Appendix D
The Education of Public Health Professionals in the 20th Century

Elizabeth Fee

PREAMBLE

Over the past 50 years or more, many reports and conference proceedings have discussed the nation’s system of public health education. In general, these tend to deplore the general state of public health education and the inadequate preparation of the public health “workforce.” Recently, Kristine Gebbie crisply summed up the contemporary state of the discussion in her editorial, “The Public Health Workforce: Key to Public Health Infrastructure.”1 A longer version of the argument2 joins a series of recent publications and manifestos on the problems of public health education.3,4 These in turn appear to derive some of their general framework from the rather unflattering view of public health encapsulated in the Institute of Medicine’s report of 1988 on The Future of Public Health.5 Briefly character-

1  

Kristine M. Gebbie, The Public Health Workforce: Key to Public Health Infrastructure, American Journal of Public Health, 89, 1999:660–661.

2  

Gebbie K, Hwang I. Preparing Currently Employed Public Health Professionals for Changes in the Health System. New York: Columbia University School of Nursing; 1998.

3  

Public Health Functions Project, The Public Health Workforce: An Agenda for the 21st Century. U.S. Department of Health and Human Services, Washington, D.C.: 1998. This document calls for “a reassessment and a retooling of the entire public health education and training enterprise” (p. 7), with lots of “partnerships,” “collaborations,” and “stakeholder groups” measuring “performance-based competencies.”

4  

Andrew A. Sorenson and Ronald G. Bialek, The Public Health Faculty/Agency Forum: Linking Graduate Education and Practice—Final Report. Gainesville, Fl: University of Florida Press; 1993.

5  

Institute of Medicine, The Future of Public Health. Washington, DC: National Academy Press; 1988.



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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century Appendix D The Education of Public Health Professionals in the 20th Century Elizabeth Fee PREAMBLE Over the past 50 years or more, many reports and conference proceedings have discussed the nation’s system of public health education. In general, these tend to deplore the general state of public health education and the inadequate preparation of the public health “workforce.” Recently, Kristine Gebbie crisply summed up the contemporary state of the discussion in her editorial, “The Public Health Workforce: Key to Public Health Infrastructure.”1 A longer version of the argument2 joins a series of recent publications and manifestos on the problems of public health education.3, 4 These in turn appear to derive some of their general framework from the rather unflattering view of public health encapsulated in the Institute of Medicine’s report of 1988 on The Future of Public Health.5 Briefly character- 1   Kristine M. Gebbie, The Public Health Workforce: Key to Public Health Infrastructure, American Journal of Public Health, 89, 1999:660–661. 2   Gebbie K, Hwang I. Preparing Currently Employed Public Health Professionals for Changes in the Health System. New York: Columbia University School of Nursing; 1998. 3   Public Health Functions Project, The Public Health Workforce: An Agenda for the 21st Century. U.S. Department of Health and Human Services, Washington, D.C.: 1998. This document calls for “a reassessment and a retooling of the entire public health education and training enterprise” (p. 7), with lots of “partnerships,” “collaborations,” and “stakeholder groups” measuring “performance-based competencies.” 4   Andrew A. Sorenson and Ronald G. Bialek, The Public Health Faculty/Agency Forum: Linking Graduate Education and Practice—Final Report. Gainesville, Fl: University of Florida Press; 1993. 5   Institute of Medicine, The Future of Public Health. Washington, DC: National Academy Press; 1988.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century ized, these various analyses assert that public health departments are poorly staffed, and that many of the people working in them lack the specific skills, qualifications, and abilities they need to fulfill their responsibilities of protecting the public health. The faculty members of public health schools, for their part, are busy doing research, and training students to do research, but they are failing to turn out the highly educated labor pool needed to adequately staff the public health departments of the future. Phrased another way, the “theory” of public health as taught in the academy does not cohere tightly to its “practice” as performed in state and local health departments. Public health “leadership” is said to be needed to connect the fragmented pieces by taking the knowledge produced in the schools and applying it in the “laboratory” of people’s lives. Within schools of public health, most faculty members are scientists and researchers with a Ph.D. degree. Few have any work experience outside of academia, much less in city or state health departments. Not surprisingly, they have little interest in becoming engaged with the practical work of public health agencies. Many, especially in the laboratory-centered disciplines, have little knowledge of, or interest in, politics or policy, or they regard politics as merely some distasteful contaminant of an otherwise orderly search for knowledge. Even social and behavioral scientists are often more interested in their statistical methodologies than with the messy arts of organization, advocacy, and policy-making. They shy away from the popular media, television cameras, news magazines, street demonstrations—among the various modes of informing, shaping, and challenging public opinion—as perhaps undignified and definitely distracting. Nor are they often to be found in the schools, clinics, churches, and community organizations of the decaying sections of the cities in which they work. From the point of view of the faculty of public health schools and programs, there is little time for the multiplicity of things they are already being pressured to do. To be required to raise the best part of one’s own salary, and to write grants to cover research assistants, secretaries, students, equipment, or other research needs, focuses the mind admirably. All other activities become luxuries. To be successful in the research funding world requires associated and time-consuming commitments: to read the work of one’s colleagues, to review other people’s grant applications, to publish on a regular basis, to participate in academic and professional meetings, to have pieces of one’s time scattered across other people’s projects in case one’s own project lacks sufficient funding. None of this allows much leisure for intellectual or political activities that are not directly related to the research agenda, such as exploring the messy world of community organizations or writing for popular, as opposed to scientific, journals. It is only on rare occasions and more or less by accident that schools of public health harbor public intellectuals or effective public advocates for the public’s health.