Teamwork in the Service of Health HUGH R

Officia Mth of PUBLIC HEALTH

Official Monthly Publication of the American Public Health Association, Inc. Volume 44 November, 1954 Number II

Teamwork in the Service of Health HUGH R. LEAVELL, M.D., Dr.P.H., F.A.P.H.A.

We all realize that an organized ap- Here is a classic summary of what proach is needed to deal effectively with we mean by public health "teamwork," and a very pertinent appli- the complex problems and the diverse cation to our own Association. population groups we meet in our daily work. We are concerned with the total community rather than placing our em- All of us have experience in team- phasis on the individual, as the private work and we know how important it is practitioner does. in getting a job done. As an introduc- We tend to stress the preventive tion to our discussion, may we consider rather than the curative aspects of total first some of the things we in public health service. At the same time we health have in common which provide recognize that it is impossible to draw the oneness of objective so essential to a sharp line dividing prevention from good teamwork. cure. Curing one phase of a disease All of us are involved in some type of may so interrupt its natural history that organized community activity. This is complications and aftereffects are pre- the essential element that differentiates vented. public health from other forms of pre- Though we come from many basic ventive medicine, according to Profes- professions, we tend to think of our- sor Winslow's world-famous definition, selves as members of the public health which I recently found to be just about profession-a sort of "E pluribus as well known in Latin America and unum"! As professional people, and be- in Asia as in North America. May I cause of our training and experience, remind you of Professor Winslow's far- we feel that we have the right and the sighted Presidential Address entitled responsibility to speak with some degree "Public Health at the Crossroads" made of authority about health matters. before this association here in Buffalo Though some of us work in voluntary in 1926. He showed then the character- istic leadership which has inspired Dr. Leavell is professor of public health practice, Harvard School of Public Health, generations of his students. The exam- Boston, Mass. ple of teamwork which he and Mrs. Presidential address to the American Public Winslow have set is one we all might Health Association at the First General Ses- sion of the Eighty-second Annual Meeting in hope to follow. Buffalo, N. Y., October 12, 1954. 1393 1394 NOVEMBER 1954 AMERICAN JOURNAL OF PUBLIC HEALTH agencies and some for government, we exist among chickens (and among our- do not divide ourselves into two groups selves) today. on this basis, even though our problems Chester Barnard,' an outstanding may differ somewhat. business leader himself, has done much We recognize the importance of the to clarify our ideas on the subject of "public" part of public health, and leadership. He has a most useful list of know from our own experience that our leadership qualities, including vitality "health" technics can be used with max- and endurance, decisiveness, persuasive- imum effect only if the public under- ness, responsibility, and intellectual stands our objectives and is sympathetic capacity, which he considers subsidiary with them. in importance to the other qualities. His One could mention many additional definition of responsibility reminds me similarities which draw us together and of the aseptic conscience one develops provide the basis for teamwork. when working in an operating room or with microorganisms. Responsibility, Psychological Basis of Teamwork he says, is "an emotional condition that gives an individual a sense of acute The word "team" in its Middle dissatisfaction because of failure to do English origin referred to "offspring, what he feels he is morally bound to do, progeny, and family," as well as to "a or because of doing what he thinks he is line of animals harnessed together." morally bound not to do, in particular Significant for our discussion are addi- concrete situations." My New England tional meanings of the word "team": "a friends would relate this pretty closely number of persons associated together with Conscience, I believe. in any work," and "a group of persons Barnard recognizes four major sec- pulling together," also "a group of work- tors of leadership behavior which I men each completing one of a set of should like to discuss briefly: operations." These meanings are in 1. The determination of objectives addition to those relating to the athletic 2. The manipulation of the technical means team. The word "team" clearly carries for attaining the objectives the strong implication of a job to be 3. Control of the organization done cooperatively. 