Addressing Public Health through Economic Opportunity — A Conversation with Jack Markell on Effective Public Service
By Alex Goodson
Leadership requires vision. The idea itself is not new, but as circumstances change, so, too, does the vision required. Former Delaware Governor, Jack Markell, summed up this idea in a recent visit to the Harvard T.H. Chan School of Public Health. “It is very important,” he affirmed, “that everybody who’s in an executive leadership position in government have a very clear view of how the world around us is changing.” Jack Markell and Professor Gina McCarthy joined students and faculty in the Voices in Leadership studio on Tuesday, March 5, 2019, for a lively conversation on improving public health through public service and leadership.
Markell took an unconventional path to his two terms as Governor of Delaware (2009–2017). A native of Delaware, Markell earned his undergraduate degree in Economics and Development Studies at Brown University and completed an MBA at the University of Chicago. He stayed in Chicago to work in banking at First Chicago Corporation before moving on to hold senior leadership positions at Nextel Communications, Inc. and Comcast Corporation. Beginning in 1998, Markell was elected to three consecutive terms as the Treasurer of Delaware before becoming the Governor in 2009. These experiences gave Markell the preparation he needed to lead his state from the financial collapse of the late 2000s to economic recovery today.
Addressing societal problems through economic opportunities
Markell’s approach to public service and leadership draws upon his years of experience in the private sector. Even as he illustrated his idea that leadership requires having a perspective on how the world is changing, Markell highlighted his own need to have a perspective on how globalization and automation would specifically affect the people of Delaware.
Markell’s accomplishments as Governor in the area of public health are notable. In 2010, Delaware won President Obama’s “Race to the Top” competition for investment in education, and in 2016 the National Association of the Board of Education named Markell “Policy Leader of the Year”. As Professor McCarthy noted, what is especially unique about Markell is how his vision of leadership includes seeing many of today’s public health concerns as economic opportunities.
Empowering women through birth control
In 2014, Markell and Mark Edwards of Upstream USA rolled out Contraceptive Access Now, a plan to reduce the rate of unintended pregnancies in Delaware. Markell shared that in 2011, at 57%, Delaware’s rate of unintended pregnancies was significantly higher than the national average of 45%.
The majority of unintended pregnancies in the United States end in unintended births, which for many people can mean dropping out of school or the workforce. This, in turn, results in lost personal and societal opportunities. Unintended pregnancies can also mean additional healthcare costs, as the parents and babies are less likely to receive prenatal care and more likely to require interventions in the neonatal period and beyond. Markell argued that there are real human and societal costs of not supporting women in the timing of their own pregnancies. He maintained that:
“the most important thing we [can] do to help all people achieve their potential [is] really to empower women to have their babies when they [are] ready for them.”
In response to Delaware’s high rate of unintended pregnancies, Markell worked with Upstream and the healthcare sector to facilitate the utilization of long-acting reversible contraceptives (LARCs). A LARC is a form of contraception, such as an intrauterine device (IUD) or an implant, that is effective in preventing pregnancy for three or more years or until removed. LARCs are notable for their high reliability as contraception. Markell explained that since a woman taking oral contraceptives daily for 10 years has a 61% chance of getting pregnant — often due to inconsistencies in actual use of taking the medication — LARCs drastically lower pregnancy risk by eliminating the need for daily medication compliance.
Because of this initiative, the utilization of LARCs in Delaware doubled between 2014 to 2016. Markell asserted that this has led to a 24% reduction in unintended pregnancies in Delaware, as compared to a 3% reduction documented in other states.
Building on the momentum developed by Markell, Upstream, and their Delaware coalition, other states are now following suit and partnering with Upstream to improve access to contraceptives. Now that Delaware has provided proof of concept, Massachusetts, Washington, and North Carolina are currently continuing this work.
Spending wisely on criminal justice
Early in his tenure as Governor, Markell recognized that the criminal justice system was “broken” — it was locking people up but was not making Delaware any safer. In 2011, Markell created the Delaware Justice Reinvestment Task Force, a bipartisan group of legislators, judges, and representatives of the criminal justice system that, in collaboration with the Vera Institute of Justice, would help Delaware move towards an evidence-based criminal justice system. An antiquated approach to criminal justice, among other burdens, was creating unnecessary costs for the state of Delaware. Markell opined:
“…I think it’s becoming pretty well accepted that our criminal justice system is pretty much broken, that we lock people up. It doesn’t make us safer. They’re not getting rehabilitated. And we’ve got to think differently.”
