Who Will Keep the Public Healthy?

Educating Public Health Professionals for the 21st Century

Kristine Gebbie, Linda Rosenstock, and Lyla M. Hernandez, Editors

Committee on Educating Public Health Professionals for the 21st Century

Board on Health Promotion and Disease Prevention

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu



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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century Kristine Gebbie, Linda Rosenstock, and Lyla M. Hernandez, Editors Committee on Educating Public Health Professionals for the 21st Century Board on Health Promotion and Disease Prevention INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by Contract/Grant No. 042024 between the National Academy of Sciences and The Robert Wood Johnson Foundation. The views presented in this report are those of the Institute of Medicine Committee on Educating Public Health Professionals for the 21st Century and are not necessarily those of the funding agencies. Library of Congress Cataloging-in-Publication Data Who will keep the public healthy? : educating public health professionals for the 21st Century / Kristine Gebbie, Linda Rosenstock, and Lyla M. Hernandez, editor(s). p. cm. Includes bibliographical references and index. ISBN 0-309-08542-X (hardcover) 1. Public health—Study and teaching. I. Gebbie, Kristine M. II. Rosenstock, Linda. III. Hernandez, Lyla M. RA440.W47 2003 362.1’071—dc21 2003001043 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2003 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Shaping the Future for Health

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century COMMITTEE ON EDUCATING PUBLIC HEALTH PROFESSIONALS FOR THE 21ST CENTURY KRISTINE GEBBIE, Dr.P.H., R.N. (co-chair), Associate Professor of Nursing, School of Nursing, Columbia University LINDA ROSENSTOCK, M.D., M.P.H. (co-chair), Dean, School of Public Health, University of California, Los Angeles SUSAN ALLAN, M.D., J.D., M.P.H., Health Director, Arlington County Department of Human Services, Arlington, Virginia KAYE BENDER, Ph.D., R.N., Deputy State Health Officer, Mississippi State Department of Health DAN BLAZER, M.D., Ph.D., M.P.H., J.P. Gibbons Professor of Psychiatry and Behavioral Sciences, Duke University, and Adjunct Professor, Department of Epidemiology, School of Public Health, University of North Carolina SCOTT BURRIS, J.D., Professor, School of Law, Temple University and Associate Director, Center for Law and the Public’s Health, Georgetown and Johns Hopkins Universities MARK CULLEN, M.D., Professor of Medicine and Public Health, School of Medicine, Yale University HAILE DEBAS, M.D., Dean, School of Medicine, and Vice Chancellor, Medical Affairs, University of California, San Francisco ROBERT GOODMAN, Ph.D., M.P.H., M.A., Usdin Family Professor, Health Sciences Center, Tulane University ALAN E. GUTTMACHER, M.D., Deputy Director, National Human Genome Research Institute, National Institutes of Health RITA KUKAFKA, Dr.P.H., M.A., Assistant Professor of Public Health (Sociomedical Sciences) and Department of Medical Informatics, Mailman School of Public Health and the College of Physicians and Surgeons, Columbia University ROXANNE PARROTT, Ph.D., Professor, College of Liberal Arts, Pennsylvania State University SHEILA M. SMYTHE, M.S., Executive Vice President and Dean, School of Public Health, New York Medical College WILLIAM VEGA, Ph.D., Director, Behavioral and Research Training Institute and Professor of Psychiatry, Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey PATRICIA WAHL, Ph.D., Dean, School of Public Health and Community Medicine, University of Washington

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century STAFF LYLA M. HERNANDEZ, M.P.H., Senior Program Officer, Study Director MAKISHA WILEY, Senior Project Assistant MARC EHMAN, M.P.H., Research Assistant through 05/03/02 ROSE MARIE MARTINEZ, Sc.D., Director, Board on Health Promotion and Disease Prevention RITA GASKINS, Administrative Assistant, Board on Health Promotion and Disease Prevention

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century REVIEWERS This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Susan Addis, M.P.H., M.Ur.S., Vice-Chair, Connecticut Health Foundation, Former Connecticut Commissioner of Health Enriqueta C. Bond, Ph.D., President, Burroughs Wellcome Fund Patricia Flatley Brennan, R.N., Ph.D., Moehlman Bascom Professor, University of Wisconsin-Madison Wylie Burke, M.D., Ph.D., Professor and Chair, Department of Medical History and Ethics, University of Washington Noreen M. Clark, Ph.D., Marshall H. Becker Professor and Dean of Public Health, University of Michigan Eugenia Eng, M.P.H., Dr.P.H., Professor, School of Public Health, University of North Carolina Bernard Guyer, M.D., M.P.H., Chair, Department of Population and Family Health Science, Bloomberg School of Public Health, Johns Hopkins University Jeanette Klemczak, Ph.D., R.N., Director, College of Nursing, Michigan State University Deborah E. Powell, M.D., Dean and Assistant Vice President for Clinical Affairs, University of Minnesota School of Medicine Joseph Telfair, Dr.P.H., M.S.W., M.P.H., Associate Professor, University of Alabama at Birmingham Thomas W. Valente, Ph.D., Director, Master of Public Health Program, Keck School of Medicine, University of Southern California Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by M. Donald Whorton, M.D., M.P.H., WorkCare, Inc., Alameda, CA, appointed by the Institute of Medicine and Harold J. Fallon, M.D., IOM Home Secretary and Dean Emeritus, School of Medicine, University of Alabama at Bir-

