4
Future Role of Schools of Public Health in Educating Public Health Professionals for the 21st Century

OVERVIEW

The history of education in schools of public health has been one of evolution and change in response to new knowledge, the needs of the times, and opportunities for improvement. Schools are again faced with the need to evolve, in part because current problems demand new knowledge and approaches, and in part because of scientific advances and the increased understanding of the determinants of health, their linkages, and their interactions. Faculty in schools of public health come from multiple disciplines, making schools uniquely poised to embrace the transdisciplinary approach to education and research that is necessary for an ecological focus. The ecological model for public health discussed in Chapter 1 provides a focus for the following discussion, a discussion that identifies responsibilities, explores future directions, and makes recommendations for strengthening education, research, and training in schools of public health.

The committee determined that schools of public health have six major responsibilities. These are to:

  1. educate the educators, practitioners, and researchers as well as to prepare public health leaders and managers;

  2. serve as a focal point for multi-school transdisciplinary research as well as traditional public health research to improve the health of the public;

  3. contribute to policy that advances the health of the public;



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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century 4 Future Role of Schools of Public Health in Educating Public Health Professionals for the 21st Century OVERVIEW The history of education in schools of public health has been one of evolution and change in response to new knowledge, the needs of the times, and opportunities for improvement. Schools are again faced with the need to evolve, in part because current problems demand new knowledge and approaches, and in part because of scientific advances and the increased understanding of the determinants of health, their linkages, and their interactions. Faculty in schools of public health come from multiple disciplines, making schools uniquely poised to embrace the transdisciplinary approach to education and research that is necessary for an ecological focus. The ecological model for public health discussed in Chapter 1 provides a focus for the following discussion, a discussion that identifies responsibilities, explores future directions, and makes recommendations for strengthening education, research, and training in schools of public health. The committee determined that schools of public health have six major responsibilities. These are to: educate the educators, practitioners, and researchers as well as to prepare public health leaders and managers; serve as a focal point for multi-school transdisciplinary research as well as traditional public health research to improve the health of the public; contribute to policy that advances the health of the public;

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century work collaboratively with other professional schools to assure quality public health content in their programs; assure access to life-long learning for the public health workforce; and engage actively with various communities to improve the public’s health. The following pages discuss each of these responsibilities and provide recommendations for a framework for education, training, and research in schools of public health. EDUCATION The “most distinctive role of public health education lies in the preparation of public health professionals” (Fineberg et al., 1994). While most professional public health graduates receive their degrees in either 1 of the 32 accredited schools of public health (about 5,600 graduates in 1999) or 1 of the 45 accredited master of public health (M.P.H.) degree programs (approximately 800 graduates in 2001), it has been amply documented that only a small minority of the total public health workforce has received any formal public health training. In an 18-month study of the Texas public health workforce, Kennedy and colleagues (1999) estimated that only 7 percent of the public health workforce had formal education in public health. Nationally, only 22 percent of chief executives of local health departments have graduate degrees in public health (Turnock, 2001), and it is estimated that about 80 percent of public health workers lack basic training in public health (CDC, 2001a). Many of those in the public health workforce who do receive formal training in public health do so primarily via alternative pathways, that is, through certificate programs, short courses, and continuing education programs, conferences, workshops, and institutes offered by a variety of institutions and organizations. The strengths and contributions of these programs cannot be overemphasized, and the committee acknowledges their importance to the development of the public health workforce. The committee believes that education in schools of public health should be directed toward masters and doctoral level students who will fulfill many professional positions within public health, toward persons destined for practice careers in positions of senior responsibility and leadership, and toward those who will become public health researchers and academic faculty. The education and range of skills of professionals working in public health will continue to be wide. There is a need for well-educated senior public health officials who “have the preparation not only to manage a governmental agency, but also to provide guidance to the workforce with regard to health goals or priorities, provide policy

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century direction to a governing board, and interact with other agencies, at all levels of government, whose actions and decisions affect the population whose health he or she is trying to assure” (Turnock, 2001). Schools of public health are in the ideal position to focus on this needed leadership development because of the range of skills and knowledge represented within the faculty, and because of the partnerships that can be sustained with public health practice. This focus can most effectively be done if it becomes a priority for educational programs. This does not mean that schools of public health should see themselves as the only and exclusive training ground for leadership. Rather this education for senior-level responsibility in practice is important, and schools of public health should respond to the need for such education. Schools of public health will also continue to educate masters and doctoral level students to fill many professional positions within public health. Some schools will directly educate the broader public health workforce through curriculum setting, distance learning, cross training, and continuing education and other methods. However, the committee recommends that schools embrace as a primary educational mission the preparation of individuals for positions of senior responsibility in public health practice, research, and teaching. It is important for schools to emphasize responsibility to prepare future public health leaders. Both the selection of students and the approach to imparting knowledge, skills, and attitudes should be guided by this expectation. The challenges discussed in Chapter 1, and the eight important content areas described in Chapter 3, as well as other factors, speak to the need for attracting to schools of public health a wide range of students from numerous and varied populations and disciplines. Such diversity has the potential to strengthen the knowledge exchange among disciplines, moving us more rapidly toward a transdisciplinary approach to learning and an ecological model for action. Currently, schools of public health base their curriculum on five core disciplines: epidemiology, biostatistics, environmental health sciences, health services administration, and social and behavioral sciences. Recently, the Council on Linkages Between Academia and Public Health Practice outlined a list of eight competency domains intended to strengthen education in some of these areas. The competency areas are: analytic/assessment policy development/program planning communication cultural competence community dimensions of practice basic public health sciences (namely, biostatistics, epidemiology, environmental health, health services administration, and social and behavioral sciences)

