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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century 2 History and Current Status of Public Health Education in the United States HISTORY This section discusses two broad phases of public health education in America.1 The first phase, during which independent schools of public health were first created, occurred between roughly 1914 and 1939 and was privately funded by philanthropies. The second phase, which overlapped slightly with the first, was marked by federal and state funding, and encompasses the years 1935 to the present. Following this brief historical overview, we discuss the current status of public health education in the United States. Public Health Education: 1914–1939 By the end of the 19th century medical schools had proliferated. There were also many schools of nursing, established by hospitals to provide a source of well-trained labor. However, there was no distinct education or career pattern for public health officers; most were practicing physicians who were called upon to assist with epidemic diseases in times of crisis. It was in this context that staff of the Rockefeller Sanitary Commission attempted to enlist public health officers in the southern United States to 1 Material in the History section of this chapter is abstracted from the commissioned paper prepared for the committee by Elizabeth Fee, Ph.D. The paper appears in its entirety in Appendix D.
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century aid in a campaign to eradicate hookworm. They found little interest in or dedication to public health, leading Wickliffe Rose, the architect and organizer of the commission, to believe that a new profession was needed, composed of men and women who would devote their entire careers to controlling disease and promoting health at a population level. Three possible approaches for public health education were debated—the engineering or environmental, the sociopolitical, and the biomedical. Rose enlisted Abraham Flexner in the move to establish education for a separate public health career. On October 16, 1914, Flexner brought together 11 public health representatives and 9 Rockefeller trustees and officers for a meeting. It was decided that there were essentially three categories of public health officers: those with executive authority such as city and state health commissioners; the technical experts in specific fields such as bacteriologists, statisticians, and engineers; and the field workers such as local health officials, factory and food inspectors, and public health nurses. Rose laid out ideas for a system of public health education centered on a university affiliated, research intensive, scientific school, separate from a medical school, whose graduates would be strategically placed throughout the United States. This central scientific school of public health would be linked to a network of state schools that sent extension agents into the field, and emphasized not only public health education, short courses and extension courses to upgrade the skills of health officers in the field, but also demonstrations of best practices. The plan as implemented, however, focused on research and largely ignored public health practice, administration, public health nursing, and health education. The biomedical side of public health was emphasized to the exclusion of its social and economic context and no attention was given to the political sciences or to the need to plan for social or economic reforms. The Johns Hopkins University School of Hygiene and Public Health became the first endowed school of public health, opening during the influenza epidemic of 1918. Later, Rockefeller Foundation officials agreed to provide funding for additional schools of public health including ones at Harvard and Toronto. These first schools were well-endowed private institutions that favored persons with medical degrees, had curricula that leaned heavily toward the laboratory sciences, and emphasized infectious diseases. Because the Rockefeller Foundation gave fellowships to medical graduates around the world the schools tended to have an international flavor. Programs of field training were not emphasized. By 1930 these first schools were graduating a small number of individuals with sophisticated scientific education but they were not producing the needed large numbers of public health officers, nurses, and sanitarians.
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century Public Health Education: 1935 to the Present Passage of the Social Security Act of 1935 provided a major stimulus to the further development of public health education. Provisions of this act increased funding for the Public Health Service and provided federal grants to the states to assist them in developing their public health services. Federal law now required each state to establish minimal qualifications for health personnel employed using 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 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, 10 schools offered public health degrees or certificates requiring at least one year of residence: Johns Hopkins, Harvard, Columbia, Michigan, California at Berkeley, Massachusetts Institute of Technology, Minnesota, Pennsylvania, Wayne State, and Yale (Committee on Professional Education, 1937). By 1938 more than 4,000 people (1,000 of whom were physicians) had received some public health training with funds provided by the federal government through the states. Increased funding and the continuing need for additional public health graduates led many colleges and universities to open public health departments and establish programs offering training courses of a few months’ or even a few weeks’ duration. Federal training funds were allotted to California, Michigan, Minnesota, Vanderbilt, and North Carolina to develop short courses for the rapid training of public health personnel. The tremendous push in the late 1930s toward training larger numbers of public health practitioners was also a push toward practical training programs rather than research. Public health departments wanted personnel with one year of public health education: typically, the masters of public health (M.P.H.) generalist degree. If they could not attract public health practitioners holding this credential, they settled for a person with a few months of public health training. Ideally, they also wanted persons who understood practical public health issues rather than scientific specialists with research degrees. Thus, public health education in the 1930s tended to be practically oriented, with considerable emphasis on fields such as public health administration, health education, public health nursing, vital statistics, venereal disease control, and community health services. During this period, too, many schools developed field training programs in local communities where their students could obtain experience
