Now in my 73rd year, I have the benefit of looking back on decisions that affected the direction of my life. As a schoolboy, I was attracted to the law but a strong dislike of Latin, then a requirement to study law, lead me to enrol as a medical student. Many years later with a successful career as a paediatrician in academia, the politics of South Africa lead me to change direction and move into health management after 1994. Twenty years later, I ended my management career, retiring as the Head of the Western Cape Department of Health. An unplanned course but as the title of my valedictory address delivered at the University of Cape Town, my Alma Mater, in 2015 indicated, it was “The Road Well-Traveled” influenced by a series of decision points, some planned. and some unexpected.
Decision points in leadership both personal and professional are often influenced by people, circumstances, logic and emotion. The ability to remain balanced, evaluate advice and criticism that is offered, welcome or unwelcome, and then act, is essential. The art of reaching compromise even with those who are the most uncompromising speaks to real qualities of leadership. Similarly the ability to stand firm on my core beliefs, at all times maintaining my integrity despite the buffeting of circumstance, strengthened me during difficult times. Not all one’s decisions, especially with the benefit of hindsight, will be correct but if honestly made they can be justified as the best that could have been made at the time. Similarly once aware that a decision is at fault, the ability to acknowledge and then correct the error is the mark of a good, if not great leader.
It may seem strange to juxtapose President George W Bush’s book, Decision Points published in 2010 and President Barak Obama’s book, A Promised Land published ten years later in 2020. However, the process by which decisions, be they wrong or right, are made has always been a fascination as those who have read my previous posts will realise. In the two books, described very differently by very different men, the authors touch on how they reached many decisions in their personal lives and in their careers. While personal challenges are there for all of us, those in positions of authority and power face decisions, personal and otherwise that are more critical for the organisations and countries influencing the lives of many.
President Bush, a Republican, prone to verbal gaffes and regarded by some as an intellectual light-weight was nevertheless responsible for decisions that affected the world, some for good and others not. In his book, he describes at the age of forty how he came to the realisation that his dependence on alcohol was affecting both his personal and professional life. He describes quitting drinking as one of the toughest decisions he ever made but that without it none of the other decisions described in his book would have been possible.
He describes his impressions of The Gambia while visiting the country with his father, President HW Bush, in 1990. Thereafter in 1998 while discussing his possible run for president with Condolezza Rice, later to be his Secretary of State, he recalls her expressing her view that America had neglected African countries and their agreement that Africa if elected would be a serious part of his foreign policy.
As President in March 2001 he met with Kofi Annan , then Secretary-General of the United Nations, and although differing on many issues he writes that they found common ground in a determination to deal with the AIDS pandemic. In the same year on 11th September (9/11), Al-Qaeda launched the terrorist attacks that culminated in the destruction of the World Trade Center in New York. A consequence of this was the decision to invade Afghanistan and an armed struggle that persists to this day.
He recalls as President that “It broke my heart that fourteen million children had lost parents to AIDS. It also worried me. A generation of rootless, desperate young people would be vulnerable to recruitment by extremists.” By early 2002, despite a US contribution of $200 million to the Global Fund he was concerned that the Fund was too slow to act and that innocent people were dying unnecessarily. Possibly motivated to an extent by 9/11 and the concern of spreading extremism but primarily a humanitarian concern, he pushed for the creation of the the President’s Emergency Plan for AIDS Relief (PEPFAR) to provide direct assistance to countries in sub-Saharan Africa. In 2003 developed by a team of experts including the now well-known, Dr. Anthony Fauci, and based on a political consensus, PEPFAR was initiated with the initial aim of treating two million AIDS patients, preventing seven million infections and caring for ten million HIV-affected people.
