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Public Health Leadership in Challenging Times: Learning from the Past and Preparing for the Future

Public Health Leadership in Challenging Times: Learning from the Past and Preparing for the Future

and welcome to the Voices in Leadership, a series focusing
on science and leadership. I am Betty Johnson, and
I have the privilege to direct this program and
to introduce today’s guest. Dr. Margaret Hamburg is an
internationally recognized leader in public
health in medicine, where she is known for
advancing regulatory science and modernizing
regulatory pathways. From 2009 to 2015, she served as
the 21st commissioner of the US Food and Drug Administration. She was also the founding vice
president and senior scientist at the Nuclear Threat
Initiative, a foundation dedicated to reducing
nuclear, chemical, and biological threats. Her other positions
have included Assistant Secretary for
Planning and Evaluation, Health Commissioner
for New York City, and Assistant Director of the
National Institute of Allergy and Infectious Disease. As Foreign Secretary for the
National Academy of Medicine, Dr. Hamburg is
the senior adviser on international matters and
liaisons with other academies of medicine around the world. She is president-elect of
the American Association for the Advancement
of Science, as well as an elected member of the
Council on Foreign Relations in the National
Academy of Medicine. She also serves in various
advisory roles, including the Harvard University
Global Advisory Council and the Scientific
Advisory Committee by the Gates Foundation. A graduate of both Harvard
College and Harvard Medical School, Dr. Hamburg
is the recipient of many awards and
honorary degrees, too many to mention
in this setting. Although she has been
on Forbes magazine list of 100 most powerful
women in the world, her real joy and honor comes
in being one of the 20 most powerful moms. Hopefully, she can explain a
little bit about that to us today. Before I turn this session
over to today’s interviewer, Dr. Michelle Williams,
dean of the faculty, please join me as we
welcome Dr. Margaret Hamburg to the
Voices in Leadership Series at the Harvard T.H.
Chan School of Public Health. Thank you. [APPLAUSE] MICHELLE WILLIAMS: Dr.
Hamburg, thank you and welcome to our school, and thank
you for joining us here for this conversation
this afternoon. We are really
delighted to have you. And I also want to
extend a warm welcome to our audience that’s online. So I have the privilege of
starting this conversation with you this
afternoon, and I wanted to start with an easy question. You served six years in
one of the toughest jobs, admittedly, in government,
as the commissioner for the Food and
Drug Administration from 2009 to 2015. And we’re all curious, what
in your tenure as commissioner of the FDA did you
see as the greatest challenge in that role? And if you could
tell us a little bit, the story of how you were
addressed that challenge, or those challenges? MARGARET HAMBURG:
Well, first let me say it was really
a privilege to be the commissioner of the Food
and Drug Administration. It was a very hard job. I don’t disagree that
it’s one of the hardest jobs in government and
perhaps one of the most underappreciated in terms of
just how important and unique the FDA is. I mean, I really in
this era of government bashing would like
to say that I think FDA is a great example
of government in action to serve the people. Most people don’t
even understand that the FDA actually oversees
products that represent about close to $0.25 of every
dollar that consumers spend on products and things that
really matter to people, you know, from the time
you get up in the morning, to when you go to bed at
night, the food you eat, the drugs you take, the
devices you may need, just such an array of products
and important information for consumers to know. It’s a hard job because,
number one, you are overseeing such a broad range of
products and activities because you have such a
diverse and committed set of stakeholders and
constituents for the work you do and the decisions that you make. It’s also at the sometimes
treacherous interface of public health, science,
medicine, and politics. And it’s a job where
the decisions make a huge and enduring difference
in the lives of individuals and families, like
about a drug that may treat a serious, if not
potentially lethal, disease, or the pocketbooks of
stakeholders and shareholders and companies. So everything you
do is scrutinized. And you are operating
absolutely in a fishbowl. For me, what enabled
me to do the job was the sense of
commitment to the mission. FDA is a science-driven,
regulatory agency with a public health mission
to promote and protect the health of the
American people. And I think what I feel
the most proud about and what really was
the driving goal that I had was to really restore
trust and confidence in the FDA and its important work through