Together with the Vera Institute and the Task Force, Markell sought to address shortcomings in the existing criminal justice system that ranged from the prison population’s large size to high rates of recidivism. As part of their background work, the Vera Institute and the Task Force found that 23% of Delaware’s prison population — nearly 40% of the women and 20% of the men in jail — were actually being held pretrial. In response, Markell’s Task Force provided judges with instruments and data that would help them assess which pretrial detainees did not warrant detention and could avoid immediate incarceration. To prevent recidivism, the Task Force incentivized pre-prison-release training by rewarding participation with reduced prison sentences (e.g. by 1–2 months) and incentivized good post-release behavior with decreased supervised time. In just three years, Delaware saw a 33% reduction in pretrial detention.
As Markell considered criminal justice reform in Delaware, he situated his initiative in the context of a growing effort to make these reforms at the national level. Notably, Markell highlighted how expansive and bipartisan the issue is becoming. Reflecting on his invitation to speak at a conference sponsored by the Koch Brothers with the support of the American Civil Liberties Union (ACLU), he observed: “when you can find issues where you get groups like the Koch brothers to work with the ACLU, you know that something’s going on.”
Engaging the potential of people with disabilities
Reflecting on his tenure as Treasurer of Delaware, Markell shared that one site visit made a particularly lasting impression. While visiting a local bank that often employed people with disabilities, he conversed with a 25-year-old employee living with Down Syndrome who was excitedly going about his work. When Markell asked the young man what he had done before this job, he was struck by the young man’s answer: he had sat at home watching TV with his parents. Now, not only was this young man happy outside of his home working, but his job was also giving both him and his parents more independence and contributing to the economy.
Fast forward some years later, and in 2012, Markell used his term as Chair of the National Governors Association (NGA) to champion the employment of people with disabilities by beginning an initiative called “A Better Bottom Line: Employing People with Disabilities”. This initiative involved identifying barriers to employment and working with individuals and employers to overcome those barriers. Markell sought advice from long-time disability advocates such as former Senator Tom Harkin (IA) and garnered bipartisan support for his initiative. He noted that it was actually some of his peers on the other side of the aisle — such as prominent Republican Governors Scott Walker (WI), Terry Bransted (IA), and Dennis Daugaard (SD) — who became this initiative’s biggest advocates.
Certainly, Markell and his fellow governors recognized that employment could be a means of empowerment and an important step towards autonomy for individuals with disabilities. He asserted that “it’s really important that we prepare our young people with disabilities for an expectation of a lifetime of employment.” Markell also argued that the employment of people with disabilities is an economic opportunity for employers, individuals, and the State. As Governor, he noted that many of his conversations were with employers looking for employees or unemployed individuals looking for jobs. He believed that jobs needed to be filled by the best people, which included individuals with disabilities. To help connect people and opportunities, Markell worked with Delaware’s Division of Vocational Services to help connect people with disabilities to employers to strengthen the state’s employment makeup.
Making changes happen
In the aforementioned examples of Markell’s accomplishments as Governor, a common theme arises: the confluence of individual opportunity and economic interests. The issues Markell addressed — reproductive rights, criminal justice reform, and employment of people with disabilities — are significant public health concerns. Yet, he addressed them with an approach that is sometimes less commonly seen in the area of public health: an emphasis on individual opportunity and economy.
To understand what is unique about this approach, consider the very tempting alternative. Instead of using pragmatic language and explaining these public health concerns as problems of individual opportunity and economy that have logical solutions, Markell could have explained his initiatives and their importance using normative statements. He could have built coalitions, for example, around shared a priori values: that contraception should be accessible, that civilians should not sit in jail unnecessarily, and that people with disabilities should have employment because we believe they should. But the question lingers as to whether such values-driven arguments for access to contraceptives, for prison reform, or for ending employment discrimination would engender the concrete changes Markell accomplished.
As Markell explained, he was drawn to public service — and state politics — because he wanted the chance to help people go as far as they could. It may be that Markell’s real vision as a leader was to recognize the difference between language that relies upon shared a priori values and language that builds coalitions among people with different backgrounds and different values. By articulating the importance of these public health concerns in terms that could garner bipartisan support, he may have done more towards improving these areas of public health than would have been possible otherwise. In this era of politics, when finding common ground feels increasingly difficult, an aspiring public servant would do well to learn from Markell and consider the value of a pragmatic approach.
Story by Alex Goodson, a Master of Public Health student at the Harvard T.H. Chan School of Public Health. Alex received his Bachelor’s degree from Washington University in St. Louis and is currently a medical student at the University of Missouri — Columbia. Alex is interested in the relationships between medical education, the organization of healthcare delivery and patient health outcomes.
Story edited by Sherine Andreine Powerful, a Doctor of Public Health student at the Harvard T.H. Chan School of Public Health. A Diasporic Jamaican, she received her Bachelor’s degree from Yale University and holds a Master of Public Health degree from Columbia University. She is interested in gender and sexual justice in the English-speaking Caribbean, as well as resilience and anticolonial sustainable development in the context of climate change.
