5
The Need for Public Health Education in Other Programs and Schools

In addition to schools of public health, other programs, schools, and institutions play major roles in educating public health professionals. The committee believes that to provide a coherent approach to educating public health professionals for the 21st century, it is important to examine and understand the potential contributions these other institutions and programs can make. Therefore, this chapter will discuss graduate programs in public health, schools of medicine, schools of nursing, and other professional schools.

GRADUATE PROGRAMS IN PUBLIC HEALTH

As discussed in Chapter 2, a significant number of new entrants to the field of public health and existing public health workers receive their masters of public health (M.P.H.) education and training in graduate programs in public health. In contrast to “stand alone” schools of public health in university settings, these programs are generally housed within other academic departments (such as departments of preventive medicine in schools of medicine), colleges, or schools in university settings such as education. In fact, these M.P.H. degree-granting graduate programs appear to be growing at a faster pace than schools of public health although the number of students per program tends to be smaller than the number per school.

The Council on Education for Public Health (CEPH) accredits not only the schools but also graduate programs in Community Health Education (CHE) and in Community Health/Preventive Medicine (CHPM),



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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century 5 The Need for Public Health Education in Other Programs and Schools In addition to schools of public health, other programs, schools, and institutions play major roles in educating public health professionals. The committee believes that to provide a coherent approach to educating public health professionals for the 21st century, it is important to examine and understand the potential contributions these other institutions and programs can make. Therefore, this chapter will discuss graduate programs in public health, schools of medicine, schools of nursing, and other professional schools. GRADUATE PROGRAMS IN PUBLIC HEALTH As discussed in Chapter 2, a significant number of new entrants to the field of public health and existing public health workers receive their masters of public health (M.P.H.) education and training in graduate programs in public health. In contrast to “stand alone” schools of public health in university settings, these programs are generally housed within other academic departments (such as departments of preventive medicine in schools of medicine), colleges, or schools in university settings such as education. In fact, these M.P.H. degree-granting graduate programs appear to be growing at a faster pace than schools of public health although the number of students per program tends to be smaller than the number per school. The Council on Education for Public Health (CEPH) accredits not only the schools but also graduate programs in Community Health Education (CHE) and in Community Health/Preventive Medicine (CHPM),

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century while the Accrediting Commission on Education for Health Services Administration (ACEHSA) accredits programs in health administration. CHEs offer degrees solely in health education; whereas CHPMs may offer a variety of concentrations, and presently tend to be heavily weighted toward epidemiology, health administration, environmental health, maternal and child health, and general public health. In the 1970s, some of these programs sought an umbrella under which they could loosely federate for purposes not dissimilar to the role played by the Association of Schools of Public Health for schools. Because many of these early programs were housed in medical school departments of preventive medicine, it was not surprising that they sought a home base through the Association of Teachers of Preventive Medicine (ATPM) rather than create their own organizational structure. Thus, within ATPM, the Council of Graduate Programs in Public Health and Preventive Medicine, as it is now known, came into being. In 1999, ATPM’s Council, with collaboration from CEPH, surveyed the CHE, CHPM, and other M.P.H. programs to collect data on students, graduates, faculty, areas of concentration, etc., based on the 1998–1999 academic year. Results of the survey indicated that there were 75 programs in existence at the time, although others were in some phase of planning a program. The breakdown of the 75 programs surveyed indicated their accreditation status as: Accredited 38 Pre-accredited 4 Application for accreditation 9 Not accredited 24 Some of the respondent characteristics and findings indicated that about two-thirds of the students were attending part-time. The programs are generating about one in every eight M.P.H. degrees, are practice oriented, and tend to be located in states lacking schools of public health (although the Tufts University program co-habits in the Boston area with schools of public health at Harvard and Boston Universities). For some programs this is a transition phase to becoming a school but a significant number, especially CHEs, will remain programs. According to Bialek and Bialek (1999), during the 1990s significant changes were made in some public health education programs, including increased emphasis on cross-disciplinary education and use of problem-solving and case-based approaches to learning. These programs are contributing significantly to the formal graduate-degree-granting educational process for leadership in the future public health workforce and for continuing education opportunities in the existing workforce at all levels. When this reality is combined with the potential for housing educational pro-