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century financial planning and management leadership and systems thinking The committee reaffirms the importance of the long recognized core areas (epidemiology, biostatistics, environmental health, health services administration, and social and behavioral sciences). Further, the committee endorses the idea that education should be competency based and supports educational programs built upon the competency domains identified by the Council on Linkages. However, public health professionals in the 21st century must also understand the ecological nature of the determinants of health, that is, their linkages and relationships. Such an understanding is necessary to design, implement, and evaluate public health interventions. Several critical gaps have been identified in the current approach to educating public health professionals. These gaps include informatics, genomics, community-based research, global health, law, and ethics. Additionally, the committee believes that greater emphasis must be placed upon the Council on Linkages’ identified competency areas of communication, policy, and cultural competence. Finally, the committee believes that schools must carefully examine how their courses are structured and how learning is provided. Therefore, schools of public health should emphasize the importance and centrality of the ecological approach. Further, schools have a primary role in influencing the incorporation of this ecological view of public health, as well as a population focus, into all health professional education and practice. The ecological approach and emphasis on public health practice require a careful examination of how courses and other elements of the program are structured. There are probably many new and innovative ways that will better facilitate particular areas of learning (e.g., policy development) than classroom-based lectures, for example, case-based learning (see example provided in Box 4-1). The committee encourages schools to examine alternatives to traditional teaching modes. A comparison of the expanded areas of competency with current M.P.H. curricula at most U.S. institutions suggests substantial non-alignment. The present structure is heavily oriented toward teaching the basic public health sciences, augmented by specialization in one such area. Most of the education is didactic in nature; practical training is generally limited to community rotations of varying intensity. In addition, many curricula require an intensive research experience for completion of degree requirements, which is positive for those who envision careers in research, but less well-justified for those who engage in senior level practice positions. Teaching is conducted primarily by faculty with backgrounds in one of the core public health sciences. There is presently minimal participation in the educational process by those in senior practice positions or with comparable experiences, experts in medicine or its prac-

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century BOX 4-1 Case-Based Learning Example West Nile Virus You are health commissioner for a suburban county in a major metropolitan area. The previous summer several cases of encephalitis were diagnosed at area hospitals and identified as being caused by a hemorrhagic virus previously unknown in the region. Mortality, thankfully, was limited to a small number of very debilitated elderly patients. A combined effort of veterinarians, infectious disease specialists, and your colleagues documented that the virus had infected local crows (the reservoir) and was present in a high proportion of mosquitoes in the community. Efforts to control the mosquito population in neighboring towns, requiring extensive public spraying with pesticides, resulted in widespread complaints because of acute reactions to the chemicals among some chemically sensitive residents. Additionally, many environmentalists raised concerns about long term health effects of the chemicals used. It is now April, and early tests reveal a high rate of infection in crows, as well as evidence that the mosquito population is again infested. The situation is further complicated by advice from the agricultural extension service in your community that the mosquito population is anticipated to be unusually large this season because of the warm, wet winter. Local community groups are duly worried: the environmentalists, about the possibility of toxic spraying; parent groups about the infectious risks to children from playing soccer, going to the beach, etc. Physicians in the community are concerned about encephalitis risk as well, especially among the elderly. As commissioner you must devise and defend a course of action. TASKS What factual pieces of information do you need to devise an appropriate plan? How might you obtain them? What will you do if some/all are unavailable? What specific control strategies should be considered, separately or together? What infrastructure(s) would need to be in place to implement these strategies? What would you do about those which are not? How will you manage the competing concerns of the interested parties? Once you have selected an approach, what factors need to be considered for implementation? How do you plan to assess the effectiveness of your choice(s)? Under what circumstances would you modify your initial plan? tice, or those with unique skills in areas such as communication, cultural competence, leadership development, or planning. The following sections highlight strategies and recommendations to achieve the proposed realignment. In addition, the allocation of appropriate financial resources to achieve these proposals is essential. Recommendations for funding appear in Chapter 6. Educating Leaders in Public Health Practice Successful transition to programs with appropriate emphasis, faculty, and teaching approaches consistent with the proposed competencies will