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century If schools of public health have become mainly research institutes, where students learn the art of preparing grant proposals and writing scientific articles, what about the local departments of public health? In general, these are staffed by people with little public health training— people who learn the processes and problems of public health on the job. Some have scientific, medical, nursing, or engineering degrees that may be relevant to their work but the matching of credentials to tasks is often haphazard. Certainly, there is no assumption that all members of a local health department will be graduates of an accredited school of public health. Salaries in public health are low and political pressures are often strong; many public health departments survive in a more or less permanent state of crisis, coping with the last budget cut and waiting for the next one. Their contact with the schools of public health is likely to be sporadic—a lecture series here and there, an occasional joint project. If there is indeed something lacking in the structure and processes of public health education, then, from the historian’s perspective, it is useful to find out when the problem started. Has it always been thus? How did this state of things come to pass? What forces are responsible for the peculiar disjuncture between schools of public health and the departments of public health where the work of public health gets done? In order to explore these questions, we need to examine the two general phases of public health education in America: the phase of private funding by the great philanthropies when independent schools of public health were first created and second, the period of federal and state funding. Although there is overlap between these two phases, it seems reasonable to date the first as 1914–1939, and the second as 1935 to the present. As part of phase two were the wartime programs in public health funded by the armed services. After the war, as in other sectors of the economy, there was a long era of postwar expansion, with smaller bumps and recessions along the way. Overall, funding for public health education has been on an upward trajectory but the development has been uneven; wavelike patterns of expansion and retrenchment make for instability and great difficulty in planning. If health departments have often lurched from crisis to crisis, schools of public health have accustomed themselves to an often erratic funding cycle, with sudden infusions of funds for special areas of concentration, political shifts and cutbacks, and the giving and taking away again of grants and training funds. The miracle of it all is that so many excellent and talented students pass through, are educated, and receive credentials, before emerging into the intersecting worlds of government agencies, voluntary associations, foundations, academia, international organizations, and managed care companies.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century THE FOUNDING OF SCHOOLS OF PUBLIC HEALTH The first independent schools of public health in the United States were funded and nurtured by the Rockefeller Foundation. Rockefeller philanthropies were by far the largest and most important in terms of their influence on public health education, so I will focus on them here, but it is notable that other foundations, such as Commonwealth, Kellogg, and Milbank, were also extremely involved in and supportive of public health education during the interwar years. Not until 1935 did the federal government provide any significant level of funding for public health education. To set the context for the recurring struggles over public health education, it may be helpful to note that medical schools had proliferated throughout the 19th century because they were economically advantageous to both faculty and students. A few faculty members could get together, create a medical school, and charge tuition; assuming the fees were not too high, nor the entrance requirements too strict, the students would come. Then as now, medical students were making a wise investment in their future earnings. Schools of nursing, by contrast, were created by hospitals that needed a well-trained and well-behaved labor force to staff their wards; the hospitals thus had an economic interest in creating their own diploma schools. Once the nursing profession was more fully established, universities found that women students (or their families) were willing to pay tuition as an investment in a respected female career. In the case of public health, however, by the later 19th century, when cities and states were calling for public health officers, there were no established career patterns. Public health leaders were generally people like Hermann Biggs or Josephine Baker—physicians who, with lucrative private medical practices on the side, could devote themselves to the public’s health as a largely voluntary activity. The rank and file of public health officers were simply practicing physicians who could be called out in times of crisis to assist in coping with epidemic diseases, but who were otherwise fully involved in caring for their own patients. Municipalities employed a variety of health inspectors and street cleaners but these were largely untrained and often unreliable workers, many of whom obtained their positions through political patronage. It was thus the leaders of the Rockefeller philanthropies who, in the early 20th century, set themselves the task of creating a public health profession. The Rockefeller officers became involved in public health education because of their experience with the hookworm eradication campaign in the southern United States. The hookworm eradication campaign was part of a massive program to modernize the South—besides building railroads and factories, the representatives of northern capital would raise the productivity of the rural southern workforce by eliminat-

