6
Public Health Agencies: Their Roles in Educating Public Health Professionals

The previous two chapters have reviewed the role of schools of public health and of other programs and schools in educating public health professionals. While the committee is aware that public health professionals work in a variety of settings, there is a special relationship with the governmental public health agencies at the local, state, and federal level. These agencies have a major responsibility for educating and training the current public health workforce and future public health workers who have not received training elsewhere.

The following sections discuss activities and roles of local, state, and federal public health agencies. These discussions are followed by a series of recommendations targeted at what official public health agencies can do toward better educating public health professionals.

LOCAL PUBLIC HEALTH AGENCIES

Activities and Responsibilities

Local health departments (LHDs) have a fundamental and complex role as the front line for delivery of basic public health services to most of the communities in this country. There are nearly 3,000 local health departments in the United States, varying dramatically in geographic size, size and nature of population, urban and rural mix, economic circumstances, governmental structure within which they work, and governing organization to which they are accountable. The majority of local health departments provide a wide variety of services to very diverse communi-



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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century 6 Public Health Agencies: Their Roles in Educating Public Health Professionals The previous two chapters have reviewed the role of schools of public health and of other programs and schools in educating public health professionals. While the committee is aware that public health professionals work in a variety of settings, there is a special relationship with the governmental public health agencies at the local, state, and federal level. These agencies have a major responsibility for educating and training the current public health workforce and future public health workers who have not received training elsewhere. The following sections discuss activities and roles of local, state, and federal public health agencies. These discussions are followed by a series of recommendations targeted at what official public health agencies can do toward better educating public health professionals. LOCAL PUBLIC HEALTH AGENCIES Activities and Responsibilities Local health departments (LHDs) have a fundamental and complex role as the front line for delivery of basic public health services to most of the communities in this country. There are nearly 3,000 local health departments in the United States, varying dramatically in geographic size, size and nature of population, urban and rural mix, economic circumstances, governmental structure within which they work, and governing organization to which they are accountable. The majority of local health departments provide a wide variety of services to very diverse communi-

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century ties with limited resources and too few staff (the median size is 14 full-time equivalents). Although local public health services are often discussed within the framework of the 10 Essential Public Health Services, the services actually provided vary widely from state to state, from urban to rural areas, and are especially adapted to address local priorities and concerns. Despite considerable variation, however, more than two-thirds of local health departments provide the following core services: adult and childhood immunizations; communicable disease control; community outreach and education; epidemiology and surveillance; environmental health regulation such as food safety services and restaurant inspections; and tuberculosis testing (NACCHO, 2001). The past decade has been a period of significant challenges and transitions in local public health. For many LHDs, resources for some traditional services have been shrinking at the same time that challenges and demands have been increasing. More people lack health insurance and are looking to “safety net” providers for health care. Rapidly growing immigrant communities are creating a need for new services or for providing traditional services in a different way. Many LHDs are shifting from “personal health care” services to “population-based” services. In the aftermath of bioterrorism, health departments have greatly increased disease surveillance activities and are now at the center of many of the federal, state, and local emergency planning activities. With these challenges and changing circumstances, there is increasing urgency for an assessment of how new public health professionals are educated and how the current workforce can be trained for new skills. The education and training of the public health workers poses a difficult challenge to local health departments, one for which they will require the engagement and support of many partners, most notably the schools that educate health and public health professionals. Training and Education in Local Health Departments LHDs have serious and urgent needs for preparing new public health professionals and for upgrading the skills of current public health professionals (NACCHO, 2001). They face an on-going need to train new and current workforces in how to respond to emerging areas, changing diseases, new priorities, and new technologies. Because LHDs are experiencing significant changes in the types of services they provide and the roles they are expected to fulfill, education and training are needed to prepare new and current local public health staff to meet these changing expectations. As discussed earlier, the vast majority of current public health workers do not have formal public health training. Many have training in a primary health profession, such as nursing or environmental health, and