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century require radical change. First and foremost, since the goal is to inculcate a broad ecologic perspective, and the sheer amount of content material is increasingly vast, integrative teaching techniques (such as case-based learning) may prove more appropriate than the traditional single discipline courses. Consideration may need to be given to upgrading the M.P.H. admissions requirements to ensure a high level of knowledge in basic science areas such as human biology, math, computer literacy, and environmental science. Second, the practical intention of the training would suggest that classroom teaching be substituted to the extent feasible by hands-on “rotations” with agencies and organizations of the type in which trainees are being prepared to function, including private sector organizations. Although long the preferred method for training physicians in preventive medicine, supervised, responsible, highly intensive and diverse experiences covering a gamut of public health settings are not currently available at most schools of public health. Implementation of increased “rotations” will require schools to develop and maintain relationships with the agencies and organizations that could serve as the practice sites. Therefore, the committee recommends a significant expansion of supervised practice opportunities and sites (e.g., community-based public health programs, delivery systems, and health agencies). Such field work must be organized and supervised by faculty who have appropriate practical experience. Problems with emphasizing the practice component in education delivered in schools of public health include lack of funding for quality practice experiences and the incentive and reward structures for academic faculty that do not reward practice scholarship. Academic institutions need to recognize faculty scholarship related to public health practice and service activities. Further, potential practice sites must be ready to receive and supervise public health students. This requires adequate funding for such activity, including training of practice site staff. Recommendations for such funding are discussed in Chapter 6, under the federal agency responsibility for public health education. Many senior positions in public health will continue to demand or attract physicians, trained managers, lawyers, and others without formal public health training. Streamlined variations of the new practice curriculum that are oriented toward these individuals who have already obtained an M.D. (doctor of medicine), J.D. (doctor of law), M.B.A. (master of business administration) degree, or the equivalent will need to be developed to inculcate the core public health competencies in a practicable fashion as is currently done in preventive medicine training. Joint degrees in public health and these disciplines might be offered by universities with the appropriate schools and resources, as is currently the case on many campuses. Ideally such training might be incorporated into the

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century medical school curriculum itself, as has been proposed by Lasker (1999) and others and is further discussed in Chapter 5 of this report. The committee recommends that schools of public health should embrace the large number of programs in public-health-related fields that have developed within medical schools and schools of nursing, and initiate and foster scientific and educational collaborations. The focus on preparing individuals for leadership roles and senior practice positions requires re-design of curricula and teaching approaches to incorporate: enhanced participation in the educational process by persons in senior practice positions or with comparable experiences, experts in medicine or its practice, or those with unique skills in areas such as communication, cultural competence, leadership development, policy, or planning; reconsideration of M.P.H. admission requirements to ensure that selected candidates are adequately prepared for the expanded didactic and practical training envisioned; vastly expanded practice rotations; and enhanced education for competence in specific careers (e.g., biostatistician or health care administrator). Educating Public Health Researchers As discussed later in this chapter, the range of future research in public health will also be radically different from what we see today. To a far greater degree, public health research will be transdisciplinary in nature, involving applications of basic biology and social sciences, and direct participation of the community. Moreover, a far larger portion of the research portfolio is likely to be evaluative and/or intervention-focused, with interventions at the individual, community organizational, and even societal levels. Training of the workforce to conduct this research will require an equally radical new approach to the current strategy of advanced degree education at the doctoral level. The breadth of the envisioned future enterprise, and its many intersections with other scientific, biomedical, and social scientific fields, suggests that an important component of science training will be directed at those who enter public health with an advanced degree in another discipline, typically an M.D. or Ph.D. Such future investigators should have exposure to the core competencies and specialized advanced courses in relevant disciplines such as epidemiologic methods, methods for intervention research, or health economics. These types of courses may be necessary to transform the prior disciplinary research focus of these students to a new focus on public health questions. Efforts to make the educational experience effi-

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century cient and flexible, as well as identifying sources to make this training economically feasible will be major determinants of success. For a variety of reasons, it may make sense for only some selected schools of public health—presumably those with a high base of external research activity and support—to perform this educational function, possibly even on a specialty-by-specialty basis. In other words, the several centers with advanced capability in international research methods might serve as “magnets” for this training; the handful with broad research expertise in occupational and environmental health sciences might do likewise for that field. At the same time, some individuals may choose to obtain their primary doctoral level education at a school of public health. Doctoral candidates might be expected to have mastered undergraduate courses such as probability and statistics, computer applications, chemistry, biology, and human biology as prerequisites for admission directly into a doctoral program. In addition, given the intent for research training, such students would require external support throughout their education comparable to graduate students in other research-focused careers. Research training must not be construed as professional education geared toward practice in a high paying biomedical profession if the ambition is to train scientists. The committee recommends that doctoral research training in public health should include an understanding of the multiple determinants of health within the ecological model. Doctoral research candidates should have exposure to core public health disciplines as well as areas identified as critical gaps in earlier discussion in this chapter, and researchers must be trained to understand communities and to engage in transdisciplinary research (see the section on transdisciplinary research). Collaboration with Non-Traditional Programs As discussed earlier, devising and implementing interventions that address the multiple determinants of health require interdisciplinary and multidisciplinary cooperation. Public health as a discipline and as a profession must be collaborative with other disciplines and professions, especially those within the broad health arena. Its modes of thinking and its distinct competencies must be applied across a range of organizations that exist within the community, especially those organizations that are directly concerned with, and have an impact on, health care and the health of the community’s population. The disciplines with which public health professionals must collaborate are, of course, not limited to health practitioners. They include lawyers, social workers, educators, housing specialists, community planners, and administrators of assisted-living facilities, to name a few. In a

