Perspectives on Leadership from the Nation's Doctor: Jerome Adams

[music]

0:00:11.1 DuBois Bowman: Good afternoon and thank you for joining us for Ahead of the Curve, a speaker series from the University of Michigan School of Public Health. My name is DuBois Bowman, and I have the pleasure of serving as dean of the School of Public Health. I'm delighted that we're joined today by Dr. Jerome Adams, the former US Surgeon General.

0:00:29.0 DB: Ahead of the Curve speaker series focuses on conversations about leadership, and throughout this series we have discussions with contemporary public health leaders spanning many sectors, just to hear their insights and stories of perseverance. Leadership is a critical component of navigating complex public health challenges and building a better future through improved health and equity.

0:00:54.1 DB: We wanna hear about the important factors that shape great leaders, and we wanna learn how they continue to evolve and grow so that in turn, we can help the training the next generation of leaders. I'm really excited to welcome our guest today. Dr. Adams, welcome, and thank you for being here.

0:01:12.0 Dr. Jerome Adams: Well, thank you so much for having me. It is such a pleasure to be able to talk with folks at the University of Michigan again. Some of you may remember that I was there as Surgeon General, speaking with members of the Business School, the anesthesia department, a couple of other departments about the opioid epidemic, and I just appreciate the opportunity to talk to students because that's one of my favourite things to do.

0:01:35.3 DB: Terrific, terrific. In addition to being a board-certified anesthesiologist, Dr. Adams received a Master of Public Health degree at the University of California, Berkeley with the focus on chronic disease prevention, and he's worked across many levels, he worked in local public health at the City of Berkeley's health department, as well as in state public health where he ran the Indiana State Department of Health during a Ebola, Zika and HIV crises.

0:02:05.2 DB: And then at the federal level, Dr. Adams served as the 20th US Surgeon General. He's been a leader in numerous professional societies and has continued his anesthesia practice over the past 20 years, remarkably, even while still serving as Surgeon General. Most recently, he became a distinguished professor, presidential fellow and executive director of health equity initiatives at Purdue University.

0:02:32.6 DB: So we're looking forward to learning more about how Dr. Adams has advanced public health in all of his positions, including throughout the COVID-19 pandemic. So if you're ready, let's go ahead and dive in into questions.

0:02:45.4 DA: Let's do it, and please remember that even though I'm a Boilermaker and we're Big 10 rivals today, we're all friends, so I go easy on me.

0:02:54.1 DB: Fair enough, fair enough. [chuckle] So to begin, I'd love just to start really at the beginning to think about what prompted your interest in public health? Is it something that you were aware of early as you were growing up or in your schooling? Or was there something else in college or your medical training that piqued your interest in pursuing public health?

0:03:15.8 DA: Interestingly enough, I had very little interest in professionally pursuing anything in health when I was growing up, and it's not for the reasons that you might think. I actually had a 3.9 GPA, was second in my class, really enjoyed STEM, took AP Calc and a couple of other AP courses, but I had never met a Black physician or really another Black health professional other than maybe a few African-American nurses along the way, throughout my entire childhood, and that's despite me being in and out of the hospital constantly when I was younger.

0:03:53.8 DA: I often tell folks, "You gotta see it to believe you can be it." I'm an embodiment of that. The first African-American physician whom I met in my life with when I was in college, and that was Dr. Ben Carson. And so that was my interest in medicine. Public health came about because as much as I love to medicine, I realised that there were always gonna be more patients that needed to be taken care of than I had the capability to care for myself.

0:04:20.9 DA: Or to use that famous public health story analogy metaphor, I was busy fishing people out of the stream, but there were people falling into the stream at two, three, four or five times the rate that I could fish them back out. It felt like there was something more that I could be doing to really change people's outcomes and impact population level disparities that I saw.

0:04:45.5 DA: Now, when you talk about the social determinants of health, back before we even knew what to call them, I inherently felt that they were impacting me. I was a kid who had severe asthma growing up, Black boys die from asthma at significantly higher rates, twice the rate of White females.

0:05:04.0 DA: In many cases, it's due to social determinants of health, lack of access to health insurance, lack of transportation, geography, inability to be able to afford medications, and for me, all these things play a role in me ending up in the hospital over and over and over again for my asthma.

0:05:23.6 DA: So even though it wasn't in my professionally to think about pursuing a career in public health, a lot of the ingredients that pushed me towards the realisation that public health was gonna be where I could have the biggest impact were instilled in me from the time I was young.

0:05:39.7 DB: Terrific, and two remarks. One is that it's wonderful that in the field of public health, you bring all of your experiences with you, and I know that those experiences that you just described and many more help to shape the work and leadership that you provide today. And then your other remark, just thinking about your leadership posts and being the second African-American male to serve as Surgeon General, that you certainly inspire many who will come behind, I'm sure in ways that you never know.

0:06:08.1 DB: Thinking now just about your response to finding your way to public health, I wanna ask now about the direction or path that you ultimately took within public health. So you spent some time at the City of Berkeley's health department, and then in 2014, you are appointed Indiana State Health Commissioner, and so moving into government public health, the public sector, was that something that you knew pretty early on that you wanted to do? Or how did that part of your pathway evolve?

0:06:35.9 DA: Well, that once again was something that happened by accident. So what I would say to the students out there is, if you talk to me or Dean Bowman or anyone else at our level and ask them if they knew when we were at your stage in our careers and in our lives, if we would be exactly where we are right now, almost no one's gonna tell you the answer to that question is yes.