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century ing the “germ of laziness.”6 This was a perfectly logical approach because hookworm infestation produces anemia and thus decreases the population’s ability to work; a healthier workforce would indeed be more productive. Members of the Rockefeller Sanitary Commission’s staff had initially assumed that they could rely on public health officers in the southern states to help carry out their program. But to their distress, they found these part-time health officers displayed little interest in or dedication to the task. Rural southern physicians disliked the northern Yankees, resented being ordered about, and generally refused to believe that hookworm was a serious problem. Wickliffe Rose, the architect and organizer of the Rockefeller Sanitary Commission, came to believe that a new profession was needed—separate from medicine—composed of men and women who would devote their whole careers to the control of disease. Rose insisted that there must be two professions: medicine, for treating disease at an individual level, and public health, for controlling disease and promoting health at a population level. Rose turned to Abraham Flexner whose “Flexner Report” of 1910 had been central to the reorganization of American medical education.7 Flexner was then head of the General Education Board, the Rockefeller organization responsible for education programs. Flexner was involved in a struggle to make medical school professors “full-time” faculty—to separate teaching and research from private practice so that professors would be able to devote their entire attention to their academic pursuits. To Rose, the problem of part-time health officers appeared in a similar light: public health practitioners should be “full-time” so that they would devote their whole attention to the needs of public health and not be distracted by the demands of private practice. Flexner found that Rose’s concerns were widely shared by prominent leaders in public health. Indeed, the Massachusetts Institute of Technology and Harvard University had already put together an impressive curriculum for training health officers in communicable diseases, sanitary engineering, preventive medicine, demography, public health administration, sanitary biology, and sanitary chemistry.8 Students generally entered with professional degrees—they could be engineers or physicians— and completed a two or three year course of additional study before receiving a certificate in public health. The combined program graduated a small number of highly-trained health officers each year. 6   John Ettling, The Germ of Laziness: Rockefeller Philanthropy and Public Health in the New South. Cambridge: Harvard University Press, 1981. 7   Abraham Flexner, Medical Education in the United States and Canada. Bulletin No. 4. New York: Carnegie Endowment for the Advancement of Teaching, 1910. 8   Jean Alonzo Curran, Founders of the Harvard School of Public Health with Biographical Notes, 1909–1946. New York: Josiah Macy, Jr., Foundation, 1970.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century Hearing about the interest of the General Education Board, and hoping for some of the Rockefeller largesse, several universities submitted competing proposals for a school of public health. Harvard University naturally thought that the project could best be entrusted to them, and had in mind an expanded School for Health Officers. Charles-Edward A. Winslow, however, argued in favor of a school in New York City that would focus on training public health nurses, sanitary inspectors, and health officers for small towns—the rank and file of the profession, not just the most highly educated elite. Wickliffe Rose agreed that one or two schools could be established and asked Abraham Flexner to organize a planning conference for October 1914.9 Columbia University now submitted a plan for a school—combining medical, engineering, and social science courses—to be established in New York. The Columbia plan especially emphasized the social and political sciences, in contrast to the more usual emphasis upon biological sciences and sanitary engineering. In the discussions that followed, three competing conceptions of public health emerged: the engineering or environmental approach, the sociopolitical, and the biomedical. In the end, the biomedical approach would dominate, with sociopolitical and environmental concerns relegated to a very subsidiary role. Wickliffe Rose asked Abraham Flexner to consult with medical school professors, members of the newly formed United States Public Health Service, the medical departments of the army and navy, state and city health departments, registrars of vital statistics, representatives of life insurance companies, and health managers of large industries. Flexner, however, preferred to rely on the advice of a few trusted friends and never consulted most of these varied experts. Instead, he brought together a group of 20:11 public health representatives and 9 Rockefeller trustees and officers for a one-day meeting on October 16, 1914. The decisions made during that conference would shape public health education for the next 25 years. First was the question of the types of practitioners for whom training was needed. Hermann Biggs, the health commissioner of New York state, declared that there were essentially three classes of public health officers. The “health officials of the first class,” were those with executive authority such as city and state health commissioners. The health officials of the “second class” were the technical experts in specific fields: bacteriologists, statisticians, engineers, chemists, and epidemiologists who would run health department programs and conduct research. The “third class,” the “subordinates” or “actual field workers,” were the local health officials, 9   These matters are discussed in greater detail in Elizabeth Fee, Disease and Discovery: A History of the Johns Hopkins School of Hygiene and Public Health, 1916–1939. Baltimore: The Johns Hopkins University Press, 1987, esp. 26–56.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century factory and food inspectors, and public health nurses. Members of this last and most numerous group would be the “foot soldiers” in the war against disease. The most difficult question was whether the “first class” officials had to be medical men. If public health were to become a full-time career, was it reasonable to suppose that physicians would be willing to give up their independence to become salaried employees? As a consequence of the Flexner reforms in medical education, physicians’ incomes were rising sharply, so it was hardly a propitious time to expect a large influx of doctors into public health. But William Henry Welch of Johns Hopkins brushed these concerns aside, stating—as it would turn out, with excessive optimism—that physicians would be eager for the “splendid opportunity” of education in public health. Hermann Biggs argued in vain that the requirement of a medical degree was unrealistic, for most of those present at the meeting believed that only medically qualified health officers would be able to gain the cooperation of medical men in the community. Already, the potential for conflict between medical men and public health officers was evident to these experienced observers but the proposed solution—to make public health officers medical men—would prove ineffective. It did not address the real source of the conflict and ignored the looming contradiction between the interests of the majority of the medical profession, engaged in fee-for-service private practice—and a new minority group of salaried