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Te timing for this book is perfect. As healthcare moves from caring predominantly for the sick
to the Triple Aim—better care, improved health for our communities, and lower costs—we need
new perspectives and skills to lead the transformation. Tis book is the perfect guide to building
the leadership and governance systems we’ll need to get there. Gabow’s wonderful defnition of
what women leaders bring to these challenges is inspirational and practical. She defnes the unique
approaches used by many women leaders, including seeing across the whole system, building multi-
generational and multiprofessional teams, including all parts of the community and more. Te book
is flled with helpful advice for women in healthcare and for those who mentor them. A must-read
for all in healthcare leadership today!
Maureen Bisognano
President Emerita and Senior Fellow, Institute for Healthcare Improvement

Patricia Gabow ofers a new and unique perspective on leadership for women in healthcare. As a
physician and CEO of a major safety net health system, Dr. Gabow provides a view of leadership
that women in healthcare rarely see. She does this in a way that is extremely approachable, authen-
tic, often humorous, and always practical. Dr. Gabow recognizes the obstacles confronting women
who aspire to lead and importantly, remains optimistic. She gives clear examples and guidance for
those who are navigating the path towards leadership, those transitioning into leadership roles, and
has words of wisdom for senior leaders too. Chapter 6, entitled, “Now You are a Leader,” ofers
a playbook and is essential reading for all as they enter new leadership roles. Dr. Gabow, always
inclusive, rounds out her guidance by including and synthesizing the observations of women in
health leadership across the U.S. Te book ofers many important insights and lessons and reminds
us that as healthcare leaders we must lead with our values and always place our commitment to the
patient frst.
Carrie L. Byington, M.D.
Executive Vice President, University of California Health
Past (held concurrently) Jean and Tomas McMullin Professor and Dean of the
College of Medicine
Senior Vice President for Health Sciences and Vice Chancellor for Health Services,
Texas A&M University

Leadership, especially for women, starts with taking the next right action. Dr. Patricia Gabow’s
insightful and well-written book will inspire any leader, and especially women leaders, to do those
things that matter: for their own personal growth, their organizations, and healthcare nationally.
Whether you’re aspiring to be a physician leader, a corporate leader, or want to chart your own
course as an entrepreneur, TIME’S NOW for Women Healthcare Leaders will give you the confdence
and wisdom to help you achieve the success you want.
Halee Fischer-Wright, M.D., MMM, FAAP, FACMPE
President & CEO, Medical Group Management Association

I wish I had TIME’S NOW for Women Healthcare Leaders early in my career. Dr. Gabow is master-
ful at laying out why more women are needed in healthcare leadership and breaking down how
women can make it happen—including the critical path to be successful once in a leadership role.
Her use of thought exercises challenges each of us to not just read but to take action no matter
where we are on our individual journey.
Evon Holladay, MBA
Past Vice President, Catholic Health Initiatives
TIME’S NOW for Women Healthcare Leaders successfully navigates many topics pertinent to women
leaders, starting from developing a vision and values all the way to managing a board.

We all know that the characteristics of women being more collaborative and better communicators
are factors that support an organization’s success, including fnancially. TIME’S NOW helps individual
women, as well as organizations, understand how to leverage these characteristics into a winning efort.
TIME’S NOW provides the reader with an understanding of the critical skills women need that can make
them successful leaders as well as the weaknesses that can hold them back. What I enjoyed the most in
TIME’S NOW is when Dr. Gabow, in particular, and the other women leaders, shared real-life examples
of their successes and failures. Dr. Gabow is a pioneer in leading large healthcare organizations. In this
book, she paints an “end to end” experience for aspiring women leaders: from knowing “who’s your boss”
to “making the trains run on time” to spelling out many of the early steps a woman needs to pursue
before she moves into senior leadership. I wish I had this book before I started on my leadership journey.
Donna Lynne, DrPH
CEO ColumbiaDoctors and COO, Columbia University Medical Center
Past Lt Governor of the State of Colorado
VP Kaiser Foundation Health Plans

In its opening pages, the book TIME’S NOW for Women Healthcare Leaders eloquently describes the
imperative for transformational change in the U.S. healthcare system and the compelling need for
women’s leadership skills and voices to help drive the necessary change. Te book is more than an
anthem for female empowerment. It is a carefully researched and powerfully constructed business
case for why women need to be at the leadership table. It is, therefore, worthwhile reading for both
women and men interested in improving healthcare in America. Dr. Patricia Gabow is a nation-
ally recognized healthcare leader. She acknowledges that the glass ceiling still exists but “there are
stairways to the top even if some of them seem hidden or hazardous.” Dr. Gabow then proceeds
to identify and clarify the important skills and steps of a woman’s professional journey to leader-
ship, infuence, and impact. Along the way, she engages the reader in a series of thought exercises
designed to encourage the reader to refect more deeply on how the issues discussed defne their
personal and institutional perspectives and reality.

TIME’S NOW is flled with practical and philosophical insights and advice for both aspiring and
experienced women leaders. It is worth reading not only once, but again to absorb the complex and
nuanced observations ofered by Dr. Gabow and further enriched by the perspectives and wisdom
of a dozen successful women healthcare leaders who were interviewed. All of these women were
unifed in the belief that successful leadership is not about the acquisition of power and title but
the ability to use one’s power and infuence to make a diference and have a positive impact on the
health and lives of others.
Lilly Marks
Vice President for Health Afairs, University of Colorado Anschutz Medical Campus

TIME’S NOW is an important addition to our growing literature on leadership. Patricia Ann
Gabow M.D. is an American academic physician, researcher, consultant, and, for two decades, the
highly successful Chief Executive Ofcer of Denver Health, transforming it into a model of fnan-
cially secure community service. Tis eminently readable book is aimed at a particularly under-
served niche—women leaders in healthcare—but the lessons described apply to all organizations
interested in doing well by doing good.

Dr. Gabow’s conversational style, coupled with her wisdom and humility, allow the reader to
readily imagine successfully using the tools and techniques she discusses in other arenas. Her
real-world vignettes bring home the realization that every physician must lead. She doesn’t shy
away from the difficult issues of managing sexual harassment and outdated management practices
that stifle women. The use of personal stories and comments from other prominent women in
healthcare, and the distillation of the pertinent points into self-help questions, is particularly
effective.

TIME’S NOW should be required reading for all women in healthcare leadership—as well as all the
men who work with women.
Barbara L. McAneny M.D., FASCO, MACP
Past President, American Medical Association

Patty Gabow is a giant among healthcare, public health and community leaders. She has inspired
many to take on the challenging role of leadership and has brought inspiration and guidance for
many of us who have followed in her footsteps. Now she has taken time to put down in writ-
ing much of her personal philosophy and experience. This book combines the topics of women’s
advancement and leadership in an individualized approach that allows thoughtful preparation and
helpful guidance for those in leadership. If you know Dr. Gabow, read this book, if you don’t know
Dr. Gabow read this book and learn from a master.
Janis M. Orlowski, M.D., MACP
Chief Healthcare Officer, AAMC

TIME’S NOW for Women Healthcare Leaders could not have arrived at a more urgent and yet prom-
ising time in the pursuit of gender equity in healthcare. Patricia Gabow’s book not only lays out the
ethical, business and performance cases for gender equity in healthcare leadership, but also provides
insight into the barriers women face, first-hand accounts of the challenges and successes of women
leaders, and steps that women can take in pursuit of leadership roles in healthcare. This is a must-
read for all who seek the best outcomes for our American healthcare system.
Nancy Spector, M.D.
Professor of Pediatrics
Executive Director, Executive Leadership in Academic Medicine
Associate Dean of Faculty Development
Drexel University College of Medicine

Dr. Gabow has written another valuable book, this one with a timely focus on what women bring to
executive roles in healthcare and how we could use more of that! Using direct quotes from women
leaders, national data on current trends, and her own voice of experience, she covers the personal to
the political. I strongly recommend this book to women who now lead or who aspire to healthcare
leadership.
Nanette Santoro, M.D.
Professor and E. Stewart Taylor Chair of Obstetrics & Gynecology
University of Colorado School of Medicine
TIME’S NOW for Women
Healthcare Leaders
TIME’S NOW for Women
Healthcare Leaders
A Guide for the Journey

Patricia A. Gabow, M.D., MACP

A PRODUC TIVIT Y PRESS BOOK

First published 2020
by Routledge
52 Vanderbilt Avenue, New York, NY 10017
and by Routledge
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN

Routledge is an imprint of the Taylor & Francis Group, an informa business

© 2020 Taylor & Francis

The right of Patricia A. Gabow to be identified as author of this work has been asserted by her in accordance with
sections 77 and 78 of the Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any elec-
tronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or
in any information storage or retrieval system, without permission in writing from the publishers.

Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for
identification and explanation without intent to infringe.

Library of Congress Cataloging-in-Publication Data

Names: Gabow, Patricia A., author.

Title: Time’s now for women healthcare leaders : a guide for the journey /
Patricia A. Gabow.
Description: New York, NY : Routledge, 2020. | Includes bibliographical
references and index.
Identifiers: LCCN 2019056527 (print) | LCCN 2019056528 (ebook) | ISBN
9781138365582 (hardback) | ISBN 9780429430671 (ebook)
Subjects: MESH: Health Facility Administrators | Women, Working |
Leadership | Administrative Personnel | Vocational Guidance | Women’s
Rights | United States
Classification: LCC RA564.85 (print) | LCC RA564.85 (ebook) | NLM WX 155
| DDC 362.1082--dc23
LC record available at https://lccn.loc.gov/2019056527
LC ebook record available at https://lccn.loc.gov/2019056528

ISBN: 978-1-138-36558-2 (hbk)

ISBN: 978-0-429-43067-1 (ebk)

Typeset in Garamond
by Deanta Global Publishing Services, Chennai, India
To the generations of women in my family—my great grandmother,
great aunt, grandmother, mother, and daughter—for their
strength, resilience, great kindness, and inspiration.
Contents

Foreword...........................................................................................................xiii
Acknowledgments ............................................................................................. xv
Author..............................................................................................................xvii
Introduction .....................................................................................................xix
1 Why Should Women Lead? ....................................................................1
American Healthcare ...................................................................................2
Tought Exercise.....................................................................................2
What Women Bring ....................................................................................7
Tought Exercise.....................................................................................7
What Leaders Told Me ..............................................................................11
Perspective of Other Women Leaders....................................................11
Denver Health Women Leaders ............................................................12
Aspiring Women Leaders ......................................................................14
Tought Exercise...................................................................................15
Male Physician Leaders .........................................................................15
2 Lay of the Land.....................................................................................19
Women Healthcare Pioneers ......................................................................20
Tought Exercise...................................................................................21
Women’s Role in Health and Caregiving ...................................................23
Maternal-Child Health .........................................................................23
Tought Exercise...................................................................................24
Women’s Role in the Care of the Family ...............................................24
Women in the Healthcare Professions........................................................25
Nursing .................................................................................................25
Physicians..............................................................................................26
Other Healthcare Professions ................................................................28
Women in Research ...................................................................................29
Women as Investigators.........................................................................29
Women as Research Subjects.................................................................31
Gender and Pay..........................................................................................32
Nursing Pay...........................................................................................33

vii
viii ◾ Contents

Physician Pay.........................................................................................33
Tought Exercise...................................................................................35
Addressing Gender Pay Inequality.........................................................35
Women in Healthcare Leadership..............................................................36
Going Forward ..........................................................................................39
3 Obstacles and Opportunities................................................................41
Bias............................................................................................................43
Bias in Language.................................................................................. 44
Tought Exercise.................................................................................. 44
Tought Exercise...................................................................................45
Motherhood Penalty..............................................................................45
Addressing Institutional Gender Bias ................................................... 46
Tought Exercise...................................................................................47
Sexual Harassment ....................................................................................47
Tought Exercise...................................................................................50
Burnout .....................................................................................................52
Tought Exercise...................................................................................56
Imposter Syndrome....................................................................................56
Tought Exercise...................................................................................58
Responses to Obstacles..........................................................................58
Opportunities ............................................................................................59
Changing the Culture ...........................................................................59
Improving Care.....................................................................................61
4 First Tings First ..................................................................................63
Values ........................................................................................................63
Tought Exercise.................................................................................. 64
Tought Exercise.................................................................................. 66
Living the Values...................................................................................68
Tought Exercise...................................................................................69
Aligning Values .....................................................................................69
Tought Exercise...................................................................................71
A Vision of Leadership...............................................................................72
Tought Exercise...................................................................................74
5 You Can’t Parachute into Leadership ...................................................75
Leading from Where You Stand.................................................................76
Tought Exercise.................................................................................. 77
Tought Exercise...................................................................................79
Tought Exercise...................................................................................82
Using Clinical Training .............................................................................83
Formal Leadership Preparation ..................................................................85
Training for the Clinician .....................................................................85
 Contents ◾ ix

Tought Exercise...................................................................................87
Training for the Administrator..............................................................87
Tought Exercise...................................................................................88
Documenting Your Accomplishments .......................................................88
Tought Exercise...................................................................................89
Applying for Leadership.............................................................................89
Battlefeld Promotions.......................................................................... 90
Role Models, Mentors, Sponsors, and Coaches ..........................................91
Tought Exercise...................................................................................92
Tought Exercise...................................................................................93
6 Now You Are a Leader ..........................................................................97
Introducing Yourself ..................................................................................98
Tought Exercise...................................................................................98
Building Your Team...................................................................................99
Establishing Relationships.....................................................................99
Recruiting ...........................................................................................100
Tought Exercise.................................................................................101
Tought Exercise.................................................................................101
Tought Exercise.................................................................................102
Evaluating, Mentoring, Sponsoring, and Supporting...............................104
Evaluating ...........................................................................................104
Tought Exercise.................................................................................105
Mentoring, Sponsoring, and Supporting .............................................106
Supporting the Workforce...................................................................106
Tought Exercise.................................................................................107
Accountability: What Are the Rules and What Do Tey Mean? .............108
Changing Roles, Disciplinary Actions, and Terminations ...................108
Communication ...................................................................................... 111
Tought Exercise.................................................................................112
Tought Exercise................................................................................. 113
7 Even Leaders Have a Boss................................................................... 117
Tought Exercise................................................................................. 117
Te Boss on the Chart ............................................................................. 117
Tought Exercise................................................................................. 118
Tought Exercise................................................................................. 119
Tought Exercise.................................................................................120
Your Peers ................................................................................................120
Tought Exercise.................................................................................120
Te Board ................................................................................................121
Tought Exercise.................................................................................123
Tought Exercise.................................................................................123
x ◾ Contents

Te Community ......................................................................................124
Tought Exercise.................................................................................124
Tought Exercise.................................................................................125
Tought Exercise.................................................................................126
Afliated Organizations...........................................................................126
8 Making the Trains Run on Time and Laying New Tracks.................129
Tought Exercise.................................................................................130
Data Is Your Friend..................................................................................131
Tought Exercise.................................................................................132
Tought Exercise.................................................................................133
Tought Exercise.................................................................................134
Research is a Teacher ...............................................................................134
Tought Exercise.................................................................................135
Making Decisions....................................................................................135
Tought Exercise.................................................................................137
Tought Exercise.................................................................................138
Making the Trains Run on Time............................................................. 141
Tought Exercise.................................................................................142
Laying New Tracks..................................................................................143
Tought Exercise.................................................................................143
Tought Exercise................................................................................. 145
Create a New Financial Model ............................................................ 145
Become an Independent Entity ...........................................................146
Adopt and Adapt Lean ........................................................................146
Change the Care Delivery Model........................................................147
Changing Landscape and Risk............................................................147
9 Sharing and Receiving Lessons Learned ............................................149
Sharing Your Lessons Learned .................................................................149
Barriers to Sharing ..............................................................................149
Tought Exercise.................................................................................150
How to Share ......................................................................................150
Tought Exercise................................................................................. 151
Tought Exercise................................................................................. 152
Tought Exercise.................................................................................154
Receiving Lessons Learned ...................................................................... 155
Tought Exercise................................................................................. 155
10 Remember the Obvious ......................................................................157
Balance .................................................................................................... 157
Tought Exercise................................................................................. 159
Children.............................................................................................. 159
Beyond Children.................................................................................162
 Contents ◾ xi

Support ...............................................................................................162
Tought Exercise.................................................................................163
Well-Being ..........................................................................................163
Appearance ..............................................................................................164
Tought Exercise.................................................................................165
Behaviors .................................................................................................165
11 Refections of Women Leaders ...........................................................169
Appendix .....................................................................................................187
References ...................................................................................................189
Index ...........................................................................................................205
Foreword