Seventeen years later PEPFAR had invested a total of $85 billion on the global HIV/AIDS response. While certain aspects of the program, such as the anti-abortion stance, have been criticised, in South Africa the provincial department that I headed from 2002 until 2015 benefited greatly from grants received from both the Global Fund and PEPFAR. President Bush is probably remembered more for the invasion of Afghanistan, subsequently Iraq and internally for his handling of Hurricane Katrina, however viewed through a humanitarian lens his decision to move forward with the creation and funding of PEPFAR undoubtedly saved an estimated 17 million lives particularly in sub-Saharan Africa. Decision points both personal and presidential in a circuitous sequence of events had a lasting impact far beyond his home State of Texas.
In contrast President Obama, a Democrat, impressively articulate and erudite was perceived more intellectual than his predecessor. Obama of mixed Black (Kenyan) and White (American) parentage, a former State Senator and first term United States senator was an unlikely candidate for the Presidency of the United States. Initially uncertain whether to run for President he quotes his response to his wife, Michelle, questioning why he wanted to be president as follows: “I know the day I raise my right hand and take the oath to be president of the United States, the world will start looking at America differently. I know that kids around this country – Black kids, Hispanic kids, kids who don’t fit in – they’ll see themselves differently too, their horizons lifted, their possibilities expanded. And that alone would be worth it.” With that his decision to run for president was finally made becoming the first African American to be elected to the Office of President of the United States.
Elected with a campaign premised on the slogan, “Yes we can!” President Obama even before he was inaugurated faced the consequences of the 2008 so-called “subprime mortgage crisis” which resulted in American banks foreclosing on housing loans, home owners losing their homes, property prices plummeting, banks on the verge of collapse, massive job losses and the threat of an escalating recession that could have lead to a situation similar to the Great Depression of the 1930’s. Since many of these loans had been guaranteed by international lenders, the consequences of this crisis had the potential to have a worldwide impact.
Faced with a problem for which there was no clear and immediate solution, President-elect Obama moved swiftly to surround himself with people with expertise and skill. He writes in his book that he hired one person “to figure out what the hell to do (or not to do)” and another “to organise and steer the response.” To address the financial crisis he recruited a “brains trust” of lawyers, economists and experienced bureaucrats to develop an economic and fiscal response. The result was the decision to adopt a Keynesian approach which reasoned that a government had to step in a the “spender of last resort” to stabilise and restart the economy, a policy direction not popular with Republicans who were opposed to what they considered “big government”. The challenge for Obama was, despite having a majority in both House and Senate, to obtain approval for the policy. Ultimately, persuaded by cogent arguments and political arm twisting the American Recovery and Reinvestment Act (Recovery Act) that over time stabilised the American and international economy would receive sufficient bipartisan support and be signed into law on 17th February 2009, remarkably less than a month after President Obama assumed office.
Healthcare reform had been a presidential campaign issue and one that had challenged previous US Presidents. While Medicare (for seniors) and Medicaid (for the poor) introduced during the term of another Democrat President Lyndon Johnson had assisted many Americans, as Obama commenced his first term over 43 million Americans had no medical insurance and those with medical insurance faced escalating premiums and decreasing coverage. His advisors warned him that healthcare was an issue, that could “blow up in his face” and potentially result in his losing a second term presidential election. Despite this he decided to persist.
The twist and turns, so characteristic of American politics, that ultimately lead to the approval of the Affordable Care Act (ACA or Obamacare) on 23rd March 2003 are too long to describe here. In the book Obama describes the tortuous process involving experts, politicians, public sentiment, fact and fiction required to finally garner enough votes to approve the final version of the ACA. The final 906 page ACA in his words is “dense, politically impactful and surely imperfect” but it was nevertheless an important step forward in healthcare reform in the US. As I learned during my years in health management, facts and logic alone are not what sways politicians and decision-makers. At times it is necessary to compromise to reach the best option possible taking into account the prevailing environment. In Obama’s own words, “democracy requires compromise, even when you are 100 percent right … you still are going to have to engage folks who disagree with you.”
Decisions and decision points govern the lives of all of us, both the powerful and the weak, but the worst sin is never to make a decision at all.
“There is a tide in the affairs of men,
Which taken at the flood, leads on to fortune;
Omitted, all the voyage of their life
Is bound in shallows and in miseries.”
William Shakespeare Julius Caesar