4. Stimulation of coordinated action Literature on the psychology of team- Determination of team objectives is work as such is not abundant. There is, vitally important. Pearson 2 notes that however, a rapidly growing volume of "The team must believe that the kind of data on the dynamics of the human game for which it is organized is worth group, especially the small group, and playing." Team members cooperate on the subject of leadership. Much of with the leader when they believe it to this is pertinent to understanding the be in their own best interest to do so. team. This is not the time to review the Whether their interest is altruistic or literature, though it is important to sum- selfish, the result from the standpoint marize points relevant to our discussion, of cooperation is the same. There will especially those related to leadership. be effective teamwork only when the None of us will question the im- leader can make his objectives and those portance of leadership in teamwork. of the followers essentially the same. Leaders have existed since the begin- Therefore, the "leader will listen" as nings of human history. There were Homans 3 has said, to learn what the fol- doubtless animal leaders before that, lowers think, and to profit by their ideas. with their "pecking orders" just as they Out of all the suggestions and ideas PRESIDENTIAL ADDRESS VOL. 44 1395

that may arise, choices must be made. with which we are working, or the To make such choices the good leader legally constituted health officer. When must have, "an understanding that leads badges such as these are normal parts of to distinguishing between the important our culture we tend to accept them up and the unimportant in the particular to a point. However, in the final concrete situation, between what can be analysis, as Homans has said, "The done and what cannot be done, between authority of an order always rests on what will probably succeed and what the willingness of the persons to whom will probably not, between what will it is addressed to obey it." Ordway weaken cooperation and what will in- Tead 4 says, "Every good leader is at crease it." 1 The leader is something heart summoning loyalty for a purpose more than a chairman of the group which commends itself deeply and truly comprising the team; he cannot always to the led and to the best they know and take a vote and let the majority rule. feel." When all the followers have had their Barnard's 1 second sector of leader- say and made the issues clear, the leader ship behavior is that in which the leader must decide. This attribute of decisive- manipulates the technical means of ac- ness is one essential quality of leader- complishing the team's objectives. Tech- ship which seems to be universally nical processes loom large in our healtlh agreed upon. Barnard calls it, "The work. We tend, perhaps, to equate tech- element of critical importance in all nical competence with leadership more leadership." Some ways of being de- than is done in some other types of cisive favor cooperation and others have teamwork. The leader naturally must the reverse effect. Then, too, there are have an adequate understanding of the situations when decisiveness on the technical processes his team performs, leader's part is absolutely essential and but he need not be the most proficient others in which it is not crucial. If the technician on the team. leader has convinced his team that his Because the physician has technical basic objectives and theirs are similar, competence and is legally empowered to his decision will "stick." prescribe therapy for the sick; because This raises the basic question of he has taken a course of training which authority. Authority is not an oily sub- is probably longer, more arduous, and stance with which some high priest may more expensive than that taken by other anoint the heads of leaders. Authority members of the public health team; and is rather an attribute with which the because of the high status which the followers cloak their leader. The size of physician holds in society-all these and the cloak the followers are willing to other reasons have made it customary give him depends on the oneness of ob- for the physician to be designated as jectives and the confidence the followers leader of the health team. have in their leader's ability to be useful Leadership based on technical compe- to the team in accomplishing those ob- tence alone does not go unquestioned. jectives. We are accustomed to thinking Public administration experts stress the of the trappings of leadership, the value of filling many top posts with badges of "authority" which designate "generalists" in administration, rather those whose instructions we are sup- than with technical people. Barnard 1 posed to follow. Among such badges of says, "At present we overestimate the authority are the policeman's uniform, importance of technical skill and compe- the insignia or "brass" worn by military tence and undervalue, or even exclude, officers, the panelled office of the "boss," the less tangible and less obvious factors the designated chairman of a committee in leadership." Specialized training, 1396 NOVEMBER 1954 AMERICAN JOURNAL OF PUBLIC HEALTH such as the physician receives to an ever- that the formal type has lost some of its increasing degree, restricts the time charm. Far be it from me as a teacher young men have for training in leader- of public health administration to belittle ship-"they are necessarily diverted to organization charts, concepts of span of a considerable extent from experience control, staff and line activities, and the with men, organizations, and social sit- like. Such concepts are valuable; they uations, the distinctive fields of applica- clarify our thinking; and they are use- tion of leadership ability." ful in devising organizational set-ups It is certainly not my desire to make