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century continue to receive training updates from the schools and through their professional associations. One of the major training needs for LHDs is the capacity to support their professional staff in maintaining their professional credentials or licensure through on-going continuing education. Much of the training for local public health staff is obtained through the initiative of individual employees, seeking continuing education in areas of special interest to them or for the continuing medical education or continuing education units that are required to maintain their professional credentials. LHDs provide a significant amount of direct staff training, primarily for focused technical skills specific to their services and programs. Most LHDs have very limited financial and staff resources for providing or obtaining training or for supporting education for their staff, and they rarely have staff who are professionally prepared to be trainers or educators. Linkages with schools of public health could enhance the capacity of LHDs to provide broader and higher quality training. LHDs can play an important role in training and education by assessing the skills and training needs of their workforce. This assessment role is proposed in the National Public Health Performance Standards (NPHPS) (CDC, 1998), as part of Essential Service 8 (Assure a Competent Public and Personal Health Care Workforce) (Public Health Functions Steering Committee, 1994). The NPHPS also proposes that LHDs adopt “continuous quality improvement and life-long learning programs for all members of the public health workforce, including opportunities for formal and informal public health leadership development.” They further recommend that LHDs “[p]rovide opportunities for all personnel to develop core public health competencies.” Many sources of education and training are currently available for local health department staff, including state government agencies, professional organizations, academic institutions, federal government agencies, consultants, other local government agencies, and in-house training (Bialek, 2001). However, there is little systematic information about the extent to which LHDs actually use various sources, which courses and topics are most frequently sought, or the effectiveness of the alternative sources of training. “Distance learning” has become increasingly available, but there has been no assessment of the level of use or value for local public health professionals. Incentives for Public Health Training for LHD Professionals Most LHD professionals do not have formal public health training. Few M.P.H. graduates work in LHDs, at least in part because pay scales of LHDs usually are not competitive. Also, most LHDs are unable to provide support or incentives for current staff to obtain the formal public

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century health training that would increase the quality of the workforce. For example, they have limited ability to provide tuition reimbursement or educational leave to current employees who might wish to obtain an M.P.H. Most LHDs cannot provide pay increases or other incentives to staff who obtain additional public health training or degrees. The National Public Health Performance Standards recommend that LHDs “[p]rovide incentives (e.g., improvements in pay scale, release time, and tuition reimbursement) for the public health workforce to pursue education and training (Essential Service 8). This will become possible only if additional resources become available to LHDs. In many cases, significant changes would also be required in local government personnel rules and systems. Efforts should be directed toward engendering increased understanding and financial support from local governments as well as from other funders and policy makers, regarding the importance of on-going training and a higher level of initial education for staff working in public health. LHDs as Partners with Programs and Schools of Public Health Partnerships linking LHDs with programs and schools of public health would offer many potential benefits to both partners. The National Public Health Performance Standards recommends that LHDs “[p]rovide opportunities for public health workforce members, faculty and student interaction to mutually enrich practice-academic settings” (Essential Service 8). Field Placements Field placement programs are probably the most frequent collaborative activity that currently occurs between local health departments and academic institutions for health professions. Most of the students are at the baccalaureate level. Students participating in field placement programs rarely or never receive financial support from either the academic institution or the health department. The student field experience varies widely among the programs and schools of public health. Implementation of this committee’s recommendations related to improving the practice experiences of students in schools of public health (see Chapter 4) would greatly enhance the value of these experiences for both the students and LHDs. Staff and Faculty Exchanges Local health department staff offer practical experience that could be of value in the education of public health and other health professionals.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century Available information suggests that staff and faculty exchanges are not currently a major collaborative activity between local health departments and academic institutions for health professions. LHD staff and academic faculty might benefit substantially from programs allowing them to spend significant time in such activities. Many LHDs have indicated that they would be interested in having department staff placed in faculty appointments (Bialek, 2001). Such interest corresponds well with the committee recommendation (see Chapter 4) that there be enhanced participation of practitioners in the education of students in schools of public health. Other activities offering the potential for collaboration include special projects, seminar courses in the academic setting, and practical training in LHDs. Few LHD staff serve on academic institution steering or advisory committees. Research Opportunities Because LHDs are intimately involved with their communities, they have an immediate and detailed knowledge about local public health issues that need to be investigated. They also have the types of credibility with those communities that would facilitate community-based research, providing another cornerstone for working collaboratively with faculty and the community to facilitate such research. Local Public Health Leadership Because persons in leadership positions in LHDs are responsible for setting the policies and priorities of their departments and also for coaching and training their subordinate staff, it would be desirable for these leaders to have formal education in the full range of public health principles and skills. However, a 1992–1993 survey of LHDs showed that 78 percent of LHD executives had no formal public health training, although executives of larger jurisdictions were more likely to have a public health degree (NACCHO, 2001). Many LHD leaders do not have access to the financial support nor the educational leave necessary to obtain a formal public health degree. Flexible and creative approaches, such as certificate programs and public health leadership institutes, are needed to provide substantial public health training to the majority of the current LHD leadership. The many state, regional, and national public health leadership institutes that have arisen in recent years are of increasing prominence as sources of training for these upper-level LHD professionals. The leadership institutes are important sources of training in management and leadership skills for the current workforce. In some cases, they also provide training in public health theory to current managers who do not have

