series. However, as the Lancet editorial suggested ‘Oliver, who has been accused in the past of being an annoying publicity seeker, is not doing this for political gains. He is a rebel chef who genuinely cares about food and nutritional standards’.16 However, would Oliver have been willing to front a campaign for an alternative public health issue? Michael Bloomberg is an American businessman, politician and philanthropist. He is the founder of Bloomberg L.P., a financial data-services firm. In December 2013, he was listed by Forbes Magazine as 13th wealthiest person in the world19 and 29th most powerful person in the world (even after standing down as Mayor of New York City).20 In 2001, the Johns Hopkins School of Public Health was renamed the Johns Hopkins Bloomberg School of Public Health21 in recognition of Bloomberg’s financial support to the School and Johns Hopkins University ($107 million, of which $35 million was designated for the School of Public Health). Viewed in isolation, Bloomberg’s donation could simply be seen as a way of reducing his tax liability or promoting his alma mater. But his actions went well beyond financial support to a single institution devoted to public health. Bloomberg served three terms as Mayor of New York City between 2002 and 2013. In 2002, New York City began implementing a five component tobacco control strategy22 which included an increase in the city’s cigarette tax (from $0.08 to $1.50 per pack) and enforcing a ban to make virtually all indoor workplaces, including restaurants and bars, smoke free. In 2006, New York City became the first jurisdiction in the USA to begin phasing out artificial trans-fats in food sold in the city’s restaurants, catering businesses and by mobile vendors.23 A partnership of many city agencies, architects and academic planning experts established new Active Design Guidelines in 2010.24 In 2012 the City’s Board of Health announced a ban on the sale of sugar-sweetened beverages in containers .16 ounces in fast food restaurants and convenience stores.25 In 2013, New York City implemented a

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the USA. He also excluded diplomats and politicians who achieved celebrity status: for example, Henry Kissinger who served as Secretary of State in the Richard Nixon administration in the USA or Nelson Mandela, former president of South Africa. This paper explores the opportunities (and lesson) for public health from recruiting and working with celebrity diplomats and focuses on two exemplars. We are not suggesting that a public health professional, working for example, in a small deprived town in the North of England, needs to recruit the latest international hit pop group to front a health promotion campaign aimed at young people. However, there may be learning from the impact of a celebrity diplomat that can be applied at every level.

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controversial bike-share programme, complete with new bike lanes in many city streets.26 Bloomberg also championed initiatives globally.27 Unusually for a politician, Bloomberg also authored papers on smoking and climate change in scientific and medical journals.27 – 29 Bloomberg stressed the importance of forming alliances for common cause and mutual advantage.27 Bloomberg brought an entrepreneur’s ‘can-do’ approach to a public health challenge:

Motivations, personal humility and professional will When Bloomberg first proposed his tobacco control measures he did not do it to increase his popularity, indeed he initially suspected that it would have the opposite effect.30 Similarly, his interest in tobacco control was not narrowly focused solely on the health and economic productivity of the population of New York, as he also committed $125 million to a global initiative to reduce tobacco use. According to Collins,8 ‘Level 5’ leaders ‘build enduring greatness through a paradoxical blend of personal humility and professional will’. It may seem implausible that a billionaire businessman with the hubris to seek mayoral office exhibits ‘personal humility’. Bloomberg adopted evidence-based public health policies, using his Board of Health as the focal point. We contend that he did not make those policies an overt test of his personal charisma or political power. Furthermore, he has persisted with some of the policies in the face of substantial opposition and personal political risk (although he could always step aside and still be a billionaire). We suggest that the passion for making a difference and taking a risk by wading into unfamiliar often daunting issues reflects a form of humility. Indeed Collins himself noted that: Level 5 leaders channel their ego needs away from themselves and into the larger goal of building a great company. It’s not that Level 5 leaders have no ego or self-interest. Indeed, they are incredibly ambitious – but their ambition is first and foremost for the institution, not themselves’. 8 ( p. 21) Such leaders are incredibly successful in other walks of life. The reason their influence spills over into public health is through charismatic leadership and credibility and the links between the public health cause with their own beliefs and expertise. This is not always obvious. For example, it may be

obvious that Oliver has an interest in food, but why did Bloomberg have a passion for tobacco control and environmental issues, in a way over and above what would be expected of a politician? It is possible that through his connections with the Johns Hopkins School of Public Health and the New York Board of Health, Bloomberg became educated in the key public heath challenges and began to consider how he could use his political capital as well as his financial capital to take on those challenges.

