Compassion, Care, and Caution on the Front Line: Interview with Duncan Selbie

Compassion, Care, and Caution on the Front Line: Interview with Duncan Selbie

. 10 min read

Professor Duncan Selbie is president of the International Association of National Public Health Institutes (IANPHI), which brings together 115 institutes from 98 countries. He is also chief adviser of the Public Health Authority of Saudi Arabia. His UK public service career spanned 41 years in Scotland and London and, from 2012 to 2020, he was chief executive of Public Health England.

Before you were appointed as the chief executive of public health in England as well as the President of IANPHI, you had worked in many different roles and layers of the healthcare system. Can you explain how these experiences affected your transition from working in a more broad medical field to working in public health?

I joined the NHS in Scotland in 1980, 43 years ago. I started at the very bottom of the system and went through all the different layers. Eventually, I became a chief executive in psychiatry when I was 34 or 35. Then, I became the chief executive of the new strategic health authority in southeast London, and then the first Director General of Performance and Planning for the NHS, and then commissioning, and then I led in a trauma center. From there, I went to join Public Health England.

Now how on earth do you move on to public health? It was the first time that in England, all of the public health services [had] been brought together, embracing both health protection and health improvement. And interestingly, what we call health care, public health, is looking at variations, outcomes, costs, and priorities, and so on. It just felt really exciting. It was something that hadn't been done before. I'd been a chief executive of a number of organizations, and after a number of years, I felt that I could offer something. In a very un-British way, I knew how to build teams that were capable of doing extraordinary things. I knew that in public health, they had extraordinary people, but we needed to build a team capable of doing extraordinary things. So Public Health England was that opportunity and I led it from 2012 as the founding chief executive until midway through the pandemic in 2020.

Could you describe how your experience working in England translated when working with your current organization on an international scale?

Yes, it was during Ebola in 2014 when Public Health England got involved in Sierra Leone in the way that the US and France were. The focus for Great Britain was Sierra Leone, and Public Health England did half of all the field testing there. We sent hundreds of our team over to Sierra Leone. At the time, we were concerned about having enough people, given the heat and the circumstances, to keep the beat going with the testing. I had to write to colleagues around the world to ask if they could deploy staff to England where we would train and support them in West Africa, and it felt really odd to me.

So I got involved in IANPHI, which is the international gathering of National Public Health Institutes. It's the world's gathering of Public Health England’s if you might, and I spent the next seven years going out and meeting colleagues around the world – the U.S., China, Pakistan, India, various countries in Africa, and Japan. Public health is, as we've learned through facing the pandemic, completely interdependent. One part of the world gets a cold and the rest of us [get] it 40 hours later. So I first got involved because of that learning through the Ebola experience, and as a consequence, I eventually became the treasurer of IANPHI, and then I was elected as the president in December 2020.

Coming in as president in 2020, such a pivotal time for IANPHI and global healthcare in general, can you describe some of the leadership challenges that you had to navigate on an international scale?

Obviously, what we learned in the first 12 months is very different [from] what we learned in the second year in how we were searching for and understanding each other's positions and sharing knowledge about what was working. The debate was about how none of us knew how this virus was. We simply did not know that you could have asymptomatic transmission of the virus, and there was no vaccine, no treatment that we were confident about. We were variably ready around the world in regards to testing and tracing. We weren't interoperable in the sense that we weren't able to share information, understand that we were looking at the same data and that [it] had the same meaning to all of us. So we held webinars, we held events, we did a laminate exercise, and we've published that. It was a lot of pastoral care in being able to speak to directors, leaders and public health systems all over the world who were going through a time that no one had ever expected and very few have ever experienced.

One of the great truths about when people say what they would have done is that you can agree with them that they may well have handled things differently. And they may well have handled things better, but the only difference between them and the people that are on the frontline is that we were there and they weren't. Governments and public health advisors were making good decisions, and they were making bad decisions. And it was the same people that were making these decisions. So when we think about what we have learned from this, it is to look out for and after the people that were making these difficult decisions, because if there were easy decisions to take, then the world would have been obviously better prepared and responded in a better way. So it's possible to be incredibly proud about what happened [while] recognizing that actually, we weren't ready, and that there was an awful lot that we had to learn. And when you asked me the question about what do we do differently next time? Hopefully, we can see what we benefited from this time.

I would like you to talk a little bit more about how our response to COVID-19 will affect how we respond to future pandemics, such as the speed at which we can respond, the decision making process negotiations, and the infrastructure. Given recent worries in the media about climate change and interspecies interactions, there's been discussion about the possibility of a future pandemic. How concerned do you think we should be about this emergence of a new pandemic, and would we be ready to respond to it better than we did for COVID?

In history, we've had chronic underinvestment. Understandably, health care is what you immediately see if you're a member of the public or a politician or a decision maker. You see the cancer center, or the fast access, or the improving outcomes, the access to new medicines, and so on. If you don't see it, it's because it's doing its job, and you only have time to think about it when something terrible has gone wrong. There's a cycle that I will call “panic and forget.” And there might be a middle bit which says “panic, respond, and forget,” [that] the world keeps on doing. This time, the world is more prepared. How do we make sure that in three or four years time, where memories have receded, that we are getting back into that old cycle of the next time, because there will be a next time? Can we be more confident we will be more ready?