public health doctors. At the October conference, Wickliffe Rose laid out a carefully articulated vision of the future of public health education. At the center he placed a scientific school, well endowed for research. This school would belong to a university but be independent—specifically, it would not be a department of a medical school. Students attending the school would be selected from across the country and its graduates would be carefully placed in strategic positions throughout the United States. This central scientific school would be linked to simpler schools of public health to be established in every state; these state schools would focus on teaching rather than on research. The state schools would in turn be affiliated with medical schools and with state health departments and would offer short training courses for health officers already in the field. Following the pattern of the agricultural extension courses and farm demonstration programs that the Rockefeller Foundation had already used to modernize agriculture in the southern states, they would offer extension services for rural health education.10 Both central and state schools would teach public education methods and seek to extend public health information to the entire population. The central school would take the whole country as its 10   See Abraham Flexner, The General Education Board, 1902–1914. New York: General Education Board, 1915, pp. 18–70.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century “field of operations,” sending out “an army of workers” to demonstrate the best methods of public health, and bringing back their practical experience to be “assembled and capitalized” at the center of operations.11 Rose and Welch were given the task of writing up this draft plan to be mailed to the meeting participants for their criticisms and suggestions. Rose now outlined a memorandum entitled “School of Public Health,” and Welch countered—at the last possible minute—with a plan for an “Institute of Hygiene.”12 Because of Welch’s perhaps unconscious procrastination, there was no time to circulate this document to the meeting participants before its official presentation to the General Education Board; although Rose himself had not had time to review the draft, it was presented as the “Welch-Rose Report.” As I have previously argued, Welch’s version of the plan was more oriented to scientific research than was Rose’s more practice-oriented model; Welch’s version dropped almost all mention of Rose’s system of state schools, practical demonstrations, and extension courses.13 Enthusiastic paragraphs about the need for an army of public health nurses and special inspectors had been eliminated; instead, Welch dwelled happily on the development of “the science of hygiene in all its branches” that would be the focus of the central school of public health. He dropped Rose’s phrases about the divergent aims of medicine and public health and instead suggested that the new school of public health should be close to a good teaching hospital. Some of the participants at the October conference and other public health leaders complained that Welch’s version of the report was closer to the German than to the English conception of public health. In other words, the focus on research largely ignored public health practice, administration, public health nursing, and health education. The medical side of public health was emphasized to the virtual exclusion of its social and economic context; no mention was made of the political sciences or of the need to plan for social or economic reforms. Public health was to be biomedical, not social in orientation. Abraham Flexner, who greatly admired Welch, brushed aside all such objections and subtly maneuvered the decision-making process towards Welch’s ideas and the selection of Johns Hopkins University as the site of the first endowed school of public health. The Johns Hopkins School of Hygiene and Public Health opened its doors to its first class of students during the influenza epidemic of 1918. Only later did the Rockefeller officials agree to provide funding for other schools of public health, most notably at Harvard and Toronto. 11   Wickliffe Rose, “School of Public Health,” May 1915, p. 10. Rockefeller Foundation Archives, Record Group 1.1, Series 200. Rockefeller Archive Center, North Tarrytown, New York. 12   William Henry Welch, “Institute of Hygiene,” May 27, 1915, Rockefeller Foundation Archives, Record Group 1.1, Series 200. 13   Fee, Disease and Discovery, 40-42.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century Wickliffe Rose’s grand conception of a network of state schools with extension agents fanning out into the countryside, major emphases on public health education, short courses and extension courses to upgrade the skills of health officers in the field, and demonstrations of best practices in public health were not implemented by the Rockefeller Foundation—although much would later come into being albeit in a more haphazard and less carefully planned fashion. For most of the Rockefeller men of that era, it made sense to start at the top, create one or two elite schools of public health, and let the rest flow from the center. Had the emphasis on modernization and increasing worker productivity that had been characteristic themes of the hookworm eradication program been maintained as the central motive and justification for public health campaigns, perhaps other private interests would have helped bankroll the rest of Rose’s initial vision. But as history turned out, it would take the crisis of the Depression and the creative responses of the New Deal to impel the next major leap forward in public health education. The first schools of public health: Johns Hopkins, Harvard, Columbia, and Yale, tended for the most part to follow the model set by the Hopkins school. They were well-endowed private institutions with high admission standards; they favored medical graduates, and often admitted rather distinguished mid-career people already experienced in public health. In the 1920s and early 1930s, the curricula of the schools tended to be heavily weighted toward the laboratory sciences: bacteriology, parasitology, immunology, and what was called “physiological hygiene,” along with instruction in epidemiology, vital statistics, and public health administration. The main emphasis was on infectious diseases, with some attention to nutrition (biochemistry), water quality, and occupational hazards. In the 1920s, little was attempted in the way of field practice but this was, perhaps, relatively unimportant as so many of the students were already experienced practitioners. The Rockefeller Foundation gave fellowships to medical graduates around the world who were interested in studying public health, so that from the beginning, the schools tended to have an international flavor. The Foundation would later use these graduates to help establish schools of public health in Brazil, Bulgaria, Canada, Czechoslovakia, England, Hungary, India, Italy, Japan, Norway, the Philippines, Poland, Rumania, Sweden, Turkey, and Yugoslavia. The Rockefeller Foundation also tried to convince the schools to establish programs of field training. Using the model of medical school education, the students, they argued, should learn to practice in the community much as medical students learned their art in the wards of a hospital. Johns Hopkins under Welch had been reluctant to pay much attention to practical training but in the 1930s, with additional funding from the Rockefeller Foundation, Hopkins did establish the Eastern Health District, consisting of a study population of about 100,000 people