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century in the practical world of public health and prepare for roles within local health departments. The 1930s were thus the prime years of community-based public health education. The growth of short training programs in public health education continued throughout the war years to meet the demand for physicians, nurses, and sanitarians with at least minimal training in tropical diseases, parasitology, venereal disease control, environmental sanitation, and a variety of infectious diseases. For the burgeoning industrial production areas at home, industrial hygiene was in demand; for areas with military encampments, sanitary engineering and malaria control were urgent concerns. Schools of public health and public health training programs revamped their educational programs to meet these needs and turned out large numbers of health professionals with a smattering of specialized education in high-priority fields. The research-oriented schools of public health, such as Hopkins and Harvard, maintained their research programs largely by recruiting foreign students—many from Latin America—to staff their laboratory and field programs. Deans of schools of public health were concerned about the rapid growth of public health education programs and in 1941 organized the Association of Schools of Public Health (ASPH) to promote and improve graduate education for public health professionals. In 1946 the Committee on Professional Education of the American Public Health Association began monitoring the standards of public health education amid complaints that profit-making public health training courses of questionable quality were offering public health degrees by correspondence from faculty who did not even know of their appointment (Shepard, 1948). Demand for minimum adequate standards was increasing. However, a 1950 survey of schools of public health found major difficulties here, too. These schools were overcrowded and under-funded, and lacked key faculty members, classroom and laboratory space, and necessary equipment (Rosenfeld et al., 1953). Under pressure to provide more practical experience, the Deans argued that they needed a 70 percent increase in full-time faculty to expand the applied fields of instruction; they further believed they could double the number of enrolled students if necessary financial support was forthcoming (Rosenfeld et al., 1953). Given the high demand for public health graduates and the need for schools and programs to train them, it is not surprising that the criteria for accreditation of schools of public health as implemented at mid-century were relatively undemanding by current standards. To become accredited, schools were required to have at least eight full-time professors as well as lecture rooms, seminar rooms, and adequate laboratory facilities; and were to be located close to local public health services that could be used for “observation and criticism.” Additionally, these public health
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century services had to be of sufficiently high quality “to make observation fruitful” (Winslow, 1953). For a few years following World War II the concepts of social medicine, social epidemiology, and the ecology of health achieved prominence. New courses were developed that emphasized the social and economic context of health problems. Schools of public health instituted classes that focused on world population and the food supply; the impact of industry and transportation on health; the impact of cultural, social, and economic forces on health; evaluation of health status; and public health as a community service (Winslow, 1953). At Pittsburgh, Thomas Parran had decided that the curriculum should be organized around “the systematic presentation of illustrative topics which deal with the interrelation of man and his total environment and with the political, economic, and social framework within which the health officer must work” (Blockstein, 1977). Yale’s core course on “Principles and Practice of Public Health” was similarly organized around a series of interdisciplinary seminars running throughout the academic year. Winslow commented approvingly that the eleven schools of public health constituted “eleven experimental laboratories in which new pedagogic approaches are constantly being devised” (Winslow, 1953). The overall impression of the accredited schools of public health in 1950 was that they were doing a good job of preparing public health practitioners through courses and fieldwork, that the numbers of faculty and students were growing, and that curricular and research innovations seemed promising. The main complaints of the schools seemed to be lack of funding to pay faculty, expand space, and purchase equipment. While schools of public health were concerned about a lack of money, major funding was financing the construction of community hospitals through the Hill-Burton Program, and the National Institutes of Health (NIH) was experiencing rapid growth in research funding. The institutes expanded with enormous increases in financial resources, transferring most of their funds to universities and medical schools in the form of research grants. Grants were awarded based on the decisions of peer review committees composed of non-federal experts in the relevant fields of research. Liberals, conservatives, medical school deans, and researchers were all happy with the system, and members of Congress were pleased to bankroll such a popular and uncontroversial program (Strickland, 1972; Ginzberg and Dutka, 1989). In this environment schools of public health had to compete with medical schools for research grants in a system dominated by powerful medical school professors. The historic core funders of schools of public health (the major foundations) were turning their interest to building departments of preventive medicine and community medicine within medical schools. Further, increasing political conservatism and the