lots of different programs and activities in lots
of different ways. But when I came on board,
FDA was, I would have to say, sort of embattled. There had been a series of
crises, some drug safety issues, some
food-borne outbreaks. Congress was hauling up
the leadership of the FDA to hearings. The media was scrutinizing
and pointing fingers. The political environment
was very charged. And FDA had sort of
circled the wagons, and people didn’t want to
stick their necks out for fear that they might get
their heads chopped off. And I felt it was really
important, number one, to open up the agency,
to explain what we did, how we did it, and why. If people can’t see
what you’re doing, don’t understand what
you’re all about, then they are more likely
to revert to suspicion. But if they understand,
even if they don’t like the
decisions you make, I think that it does build
trust and confidence. In addition, I felt
it was crucially important to make sure
that the work of the FDA was driven by the
best possible science. And that isn’t to say that
you always have all the data that you need to make
hard, complex decisions. But if you don’t use science as
your North Star, so to speak, you can get buffeted about by
all the competing priorities, the different
stakeholders, the politics. And so that was
another critical issue was to drive forward
on the basis of science to build stronger science
within the walls of FDA and importantly to engage
with academia and industry scientists to continue
to build and extend a strong scientific
foundation for FDA’s work. MICHELLE WILLIAMS: I’m so glad
that you are shining the light on how important it is
to improve the public’s perception on the importance
of science in decision-making. I think we’re at
a place in history where many of us in
academia and in science are wondering if we are doing
well enough in communicating the relevance, the importance
of science and evidence to decision-making. Could you share with
us a concrete example of how you were able to break
through to a general audience this relevance, the
importance of evidence in your decision-making
capacity as commissioner? MARGARET HAMBURG: Can I go back
to when I was commissioner of– MICHELLE WILLIAMS: Sure. MARGARET HAMBURG: The health
department in New York? There are some
examples from FDA also. But for me, it was a
profound experience when I was in New York
City’s Department of Health to see a hard decision being
made on the basis of science. And because it was early in my
career, it sort of, I think, helped me as I move forward. And this was not a
decision that I made. It was actually a decision
that Mayor Dinkins made. And he was the mayor that
hired me in as commissioner. And he actually– I
probably shouldn’t tell this story
in this setting– but he had to go to
City Council and change the charter because
I didn’t have a master’s in public health. And instead they put in
language about a master’s in public health or
equivalent experience. But this had to do with the
issue of needle exchange, which was very controversial
at the time. And Mayor Dinkins is the
first African-American mayor and someone committed to the
African-American community in New York City and beyond,
had very strong views about needle exchange, and
was very, very concerned that needle exchange
actually enabled continuing intravenous
drug abuse that had been so devastating to so many. And he had campaigned
against needle exchange. And when he became
mayor, he actually dismantled the one very
small needle exchange program that was operating in the city. But there was an article
in The New York Times on the front page
about a study– dare, I say it–
from Yale University that was heralded as the
first quantitative study that showed that needle exchange
actually reduced HIV infection. And he called me
up, and he said, I want you to look
at this study, because if it’s really true,
we may need to rethink. And I was actually acting
commissioner at the time. I wasn’t officially
commissioner. And I thought, wow, you
know, surprising, because he was so adamant on this issue. So I put together
a little task force that included a number of
people, some of whom I knew were trusted by the
mayor, for example, someone who headed the Health
and Hospitals Corporation and had worked with
the mayor for years, some academic
leaders and others. And we looked not
just at that study, but the whole literature
around needle exchange. And I went back to
the mayor, and I said, the evidence is compelling, and
needle exchange can and should be done to reduce
HIV transmission, but in a context
that’s comprehensive, that ensures linkage into other
important medical and social services that gives addicts,
not just the opportunity to have clean needles
and protect themselves from infectious
disease, but also to get linked into drug
treatment services and other important services. And I’ll never forget
when he made the decision to allow needle exchange
programs to go forward. At the press