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century living in the neighborhoods around the School of Hygiene. These families were intensively studied through a house-to-house health census every three years; as a local newspaper described the population, “They are, by all odds, the most interrogated, surveyed, investigated, and card-indexed citizens of Baltimore—and probably of the 48 states, Alaska, Hawaii, Puerto Rico, and the Philippines.”14 Many of the Hopkins doctoral students wrote their dissertations on some aspect of the health of this population. By 1930, the first schools of health were turning out a small number of graduates with a sophisticated scientific education. The schools however were doing little or nothing to turn out the large numbers of public health officers, nurses, and sanitarians needed across the nation. In 1932, the American Public Health Association established a Committee on Professional Education chaired by Waller S. Leathers, Dean of the Vanderbilt Medical School, which included many of the then leading names in public health circles, such as Thomas Parran, W.G. Smillie, Allen Freeman, and Huntington Williams, among others. This committee prepared 20 reports on the educational qualifications of 15 professional specialists, and ultimately distributed some 250,000 copies of these reports.15 The idea of this very considerable effort was to inform state and local health departments about the types of employees they should be seeking and the kinds of qualifications appropriate for each, with the idea of creating national standards that, if used by the multiplicity of local health departments, could create some degree of uniformity across the nation. FEDERAL FUNDING FOR PUBLIC HEALTH EDUCATION A major stimulus to the further development of public health education came in response to the Depression, with the New Deal and the Social Security Act of 1935. The Social Security Act expanded financing of the Public Health Service and provided federal grants to the states to assist them in developing their public health services. Federal and state expenditures for public health actually doubled in the decade of the Depression. Federal law required each state to establish minimal qualifications for health personnel employed through federal assistance, and recommended at least one year of graduate education at an approved school of public health. For the first time, the federal government provided funds, administered through the states, for public health training. Overall, the states budgeted for more than 1,500 public health trainees, and the existing 14   “Where Doorbells Are Always Ringing,” Evening Sun, September 13, 1939. 15   William P. Shepard, “The Professionalization of Public Health,” American Journal of Public Health, 38, 1948:145–153.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century training programs were soon filled to capacity. As a result of the growing demand for public health credentials, several state universities began new schools or divisions of public health and existing schools of public health expanded their enrollments. In 1936, the American Public Health Association reported that 10 schools offered public health degrees or certificates requiring at least one year of residence; of these, the largest were Johns Hopkins, Harvard, Columbia, and Michigan.16 Also offering degrees in public health were the universities of California at Berkeley, Massachusetts Institute of Technology, Minnesota, Pennsylvania, Wayne State, and Yale. By 1938, more than 4,000 people, including about 1,000 doctors, had received some public health training with funds provided by the federal government through the states. The economic difficulties of maintaining a private practice during the Depression had pushed some physicians into public health; others were attracted by the availability of fellowships or by increased social awareness of the plight of the poor and of their need for public health services. In 1939, the federal government allotted over $21 million for public health programs: $8 million for maternal and child health, $9 million for general public health work, and $4 million for venereal disease control. Of course, many students and health departments desired the most efficient and least time-consuming process of credentialing they could find. The market favored programs that could produce the largest numbers of graduates in the least amount of time. When there were not enough places in schools of public health to supply the need, many colleges and universities opened public health departments and programs, some offering training courses of just a few months’ or even a few weeks’ duration. Engineering programs turned out sanitary engineers by the score. Summer sessions in public health nursing at Berkeley, Michigan, Minnesota, Columbia, Syracuse, Western Reserve, and several other universities produced over 3,000 graduates annually. These short programs offered a variety of diplomas and certificates in public health; by 1939, 45 institutions were offering 18 different degrees, certificates, and diplomas in public health. Of these 45, 10 were independent schools of public health, 20 were colleges and universities offering programs in public health nursing, and 12 were engineering colleges offering programs in sanitary engineering. Despite a great expansion of public health training facilities, there were still far from enough graduates to meet the demand. Federal training funds were now allotted to California, Michigan, Minnesota, Vanderbilt, and North Carolina to develop short courses for the rapid training of 16   Committee on Professional Education, “Public Health Degrees and Certificates Granted in 1936,” American Journal of Public Health, 27, 1937, 1267–1272.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century to urge its members to support public health education. They found an especially sympathetic audience in Senator Lister Hill and Representative George M. Rhodes, and in 1958, Congress enacted a two-year emergency program authorizing $1 million a year in federal grants to be divided among the accredited schools of public health. The First National Conference on Public Health Training in 1958 noted that these funds had provided 1,000 traineeships and had greatly improved morale in public health agencies. The Conference further requested appropriations for teaching grants and construction costs for teaching facilities, and urged that faculty salary support be provided for teaching. Their report concluded with a stirring appeal to value public health education as vital to national defense: The great crises of the future may not come from a foreign enemy…”D” day for disease and death is everyday. The battle line is in our own community. To hold that battle line we must daily depend on specially trained physicians, nurses, biochemists, public health engineers, and other specialists properly organized for the normal protection of the homes, the schools, and the work places of some unidentified city somewhere in America. That city has, today, neither the personnel nor the resources of knowledge necessary to protect it.60 President Eisenhower signed the Hill-Rhodes bill, authorizing $1 million annually in formula grants for accredited schools of public health and $2 million annually for five years for project training grants; between 1957 and 1963 the United States Congress would appropriate $15 million to support public health trainees. The worst of the crisis was over. In the 1960s, Lister Hill would continue to champion the cause of the schools of public health in the Senate and John E. Fogarty became their main supporter in the House. The Congress raised the ceiling on the formula grants, provided grants-in-aid for training to state health departments, and authorized special training grants, fellowships for faculty development, and construction grants for schools of public health. New Life in the Sixties The federal government now began to reverse the damage that had been done to public health by providing traineeships, formula grants, and project grants to develop new curricular areas. The downward trend in public health enrollments was halted; in 1960, student enrollments again began to climb. The Association of Schools of Public Health happily dis- 60   Report of the National Conference on Public Health Training to the Surgeon General of the Public Health Service, July 28–30, 1958. Washington, DC: United States Department of Health, Education, and Welfare, p. 3.