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century special way, those with whom public health must collaborate include health care practitioners such as physicians, nurses, physical therapists, occupational therapists, speech pathologists, audiologists, and dentists. Necessary collaboration will be enhanced to the extent that public health educators and students have the opportunity to meet with and share philosophical and methodological perspectives with educators and students in other professions. Moreover, education toward collaboration will be enhanced and perhaps even maximized to the extent that other professionals can be educated within a school of public health. As students within a particular professional discipline, they will be required to follow a curriculum prescribed by national accrediting organizations. Nevertheless, as students within a school of public health, they will be exposed to ways of thinking and problem-solving, and concepts that take them beyond the confines of their specific disciplines, allowing them to see and understand the individual within the context of the health of the community. Thus the school of public health gives these students a new set of lenses through which to view reality and to develop a greater appreciation for community-based lifelong learning. At the same time, public health professionals will have available potential “laboratories” for the application of public health principles. Consider, as an example, the discipline of speech-language pathology. These practitioners provide services in a variety of organizational settings, such as schools, hospitals, nursing homes, and home care agencies. Traditionally speech-language pathologists have been educated within schools of education. However, approximately 50 percent of them will practice within a health care setting; those practicing within schools will treat children whose health conditions or disabilities warrant care by practitioners who are more “medically” knowledgeable. Speech-language pathologists provide services to children and adults from diverse demographic and socioeconomic backgrounds. Their education within a school of public health will enhance their ability to see the individual patient or client within the context of personal and social characteristics that greatly impact their lives and their response to treatment, and their sensitivity to situations that warrant further investigation from a public health perspective. Furthermore, to the extent that speech-language pathologists are exposed to public health competencies, they will bring to the front line of health care organizations (including, in some cases, the patient’s home) and community schools an additional source of public health education. Collaboration with other disciplines not only strengthens students from other professions but brings to schools of public health new ideas and concepts, contributing to the transdisciplinary approach to education.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century TRANSDISCIPLINARY RESEARCH Public health research differs from biomedical research in that its focus is on the health of groups, communities, and populations. Rather than focusing on the mechanism of disease at the cellular or organ system level, it focuses on the origins of disease as it relates to human activity— in human behavior, interactions with the environment, and within societies. Prevention of injury and disease and their control within defined populations—not treatment of individuals—is the intended application for the knowledge public health research yields. Public health research answers the questions: What are the consequences to human health of the way we live, and what can be done to improve it? As discussed previously, the committee views this approach within the framework of the ecological model of public health. Many changes in the scope and conduct of such research during the coming century can already be anticipated and will be briefly outlined here. What is unlikely to change is the reality that schools of public health will serve as the nidus for much if not most of that research. Some health agencies (e.g., the Centers for Disease Control and Prevention [CDC] and state departments of health) and other organizations in the private sector (e.g., industry and pharmaceutical companies) will continue to sponsor and conduct public health research. However, the academic community and, in particular, schools of public health will likely continue to carry the major responsibility for public health research. The most striking change in public health research in the coming decades is the transition from research dominated by single disciplines, or a small number, to transdisciplinary research. Transdisciplinary research involves broadly constituted teams of researchers that work across disciplines in the development of the research questions to be addressed. Traditionally, research has been either interdisciplinary or multidisciplinary in nature. Interdisciplinary refers to the collaboration of two investigators from different departments or fields to answer a question of joint or mutual importance. An example might be an urologist and an epidemiologist participating in a study to find a new cause of bladder cancer. Multidisciplinary refers to research that offers the potential to resolve questions of both mutual and separate interest among participating investigators. For example, the urologist and epidemiologist identified above might be joined by an industrial hygienist interested in developing a new model for measuring coal tar pitch volatiles. Likewise, a cancer biologist might want to use the study to test the value of a new immunologic tool for early cancer detection. While the output of his/her work would be used by the epidemiologist, separate research questions would pertain to the additional disciplines. Transdisciplinary research implies the conception of research questions that transcend the individual departments or specialized knowl-