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century formal public health training. Many of these leadership institutes are linked with or located within academic institutions, in some cases schools of public health. Many different organizations and professions contribute to the health of a community, but local governmental public health agencies have a special, fundamental role. They provide services that either cannot be provided or will not be provided by anyone else. In most cases, local health departments provide the most basic public health services in a community, while also establishing the framework for the network of population-based services provided in the community. As we write this report, local health departments are increasingly engaged in emergency and bioterrorism preparedness. A decade ago, LHDs faced the emerging epidemic of AIDS and HIV. To respond effectively to the current and to future challenges, LHD professionals need the ability and resources to rethink and refocus services and to adapt as each new problem arises, as the population changes, or as the community expectations evolve. To do this effectively, they need an ecological perspective and preparation that is grounded in the fundamental skills of public health. Local public health officials welcome the diffusion of public health approaches and methods of analysis and approach into other components of the health services system and related fields. At the same time, there is a striking disconnect between the current focus of the academic institutions for the public health profession and persons actually practicing in the field. This results from a very complex set of demands and constraints, discussed earlier, including the limited funding available to provide meaningful practice experiences in both education and research. Although this quandary is not easily resolved, it must be confronted and addressed to ensure that the future leaders of state and local public health will have the professional skills and knowledge that they require to effectively address our public health needs. Local public health works closely with community health care providers, and all health professionals should function to some degree as part of their community’s system of public health. Therefore, public health at the local level would be greatly enhanced by including basic public health education in the training of all health professionals. It would be a great benefit to our public health services and to our communities if all physicians, nurses, and other health professionals had some education in basic public health concepts and systems. In particular, they need familiarity with legal context and responsibilities, the meaning and value of a “population health” approach, and epidemiologic techniques. This improves their ability to work appropriately with their local public health department. Associations representing LHDs have participated in national discussions urging that education of all health professionals should

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century be competency-based and should recognize the broad determinants of health, including social determinants. STATE PUBLIC HEALTH AGENCIES The 1988 Institute of Medicine report The Future of Public Health described the need for well-trained public health professionals who can address the needs of the public health system associated with technological advances, leadership and political will, and social justice. That report briefly described major barriers to meeting those needs: lack of public health training among the leadership of public health systems, lack of financial resources, and the general limitations of the governmental environment. Those observations were significant for the times, but that landmark report did not offer additional analysis regarding the issue of workforce development. Much has changed during the past decade and a half. Since 1989, new challenges for public health have emerged, with new emphases on surveillance of complex disease patterns and syndromes, emergency preparedness with regard to chemical and biological terrorism, and the increasing diversity of the population as a whole. These challenges have escalated at a time when most states are dealing with budget cuts, personnel hiring freezes, and difficulty in recruiting and hiring public health professionals. Since two-thirds to three-fourths of the state health departments’ budgets are personnel related, the cost of weak workforce development is magnified. The Organizational Climate All states and territories and the District of Columbia have a designated entity known formally as the state public health department. There are a total of 56 such designated units in the United States and its territories. The mission, authority, governance, and accountability of these agencies vary according to the state statutes that establish the public health departments. Some are located within a comprehensive health and human services umbrella agency; some are divisions within the governor’s organizational structure; and some are stand-alone state agencies. According to the Association of State and Territorial Health Officials (ASTHO), in 2001, 35 state health departments described themselves as free-standing agencies, while 21 listed themselves as being part of a larger umbrella agency. The executive-level leadership of state health departments also varies. Most states have statutory requirements for the appointment of the state health official, but the legal requirements differ. Twenty-eight states require the official state health executive to hold a license to prac-

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century tice medicine in the state; others do not. The state health department’s organizational climate will often emulate the philosophy of the top executive, especially with regard to workforce development. Therefore, the educational background and previous experience of the state health official is important to the process of educating the public health workforce. Regarding the mission of the organization, the majority of state public health departments have published mission statement language that describes protecting and promoting the health of the public. Most states have a combination of state and local health departments; some states operate the local health departments; and a few states have no local health departments at all. State level public health staffs are often health professionals without public health degrees. Regarding governance, 34 state public health agencies have a state level board of health, while 22 state public health agencies do not. Seven state public health departments are designated as the official environmental health agency. Four state public health departments are the official mental health agency. Four state public health departments are the official Medicaid agency. Recent emphasis on the development of state-level public health system performance measures offers an exceptional opportunity to articulate the unique role of state health departments within the overall public health system. The process of developing measures has challenged ASTHO, the Centers for Disease control and Prevention (CDC) and other partner organizations to delineate the basic public health functions that all states have in common, regardless of variations in organizational structures. Based on the set of essential public health services (see Box 6-1), performance measures enable states to take an enterprise-level view of key functions that must be in place to improve population-based health. The 10 Essential Public Health Services, by their nature, cut across categorical distinctions and allow for a more universal perspective on the principal state public health capacities and functions. The state health department’s role in any given state is to facilitate the implementation of the Essential Public Health Services, either by carrying them out directly or by indirectly supporting the efforts of the local public health agencies, and to articulate the needs of the public health workforce to federal partners. Responsibility of the State Health Department One of the 10 Essential Public Health Services specifically focuses on assuring a competent public health and personal care workforce, and state health departments have specific responsibilities in this area. Continuous improvement in the quality of services delivered to the citizens of a state includes an ongoing and systematic assessment of the profes-