a which make it easier for the team to case against the physician as leader of function. But we cannot depend on the health team. I am proud to be a these more or less mechanical con- physician and to come from a family of trivances to get the job done. The mem- physicians. I believe that in the future bers of the team do the work; they are it will be even more logical than in the people, with the strengths and weak- past for the physician to serve as team nesses inherent in people. leader, for health work will doubtless This brings us to Barnard's fourth concentrate more and more on the indi- sector of leadership behavior, which is vidual in his environment, rather than the stimulation of coordinated action. on the environment itself, at least in the "Coordinate" has become something of more industrially developed countries. a fighting word. If we do the coordi- My point is simply this-because of nating, it is a fine thing; but we rebel being a physician, a man is not neces- at the idea of being coordinated by sarily a proper leader. He must have someone else. My dictionary tells me qualities of leadership, and he must cul- the prefix "co" is derived from the Latin tivate those qualities assiduously if he "cum meaning "with, together, in con- is truly to deserve to be the leader, and junction, jointly." I am left in some if his leadership is to be effective. confusion when dictionaries differ as to Organization, Barnard's third sector the meaning of "ordinate." One tells of leadership behavior, is obviously me it means "arrange," but another basic to organized community action for better explains our reactions to coordi- health. In discussing the thinking about nation by saying it means "regulate." organization and administration in And we all dislike being regulated! recent years, Sayre 5 points to the loss However, we recognize that the leader of "certainty" that arose between 1940 has a job of coordination to do, espe- and 1950. In prewar days the founda- cially with teams as diverse as ours in tions of administration were considered public health. There are many ways of firmly based in "scientific manage- doing this effectively, including orienta- ment." "Confident and experienced tion of new staff members, inservice men wrote eloquently and with con- training, refresher courses, staff meet- tagious conviction of a public adminis- ings, maintaining proper channels of tration which was nearing the nature of communication-in two directions, of science." course-and so on. Coordination seems Today it is more apparent that ad- a less unpleasant process when we recall ministration is a social process, deeply that it gives us the opportunity to make involved in the problems of human re- our contribution to the team's total lations. Today, more than formerly, product. This is obviously so much we think of the organization chart in bigger and more important than any- terms of the team of people it represents. thing we could do alone that we can find We have learned so much of the great joy in being part of a great enterprise. importance of informal organization, Tead 4 says, "Leaders are those who in- PRESIDENTIAL ADDRESS VOL. 44 1397

fluence others to a joint exercise of quently attempted. Such a sharp power" which is a nice idea to remem- division overlooks the biological nature ber, I believe. of disease. Administrative dividing lines may be set up on such a basis arbi- Members of the Health Team trarily, as distinguished from biologic ones which are by no means distinct. The health team includes an astound- The natural history of disease is a dy- ing array of workers running from the namic process which goes through suc- highly skilled neurosurgeon on one end cessive phases of interaction of host, of the broad spectrum of training to the agent, and environment, ending in cure, unskilled laborer on the other. Medicine disability, or death, as the case may be. recognizes some 20 major specialties; As we learn more we can influence this dentistry has not a few; nursing has its biologic process favorably for man at collegiate graduates, hospital school various stages in the unfolding natural graduates, practical nurses, nurses aides, history. Barriers. may be erected which etc. There are public health engineers, retard or stop the process. Such bar- sanitary engineers, sanitarians and sani- riers may be divided from the beginning tary inspectors, myriads of technicians of the natural history to its end into and laboratory workers. We have our broad bands which may be called "levels epidemiologists, biostatisticians, non- of prevention." They may be desig- medical administrators, health educa- nated, promotion of health, specific pro- tors, nutritionists, social workers, tection, early diagnosis and prompt specialists in community organization or treatment, limitation of disability, and hospital administration, rehabilitation rehabilitation. These broad bands rep- workers, veterinarians, and many others. resent stages in the developing natural Shepard 6 has pointed out that "unlike history at which man may make his most other professions . - . public health attacks. A given society might choose recruits its workers from (these) several to assign to governmental health depart- other professional fields.... It is aston- ments concentration of work at the levels ishing how this cause has gradually of promotion of