0:07:00.9 DA: This whole idea that you've gotta have it all figured out is a myth, and I think it's a myth that dis-serves many of you. You've gotta know which direction in general you wanna point your car, but you also have to realise there are gonna be many, many exits along the way that you take off on, and you may take off on one of those exits and realise that that's actually the path that you were meant to be on all along, or the path that is most fulfilling to you.

0:07:25.6 DA: For me, my story involved a trip to Hawaii. So as a medical student, I got told that if you sign up for the American Medical Association student section, you'll get a free trip to Hawaii, and I'm a poor Black kid from the rural south, Hawaii is like the embodiment of you've made it, if you get a chance to lay on the beach in Hawaii.

0:07:44.2 DA: So I signed up, went to Hawaii for the American Medical Association student section meeting, and then fell in love with political advocacy. Thousands of people there putting forth resolutions and having conversations about what we should be advocating for on a state, on a federal governmental level, and within policy institutions on behalf of our patients.

0:08:06.4 DA: And so that allowed me the opportunity to learn about government advocacy, to meet other leaders, both within academic departments and health systems, but also on a state and federal level. Then when I became an anesthesiologist, I joined the American Society of Anesthesiologists, and would go back and forth to DC and lobby on behalf of my patients in my profession, to different people in Congress, and one of those people happen to be then Representative Mike Pence.

0:08:34.9 DA: When Representative Mike Pence became Governor Mike Pence and he needed someone to run his State Department of Health, my name got thrown into the hat because by that point I was on the board of the Indiana State Medical Association, and he knew me from seeing me over and over again through these professional organisations, coming back to Washington, DC. So that's how I ended up becoming the Indiana State Health Commissioner.

0:08:57.3 DA: It wasn't something that I planned out, it wasn't something I could have ever imagined being a kid from the rural Black South that I'd ever end up working for a very conservative White governor in Indiana, but following those doorways and following my passions is what led me to that place, and again, getting involved with professional societies was something that for me opened up many of those doors.

0:09:22.8 DB: Terrific. And the next stop for you from being the health commissioner in Indiana to then Surgeon General, I'm trying to put myself in your shoes. That must have been a sort of surreal experience. And so can you remember the day that you found out that you're gonna be nominated or that you were gonna serve as Surgeon General? Did you get a phone call from Washington? How did that play out?

0:09:45.8 DA: Well, it played out in a much longer fashion than what a lot of people realise. In many cases, you're being vetted leading up into the election. And interestingly enough, and I've never told anyone this before, there were folks from Hillary Clinton's campaign who are reaching out to me and asking me if I'd be interested in a role in the Clinton campaign when they won. That was the assumption.

0:10:10.2 DA: And so, interestingly enough, had Clinton won the election, they would have had most of the positions filled out on day one, because they had this big political machine behind them. Trump had no political experience, and so there was a lot of work to be done to fill out those permissions, and I went out very early before inauguration to speak with President Trump and the team, and interestingly enough, I had to help them understand a lot of the different health positions and help them think through who they should be talking to and vetting for various health positions, for CDC Director, for HHS Secretary and beyond.

0:10:48.6 DA: And so that was a good opportunity for me to be able to get involved, to earn their trust, but initially they were vetting me for HHS Secretary, not for Surgeon General of the United States. And I actually said to them, "I think my skill set is more suited towards public health and health advocacy and leading the Public Health Service," which is what the Surgeon General does, versus some of these other roles which are more politically oriented.

0:11:17.3 DA: But that said, that was November. I didn't get a call back again until July of the next year saying, "Hey, we wanna nominate you to be Surgeon General of the United States." So I was in limbo from November till July. And mind you, when I went out in November a TV camera saw me, it was all on C-SPAN, there was speculation, there were news articles about what position Dr. Adams is gonna get.

0:11:41.4 DA: So my job, the job where I was working is saying, "When are you leaving? When are you leaving? You gotta let us know. We need to replace you. You can't leave us high and dry." There is all this pressure on me while you're sitting there in limbo. And these political appointments can drag on for months, some of them even years, while you're in limbo waiting to get nominated or waiting to get Senate confirmed.

0:12:00.5 DA: It was Vice President Pence who called me up and said, "Hey Jerome, we want you to be Surgeon General, and if you're still okay with that we're gonna nominate you." And so they nominated me, and I was actually one of the fastest Trump appointees to be actually Senate confirmed from the time I was nominated, largely because of the trust I'd built through those professional organisations, through the American Medical Association and the American Public Health Association.

0:12:23.0 DA: A lot of the work that I'd done in the past helped pave the way for me to get confirmed pretty quickly, but it took from November of 2016 till September of 2017 for me to actually go from first conversation to being actually Senate confirmed.

0:12:39.4 DB: Wow, wow. So the better part of a year, you pointed to the students in our audience, and we do have a varied audience, but just thinking about our students and young professionals, seeing the finished product of a Surgeon General. Will you talk a little bit about the preparation that you did during that year?

0:12:58.8 DB: Because while you're awaiting news to indicate that things will be moving forward, you're also preparing yourself in the event that things do go forward then that you're able to hit the ground running. And so just as a, from a leadership standpoint, how did you approach that period of preparation?