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century grams within major state and local health departments and collaborating with undergraduate institutions, the importance of these programs to the education of public health professionals is further highlighted. The committee recognizes the contributions to the education of public health professionals that have been made by these programs and encourages programs to make further advancements in public health education. Therefore, the committee recommends that these graduate M.P.H. programs in public health institute curricular changes that: emphasize the importance and centrality of the ecological model, and address the eight critical areas of informatics, genomics, communication, cultural competence, community-based participatory research, global health, policy and law, and public health ethics. MEDICAL SCHOOLS Physicians have historically played a central, though not exclusive, role in ensuring the health of the public. The Hippocratic physicians knew the importance of the physical and social environment to the health of communities: Who ever wishes to investigate medicine properly should proceed thus: in the first place to consider the seasons of the year, and what effect each then produces. Then the winds...in the same manner, when one comes into a city to which he is a stranger, he should consider the situation, how it lies as to the wind and the rising of the sun...one should consider most attentively the water...and the mode in which the inhabitants live, and what are their pursuits, whether they are fond of drinking to excess, and given to indolence, or are fond of exercising and labor (Hippocrates, 400 B.C.). In the late 19th and early 20th centuries, most public health professionals were physicians (Hager, 1999) who contributed greatly to public health. During the 19th century, the physician John Snow conducted a series of classic epidemiologic studies of the cholera epidemic in London in 1854. During the early 20th century, William Gorgas, a physician working with the U.S. Army Corps of Engineers, implemented an extensive program of mosquito eradication in the Panama Canal Zone and virtually eliminated yellow fever among workers on the canal (McCoullough, 1978). A. Bradford Hill, a biostatistician who later became a physician, explored the relationship between cigarette smoking and lung cancer along with his colleague Richard Doll, providing the first strong empirical evidence of the association between smoking and cancer. Beginning in the 20th century, however, the association between public health and mainstream medicine declined (although many physicians

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century continue to lead or participate in local, state, and national public health efforts). In fact, increasing tensions resulted in a schism between medicine and public health. Reasons for this tension include the following: Public health was viewed as infringing on the doctor-patient relationship when it called for reporting communicable diseases. Public health agency delivery of health care services was viewed as economically threatening to the medical profession. The rise of the tertiary care hospital furthered separation. Basic views of promoting health widely differed, with medicine focused on individual care and the biomedical paradigm while public health focused on prevention (Brandt and Kass, 1999). Table 5-1, lists traditional distinctions between medicine and public health, identified by Fineberg, that contribute to our understanding of why this separation has occurred. In 1950 about 30 percent of graduates of public health education programs were physicians. By 1988 that figure had shrunk to 22 percent of graduates, and half of these were from countries other than the United States (Bialek and Bialek, 1999). However, meeting the public health challenges of the 21st century will require that medical, scientific, and public health communities work together. Reasons include the changing spectrum of health problems and the crisis in health care costs (Lasker, 2001), development of scientific and methodological underpinnings of medicine and public health (Tuckson, 1999), and the slowly changing values of purchasers and the growth of generalism and primary care (Shine, 1999). The divergence between medicine and public health that developed in the 20th century must be corrected because, in the words of Koplan and Fleming (2000), the two fields “share in the responsibility and have an unprecedented opportunity to apply current knowledge to improve the health of the nation.” An adequate infrastructure and joint training and research opportunities should be created to support a productive collaboration of medicine and public health. Advances in genetics and bioinformatics create a unique opportunity for these two fields to join forces in preventive care of chronic diseases, susceptibility to which can now be detected decades earlier. There have been previous efforts to bridge the chasm between medicine and public health. The 1998 conference Education for More Synergistic Practice of Medicine and Public Health (sponsored by the Josiah Macy, Jr., Foundation) was organized to discuss the most effective ways to “educate and train physicians and public health professionals to collaborate more effectively” (Hager, 1999). During that conference, Lasker (1999) urged that medical students learn the relevance of population-based methodologies and population-based strategies to the provision of medical care. The conference concluded that the “spirit of collaboration” must