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century BOX 6-1 Essential Public Health Services Assessment Monitor health status to identify community health problems Diagnose and investigate health problems and health hazards in the community Policy Development Inform, educate, and empower people about health issues Mobilize community partnerships to identify and solve health problems Develop policies and plans that support individual and community health efforts Assurance Enforce laws and regulations that protect health and ensure safety Link people to needed personal health services and assure the provision of health care when otherwise unavailable Assure a competent public health and personal health care workforce Evaluate effectiveness, accessibility, and quality of personal and population-based health services Serving All Functions Research for new insights and innovative solutions to health problems SOURCE: Public Health Functions Steering Committee, 1994. sional workforce available to deliver those services. The following sections describe specific components of a state-based public health system quality review process related to workforce development. Review of the Public Health System’s Progress Toward Achieving Goals and Objectives from Healthy People 2010 For the first time, these national health objectives also contain a call to improve the public health infrastructure. Specifically, states are encouraged to address the need for workforce development in areas related to public health competencies, and continuing education regarding the 10 Essential Public Health Services. States are challenged to develop specific, measurable strategies for action. States who use the Healthy People 2010 objectives to measure their progress must deal with the subject in a direct, measurable way. Concern for Deterioration in 2002 of State Fiscal Conditions, as Nearly Every State Reported a Budget Gap to Their Legislature The National Conference of State Legislatures (NCSL, 2001) conducted a survey to ascertain the extent of the problem. Results of the

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century survey revealed that although most of the problem relates to revenue shortfalls, many states are now facing spending overruns. Unfortunately, the Medicaid shortfalls have occurred at the same time that many states have also experienced budget shortfalls in public education and corrections. Therefore, most state programs, including public health departments, have been affected by these budget constraints. Fifteen states and the District of Columbia have earmarked reserve funds to get through this fiscal year, and another 10 states are considering doing so. Eight states have plans to use their tobacco settlement funds, not for expansion programs or services, but to support the current budget. Other budget management issues have included shifting financing for previously approved projects to cover the budget shortfall in other areas; instituting hiring freezes; redirecting special fund revenues into the general fund; boosting gaming revenues; delaying scheduled tax cuts and increasing state employee contributions to health care plans. The net effect is that, at the very least, public health departments will not have stable funding for improving population health and may in fact, lose critical resources. Despite competing demands and insufficient resources, states are attempting to conduct detailed reviews of human and capital resources as well as trying to provide public health services. Workforce development programs often are the first to be eliminated when state budget constraints emerge. State health departments have a pivotal role in assuring that the workforce available in these difficult times is well trained and well prepared to fulfill its important functions. The leadership of the state health departments is critical to assuring this objective. Continuum of Workforce Development Assessment Activity Should Exist in States Where Personal Health Service Delivery Remains a Viable Activity Some states use interdisciplinary teams comprised of nurses, social workers, nutritionists, and clerical staff to conduct reviews of the patient care process through the use of standardized tools, often developed by the team. Clinical indicators for program areas might also be considered in reviews of this nature as means for determining whether a more detailed review is required. Environmental health program components, if applicable, are typically included in this type of review. For example, a program for reducing lead poisoning should include an assessment of environmental exposure to lead-based paint or other sources, and methods to abate this exposure. The underlying strategy for this level of review is a focus on process of care or the delivery of specific services. State health departments have the responsibility for assuring that standards are in place for conducting these reviews, and for policies and procedures that provide for the continuing learning

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century needs of staff. Continuing learning needs may also have to address the natural tension that exists for those staff that have responsibility for assuring both personal and population-based health. Program Staff at the State Level of a Public Health Agency Might Work with Their Respective Local Staff to Review County or Regional Progress Toward a Program’s Overall Goals and Objectives Items included in this type of review process are generally categorical in nature and may include target population information, status reports on progress toward health status changes, and comparisons with other geographical entities. Review may include process, impact, and outcome components. Full program evaluations may also be conducted on a regular basis, using models that vary from state to state. In many states, the tools used to review program status are developed or adapted by state level program staff, with technical assistance or input from federal program staff or local public health staff. State-level public health program directors and consultants need to work in an organizational environment that provides them with the tools to manage their programs and to provide leadership to local public health agencies in that regard. Assurance of this type of learning environment requires an ongoing commitment to assessing the needs of this sector of the public health workforce and partnering with programs and schools of public health to develop programs to meet those needs. Window of Opportunity The recent appropriation of federal dollars for emergency preparedness provides a potential window of opportunity for state health departments to make much-needed progress in workforce development. Appropriation of the money through the existing cooperative agreements with the CDC requires that a portion of the emergency preparedness plans address workforce development and education. At the time of this writing, the plans were under review. However, it appears many states will use the opportunity provided by this funding to develop strong relationships with schools of public health for the assessment of public health workforce needs and the planning of multiple strategies to meet those needs. Opportunities to enhance the distance learning technology within states also have been provided, using a variety of methods. State health departments would be wise to use this time of resource availability to conduct their own training readiness inventory in order to foster organizational climates that favor strong workforce development programs. One method for assessing a state’s readiness to provide leadership in the development of the public health workforce is through