0:13:12.6 DA: Any time you're going into a new job and a big job, you wanna find out who your boss is gonna be, or bosses are gonna be, you wanna find out who your colleagues are gonna be, so I was reaching out to both and federal government to find our, "Okay, who else is gonna be in charge?"

0:13:27.0 DA: Tom Price was the secretary, the first secretary that was named, and so I was reaching out to Tom Price and the people who knew him to find out, "Okay, what's his style, what's he like, what are his priorities going to be?" I also was doing a lot to get up to speed on the US Public Health Service. So the US Public Health Service Commissioned Corps is one of the eight uniformed services.

0:13:48.7 DA: There's Army, Navy, Air Force, Marines, Coast Guard, National Oceanic and Atmospheric Administration, now the Space Force, but the Public Health Service is the only uniformed public health service in the world, 6000 people, and the Surgeon General is the operational head of that. And so there's a lot of military protocol, we wear a uniform 'cause we have to understand how to engage in a very different environment and in a very different hierarchy, so learning a lot about that.

0:14:16.2 DA: And then also learning about the people who I was gonna work with, like Brett Giroir, who was nominated to be the Assistant Secretary for Health and works closely with the Surgeon General, and is actually the four star within the Public Health Service. You also are trying to get your family ready. I'm the first Surgeon General in modern times to have school-age kids. My daughter was eight, and my boys were 13 and 14 when we were going through all of this initially.

0:14:42.4 DA: And so you're thinking through, "Okay, I gotta get my kids ready to leave school, I gotta sell my house, I gotta pack up and move across the country, and then we gotta figure out where we're moving into and get them back into school," it's just the normal stuff of parents moving, on top of the fact that it's this high profile job and you're trying to get Senate confirmed.

0:15:00.3 DA: So I say all that, and the lesson there is that we need to be much more appreciative, and this isn't about me, this is about the other folks out there, of our public servants who sacrifice a lot. Who sacrifice family, who sacrifice salary. I took a 75% pay cut to be Surgeon General of the United States, I actually liquidated my 401K to be able to afford to move out to DC to be Surgeon General of the United States.

0:15:29.4 DA: There's not a lot of people who are in a position to do that. Fortunately, I was an anaesthetist and had put a lot towards my retirement beforehand, but I actually am in the hole right now because of my public service, while many people are out there thinking that somehow I got rich being the Surgeon General of the United States.

0:15:49.4 DA: And that's my story, but there are many other people who are in public service jobs that are much lower profile, even lower paying than the job that I was, who are sacrificing because they're passionate about it, and if we continue to attack them, then we're gonna get lower and lower quality people running our public health institutions.

0:16:06.7 DB: Yeah, no, absolutely, and appreciate your service and commitment and sacrifice along with all of those others on the front line, helping to really work in our interest to keep all of us safe and healthy. And so you've been nominated, you move through the confirmation process, and then you start a Surgeon General, although by number of years, not that long ago, it was a remarkably different world because it's pre-COVID.

0:16:34.6 DB: And so your stated goals when you began were addressing mental health challenges and the opioid epidemic, and still two very relevant areas, but how did you determine those as your priorities, and why?

0:16:44.1 DA: Number one, the Surgeon General's job is to help raise awareness about issues that are impacting the public's health and help people understand what measures they can take to improve their health. So once upon a time, Luther Terry, C. Everett Koop as Surgeons General said smoking is killing far too many people, and the measures that we can take to help people improve their health and save their lives, so they raised smoking up as an issue.

0:17:14.2 DA: For me, it was the opioid epidemic that I saw both in my professional and personal lives, was wrecking families. A person dying of an opioid overdose every 11 minutes in this country. Many people knew me before I was Surgeon General of the United States, because I ran the Indiana State Department of Health when we had the HIV outbreak in Scott County, Indiana, where a small rural community that had had three cases of HIV in the previous decade, in less than a year had 200 cases of HIV related to injection drug use.

0:17:43.1 DA: That was a professional reason why I felt this needed to be addressed, but many of you have also heard me share the story about my brother Phillip. So while I'm in the White House standing next to the most powerful people on the planet, my brother's sitting in a prison cell about 25 miles away in Jessup, Maryland, due to crimes that he committed to support his addiction.

0:18:04.1 DA: I would often say, "If this can happen to the brother of the Surgeon General of the United States, then it can happen to anybody in any family." And so it was important for me to personally and professionally raise that issue up, and I felt that there was also something actionable we can do.

0:18:20.1 DA: So one of the first things I did, and one of the things I'm most proud of as Surgeon General that I did, was actually enact the first Surgeon General's advisory in over a decade. That advisory was calling on people to know about and to carry naloxone. After that advisory came out, we actually saw naloxone dispensing go up by about 400% nationwide, so we literally saved thousands of lives with that advisory that came out of our office.

0:18:48.9 DA: To me, that's what the Surgeon General's job is all about, letting people know, "Hey, there's an issue in your community, and there's an action you continue to protect yourself or your family or your loved ones and your friends," and then enabling people to be able to make healthier choices.

0:19:03.2 DB: Terrific. So thinking about that as an accomplishment, possibly as a response, but I wanna ask it as an open-ended question. What do you feel like were your most significant accomplishments, or accomplishments that you feel most proud of personally? And then how did you approach them strategically just to ensure progress?

