Liberation Health and the Role of the Public Health Leader

doi:10.4236/ojl.2013.24012

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Open Journal of Leadership

2013. Vol.2, No.4, 82-84

Published Online December 2013 in SciRes (http://www.scirp.org/journal/ojl) http://dx.doi.org/10.4236/ojl.2013.24012

Open Access

Liberation Health and the Role of the Public Health Leader

Courtney Keeler

School of Nursing and Health Professions, University of Sa n Francisco, San Francisco, USA

Email: [email protected]

Received September 12th, 2013; revi sed Oc to ber 2nd, 2013; accepted October 9th, 2013

tribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the

original work is properly cited.

The following short report lays the groundwork for rethinking the practice and implications of public

health leadership in the context of liberation health. Liberation health reduces to a universal idea: health is

freedom. In short, everyone holds a subjective notion of health and, within certain bounds, has the right to

promote and maintain that health. This report briefly describes liberation health, discusses the implica-

tions of liberation health for public health leadership, and outlines two needed transformations in moving

towards a liberation health model of leadership. The report details areas for future research on this topic

among public health leaders and within public health curricula.

Keywords: Healthcare Leadership; Leadership in Public Service; Ethics and Leadership; Leadership in

Education and School; Religion and Leadership; Theories of Leadership

Introduction

As Wiley Souba suggests, the status quo of the United States

healthcare system is unsustainable (Souba, 2013), making the

role of the public health leader difficult. Albert Einstein defined

insanity as “doing the same thing over and over again and ex-

pecting different results”. In the context of the many ongoing

transformations in healthcare driven by a complex array of

factors, including the Affordable Care Act, we have an oppor-

tunity to break the cycle of insanity; nevertheless, we need a

paradigm shift to achieve a more equitable and sustainable

system. Building on Souba (2013), we must not only alter how

we think about healthcare but also, necessarily, reframe how we

think about healthcare leadership, and, within the setting of this

report, specifically public health leadership.

The World Health Organization (WHO) believes that public

health encompasses “… all organized measures (whether public

or private) to prevent disease, promote health, and prolong life

among the population as a whole. Its activities aim to provide

conditions in which people can be healthy and focus on entire

populations, not on individual patients or diseases. Thus, public

health is concerned with the total system and not only the

eradication of a particular disease” (WHO, 2013). Distinct from

the practice of medicine, public health practitioners seek “… to

promote population health through shared responsibility, or-

ganized efforts, and managed care” (Holmes Jr., 2008: p. xxiv).

The following report lays the groundwork for rethinking the

practice and implications of public health leadership in the

context of one possible model—liberation health. Liberation

health also presents an opportunity for reevaluating public

health curricula, and, resultantly, rethinking how we train future

public health leaders.

What Is Liberation Health?

Increasingly, effective public health leadership requires ef-

fective health facilitation and advocacy. Many successful public

health leaders mirror Greenleaf’s (1973) profile of a “ser-

vant-leader.” According to Greenleaf (1973), “… the only au-

thority deserving one’s allegiance is that which is freely and

knowingly granted by the led to the leader in response to, and

in proportion to, the clearly evident servant stature of the leader.

Those who follow this principle … will freely respond only to

individuals who are chosen as leaders because they are proven

and trusted as servants, (Greenleaf, 1973: pp. 3-4).

Augmenting the tenets of servant leadership, liberation health

draws from the broader concept of liberation theology, which

rallies us to “listen first and foremost to the voices of those who

suffer” (Campbell, 1995: pp. 1-2). While the religious context

of liberation health may unsettle, the pricklier and more conten-

tious theological indications quickly fade, leaving a secular and

universal idea: health is freedom. In short, everyone holds a

subjective notion of health and, within certain bounds, has the

right to promote and maintain that health.

Campbell describes two types of freedom: “freedom from” or

negative freedom and “freedom to” or positive freedom. He

explains, “Negative freedom consists of not being prevented

from carrying out one’s wishes … Positive freedom, on the

other hand, describes an internal as well as an external state, a

state in which one is enabled to carry out one’s chosen purposes,

to control and direct one’s own life, and to reevaluate and

change that life according to values that transcend individual

wants and desires—values gained through interaction with oth-

ers,” (Campbell, 1995: pp. 12-13).1

Therefore, the production of personal freedom in health

1To a greater or lesser extent, the boarder community influences individual

definitions of health. Akerlof’s social interaction theory implies that indi-

vidual health behaviors and definitions of health result from

oth a social

and individual decision-making process (Akerlof, 1997). As Campbell

suggests, each individual has his or her own definition of health and he o

she individually chooses health behaviors that promote or hinder that health

nevertheless, social networks (e.g., family, peer groups, community) shape

what behaviors are socially acceptable. Resultantly, social interaction im-

acts individual perceptions of health and health freedom as well as one’s

ability to achieve freedom in health choices.