health and of specific amalgamated such varied professional protection. Private practitioners might interests into what is now a profession" work principally at the levels of early -the profession of public health itself. diagnosis and prompt treatment and of It is natural that with such diverse pro- disability limitation. Rehabilitation fessional backgrounds there should be might be relatively neglected. This is some division of loyalties among the approximately the pattern which the members of the public health team. United States has followed, with some Does primary loyalty belong to the pro- maj or exceptions. fession from which we came or to public It is well to clarify the meaning of health itself? Ordinarily, there should the word "prevention" when used in be no need for a conflict of interests. speaking of "levels of prevention." Dr. Should the need for decision between the Mather7 of British Columbia has two interests arise, it is important to re- pointed out that in this context the word solve the conflict. If the public health is used with the meaning it had in worker's chief loyalty is not to the team Elizabethan times when "prevent" meant on which he works, he may be on the to come before or precede. Two ex- wrong team. amples from the King James Version of Division of health workers according the Bible illustrate this use: to whether they are engaged in "curative" or "preventive" Psalm 88:13-"But into thee have I cried, work is not infre- 0 Lord; and in the morning shall my prayer 1398 NOVEMBER 1954 AMERICAN JOURNAL OF PUBLIC HEALTH prevent thee." The revised version reads, "But with each member doing that for which I, 0 Lord, cry to thee; in the morning my he or she is best prayer comes before thee." qualified. Psalm 119:147-"I prevented the dawning The usual members of the health team of the morning, and cried." The revised ver- unaided can scarcely deal adequately sion reads, "I rise before dawn and cry for with such broad fields as mental health. help." Psychiatrists, psychologists, and psychiatric social workers are too few to Obviously, if we use the word "pre- handle the field alone, and their training vention" only in terms of keeping some too costly to make it economical for possible event from happening, our use them to do the whole job. Even when of the word is a different one. In this the specialized mental health workers sense, no one is going to try to "prevent" have help, as they should, from other either the Lord or the dawning of the members of the health team, such as morning. If the meaning is that of an- practicing physicians and public health ticipatory action, however, anyone prac- nurses, they simply do not have contact tices preventive medicine when he with a sufficient number of people in a provides the best care available with sufficient proportion of the mental and modern methods, doing all in his power emotional crises of their lives to meet to prevent the progress of the natural the needs. Parents, clergymen, school history of disease. teachers, recreational leaders, and others When all the various team members must understand the mental health prob- recognize their common objective of lem so they can do their parts, and we throwing up these barriers at whatever must help inspire them to do so. point "on the production line" they I shall simply mention the vast prob- happen to stand as the natural history lem of recruitment, so admirably dis- passes through "their" territory, they cussed at the 1954 Forum of the can be a real team with a common goal National Health Council.8 It is very of building a healthier community. heartening to know that a great in- Then, when jurisdictional disputes arise surance company is providing funds to at the dim boundaries set for adminis- the council to assist in recruiting new trative convenience, they will be recog- members for the health team. nized as such. When they are recog- nized as administrative problems only it Citizen Members of the will become relatively simple to solve Team them as such. When the time comes At the beginning of our school year that a single individual or group has at Harvard I usually walk silently into responsibility for comprehensive and the classroom and write on the black- continuous care for a patient throughout board the question, "What do the people the natural history of health or of what- want done about their health?" The ever disease may befall him, these juris- people must be part of our health team dictional disputes will largely vanish. if our work is to be effective. We must It is wasteful to have highly trained use modern technics of attitude sampling workers doing jobs that less well trained to learn more about their attitudes and people could do as well or perhaps we must include representative citizens better. We might profitably follow the in the planning stage of the work. splendid example the nurses have set in Learning people's attitudes about making job analyses to show the types health, having the value of their advice of work which safely may be assigned in planning, and giving them the oppor- to workers at various levels of training. tunity to participate in working out their Thus a balanced team can be organized, own health programs-this is helping PRESIDENTIAL ADDRESS VOL. 44 1399