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century TABLE 5-1 Traditional Distinctions Between Medicine and Public Health Medicine Public Health Primary focus on individual Primary focus on population Personal service ethic, conditioned by awareness of social responsibilities Public service ethic, tempered by concerns for the individual Emphasis on diagnosis and treatment, care Emphasis on prevention, health promotion for the whole patient and for the whole community Medical paradigm places predominant emphasis on medical care Public health paradigm employs a spectrum of interventions aimed at the environment, human behavior and lifestyle, and medical care Well-established profession with sharp public image Multiple professional identities with diffuse public image Uniform system for certifying specialists beyond professional medical degree Variable certification of specialists beyond professional public health degree Lines of specialization organized, for example, by: • organ system (cardiology) • patient group (pediatrics) • etiology, pathophysiology (oncology, infectious disease) • technical skill (radiology) Lines of specialization organized, for example, by: • analytical method (epidemiology) • setting and population (occupational health) • substantive health problem (nutrition) Biological sciences central, stimulated by needs of patients; move between laboratory and bedside Biological sciences central, stimulated by major threats to health of populations; move between laboratory and field Numeric sciences increasing in prominence, though still a relatively minor part of training Numeric sciences an essential feature of analysis and training Social sciences tend to be an elective part of medical education Social sciences an integral part of public health education Clinical sciences an essential part of professional training Clinical sciences peripheral to professional training   SOURCE: Permission to print from author, Harvey V. Fineberg, M.D. diffuse through both medicine and public health, with students in the fields of medicine and public health needing exposure to the academic disciplines and practice of the other. Current changes in the delivery system also foster the need for physicians educated in basic public health. The number of physicians working in settings such as a health maintenance organization (HMO) or a large multidisciplinary group is increasing; academic physicians also work in large health systems. These systems must account for the overall health of

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century a group of patients. With a growth in the numbers and the size of systems has come increasing demand for physicians to play a more central role in planning the delivery of health care to patients in these systems. Further, physicians have become much more aware (as have other health care professionals) of the impact of population health upon individual practice. Examples include the threat of bioterrorism, medical care cost constraints that require developing priorities, and the rising interest in health promotion and disease prevention among the population at large. Because of these changes, it is important that schools of medicine incorporate into their core curriculum basic public health education such as basic screening techniques for adverse health habits (such as smoking and alcohol/drug abuse); nonpharmacological preventive strategies (such as smoking cessation and weight reduction); the costs and benefits of various screening methods (such as mammography and PSA screening for prostate cancer); and population monitoring of disease burden (such as tracking both acute and long lasting epidemics). Because medical school curricula are already tightly organized, it may appear difficult to introduce another area for learning. The first two years of medical school are spent on basic science preparation which is followed by clerkships in clinical disciplines during the third year. The fourth year features a mixture of elective and required course work in disciplines such as radiology, anesthesiology, and the medical and surgical sub-specialties (Anderson, 1999). However a growing number of medical schools include social science in the required curriculum and provide opportunities for work with other health care professionals. In 1998 it was reported that 56 of the 125 accredited U.S. medical schools taught separate required courses on such topics as public health, epidemiology, and biostatistics and that 36 medical schools offered a combined M.D. (doctor of medicine) and M.P.H. degree (Anderson, 1999). There are existing examples that, with some modification, could produce professionals with both an M.D. and either an M.P.H. or Ph.D. (doctoral) degree in public health. Graduates of these programs would have the requisite education to become leaders to bridge the chasm between the two disciplines. In the joint program linking the University of California at San Francisco (UC San Francisco) and the school of public health at the University of California at Berkeley (UC Berkeley), for example, 12 students are admitted by a joint admissions committee from the UC San Francisco School of Medicine and the UC Berkeley School of Public Health. They spend the first three years at Berkeley, during which they satisfy the