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century McCarthy era were having a negative impact on views about public health. To survive, schools of public health turned to research funding to pay the salaries of additional faculty members, using the rationale that new faculty could spend some of their time teaching and some of their time on funded research. As this strategy was implemented, the following pattern emerged. If a particular department within a school was devoted mainly to teaching or to public health practice, the numbers of faculty stayed stable or gradually declined. If the department was devoted to research, and was reasonably successful at funding that research, the department grew, sometimes at an impressive rate. Even deans who strongly favored teaching and field training over research became unable to resist the pressures that encouraged research over practical training. Available funding, and faculty who were suited by education, experience, and personality to succeed in the research system, shaped the schools of public health and drove their priorities. Because the system of research funding was not oriented toward field research, public health practice, public health administration, the social sciences, history, politics, law, anthropology, or economics, the laboratory sciences tended to thrive while the practice and other non-quantitative disciplines suffered. The community-based orientation of the 1930s disappeared, and the field training programs virtually ceased to exist. As faculty withdrew into their laboratories, they further distanced themselves from the problems of the local health departments, which were experiencing increasing difficulty. Federal grants-in-aid to the states for public health programs steadily declined during the 1950s as the total dollar amounts fell from $45 million in 1950 to $33 million in 1959. Given inflation, this represented a dramatic decline in purchasing power (Terris, 1959). Lacking funds, health departments could not afford new people or initiate new programs. Health departments ran underfunded programs with underqualified people who answered to unresponsive bureaucrats. Between 1947 and 1957 the number of students educated in schools of public health fell by half. Alarmed, Ernest Stebbins of Johns Hopkins and Hugh Leavell of Harvard, representing ASPH, urged Congress 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.
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century Its report concluded with a stirring appeal to value public health education as vital to national defense: 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 (U.S. DHEW, 1958). President Dwight 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 appropriated $15 million to support public health trainees. The downward trend in public health enrollments was halted. Between 1960 and 1965 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 (Fee and Rosenkrantz, 1991). Following the passage of Medicare and Medicaid legislation in 1965, state health agencies turned to schools of public health to provide the scientific basis for rational decision-making in health services delivery and training for medical care administrators and financial managers. ASPH estimated that 6,220 new positions in medical care administration required graduate-level education (ASPH, 1966). The U.S. Public Health Service provided quick funding to schools of public health to provide short courses in health services administration. The 1960s brought major progress for the civil rights movement and for President Lyndon B. Johnson’s War on Poverty which included the Office of Equal Opportunity (OEO). The OEO helped create 100 neighborhood health centers and the Department of Health, Education, and Welfare (DHEW) supported another 50. A strong environmental movement developed following the publication of Rachel Carson’s Silent Spring in 1962. In 1970 Earth Day attracted 20 million Americans in demonstrations against assaults on nature; by 1990 Earth Day brought out 200 million participants in 140 countries (McNeil, 2000). The Environmental Protection Agency (EPA) was created and the first Clean Air Act was passed in 1970. Also created during this period were the Occupational Safety and Health Administration (OSHA) and the National Institute of Occupational Safety and Health (NIOSH). Throughout the 1960s and early 1970s, schools of public health thrived with federal funding available for both teaching programs and research.
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century In 1960 there were 12 accredited schools of public health in the United States, 8 were added between 1965 and 1975. Between 1965 and 1972, student enrollments again doubled, with the large majority being candidates for the master of public health (M.P.H.) degree. The trend to admit more students who were not physicians, and more students without prior experience in public health continued. In 1946, 61 percent of all students admitted to schools of public health for the M.P.H. were physicians; by 1968–1969 that figure had dropped to only 19 percent of M.P.H. candidates (Hall, 1973). 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. Graduate programs were established in a variety of university departments and schools (e.g., engineering, medicine, nursing, business, social work, education, and communication) offering degrees in such fields as environmental health, health management and administration, nutrition, public health nursing, and health education. Universities were creating popular baccalaureate programs in health administration, environmental engineering, health education, and nutrition. By mid-1970, some 69,000 students were enrolled in various allied health programs (Sheps, 1976). Although 5,000 graduate degrees in public health were awarded each year, approximately half of higher education for public health was occurring outside of accredited schools of public health. Then, in 1973, President Richard M. Nixon recommended terminating federal support for schools of public health and discontinuing all research training grants, direct traineeships, and fellowships. J. Thomas Grayston of the University of Washington reflected the thoughts of the field when he said: 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 (Grayston, 1974). The threatened elimination of funding was averted, however, and in 1976 Congress passed the Health Professions Educational Assistance Act (P.L. 94-484), which provided for a number of programs in health professions education. The trend, however, was toward ever more reliance on targeted research funding. Also in 1976 the Milbank Memorial Fund issued its extensive report, Higher Education for Public Health, proposing a new structure for the public health educational system—a three tiered structure. First, schools of public health were to educate people to assume leadership positions. Next, programs in graduate schools would prepare the large