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century workforce gaps and decrease performance deficiencies; and assurance of educational course work to enhance the skills of the workforce of local public health systems. State public health agencies, working in collaboration with local public health systems, can develop incentives that support workforce development activities. Evaluation and quality improvement of the statewide system for workforce development. To be successful in this area, the state public health agency would periodically and consistently review the state’s activities to assure that a competent public and personal care workforce uses the results from reviews to improve the quality and outcome of its efforts. These reviews would include current and future workforce distribution and continuing education needs as well as public health system assessment for its success in meeting those needs. The public health system in the United States has been described as being ill-prepared, in disarray, and under-funded to meet the current (much less the future) needs of the population (IOM, 1988). Attention is being paid to the development of multiple strategies to strengthen the public health infrastructure. If these strategies are to be successful in the future, the developmental and educational needs of the public health workforce must be addressed. If the historic underfunding of public health human resource development continues, the public health system as a whole will be further weakened. State public health agencies, working in partnership with local public health systems and the federal government, must take the lead in strengthening the quality of the public health workforce. FEDERAL PUBLIC HEALTH AGENCIES Federal agencies are important to the development of the public health workforce generally, and specifically to the education of public health professionals. The roles of these agencies have included developing the research base that provides education; testing educational approaches; helping schools develop infrastructure; supporting faculty development; and providing funding for students. Key agencies include the National Institutes of Health (NIH), the Health Resources and Services Administration (HRSA), CDC, the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Agency for Healthcare Research and Quality (AHRQ), and their predecessors. They are located within the Department of Health and Human Services (DHHS), but the size of the department and the diversity of missions of the component units makes it critical that the discussion be specific to the individual agency. From the broadest public health education perspective, HRSA and CDC have been central and will be the focus of this discussion. HRSA

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century includes the Bureau of Health Professions (BHPr), which has the mission to help to assure access to quality health care professionals in all geographic areas and to all segments of society. BHPr puts new research findings into practice, encourages health professionals to serve individuals and communities where the need is greatest, and promotes cultural and ethnic diversity within the health professions workforce. The bureau identifies several specific programs for the public health workforce: Public Health Training Centers assess workforce learning needs and provide tailored distance learning and related educational programs. Public Health Special Projects community and academic partnerships improve skills and competencies of the public health workforce, provide distance learning, curriculum revision, and course content in areas of emerging importance. Public Health Traineeships train eligible individuals in public health professions experiencing critical shortages. Preventive Medicine Residencies support existing and develop new residency training programs, and provide financial assistance to enrollees. Health Administration Traineeships and Special Projects increase the number of underrepresented minority health administrators and the number of health administrators in underserved areas, support academic and practice linkages, and develop outcomes-based curricula. Beyond these programs, other HRSA components that focused on maternal and child health, HIV/AIDS, primary care, and rural and migrant health have included support for preparation of workers to attend to issues that are both personal care and public health in nature. The most recent visible activity of HRSA in public health workforce development has been the funding of 14 Centers for Public Health Training, supporting school of public health-based efforts to strengthen ties between practice and academics, offer improved distance-based continuing education, and work toward a stronger, more diverse public health workforce. The CDC’s predecessor agencies were the source of early efforts to identify the public health workforce and encourage the development of public health agencies in local jurisdictions across the nation. The programs of CDC have supported technical training for public health laboratory staff and for program staff in tuberculosis control, sexually transmitted disease control, HIV/AIDS prevention, school health, and, more recently, in chronic disease prevention and injury prevention. The Public Health Practice Program Office has provided a home base for the multi-organization Public Health Workforce Collaborative, begun in partnership with HRSA and involving nearly every identifiable organization representing some segment of public health workforce develop-