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century edge bases, typically because they are intended to solve applied public health research questions that are, by definition, beyond the purview of the individual disciplines. In transdisciplinary research broadly consituted teams of researchers work across disciplines in the development of the nature of the public health problem to be resolved. For example, the “team” might now include an economist, health psychologist, and chemical engineer to compare alternative strategies for reducing bladder cancer risk including development of a pitch substitute, economic incentives to eliminate pitch, or methods to cajole all exposed subjects to come early and often for screening. In the current paradigm, the prominent research mode is for single disciplines to join in interdisciplinary or multidisciplinary research. Research methodology typically reflects the repertoire of the principal investigator’s discipline, complemented by consultant co-investigators with additional skills. For example, at present a chronic disease epidemiologist might study the effect of an ambient air pollutant on mortality. He would obtain input from an environmental chemist to help measure the independent variable (air pollutants) and a biostatistician to allow exploration of advanced causal models. By definition, transdisciplinary research goes beyond and transcends individual disciplines by crossing traditional professional boundaries; individuals strive to adapt their own discipline’s theories and research to the needs of other disciplinary members of the group—each is able to transcend his individual perspective. The practical ramifications of such an approach are that the disciplines will no longer function like “silos” that exist side-by-side, deeply rooted in their respective traditions. Rather, these disciplines will involve more broadly constituted and integrated “teams.” For example, study of the health impact of air pollutants could involve more broadly constituted “teams” comprised of social scientists (to measure covariation in health status caused by social factors that in the present paradigm would be viewed as “confounders”), experts in lung and cardiovascular biology (to evaluate early markers of health effect because mortality, while easily measured, is too crude an end-point given the broad and diverse population at risk), and perhaps industrial engineers and economists to evaluate, in the research context, the feasibility and costs associated with alternative strategies for modifying air quality. Another example of the transdisciplinary approach is demonstrated by considering the prevalent public health concern, diabetes. Diabetes is especially prevalent among minority populations of American Indians, African Americans, and Hispanics. Lifestyle in terms of diet, weight, and lack of exercise can be contributing factors. Moreover, the availability of services, be they medical services including physician awareness for screening, or the availability of healthy food alternatives, are environmental factors that add complexity to individual lifestyle choices.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century Further, service patterns are determined in part by demographics, for example, the urban and rural nature of place, the ethnic and racial makeup of community, and the relative degree of affluence or poverty. Cultural patterns also are expressed in the types of food that groups eat and the traditions and attitudes that groups hold toward medical interventions. Furthermore, policy has an impact on the attention devoted to diabetes, for instance, how much funding is dedicated to research, prevention, and treatment. When the public health researcher is confronted by diabetes, an ecological framework is most pertinent because the disease has complex and interacting components that are individual behavioral and psychosocial, community, cultural, social, economic, and political as well as biological. Inter- and multidisciplinary models, in which disciplines share input, are valuable but do not blend the perspectives to produce a holistic view of the problem and possible research solutions. The practical ramifications of the transdisciplinary approach to education are that schools of public health may need to rethink their structure and modes of instruction in order to develop professionals that can interact synergistically when confronting health concerns. Fundamental questions arise when moving toward a transdisciplinary educational focus, such as does it make sense, in this day and age, to retain single discipline courses and departments that reinforce singular specialties by educating in the traditional silos. Perhaps it makes greater sense to structure education with a blending of disciplines by concentrating on public health case studies such as diabetes, so that comprehensive public health responses are melded in the educational process itself. A transdisciplinary approach that emphasizes the ecological model for addressing complex health issues may well result in more effective interventions. Closely related to the move toward more transdisciplinary approaches to complex health issues such as the one discussed above will be the move toward more intervention oriented research. In most domains of biomedical investigation, research regarding the mechanism of a disease is followed by study of therapeutic interventions, resulting in new strategies for disease diagnosis or treatment. In public health the linkage between discovery of etiology and strategies for control and prevention has not followed a biomedical research pathway, because the link is fundamentally social. Recognition of causal factors contributes to improvements in public health only insofar as feasible, socially palatable, and economically viable intervention strategies can be established. As such, rigorous testing and evaluation of interventions will increasingly dominate the landscape of public health research and will most likely become a dominant theme distinguishing public health from other aspects of biomedical research. Not surprisingly, the study of interventions will, in turn, dictate the third sea-change in public health research: community participation. Whereas

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century the study of clinical interventions can usually be achieved by recruiting consenting patients or subjects, interventions at the community level require an altogether different paradigm, in which investigators and the community or population to be studied are partners. Models for such research already exist (see discussion in Chapter 3). However, the preeminence of such research in schools of public health in the coming decades will mandate new expertise in these research modalities. In addition, such research will fundamentally alter relationships between schools of public health, the communities in which they are embedded, and the public and private agencies with responsibility for the health of these communities or populations. The committee recommends that schools of public health reevaluate their research portfolios as plans are developed for curricular and faculty reform. To foster the envisioned transdiciplinary research, schools of public health may need to establish new relationships with other health science schools, community organizations, health agencies, and groups within their region. Schools of public health have a primary responsibility for educating faculty, researchers, and senior-level practice professionals. The challenges of the 21st century require an educational approach that is ecological in nature, an approach that emphasizes the determinants of health and their interaction. Education for public health in the 21st century requires cultural competence, and broad new competencies in information technology, communication, and genomics, and a vast reemphasis on practical aspects of training. POLICY The Future of Public Health aptly characterized public health as a “problem-solving activity” and described the “appropriate and fundamental” role of politics in health policy-making (IOM, 1988). Public health professionals across the disciplines of public health cannot be fully effective without an understanding of how policies are made and put into practice (Burris, 1997; Gostin et al., 1999; Gebbie and Hwang, 2000; Reutter and Williamson, 2000; Weed and Mink, 2002). An ecological understanding of public health only makes this skill set more salient. Identifying social determinants of health means challenging settled practices, institutional arrangements, and beliefs that are perceived to be beneficial to at least some members of the community. Schools of public health play a primary, albeit variable, role in health policy development and dissemination. In addition, the application of policy, which by nature includes understanding the politics of policy development and implementation, must be addressed. Simply put, using the crude formula that “science + politics = policy,” dwelling on the science without appropriate attention to both politics and policy will not be sufficient for schools