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century number of professionals engaged in providing clearly differentiated specialty services, for example, public health nurses, health educators, and environmental health specialists. Finally baccalaureate programs could provide some of the “trained entry-level personnel” (MMF, 1976). The report identified three core areas of public health on which the schools should focus: epidemiology and biostatistics, social policy and the history and philosophy of public health, and management and organization for public health. In addition, the report recommended that schools should serve as regional resources by helping faculties in medical and other health-related schools to develop teaching programs and research in public health; they should become involved in the operation of community health services; and schools should design their research within a broad framework established by the needs of public health practice. The report had little impact. Under President Ronald Reagan the pressures intensified. Between 1980 and 1987, spending for health professions’ education by the Department of Health and Human Services (DHHS) Bureau of Health Professions declined annually by more than 50 percent from a high of $411,469,000 in 1980 to $189,353,000 in 1987. General purpose traineeship grants to schools of public health dropped from $6,842,000 in 1980 to $2,958,000 in 1987. Project grants for graduate training in public health were funded at $4,949,000 in 1980, but dropped to zero funding in 1982 and remained unfunded through 1987. Curriculum development grants, funded at $7,456,000 in 1980, were not funded at all in 1981 and 1982, but then recovered with funding at $1,740,000 in 1983, then at $2,856,000 in 1984 rising to $9,787,000 in 1987. Grants for graduate programs in health administration were funded at $2,967,000 in 1980, dropped to $726,000 in 1981, and then rose to $1,416,000 in 1982 where funding remained fairly steady, with 1987 levels at $1,482,000 (U.S. DHHS, 1988). Funding has continued to be problematic for public health education programs and schools of public health. Through the 1990s funding levels remained nearly constant. During that time tuition and other costs continued to increase, resulting in a reduction in the amount of public health professional education actually provided. At the beginning of the 21st century we find a major barrier to workforce development is the “incredibly weak” budget allocated for training (Gebbie, 1999; PHLS, 1999). Following the events of September 11, 2001, there has been new interest in public health and promises of increased funding. If used wisely, these promised funds will strengthen the public health system through investments in both needed technologies and properly educated and prepared public health professionals. To better understand the future needs of public health education, it is important to examine its current status. The following pages provide a brief overview of public health education in the United States, examine schools of public health in greater detail,
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century and describe progress made since the landmark report The Future of Public Health (IOM, 1988). CURRENT STATUS Many college graduates who work in public health are educated in other disciplines. For example, of the total public health workforce, nurses make up about 10.9 percent and physicians comprise about 1.3 percent (Center for Health Policy, 2000). The HRSA list of categories of public health occupations includes administrators, professionals, technicians, protective services, paraprofessionals, administrative support, skilled craft workers, and service/maintenance workers. Within these categories fall a number of different kinds of positions (see Appendix E for complete list) including administrative/business professional, public health dental worker, public health veterinarian/animal control specialist, environmental engineering technician, and community outreach/field worker. Within public health education, the basic public health degree is the M.P.H., while the doctor of public health (Dr.P.H.) is offered for advanced training in public health leadership. There are also individuals working in public health who receive academic degrees (e.g., M.S. and Ph.D.) in public health disciplines such as epidemiology, the biological sciences, biostatistics, environmental health, health services and administration, nutrition, and the social and behavioral sciences. The public health workforce also includes many professionals trained in disciplines such as social work, pharmacy, dentistry, and health and public administration. Most persons who receive formal education in public health are graduates of one of the 32 accredited schools of public health or of one of the 45 accredited M.P.H. programs. The Council on Education for Public Health (CEPH) is responsible for adopting and applying the criteria that constitute the basis for an accreditation evaluation. In 1998–1999 there were 5,568 graduates from the then 29 accredited schools of public health (ASPH, 2000). The majority of these graduates (61.5 percent) earned an M.P.H. degree, an additional 28.4 percent received a masters degree in some other discipline, and 10.1 percent earned doctoral degrees (ASPH, 2000). According to a survey conducted by Davis and Dandoy (2001), the 45 accredited programs in Community Health and Preventive Medicine (CHPM) and in Community Health Education (CHE) graduate between 700 and 800 master’s degree students each year. There are other programs in which students receive master’s level training in public health. These include programs in public administration and affairs, health administration, and M.P.H. programs in schools of medicine. In 1997–1998 an unknown number of the 9,947 graduates of masters degree programs in public administration and affairs (M.P.A.) emphasized public health in their training (NASPAA, 2002). The Association of University