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century ment. An Office of Workforce Planning and Policy (OWPP) was created as the organizational locus for external workforce development activities within CDC and the Agency for Toxic Substances and Disease Registry (ATSDR) (a recommendation of the CDC/ATSDR Strategic Plan for Public Health Workforce Development, 2000). The OWPP assures coordination and accountability for implementing the strategic plan, oversees the development of workforce policies and standards, and convenes partners, as needed, to address issues and to provide support and technical assistance. The goal is to improve the ability of public health workers, nation-wide, to perform the essential services of public health, and to prepare the workforce to respond to current and emerging health threats. The CDC has funded 15 Centers for Public Health Preparedness based in schools of public health that are specifically charged to assure that the nation’s public health workforce is ready to respond to emergencies, especially those associated with bioterrorism. This specialized activity has eclipsed the more general support for implementing the Strategic Plan for the Development of the Public Health Workforce created in 2000. The potential roles for federal agencies in developing the public health workforce for the 21st century could take several forms, and are in the following categories: Research Development of academic programs Development of faculty Support for students Continuing education Technology development Modeling Research The education of public health professionals is built on a very slender research base. There is little or no research to support advancing the M.P.H. degree as the hallmark of readiness to practice public health, or on the differential contributions to public health of persons educated in various combinations of professional and on-the-job programs. Neither is there a research base on the relationship of staff preparation to outcomes of public health programs. While there has been discussion of building a public health systems research base (parallel to that available for studying questions about personal care and the medical care system), only the first steps have been taken. The federal agencies, especially CDC and HRSA, should make funds available for this important research, either as specifically funded studies or as components of other research portfolios.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century Development of Academic Programs Federal agencies should continue to support schools of public health and other institutions that train public health professionals (e.g., schools of nursing, medicine, dentistry, environmental sciences, and others), especially by providing pilot funds for the development of curriculum in emerging areas of practice (e.g., the eight content areas of informatics, genomics, communication, cultural competence, community-based participatory research, policy and law, global health, and public health ethics that were identified in Chapter 3). This support could come in the form of institutional grants that can allow for faculty time to develop new courses, development of information technology to support education, support for student experiences in practice settings, and travel to meetings with others developing similar programs. Special attention should be paid to developing collaborations that can assure that the best of public health education is shared across schools, and re-invention of programs is kept to a minimum. A council parallel to the Council on Graduate Medical Education that is charged with continuous monitoring and improvement of the public health workforce development process could be an immense aid in this effort. Development of Faculty Federal agencies are in an ideal position to support faculty development. Creation of grants such as those already in place at NIH to support new biomedical and clinical researchers should be explored. Support might take the form of institutional grants (e.g., the NIH T32 model), given to an institution to develop or enhance research training in a specific area of study by funding predoctoral, postdoctoral, and short term research training. Other support could be through individual grants (e.g., the NIH K01 model), given to an experienced individual for 3–5 years of mentored research in a new area or using new research methods. Expanding the opportunities for early and mid-career faculty to do short-term rotations in government, private, or voluntary public health organizations would foster linkages between academic public health and practice, and the development of the research base. Fellowship programs to assist those who have extensive practice experience but lack the credentials for academic appointment could bring more practitioners into the ranks of those teaching public health. Support for Students At one time there were individual fellowship programs that provided financial support to persons employed in public health but lacking finan-

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century cial support to complete the M.P.H. degree. These programs have become scarce, making it more difficult for persons recruited to public health in mid-career, as is often the case, to obtain the additional training that would make them even more effective and that would encourage them to continue in public health practice. A new degree-oriented fellowship program might include support during pre-professional training to persons who make a commitment to specialty education and later practice, as well as support in collaboration with employing agencies for return-to-school programs for persons already working. Special attention should be paid to using this student support as a mechanism for increasing the racial and ethnic diversity of the public health workforce. Continuing Education While federal public health agencies have supported much technical and programmatic education for workers in federally funded public health program areas, the more recent work to make this education available via distance technology and to assure that it carries continuing education credits appropriate to the intended audience must be expanded. It may be that the CDC Public Health Training Network (described in Chapter 2) is best suited to acting as a mechanism for disseminating information about programs of suitable quality and connecting the workforce to the rich range of opportunities available. It is also critical that the federal agencies involved in public health practice attend to the continuing education of their own workforce, assuring that federal staff are not only technically competent in specific programs, but also that they are kept abreast of evolving organizational, ethical, and communication concerns of the practice community. Technology Development Much attention has been paid to the uneven availability of current information technology across the range of organizations engaged in the public health enterprise. CDC has paid particular attention to this and has invested significant funds in assuring at least a minimum of Internet connectivity for state and local public health agencies. As communications technology and teaching and learning technology continue to advance, federal agencies are in the best position to evaluate the applicability of these advances to the range of practice and educational settings and to provide incentives or other support for adoption of technologies deemed most likely to support an effective public health workforce. Such a role should not, however, be carried out in a vacuum but, instead, in partnership with practice agencies and schools.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century Modeling A final role that federal agencies can play in supporting the education of public health workers in the 21st century is modeling the best of what is known in recruitment, promotion, and retention policies. This would include assuring that all position descriptions for public health workers are based on public health competencies as developed by the field. Position announcements and recruitment should recognize (as many currently do) the importance of formal education in public health. When federal agencies hire persons who lack public health education for particular specialized tasks, on-the-job training, continuing education, and opportunities for formal education should include, at a minimum, a basic orientation to the core competencies in public health. Worker developmental activities should continue to include opportunities for short- and longer-term rotations to other practice agencies and to academic institutions, which are mechanisms through which the overall public health enterprise can be enriched and enlivened. While the preceding discussion focused on HRSA and the CDC, the ideas are relevant to all branches of DHHS that are engaged in delivering one or more of the essential services of public health, and also to other federal agencies such as the Occupational Safety and Health Administration (OSHA) and the Environmental Protection Agency (EPA), and to the public health activities of the Department of Defense. The presence and leadership of these important federal partners in the public health enterprise cannot be overemphasized. Neither can the need for them to proceed in ongoing partnerships with the range of academic and practice agencies contributing to the same overall goal. RECOMMENDATIONS Local, state, and federal health agencies all play a critical role in educating public health professionals for the 21st century. Local health departments are the backbone of service in public health, meeting a broad range of public health needs of the diverse communities within their jurisdictions. To be able to engage in the most effective public health practice, practitioners in local health departments must be well educated and trained to fulfill their roles. To assure this is the case, we need to know what services they provide, and what skills and knowledge they need to ensure that their levels of competency are maintained and improved through appropriate training and educational opportunities. At the state level, state health departments facilitate the implementation of the Essential Public Health Services either by carrying out these services directly or by supporting the efforts of the local public health agencies. One of these essential services is to assure a competent public