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century mingham, appointed by the NRC’s Report Review Committee, who were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century Acknowledgments Many people willingly shared their expertise and insights with the committee and staff during the course of this study. Their contributions invigorated committee deliberations and enhanced the quality of this report. William L. Roper, M.D., M.P.H., conceived the idea to examine public health professional education in the 21st century, thereby prompting this study. The committee expresses its appreciation to the Robert Wood Johnson Foundation (RWJF) for sponsoring the study and, in particular, to Pamela Williams Russo, M.D., M.P.H. Elizabeth Fee, Ph.D., commissioned to write a paper on the history of public health education in the United States, provided a tremendously thorough and extremely readable paper that elucidated for the committee the issues, events, and evolution of public health education over the past century. Additionally, her comments on an earlier draft of this report were informative and helpful in clarifying ideas. The commissioned paper by James C. Thomas, M.P.H., Ph.D., on teaching public health ethics highlighted issues of critical importance to public health education and contributed greatly to the committee’s examination of the role of ethics in public health education. The committee greatly appreciates the input of speakers whose presentations informed committee thinking including: Mohammad Akhter, M.D., M.P.H.; Elaine Auld, M.P.H.; Ronald Bialek, M.P.H.; Patricia P. Evans, M.P.H.; Virginia Kennedy, Ph.D.; Maureen Lichtveld, M.D., M.P.H.; William Livingood, Ph.D.; Samuel Shekar, M.D., M.P.H.; Harrison Spencer, M.D., M.P.H.; and Vaughn Upshaw, Ed.D., Dr.P.H. The committee extends its thanks to the Association of Schools of Public Health, the Association of State and Territorial Health Officers, the Centers for Disease Control and Prevention, the National Association of County and

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century City Health Officials, and the Public Health Foundation for their thoughtful and detailed input about the challenges facing public health and the educational needs of public health professionals. The Association of Schools of Public Health was also helpful in reviewing and distributing a committee survey. Their participation was critical to the successful conduct of this survey on progress made by schools of public health in implementing recommendations of the 1988 Institute of Medicine (IOM) report, The Future of Public Health. The committee is grateful to the 25 schools of public health at the following universities that took the time and put forth the effort to complete the survey: Boston University Emory University Harvard University Johns Hopkins University Ohio State University Saint Louis University San Diego University Texas A&M University Tulane University University of Alabama, Birmingham University of Albany (SUNY) University of California, Berkeley University of California, Los Angeles University of Massachusetts University of Iowa 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 The work of this committee has been informed by several high quality IOM reports on relevant topics including: The Future of Public Health (1988); Linking Research and Public Health Practice: A Review of CDC’s Program of Centers for Research and Demonstration of Health Promotion and Disease (1997); America’s Vital Interest in Global Health (1997); Promoting Health: Intervention Strategies from Social and Behavioral Research (2000); Health and Behavior: the Interplay of Biological, Behavioral, and Societal Influences (2001); and Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (2002). We acknowledge our indebtedness to the committees and staffs of these reports. The committee was extremely fortunate in their staffing for this study. We wish to thank our study director, Lyla M. Hernandez, for her enormous effort in producing a clearly written, well-organized report that reflects the collective thought of the committee. Our appreciation also goes to Makisha Wiley for her administrative support, coordination of committee meetings, and maintenance of project files, and to Marc Ehman who provided research assistance throughout the initial phases of the project.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century Contents     ABSTRACT   1     SUMMARY   3     Committee Charge,   3     Definition,   4     Challenges,   4     The Future of Public Health Education,   5     Schools of Public Health,   8     Other Programs and Schools,   17     Public Health Agencies,   20     Conclusion,   25 1   INTRODUCTION   27     Public Health Professionals,   29     Determinants of Health,   31     Challenges,   34     Summary,   39 2   HISTORY AND CURRENT STATUS OF PUBLIC HEALTH EDUCATION IN THE UNITED STATES   41     History,   41     Current Status,   50     Summary,   60 3   THE FUTURE OF PUBLIC HEALTH EDUCATION   61     Informatics,   62

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century     Genomics,   68     Communication,   72     Cultural Competence,   78     Community-Based Participatory Research,   84     Global Health,   93     Policy and Law,   95     Ethics,   98     Summary,   105 4   FUTURE ROLE OF SCHOOLS OF PUBLIC HEALTH IN EDUCATING PUBLIC HEALTH PROFESSIONALS FOR THE 21st CENTURY   108     Overview,   108     Education,   109     Transdisciplinary Research,   117     Policy,   120     Academic Collaboration,   121     Access to Life-Long Learning,   122     Community Collaboration,   125     Faculties for Schools of Public Health,   126 5   THE NEED FOR PUBLIC HEALTH EDUCATION IN OTHER PROGRAMS AND SCHOOLS   129     Graduate Programs in Public Health,   129     Medical Schools,   131     Schools of Nursing,   136     Other Schools,   142 6   PUBLIC HEALTH AGENCIES: THEIR ROLES IN EDUCATING PUBLIC HEALTH PROFESSIONALS   145     Local Public Health Agencies,   145     State Public Health Agencies,   151     Federal Public Health Agencies,   157     Recommendations,   162     CONCLUSION   168     REFERENCES   171

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century     APPENDIXES     A   SCHOOL OF PUBLIC HEALTH CATALOGUE ABSTRACTION   183 B   SCHOOL OF PUBLIC HEALTH SURVEY INSTRUMENT   190 C   ORGANIZATIONAL INPUT   199 D   EDUCATION OF PUBLIC HEALTH PROFESSIONALS IN THE 20TH CENTURY   222 E   OCCUPATIONAL CLASSIFICATIONS   262 F   A COLLECTION OF COMPETENCY SETS   265 G   PUBLIC MEETING   278 H   COMMITTEE BIOGRAPHIES   283     INDEX   289

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century Who Will Keepthe Public Healthy?

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century