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century TABLE D-1 Federal Support for Schools of Public Health1 Year Traineeships Project Grants Formula Grants 1957 1,000,000     1960 2,000,000   1,000,000 1963 4,000,000 2,000,000 1,900,000 1966 7,000,000 4,000,000 3,500,000 1969 8,000,000 4,917,000 4,554,000 1972 8,400,000 4,517,000 5,554,000 1Table from Higher Education for Public Health, p. 164. cussed the “ferment” in schools of public health around the new, or newly recognized, problems of chronic illness, mental disorder, air pollution, medical care organization, aging, injuries, and radiation hazards. The new federal funds provided some basic operating costs but also encouragement to explore targeted areas of research and training. New schools of public health were created at the University of California, Los Angeles, and in Puerto Rico, and many schools expanded their previously cramped facilities. In 1963, the federal government doubled the ceiling on formula grants and also began offering construction grants to schools of public health. This was an exciting time for the schools; between 1960 and 1964, the total number of applicants to schools of public health more than doubled; the number of faculty members increased by 50 percent; the average space occupied increased by 50 percent; and the average income of the schools more than doubled.61 New faculty appointments were made in such fields as medical care organization, social and behavioral sciences, public health administration, human ecology, radiation sciences, population studies, and international health. The newly created Agency for International Development (AID) encouraged schools of public health to develop international health training programs whose students would become “ambassadors of American science” abroad.62 By 1965, the whole country seemed to have become concerned about the “population explosion,” and the United States Congress was voting money to provide technical assistance, often in the form of contraceptives, to the developing world. The passage of Medicare and Medicaid legislation in 1965 generated 61   Elizabeth Fee and Barbara Rosenkrantz, “Professional Education for Public Health in the United States,” in Elizabeth Fee and Roy M. Acheson, eds. A History of Education in Public Health: Health that Mocks the Doctors’ Rules. Oxford: Oxford University Press; 1991, 230–271. 62   Minutes, April 7–8, 1964, Executive Session, Association of Schools of Public Health, pp. 6–7. Alan Mason Chesney Archives of the Johns Hopkins Medical Institutions, RG 1, Box 48.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century considerable excitement in schools of public health. State health agencies were concerned about being able to monitor and evaluate medical care services and wanted the schools of public health to provide the scientific basis for rational decision-making in health services delivery. They also wanted the schools to provide training for medical care administrators and financial managers. In 1966, a Special Study Commission of the Association of Schools of Public Health estimated that 6,220 new positions in medical care administration required graduate-level educational preparation.63 The United States Public Health Service curtailed its usual grant application procedures to provide quick funding to schools of public health willing to provide short courses in health services administration. As in the 1930s, short courses would be developed to meet the urgency of the national need. In the context of the Civil Rights movement and the demand for more community participation in health care, education, and other sectors of civil life, the Kennedy administration supported the movement away from mental hospitals and toward community mental health centers, run on an outpatient basis. Community mental health centers were financed by the federal government and locally controlled, thus largely bypassing the states. Many of the other programs of the 1960s and 1970s would be created as independent ventures, thus directly or indirectly weakening the role of the states and of state health departments. In the year before he died, Kennedy began developing an anti-poverty program and, after his assassination, President Johnson expanded this into the “War on Poverty.”64 As part of this general effort, the Office of Equal Opportunity (OEO) helped to start 100 neighborhood health centers and the Department of Health, Education, and Welfare (HEW) supported another 50.65 The aim of these health centers was to provide comprehensive primary care services and to encourage community participation in running the organizations. The centers were, however, dependent on public funds for their survival, and an ambitious plan to build 1,000 centers across the country was never realized. In the generally progressive social ferment of the 1960s, a strong environmental movement developed around the catalyst provided by publication of Rachel Carson’s Silent Spring in 1962.66 Earth Day in 1970 at- 63   Report of the Special Study Committee, “The Role of Schools of Public Health in Relation to Trends in Medical Care Programs in the United States and Canada,” April 6, 1966. Association of Schools of Public Health, Alan Mason Chesney Archives of the Johns Hopkins Medical Institutions, RG 1, Box 48. 64   Karen Davis and Cathy Schoen, Health and the War on Poverty. Washington DC: Brookings Institution, 1978. 65   Paul Starr, The Social Transformation of American Medicine, p. 371. 66   Rachel Carson, Silent Spring. Boston: Houghton Mifflin, 1962.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century tracted some 20 million Americans in demonstrations against assaults against nature; by 1990, Earth Day brought out 200 million participants in 140 countries.67 Within the federal government, the environmental movement spurred the creation of the Environmental Protection Agency (EPA) and passage of the Clean Air Act of 1970. At the same time, labor mobilization and public distress over the toll taken by industrial accidents and mining disasters prompted the creation of the Occupational Health and Safety Administration (OSHA) and the National Institute of Occupational Safety and Health (NIOSH). Environmental protection agencies, like the neighborhood health centers and the community mental health centers, were organizationally independent of state health departments, although they were clearly important agencies for the public’s health. Questions of the definition of public health now became more problematic: public health in the broad sense included many of the activities and responsibilities of a wide variety of agencies: the work of departments of public health now represented only one aspect of public health: public health as narrowly defined. At the federal level, public health was also losing administrative focus. The formation of the Department of Health, Education, and Welfare in 1953 had reduced the visibility and centrality of the Public Health Service; further reorganizations and changes continued to diminish its role. By 1975, it was clear that the Surgeon General no longer functioned as the head of the Public Health Service. Instead, the Office of the Assistant Secretary of Health had been strengthened and the main health agencies, including the National Institutes of Health, the Food and Drug Administration, and the Center for Disease Control reported directly to him. The Surgeon General had become a figurehead, a spokesperson without direct line authority. Throughout the 1960s and early 1970s, schools of public health thrived with federal funding available for both teaching programs and research. In 1960, there were 12 accredited schools of public health in the United States; 8 more were added between 1965 and 1975. Between 1965 and 1972, student enrolments again doubled, with the large majority being candidates for the M.P.H. degree. The trend to admit more students who were not physicians, and more students without prior experience in public health, continued. Whereas in 1946–1947, 61 percent of all students admitted to schools of public health for the M.P.H. were physicians, by 1968–1969, physicians constituted only 19 percent of M.P.H. candidates.68 Many schools admitted students fresh from their undergraduate degrees. 67   J.R. McNeil, Something New Under the Sun: An Environmental History of the Twentieth-Century World. New York: W.W. Norton, 2000, p. 339. 68   T. Hall et al. Professional Health Manpower for Community Health Programs. Report Compiled by School of Public Health of the University of North Carolina at Chapel Hill, North Carolina. 1973.