The difference between leaders for public health and celebrity patronage It is important to emphasize that the individuals who need to be recruited as leaders for public health are different from celebrities and personalities, from film, television, sports, etc., who just give their time and/or money for a particular cause. While the celebrity may gain by increasing their positive public profile, the public are less likely to remember the actual good cause that they are supporting.31 There may be a contradiction between terms ‘celebrity’ and the quality of ‘personal humility’ referred to in Collins definition of Level 5 leader. For those celebrities who are mainly focused on building or rebuilding their careers, there may be limited value in championing a cause with a real public health value. There are exceptions to this, for example the AIDS charity benefits and galas in the 1990s, although there have been criticisms of the red ribbon campaign32 and the relative investment in HIV/AIDS research relative to other diseases.33 In comparison there has been a dearth of such events to raise awareness of chlamydia, syphilis or gonorrhoea. Bloomberg has been quoted as saying: I always thought it made more sense to prevent disease than to cure it . . . Unfortunately, a lot of us don’t focus on things like that because they don’t have a lot of sex appeal. You don’t get any points for preventing a disease or stopping its spread; you only get points when you cure it’.21 It is important to understand the motivations behind ‘celebrity’ endorsement, even in the context of public health issues. For example, Elwood was critical of Nancy Reagan’s role as spokeswoman for the ‘Just Say No’ to drugs campaign and suggested that it ‘may have been a successful public relations effort to recreate Nancy Reagan’s persona and to divert possible news media attention from her own addiction to prescription drugs’.34 Of course, even though a celebrity’s motives may not be entirely altruistic, it is important to ensure that they are the right person to lead the right campaign and arguably Nancy Reagan had limited credibility to influence the behaviour of young people from disadvantaged groups.

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Of course, the skeptics say that the problem of tobacco use is too culturally entrenched to solve. But part of taking on an entrenched problem – whether it’s in health or education or public safety – involves challenging people’s expectations of what is possible’.30

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The passion that influential individuals may have in relation to public health issues may also be misplaced and ill-informed. They may influence the debate in unintentional ways or, worse still, campaign with opponents of the policy or public health initiative. For example, in 2002, the then Mayor of London, Ken Livingstone publicly said that he would not give his child the combined measles, mumps and rubella (MMR) vaccine and also advised Londoners against MMR vaccination.35

Recruiting leaders for public health

† Have a clear written policy for involving a celebrity; † Consider aspects of the celebrity’s reputation that might harm the organization’s reputation; † Assess the appropriateness of the celebrity for the activity proposed; † Specify the desired length and depth of the relationship with the celebrity; † Fully brief the celebrity about the organization and the activity; † Clarify in writing the expectations of both the organization and the celebrity; † Assess risks associated with volunteer celebrities dropping out of events. A similar approach is needed when working with leaders for public health, although the relationship will differ from expecting a celebrity to just turn up at a particular event to

† Networking-connecting: initiating, maintaining and cultivating relationships between individuals and organizations to build influence and credibility. † Mentoring-nuturing: articulate strong sense of public healthshared values and develop talent to join and progress the public health cause. † Shaping-organizing: influencing the public health agenda through preparation, administration and delivery. † Knowing-interpreting: generating, synthesizing and communicating information to derive power and authority via interpretation for others. † Advocating-impacting: combing the powers of persuasion, political currency and the ability to take appropriate risks to make the right decisions happen. While the focus of this paper has been on recruiting wellknown individuals, public health also needs leaders from other sectors who do not have celebrity status or widespread public name recognition, but who nonetheless can be very effective because of their knowledge, skills, connections and deep commitment just as the more celebrated individuals we focused on here. Colleagues in the UK are experiencing a new dynamic as many now work within local government. As with their peers in other nations, they will want to recruit diplomats who may not meet the definition of celebrity but share much of the attributes we have described. An interested councillor, a local business woman, a notable teacher—who at the local level may be a local celebrity—may be the catalyst for partnership for public health.

Acknowledgements We are grateful to those who attended or made contributions to the project meetings.

Funding This work was supported by the Worldwide Universities Network [WUN RDF 2010].