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century health and personal care workforce. The state health department, in cooperation with local and federal public health agencies, has a major role to play in facilitating the competency of the public health workforce. Finally, as described earlier, federal public health agencies are crucial to the education of public health professionals and the development of the public health workforce. Federal agencies can and must play important roles in many areas as discussed earlier in this chapter. These areas include public health research, development of academic programs, development of faculty, support for students, continuing education, technology development, and modeling. The importance of leadership and action at the federal level is critical to success in educating public health professionals if the public workforce is to meet the challenges of the 21st century. Therefore, the committee recommends that local, state, and federal health agencies: actively assess the public health workforce development needs in their state or region, including the needs of both those who work in official public health agencies and those who engage in public health activities in other organizations; develop plans, in partnership with schools of public health and accredited public health programs in their region, for assuring that public health education and training needs are addressed; develop incentives to encourage continuing education and degree program learning; engage in faculty and staff exchanges and collaborations with schools of public health and accredited public health education programs; and assure that those in public health leadership and management positions within federal, state, and local public health agencies are public health professionals with M.P.H. level education or experience in the ecological approach to public health. Assessment of workforce education and training needs and development and implementation of programs to meet these needs are major roles for local, state, and federal agencies. The issue of workforce training and competency is central to the success of any public health system. CDC and other public health agencies and organizations, including the National Association of County and City Health Officers (NACCHO), the Association of Schools of Public Health (ASPH), and the American Public Health Association (APHA), are examining the feasibility of creating a credentialing system for public health workers based on competencies linked to the Essential Public Health Services framework. Ideally, every

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century state department of public health would be led by an individual who has formal credentials in public health. While local, state, and federal agencies all play a role in developing a competent workforce, there is a role that is primarily the responsibility of federal agencies, that of providing funding to support efforts throughout the system. As detailed in Chapter 2, public health teaching, research, and infrastructure support were well funded during the 1960s and 1970s. Major reductions in funding occurred during the 1980s, with little or no improvement during the 1990s. Meanwhile tuition and other costs increased substantially, with the result that a reduction occurred in the amount of public health professional education actually provided. Renewed interest in public health and the promise of increased funding may mean that needed investments to strengthen the public health infrastructure and workforce will be forthcoming. However we must ensure that funds are used for more than crash courses in a particular topic area (e.g., the current response to the threat of bioterrorism). We must also build the framework that will allow us, over the longer term, to ensure that public health professionals are prepared with the skills and knowledge necessary to improve population-level health. This means that increased funding must not only be a short-term response to a specific need but, instead, must be sustained over the long term. Such funding is crucial to developing the educational and research infrastructure necessary. The committee has carefully considered the rationale and feasibility of implementing recommendations to significantly enhance federal funding for both public health education and leadership development and for public health research overall, including research on population health, public health systems, and public health policy. Investment in public health education is inadequate. Federal support for non-physician graduate-level public health training is minimal, as described in Chapter 2. Funding for residencies in preventive medicine is less than 1 percent of the overall federal investment in health professions training (about $1 million of the $300 million) (Glass, 2000). The report Addressing the Nation’s Changing Needs for Biomedical and Behavioral Scientists (NRC, 2000) states that there is clear evidence of a decline in the number of M.D.s conducting research and concludes that enormous opportunities exist for more broadly trained investigators. Therefore, the committee recommends that federal agencies provide increased funding to develop competencies and curriculum in emerging areas of practice; fund degree-oriented public health fellowship programs; provide incentives for developing academic and practice partnerships;