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century to be significant players in the future of public health and health care. The appreciation of the importance of this role and the more systematic incorporation of policy efforts being linked to the schools’ educational mission are critical to charting the future. These same elements must also be enriched in research and service missions of schools of public health. Academic public health leaders—whether they reside in schools of public health, public health programs, medical schools or elsewhere—are often turned to for information needed in the formulation of policy. They are viewed as credible spokespersons who can make issues understandable to decision makers, the media, and the public. Faculty researchers are contributing greatly to the rapidly growing new knowledge about critical health care challenges, such as the multiple determinants of population health, the effectiveness and quality of health care delivery, and environmental hazards and their control. Yet the very same experts are at worst steered away from and at best not encouraged to move along the continuum from science to policy. Even if induced to do so, most faculty are not prepared to do so effectively, nor are faculty colleagues available to assist them. Part of the disincentive for researchers is that the current academic reward system generally acknowledges only research productivity and not the translation of scientific findings and knowledge to inform evidence-based policy making. This must change if schools are to maintain, let alone enhance, their status as important players in the public health and health care delivery arena. The committee believes that it is the responsibility of schools of public health to better prepare their graduates to understand, study, and participate in policy related activities. Therefore, the committee recommends that schools of public health: enhance faculty involvement in policy development and implementation for relevant issues; provide increased academic recognition and reward for policy-related activities; play a leadership role in public policy discussions about the future of the U.S. health care system, including its relation to population health; enhance dissemination of scientific findings and knowledge to broad audiences, including encouraging the translation of these findings into policy recommendations and implementation; and actively engage with other parts of the academic enterprise that participate in policy activities. ACADEMIC COLLABORATION The events of fall 2001 made it evident that public health systems need to have strong collaborative relationships with all parts of the health

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century system, and all health professionals need to have a solid grasp of public health principles and practices. Community-based physicians and hospital-based nurses were rapidly involved in surveillance and public education (and in some cases administration of prophylaxis). Community members turned to their neighborhood health centers and providers for assistance in interpreting media reports and defining levels of risk. In many cases, those from whom help was sought were themselves seeking to understand who was in charge, how the public’s health was being protected, and what information was reliable. One way to strengthen the capacity to respond is to increase the proportion of health and related professionals who have had a solid introduction to public health as a part of their basic professional education. Some other schools have existing requirements for public health, community health, or preventive medicine content but may not see these as central to their mission and thus may not give them sufficient attention. In other cases, the public health content may not be required, but would enhance the ability of the graduate to be an active part of a community health system. It is not the responsibility of a school of public health to solve the curricular problems of other schools or to monitor the education provided there. In fact, assumption of such roles would not be met with pleasure from the other schools. The expertise of a school of public health, however, in public health sciences, the ecological approach to health, or in specific topics such as risk communication or community partnerships could be useful to faculty in other schools. At some level, the relationship of a school of public health with other health-related schools and departments could be seen as parallel to the relationship between a local health department and other health-related resources in the community. Following that model, public health experts can make themselves available partners in defining educational goals for public health units or courses, in developing classroom or other teaching resources, and in looking for opportunities to allow students from multiple disciplines to work with public health students in models consistent with a 21st century view of improving the public’s health. Therefore, the committee recommends that schools of public health actively seek opportunities for collaboration in education, research, and faculty development with other academic schools and departments, to increase the number of graduates in health and related disciplines who have had an introduction to public health content and interdisciplinary practice, and to foster research across disciplines. ACCESS TO LIFE-LONG LEARNING Earlier in this chapter we asserted that schools of public health should focus on preparing senior-level public health professionals, leaders, re-

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century searchers, and faculty. This is a primary role for schools of public health. However, a secondary, but essential role of schools of public health as well as of other public health education programs is to provide continuing education to the existing workforce in two different ways. The first is new training reflecting evolutions in the field in order to update skills. The second is to provide the basic education needed by workers who have no previous training in the public health aspects of their positions. Because of the breadth and depth of their expertise across all disciplines of public health and their regional and national presence and influence, schools of public health have a responsibility to assure that appropriate, high quality education and training are available to the current and future public health workforce. In fulfilling this assurance role, schools contribute to enhancing the professionalism of public health. Schools are not, however, the sole direct providers of such training. The assurance role, often accomplished by working with partners in the community, is analogous to that of the public health system which does not always provide the necessary health services to individuals or communities but assures that their health care needs are met. There are several models that might be considered for assuring that education and training of the current and future public health workforce are available. An uncommon model, but one frequently believed to be predominant, is one in which schools of public health assume the sole responsibility for this comprehensive education and training. Under this model, schools, in addition to preparing graduate-level public health practitioners, provide training for current public health employees who may or may not have had any public health training through a variety of educational modalities. While there are some schools of public health that fulfill this role, it is not the norm for the majority of schools, nor do we envision that it should be. Schools of public health do, however, have a role to play in providing education and training to the larger workforce, given their enormous expertise in the various disciplines of public health that underlie public health practice. Additionally, faculty are experienced in developing, presenting, and evaluating educational material, in assessing student learning, and in using various pedagogical modalities. Distance learning provides one mechanism through which these strengths are increasingly being used for training and continuing education of the public health workforce. Recent technological developments have made the expertise of school faculty potentially more accessible to many public health agencies and organizations that are not located near schools of public health. Unfortunately, not all health departments have the necessary technological capabilities to take advantage of distant training opportunities. In addition, the transmission of knowledge in certain public health disciplines is not easily accomplished through distance learning. Furthermore,