conference, he could not say he supported
needle exchange. He said he was relaxing
his opposition. But the critical
thing was that he as a non-science or medical
or public health professional said we have to look at
the data to save lives. And there were a lot of people
that were mad at him, mad at me too, about this
decision and didn’t think it was the right one. But I had enormous admiration
that he was willing to do that and that we were able to provide
the scientific data to support an important program
going forward. MICHELLE WILLIAMS:
That’s a great example of how important it is
to have the evidence and have that inform
tough decision-making. I wanted to go back and ask
about your leadership style that you aimed– in leading the FDA, you
took a deliberate decision to lead the FDA in having
a global influence. And I wondered if you
could share with us in the process of doing that
very big, bold leadership decision to take for a
very important agency, what leadership style
did you take on? Was there a particular leader
or mentor in your career that you elected to emulate in
taking on such a large task? MARGARET HAMBURG: Well,
that’s a really big question. And I want to sort of divide
it up into two questions. One is how when you start in a
new important far reaching role do you sort of set your
priorities, your vision, and how to take on
your leadership role? And it was interesting,
because a lot of people, some
former commissioners, and some others just
savvy in Washington ways said, FDA is such a huge and
bureaucratic organization, most FDA commissioners
don’t last but about two years in modern history. Don’t think that you’re going
to be able to really get that much accomplished. So decide on a few
discrete things that can be done in a relatively
short frame and pursue those. And I came in and I looked
at the FDA and where it was and what needed to
be done, and I just felt there was no choice but to
really take on some big tasks and really try to reposition
the FDA for the 21st century and beyond. And that meant you know really
focusing on building out the science as we talked about. And it meant also really
looking at how did FDA work. It focused on rebuilding
trust and confidence that we’ve also touched on. And it also meant
recognizing that FDA operated in a globalized
world, and that if we were going to fulfill
our mission of promoting, protecting the health
of the American public, we could only do it by finding
new ways of working globally. It was a shock to
me when I got there to learn that the
drug and device side, 40% of finished
drugs used in this country are actually made abroad. 80% of the active pharmaceutical
ingredients in those drugs was coming from other countries. Somewhere around 40%
of medical devices were being made in
other countries. On the food side, the numbers
were equally startling. About 50% of fruits
and nuts were coming from other countries. About 85% of seafood coming from
waters outside of our borders. And I might add
that those are some of the most vulnerable foods
to contamination as well. And there was just no choice. We couldn’t pretend that we
could use the old approach that the FDA had
really been mainly focused on of screening things
as they come across the border. 50 years ago, 75 years
ago more realistically, it might have made sense
that you could say, take that tub of
molasses off the ship and we will inspect it and then
bring in the full shipment. The only way that we could
really make a difference was to reach outside
of our borders, collaborate more
with both counterpart regulatory authorities
and also industry, but also in some instances to
help build regulatory capacity, particularly in
developing economies where a surprisingly large
percentage of these products were coming from, because the
stronger the ability to provide safe, quality products from the
very beginning, the stronger that capacity was, the
better off we were. And so we really worked hard
to create new collaborative relationships to
share information, in fact, to share workload,
because other countries were having the same problems, not to
the degree that the US was just because of the nature
of our country. But everybody was
struggling with how can we protect the health and
safety of our populace when products are coming
from all over the world through these complex
supply chains. So we actually tried to
create a whole new mechanism for global governance as well. And progress is being made. It takes time. And the world is only
getting more complicated. But one of the things
that I worry about frankly in this current
political environment is that we not let a strong,
nationalistic focus cloud our vision about what needs to
be done in terms of the fact that we live in a
globalized economy. And I don’t think
that’s going to change. MICHELLE WILLIAMS: So
America first really is not incompatible with
global collaboration. MARGARET HAMBURG: And then
in terms of leadership style you asked about, I mean, I
