Exploring the spiritual foundations of public health leadership

The Covid-19 pandemic has laid bare the challenges of public health leadership. Faced with criticism, threats, and even violence, many public health leaders have left the field. A healthier future for the nation may well rest on training aspiring public health leaders to build deeper capacity for perseverance, healing, and resilience. Reflecting the growing experience of a team of public health educators at the Harvard T.H. Chan School of Public Health (Harvard Chan), this article offers recommendations for public health schools to recognize, and incorporate into leadership education, themes of spirituality—ie, the way people seek ultimate meaning and purpose and deep connectedness to something larger than themselves. Doing so can serve as a foundation for the lifelong journey of leadership. Over the past decade, Harvard Chan has incorporated meaning, purpose, and connectedness themes to complement more traditional coursework addressing research and translation. While many established leadership frameworks address the “what” and “how” of career development, the spirituality framework can support aspiring leaders to more fully understand their “why” and its alignment with challenging work. Such a deeply personal topic, traditionally kept private, has been shared and nurtured in Harvard Chan classrooms through a range of pedagogical strategies including personal reflection, one-on- one coaching, experiential learning, case discussions, and candid conversations with public health leaders. By encouraging a values-based foundation for decision-making in crises and difficult leadership moments, such grounding can help aspiring leaders navigate the challenges of public health leadership that inevitably lie ahead.


Introduction
Covid-19 has laid bare the challenges of public health leadership.Through the pandemic, leaders struggling to provide health guidance to an anxious public have endured searing experiences involving harassment, threats, and even violence (1).Such unsettling and even traumatic episodes have contributed to a steady exodus from the field (2,3).According to some estimates, at least 500 top national and local public health leaders had, just a year into the pandemic, resigned or been fired (4).Moreover, almost half of the state and local public health workers left their jobs (4).
The nation's ability to not only weather such health crises but also build better systems for the future may well rest on explicit training to build motivation, stamina, and resilience for aspiring leaders (5).In this article, we describe how one public health school has attempted to achieve such goals by steadily incorporating themes of meaning, purpose, and connectedness into leadership education.Such themes can be broadly captured under the term "spirituality, " defined in an international consensus conference as "a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred" (6).For some, spirituality involves connection to organized faith traditions.For others, it involves connection with a cause or some significant entity that is greater than themselves.People can be spiritual but not religious; indeed, those who identify as atheists and agnostics can be, according to this definition, highly spiritual.But for all people, such themes are deeply personal, often rooted in cultural upbringing, and/or associated with major life experiences that shape values and beliefs (7).
To date, public health leadership educators have largely overlooked these themes.A review of the literature shows virtually no attention to the spirituality theme as part of public health leadership education.Over the past decade, however, our teaching team at the Harvard T.H. Chan School of Public Health (Harvard Chan) has steadily curated a curriculum that explicitly calls out meaning, purpose, and connectedness as fundamental to leadership.In this article we briefly describe this approach and its rationale, together with reflections on ways such spiritual dimensions might complement other leadership competencies more frequently noted in the published literature (8).

Public health leadership education and spirituality
Leadership poses extraordinary challenges for public health, a field in which highly complex and seemingly unsolvable problems characteristically abound.Often enormous in scale and impacting populations broadly, public health challenges usually, if not inevitably, fall outside the control of a single authority in volatile and politicized setting that involve passionate stakeholders, powerful vested interests (9) and controversies about how best to distribute finite resources to address infinite needs (10).Moreover, the field, by definition, requires performing "on stage, " with leaders subjected to intense scrutiny and where everything is "fair game for comment, criticism, and interpretation (or misinterpretation)" (11).
Despite these challenges, only 55% of accredited public health schools offer any kind of course on public health leadership (12).Even when they do, the emphasis is more often, as noted by Ganz, on external strategy ("head") and action ("hands"), and less often on the personal narrative of motivation ("heart") (13).However, Sinek advocates "starting with why"-ie, "working from the inside out"-as a way for aspiring leaders to ground their work and actions in a foundation of meaning, purpose, and connectedness (14).Guiding one's work in this way also equips students to better connect with the "who, " ie, the "Ps" of public health-that include policymakers, purchasers, and the press, not to mention passionate advocates and penurious budget officials (5,9,15).In this way, leaders can better recognize the source of both their motivations and biases, persevere through crises (9), include other voices in collective action, navigate uncertainty, and ultimately find renewed and deeper meaning and purpose.Solidifying this foundation readies them, in a way current training systems may not, to lead teams, organizations, and systems in whatever the future befalls them.
A recent national expert panel has similarly urged more integration of the worlds of spirituality and health, given growing evidence of their strong links (16).One relevant meta-analysis of 10 prospective studies of ~136,000 participants associated a high sense of purpose in life with a reduced risk for all-cause mortality and cardiovascular events (adjusted pooled relative risk = 0.83) (17).Another recent comprehensive study by Balboni et al. (16) analyzed the century's nearly 600 highest-quality related studies (2000-2022) on the subject and associated spirituality with greater years of life and health-related quality of life.
Public health can also learn from other sectors that have demonstrated the value of incorporating spirituality themes in enhancing leadership.In business, for example, Fry and colleagues have found their model of spiritual leadership in the workplace linked to greater organizational commitment and productivity (18) through a heightened sense of "engagement of the whole person, " belonging, and life satisfaction (19).In medical education, the concept of finding a sense of professional belonging has been called "socialization into profession" (20).The field of public health may be particularly amenable to such themes, as it inherently features a sense of mission and calling, especially through difficult times like a pandemic.
Encouraging public health students to share the origins of their "why" in classroom discussion may free them to let down their guard, "bring their whole self " to discussions, and convey authenticity and transparency.It can also provide a means to connect to a shared sense of purpose, promote empathy, build genuine curiosity and appreciation for others' motivations, and cultivate the sense of interdependence so elusive in the vitriol of the pandemic (21).This approach has the potential to advance for students the overarching educational goal of fostering "confidence in their authentic self rather than trying to adhere to a prescribed definition of leadership" (22).
Addressing the "why" in the classroom to understand diverse views and belief may lead some students to share strong personal beliefs of faith and religion.For some listeners, that may trigger discomfort and concerns about inclusivity and vulnerability; indeed, explicit expressions of religion may be helpful for many while hurtful for many others.However, it can be argued that such sharing in a student-centered approach can offer healing in the midst of difficult conversations regarding issues of pain and even trauma.Frankl has noted, that "life is never made unbearable by circumstances, but only by lack of meaning and purpose" (23) and as noted by Miller, Gupta, and others, many religions highlight themes common in public health, regardless of specific faith (24,25).From his personal teaching experience, the lead author of this paper regularly asks students to reflect on if, and how, spirituality has impacted their public health leadership journey.In general, students appreciate direct conversations about spirituality, although some have also been explicit about how religion has negatively impacted their lives.Meanwhile, theologians from different denominations regularly emphasize themes of human interconnectedness, service to others, and discovering deeper meaning in difficult times.Thich Nhat Hanh noted "our own life has to be our message" (26).Martin Luther King noted that we are all a part of "…an inescapable network of mutuality, tied in a single garment of destiny.Whatever affects one directly, affects all indirectly" (27) and William Sloane Coffin urged that we should "care most for those society counted least and put last" (28).