0:19:21.7 DA: Well, again, the naloxone advisory was one that I approached very much from a personal standpoint. You wanna identify a problem, you wanna frame it for people, and you don't just wanna say, "This is a problem," you wanna give them a tangible action that they can take. So from a leadership perspective, that's how and why I picked naloxone.

0:19:42.2 DA: There are so many different facets of the opioid epidemic that we could have tackled, and we talked about a lot about them at Michigan. We talked about curbing prescription drug misuse, we've talked about making medication assisted treatment more available. We've talked about alternative to treating pain with other things besides opioids.

0:20:02.1 DA: But none of those were things, even though I promoted all those things, there wasn't a message for me clearly to take to the public and saying, "If every single one of you does this, then we can lower the number of people who are dying and help the public." With naloxone I said, "If every one of you knows about naloxone and even just a few of you are willing to carry it, we can save lives." And so that's how I approached that.

0:20:25.6 DA: But one of the things that I'm most proud of is also related to the opioid epidemic, and that's the fact that during a Scott County HIV outbreak, syringe service programs were illegal in Indiana. And so not only did I have an HIV outbreak that I had to deal with, but the number one public health tool that you would bring to the table to deal with it was legally off the table for me.

0:20:48.7 DA: And so I had to help the community, I had to help the governor, I had to help the state legislature, all these people wrap their heads around why we should be doing something that currently is illegal in the state, because the citizenry didn't feel like it was an acceptable option. And so what did I do there?

0:21:10.3 DA: I'm a big believer in being present in participatory leadership, and so I got up off my feet in my Indianapolis office, and I would drive two hours down to Scott County, Indiana, and I would meet with the local sheriff, with the local pastors, with the local community leaders and ask them what their concerns were.

0:21:34.0 DA: See, a lot of people in public health actually wanted me and wrote articles about how terrible our response was because we didn't go down and use our public health authority to bully that community into opening up a syringe service program. I want you all to understand this, because there was articles in New England Journal of Medicine and the APHA Journal criticising our response for not forcing our public health authority on that community.

0:22:01.9 DA: And interestingly enough, you saw some of the pushback from America about mandates and about people feeling like they're abusing their public health authority. The key word in public policy is "public". You've gotta get public buy-in. By me going down there and working with these folks and sharing my story about my brother, and them seeing me down there every day, I was able to get buy-in around the idea of a syringe service program for the community and we were actually able to successfully open it.

0:22:31.4 DA: So with the community's not just support, but they were the ones calling for it. So it wasn't me saying to the governor, "I think we should do this," it was a community saying, "We want this for our community," and that created a very different narrative. And the reason why I'm even more proud is because after that, Kentucky went from zero syringe service programs, it was illegal in Kentucky, to over 70. Ohio doubled their number of syringe service programs. Arizona and Florida opened up syringe service programs.

0:22:58.6 DA: We actually moved harm reduction further faster because of Scott County and because of a conservative governor who no one would have ever expected to be a cheerleader for syringe service programs, coming to terms with it, than what we ever have in the history of the United States.

0:23:16.2 DA: And so we need to understand that sometimes you can do amazing things in situations you wouldn't expect, but you've gotta be there, you can't change the game from the sidelines, you've gotta be there. And the other lesson there is that people need to know that you care before they care what you know.

0:23:32.5 DA: You're not gonna beat them over the head with a public health book and get them to buy in, you've gotta show up, you've gotta listen to them. Sometimes you gotta be willing to take half a loaf of bread instead of the full loaf you want, because that's where the community is. But then that shows them that, "Hey, I'm listening to you." And then you might be surprised at some of the things that you can accomplish.

0:23:51.6 DB: Absolutely, absolutely. There's an important element built into your response in that story, which is a fascinating one, but from a public health perspective, thinking about the importance of community engagement, and I think that's an important part of your response that really allowed you to have success of leading through conversation, leading through partnership, and understanding and leading in a more informed way, it's not just a demonstration of your willingness to listen, but it allows you to move forward in a more informed way.

0:24:21.9 DA: And sometimes recognising that you're not gonna win, even if you feel like you've got the winning argument. I often will say, ask audiences to raise their hand if they believe in democracy, and if we were in an audience, I would hope every single one of you all in the audience raised your hand.

0:24:37.6 DA: And then I often say, well actually, many of you believe in democracy when it delivers the results that you want, but all of a sudden when something happens that you don't agree with, you go, "Whoa, whoa. I don't like that. I don't want that to happen." In a democracy, you make your case, somebody else makes their case, if they make it better, then they win, and you move on to the next fight.

0:24:58.4 DA: And so that's a real challenge in leadership, learning how to put up the best fight, but then also recognising that you're not gonna win them all, sometimes you just gotta say, "Okay, I lost that one. I'm gonna go back and figure out what we did wrong and regroup, and then we're gonna try again later in a different way," but not to pout about it, or to say that, "It's not working because they didn't listen to me." It takes some introspection and some humility to be able to lead in an environment when you're losing.

0:25:27.4 DB: Absolutely. Absolutely. So let's move now to late 2019, early 2020, just sort of the beginning phases where even for the broader public, we're just becoming aware of concerning activity with respect to a novel virus, and I'm sure you were at in conversations to be at the early phases of that. Do you remember a time or a specific meeting or a conversation that you were in where you realised that COVID was just gonna change everything for us?

0:25:57.3 DA: It is fascinating because it's easy to forget even just two years ago, how this was playing out. And a lot of people wanna put it into a political context, and when I say "political", of Republican versus Democrat. It was political, but we have to realise that politics more often than not come down to money.

