During the 20th century great achievements in public health contributed to reductions in both morbidity and mortality in the United States. Nonetheless, the primary foci of U.S. health efforts were on scientific advances and medical care tailored to the individual, and particularly to already manifest diseases. Accordingly, most investments in capacity building in the last century have paralleled the dominance of this biomedical model, with public (mostly federal) dollars directed at capital investments in hospitals and medical schools, and on research activities on these issues in academic medical centers (Boufford and Lee, 2001). Health investments in population-based or public health capacity building, whether in laboratories, information systems, research, or workforce development and training have lagged woefully behind (IOM, 1988).
A variety of forces—among them globalization, technologic and scientific advances, and rapid demographic shifts—are hastening the need to refocus attention and resources away from these traditional biomedical efforts toward those of population health. The committee has relied on an ecological model of health to shape the implications of these changes on public health workforce needs; developing a framework for education, training, and research based on the ecological model. The ecological model recognizes accumulating evidence that the health of individuals and the community is determined relatively little by health care per se and far more by multiple other factors, and by their interactions. These factors include biology (e.g., genetics), the social and physical environment, education, employment, and behavior (e.g., healthy behaviors such as exercise and unhealthy ones such as overeating).
We have developed a working definition of public health professionals. A public health professional is a person educated in public health or a related discipline who is employed to improve health through a population focus. The committee believes that well-educated public health professionals, who have a real understanding of the multiple determinants of health and their interactions (the ecological model), are critical to shaping new knowledge, programs, and policies relevant to both individual health and health care, and to population health in the coming century. These professionals must have a broad range of skills and information. They must be able to understand and apply new advances in science (e.g., genetics), information, and computer science technology to public health practice and learning (i.e., public health informatics). They must be proficient in communication in order to interact effectively with multiple audiences, to understand and incorporate the needs and perspectives of culturally diverse communities in public health interventions and research, and to inform policy. Further, public health professionals will need to apply new approaches to research, approaches that involve practitioners, researchers, and the community in joint efforts to improve health and to understand global health issues that increasingly transcend national boundaries. Of course, public health professionals must be able to identify and address the numerous ethical issues that arise in public health practice and research.
Public health professionals come from a variety of professions and are educated in a number of different types of institutions. Because education for all public health professionals, no matter where they are educated, must be both relevant to the challenges of the 21st century and of high quality, the committee has focused its recommendations not just on programs and schools of public health, but also on schools of medicine, nursing, and other professional schools (e.g., law), as well as on local, state, and federal public health agencies. Education, research, and practice linkages among these institutions must be fostered. Recent events, particularly those of September 11, 2001, and their aftermath, have brought public health and its professional practitioners from relative obscurity to broad visibility. These events have dramatized the need to connect the spheres of health care and public health, both to each other and to their interaction with the public. Clearly demonstrated was the need for public health and health care sectors to be better able to characterize and communicate risk and uncertainty.
The committee tackled the challenges faced by public health and its professionals, given this moment in history, recognizing the opportunity for public health to address many infrastructure and workforce needs because of its increased visibility. As stated earlier in the report, previous efforts to design truly effective systems of public health education generally foundered because of lack of political will, public disinterest, or pau-
city of funds. Despite the opportunities provided to public health in terms of resources and attention directed at disaster preparedness as a result of September 11, 2001, and the subsequent anthrax attacks, it is critical that this admittedly important issue not dwarf other challenges of public health and that necessary attention and support be given to strengthening the public health system, including educating public health professionals.
It is against this background that the committee developed its recommendations. Our recommendations are sometimes incremental, occasionally quite radical given our current baseline, but always grounded on a vision that if we lose sight of who will keep the public healthy, we will have lost an opportunity to improve the public’s health during the 21st century.