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century some public health workers desire education and training in a classroom setting. For situations in which distance learning is not feasible or desirable, schools of public health should partner with local educational institutions. Many locales throughout the nation have community colleges or other two-year institutions. Schools of public health, through partnerships with these institutions, can provide the educational materials and instructor support for localized public health training. This also will give students in alternative settings the opportunity for exposure to public health courses and public health careers. Finally, it is recognized that basic public health training related directly to practice is often better provided by the local and state health departments than by schools of public health. However, schools of public health have a critical role in assisting health agencies in the development of training materials, providing expertise in the delivery, presentation, and evaluation of the materials, and in the assessment of student learning. For example, through the University of Washington Northwest Center for Public Health Practice, a network of state and local health departments in Alaska, Idaho, Montana, Oregon, Washington, and Wyoming, has been established with funding from CDC and the Health Resources and Service Administration (HRSA). The network will assess public health workforce training and preparedness needs and develop appropriate materials, including materials for distance learning, for use by various educational institutions in these states. Schools of public health are well positioned, because of their institutionally neutral location, to coordinate the sharing of “best practices” across public health agencies and the development of information networks among the agencies. For example, faculty members with expertise in environmental health could develop and maintain a Web site for the exchange of important information relevant to state environmental health directors. Schools of public health also provide more individualized education and training on specialized topics to the public health workforce. A faculty member from environmental health with particular expertise on assays for different types of microbes found in water could, for example, be available to respond to queries. State public health laboratories and local health directors could request information about the appropriate assays or, if local facilities are not available, the expert could conduct the assay in his or her lab. Local health department directors frequently consult with academic epidemiologists about protocols for responding to infectious disease or food-borne outbreaks. There are many potential roles that schools of public health have, either directly or indirectly, in the education and training of the public health workforce. Depending on the mission, expertise, resources, funding, and capacity of any particular school, it may do all or only a selection

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century of the above. However, the broad knowledge and expertise of schools of public health in public health disciplines and educational methodology positions them well to assure that comprehensive, high quality public health workforce education and training is available in the region served by each school. Therefore, the committee recommends that schools of public health fulfill their responsibility for assuring access to life long learning opportunities for several disparate groups including: public health professionals; other members of the public health workforce; and other health professionals who participate in public health activities. COMMUNITY COLLABORATION The previous sections have focused on the responsibility of schools of public health as they relate to practitioners, researchers, and educators within the field. However, there is a much larger audience with which schools of public health are inextricably linked; that audience is the public and the communities within. Implementing effective interventions to improve the health of communities will increasingly require community understanding, involvement, and collaboration. Schools of public health have a responsibility to work with communities to educate them about what it takes to be healthy and to learn from them how to improve public health interventions. Through research and service, schools of public health have the opportunity to engage communities in the task of improving the health of the public. The report, New Horizons in Health (IOM, 2001b) describes the importance of increased research funding for the study of communities. For schools of public health, the commitment to community must incorporate and emphasize community-based research, but also address the other key missions of teaching and service, including policy development and advocacy, as discussed earlier. Schools of public health will play a leadership role in advancing knowledge about the multiple determinants of health and how to apply this knowledge in varied arenas, including governmental policies and programs. The research base for much of this knowledge and the application of the knowledge will largely be community-based. Traditionally, single or multiple investigators have considered the community a “laboratory,” in much the same way that clinical investigations viewed the bedside as the laboratory. But the future calls for a different approach, one recognizing that by collaborating with the community (geographically or otherwise defined), both schools of public health and the community will benefit. Community organizations and leaders must have the opportunity to contribute to and influence research (often research on intervention effective-