0:26:20.8 DA: And so you didn't just have Republicans, you had Nancy Pelosi walking through Chinatown saying, "We will not shut down Chinatown." Governor Cuomo from New York, who literally told us, "If you all try to shut down in New York City, it's gonna be a war." He literally said that. And so we have to understand from a public health standpoint, from the beginning, was trying to convince politicians and the people who elected those politicians that we need to take this more and more seriously.

0:26:46.6 DA: But there was a key moment, and what's interesting is the key moment that America finally woke up and realised this was real, it was when that Utah Jazz, Oklahoma City Thunder game got canceled. It was when that game got canceled that America said, "Oh my gosh, this is serious." And then a few days later, the NCAA cancelled the Final Four, and that's when it was like, "Oh wow," and everybody started to say, "Okay, well, what do we need to know? What's going on? What's happening here?"

0:27:17.2 DA: What's the lesson there for you all? The number one issue people vote on in this country is jobs and the economy. The number two issue people vote on, Democratic or Republican, Black or White, rich or poor, safety and security. You know what people don't vote on? Health. They rarely vote on health.

0:27:37.4 DA: And you need to understand that because if you wanna be a health advocate, you've gotta learn to frame health in what you're asking people to do through the lens of some of these other priorities in their lives, so that they see that what you're selling is delivering them something that they care about.

0:27:52.2 DA: At Purdue University for instance, we actually got tremendous buy-in from our student body for COVID prevention measures. We didn't get it for the sake of health. If we'd gone to them and said, "You all all need to wear a mask and get vaccinated or else you're gonna die," they would have blown us off.

0:28:06.0 DA: What we said was, "Hey, we wanna preserve in-person school for you all as much as possible and as long as possible, and if we do these things, that will give us a better chance to keep you in person at school. If we don't, you're gonna go home and live with your mother and your father again, and you're gonna be doing homeschooling." And so we framed it through the lens of something that was a priority for them.

0:28:32.5 DA: Once sports started up again, we were like, "Okay, we wanna be able to have people in person at games," because remember when sports first started up again, it was still no fans. We want you to be able to be at games. If we can get to a certain level of vaccination and people will wear masks at games, we can get students back to the games.

0:28:48.0 DA: They were like, "Okay, we're on board, let's do this," and you had fraternities and sororities out there supporting public health measures, not because they were scared they were gonna die, but because they wanted to get back to those football and basketball games.

0:29:00.4 DA: So public health is as much about marketing as it is about the science, and I think that up until now, people have thought of that as being a dirty concept that we've gotta sell ourselves, but we really do, because right now, and consistently throughout American history, people haven't been willing to buy health for health's sake, they've only been willing to embrace it for the most part on a population level when it starts to impact their other priorities.

0:29:27.0 DB: Absolutely, absolutely. I think those lessons are still very relevant for us as we've evolved into a management phase, but I think finding that common ground of just preserving many of the activities and opportunities that we all cherish that were impacted over over the last couple of years.

0:29:45.5 DB: And so thinking about now that as a turning point, did that forever changed your job as the Surgeon General? Were there elements of your job before that... Or your priorities that were already in progress that you are still able to attend to?

0:29:58.3 DA: Everything else came to us screeching halt, just to be honest. And it still in many ways has, and I'm still trying to escape that halt that I was ground to. I went from Jerome Adams, Surgeon General, to Jerome Adams, COVID spokesperson. I literally today, because of the removal of the mask mandate, had been getting blown up by CNN, by NBC, by NPR, not asking me to come and talk about the opioid epidemic, not asking me to come and talk about chronic disease, which is my true area of passionate of interest, and my hypertension Call to Action that I put out.

0:30:33.3 DA: Not to talk about maternal mortality and morbidity, which is another Call to Action I put out, but to talk about COVID. And to talk about COVID as Trump's Surgeon General. And so it changed things because I went from, again, the Surgeon General of the United States, who people think of as being anti-smoking, to Trump's COVID guy, and in many ways it's been to the detriment of our health.

0:30:55.9 DA: We see that cancer screenings are down, we see that diabetes screenings are down, we see that cardiovascular incidents are up for people, we see that mental health issues are worth, all these other things that are still happening are being ignored because of our single-minded focus on COVID, and we've gotta learn how to walk and chew gum at the same time moving forward.

0:31:20.1 DA: 500,000 people die every year from uncontrolled hypertension, which is why I put out a hypertension Call to Action. Remember again, as a leader, identify a problem, identify steps that you can get people to take to actually help address that problem. That was the approach I took with my calls to action.

0:31:36.0 DA: More people die every year from uncontrolled hypertension than die from COVID. That's not to at all to diminish the impact of COVID, but that is to say that we can't afford to ignore hypertension while we continue to address COVID, or we're gonna see more people die than what would have happened otherwise.

0:31:54.0 DB: Absolutely, absolutely. And just thinking about the early phases of the pandemic, there are some things that we got right, there's some things that we got wrong, but it was a very challenging period for all of us because of the uncertainty. One of the things that makes leadership immensely difficult and challenging is when the assumptions that you're making or the projections that you're making are changing so rapidly.

0:32:18.5 DB: If you can go back to that early period and just tell us about your experience leading in the face of uncertainty during that initial period when COVID began to emerge?