think everybody has to find their own leadership style. And you have to be
true to who you are. And I was sometimes criticized
because people wanted me to pound the table more. But that isn’t my style. My style is a much more
sort of, dare I say, gracious leadership style. I like to listen and learn
from those around me. I like to try to move
towards consensus. I know that I don’t
know everything that is important for the job. So I also like to ask questions. Someone once described me
as being a steel magnolias. But you know, you have to have
your own style, your own voice. And I think for
whatever reasons, my style at that moment
probably was an effective one. And I’m very mission driven. Really that sense of
purpose and commitment– and working at the
FDA, the employees are amazing in terms of their
dedication and integrity. And I just every day
felt proud to work there and proud to be their leader. MICHELLE WILLIAMS: That’s great. I have a question
here that is related to the definition of healthy. So the Food and Drug
Administration currently has an open comment period
for public suggestions for revisions to the current
definition of healthy, both from the broadest
sense and also in reference to front of package
labeling on food products. And I’m wondering, are
you at all surprised by this phenomenon? And what do you think it means
for the FDA and public health as a whole to be reconsidering
the definition of healthy in 2017? MARGARET HAMBURG: Well,
I think, first of all, it reflects the fact that the
public is much more concerned about issues of
health and wellness and what can
individuals do to make smart choices for their
health and the health of their families. And the amount of
interest in the work that FDA did in the
nutrition area was enormous. But it’s a hard challenge. And it’s not just the
definition of healthy the FDA has been asked to
grapple with but also natural. And in some ways you’re
getting into the existential. But I think it’s one thing to
create a regulatory definition for what criteria have to
be met for something to have a certain label or
promote in a certain way. It’s another to actually
answer the whole question. But it’s much harder
than you would think. And I think it’s
still up to science to help us better understand
what are the things, if you just look at
nutrition for example, the science around
nutrition is very confusing. And the studies are hard to do. And the database has to
be constantly renewed. But even some of
the debates around– one of the surprisingly
controversial issues that I dealt with
as FDA commissioner was updating the
nutrition facts panel on all processed food and many
other foods that you purchased. And the issue of whether
sugar should just be amount of sugar
in the product or whether it should
specify added sugar, because as you
probably all know, many food products have sugar
in them naturally, milk, fruits, all kinds of things. But then often when
the product is made, there’s additional sugar
or sweetener added. And we thought it was
important for people to understand what amount of
added sugar was in the product because that essentially
represents empty calories. But it was very controversial. The final recommendation
was to pull out added sugar. That, I think, is still being
debated in many quarters. And there may be modifications. But I think my goal
is commissioner and I think the appropriate
role for the FDA is to provide consumers with
information that they want and need to make choices. And then people can
make the choices that they want about
the food that they eat. But it’s good to
have information. MICHELLE WILLIAMS: Thank you. I am going to change gears
and go back to a comment that we heard at the
beginning of the session about your being voted
the 20 most powerful mom. And we’re approaching
Mother’s Day. And we have an audience
filled with individuals I know from discussions
about work life balance. And I wonder if you could
speak to that a little bit and share with us how
you’ve managed in these very tough jobs, both as
commissioner of New York Health, but also FDA, how you’ve
managed your leadership responsibilities at
such broad, open stages, but also managed to have
the outstanding career achievement of being the
20 most powerful moms. MARGARET HAMBURG:
Well, one thing about leadership I’ll just
say as an aside that you learn quickly is that once
you leave certain roles, you’re no longer on of the
100 most powerful women or 20 most powerful moms list. So I don’t have that title
anymore, I don’t think. But, you know, it is hard. And balancing all the
different pressures in life is the hardest task. And I was mentioning earlier
that my children are now out of the house, but
my elderly parents are now living with us in our
home, so that you sort of never get out from under. But I think that
one of the lessons is we all have to
help each other. And the question of
leadership styles, I mean I learned to delegate,