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century preclinical requirements of medical school and complete a thesis for a master’s (M.S.) degree in public health from Berkeley. They then transfer to UC San Francisco to complete the third and fourth years of medical school and graduate with the M.D. degree from UC San Francisco. The joint program linking Duke University and the University of North Carolina is organized somewhat differently. Between 20 and 25 students out of 100 third-year medical students at Duke elect to enroll at the University of North Carolina School of Public Health. In addition to a generic M.P.H. degree developed for physicians interested in public health, students work toward degrees in epidemiology, maternal and child health, health services administration, or environmental health sciences. Given Duke’s unique curriculum (which permits a year of scholarship during the four years of medical school), students who elect this program can acquire an M.P.H. and an M.D. degree within four years. The program at the University of Southern California is an example in which the Keck School of Medicine and the Master of Public Health Program (located within the medical school) work together. Students from the school of medicine can insert a year between their second and third years of medical school to complete the M.P.H. degree in the public health program, returning to the medical school to complete their M.D. degree training. The committee’s goal in developing recommendations for programs and approaches for public health education in medical schools is to foster improved public health training for all medical students. We envision a future in which one-fourth to one-half of medical school graduates are fully trained in the ecological model of health at the M.P.H. level. An ecological understanding of health and a transdisciplinary approach require physicians who are fully prepared to work with others to improve health. Therefore, the committee strongly recommends that: all medical students receive basic public health training in the population-based prevention approaches to health; serious efforts be undertaken by academic health centers to provide joint classes and clinical training in public health and medicine; and a significant proportion of medical school graduates should be fully trained in the ecological approach to public health at the M.P.H. level. Further, when a school of public health is not available to collaborate in teaching the ecological approach to medical students, the committee recommends that medical schools should partner with accredited programs in public health to provide for public health education. Medical schools and schools of public health should collaborate on educational and scientific programs that address some of our most prevalent and troublesome chronic diseases, such as Alzheimer’s disease, obe-

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century sity, and severe or unremitting psychiatric disorders. Evidence of the success of such collaboration can be found in the area of cardiovascular diseases and, to some extent, various cancers. Additionally, ongoing collaborations between schools of medicine and public health could focus on understanding how recent advances in genomics and biomedicine in general will make an impact on the public’s health over time. Students in both schools should be exposed to dialogues between leaders in medicine and leaders in public health on central topics related to the public’s health (e.g., regarding the impact upon and cost to society of new generation, subject specific pharmaceutical products). Therefore, schools of medicine and schools of public health should develop an infrastructure to support research collaborations linking public health and medicine in the prevention and care of chronic diseases. SCHOOLS OF NURSING Nurses constitute the single largest group of professionals practicing public health. The estimated numbers available are somewhat inconsistent, given various data sources and definitions. In the 2000 estimated enumeration of the public health workforce, nearly 11 percent of the professionals identified were nurses, and there are probably a good many more practicing under more general job titles. (Center for Health Policy, 2000) These data come primarily from state and local health departments. However, many additional nurses in public health practice are employed elsewhere, including departments of education, as school nurses; workplaces, as occupational health nurses; community clinics, as educators and outreach coordinators; hospitals, as epidemiologists; and in voluntary health organizations in a wide range of population-focused activities. In most local public health departments, nurses are the largest component of the workforce. In very small departments they may be the only health professional staff member(s) (Gerzoff et al., 1999; Richardson et al., 2001). Anecdotal information suggests that states moving to establish local public health agencies or offices have made nursing the first locally based office, often using federal grant or reimbursement mechanisms for funding. The complexities of the field of nursing are illustrated in the fact that leadership for public health nursing and public health nursing education comes from a multi-organizational group known as the Quad Council of Public Health Nursing Organizations. Members include the Association of State and Territorial Directors of Nursing, the Association of Community Health Nurse Educators (ACHNE), the Public Health Nursing Section of the American Public Health Association, and the American Nursing Association (ANA). Regular communication within the Quad Council has meant that the interests of the practice field are regularly brought to