0:32:30.1 DA: One of my surprising mentors throughout was Colin Powell. So Colin Powell and I talked on a couple of occasions, and Colin Powell has a famous 40/70 rule. He said, when you're in leadership, you're not always gonna be right, so the first thing you gotta do is wrap your head around the fact that sometimes you're gonna be wrong, but still you've gotta make a decision.

0:32:51.6 DA: And his 40/70 rule says, if you make a decision before you've got at least 40% of the information, you're likely to be wrong. If you wait until you got more than 70% of the information you're likely gonna have missed the moment and your decision isn't gonna have an impact on outcomes anyway.

0:33:08.6 DA: And so interestingly enough, the CDC has frequently been on the high side of that 40/70 rule, they wait so long to actually make a recommendation, that the public has moved on already anyway, they've already decided, "Either I'm gonna do it or I'm not do it," before the CDC actually changes their guidance.

0:33:24.8 DA: In the beginning we were on the wrong side of the 40/70 rule, or the low side, when it comes to masks. And why? Well, it was because we didn't get information in a forthright manner from China about the spread of the virus. Initially, China withheld from us information about asymptomatic spread of the virus, and so we made recommendations based on what we knew about every other respiratory virus up until that point, and that's that you would not have high degrees of asymptomatic spread.

0:33:56.0 DA: If any of you all had the flu and we were sitting in a room together, we'd know it. We'd see it. You look sick, you'd be coughing, you'd feel bad. You would probably self-select not to be there because you would be symptomatic. That's the way most respiratory viruses have behaved throughout the history of this planet.

0:34:14.7 DA: Well, COVID was incredibly different because up to 50% of the people could spread it asymptomatically. China knew that, we didn't... And we knew but we didn't know that health officials were actually being harmed because they couldn't get masks, because there was a supply chain shortage.

0:34:33.1 DA: And so we're dealing with science, we're dealing with lack of information, we're dealing with supply chain, and so based on the information that we had, we gotta go out and to all the American public to stop hoarding these mask because there's no scientific indication that we have that it's a benefit for them to use them if they're the general public, and there's actually harm being done to healthcare workers because they can't get them.

0:34:56.6 DA: So we went out and said it, I tweeted out, "Don't buy masks." Well, guess what? About two weeks later, the news broke from China that we had a high degree of asymptomatic spread. So as soon as that happened, I said, "Look, we have new information, we've gotta change our recommendations to the public."

0:35:12.7 DA: And so I went out, and many of you will remember, that's when I actually showed the public how to make a cloth mask out of materials that you had at home. Because we said we still need to preserve the medical mask for the medical professionals, but there is gonna be some benefit to people wearing cloth mask, and so we said, "Let's recommend that people where a cloth mask if they can get them, and we'll show people how to wear cloth masks."

0:35:35.7 DA: So the thing is, that's exactly how science is actually supposed to work, you make recommendations based on the information you have, and sometimes you're gonna be right and sometimes you're gonna be wrong, but you continue to look for new information to either prove your theory correct or to prove your theory incorrect.

0:35:54.9 DA: And if you get new information that causes your recommendations to change, you go out and you tell people, "Okay, we got new information and we're changing our recommendations." Unfortunately, we were in a highly politicised environment, and we were in an environment where America is not used to seeing the sausage get made, they're not used to seeing science play out in real time, and to understand that that's actually how it works.

0:36:17.9 DA: Consistently, science is actually wrong more than it's right throughout the history of man, but you usually don't see it play out on live TV in real time with direct implications on whether or not you can go to work or school, or what have you. All those things feed into your ability to be an effective leader and an effective public health advocate.

0:36:36.0 DA: Can I get the right information? What are the politics that are going on? Are there external barriers like resources? It's one thing to tell people to do X, right now we tell people, "Look at the mask mandate again that got pulled away." A lot of people are saying, "Well, anyone who wants to wear a mask can just wear a mask, and that fixes everything."

0:36:53.9 DA: Well, guess what? Everyone still can't get an N95 mask. And so there's a resource issue that we have to take into account when we're deciding whether or not to make public health recommendations, because if you don't, then you have inequities. You have the "haves" being able to do things that the "have nots" can't do.

0:37:12.9 DA: Let's look at the Gridiron event that happened recently in Washington, DC. Well, it's all well and good to say, "I'm gonna go and hang out with my buddies," if you know that if you get sick, you can go and get Paxlovid immediately. That's not something that's available to every community.

0:37:29.1 DA: So should we be normalising the idea of people congregating in large groups with the knowledge that a lot of these people who are seeing the leaders do this aren't gonna have the resources to be able to bail themselves out on the back end if they get into trouble? These are what these decisions complicated. And so you want a good team around you, and you wanna make sure that you're on the right side of that 40/70 rule whenever you can be.

0:37:51.1 DB: No, that's right, that is a wonderful advice from Colin Powell that will be useful for many of us as we move forward in our own daily leadership activities. And so you've touched upon something that I'd actually like to ask explicitly, and in part because we receive some input from our students, and I know our students were curious about this.

0:38:12.8 DB: And so I'll frame the question in this way. On the one hand, the mission of the Surgeon General is apolitical, but the person in the position has to operate within a political environment and is themselves appointed by the current President. And so I imagine that as your remarks have suggested, that that must have created a challenging leadership context for you.