not only because it enabled me to go to my kids’
recitals or events or get home at a decent
hour, but also because that’s how you help new leaders grow
and how you recognize people’s accomplishments
and capabilities. And it’s how you manage a
really complex workload. I think you also have
to learn to prioritize. And one of the things
that I always felt was one of my great
assets as FDA commissioner was that actually because of
my experience in New York City, I learned to know when
something was a real fire and when there was
just a lot of smoke. And I saw a lot
of people burn out just constantly going crazy
over crises that weren’t truly crises. And in fact, they made it worse. So learning how to put things
in perspective, et cetera. Learning that sometimes you are
going to disappoint somebody either at work or
at home and trying to have a track record where one
disappointment didn’t undermine your credibility. And I think one of the things
that I tried hard at FDA to do with to make it OK to be
achieving balance in your life. I was very struck
the first week that I was at the FDA, which starting
that job was pretty terrifying, I’d have to say, but
I was going home. And it was like around 7:30
night and I had kids at home. And I encountered a couple
of people in the hall, and I said, well, I
guess I’m the one that’s going home early. And these were two
men I might add. But one of them
said to me, well, you shouldn’t tell people
that you’re going home, you should say you’re
going to an event. And I said, no, I’m
going to tell people that I’m going home,
and you should go home, because you have two
young kids at home. And I think the leader
can set a standard also that there’s no shame in
caring for your family. MICHELLE WILLIAMS:
Was there a leader or a mentor or some
network that you count on in coming to this conclusion
that you just shared? What were your touchstones
when faced with these balance questions in your career? MARGARET HAMBURG:
Well, I was really fortunate in that I had
two parents that I loved and admired and were incredibly
supportive to me growing up, but also had remarkable careers. And I learned a lot about work
life balance watching them. And also in terms
of leadership style, I think your earlier
question as well, so not everybody is as
fortunate as I in that regard. And I would say that
one of the things that was a disappointment to me when
I was training in medicine here at this great institution
when I was at Harvard Medical School, that there weren’t
a lot of role models. And I didn’t see a lot
of people that I sort of said I want to be like them. And I think, number
one, my sense is that medical
education actually has been undergoing some
changes and it’s better now. But it certainly has
made me especially as the arc of my career
is moving more to the end, it’s made me committed
to really trying to be a mentor and a role
model and to reach out to young people at earlier
stages of their career and whatever I can do both
to provide some wisdom and insight, but also to help
open some doors because it really does matter. MICHELLE WILLIAMS: Yes, it does. I know that as you are at
this stage in your career, you have been considering
and are actively searching on a number of
boards and foundations in continuing your
leadership contributions on a global scale. And I wondered if you could
share with our audience, what are some of the things
that you think about as you take on these initiatives
and new responsibilities? MARGARET HAMBURG: Well, this
is an ongoing challenge. When I left the FDA after six
years of really hard work, gratifying work, but I
was pretty exhausted, I made a very conscious
decision that I didn’t want to make another
institutional commitment, another major leadership
role for a period. I wanted to let my experiences
sink in and consolidate and wanted to think
about where I really wanted to spend the
next years of my life and what focus I wanted. And I was warned, don’t
commit to things too quickly. But I went from this intense
job to not having a lot of activities. So people asked me to do things
and they sounded interesting and I said yes. And then before I knew it, my
dance card was pretty full. There also seems to be
a phenomenon of nature that all boards and advisory
groups meet on the same days. And I would like
someone to figure out that scientific issue
and a solution to is. But I’m now finding that
I’m much busier than I ever wanted to be. I have the luxury of working
now on a range of issues and with a lot of
organizations and institutions that I care about. But I’m still struggling with
this question of it’s one thing to have what I’ve now learned
is called the portfolio life, where you’re doing
a lot of different things, and that institutional identity
sense of purpose and mission that comes from one job that
you’re living and breathing 24 hours a day. And I do miss that
intensity, I’d have to say. I do miss that sense of