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century Programs in Health Administration report that in 2000 there were 1,778 graduates who received masters degrees, with some (again an unknown number) of them the M.P.H. and M.S. degrees (AUPHA, 2000). In 1998 of the 125 accredited U.S. medical schools, 36 medical schools offered a combined M.D./M.P.H. degree, and 56 reported that they taught separate required courses on such topics as public health, epidemiology, and biostatistics (Anderson, 1999). Public health workers also may receive undergraduate training from colleges or universities that offer programs in the environmental sciences or in health education and health promotion. While it is unclear exactly how many public health workers there are in the United States today, it is estimated that about 450,000 people are employed in salaried positions in public health, and an additional 2,850,000 volunteer their services (Center for Health Policy, 2000). This is probably an undercount, according to the Center for Health Policy (2000), because states reporting the number of workers within their jurisdiction almost never include information about public health workers found in non-governmental and community partner agencies. Additionally, limited information is obtained regarding the numbers of volunteers and salaried staff in voluntary agencies. Persons who graduate with training in public health are, however, only a small portion of the public health workforce. Nationally, it has been estimated that 80 percent of public health workers lack specific public health training (CDC, 2001c) and only 22 percent of chief executives of local health departments have graduate degrees in public health (Turnock, 2001). Schools of Public Health Schools of public health vary in many ways including size, organization, and degrees offered All schools offer courses in the five areas identified as core to public health: biostatistics, epidemiology, environmental health sciences, health services administration, and social and behavioral sciences. The extent and breadth of offerings within these categories varies, however. In addition, schools offer courses in a number of other areas including nutrition, biomedical and laboratory sciences, disease control, genetics, and much more (please see Appendix A). Progress in Schools of Public Health In 1988 the Institute of Medicine (IOM) report, The Future of Public Health, described the field of public health as being in disarray (IOM, 1988). The focus of that report was on public health practice but it did have a number of recommendations for schools of public health. These recommendations called for
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century new linkages between public health schools and programs, and public health agencies at the federal, state, and local levels; the development of new training opportunities for professionals who are already practicing in public health; development of new relationships within universities between public health schools and programs and other professional schools and departments; the conduct of a wide range of research that includes basic and applied research and research on program evaluation and implementation; more extensive approaches to education that encompass the full scope of public health practice; and strengthening the knowledge base in the areas of international health and the health of minority groups. The report also urged schools of public health to serve as resources to government at all levels in the development of public health policy. In summary, the task defined by the IOM report 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” (IOM, 1988). The following describes the progress schools of public health have made in implementing the IOM report recommendations. Strengthening the link with public health practice. Fineberg and colleagues (1994) identify the 1988 IOM report’s insistence “that professional education be grounded in ‘real world’ public health” as the most influential recommendation in the report. This recommendation generated a number of initiatives aimed at establishing a closer relationship between schools of public health and public health practice. One of the first efforts following the IOM report was a collaborative study by the Johns Hopkins School of Hygiene and Public Health and the ASPH (funded by HRSA and CDC in 1989) to define the essential elements of the profession of public health. Public health practitioners and faculty from the schools of public health were brought together in the Public Health Faculty/Agency Forum, issuing a report in 1991 that emphasized: public health education based upon universal competencies of public health practice; and cooperation between schools of public health and public health agencies, including supervised practica for students (Fineberg et al., 1994). The forum also recommended changing accreditation criteria to em-
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century phasize the practice of public health. In response, CEPH revised accreditation criteria to include a required practicum experience. In 1991 the Council on Linkages Between Academia and Public Health Practice was established to “promote activities that link public health academic programs with the practice community through refining and implementing the forum recommendations” (Eisen et al., 1994). The Council, which includes representatives from national public health academic institutions and practice organizations, has initiated many efforts to enhance academic/practice collaboration. These include demonstration programs that examine academic/practice linkage approaches (Bialek, 2001), a national public health practice research agenda (Conrad, 2000), and a set of core competencies for public health professionals. The core competencies are organized around three job categories—front line staff, senior level staff, and supervisory management staff (Council on Linkages, 2001). Schools of public health also have undertaken new initiatives to increase practice linkages. One of these is community-based participatory research, a research approach that involves all stakeholders in