0:38:33.0 DB: Our students ask if you can talk about how you navigated politics while also staying true to public health values and principles and training?

0:38:41.8 DA: It's incredibly difficult for anyone in this position, and not just Surgeon General, I used to be health commissioner, and there are health commissioners for all the states and territories, and they are all appointed by their governor. There are things that you can do with a citizen and as a legislature to promote and protect independence.

0:39:00.2 DA: So interestingly enough, I believe it's Mississippi's health commissioner, once you're appointed, then you're there, you got a term, and so you're protected to be able to make decisions without great fear. You can still be recalled. Whereas in most states like Indiana where I was, you make the governor mad and you can be fired in the next five minutes, and so you have to kind of walk that line.

0:39:21.7 DA: The advice I got from a leadership perspective a long time ago from a mentor was to have your resignation letter written on day one. You go into these jobs and you've gotta realise that there's a chance, a good chance that you're gonna have to walk away. And you gotta make peace with that from the beginning.

0:39:37.9 DA: And you've also gotta understand, "What are my parameters? What are my guardrails? What are the benefits that I hope to get out of this job?" And every single day, every single day I was Surgeon General, I would go to sleep and I'd say that I accomplished more good today than harm. And then I'd wake up in the morning and say, "Am I still excited to go to work? And am I still on the right side of that resignation letter that I wrote, that virtual resignation letter that I wrote?"

0:40:02.4 DA: The answer that question was always yes, because if not me, then who? If I'm not Surgeon General of the United States, someone's gonna be Surgeon General of the United States. It's likely not gonna be an African-American who grew up poor in the South with asthma. So while I'm not gonna get everything that I want by being at the table, I'm gonna get 0% of what I want if I'm not at the table.

0:40:27.3 DA: But the politics, they did, they made it tough, and I'll give you a real example that many of you who follow me on Twitter know that I've been talking about a lot recently. Ashish Jha is someone who I know, who I respect. He's in a challenging role right now as the White House COVID coordinator.

0:40:40.9 DA: He was on the Sunday shows this weekend, and they asked him directly, should they have the White Health Correspondents Event? Bit? And he said, "Yes, I think they should have the White House Correspondents Event." He got ripped by a lot of people in the public health community because guess what, they just had a super spreader event at the Gridiron.

0:41:00.5 DA: What I said about what Ashish said, is I said, he fell into that trap that they set up for you, and the media do set you up for these traps of feeling like he had to defend the White House because he was the White House COVID Response Coordinator. How did I handle it? When they would ask me questions about Trump or about Biden or about politics, what I would always do is I would say, "Well look, my job is to be a doctor, and here's what the science says."

0:41:30.5 DA: I would walk them through the science, and I'd say, "Now ultimately it's gonna be up to the individual person or to the leader who's making that decision to decide whether or not they're going to listen to the science. That's not my job to criticise one person or another, it's my job to help them understand the science."

0:41:48.1 DA: And I got ripped for it by many... Probably many of you all. Why? Because you wanted me to rip Trump versus to speak solely to the science. But I also want you to understand in a leadership role where my job is to represent everybody, if I rip people for going to a Trump rally and I'm staying true to the science, then shouldn't I also rip people for going to a George Floyd rally?

0:42:09.4 DA: The science doesn't change, you're still gathering people in the midst of a pandemic. It's not my job to make value judgments about why people are going. It's my job to say, "Hey, this is a high-risk environment. Or this is how you calculate your risk, and this is how you protect yourselves."

0:42:26.7 DA: That was the approach I personally took, and it allowed me to stay in there and to feel good at the end, that I was talking from a place of being a physician and of the science, versus of a political place. I know we're running out of time, but I wanna tell you all a really funny story about how politics impacted me, and I was staying true to the science and to what I knew to be true.

0:42:49.6 DA: When Joe Biden had finally beat up Bernie Sanders to be the Democratic nominee, Joe Biden said, "If you elect me President of the United States, I promise you I will enact a national mass mandate." Joe Biden said that, you can look it up. Said it on like a Thursday night, and then on Sunday, I was on the Sunday shows, just like Ashish Jha was this weekend.

0:43:11.6 DA: I was on Face the Nation with Margaret Brennan, and she said, "Dr. Adams, Joe Biden says when he becomes President of the United States, he's gonna enact a national mass mandate. Donald Trump doesn't believe in mask. Who's right?" That's what they asked me, and I said, "Look," I said, "here's what you need to know, and I walked them through what I actually walked you all through with our changing knowledge about mask."

0:43:32.4 DA: I said, "And I want people to know that wearing a mask will protect you and I wanna encourage people to wear a mask." I said, "But here's the problem, we don't have the public health authority on the federal level to enact a national mask mandate, unless we're willing to send in the Army to start arresting people for not wearing masks. We don't have the federal authority."

0:43:50.2 DA: I said, "So I'm gonna work with governors, I'm gonna work with local officials to help them understand the statistics, help them understand what they can do to keep their community safe." I said that, I felt good about that. I got ripped to shreds by the Democrats. True story. Axl Rose, Guns N' Roses, famously called me a piece of shit, and it went viral on Twitter. Don Cheadle actually attacked me. D.L Hughley attacked me.

0:44:13.0 DA: So a King of Comedy, an Avenger, and a rock god, all attacked me and said I should resign because I didn't support Biden's national mask mandate. Well, here we are almost a year and a half into a Biden administration. Do we have a national mass mandate? No. As a matter of fact, we've gone backwards on masking. Why? Because they don't have the federal authority to enact a national mask mandate.