Time’s Now for Women Healthcare Leaders is an important book and a welcome
addition to the healthcare debate. And Dr. Patty Gabow is uniquely qualifed to
write this volume, since she is one of the most successful woman health leaders in
America.
No one has to be convinced that healthcare is a critical issue for most Americans.
Our political debate is saturated with healthcare discussions, most Americans know
and agree that costs are too high and care is too often mediocre, and America is los-
ing ground as a healthy nation compared to other developed countries, with shorter
life spans, more chronic disease, and more uninsured people within our borders.
Te issue that hasn’t often been a focus of this dialogue is the role that women
play in the healthcare system. As a majority of the population, women are the
majority of patients. Since we live longer than men and often have fewer resources
later in life, we often face additional health challenges in our senior years.
Women perform the majority of caregiving work for ourselves, our children, and
aging family members, so the majority of healthcare decisions are made by women.
And women comprise the largest share of the healthcare workforce, EXCEPT in
leadership positions.
Tis is the focus that Dr. Gabow exposes and explores in this book. After lay-
ing out some well-known issues with the American healthcare delivery system,
she writes about the paucity of women leaders and what that means to the system.
But most important, she provides some ideas about how to change the current
structure, and how women in healthcare can prepare themselves for leadership
positions.
Some of what Dr. Gabow discusses as barriers to women’s advancement in
healthcare are found in any workplace in America: the “motherhood penalty,”
limited access to paid parental leave, sexual harassment and gender bias, and pay
equity issues. But there are also some distinct challenges for leadership positions
in medicine and medical research, like the so-called imposter syndrome, difculty
accessing research grants, less attention to the health needs of women, and more
controversy around women’s reproductive health, which is often treated as a politi-
cal debate instead of a healthcare issue.

xiii
xiv ◾ Foreword

Dr. Gabow was CEO of the Denver Health and Hospital Authority for 20
years. I know Patty and her work—she was legendary in the advocacy commu-
nity—and had the opportunity to both study her results at Denver Health and visit
her facility when I served as Secretary of HHS.
I went to Denver to try to get a frst-hand view of how Dr. Gabow achieved such
high-quality care results and ran a proftable health system with a patient popula-
tion that was almost entirely uninsured or on Medicaid, which is often considered
the most challenging health population in the country. Her team consisted of a
high number of women leaders, and their collaborative style of patient care, mea-
suring results, and holding themselves accountable for outcomes was a beacon for
those of us searching for successful models.
But this book doesn’t rely just on Patty’s experiences and background, as impres-
sive as they might be. She has included the insights of 12 other women healthcare
leaders, as well as very practical steps that the women who comprise almost 80% of
the healthcare workforce can do to “lead where they stand.”
Management experts have long identifed that companies and fnancial enti-
ties with women leaders and women board members produce better results. While
I have never seen a study focused only on women in health leadership, perhaps
because they are so few, it’s hard to believe that the results wouldn’t be similar.
As we search for various solutions to our current American healthcare chal-
lenges, where we spend too much to achieve mediocre health outcomes, TIME’S
NOW for Women Healthcare Leaders identifes a problem that has received far too
little focus—the small number of women in healthcare leadership. And following
some of Dr. Gabow’s ideas for a more balanced health system could improve the
overall health and well-being of our country.

Kathleen Sebelius
21st U.S. Secretary of Health and Human Services
Acknowledgments

My frst thank you must go to Denver Health and the University of Colorado
School of Medicine. Tese institutions, especially Denver Health, provided me
with the opportunity to be a leader and to interact with colleagues who inspired
and taught me. Tese experiences enabled me to write this book.
I am grateful to Secretary Kathleen Sebelius who graciously agreed to write the
Foreword to this book. Her leadership roles, especially as Secretary of Health and
Human Services, give her a unique perspective from which to view this book.
Te amazing women leaders who enthusiastically agreed to be interviewed
deserve special thanks: Nancy Agee, Kim Bimesterfer, Evalina Burger, Linda Burnes
Bolton, Carrie Byington, Karen DeSalvo, Leah Devlin, Halee Fischer-Wright, Risa
Lavizzo-Mourey, Donna Lynne, Lilly Marks, and Nanette Santoro (their titles and
positions are in Table 11.1). Tey added valuable perspectives from their diferent life
journeys, professions, and the components of the healthcare system that they led.
Teir input not only added richness to the book, but they inspired me in its writing.
Te women leaders from the Denver Health Executive staf have been with
me on my leadership journey for many years, some for decades: Kathy Boyle,
Peg Burnette, Darlene Ebert, Paula Herzmark, Stephanie Tomas, and Elbra
Wedgeworth (their titles are listed in Chapter 1). Tey were instrumental in creat-
ing Denver Health’s success. I appreciate their sharing their insights into that lead-
ership experience and the contributions that women healthcare leaders can make.
I thank the male physician Directors of Service who shared their perspective
on the infuence of a predominantly female Executive staf on them and Denver
Health: Richard Albert, M.D.; John Christopher Carey, M.D.; Robert House,
M.D.; Paul Melinkovich, M.D.; and Ernest Moore, M.D. (their titles are listed in
Chapter 1). Tey underscored that women’s journeys to leadership will be facili-
tated by men like them who accept women as leaders.
Te views of early and mid-career women from medicine, nursing, and research
ofered important insights on the ongoing challenges women face. I thank them for
their openness in sharing: Mona Abaza, M.D., M.S. (Dept. of Otolaryngology-Head
and Neck Surgery, University of Colorado School of Medicine (UCSOM), Anschutz
Medical Campus (AMC)); Katie Bakes, M.D. (Dept. of Emergency Medicine, Denver
Health and UCSOM); Marisha Burden, M.D. (Hospital Medicine, UCSOM,

xv
xvi ◾ Acknowledgments

AMC); Lilia Cervantes, M.D. (Dept. of Medicine, Denver Health and UCSOM);
Melanie Cree-Green, M.D., Ph.D. (Pediatric Endocrinology, Children’s Hospital
of Colorado and UCSOM, AMC); Debra Gardner, MSN, RN,NE-BC (Nursing,
Denver Health); Tracy Johnson, Ph.D. (Ambulatory Care Services, Denver Health
and CO School of Public Health), Nicole Staford, MBA, MSN, RN, NEA-BC
(Nursing, Denver Health); Sarah Stella, M.D. (Dept. of Medicine, Denver Health
and UCSOM); Elaine Stickrath, M.D.(Dept. of Obstetrics and Gynecology,
Denver Health and UCSOM); Tida Tant, M.D. (Dept. of Psychiatry, UCSOM,
AMC); Jennifer Whitfeld, M.D. (Dept. of Emergency Medicine, Denver Health
and UCSOM), and Florence Wu, M.D. (Dept. of Pediatrics, Denver Health and
UCSOM). Tey not only provided a relevant perspective, but they also demon-
strated that this new generation of women has the capacity to make our healthcare
system focus on doing what is good and right.
Finally, I want to thank my family—those who I am blessed to still have with
me and those who are gone. My grandparents, parents, and many uncles and aunts
started me on the right path in life with love and guidance. My children, Tenaya and
Aaron, give me joy and added balance to my work life. My husband Hal of 48 years
has supported me in every step of my life and career with love and encouragement.
Te many individuals to whom I owe thanks underscores an important lesson
of leadership—none of us can make the journey alone.
Author