each aspect of a study designed to evaluate the application and impact of new discoveries aimed at improving the health of a defined population. This approach to research is discussed in greater detail in Chapter 3. It requires active partnerships between the community and researchers who may or may not be members of that community. Partnerships and coalitions are important in developing prevention and health promotion programs or research today, because no single agency has the resources, access, and trust relationships to address the wide range of community determinants of public health problems (Green et al., 2001). Other approaches to strengthening ties between schools of public health and public health practice were reported in a survey of schools of public health. The committee conducted a survey of schools of public health (Appendix B) that listed recommendations from The Future of Public Health (IOM, 1988) and asked schools to indicate what they had done in response. The survey was mailed by ASPH in February 2002 to all accredited schools. Of the then 31 accredited schools of public health, 25 responded to the survey, a response rate of 80.6 percent (see Table 2-1 for list of respondents). One key recommendation in the 1988 report concerned linkages with state and local health departments, which are important to strengthening ties with the practice community. Each of the respondent schools indicated that at least some, and in some instances many, of their faculty have professional working relationships with state or local health departments or both. Their activities include conducting requested research projects, providing technical assistance, serving as the local epidemiologist or health officer, providing staff development or training, or serving on professional advisory committees. Major barriers to student involvement in
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century TABLE 2-1 Respondent Schools of Public Health (n = 25) Boston University Emory University Harvard University Johns Hopkins Ohio State University Saint Louis University San Diego State University Texas A&M University Tulane University University of Alabama, Birmingham University at Albany (SUNY) University of California, Berkeley University of California, Los Angeles University of Iowa University of Massachusetts University of Medicine and Dentistry of New Jersey University of Michigan University of Minnesota University of North Carolina, Chapel Hill University of Oklahoma University of Pittsburgh University of South Carolina University of Texas, Houston University of Washington Yale University activities with state and local health agencies were identified as lack of financial support and geographical distance from the health department. The survey also asked about the importance of practice experience as criteria for admission of student applicants or in the faculty hiring process. For faculty recruitment, prior practice experience was rated very important or important by about one-third (32 percent) of the respondent schools while for student admission about one-half or 52 percent of schools rated prior experience very important or important. Ties between schools of public health and the practice communities have been strengthened, but barriers remain. Foremost among the barriers is a lack of funding and incentives for such activities. As discussed earlier, schools of public health obtain most of their funding primarily through research grants and contracts, because federal support for teaching and practice activities has declined enormously during the past two decades and has not been replaced by state or private sources of funding. Additionally, the incentive and reward structure for faculty tenure and promotion is weighted heavily toward research and publication; teaching and practice activities carry comparatively little weight. Another 1988 recommendation for linking schools to practice is for schools to participate in policy development. The survey asked schools to indicate how they fulfill their potential role as significant resources to government at all levels in the development of public health policy as well as barriers to engaging in this role. The vast majority of schools that responded have faculty who engage in numerous policy development activities as reflected in Table 2-2. New training opportunities. The Future of Public Health (IOM, 1988) recommended that schools of public health improve their educational approaches for the practicing public health workforce through short courses and continuing education. Currently, all accredited schools of public health
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century TABLE 2-2 Number and Percent of Schools Engaged in State Governmental Activities During the Past Five Years (n = 25) Policy Development for Legislative Body Public Health Advocacy with State Government Public Health Advocacy with Local Government Research Requested by State Policy-makers Research Requested by Local Policy-makers Public Health Workforce Development Number 23 23 22 23 21 24 Percent 92 92 88 92 84 96 offer continuing education for public health professionals, as do the accredited programs. The overarching goal of continuing professional education is to educate and support public health professionals through enhancement of their knowledge and skills in public health practice, theory, research, and policy. Continuing education is an essential component of any career, according to Gordon and McFarlane (1996), and all schools and practice agencies should develop appropriate support systems for relevant continuing education for public health practitioners. One approach to continuing education is to offer yearly conferences or workshops on specific topics. These programs can be sponsored by a college or university or in partnership with public health programs, agencies, or associations. They usually carry continuing education credits to meet the re-certification needs of the anticipated audience. Certificate programs are another approach to educating those currently working in public health. About one-third of the accredited schools of public health currently offer certificate programs. Standards for admission and completion vary across schools. Certificate programs may be general and emphasize core public health concepts from the five core content areas taught in M.P.H. programs, that is, epidemiology, biostatistics, environmental health sciences, health services administration, and social and behavioral sciences. Others focus on a specific content area such as international health, environmental health, occupational health, injury control, health policy, or health administration. The CDC Graduate Certificate Program (GCP)—a program no longer funded—was a prime example of certificate programs. It was designed for CDC field officers, state health department personnel, and selected others with at least three to five years of experience in public health practice. The program allowed CDC Public Health Advisors working in state and local health departments to earn a graduate certificate in public health and was available from one of four accredited schools of public health: Tulane University School of Public Health and Tropical Medicine, Emory University Rollins School of Public Health, Johns Hopkins University