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century Graduate Programs in Other Schools of the University Along with the growth in the accredited schools of public health came a rapid growth in other forms of public health and health services education. Some of these were graduate programs in a variety of university departments and in schools of engineering, medical schools, schools of business administration, schools of nursing, schools of social work, and schools of education and communication. They were offering degrees in such fields as environmental health, health management and administration, nutrition, public health nursing, and health education. Somewhat to the distress of accredited schools of public health, most employers did not distinguish between accredited and non-accredited programs.69 By 1975, there were some 43 graduate programs in health administration offered in schools of public or business administration and 15 graduate programs in nutrition offered by departments of home economics, education, and human development. More than 30 nursing schools offered graduate programs in public health nursing and community nursing. In addition, all nurses enrolled in baccalaureate programs received some public health education; associate degree programs and diploma programs generally did not provide this. About 30 schools of education or allied health offered graduate health education programs and at least 59 technical and engineering schools and departments of environmental sciences offered graduate training in environmental health. In addition to this flourishing of programs across university campuses, there had been a dramatic growth of junior and community colleges. By the mid 1970s, some 69,000 students were enrolled in various allied health programs.70 Universities were setting up popular baccalaureate programs in health administration, environmental engineering, health education, and nutrition. Some 58 academic units offered four-year undergraduate programs in environmental engineering; 25 colleges offered undergraduate degrees in community health education, 75 in school health education, and 83 in nutrition. Schools of public health were, at best, ambivalent about undergraduate education in public health. Several schools of public health (Berkeley, UCLA, North Carolina, Michigan, and Puerto Rico) had earlier offered undergraduate degrees but tended to phase these out in the 1960s; some however were adding new programs in response to perceived manpower needs. As the Milbank Commission Report noted in 1975, public health education was a growth industry with no apparent end in sight. But the system was fractured: although 5,000 graduate degrees in public health were awarded each year, approximately half of higher education for pub- 69   Cecil G. Sheps, Higher Education for Public Health: A Report of the Milbank Memorial Fund Commission. New York: Prodist, 1976, p. 82. 70   Ibid., p. 86.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century lic health was occurring outside of accredited schools of public health. Were schools of public health still needed? THE THREATENED WITHDRAWAL OF FEDERAL FUNDS Evidently, President Richard Nixon thought not, for in 1973, he recommended terminating federal support for schools of public health and the discontinuation of all research training grants, direct traineeships, and fellowships. This sent shockwaves through a system that had grown dependent on a steady flow of federal funding for its basic support. The strain of the funding cutback threats is reflected in the papers from a Macy Foundation-funded Conference held at the Rockefeller Foundation’s Study and Conference Center in Bellagio, Italy, in 1974. In the volume published from that conference, Cecil Sheps, then Vice Chancellor of the University of North Carolina, noted that leading schools of public health were wondering “seriously and agonizingly” about their future.71 The participants offered a generally gloomy assessment of public health education. According to Russell Nelson of the Johns Hopkins Medical Institutions, corridor talk at his campus said that public health was dead. At Hopkins, moves to absorb the School of Public Health into the medical school had been held back mainly because the medical school faculty were unenthusiastic.72 Herbert Longnecker, the President of Tulane University, gave voice to his medical school’s position when he said, “I think I am correct in stating that the record of fundamental scientific contributions of schools of public health is minor.”73 John C. Hume, now Dean of the Johns Hopkins School of Public Health, spoke about the changes that he had experienced over 20 years as a consequence of the patterns of federal support for biomedical research. The once cohesive nature of the school had been lost, he said: there was little shared conversation, and no coherent teaching program. The autonomy and independence of departments and faculty did encourage initiative but also resulted in isolation and fragmentation. Instead of a unified school of public health, the departments constituted “a series of mini-schools with limited interests.” Hume noted that his major problem as Dean was to cope with the fiscal tides—the waxing and waning of federal enthusiasm for particular topics. In the 1960s, for example, population studies had been elevated in impor- 71   Cecil G. Sheps, “Trends in Schools of Public Health in the United States Since World War 11,” in Schools of Public Health: Present and Future, Report of a Macy Conference, ed., John Z. Bowers and Elizabeth F. Purcell. New York: Josiah Macy, Jr. Foundation, 1974, p. 9. 72   Russell A. Nelson, “Organizational Relationships of Schools of Public Health with Schools of Medicine,” in Schools of Public Health: Present and Future, pp. 11–14. 73   Herbert E. Longnecker, “Organizational Relationships of Schools of Public Health with Universities,” in Schools of Public Health: Present and Future, pp. 19–24.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century tance with the influx of new funding, but by the end of the decade, this interest had largely evaporated.74 Representatives of all the schools of public health appeared to agree with J. Thomas Grayson of the University of Washington’s relatively new and rapidly-expanding School of Public Health and Community Medicine: “The greatest immediate challenge to the School of Public Health and Community Medicine is the uncertainty of federal funding brought about by the administration’s announced intention to end, or greatly curtail, federal support for the training of public health manpower, coupled with a similar proposal to decrease support for research training.”75 The one student representative at the conference, identified as recent graduate Frank C. Ramsey, stated the students’ distress with an educational system focused on soft money: The financing of the school I attended is such that the departmental heads and faculty members are mainly responsible for raising money. Most of the funds come from federal sources and virtually all of them go into research. The heads of departments with popular programs find it easier to raise funds than is the case with heads of departments with less research-oriented programs. The grant system influences the school’s organization, function, and orientation...[it] places constraints on the type of professionals employed and the work performed...[among the students] there was a fairly general belief that solutions to societal problems were being sacrificed on the altar of scientific research.76 Some of the threatened funding cuts were restored, but the trend in the 1970s was toward ever more reliance on targeted research funding, thus exacerbating the problems to which Ramsey had referred. In 1976, the Milbank Memorial Fund issued its extensive report, Higher Education for Public Health.77 The Milbank Commission, chaired by Cecil Sheps, asked the usual questions: Why was there not a closer relationship between professional education and professional practice? Should education change or should the practice model? Could departments of community medicine in medical schools serve some of the functions of schools of public health? 74   John C. Hume, “The Future of Schools of Public Health: The Johns Hopkins University School of Hygiene and Public Health,” in Schools of Public Health: Present and Future, pp 60– 69. 75   J. Thomas Grayston, “New Approaches in Schools of Public Health: The University of Washington School of Public Health and Community Medicine,” in Schools of Public Health: Present and Future p. 58. 76   Frank C. Ramsey, “Observations of a Recent Graduate of a School of Public Health,” in Schools of Public Health: Present and Future, pp. 130–133. 77   Milbank Memorial Fund, Higher Education for Public Health: A Report of the Milbank Memorial Fund Commission. New York: Prodist, 1976,