Patricia A. Gabow, M.D., MACP is a national leader in

healthcare delivery innovation and the care of vulnerable pop-
ulations. She served as CEO of Denver Health and Hospital
Authority (DHHA), an integrated safety net healthcare sys-
tem for 20 years, before retiring in 2012. Under her leadership,
Denver Health was transformed from a struggling city/county
healthcare system to an independent entity that became a
national model. It was the frst healthcare entity in the world to
earn the Shingo Bronze Medallion for Operational Excellence.
Dr. Gabow began her career as an academic practitioner and medical researcher
in nephrology, focusing on acid-base disorders and polycystic kidney disease. She
is the author of more than 130 articles, 36 book chapters, and two books. Te
Lean Prescription: Powerful Medicine for Our Ailing Healthcare System received
the Shingo Institute Research and Professional Publication Award. Her awards
include the American Medical Association Nathan Davis Award for Outstanding
Public Servant, the National Healthcare Leadership Award, the David E. Rogers
Award from the Association of American Medical Colleges, the Ohtli Award from
the Mexican Government, the Health Quality Leader Award from the National
Committee for Quality Assurance, the University of Colorado Florence Rena Sabin
Award, the Distinguished Graduate Award from the University of Pennsylvania
School of Medicine, and the Gustav O. Lienhard Award from the National
Academy of Medicine. She was a founding member of the federal Medicaid and
CHIP Payment and Access Commission (MACPAC). She currently serves on
the Robert Wood Johnson Foundation Board of Trustees and the Lown Institute
Board. She was elected to the Association for Manufacturing Excellence Hall of
Fame and the National Academy of Social Insurance. She has been granted honor-
ary degrees by the University of Colorado School of Medicine and the University
of Denver.
Dr. Gabow graduated from Seton Hill University and the University of
Pennsylvania School of Medicine. She is Professor Emerita of the University of
Colorado School of Medicine and a Master of the American College of Physicians.

xvii
Introduction

The time is now for women in healthcare to step into leadership. Tere is an
increased awareness that American healthcare is desperately in need of change.
Tere is also growing acknowledgment that women, who have been excluded from
the tables of healthcare leadership, have valuable perspectives, talents, and skills to
facilitate that change. Tis ofers women an unprecedented opportunity. Women
must be ready and willing to meet the challenges, grasp the opportunity, and shine.
Te purpose of this book is to clearly articulate those challenges, provide
a guide for overcoming them, and share insights for succeeding as a woman
healthcare leader. It captures the journeys of those who have walked the boul-
der-strewn road and become successful leaders. Te book has three major com-
ponents, refecting both documented observations and learnings from personal
experiences. Te frst three chapters provide extensive information on the current
state of American healthcare, the journey and current state of women health-
care professionals, and the challenges and obstacles that still exist for women in
healthcare. Chapters 4 through 10 delve into the foundations, preparation, and
execution of healthcare leadership. Chapter 11 ofers the insights and guidance of
twelve senior women leaders.
Healthcare and a leadership journey were an unlikely path for me. I grew up in
an Italian immigrant family in rural Pennsylvania. My father was killed in WWII
when I was a baby. My mother and I lived with my grandparents and an uncle
until my mother remarried years later. Tese adults gave me support, guidance,
and direction. Te stories of my grandparents and great grandparents who as young
people journeyed from Italy to America to start a new life were an inspiration. My
maternal grandfather shared many old-country sayings flled with wisdom. Two
guided my life: “If you have a gift and you don’t use it, no confessor on earth can
absolve you” and “If you get an education in America, there is nothing you can’t
do.” He acted on the latter, sending my mother and her two brothers to college dur-
ing the Depression. Tey and my stepfather were all schoolteachers. Tey embraced
the beneft of education for men and women and encouraged my journey. But how
I veered from teaching to medicine was a mystery to both them and me.
I started on the path to healthcare leadership as one of six women in my medi-
cal school class and the only woman in my internship and fellowship group. When

xix
xx ◾ Introduction

I joined the Department of Medicine at Denver Health and the University of

Colorado School of Medicine, I was the only woman. Role models, mentors, and
sponsors helped me move around or through the barriers and enabled me to persist.
At Denver Health I found an institution with a noble mission and dedicated col-
leagues who inspired me (see Appendix). My journey led to my being a successful
academician and CEO of a major healthcare system for twenty years, transforming
it from a struggling safety net to a national model.
On this journey I have seen and experienced much and gained an understand-
ing of our healthcare system and of the qualities and practices of leadership. At this
moment of opportunity for women I want to pay forward my learnings and help
other women become tomorrow’s leaders. I realize I have only one perspective. Part
of that view is of a white woman who has not experienced the same journey as a
minority woman. But I believe much of these learnings are valuable to any woman
(or man) who aspires to leadership. To broaden the perspective in this book I have
interviewed other women leaders and up-and-coming women healthcare profes-
sionals from medicine, nursing, and research.
In becoming leaders, we need to be clear-eyed about the myriad problems of
American healthcare before we can provide new directions. American health-
care must change—expenditures must come down and access and quality must
improve. But change will not come without a new vision and diferent people at the
tables of healthcare leadership.
As women we have unique talents to bring to these tables. Te book provides
evidence of those talents. We are the child-bearers and we are the care givers. Tis
gives us a unique perspective on the healthcare system. We are motivated by doing
good and serving others. Our leadership presence in organizations improves perfor-
mance in multiple dimensions. Yet, we are not equitably represented at the tables of
healthcare leadership. Women compose almost 80 percent of the healthcare work-
force but only 13 percent of the healthcare CEOs. Te barriers that are blocking the
path to leadership are myriad: lack of equitable policies, bias, harassment, burnout,
and the self-doubt that these barriers produce. Tis book presents these issues and
their solutions.
Despite the barriers and challenges, there is a path for women not only to be
leaders but to be great leaders. Great leadership is grounded in values—values
which women embrace and exemplify. Women’s leadership can come alive in rela-
tionships, communication, decision-making, the hard work of delivering opera-
tional excellence, and a vision for the future. Te book details the perspectives,
processes, and skills that facilitate what women can bring to each of these key
leadership elements.
At its core this book is a call to action. Women can and should lead. We can
make a diference—a needed diference.
Chapter 1

Why Should
Women Lead?

“What changes when a woman leads business—Everything.”

Goldman Sachs Ad New York Times October 7, 2018

Tere are three short, straight-forward answers to the question, “Why should
women lead?” Te frst is that fairness demands women have equal representa-
tion in healthcare leadership. Te second is that in not achieving gender equality
in healthcare leadership we are failing to utilize all the available talent. Te third
is that healthcare has myriad problems and women leaders can bring a new and
needed perspective to the solutions. Tese answers are based on a series of general
and healthcare-specifc facts:

◾ Women are 50.8 percent of the United States population.

◾ Women constitute 47 percent of the American workforce (74.6 million civil-
ian workers).
◾ Women’s presence in the workforce accounts for 25 percent of GDP.
◾ Women make up 75 to 80 percent of the healthcare workforce but less than
15 percent of the top leadership positions.
◾ Women make 80 percent of the healthcare buying and use decisions.
◾ Women are 75 percent of the family caregivers.
◾ Women bring unique perspectives and skills to leadership.

If the Goldman Sachs’ declaration above is true, and I believe it is, then women
must answer the call to become healthcare leaders. Moreover, if women constitute
the majority of the healthcare workforce, why should men primarily develop and

1
2 ◾ TIME’S NOW for Women Healthcare Leaders

oversee policies, conditions, and goals in the system? Women need to be equally
represented among healthcare leaders not solely, or even most importantly, for their
own beneft, but for what they will bring to health and healthcare. If, as women, we
succeed in achieving fair and equal leadership representation throughout health-
care, but our presence does not drive major transformation, the full promise of
women’s healthcare leadership will not have been achieved.
Men have almost exclusively led all the components of our society that have
shaped American healthcare: physicians, health systems, insurance companies,
pharmaceutical and device industries, and government. Tis is not to say that male
leaders are the cause of our healthcare system’s problems. But it is to say that we
need a diferent outcome and if we are to achieve that outcome, we need diferent
voices at the table—women and men, people of color and white individuals, and
the young and old.

American Healthcare
While American healthcare has achieved amazing breakthroughs in some areas, it
is failing in many aspects and is not delivering population health, both objectively,
and in comparison to other developed countries. If women are to play a pivotal role
in the solutions, we must clearly see the failures before we can address them. We
cannot sing from the old song sheet that America has the best healthcare system in
the world. We need to be clear that although the system is exceptionally good in
some ways, it is exceptionally bad in others. We must preserve and build on what is
good and minimize or eliminate what is bad.