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century Bloomberg School of Public Health, and University of Washington School of Public Health and Community Medicine. Academic institutions (including schools of public health) also offer summer institutes and courses. Subjects encompassed range from basic biostatistics, epidemiology, and Geographic Information Systems (GIS) applications, to management and administration for middle to senior managers. Such programs can vary in length from a single one-day course to week-long offerings. Another approach to traditional continuing education programs, as described by Halverson and colleagues (1997), involves the creation of masters- and doctoral-level executive programs that minimize time lost from work through use of distance learning teaching methods. By enabling workers to continue in their work responsibilities while completing self-paced coursework, this approach reduces the burden overworked and understaffed agencies feel as their staff members participate in educational programs. The introduction of Web-based tools for education is producing a major change in the way schools and colleges conduct classes, particularly in the area of continuing education. The use of such technology is referred to as distance learning (Riegelman and Persily, 2001). This development builds upon more than two decades of computer networking activities (e.g., e-mail and bulletin board systems), and the increased availability of the Internet has produced phenomenal growth in the extent and scope of online education. Distance learning today has become an important alternative to traditional methods of education, because the existing technology has the potential to facilitate complicated distance learning environments and highly structured learning methods (Mattheos et al., 2001). The Public Health Training Network (PHTN) is an example of successful promotion of distance learning. This network has linked nearly one million people to training on a wide range of subjects in a variety of formats: print-based self-instruction, interactive multimedia, videotapes, two-way audio conferences, and interactive satellite videoconferences (CDC, 2001b). Links with other departments and schools. The Future of Public Health (IOM, 1988) recommended that schools of public health develop new relationships with other schools and departments both within their universities as well as with other institutions of higher learning. Such collaboration is taking place, according to survey data. For example, 96 percent of reporting schools (n = 24) indicated that their public health students could take courses in schools of medicine that would count toward their degree, as did 64 percent (n = 16) for courses in nursing, 44 percent (n = 11) in dentistry, 68 percent (n = 17) in law, and 72 percent (n = 18) in social work. Fifty-six percent (n = 14) of responding schools
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century reported that students “often” avail themselves of these opportunities in other schools and departments and 28 percent responded “sometimes.” Research. “[R]esearch in schools of public health should range from basic research in fields related to public health, through applied research and development, to program evaluation and implementation research” (IOM, 1988). To describe the range of research conducted in schools of public health the committee survey asked each school to estimate the percentage of research undertaken at the school that the respondent would characterize as: basic or fundamental research, that is, research conducted for the purpose of advancing our knowledge; applied research, that is, research designed to use the results of other research (e.g., basic research) to solve real world problems; translational research, that is, research on approaches for translating results of other types of research to community use; or evaluative research, that is, the use of scientific methods to assess the effectiveness of a program or initiative. Among respondent schools the distribution of the types of research undertaken varied greatly. On average, applied research was reported most often (35 percent mean, range of 10–60 percent), followed by basic research (27 percent mean, range of 0–70 percent), evaluative research (20 percent mean, range of 1–50 percent), and translational research (17 percent mean, range 0–30 percent). Broadening the scope of public health education. The 1988 IOM report recommended that schools of public health provide an opportunity to learn the entire range of skills and knowledge necessary for public health practice. Recent efforts to encompass a broad scope of education have focused on identifying basic competencies in public health and on developing curricula that teach the information and skills necessary to meet those competencies. The CDC Office of Workforce Policy and Planning (CDC, 2001c) has developed a table of public health competency sets (Appendix F). One of these is a set of core competencies developed by the Council on Linkages Between Academia and Public Health Practice (Council on Linkages, 2001). The ASPH has endorsed the Council on Linkages competencies and plans to develop complementary competencies for M.P.H. students. One competency area relates to cultural competence. The committee survey of schools of public health requested respondents to indicate courses that they offer students in cultural or international health as well as other selected areas. Table 2-3 presents their responses.