really making a difference. Every morning when I got up and
every day when I went to bed, I knew exactly what I
was focused on and why. Here, it’s more diffuse. But you can make a
difference in a lot of ways. And I’m still struggling. You know, you think
at a certain point your career everything is set,
but it’s a continuing process no matter how old you
are, no matter what you’ve accomplished. You’re always
living and learning. MICHELLE WILLIAMS:
I remember when we were talking earlier you
said that you let things unfold. And that’s so compatible,
your response. This sort of thinking about
having the events unfold. MARGARET HAMBURG:
And the truth is that I never dreamed that
I would pursue the career path that I pursued. I mean, it would
probably be quite amusing to go back and
look at the letters that I wrote when I was
going to medical school, because I thought I wanted
to be an academic physician. I thought I wanted to do either
reproductive endocrinology or endocrinology. I wanted to teach. I wanted to take
care of patients. And I wanted to do research. Then I started medical
school, watched the HIV/AIDS epidemic unfold. We were literally taught as
first year medical students that the era of
infectious diseases was more or less over with the
advent of vaccines and drugs. And then this strange,
inexplicable disease that nobody knew what caused
it, nobody knew what to call it, and we certainly had
no treatments for it, and then by the time I was a
medical resident in New York City taking care
of so many patients and watching them all
follow the inevitable course towards death,
really made me think about the intersection
of medicine with broader social,
legal, ethical issues. It made me think also much
more about public health, because as I mentioned,
I didn’t have an MPH. I hadn’t really been exposed
to public health in the way that I think students now are
much more in medical school. And I’m really
sorry that I wasn’t. But I didn’t really learn about
public health until till later. And it was the
AIDS epidemic that brought me into public
health and health policy and altered my
career inexorably, but I think in ways that have
been profoundly rewarding. And hopefully, I’ve been
able to make a difference. MICHELLE WILLIAMS: I
think we’re all delighted that Mayor Dinkins did
work to change the charter, because although you didn’t
have the credentials, you’re taking on large issues,
like TB control, health services for women and
children, in those early days in your career in New
York was very much frontline public health work. So thank you for
sharing that story. MARGARET HAMBURG: When I became
Health Commissioner in New York City, my Great Aunt
Winnie, who was sort of like my grandmother,
was really upset though. She said, why can’t she
just be a regular doctor? Why is she throwing away? Because in her
world, being a doctor was the best thing you could do. And my father sort
of said, well, she is still a real
doctor, but now she’s got eight million patients. MICHELLE WILLIAMS: Populations
at a time with orientation towards prevention. I wanted to ask– I’m hearing, seeing that
we should be wrapping up. And so I’m going to
not ask the question I was planning but
will ask you a question that I know our
students in the audience and Fellows in the
audience are eager to hear. And I wonder if you would– across your impressive
career, you’ve offered just here some valuable
stories of leadership lessons. And I wondered if we could
end if you could share with our audience two
leadership strategies that you relied on, rely on
in the course of your career in leading these large,
important agencies. MARGARET HAMBURG: Well, I think
one is a sense of partnership and collaboration. Get the people in the room that
know the most and the people in the room who have
the most at stake. And really listen and learn
and try to craft a policy is one strategy. You can’t always do that. And you certainly aren’t
going to make everybody happy whatever you do. An important leadership
lesson is that not everybody is going to like you. And that was a hard one for
me in the very beginning. But it just is true. But you have to know that
you’re making choices based on the best
possible information. And I think integrity,
I think that’s just– you can’t get away
from the importance of being trustworthy and having
integrity about who you are, about the work you do,
about how you make decisions and how you lead. MICHELLE WILLIAMS:
Very important. I want to take this
opportunity to thank you for spending the time
with us, with our audience here in the studio and
our audience online. And if you could
join me in thanking Dr. Hamburg for her time
and her warm responses to our questions. [APPLAUSE] ANNOUNCER: If you are interested
in supporting this program and others like this
from the Leadership Studio at the Harvard T.H.
Chan School of Public Health, please call 617-432-1318
for further information. [MUSIC PLAYING]

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