Thought Exercise
What do you see as the major issues in our healthcare system? How do we compare
in outcomes with other high-income countries (HIC)?
In assessing the performance of our healthcare system, we need to look at how
American healthcare performs in the areas of cost, coverage, access, quality, and
disparity/equity. We are currently spending almost 18 percent of nation’s GDP,
or $3.5 trillion on healthcare—twice as much as other high-income countries and
over the years our costs have risen faster than in any other HIC (National Health
Expenditure Data, 2018; Anderson et al., 2019).
Given the complexity of American healthcare, it is not surprising that the causes
of this exaggerated healthcare expenditure are myriad:

◾ Prices
◾ Salaries
◾ Care fragmentation
◾ Administrative complexity
 Why Should Women Lead? ◾ 3

◾ Overuse and misuse of therapies

◾ Waste

When asked why American healthcare is so expensive, the well-known health econ-
omist, Uwe Reinhardt, famously declared, “It’s the prices, stupid” (Anderson et
al., 2003). Tis central role of prices has recently been confrmed (Papanicolas et
al., 2018; Anderson et al., 2019). Tis work underscores the major contributions of
products, including pharmaceuticals, procedures, and people to our sky-high costs.
Te annual per capita cost of pharmaceuticals in the United States is $1443 com-
pared to a mean of $749 in other HIC (Papanicolas et al., 2018)—$700 per person
creates quite a stack of money at the end of the year! Tis price diferential becomes
shocking for some high-cost drugs. For example, the average price of Humira in
the United States is 96 percent higher than in the United Kingdom (Kamal and
Cox, 2018). We have higher costs of high-margin, high-volume procedures. For
example, the average cost of a total knee replacement is over $28,000 in the United
States and can reach more than $60,000 in some healthcare systems compared to
about $18,000 in the United Kingdom (Millman, 2015; Kamal and Cox, 2018).
No wonder healthcare tourism has emerged.
We pay more for components of the American healthcare workforce than do
other HIC. Physicians, both primary care doctors and specialists, earn almost dou-
ble that of other HIC. Tese wages are higher even after correcting for purchasing
power and for the average medical school debt of American physicians (Papanicolas
et al., 2018). Although there is variability in nurse salaries, hospital-based nurses
earn almost $20,000 per year more in the United States than in other HIC
(Anderson et al, 2019). Te salary diferential is more surprising for health system
administrators. Te highest hospital administrator’s yearly earnings in the United
Kingdom in 2015 was a record £340,000, about $430,000 in United States dollars
(Donnelly, 2016). Te four highest salaries for healthcare system administrators
in the United States ranged from $10 million for the CEO of Kaiser Permanente
to over $17 million for the CEO of HCA, and 17 hospital administrators in the
United States earned over $5 million per year (Knowles, 2018).
Te care of patients is often fragmented due to lack of a primary care physi-
cian, use of emergency departments for care amenable to ambulatory care, and
inadequate communication between providers and systems of care. Te fragmen-
tation and complexity are compounded by myriad insurance coverages, all with
diferent benefts and rules. Even at the federal level, there is coverage via Medicare
(with its multiple alphabet components), Medicaid (with a version for every state
and territory), the Child Health Plan (with state variations), the Veterans Health
Administration, the military services health system, and the Federal Employees
Health-Benefts Plan. If this wasn’t enough, there are hundreds of health insurance
companies. Because of the fragmentation and complexity, administrative costs in
the United States are about 8 percent of total healthcare expenses compared to 3
percent in other HIC (Papanicolas et al., 2018). Tese administrative complexities
4 ◾ TIME’S NOW for Women Healthcare Leaders

have human costs in burdening providers and patients as well as fnancial costs to
the system.
Despite spending a great deal more than other HIC, unlike these other coun-
tries, we do not provide health insurance coverage for everyone. In 2013 there were
44 million Americans who were uninsured (Kaiser Family Foundation, 2018). By
2016, with the implementation of the Afordable Care Act (ACA), that number had
fallen to 26 million—much better, but still not zero. However, by 2017 the number
of uninsured had increased by 700,000 people (Kaiser Family Foundation, 2018).
Tese numbers will likely continue to grow as the federal government and many
states seek to signifcantly alter the ACA and Medicaid coverage. With the advent
of high-deductible plans, even the insured are often substantially underinsured.
In America insurance matters. In 2017, the uninsured were four times more
likely than those with Medicaid or private insurance to lack a usual source of care,
and these patients were much more likely to postpone care, go without care, or
not fll a prescription because of cost—hardly a path to well-being (Kaiser Family
Foundation, 2018). Tose of us who take care of patients understand that as impor-
tant as health insurance is as a ticket to healthcare, it does not guarantee access.
Recent access problems with long waiting times for care within the Veterans Health
Administration dramatically underscored this reality. Access, especially to specialty
care and dental care, is also a problem for Medicaid patients, as some physicians
and health systems either limit their numbers or do not take them.
Even when individuals get access to care, they do not always receive the appro-
priate preventive care or care that is indicated. In fact, 10 to 30 percent of the care
they do receive is either not indicated or harmful (McGlynn et al., 2003). In 2018
the Medicare Payment and Advisory Commission (MedPAC) noted, “there is sub-
stantial use of low value care—the provision of a service that has little or no clinical
beneft or care in which the risk of harm from the service outweighs its potential
beneft” (Medicare Payment and Advisory Commission, 2018). Tis low value care
cost Medicare as much as $6.5 million in 2014 (Medicare Payment and Advisory
Commission, 2018).
You would think that since we spend twice as much as other HIC on health-
care, the outcomes for Americans would be signifcantly better than that in these
other countries. Sadly, this is not the case. One commonly used measure of care is
life expectancy, as most of us desire a long life, and it is an unambiguous endpoint
with reliable data. Te United States has the lowest life expectancy of all HIC—
more than three years less on average (Gonzales et al., 2019). Tat might not seem
like much, unless it is you or your family. Not only is our life expectancy lower;
it has fallen for three successive years for the frst time since 1915–1918, when the
First World War and the Spanish fu were taking their toll (Dyer, 2018). Tis short-
ened life expectancy starts from birth. Te United States has the highest infant
mortality of all HIC.
Tere are several ways to look at this decreased life expectancy, which are sur-
prising, if not shocking. One way is to compare life expectancy against healthcare
Another random document with
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thermometer, which was set up beneath a little wooden shelter daily,
reached extraordinary maxima. For one whole month the maximum
fluctuated between forty and fifty degrees Centigrade, the
atmosphere becoming heavier and more exhausting as the day wore
on until sunset. During the night the maximum was generally a little
over thirty degrees, and you must remember that I am speaking of
the winter, when the air was pretty well saturated with moisture.
I have read in books of travel of countries where, to avoid
succumbing from the heat, Europeans live in holes dug in the earth,
and make negroes pour more or less fresh water on their heads from
calabashes to keep them cool. We never got as far as that, but I do
think that Say, at least in June and July, can compete in intensity of
heat with any other place in the world.
In such an oven we quite lost our appetites!
Now ensued a time of terrible ennui. All our energy, all our gaiety,
all our philosophy melted away before the awful prospect of living in
this remote and hostile corner of the earth for five whole months; five
months during which we knew we could not stir from the island; five
months in which we must endure all the storms of heaven in our frail
huts, and be exposed to the ceaseless plots against us of Amadu.
The dreary, monotonous days in which nothing happened, did not
even supply us with topics of conversation, so we talked more and
more of France, which of course only intensified our home-sickness.
Taburet, who had a wonderful memory for dates, seemed to find
every day of the month an anniversary of some event.
It became a more serious matter when our ennui resulted in
constant attacks of fever, but fortunately these attacks, thanks to the
daily dose of quinine, were never very serious, only their recurrence
was weakening, the more so that they were accompanied by what
we called the Sudanite fever, a kind of moral affection peculiar to
African soil.
This Sudanite affection betrayed itself by different eccentricities in
different people. It really is the effect of the great heat of the sun
upon anæmic subjects, or upon those whose brains are not very
strong. Sometimes, at about four o’clock in the morning, we used all
of a sudden to hear a series of detonations inside the enceinte.
“Holloa!” we would exclaim, “some one has got an attack of Sudanite
fever, and is working it off by firing at bottles floating on the river.” Or
another of the party would seal himself up hermetically in his hut,
blocking every hole or crack through which a ray of sunlight could
penetrate. The whole of the interior would be hung with blue stuff,
under the pretence that red or white light would give fever. Another
case of Sudanite!
We could cite many more examples of the disease during our stay
at Fort Archinard.
However different may be most of its symptoms, one is always the
same—a patient afflicted with it contradicts everybody and shows an
absolutely intolerant spirit.
Truth to tell, I must add, in common fairness, that we were all
more or less affected by it. We might have managed to pull along
peaceably in an ordinary station with occupations which separated
us from each other sometimes, but in this island, this cage, for it was
little more, we were always rubbing shoulders, so to speak, and
constant friction was inevitable. In fact, we ran our angles into our
neighbours instead of rubbing those angles down. We were regularly
prostrated with our inactive, almost idle life, and the true characters
of each one came out without disguise.
 THE MEMBERS OF THE EXPEDITION AT FORT ARCHINARD.