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The challenge is to understand why Oliver, Bloomberg and others became leaders for public health, in order to inform a strategy to encourage other to join the public health cause. Such individuals may have limited understanding of what public health professionals do, nor consider that their particular area of interest is part of a wider public health agenda. They may or may not act from a conscious motivation to be leaders for public health, and indeed they may not even recognize the term ‘public health’ or consider it part of their identity. Their enthusiasm and commitment may also be finite, and the time that they would be able to commit will almost certainly be limited. However, leaders for public health do more than chair a fundraising board, are more than just a name on a letterhead or a donor on the balance sheet. You get someone who energizes individuals, organizations and governments to do great things. Identifying and recruiting more leaders for public health is therefore a particular priority for campaigns that transcend geographic or organizational boundaries and where broader action is needed. Guidance has been published on issues for fundraising organizations to consider when working with celebrities.36 For example:

convey simple media messages. Leaders for public health are likely to want to be proactive to set or influence the agenda. They are contributing their expertise rather than just their name, although their reputation will be critical in influencing policy-makers and other key stakeholders. While a charity may need a celebrity with ‘street-cred’, public health organizations require opinion formers with ‘Downing Street-cred’. The key to forming collaborations for public health is to utilize what we have described elsewhere11 as the five talents for public health leadership:

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20 Forbes. The world’s most powerful people. http://www.forbes.com/ powerful-people/list/ (4 December 2013, date last accessed). 21 Hill M. Hopkins hail top donor by renaming health school. The Baltimore Sun, 2001. http://articles.baltimoresun.com/2001-04-23/ news/0104230114_1_bloomberg-school-hopkins-public-health (4 December, 2013, date last accessed). 22 Frieden TR, Mostashari F, Kerker BD et al. Adult tobacco use levels after intensive tobacco control measures: New York City, 2002–2003. Am J Public Health 2005;95:1016–23. 23 The New York City Department of Health and Mental Hygiene Board of Health. Notice of adoption of an amendment (§81.08) to Article 81 of the New York City Health Code. Adopted 5 December 2006. http://www.nyc.gov/html/doh/downloads/pdf/ public/notice-adoption-hc-art81-08.pdf (4 December 2013, date last accessed). 24 New York City Department of Design and Construction. Active Design Guidelines: Promoting Physical Activity and Health in Design. New York: City of New York, 2010. http://centerforactivedesign. org/guidelines/ (4 December 2013, date last accessed). 25 The New York City Department of Health and Mental Hygiene Board of Health. Notice of adoption of an amendment (§81.53) to Article 81 of the New York City Health Code. Adopted 13 September 2012. http://www.nyc.gov/html/doh/downloads/pdf/ notice/2012/notice-adoption-amend-article81.pdf (4 December 2013, date last accessed). 26 New York City Department of Transport. NYC Bike Share: Designed by New Yorkers. New York: City of New York, 2013. http://www.nyc. gov/html/dot/downloads/pdf/bike-share-outreach-report.pdf (4 December 2013, date last accessed). 27 Bloomberg MR, Aggarwala RT. Think locally, act globally: how curbing global warming can improve local public health. Am J Prev Med 2008;35:414– 23. 28 Frieden TR, Bloomberg MR. How to prevent 100 million deaths from tobacco. Lancet 2007;369:1758 – 61. 29 Bloomberg MR. Forewords to climate change adaptation in New York City: building a risk management response. Ann N Y Acad Sci 2010;1196:1 – 3. 30 Bloomberg MR. The way to save millions of lives is to prevent smoking. Newsweek 3008;152:48, 50. 31 Brockington D. Charities need to rethink celebrity. Third sector, 2011. http://www.thirdsector.co.uk/news/Article/1102612/AnalysisCharities-need-rethink-celebrity/ (4 December 2013, date last accessed). 32 Moore SHE. Ribbon Culture: Charity, Compassion, and Public Awareness. Houndmills, Basingstoke: Palgrave MacMillan, 2008. 33 Brower V. The squeaky wheel gets the grease. EMBO reports 2005;6:1014 – 7. 34 Elwood WN. Rhetoric in the War on Drugs: The Triumphs and Tragedies of Public Relations. Westport, CT: Greenwood Press, 1994, p. 76. 35 Bennett C. So what did Ken really say about the MMR? The Guardian, 4 July 2002. http://www.guardian.co.uk/politics/2002/jul/04/ society.london (4 December 2013, date last accessed). 36 Hammond E. Patrons, Presidents and Personalities: Working with High-Level Volunteers. London: Directory of Social Change, 2008.

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6 The Joint Task Group on Public Health Human Resources. Building the Public Health Workforce for the 21st Century: A Pan-Canadian Framework for Public Health Human Resources Planning. Ottawa: Public Health Agency of Canada, 2005. http://publications.gc.ca/collections/ collection_2008/phac-aspc/HP5-12-2005E.pdf (4 December, 2013, date last accessed).

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Mind the public health leadership gap: the opportunities and challenges of engaging high-profile individuals in the public health agenda.

Public health leadership has been criticized as being ineffective. The public health profession is relatively small. Critics have argued that there is...
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