people to help themselves, which has health work we are fortunate to be able become such an important watchword in to discuss our problems more freely with international health work. This is part our families than can those who are of community organization and each of bound by the confidential nature of the us in public health can understand its private physician-patient relationship. principles sufficiently well to make our Our husbands or wives can thus be real work more productive. We should not partners in our jobs and help us find the leave this as the sole province of the strength so sorely needed. community organization specialist. Evidence on all sides shows that the International Health enduring health programs are those the people have understood and those they The international field provides op- have had a hand in developing. portunities for teamwork of the highest Hydrick,9 who worked in Indonesia and order and imposes considerable strains later in Peru, put great emphasis on at- even on those with the best of good will. tempting "to awaken in the people a There are so many differences to be permanent interest in hygiene." He said overcome-differences in language, in very frankly, "There would be no objec- semantics even in the same language, in tion whatever to the use of coercion if its cultures and in value systems, in literacy use could secure permanent results. But levels, in transportation, and means of it has been tried so often without suc- communication. cess." The principles Hydrick worked When a health worker from our out in Indonesia when it was still under country returns home after a successful the Dutch are being used today in the foreign assignment he will be a more health program there. But now that the useful person than before in his own people have their freedom, they are less environment. He will see differences at suspicious of their health workers, and home to which he was blind before, and much more cooperative than was the his tolerance for differences will be in- case when the Dutch were in control. creased. Our professional organizations Allport 10 has summarized very neatly have here an opportunity for teamwork the universal psychological need for par- which we must not miss. We can ticipation. He says: ". . . people must broaden the view of our appointing have a hand in saving themselves; they authorities, helping them realize that cannot and will not be saved from the foreign experience is useful training for outside . . . people have to be active in work on the domestic scene. This will order to learn, in order to store up encourage better people to undertake efficient memories, to build voluntary foreign service, as they will not fear control, to be cured when they are ill, losing out in their professional careers. restored when they are faint. ..." And the better the people we can send At a recent meeting of the National abroad, the better our foreign relations Advisory Committee on Local Health will be. Units " the following important state- ment was made: Preparation for Teamwork "A community must be helped to find and satisfy its own needs rather than It takes work to build teamwork and urged to accept a standard service pre- experience in working together. Un- scribed by professionals." fortunately, many of our professional No "citizen" members of the health schools tend to live somewhat in isola- team are more essential to success than tion, providing students with few oppor- our wives (or husbands). In public tunities for working with other members 1400 NOVEMBER 1954 AMERICAN JOURNAL OF PUBLIC HEALTH of the health team. Our schools of pub- know. The loyalty shown it is tre- lic health, with representatives of several mendous. When any of us are given of the different professions among the responsibilities for the APHA we do not student body, have excellent opportuni- take them lightly. Pettiness and self- ties for breaking out of this isolation. interest seem to vanish and the good of Even though the students' academic the whole becomes the primary con- backgrounds differ, and though there sideration. We have our blocs and are teaching problems in putting the special interests, as is true of any con- different disciplines together in classes, siderable collection of people, but when it is most important to provide ex- the chips are down we remember our perience in teamwork during academic broad responsibilities to the great training. This will also show the student groups of people to whose service we are clearly that his teacher places great dedicated. value on the importance of the team in If not to the APHA, where can the the public health work for which the people of this country look for public student is being trained. From my own health leadership? Our membership in- experience as a health officer, I am sure cludes those who have legal responsi- that graduates of schools that emphasize bility for the health of our communities; teamwork make better staff members those concerned with planning for best than do the graduates of places that lack use of the community's total health re- this experience. sources; those responsible for the desti- In p' eparing for teamwork it is also nies of the powerful national voluntary valuable for us to recall the two parents health agencies, as well as the great in our family tree. Our "health" parent- many field workers who go directly into age comes from the natural sciences. the nation's homes and see the people Our "public" parentage is in the be- faced with their health problems and havioral sciences of sociology, anthro- their social problems. I believe we have pology, psychology, and political the responsibility for national leader- science. We need to look up our an- ship. When all of you as members of cestors more in the future. Our gene- this great Association recently expressed alogy is an honorable one, and we can yourselves about our purposes as an advantageously study it. organization, you confirmed this belief. How can we exert this leadership most Value of the APHA Team effectively? First, we must study our national health problems, and we have The APH.A is a very remarkable or- the epidemiological method as the tool ganization. Our 13,000 members make designed for just this purpose. We have us the largest public health association our standing committees, and our Sec- in the world, though a number of pro- tions, our Affiliated Societies and our fessional societies are larger. We are Branches to make such studies. We have reasonably mature in terms of age, but our democratically elected Governing not yet in need of gerontological care. Council by which we may fix our basic Our annual budget of more than half a policies after debating the issues. We million dollars is a lot of money and have membership in the National Health hard to get, but our wealth alone is in- Council with its declared purpose of sufficient to give great prestige. bringing together representatives of After working for a good many years those national health agencies that are with members, officers, and the staff of interested in working together for the the APHA I feel strongly that it is the nation's health. finest organization of its kind that I All the necessary mechanisms for PRESIDENTIAL ADDRESS VOL. 44 1401

study and for joint planning are in ex- more clearly than most. To fulfill our istence. The principal additional factor manifest destiny we must do this, and we needed to make our leadership effective must make our voice heard in the coun- is the strong will to do so. There is cils of the Nation. Only in this way can some question in my mind as to how we maintain our faith in ourselves and strong this will has been in recent years. in our Association. We seem to have been wavering, to have been fearful and uncertain. Per- REFERENCES haps we have feared making enemies 1. Barnard, Chester I. Organization and Management, among powerful groups with whom it Nature of Leadership. Cambridge, Mass.: Harvard is highly important us University Press, 1948. Chap. IV, pp. 80-110. for to have har- 2. Pearson, John. Chap. IV in Public Management in monious relationships and whom we the New Democracy. Edited by Fritz Morstein-Marx. New York, N. Y.: Harper, 1940. should like to count among our friends 3. Homans, George C. The Human Group, The Job of and supporters. In the heritage of our the Leader. New York, N. Y.: Harcourt Brace, 1950. Chap. 16, pp. 415-440. past there have doubtless been periods 4. Tead, Ordway. The Art of Leadership. New York, of similar uncertainty, but such periods N. Y.: Whittlesey House (McGraw-Hill), 1935, pp. 270-271. are not the basis of the greatness of the 5. Sayre, Wallace S. Trends of a Decade in Administra. APHA. We may tive Values. Pub. Administration Rev. 11:1-9 be forgiven for falter- (Winter), 1951. ing occasionally. We cannot be forgiven 6. Shepard, W. P. Public Health Becomes a Profession. Yale J. Biol. & Med. 19:771-777 (Mar.), 1947. if we do not soon recognize our weak- 7. Mather, James M. Discussion at Conference of Pro. nesses and return to seek the source of fessors of Preventive Medicine, Colorado Sprinp, Colorado, Nov. 1952, Preventive Medicine in Medical our true strength. Unquestionably this Schools, Report of Colorado Springs Conference, strength comes from a dedication to the Nov. 1952. Baltimore, Md.: Waverly Press, 1953. 8. Highlights of the 1954 National Health Forum on best interests of all the people. Our Changing Factors in Staffing America's Health strength does not Services. New York, N. Y.: National Health Council, come from blindly fol- 1954. lowing segments of the people, whether 9. Hydrick, J. Intensive Rural Hygiene Work in the or not such Netherlands East Indies, Netherlands and Nether. segments are professional. lands East Indies Councils, Institute of Pacific Rela. We are in strategic positions from which tions (Original by the Public Health Service of the Netherlands, 12 21-22, 1937), 1942. we should be able to see the needs, 10. Allport, Gordon W., and Postman, Leo. The Pay. resources, and attitudes of the people at chology of Rumor. New York, N. Y.: Holt, 1947. 11. National Advisory Committee on Local Health Units. least as clearly as any other group, and May 25, 1954.

Mental Health Training Grants The Public Health Service announces that December 15, 1954, is the closing date for filing applications for training grants under the National Mental Health Act for the academic year 1955-1956. Applications are also being accepted for the support of projects directed toward the development and evaluation of current and new teaching and training methods in psychiatry, clinical psychology, psychiatric social work, and psychiatric nursing. Application forms and additional information from Training and Standards Branch, National Institute of Mental Health, Bethesda 14, Md.