At table every discussion led to a kind of squabble. Each of us

stuck to his own opinion, even when the most astounding paradoxes
had been enunciated. Sometimes, after a regular row, we all sat
perfectly mute glaring at each other, and wondering what was to
happen next.
At night, or in the hour of the siesta, I used to get out my flute—
another form of the Sudanite fever—and play melodies from the Or
du Rhin or Tristan et Yseult, but even music failed to calm the
disputants. The tension was too great, and I was afraid that, even at
this late period of our expedition, things would go wrong in
consequence.
All of a sudden a happy idea occurred to me, a regular inspiration
from Heaven, which every one fell in with at once.
This idea was simply that we should all work, and the result was
the immediate restoration of order.
 It was a simple task enough that we now set ourselves to do, just
to make vocabularies of the various more or less barbarous idioms in
use in the Niger districts. There were plenty to choose from, for there
is more confusion of tongues, such as is described in the Bible, in
these parts than anywhere else. There is a perfectly inexhaustible
supply of peculiar phrases.
For instance, between Abo, in the highest part of the delta of the
Niger, and the sea, as an officer of the Royal Niger Company told
me, there are no less than seven dialects spoken, none of which
have the very slightest affinity with each other. It would appear that
one wave of migration has succeeded another, as the breakers do
on the beach, the natives composing the different parties of
emigrants dying out, or leaving only a few survivors stranded like
islets in a flood in the tropical forests, retaining their original customs
and dialects, and continuing to offer sacrifices in the old way,
uninfluenced by the other native populations.
It has been different further inland, for the last emigrants have
been absorbed by the earlier settlers, rather than driven back, but at
the same time their characteristics have not been merged in those of
other tribes, so that we still find side by side totally different customs,
and people speaking different dialects quite unlike each other, such
as the Tuareg, Fulah, Songhay, Bambara, Bozo, Mossi, etc., almost
equally distributed over extensive districts.
So we all set to work. Father Hacquart and I buckled to at the
Tuareg language. Pullo Khalifa turned out to be an indifferent
teacher, though he was full of good-will. He was never at a loss for
the signification of a word, but his renderings were mostly merely
approximate. I have already dwelt upon the peculiarities of the
Tuareg language in a previous chapter, so I will only add here that
we had two other instructors in it, another Fulah, a Mahommedan,
who shilly-shallied a good deal in his interpretations, and a female
blacksmith of Bokar Wandieïdiu, now attached to the service of
Ibrahim Galadio, who lent her to us. The last-named was certainly
the most interesting of our linguistic professors. She had a
tremendous voice, and was as ugly as sin, but she gave herself
many airs and graces. With the aid of these three and a few others
we drew up quite an imposing comparative vocabulary of the Tuareg
language.
Father Hacquart also devoted some time to the study of Songhay,
which is spoken between Say and Timbuktu, and also in other
districts beyond those towns in the east and west, for we meet with it
again at Jenné and at Aghades. Near Say, they call the Songhay
language djermanké. Pretty well every one undertook to teach us
Songhay; it was a simple dialect enough, spoken through the nose,
and it was likely to be very useful to us. The Pères blancs of
Timbuktu give especial attention to its study.
Tierno Abdulaye Dem, a few coolies, old Suleyman, who had
deserted Amadu, tired of wandering about after him, and had
rejoined us to go back to his beloved Foota, used to assemble every
day in Baudry’s hut, which was transformed into a Fulah academy.
Most unexpected results ensued from these meetings. The Fulah
language is a very charming one, and has been carefully studied by
General Faidherbe and M. de Giraudon, but there is still a good deal
to be learnt about it. It is very difficult to connect it with any other. It is
the one language necessary for travelling or for trading between
Saint Louis and Lake Tchad. There have been many theories on the
subject of the Fulah migration, and a great deal of nonsense has
been talked about it. Baudry, who studied the language with the
greatest zeal, discovered some extraordinary grammatical rules in it
and strange idioms, enough to frighten M. Brid’oison himself. No one
could now utter two or three words at table without Baudry declaring
how they could be translated into one Fulah expression. The
following example will give an idea of how much could be expressed
in a Fulah word. I must add, however, that Baudry and Tierno
Abdulaye agree in saying it is very seldom used.
The word I allude to is Nannantundiritde, which signifies to
pretend to go and ask mutually and reciprocally for news of each
other.
Tierno Abdulaye, who was a Toucouleur from the Senegal
districts, gave out that he could speak his maternal language or
Fulah pretty perfectly. When, however, Baudry set to work to explain
to him the formation of Fulah words which he claimed to have
discovered, Tierno realized that after all he did not know much about
it, so he tried to acquire grammatical Fulah, with the result that many
of his fellow-countrymen could not understand what he said. They
were completely confused by all these new rules, but Baudry was
delighted at having won a disciple.
The people of Massina, or the districts near the great bend of the
Niger, speak very quietly and in a low voice, as if they realized the
beauty of their language, and do not trouble themselves very much
about strict grammatical accuracy. The Fulah tongue, in fact, admits
of an immense number of shades of expression, and though there is
not perhaps exactly anything that can be called Fulah literature,
except for a few songs which can only be obtained from the griots
with the greatest difficulty, the language simply teems with proverbs.
Here are a few examples, but of course, like all such sayings, they
lose terribly in translation:—
“When you cannot suck the breasts of your mother, you must suck
those of your grandmother.”
“When a man has eaten his hatchet and his axe, he is not likely to
sputter much over broiled pea-nuts.”
“A stick may rot in the water, but that does not make it a
crocodile.”
“There is the skin of a sheep and the skin of a cow, but there is
always a skin.”
Thanks to Osman, Bluzet had unearthed a cobbler or garanké, a
native of Mossi. He was a very worthy fellow, but, it seems to me,
most of his fellow-countrymen are equally estimable. The Mossi, at
least those we knew, were all very easily intimidated, but honest and
trustworthy. At first Bluzet had a good deal of trouble to get any
information out of this Mossi, but when he gained a little confidence
he got on apace, and used to indulge on occasion in long
monologues, as when he treated us to the following little tale, which
he related to us all in Mossi in Bluzet’s hut.
 “One day, a woman going along the road to Say, taking some milk
to market, sat down at the foot of a tree and fell asleep.
“Presently three young men came up, and when they saw the
woman one of them said to the others—
“‘Follow me, and imitate everything I do.’
“They approached her cautiously, making a détour round the
brushwood. ‘Hu! hu!’ cried the leader, when he got close to the
sleeper, and the others shouted after him, ‘Hu! hu!’
“The woman started up terrified, and ran away, leaving the
calabash of milk on the ground.
“Then the eldest of the three young men said, ‘This milk is mine
because I am the eldest.’ ‘No,’ said the second, ‘it is mine because I
thought of crying, Hu! hu!’ ‘No, no,’ cried the third, ‘I mean to drink it,
for I am armed with a spear, and you have only sticks.’
“Just then a marabout passed by. ‘Let him be the judge!’ said the
disputants, and they put their case before him.
“‘I know of nothing in the Koran which applies to your difficulty,’
said the holy man; ‘but show me the milk.’ He took the milk, he
looked at it, he drank it. ‘This is really good milk,’ he added, ‘but
there is nothing about your case in the Koran that I know of.’”
With two other vocabularies of Gurma and Bozo expressions, less
complete than those of the Songhay and Fulah languages, we made
up a total of more than ten thousand new words, to which we added
many very interesting grammatical remarks.
This absorbing occupation, which fortunately became a positive
monomania with some of us, contributed more than anything to our
being able to survive the last month of our stay at Fort Archinard.
OUR QUICK-FIRING GUN.
NATIVES OF SAY.
 CHAPTER VIII