Integrating spirituality themes into health leadership education at Harvard Chan
Over the past decade, Harvard Chan has encouraged students to clarify their meaning, purpose, and sense of connectedness as a foundation for their professional journey.
Introduction to the topic starts on the opening day of orientation, where faculty note that a sense of vocation and mission can be integral to the profession.In fact, in an orientation poll, when students are asked to choose between "I never thought I would be attending a public health school but here I am" versus "I always knew I wanted to attend a public health school, " the results, routinely 2:1 in favor of the former, regularly spark discussions about calling and vocation as part of a public health career.Students can dig deeper in the related orientation workshop "Calling to Public Health," where they share values and beliefs that fuel their professional aspirations.
Harvard Chan also offers additional optional opportunities for students to explore their leadership "why."The non-credit Public Health Leadership Lab, a semester-long co-curricular program with weekly workshops, provides students a venue to develop a greater understanding of their motivations through shared reflection.Such workshops focus on attentive listening to self and others as a basis for understanding organizations and systems.Faculty model how listening can serve as a powerful method of staying connected to one's purpose and that of others.Interested students can also seek peer coaching as well as executive coaching by seasoned mentors.Moreover, several elective leadership courses allow students to pose questions about motivation, meaning and purpose to guest speakers with storied public health careers captured in case studies.Qualitative program evaluation through classroom feedback surveys and course evaluations are used for continuous curriculum revision.
In addition, the Doctor of Public Health (DrPH) program starts each cohort with a year-long development course on "personal mastery, " one of five disciplines identified by organizational leadership expert Peter Senge as essential to leading large-scale systems change (29).Personal mastery emphasizes clarifying one's vision, values, strengths, and weaknesses through the lens of connection to purpose, self, and others.Other DrPH courses focus on leading teams and addressing systems change.And the culminating doctoral project requires a leadership development statement grounded in students' purpose and values.
Bennis, for example, emphasizes that the best leaders are ones that can reframe crucible experiences-i.e., intense, unplanned and traumatic experiences that make one deeply question one's values and identity-to emerge stronger than before.Such themes reinforce writings by Nouwen who celebrated that the search for deeper meaning during tough life experiences can motivate wounded people to serve as "wounded healers" (11,45).Such reframing additionally allows leaders to stay grounded in mission while developing the "existential flexibility" (46) essential for the challenges ahead.Such skills can complement the updated 2022 Lancet Commission Report on the future of public health education, which underscores the need for leaders who can leverage a range of competencies as part of their "education for life" (8).

Discussion and recommendations
"I used to think that leadership just required learning about leadership skills, but now I think that leadership development is a lifelong process that requires active and ongoing reflection." (47)

-Harvard T.H. Chan Student Feedback, May 2022 Program Evaluation.
Harvard Chan's leadership curriculum, while evolving over a decade, is still embryonic.To our knowledge, few, if any, published articles explore the link between public health leadership and spirituality.We hope that sharing our perspectives will prompt national dialog on how to further explore and support such fundamental and deeply personal themes for future public health leaders.
To promote future dialog, we propose that schools of public health consider the following recommendations to prepare leaders: -Provide more opportunities for self-and systems-awareness practices in public health leadership education.-Build a classroom culture of belonging where students can comfortably share their inner selves and listen respectfully to others share theirs as a way of building empathy, respecting differences, and even managing difficult conversations.-Offer experiential learning opportunities in which exploration of self, purpose, and relationships are prioritized as much as traditional instruction in research methods and theories.-Invite public health leaders to speak openly about their inner lives, their sources of support in navigating uncertainty and complexity, and their practices for healing.-Build more explicit competencies in clarifying and refining values, purpose, and motivations for public health leadership work.Adding attention to spirituality could be considered for incorporation into future CEPH public health accreditation related to leadership competencies (48).
Frontiers in Public Health frontiersin.org

Conclusion
Students should not be left on their own to develop leadership skills essential to address pandemics and other highly complex challenges.Our experiences offer a way forward for public health schools to support students in exploring spirituality themes of ultimate meaning, purpose, and connectedness to something greater than themselves.In our view, such training has great potential to strengthen a foundation that encourages students to take the leap of faith that public health leadership necessarily entails.