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century the attention of educational institutions and, concomitantly, that the educators are in a position to share emerging insights in education and research with practice leaders. Key documents on public health nursing, such as the statement on scope and standards of community health nursing practice (QCPHNO, 1999) published by the ANA, are developed with the full collaboration of this entire group. The state nursing directors are also in a position to share emerging concerns of the public health nursing community with the broader public health practice field through their organizational relationship as an affiliate of the Association of State and Territorial Health Officials. Confusion regarding the roles of nurses in public health practice and education has been fostered by a decades-long debate about terminology: community health nursing as identical with or different from public health nursing. The distinction may be an important one: the mere fact that one is working in an office, a van, or on a street corner may not signify that one is concerned about the health of groups or populations, or focused on prevention. For example, the increasing use of home health and visiting nurses has meant that more and more nurses are providing individual clinical nursing care in patients’ homes rather than in hospitals. These nurses may not, however, be paying attention to family dynamics, environmental health, or health education and promotion as included in public health nursing practice since the days of Lillian Wald, who first coined the term (Erickson, 1987; Byrd, 1995). Given shifts in approaches to medical care, it is appropriate that nurses learn how to provide clinical services in a wide range of settings, including homes and community sites. This does not, however, replace the role that nurses have played and should continue to play on interdisciplinary public health teams working to improve the health of communities through disease prevention and health promotion. The two require different education and developmental opportunities, though a well-prepared public health nurse may provide clinical services as a response to community need or as a way of supporting a position that also has a community focus. As is also true for physicians, all nurses are at some level a part of the public health system, given their potential contributions to the control of nosocomial infections, the identification of conditions of public health importance, and the education of patients and families about disease prevention and health promotion. These roles may be more visible in some specialty areas (e.g., the role of nurses in obstetrical units in promoting child health) or some settings (outpatient departments in underserved rural and inner city communities), and may or may not be explicitly recognized in job descriptions or in the work of the local official public health agency. However, because of their important contributions, it is important that all nurses have at least an introductory grasp of the role of public health in the community and of the principles of health promotion

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century and disease prevention and, as discussed below, the curriculum standards for schools of nursing support this concept. Undergraduate Education Since early in the 20th century, the stated standard of preparation for a public health nurse has been the baccalaureate degree (AACN, 1999). This requirement was based on an understanding that working in the community required knowledge of community and family dynamics beyond that necessary for effective practice within an institutional setting. As standards for baccalaureate nursing education were established, public health nursing was included as a required classroom and clinical experience, and this can be seen as the major distinguishing clinical feature that differentiates the baccalaureate level of nursing education from diploma or associate degree programs. The ANA has created Standards for Public Health Nursing Practice (QCPHNO, 1999) that provide the standards against which practice should be measured. The licensing board in at least one state (California) continues to issue a separate certification for public health nursing and limits use of the title “public health nurse” to those who are so certified. The exact content of these public health nursing courses has changed over time, as have the associated clinical experiences. Guidelines for nursing education are provided through the school accreditation process and through standards set by educators in various specialty areas. Accreditation of schools can be done by one of two organizations, the National League for Nursing Accrediting Commission, Inc., or the American Association of Colleges of Nursing (AACN). The AACN only accredits programs at the baccalaureate or higher level and includes the expected competencies items such as social justice, community health risk assessment, health promotion, risk reduction and disease prevention, human diversity, and global health care, all of which are basic for good public health practice. Standards for associate degree programs (and the dwindling number of hospital-based diploma programs) are established by the National League for Nursing Accrediting Commission, Inc., the accrediting body. At the associate degree level, the standard requires that the curriculum provides for attainment of knowledge and skill sets in community concepts, health care delivery, critical thinking, communications, therapeutic interventions, and current trends in health care. There is nothing in the standard that suggests that these graduates are being prepared for the level of analytic skills and community dynamics that are a key part of public health nursing practice. Because of job market pressure, however, many health departments recruit and hire graduates of associate degree programs (especially in communities in