MISTAKES AND FALSE NEWS

We must now return to our arrival at Say. Although the days there
were most of them monotonous enough, they brought their little ups
and downs, and we received news now and then, of which, under
the circumstances, we naturally sometimes exaggerated the
importance. It would be wearisome for me as well as for the reader
to give an account of what happened every day during our long
winter at Fort Archinard. My notes were written under various
difficulties and in very varying moods, reflecting alike my
exaggerated low spirits when things went wrong, and my excess of
delight when anything occurred to cheer me. Consecutive pages of
my journal often contradicted each other, and any one reading them
would imagine they were written by two different persons; but this is
always the way with travellers, and even Barth himself was not
exempt from such fluctuations of mood.
My journal in extenso might serve as an illustration of the
psychology of the lie as illustrated amongst the negroes and
Mussulmans, but no other useful purpose, so I shall greatly
condense it. The reader will still, I hope, get a very good idea of all
we went through. If what I quote is rather incoherent, excuses must
be made for me, for the news we got was often incoherent enough,
and our life at the Fort was rather a puzzle too sometimes, with our
alternations of hope and anxiety.
Friday, April 10.—We are getting on with our fort; our abattis are
finished and ready for any attack. (This was written the day after our
arrival, whilst our work was still in full swing.)
We put the Aube in dry dock to-day, and it took the united efforts
of us all to haul her into position: non-commissioned officers,
interpreters, servants, all had to work, and even we white men lent a
hand. During the operation of turning her on to her side, the poor
Aube might have tumbled to pieces, for all her planks were loose.
But she held together yet once more, and, as you will see, we did not
have to abandon her until the very end of our voyage.
A new recruit joined us to-day, my journal goes on, so with
Suleyman Futanké we have two extra hands now. This was how he
came to join us. During the siesta hour we heard a man shouting
from the other side of the river, “Agony! agony!” and looking out we
saw some one waving a white cloth. We sent the Dantec to fetch
him, and when he arrived he kept shouting “Agony! agony!” in a
joyful voice. He showed us his cap of European make, evidently
expecting us to understand what he meant, but that did not explain
the use of the word “agony” so often.
It was Tedian Diarra, a big Bambarra, who had acted as guide to
General Dodds in the Dahomey campaign, who solved the mystery
at last, and told us that the man had been a porter at Say to the
Decœur expedition. He had been taken ill with an attack of some
discharge from the joints, and had been left under the care of the
chief of the village to be handed over to the first Frenchman who
should happen to pass. The poor fellow, whose name was Atchino,
—at least that is what we always called him,—was trying to explain
to us that he came from the village of Agony on the Wemé. He had
feared he should never see his native village again, with its bananas
and oil palms; but as soon as he heard of our arrival at Say, he came
to take refuge with us. Later I indemnified the man who had taken
care of him for the expense he had been put to. We made this
Atchino our gardener, and he turned out a very useful fellow, a
decided acquisition to our small staff.
Monday, April 13.—We finished the repairs of the Aube. She still
let the water in like a strainer, but, as we always said, we were used
to that. This expression, “used to it,” was perpetually employed by us
all, and it enabled us to bear with philosophy all our troubles. It is, in
fact, the expression which gilds the bitterest pills to be swallowed on
an exploring expedition, and no one need dream of starting on such
a trip as ours if they cannot adopt what we may call the philosophy of
use and wont on every occasion. Have twenty-five of us got to pack
into a boat about the size of my hand? What does it matter? go on
board, you’ll get used to it. Have we got to find place for provisions
and things to exchange with the natives when there is no more
room? Never mind, ship them all, we shall get used to them when we
settle down. Are you in a hostile district? Do rumours of war, of
approaching columns of thousands and thousands of natives uniting
to attack, trouble you? Never mind, they will turn out not to be so
many after all; you are used to these rumours now. You have some
dreadful rapids in front of you; you have got to pass them somehow.
There are so many, you can’t count them. Shall we draw back? Shall
we allow them to check our onward march? No, no, we shall get
used to them. If you take them one by one, you will find that each
fresh one is not worse than the last, and that the hundredth is just
like the first. You get quite used to them, at least if you do not lose
your boats and your life too. Which would be the final getting used to
things, the last settling down!
A diavandu and his sister one day presented themselves at the
camp. These diavandus, who are the guides and confidants of the
people, are everywhere met with amongst the Fulahs. I don’t know
what trade the sister followed, but this diavandu came to offer us his
services. He offered to perform all the usual duties of his office on
our behalf, and was ready either to sell us milk, or to act as a spy for
us. He was a little fellow, of puny, sickly appearance. We made him
drink some quinine dissolved in water, and our people told him that
the bitter beverage contained all the talismans of the infernal
regions. Certainly the witches in Macbeth never made a philtre
nastier than our mixture.
Our diavandu swore by the Koran, without any mental
reservations, that he would be faithful to us, and our spells and the
grisgris we had given him would, he knew, kill him if he were false to
us, or betrayed us in any way. Then we sent him to see what was
going on in Amadu’s camp. I do not know what eventually became of
him, but perhaps if he was false to us the quinine killed him by auto-
suggestion; perhaps he was simply suppressed by our enemies, or
he may have died a natural death; anyhow we never saw either him
or his sister again.
About the same time Pullo Khalifa appeared at Fort Archinard,
sent, he said, by Ibrahim Galadio, the friend of Monteil. He began by
asking us what we wanted, but it really was he who wanted to get
something out of us. We gave him a fine red chechia to replace his
own, which was very dirty and greasy. Later we gave him various
other presents, but, strange to say, he always came to visit us in his
shabbiest garments.

TALIBIA.

Thursday, April 23.—In the evening a sudden noise and confusion

arose on shore at Talibia, and in our camp we heard dogs barking
and women shrieking, whilst the glare of torches lit up the
surrounding darkness. Gradually the tumult died away in the
distance. Had the Toucouleurs been on the way to surprise us, but
finding us prepared given up the idea for the time being? We
shouted to Mahmadu Charogne, but no answer came. Mamé then
fired a fowling-piece into the air, but nothing came of it. All was silent
again, but we passed the night in watching, for we knew that that
very morning a man wearing a white bubu had tried to tamper with
our coolies, and to frighten away the native traders. He had shouted
from the left bank that Amadu had let loose the Silibés upon us,
giving them permission to make war on us, and promising them the
blessing of Allah if they beat us. No wonder such a coincidence as
this put us on our guard.
The next morning Mahmadu explained the uproar of the
preceding evening. It had been a question not of an attack on us, but
of a wedding amongst the Koyraberos. He told us a marriage is
never consummated until the bridegroom has literally torn away his
bride from her people, and the rite of abduction, for a regular rite it is,
is a very exciting ceremony. When the suitor comes to pay the dowry
it is customary for him to give his fiancée, it is considered good form
for the parents to shrug their shoulders, and pretend that the sum
offered is not enough; millet is very dear just now, they say, and they
cannot afford wedding festivities worthy of their daughter. They must
keep her at home until after the harvest, and so on.
The young man goes home then with bowed head and a general
air of depression. When he gets back to his own village he calls his
relations and friends together, chooses out the best runners and
those who can shout the loudest, and with them returns to seize the
object of his choice. He finally succeeds in taking her away in the
midst of screams, yells, and the sham curses of her relations, who
are really full of joy at the marriage. The so-called ravishers of the
dusky bride are pursued to the last tents of the village, and the
ceremony concludes, as do all weddings amongst the negroes, with
a feast such as that of Gamache immortalized in Don Quixote.
Soon after this exciting night our relations with Galadio began,
and throughout the winter all our hopes were centred on this man.
We counted on him to the very last moment as our best friend, and
he really was more reasonable than most of those with whom we
had to do during that dreary time. It must not, however, be forgotten
that amongst Mussulmans, especially those of the Fulah race,
wisdom means profound duplicity. The Fulahs actually have no word
to express giving advice, only one which means “give bad advice,” or
“betray by counsel given.” The idea is simple enough, and is the first
which comes into their heads. So that if by any chance they want for
once to translate our expression, “advise you for your own good,”
they have to go quite out of the way to make the meaning intelligible,
and to use a borrowed word. This is really a reflection of the Fulah
character.

TALIBIA.