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century support increased participation of public health professionals in the education and training activities of schools and programs of public health; especially, but not solely, practitioners from local and state public health agencies; and improve practice experiences for public health students through support for increased numbers and types of agencies and organizations that would serve as sites for practice rotations.* It is extremely difficult to specify needed funding levels, given the weak data base on public health outcomes, public health programs, and public health education. The committee believes that federal funding for non-physician graduate public health education should receive a significant increase. The committee further believes that public health education for physicians should also increase significantly. In terms of research funding, comparatively few resources have been devoted to supporting prevention research, community-based research, transdisciplinary research, or the translation of research findings into practice. Further, little public health systems research has been funded; such research is needed for better understanding of the factors that contribute to effective public health organization and service delivery. Current funding for research is focused almost entirely on two components of the ecological model of health—biologic determinants and medical cures. According to Scrimshaw and colleagues (2001), only 1–2 percent of the U.S. health care budget is spent on prevention and a like imbalance exists between funding for basic biomedical research and population-based prevention research. Actual causes-of-death analysis shows that at least 50 percent of mortality is due to factors other than biology and medical care (McGinnis and Foege, 1993). Because of this disproportionate spending away from preventive and public health interventions and research, we have lost major opportunities to prevent disease and disability, insofar as a substantial portion of mortality (estimated as high as 90 percent) and preventable disability is unrelated to health care per se (McGinnis and Foege, 1993). CDC plays a major role in supporting public health research through both its intramural and its extramural research programs. Intramural (or CDC-directed) research is carried out within its laboratories or in the field in collaboration with local and state health departments. Extramural research, in which decision making regarding study approach rests with the grantee, consists of programs developed and administered independently through the CDC’s Centers, Institutes, and Offices (CIOs). The *   Dr. Alan Guttmacher, because of his position as a federal employee, did not participate in discussions nor take a position regarding committee recommendations pertaining to federal funding.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century CDC has three categories of extramural research programs: program or CIO-generated research, investigator-initiated research, and research centers of excellence. CDC is increasingly funding investigator-initiated research. Some components of CDC have been engaged in this activity for decades (e.g., National Institute for Occupational Safety and Health, which uses the NIH study section for peer review of its substantial extramural research program). The new CDC Director, with broad support from groups such as the Association of Schools of Public Health and the Association of Academic Health Centers, has identified expanded extramural investigator-initiated research among her highest priorities. This direction is fully consistent with CDC’s prevention and population health mission. Despite the increase in funding for investigator-initiated research projects, this remains a relatively small endeavor. The committee believes that significant steps to increase research funding are amply justified and warranted. Research!America, for example, with support from The Robert Wood Johnson Foundation, has launched a major effort to build support for health promotion and disease prevention research. The committee supports these efforts. However, given limited information on the full scope of the research agenda to be completed or the capacity of the public health enterprise to make rapid use of a sudden large increase, the following first efforts should be supported and their impact evaluated to identify the most fruitful area(s) for futher investment. Accordingly, the committee recommends that there be a significant increase in public health research support (i.e., population health, primary prevention, community-based, and public health systems research), with emphasis on transdisciplinary efforts; the Agency for Healthcare Research and Quality spearhead a new effort in public health systems research; NIH launch a new series of faculty development awards (“K” awards) for population health and related areas; and there be a redirection of current CDC extramural research to increase peer reviewed investigator-initiated awards in population health, prevention, community-based, and public health policy research, reallocating a significant portion of current categorical public health research funding to competitive extramural grants in these areas.* *   Dr. Alan Guttmacher, because of his position as a federal employee, did not participate in discussions nor take a position regarding committee recommendations pertaining to federal funding.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century Major change is called for in the funding of public health research. There must be increased emphasis on transdisciplinary research, public health prevention, systems, and policy research, and an assurance that traditional, single-discipline scientific review neither stalls nor thwarts the appropriate allocation of funds to scientifically meritorious transdisciplinary teams and proposals. Local, state, and federal public health agencies form the backbone and the infrastructure for the public health system in the United States, and the workforce of these agencies is an essential component of that infrastructure. Public health professionals in these agencies, as well as in other organizations, must be appropriately educated to perform effectively. They must have the competencies necessary to serve as the frontline deliverers of public health services to diverse communities. They must be able to respond to rapidly changing needs, priorities, and technologies. They must have the knowledge and skills necessary to work effectively with many different disciplines, communities, and organizations. They must have an ecological perspective, grounded in the fundamental skills of public health. Educating public health professionals to function effectively and to respond to the new and emerging challenges requires funding support. There is an old saying, “You get what you pay for.” If we want high quality public health professionals, contributing through practice, teaching, and research to improved health in our communities, then we must be willing to provide quality support to the education of those professionals.