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century which there is no baccalaureate school of nursing), and the schools are responsive to inclusion of material that might make their graduates even more employable. Informal discussions would indicate that an increasing number of schools at this level are including community-based clinical practice within the curriculum but not classic population-focused public health nursing. Additional guidance on public health nursing is provided by the Association of Community Health Nursing Educators. This group contributed to the development of the ANA scope and standards, and has produced guidance on the content of public health nursing education at the undergraduate and graduate levels. Members are primarily faculty from baccalaureate and master’s degree nursing programs. There is no organizational link to any group representing more general public health professional education, such as the Association of Teachers of Preventive Medicine. A continuing concern of faculty in schools of nursing is identification of appropriate sites for clinical experience. As public health agencies have been caught up in the provision of clinical services, it has been easier to provide students with home health or other non-institutional personal care experiences and more difficult to provide community-focused experiences. As agencies operate programs with ever-tighter budgets and staffing patterns, they may also be reluctant to accommodate student space and time needs, meaning that even those students graduating from programs listing public or community health in the curriculum may have had minimal experience in population-focused practice. Graduate Education Nurses interested in advancing their skills in public health nursing practice may pursue education in public health at a school of public health, earning the master of public health degree. While at one time there were more, today only one school of public health continues to offer an M.P.H. program specific to public health nursing. Alternatively, some schools of nursing offer masters-level programs in public health or in community health nursing. Classically, these programs emphasize community assessment, development of programs of health promotion and disease prevention, use of public health analytic skills, and application of nursing knowledge and skill in the community setting. These programs have become smaller, and many have closed, as schools of nursing have concentrated master’s level preparation on midwives, nurse anesthetists, nurse practitioners, and other advanced practice nurses. Some of these advanced practice nurses are in specialty areas closely related to public health programs (midwifery, pediatric or family nurse practice). The National Organization of Nurse Practitioner Faculty (NONPF) has had philanthropic support for the last three years to encourage the inclusion of public health

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century and population-focused concepts in the advanced practice nursing curricula (Community Health Resource Center, 2000). These graduates will not be fully prepared in public health analytic or community development skills; their exposure is intended to prepare them to better work as partners with patients and communities (such as in community-based primary care programs). While any of these programs based in schools of nursing may provide excellent courses and theoretical programs, it is only with great difficulty that students are provided with opportunities to explore the interdisciplinary nature of public health practice during the learning period. Graduate education in public health or in nursing is held to be the standard for nurses moving to supervisory or leadership positions in public health organizations. The uneven geographic distribution of education programs and the location of many public health organizations in rural and underserved areas means that not all practicing nurses can easily attain this desired higher education before moving up a career ladder. Current discussions in nursing education circles emphasize the need for graduate nursing programs to extend themselves via distance learning opportunities and collaboration with practice sites to facilitate advanced learning, without the necessity of leaving job and family for extended periods (Wedeking, 2001). The Health Resources and Services Administration (HRSA) has funded a number of projects that involve collaboration across schools of nursing and practice organizations to support such a commitment. One example is the project funded through the University of Illinois-Chicago School of Nursing Peoria campus, linking multiple nursing schools with health departments and other employers of public health nurses to strengthen the curriculum, increase the number of masters degree graduates, and recruit additional nurses into public health, particularly those from ethnic or racial minorities. Another program housed at the University of Colorado is linked with the University of Wyoming and with health departments in both states, providing access to graduate education through distance learning across the region. Nursing Education and the Job Market While the standard for public health nursing practice is the baccalaureate degree, with the master’s degree preferred for leadership positions, the realities of the nursing education and job market are such that many agencies will undoubtedly continue to fill positions with under-prepared nurses rather than leave them vacant. The problems are exacerbated by the continuing nursing shortage in both the public health and the health care systems. Half of all practicing nurses are educated at the associate or diploma level, and there is little likelihood that this will shift in the near future. In some geographic areas, the only source of nursing education is the local