0:44:35.8 DA: As a matter of fact, a judge just yesterday said you don't even have the authority to do a mask mandate on federal property, or on federally controlled property. So I told the truth, I gave a scientifically sound answer and I still felt good about it, but I got ripped to shreds because many people were viewing the science through their political lens.

0:44:57.9 DA: And it's challenging, but I deal with it by saying, "I'm gonna speak to you as a doctor, not as a politician, and you can judge me and you can make up your own mind, but I can hold my head up high at the end of the day if I do that."

0:45:11.6 DB: This space of media activity, it plays such an important function for our public. And you as the "nation's doctor", played a central role in that. I am making some assumptions, but I would imagine that you didn't get training in media relations in medical school.

[chuckle]

0:45:29.6 DB: And so you've talked a little bit just about your, some tactics that you developed and how you approached it, but from a preparation standpoint, what did you do to get yourself ready to step into that space, which is on the one hand, so important, but also filled with many risks and vulnerabilities?

0:45:48.3 DA: I was very fortunate, and again, going back to my experience with professional societies, in many cases, those professional societies will give you leadership spokespersons training. And so I've done that a couple of times with the American Society of Anesthesiologists, with the American Medical Association.

0:46:06.1 DA: It's sometimes a half-a-day session where you're sitting down with media experts who are teaching you how to be a spokesperson for public health or for anesthesia, or for whatever issue you care about it. So I actually had had some training, and I actually was also just the second Surgeon General in history to have had formal experience working in a health department, the other one was Joycelyn Elders, who was Bill Clinton's health commissioner when he was the Arkansas governor.

0:46:30.6 DB: And so I had experience on a state level talking about HIV crises and talking about lead contamination crises and talking about Ebola and Zika, so I've had professional experience and some training coming into it, and the irony is, I say this with all humility, I was probably one of the most prepared people ever to be Surgeon General of the United States. When you also look at the fact that I was just the second Surgeon General to actually have formal training in public health, to actually have an MPH. On top of the fact that I ran on a state health department and worked in a local health department, and it still was just overwhelming in terms of what came at you.

0:47:09.9 DA: But try to utilise those different opportunities that you have through out your career to take leadership spokesperson training, because even if it's in the hospital or at a local level or in your community, it's gonna help you be a more effective advocate. The other thing that I did was I just tried to be true to me. So when I was standing at the White House, I said a prayer, I said a prayer before I would go on TV.

0:47:33.2 DB: I'd say, "God, please give me the wisdom to be able to speak to people in a way that resonates with them and to tell them the truth," and I would always also remind myself, "Your mother's watching, so speak to her in a way that would make her proud and speak to her in a way that she would understand." And so that was my approach.

0:47:51.7 DA: I always tried to be genuine and authentic and to speak to people the way I would speak to my mother and my father, my neighbours. That was an approach that worked for me. Tony Fauci actually is very professorial, and he and I were very different, but we were a good team.

0:48:07.1 DA: When Tony speaks, you know you're speaking with someone who's got 40, 50 years of experience in what he's talking about. We had different approaches because we're different people, but that was my approach to things, and I always figured if I go down, I'm gonna go down being me.

0:48:19.9 DA: Absolutely, absolutely. So perhaps time for a final remark, but we find ourselves in April, you're on an academic campus beginning of graduation season, and even for us here at Michigan next week we'll be celebrating our graduates and thinking of other students that we have who are continuing, and others who we'll be welcoming into the school. But what advice do you have for students who are just entering the field of public health, based on your many years of experience?

0:48:48.8 DB: Well, my advice is to be encouraged. The greatest advances we've had in health policy in this nation have come during times of war and crisis. When you look at the revolutionary changes in transfusion therapy after World War I. Antibiotic usage in Word War II. The first Operation Warp Speed was the massive production of penicillin that actually saved millions of lives during World War II. When you look at the changes in trauma care that occurred after the Gulf War.

0:49:19.3 DA: We're now at a time, a pivotal time, where people are talking about public health, they're paying attention to public health. They're looking at telehealth as a way to increase access to people. They're talking about better data collection. They're talking about how do we communicate with people? They're talking about vaccines.

0:49:34.9 DA: There are people like Dean Bowman and myself who spent our entire careers just trying to get an audience. Trying to get people to pay attention to some of these issues. Everybody's talking about them now. There's never been a more exciting time, a time when you can impact change more in public health in my lifetime.

0:49:52.7 DA: So as depressing as it can seem, as frustrating as it can seem, also know that if you leverage your skill set, your experiences, if you become a good spokesperson, you can really influence change in a way that many people who've come before you haven't had an opportunity to do so.

0:50:10.2 DB: Very well said. So that brings us to the end of today's session, a very insightful and enlightening session, but we're just now about out of time for Ahead of the Curve, and I'd like to thank Dr. Jerome Adams for taking the time to be here with us today, for sharing some really great insights just from your own leadership experiences in your really impressive and still evolving career.

0:50:34.1 DB: So thank you again, Dr. Adams, thanks to all of you who joined us for this conversation. Be well, stay safe, and I'm sure as our Boilermaker would appreciate in this session, to our audience, Forever Go Blue.

[chuckle]

0:50:47.5 DA: Take care everyone. Thank you so much.

[music]