Galadio was in this respect a thorough Fulah, although he had

Bambarra blood in his veins. His mother was a Fulah, of the Culibaly
tribe, and he deceived us perpetually with good words which meant
nothing. Still I must do him the justice to add, that he was careful to
save us from being involved in open war. Perhaps he saw how fatal
that would be to his own influence, or he may have dreaded it as a
calamity for the country he was now living in, or for the people over
whom he had been set. Anyhow he managed to run with the hare
and hunt with the hounds: in other words, to keep in with Amadu and
us. He always gave us to understand, that if the worst came to the
worst he would at least preserve a strict neutrality, and as a reward
for this he got many very fine presents. He was treated almost as the
equal of Madidu himself, and he too received from us a velvet saddle
embroidered with gold. His messengers were provided with a pass
by us, and were received with all due honour, for it was not until quite
the end of our stay that the mystery was solved, and Galadio
appeared in his true colours. Of his own free will he had concluded a
regular treaty with me, a treaty drawn up quite formally in Arabic and
French, and which he signed with his own name. He showed,
moreover, a very eager wish to enter into relations with Bandiagara.
April 30.—Khalifa is certainly an extraordinary man. To-night he is
to bring to us in a canoe, when the moon is set and all is silence,
darkness, and mystery, no less a person than the brother of the chief
of Say. We watch all night for the signal agreed upon of the
approach of our guests: the lighting of a candle on the bank of the
river, but nothing is to be seen. Was the whole thing simply a
manœuvre on the part of Pullo to get possession of a box of
matches and a candle? Perhaps so, for one of his chief delights
when he is in any of our tents,—and he is very often there,—is to
strike matches one after the other. He is not the only one with this
wasteful habit, Baudry is also afflicted with it, but fortunately we have
a sufficient supply even for such vagaries as this, which really are
very pardonable in the Sudan.
The next day Khalifa and the brother of the chief of Say actually
arrived, after a good deal more fuss and mystery. Even poor little
Arabu, who wanted to sleep in the camp, was sent away, weeping
bitter tears at the thought that his white brothers did not want him.
Very useless were all these precautions, for the brother of the chief
of Say, though perhaps rather more polite, was not a bit more
sincere than he. Our visitor explained that he had come to see us
quite independently, and that his great wish was to make friends with
us. What he really wanted, however, was a bubu and a copy of the
Koran. As his friendship was of a very doubtful quality, we put off
giving the present to another time, when he should have proved his
sincerity by getting us a courier to go to Bandiagara. He went off
promising to see about it.
 We had “big brothers” and “little brothers” ad infinitum, but as
there is no masculine or feminine in the Fulah language, the
Sudanese when they try to speak French muddle up relationships in
a most original manner, without any distinction of sex. Abdulaye said
to us, with no idea that he was talking nonsense, “My grandfather,
who was the wife of the king of Cayor;” and it is no rare thing for one
of our men to bring a young girl to us in the hope of getting a
present, who is really no relation to him at all, telling us, “Captain,
here is my little brother; he has come to say good-morning to you.”
In my journal I find the following note à propos of this confusion of
relationships. The grandson of Galadio, who came to see us, told us
he had come to pay his respects to his grandfather, and I was that
grandfather, because I was the big brother of his other grandfather.
The muddle is simply hopeless, but with it all the natives never lose
their heads, but keep in view the possible present all the time.

GALADIO’S GRANDSON.
 Sunday, May 3.—The day before yesterday some strange news
was brought us by a boy of about fifteen. He had been sent secretly
to us by the Kurteye marabout we had seen when we were on our
way to Say. A horrible plot was being concocted, he said, for Amadu,
remembering the spells of his father, who had been a great magician
at Hamda-Allâhi, had made an infallible charm against us. On some
copy-book paper, which had evidently been taken off our presents,
he had written the most awful curses, imploring Allah seven times
over to exterminate the Kaffirs, as he called us, and having washed
the paper in water he made a goat drink the decoction thus
produced. He then sent that goat to us, thinking we would buy it! But
we were warned in time.
The awful grisgris did, in fact, arrive in camp yesterday in the form
of a black goat. The poor creature did not look as if she were
charged with venom. She was plump not too old, and would make a
first-rate stew.
All our men were, however, afraid to have anything to do with her,
for in their eyes she was indeed a grisgris endowed with unholy
powers by Amadu. The negroes are all superstitious, and their
imagination often quite runs away with them. On the other hand, faith
is sometimes wanting amongst the Mussulmans. Putting on an air of
very great wisdom, therefore, we generously offered two cubits of
stuff, worth about threepence-halfpenny, for the goat filled with spells
against us, and when the trader who had brought her looked
confused, yet almost willing to let us have her at that ridiculous price,
we explained to him emphatically that our own grisgris, the tubabu
grisgris, had revealed to us the black designs of Amadu, and we
intended to have him and his goat taken back to the other side of the
river, manu militari, I very nearly said kicked back.
The Kurteye marabout who had warned us, was evidently a
friend, unless the whole story was made up to get a present from us.
Every evening now regular tornados broke near Say. Up-stream and
down-stream, at Djerma and at Gurma, torrents of rain fell
constantly, and the lightning flashed from every point of the
compass; but, strange to relate, there was no rain at Say itself, and
when there is no rain there is no harvest. The report was now spread
that we had called down on the village the curse of Allah. The other
day Amadu Saturu had publicly recited the Fatiha in the Mosque in
the hope of getting rain to fall, and we were told that in the meeting
of the notables of the place, the Kurteye marabout had got up and
asserted that Say was punished for having given a bad reception to
a man sent from God, in other words, to the chief of our expedition,
and because Amadu had broken his promise and all his solemn
oaths.
Like my uncle Dr. Barth in Sarayamo, I now found myself looked
upon as the bringer of storms. He had also been looked upon as a
marabout saint, and the Fatiha had been recited to him in the hope
that he would open the floodgates of heaven. We, Kaffirs though we
were, would soon in our turn be entreated to remove our interdict on
the rain so much needed.
May 7.—Tierno, after many a discussion, has at last succeeded in
getting us a courier in the person of an ivory merchant from Hombori.
He will take our letters for Bandiagara, an advanced French post of
Massina. Aguibu, king of Massina, and under our protection, had
sent an agent to Hombori, which is on the road there. Our man
would go for 200 francs, 100 payable at Bandiagara and 100 on his
return to us. All, therefore, was for some days excitement and bustle
in our camp. Maps, reports, letters were being rapidly got ready, and
nobody had a moment to spare. Our courier, who did not seem to
feel quite sure of his safety, sent to ask whether during his absence
his family could go to our friend Galadio, who would protect them.
We said yes, of course.
He returned a month later, and said he had not been able to get to
Bandiagara. The Habés, who had risen in revolt, had robbed him
near the village of Dé. He had only escaped with the greatest
difficulty under cover of a tornado, leaving his packet of letters in the
hands of our enemies. We think he romanced a good deal on the
subject, and I fancy that a good search in Amadu Saturu’s camp
would probably result in the discovery of our packet intact, except for
being perhaps gnawed by termites.
 I had some little doubt on the subject, however, and it is thanks to
that doubt that the courier still has his head on his shoulders. I never
saw him again.
May 13.—Great news! We are told by Osman that there are some
white men on the Dori side of the river, but no one knows exactly
how many. Barges full of white men are floating down-stream; they
are now off Ansongo. There is talk of three iron boats like ours; those
in them are all for peace, nothing but peace.
May 16.—Who is our friend Pullo bringing us this morning? Who
is that man with him who looks like a Tuareg, dressed in blue Guinea
cloth, with a grisgris on his head and a spear and javelin in his hand?
He is a Fulah, the foster-brother of Madidu, with his pockets full of
news. Twenty days ago he said he had left his “big brother” to come
to Say and sell four oxen for some of the cloth of the district. One of
these oxen had died, another had been stolen. What a good
opportunity to ask us to give him a bubu to make up for his losses.
Madidu had not known that we were still at Say. Had he done so
he would certainly have sent messengers, perhaps even have come
himself. He or Djamarata would have visited us, for they had gone
down the river as far as Ayoru to chastise Yoba for some want of
respect to us, but I am sure I don’t know what.
Our Fulah had heard a rumour of four white men having come to
trade on the Niger. Madidu had sent two of his blacksmiths to
prepare the way before them, and he had also by this time sent
envoys to Timbuktu to confirm the treaty we had made with him. He
did not know what had become of that treaty, but anyhow he had
returned with his pocket (Heaven only knows the capacity of that
pocket) full of knick-knacks and more than one present for Madidu.
The news of the approach of the barges was confirmed during the
following days, and in my notes I find the following reference to
them:—
May 17.—A man from Auru who had come to Say told us that at
Ansongo there were three hundred armed men and seven or eight
whites who had come in peace, nothing but peace, and were coming