C. KEELER

choices results from a system of checks and balances. In eco-

nomic terms, communities seek to limit negative externalities

(e.g., secondhand smoke) and encourage positive externalities

(e.g., vaccinations).

So, how do public health leaders fit into this picture? Camp-

bell proposes that “The freedom we are looking for is not some-

thing others can grant, but it may be made possible by the way

we make ourselves available to one another…” (Campbell,

1995: p. 15). Most public health officials will tell you that their

constituents can identify the health problems plaguing their

communities; however, too many communities simply do not

have the resources to enact change. Therefore, “it is essential to

listen…,” (Campbell, 1995: p. 18) to one’s community. Moving

away from a paternalistic model, the good public health leader

listens and helps community members facilitate the change

needed to enable health equity, where community members

have the freedom to pursue and maintain health. Therefore, “…

proven and trusted as servants” (Greenleaf, 1973: p. 4), libera-

tion health indicates that public health leaders can affect so-

cially just change through facilitation, attention, and awareness.

Enabling Transformation

Taken together, servant leadership and liberation health

challenge our perceived notion of public health leadership,

emphasizing that, at some level, public health leadership is in

fact public health facilitation. Liberation health spurs us to ask:

how can those working in positions of public health leadership

promote and maintain individual and community ideals of

health?

While our health care system continues to undergo quite a

few changes, transformation is necessary. Unlike change, which

improves something that is already possible, “transformation is

a function of altering the way you are being—to create some-

thing that is currently not possible in your reality” (Souba, 2013:

p. 45).

At a macro-level, system-wide factors impede the broad im-

plementation of liberation health principles. Souba (2013) em-

phasizes the instability of our healthcare system. Importantly,

many Americans simply cannot attain (or afford to attain) de-

sired health behaviors. For instance, even following Massachu-

setts’s landmark health legislation, many in the state still cannot

afford healthcare (Clark et al., 2011).2 While health equality

may be impossible, the optimal healthcare system should ide-

ally be equitable. Liberation health stresses that every individ-

ual should have the ability to pursue health behaviors of her

choosing, which would be possible in an equitable regime.

Prior to any system-wide transformations, public health

leadership must also evolve. As suggested by this report, lib-

eration health offers one of many possible templates.

In moving towards a liberation health model of leadership,

two transformations must take place. First, public health leaders

must embrace socially just, client-centered systems of practice,

where communities freely participate and serve as active stake-

holders in the process. Second, baccalaureate and post-bacca-

laureate curricula must reflect this practice.

First and foremost, however, we need to evaluate whether

our goals and missions align (both practically and ethically)

with the tenets of liberation health. In this process, we must

reflect on our vision at an aggregate and individual level. As

McKee and colleagues write, “Having a personally inspiring

vision helps [one] see how [one] can make a positive contribu-

tion to the world. What makes the world a better place for

[oneself] being with us? The answer to this question is probably

linked to [one’s] sense of calling, mission, and purpose in life,”

(McKee et al., 2008: p. 73). Is liberation health the right ap-

proach; and, if so, how can we promote this transformation?

An Example of Liberation Health in Public

Health Practice

Mobilizing for Action through Planning and Partnerships

(MAPP) offers a practical example of liberation health. An

important caveat, MAPP does not directly incorporate libera-

tion health by name into its framework nor does the National

Association of County and City Health Officials (NACCHO), a

champion of MAPP, reference liberation health. Rather, I iden-

tify a common theme in the MAPP process and liberation

health, namely the acknowledgement of a community driven

characterization of health and the struggle to realize that health

through community involvement and partnerships.

NACCHO describes MAPP as “… a community-driven stra-

tegic planning process for improving community health. Fa-

cilitated by public health leaders, this framework helps com-

munities apply strategic thinking to prioritize public health

issues and identify resources to address them,” (NACCHO,

2013a, emphasis added). Notably, MAPP reflects a community

directed process, where community members have the opportu-

nity to define health in their own terms as well as identify and

tackle obstacles inhibiting this health. Inherent to the MAPP

process, being an effective public health leader means being an

effective health facilitator, advocate, and servant-leader.

NACCHO provides a wonderful outline of the six, iterative

stages of the MAPP process on their website; each of these

stages resonates with the liberation health philosophy. For in-

stance, the initial, “organizational phase” of MAPP involves the

creation of likely and unlikely community partnerships; these

champions shepherd transformations within the community

(NACCHO, 2013b). During the subsequent “visioning phase,”

leaders “[guide] the community through a collaborative, crea-

tive process that leads to a shared community vision and com-

mon values” (NACCHO, 2013c).