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century And, most sharply: Had schools of public health become so dependent on federal funds that “their policies and programs are determined by dollars available and they no longer control their own destiny?”78 In place of a public health educational system that Cecil Sheps described as “chaotic, wasteful, and dysfunctional,” the Commission proposed what they considered a more rational structure.79 This sounded rather like an updated version of the original Wickliffe Rose design of 1914. There would be a three-tiered system of public health education. Schools of public health should educate people at the highest level to assume leadership positions; they should train the public health executives who must have a broad knowledge of the entire field and be able to function within the full range of the knowledge base for public health. Next, programs in graduate schools should prepare the large number of professionals engaged in providing clearly differentiated specialty services, e.g., public health nurses, health educators, and environmental health specialists. Third, although Commission members were uncertain about the value of baccalaureate programs, they might provide some of the “trained entry-level personnel.”80 The Commission defined the “three elements of the knowledge base generic to public health” as: Epidemiology and Biostatistics Social Policy and the History and Philosophy of Public Health Management and Organization for Public Health Their report also listed a series of “cognate fields”: clinical sciences, biomedical sciences, environmental sciences, social sciences, management sciences, law, and ethics that might well be provided by other departments of the university. The schools of public health should focus on the three core curricular areas and should receive basic core support from the federal government for doing so. They should also serve as regional resources by assisting faculties in medical and other health-related schools to develop teaching programs and research in public health. Different schools would serve as national centers of excellence for specific fields but “should avoid setting up special programs in every new area simply because funding is available.”81 Instead, faculty should become involved in the operation of community health services in areas relevant to their areas of academic responsibility, thus offering supervised field experience for aspiring public health practitioners. In general, the Commission proposed that schools of public health become smaller and more focused 78   L.E. Burney, “Foreword,” Higher Education for Public Health, p. viii. 79   Higher Education for Public Health, p. 211. 80   Ibid., p. 98. 81   Ibid., p. 123.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century on broad research plans rather than grasping at every funding opportunity. Nor should they do basic laboratory work that could as well be done in a medical school; instead, they should recognize and value their unique interdisciplinary character and craft research plans that drew upon these strengths and were relevant to the regions and communities in which they were located. The Milbank Commission Report offered faint praise for the system of research driven by changing federal funding priorities: “This is not always bad, as it sometimes results in research that is realistically related to the needs and interests of the nation.”82 By implication, schools would do better if their faculty could design their own research within a broad framework established by the needs of public health in practice. Indeed, Sheps urged faculty to take strong advocacy positions as “academic freedom, like all liberties, is bound to atrophy unless exercised.”83 The specific recommendations of the Milbank Commission had little impact. No dramatic redesign of public health education could work when the underlying forces driving the system continued unabated. Indeed, under President Ronald Reagan, the pressures intensified. In 1981, his administration consolidated numerous federal health programs into two block grants, cut the total funds by 25 percent, and gave the remainder to the states to make their own decisions how best to slash their programs.84 Meanwhile, the AIDS epidemic, largely ignored by the White House, spread across the land. As reductions in federal funding decimated many public health programs, leaving Medicaid dollars to dominate the field, local health agencies spent much time and energy providing basic health services for the poor. Twelve years after the Milbank Commission Report, the Institute of Medicine issued its own landmark report, The Future of Public Health.85 This documented the bleak landscape of many public health departments across the country. Half of the state boards of health had disappeared; important programs had been taken away from health departments; and public health was “in disarray.” The prose of this report was often vivid: “The most frequent perception of the health department by legislators and citizens was of a slow and inflexible bureaucracy battling with chaos, fighting to meet crises, and behaving in an essentially reactive manner.... Just getting through the day is the only real objective of the senior administrator.”86 82   Ibid., p. 156. 83   Ibid., p. 212. 84   G.S. Omenn, “What’s Behind Those Block Grants in Health?” New England Journal of Medicine, 306, 1982, 1057–1060. 85   Institute of Medicine, Committee for the Study of the Future of Public Health, The Future of Public Health. Washington, DC: National Academy Press, 1988, p. 6. 86   Ibid., p. 85.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century The focus of the IOM report was on public health practice but it did have a number of recommendations for schools of public health, urging them to offer educational programs more targeted to the needs of practitioners. Schools of public health should establish firm practice links with state and local health departments so that more faculty members could undertake professional responsibilities in those agencies, conduct relevant research, and train students in practice situations. Just as had the Milbank report, so too the Institute of Medicine report urged schools of public health to serve as resources to government at all levels in the development of public health policy, to assist other types of institutions in educating public health practitioners, and to take better advantage of such university resources as schools of business administration and departments of physical, biological, and social sciences. Unlike the Milbank report, the Institute of Medicine committee asked schools of public health to provide short training courses and continuing education opportunities for public health practitioners. They also suggested that schools offer undergraduate courses in public health to attract recruits into the field. In summary, the task, as they defined it, was “to assist the schools in developing a greater emphasis on public health practice and to equip them to train personnel with the breadth of knowledge that matches the scope of public health.”87 The report especially highlighted the need for short courses to upgrade the skills of “that substantial majority of public health professionals who have not received appropriate formal training” and to ensure that all public health practitioners became aware of new knowledge and techniques. Nothing was said about designing a single rationally organized system of public health education. In the years since the Institute of Medicine’s report, the public health educational system has continued to expand at an accelerated pace. There are currently 31 accredited schools of public health and 45 accredited community health programs.88 The Council on Education for Public Health estimates that the total number of accredited schools and programs may well double within the next ten years. The most dramatic growth is occurring outside the established schools of public health. Close to 40 percent of the nation’s accredited medical schools now have operational M.P.H. programs or are currently developing a graduate public health degree program. New specializations are emerging such as human genetics, management of clinical trials, and public health informatics. Many schools and competing organizations are involved in distance learn- 87   Ibid., p. 157. 88   This and the following details are derived from a presentation by Patricia P. Evans, “An Accreditation Perspective on the Future of Professional Public Health Preparation,” to the Institute of Medicine Committee on Educating Public Health Professionals for the 21st Century, March 13, 2002, Irvine, California.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century ing programs that offer the possibility of fulfilling the long-recognized need to bring public health education to the homes and offices of the public health workforce. The Internet also offers the possibility of bringing public health education to populations across the country and around the world; indeed, health information sites are among the most popular and frequently visited of all Web applications. Is this a system badly in need of rational reconstruction or is it simply a system of dynamic, if sometimes messy, innovation—an academic marketplace evolving rapidly to meet the country’s needs? Although it is not within the purview of the historian to answer such a question, it may be important to note one significant fact. Previous efforts to design truly effective systems of public health education generally foundered because of lack of political will, public disinterest, or paucity of funds. Since September 11, 2001, however, the context has changed dramatically. With public health riding high on the national agenda and an abundance of funds being promised, perhaps there is now an opportunity, as there has not been for a very long time, to shape a future system of public health education that addresses the problems that have been so often described and analyzed. 04/15/02