There are conversations going on in the world that I am fully engaged in about what we call collaborative surveillance or integrated surveillance. These are two different ways of saying the same thing, which is how we ensure that every country in the world is capable of quickly recognizing when there's an outage and responding fast, sharing information and knowledge in a common, interoperable way. These are all big words, essentially, to say that we [should] know quickly and share fast when something unusual is happening in the world. We used to think that was about laboratories only, and that laboratories would tell you when something was unusual, but what we've discovered through the pandemic is the importance of wider data, for example, social media, shopping habits, transport, and challenges of transport, so that we get a much better understanding of what's going on when there's an outbreak. Then, the second event would be like a Batman phone all over the world, which allows us to speak to each other. We would have a standing capability of experts, laboratory scientists, epidemiologists, behavioral scientists [who] are available so we don't have to start up – we have it ready like an emergency corps.

If you fail to prepare, prepare to fail. We need to invest in preparedness. If we wait until it's gone wrong, it costs way more than if we had invested in preparedness for when it goes wrong. And it's not that it won't go wrong because things do go wrong. We used to call it "an ounce of prevention is worth a pound of cure." You know, something your mother might have explained to you. The world has not been prepared. The world has not been connected, it hasn't been concerned with how we are going to act. But something happens in India and 24 hours later, it will hit Chicago, or London, or Paris. Then there's the whole scene for which we didn't think enough about. We didn't think enough about the most vulnerable. It's always the case that the most vulnerable get hit the hardest when something has gone wrong. So if we don't take care of the poorest in the world, then the more prosperous will never be safe. There's concerns about the Global South and how we get the infrastructure and support into countries that are less well off. Not only because that is morally an important thing to do, but [also because it is] economically necessary for the world.

You mention global cooperation and having a system in place so that when something happens, everybody is ready to respond. I know not every country is a member of IANPHI, so is IANPHI seeking to expand to more countries? Or if you're working across borders, what are some of the challenges associated with the different governmental styles?

IANPHI was born out of SARS. 15 years ago, it started with 30 members. It was supported financially by the Gates Foundation, and the US CDC. Over the last 15 years, it [became]115 members in 98 countries. The COVID experience has brought an explosion of interest in National Public Health Institutes as a part of a more sustainable response to health and health security. Every institute in membership of IANPHI is part of the government, so you can't separate politics from public health. IANPHI and the members of IANPHI are not think tanks or university departments, as important as they are. They are organizations that are both informing and implementing government policy in public health terms.

Our ambition, along with the WHO's, is that every country in the world has the capability to respond to what we call the essential public health functions, which are determined by the WHO. We are not saying that every country needs to have a National Public Health Institute, because that’s a structural response. What we are saying is that every country should have the capability to deploy essential public health functions. As you mature, having a National Public Health Institute is a very good thing, because that's like the focal point where you bring science and politics together. Our ambition is to strengthen public health institutes where they exist in the world, and to build infrastructure where it doesn't yet exist. We have four regions: Latin America and the Caribbean, Europe, Africa, and Asia. The principal contribution is what we call peer-to-peer support. Senior professionals from one country get alongside another country and help them together to build whatever the priorities are there. This is not a consultancy or a profit thing. There's no charge for doing this other than logistics costs of traveling, and so on. We aren't yet inclusive of the whole world, and my ambition is that that's what we achieve over the next five to ten years.

Can you describe the new partnership that you have with the World Health Organization and how that has affected the infrastructure negotiation?

The World Health Organization and IANPHI are completely aligned because the World Health Organization exists to improve the health of the people of the world. I've talked about protecting people, but you've also got to be concerned with the improvement of the health of the people through vaccines and immunization programs, through primary care programs, and so on. The COVID experience said that we have got to get health security right. But you can't have a secure population or protected population unless you have a healthy population. You can't have an economically prosperous world unless you have a healthy world. Health and wealth are two sides of the same coin and the World Health Organization brings that together. It's a team effort [with] so many actors in the world. IANPHI has a contribution, because we bring together the National Public Health Institutes of the world and others who recognize that. We signed an agreement in October at the World Health summit in Berlin to work together on a program looking at the future of the workforce for public health. Public health is the only health discipline that has not been classified by the WHO, so we need to change that so that we can create jobs, pay them properly, train and develop them, and give them a career. Countries have to make up their own idea about what public health work is. Technically, integrated surveillance can operationalize theory into practice. There's not much of a point in having a gold standard surveillance system that only a subset of the world can use. We need a surveillance system that all of us can use, so we need to be very thoughtful about how to operationalize clever thinking. The WHO has asked that we work on that and the emergency preparedness and response. I mentioned this idea of creating a standing capability in the world of scientists and public health professionals, behavioral scientists, people who know how to influence [and] communicate, so that we have preparedness.

I'm going to Geneva in two weeks’ time to spend two days with the WHO, to work through how we will take these ideas and make them implementable. There's something very special about plans that are country-contextual through peer-to-peer support. It's got to make sense to the country involved, not what we think [they] should do. For some plans, we hope they will work, but in reality, when we come to use them, they don't. We certainly can't be in the same position as we were in 2019.

Cao spoke with Selbie on February 26, 2023. This interview has been lightly edited for length and clarity.

Cover Photo courtesy of Public Health England.