Public health departments across the country are increasingly

turning to MAPP as a strategic planning tool, perhaps signaling

that the public health community is ready for a transformation

broadly along the lines of the liberation health philosophy.

Conclusion and Future Research

Health is freedom; liberation health simply formalizes this

premise. Everyone holds a subjective notion of health and,

within certain bounds, has the right to promote and maintain

that health. Based on this philosophy, effective public health

leadership requires facilitation, attention, and awareness.

Discussing the convergence of morality, politics, and health

policy, Morone highlights “… that classical political wisdom:

build a constituency” (Morone, 2005: p. 21). Liberation health

emphasizes that this relationship runs both ways. While public

health leaders lead their constituents, they also have a funda-

mental responsibility to listen and facilitate. Paraphrasing

2Clark and colleagues (2011) write, “We found that nearly a quarter o

adults who were in fair or poor health reported being unable to see a doctor

because of cost during the implementation of the reforms.”

Open Access 83

C. KEELER

Open Access

Greenleaf (1973), public health leaders must be true and trusted

servants.

In moving towards a liberation health model of leadership, I

discuss two necessary transformations, the first among public

health leaders and the second within public health curricula.

Both arenas present opportunities for future research.

For instance, in terms of public health leadership and public

health practice, one might consider whether organizations, and

equally importantly, organizational leaders, who embrace lib-

eration health philosophy experience improved patient/client

outcomes and higher levels of productivity.

Reflecting on the next generation of public health leaders,

public health education presents another prospect for novel and

important research. To what extent do colleges and universities

incorporate the idea of “health as freedom” into their public

health curricula? Do students who graduate from programs with

a liberation health focus become relatively more successful

public health leaders? Do these students hold an elevated com-

mitment to social justice? Does incorporating topics like MAPP

into the classroom curriculum enhance student credibility from

the perspective of potential employers and community partners?

Liberation health closely aligns with cultural competency; does

discussing issues like cultural competency and stereotype

threats (Steele, 2010) in the context of liberation health aug-

ment student learning? As MAPP and other liberation health

analogues emerge in public health curricula, researchers can

attempt to answer these questions. Indeed, some opportunities

for this research at the university level likely already exist.

Acknowledgements

Thanks to Judith Karshmer and Kia James at the University

of San Francisco.

REFERENCES

Akerlof, G. A. (1997). Social distance and social decisions. Economet-

rica, 65, 1005-1027. http://dx.doi.org/10.2307/2171877

Campbell, A. V. (1995). Health as liberation: Medicine, theology, and

the quest for justice. Cleveland, OH: Pilgrim Press.

Clark, C. R., Soukup, J., Govindarajulu, U., Riden, H. E., Tovar, D. A.,

& Johnson, P. A. (2011). Lack of access due to costs remains a

problem for some in Massachusetts despite the state’s health reforms.

Health Affairs, 30, 247-255.

http://dx.doi.org/10.1377/hlthaff.2010.0319

Greenleaf, R. K. (1973). The servant as leader. Ann Arbor, MI: Uni-

versity of Michigan.

Holmes, L. (2008). Basics of public health core competencies. Sudbury,

MA: Jones & Bartlett Publishers.

McKee, A., Boyatzis, R. E., & Johnston, F. (2008). Becoming a reso-

nant leader: Develop your emotional intelligence: Renew your rela-

tionship: Sustain your effectiveness. Boston, MA: Harvard Business

School Press.

Morone, J. A. (2005). Morality, politics, and health policy. In Policy

Challenges in Modern Health Care (pp. 13-25). New Brunswick, NJ:

Rutgers University Press.

National Association of County & City Health Officials (2013a).

MAPP Framework.

http://www.naccho.org/topics/infrastructure/mapp/framework/

National Association of County & City Health Officials (2013b).

MAPP—Framework: 1. Organizing.

http://www.naccho.org/topics/infrastructure/mapp/framework/phase1

.cfm

National Association of County & City Health Officials (2013c).

MAPP—Framework: 2. Visioning.

http://www.naccho.org/topics/infrastructure/mapp/framework/phase2

.cfm

Souba, W. W. (2013). The science of leading yourself: A missing piece

in the health care transformation puzzle. Open Journal of Leadership,

2, 45-55. http://dx.doi.org/10.4236/ojl.2013.23006

Steele, C. (2010). Whistling Vivaldi: And other clues to how stereotypes

affect us (issues of our time). New York: WW Norton & Company.

World Health Organization (2013). Trade, foreign policy, diplomacy

and health: Glossary of globalization, trade, and health terms.

http://www.who.int/trade/glossary/story076/en/