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century community college. The increasing competition with hospitals for the aging nursing workforce means that slower-moving public employers are unable to compete regarding salary and benefits with other systems. To the extent that public health nurses are employed in other than public settings, they may benefit from this competition. It is extremely difficult to require graduate education for those in nursing leadership positions because of the competition with other organizations to fill positions. Too often public health organizations are struggling to fill nursing vacancies before the funding for the position evaporates. Lack of adequate funding resources also affects the nurse who has gained public health knowledge through on-the-job experience, has moved to a nursing supervisory or management position, and might well be ready for a broader public health program leadership position. Lacking a formal educational credential, these nurses find themselves blocked from advancement. Because many nurses are place-bound by family obligations, they will not be able to move forward until either nursing or public health graduate education is more readily available. Continuing Role for Schools of Nursing The roles for nurses in public health practice in public health agencies, community-based practices, and elsewhere is such that the long-standing identification of the baccalaureate degree as the entry to public health practice is likely to remain the standard, even though it is often honored in the breach. Undergraduate schools of nursing will continue to be a major source of entry-level public health workers. The committee recommends that these undergraduate schools be encouraged to assure that curricula are designed to develop an understanding of the ecological model of health and core competencies in population-focused practice. Because of the ongoing debate about preparation of the associate degree graduates in community skills, the public health community should offer assistance in identifying the appropriate level and type of position for these graduates as well. In support of sound baccalaureate-level preparation in public health nursing, the public health community should be attentive to the need for student clinical experience, should collaborate in making appropriate sites available, and should consider ways to assure that nursing education does not occur in a vacuum apart from the full range of professionals practicing in public health. One approach to collaboration would be development, by schools of public health, of “liftable” public health curricular modules that could be shared with other institutions as they develop courses aimed at providing education in public health. The graduate-level role for schools of nursing is not so clear. The inclusion of public health perspectives and skills in clinical programs in a range of specialties as advocated by NONPF supports the appropriate

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century orientation of clinicians to their roles in collaboration with public health. With the exception of employment as clinicians in specific program areas, however, these are not the nurses to which public health will be looking for leadership. Schools of nursing that offer master’s degree programs in public health nursing should be encouraged to partner with schools of public health to assure that current thinking about public health is integrated into the nursing curricula content, and to facilitate development of interdisciplinary skills and capacities. Programs offering joint degrees in nursing and public health that bring the two schools together formally offer a viable and effective option for advancing public health nursing practice. OTHER SCHOOLS An ecological theory of health suggests that health emerges from the day-to-day interactions between people and their environment. A population’s health reflects how it does business, what it does in its spare time, how it is housed, the organization of its cities, its way of solving problems, and its distribution of wealth and status (Link and Phelan, 1995; Marmot, 2000). In this view, health issues arise everywhere that people make and implement decisions about how to organize and carry on daily life. Health is a consequence (and too often an unrecognized consequence) of the activities and decisions of a wide range of social actors for whom health is not mentioned in their job descriptions. Both as citizens in a democracy and as participants in the creation of the conditions of social life, the responsibility for health rests upon each of us. Public health is, by most prevailing definitions, a collective enterprise. It is what we do together as a society to attain the conditions in which we achieve the widest distribution of the highest level of health we can manage (Gostin et al., 1999; IOM, 1988). Yet, as has been repeatedly observed, securing public support for public health work can be difficult (IOM, 1988); indeed, public health issues often seem “invisible” in policy debates (Burris, 1997). Americans often see matters of health in individualistic, medical terms. Yet as Geoffrey Rose long ago made clear, many important questions of health must be asked and answered in terms of population-level causes and effects (Rose, 1985). Given the centrality of health in all of our lives, and the complexity of organizing collectively in a democracy to achieve it, there is a strong case to be made that curricula at all levels should include more training on health and human ecology. “Health literacy” can and should be a goal of our educational system as a whole (St. Leger, 2001). More specifically, the committee believes that the diffusion of health issues and responsibilities in society creates a need for health training in a range of jobs without health in the title. The enterprise of public health

