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Leading WIthout Authority

When the brother of Mirabel Douglas, the speaker of the West Dakota House of Representatives, died of the hepatitis C virus, members of the legislature discovered this stealthy disease.

When the brother of Mirabel Douglas, the speaker of the West Dakota House of Representatives, died of the hepatitis C virus, members of the legislature discovered this stealthy disease. So the legislature created the Hepatitis C Board, charged the governor with appointing its members, and told the board to fix the problem.

Officially, the legislature gave the Hepatitis C Board the narrow job of designing an overall approach for attacking the disease. It told the board to develop a set of tactics to be employed by the West Dakota Department of Health, county public health departments, physicians and hospitals, and nonprofit agencies. Of course, the legislature gave the board no authority to require any of these individuals or organizations to follow the strategy.

Moreover, the legislature gave the board no money or staff. It did, however, impose a tight deadline: By September 1, the board is required to submit a collection of guidelines, standards and protocols that, if approved by the legislature next year, would mandate specific actions by physicians, hospitals, insurance agencies and other members of the state's public health network.

The governor, not wishing to annoy the speaker, quickly appointed the required board members, including a hospital administrator, leaders of the West Dakota Medical Association and the state's insurance industry, a county public health director, a business executive living with hepatitis C, and the executive director of the nonprofit Health Education Network. And, logically, the governor picked you, the state's deputy commissioner of public health for infectious diseases, to chair the board.

The hepatitis C virus, or HCV, is transmitted from one person to another through the carrier's blood. Although the American blood supply is now thoroughly screened for HCV, many people contracted the disease years ago. Only now, however, are they beginning to show symptoms of an inflamed liver, which can lead to cirrhosis. Most victims don't die from the disease, although some predict that, within a decade, American deaths from HCV may exceed those from HIV.

At your last meeting, the board agreed (more or less) on the details of its proposed HCV strategy. Still, not everyone on the board is completely happy. After all, if your strategy is adopted by the legislature, several state agencies--and not just your Department of Health--will have to do some things differently.

For example, your strategy will require the corrections department to screen its inmates for HCV. This will cost money. And given the cuts that the legislature had to make for the FY 2003 budget, state agencies are already hurting. So, quite naturally, they have begun to "warn" the governor's budget director of this problem. And last month, at the annual meeting of the West Dakota Association of County Public Health Directors, the delegates officially asked you for a detailed explanation of the costs that your strategy would impose on their departments.

Of course, no one really wants to cross the speaker. Still, you and the rest of the board have concluded that approval of your HCV strategy requires more than her clout. Indeed, she called you last month to politely inquire about your progress and to emphasize that the board has two responsibilities: to develop an HCV strategy for the state, and to sell that strategy to the relevant stakeholders. Douglas will certainly invest her personal prestige in getting the strategy through the House. But it also has to pass the Senate. Douglas likes the approach your board is taking. Yet her subtle choice of words did not mask her clear desire that the board take a lead in building a constituency to support the new strategy.

Before the June 30 deadline, the board will publish its proposed strategy in the West Dakota State Register, the official document in which every state regulation must appear before it can be approved. The next step is to hold hearings on this proposal. Then, following the comment period, the board will revise its strategy and submit it to the legislature.

The hearings inevitably will be a pain. Opponents will flock to the state capitol auditorium to explain your stupidity to any legislator or journalists who will listen. It will be a circus.

Meanwhile, you and the other members of your board have your regular jobs. You have been getting together once a month to discuss specific components of the strategy that have been submitted by the board's various subcommittees. But now, having negotiated the final details of strategy, many members of the board see their work as done. They are committed to their strategy. Given the time they have invested in putting both the overall concepts and the specific details together, they don't want it torn apart by various interest groups, discarded because of the state's budget problems--or simply ignored.

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