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century ness) that has the potential to address local needs. Schools of public health can direct their expertise to generating and analyzing appropriate local level data and targeting significant problems. By working with the community, students in schools of public health will be exposed to far more coherent and visible community-based learning experiences. Schools of public health will be most effective in engaging in new relationships with their communities if they take a leadership role in collaborating with other important academic units, for example, medicine, nursing, education, urban planning, and public policy. Given the premise of a future where the boundaries of medicine and public health continue to blur, and the recognition that protecting and promoting population health requires consideration of a broad array of non-biological factors, schools of public health would be well served to not go down this path alone. Therefore, the committee recommends that schools of public health should: position themselves as active participants in community-based research, learning, and service; collaborate with other academic units (e.g., medicine, nursing, education, and urban planning) to provide transdisciplinary approaches to active community involvement to improve population health; and provide students with didactic and practical training in community-based public health activities, including policy development and implementation. Further, community-based organizations should have enhanced presence in schools’ advisory, planning, and teaching activities. FACULTIES FOR SCHOOLS OF PUBLIC HEALTH The curricular changes envisioned by the previous discussion will likely require substantial changes in the composition and backgrounds of future faculties of schools of public health. As schools of medicine have discovered, especially the “research intensive” schools, faculties most adept at careers in peer-reviewed and funded biomedical research, whether in basic science departments or clinical departments, are neither sufficient nor entirely satisfactory to meet the demand for educating medical students and post-graduate trainees in the practice of medicine. Accordingly, most have developed separate faculty tracks for “clinician-educators”—faculty whose primary role is classroom and bedside teaching, roles increasingly incompatible with the demands of success in the laboratory or even in patient-focused research. In a similar

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century fashion, faculties for schools of public health in the future will require both research-oriented and practice-focused components. A major barrier to increasing emphasis on practice and service relates to faculty rewards, promotion, and tenure because, within academic institutions, public health practice is not valued as highly as research activity nor is it rewarded by most academic institutions. Developing a system and criteria for evaluating the scholarly contributions of practice activities is imperative. Maurana and colleagues (2000) propose four standards for assessing the scholarly contributions of practice and service activities: (1) the service must have significance in that the issues addressed are of importance and value to project goals; (2) the context of the service is crucial in that it should have a close fit with the environment, should utilize appropriate expertise and methods, should have a substantial degree of collaboration, and should sufficiently and creatively use resources; (3) the scholarship of the service should demonstrate appropriate application, generation, and use of knowledge; and (4) the service should be able to demonstrate impact to issues, institutions, and individuals. A second model, the Competency-Based Model of Alverno College in Milwaukee, Wisconsin, divides scholarly activity into four competencies, each of which specify skills, activities and requirements that faculty must master in order for promotion. Further, the Association of Schools of Public Health (ASPH, 1999) asserts that service is relevant as scholarship if it requires the use of professional knowledge, or general knowledge that results from one’s role as a faculty member. This knowledge is applied as consultant, professional expert or technical advisor to the university community, the public health practice community or professional practice organizations. The dimension of scholarship distinguishes practice-based service from a form of service known traditionally as the general responsibilities of citizenship. For faculties with the appropriate mix of backgrounds and skills to be recruited and sustained, the committee recommends a major change in the criteria used to hire and promote school of public health faculty. Criteria should reward experiential excellence in the classroom and practical training of practitioners. One approach might be to place greater emphasis on public health practice research and service activities. Another approach may be to develop academic tracks based on teaching and practice. If this approach is taken, such tracks need to be sufficiently comparable to the existing tracks to encourage the choice of a teaching career in public health among professionals with these orientations, and sufficiently attractive to ensure heavy demand for the posts from among the best potential candidates.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century As detailed in Chapter 2, the funding stream historically has fostered emphasis within schools of public health on the research function. Such an imbalance has impeded maximizing the contributions of schools in practice and education. Moreover, the traditional single-discipline approach to agency funding has limited the repertoire of public health research. Recommendations to correct problems associated with funding have been proffered in Chapter 6 of this report. The committee emphasizes that it believes research, practice, and teaching are all important, both to the future of schools of public health and to the health of the populations served by graduates of those institutions. As discussed in Chapter 2, funding for public health education has risen and fallen over the course of the 20th century. Currently, funding for health education programs and schools of public health remains problematic, making it difficult for schools of public health as well as other programs to institute the necessary changes recommended by this report. The committee acknowledges the major contributions of philanthropic foundations to the development of public health education in the United States and emphasizes the renewed importance of foundation support to fund new initiatives and experiments in public health education. However, greater support for public health education is needed from state and federal governments to ensure that a competent, well-educated public health workforce is available (see Chapter 6 for specific recommendations). Public health professionals, knowledgeable about the ecological approach to health and educated in a transdisciplinary fashion, are essential to preserving and improving the health of the public. Well-educated researchers are needed to help us understand the kinds of interventions and policies that lead to improved health and the kinds of barriers that must be overcome to design and implement effective interventions. Knowledgeable faculty, with both practice experience and research expertise, are needed to prepare the next generation of practitioners and researchers with necessary competencies. Highly trained practitioners are needed for leadership and senior positions of responsibility to guide the development and implementation of programs, policies, and systems that will benefit the health of the public. Schools of public health are uniquely positioned to educate these professionals but can only do so if sufficient funding is available to develop the programs and approaches necessary to prepare future public health professionals for the challenges and opportunities of the 21st century. Recommendations for such funding are discussed in Chapter 6. The following chapter discusses the role of programs and other schools in educating public health professionals.