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century cannot succeed as a niche speciality. Creating the conditions in which Americans can be healthy requires the informed collaboration of planners, executives, and lawyers. Indeed, there are many professions whose practitioners play an important role in health, and whose trainees are appropriate candidates for health training. Law plays essential roles in public health. As a tool for regulation, it provides incentives for healthy behavior and deters insalubrious activities (Gostin, 2000). It structures and limits public health activities (Burris, 1994; Gostin et al., 1999). Laws and regulations provide public health with various powers under certain conditions, ranging from the authority to quarantine individuals through civil and criminal enforcement when necessary to protec the health of citizens. More fundamentally, an ecological view of health reveals the role of law in structuring social determinants of health, in mediating their effects, and as a tool of “structural intervention” at the level of policy (Blankenship, 2000; Burris et al., 2002). Public health is marginal or entirely missing as a component of the curriculum at most of the country’s nearly 200 law schools (Goodman et al., 2002). Without training in public health, it is not surprising that lawyers in practice—as advocates, legislators, executives, and judges—have difficulties unraveling complex health issues. As Parmet and Robbins observe, “thinking like a lawyer” does not currently include adopting a public health perspective. Cases are brought, decisions are made, and statutes are drafted with a profound effect upon the public health, yet with little appreciation of what that means. Thus, the U.S. Supreme Court in Bragdon v. Abbott seemed confused about what it means for the Centers for Disease Control and Prevention to be unable to prove that seven dental workers who were HIV-positive had not been exposed at work. The dissent went further, suggesting that risks can be assessed without considering denominators. Likewise, the Supreme Court rejected state regulation of tobacco marketing, failing in a fundamental way to comprehend that public health is not a matter of individual choice (Parmet and Robbins, 2002). Renewed appreciation of the importance of socio-economic factors in public health points to business as a neglected but crucial actor in public health (Woodward and Kawachi, 2000). From the availability of HIV/ AIDS drugs (James, 1998) to the prevalence of fast-food outlets (Nestle and Jacobson, 2000), the conditions of health reflect decisions by national and international concerns. Business decision-makers, moreover, are community leaders. Their partnership is recognized as essential in developing and implementing collective health strategies (Williams et al., 1991; Sumartojo, 2000). Setting aside the question of regulation, the importance of business to health suggests the value of training future business leaders about the health consequences of their decisions. Like other activities, business can be informed by ethical considerations (Danis and Sepinwall,

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century 2002), which, in turn, depend upon a grasp of the underlying facts about how economic factors influence health. However, the practice of public health can benefit from better understanding and use of business management techniques (Guarino, 1997). Urban planning—including zoning, design, sanitary regulations and construction standards—was one of the most pressing preoccupations of 19th century public health (Duffy, 1990; Novak, 1996). During the 20th century, the health aspects of planning grew less pressing, and the focus of the profession turned elsewhere. While the proposition that planning matters to health would not be disputed in the urban planning profession, health concerns remain on the periphery of training and practice. Yet as new research continues to show, the physical environment matters to health (Cohen et al., 2000), and planning can be a tool of intervention—or a means through which social inequalities produce health inequalities (Bullard and Johnson, 2000; Maantay, 2001). The committee believes that public health is an essential part of the training of citizens, and that it is immediately pertinent to a number of professions. Specialized interdisciplinary training programs, such as those offering joint J.D. and M.P.H. degrees or joint M.P.H. and M.U.P. (masters of urban planning) degrees can create specialists and are important. Our view, however, is that more is needed. Public health literacy, entailing a recognition and basic understanding of how health is shaped by the social and physical environment, is an appropriate and worthy social goal. Further, education directed at improving health literacy at the undergraduate level could also serve to introduce persons to possible careers in public health. The committee recommends that all undergraduates should have access to education in public health. It is beyond both our charge and our capacity to make specific recommendations about how to incorporate health into diverse curricula. Doubtless the usual challenges to curricular change will arise—faculty flexibility, scarce resources of time, and student interest. The committee does, however, stress the importance and recommend the integration of a more accurate and ecologically oriented view of health into primary, secondary, and post-secondary education in the United States. This chapter has emphasized the importance of public health education in graduate programs of public health and in other schools and institutions of learning. The following chapter examines the role of local, state, and federal agencies in educating public health professionals.