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century TABLE 2-3 Number and Percent of Responding Schools Offerings Courses in Selected Areas (n = 25) Cultural Competencies Ethics Health Disparities Social Justice Human Rights International/ Global Health Social Epidemiology Number 16 22 19 17 13 18 15 Percent 64 88 76 68 52 72 60 The final question on the committee survey of schools of public health asked for input on identifying the most important challenges and opportunities facing schools of public health and M.P.H. programs over the next 10 years. The following summarizes responses to this question. Survey responses identifying challenges and opportunities. According to respondents, public health as a profession is not well defined. Lack of clear definition is one reason the public does not understand the field. Raising public awareness of public health’s contributions to health and quality of life is important. Such awareness would help assure adequate support for public health programs. Lack of support and funding was a major issue identified frequently. Respondents indicated that increased funding is needed to support students and workforce development, and is critical to maintaining stable support for key academic programs including teaching. The major revenue source for schools of public health (i.e., external research funding) is seen as incongruent with the teaching mission and results in devaluing teaching and educational activities. Respondents indicated that the changing environment and ever-widening scope of public health requires collaboration and partnerships with other disciplines. Additionally, within the field, schools need to build strong relationships among academia, scientists, and the professional practice community, thereby allowing each to benefit from the assets of the others. Education and training issues were identified by numerous respondents. As one person wrote, “Public health is no different than other academic programs in that we tend to produce graduates for yesterday’s workplace and yesterday’s problems. Producing M.P.H. graduates responsive to what is needed today requires an understanding of the driving forces that affect public health practice and the public health workforce.” Respondents indicated that major needs include understanding that multiple factors influence health and that public health issues require societal change as well as changes in individual behavior for risk reduction. One respondent indicated that the primary goal of schools of public health should be to train the next generation of leaders as public health
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century scientists and public health professionals, stating that “Research informs practice and policy. Leadership guides them all.” The need for competencies in public health was mentioned several times. Other educational or training issues included: Education at the M.P.H. level should be comprehensive, integrated, and broad-based to support the need for general public health preparedness, necessary for such things as bioterrorism preparedness. M.P.H. programs need to be redesigned to permit greater flexibility in the development of clusters of skills and competencies in response to the rapidly changing public health environment. Baccalaureate training in schools would provide a vehicle for attracting a new cadre of students into public health. There is a need for opportunities for training in non-degree programs for part-time and mid-career students, and for increased distance learning programs. There is a need for more practical experience for graduates. Faculty issues were also addressed. Respondents indicated the need to recruit minority faculty to achieve diversity, that it was difficult to recruit faculty in specific disciplines such as biostatistics and epidemiology, and that it is necessary to maintain and improve faculty salary levels to be competitive with other sectors. Another issue identified as important was building the public health infrastructure. Some respondents indicated that there should be national attention and standards for trained personnel, along with funding to meet those standards. Respondents indicated that schools should be expected to be a resource to provide training and to meet these standards and that a lack of standards and funding results in an inadequately prepared public health workforce. It was suggested that certification or credentialing of public health professionals is an important issue. One person suggested that certification might result in more uniform and rigorous programs to address core content needs. It was proposed that schools assist in the accreditation process for local departments of health by helping them meet their continuing education needs. Respondents also indicated that the emphasis of public health research must be reviewed periodically. More prevention research is needed, including increased federal interest in prevention research. Schools of public health must more effectively promote prevention as a powerful means of health protection. Public health must find new approaches to reach the public on a level that effectively encourages primary prevention and enables individuals to change known risk behaviors to healthy behaviors. There should be increased emphasis on partnerships to develop viable
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century research programs. Understanding and addressing the determinants of ethnic and racial health disparities is an important research focus. It was suggested that new monies flowing into public health for bioterrorism response should be used to help build the infrastructure. Finally, respondents identified, but did not elaborate on, the following challenges: Globalizaation Re-emerging infections Human genome Quality of health care Un- and under-insured populations Population aging SUMMARY The establishment of the Johns Hopkins University School of Hygiene and Public Health in 1918 marked the beginning of public health education in a school dedicated to the field. There are currently 32 accredited schools of public health and 45 accredited community health programs. The Council on Education for Public Health estimates that the total number of accredited schools and programs may well double within the next 10 years and that the most dramatic growth is occurring outside the established schools of public health. Many of the nation’s accredited medical schools now have operational M.P.H. programs or are currently developing a graduate public health degree program (Evans, 2002). 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 learning 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. Previous efforts to design truly effective systems of public health education generally foundered because of a lack of political will, public disinterest, or a paucity of funds. Since September 11, 2001, however, the context has changed dramatically. With public health rising 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.
Representative terms from entire chapter: