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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century 1 Introduction The 20th century saw great achievements in public health. Vaccines and improvements in sanitation and hygiene led to reductions in mortality and morbidity associated with infectious disease. Food safety and workplace safety improved, flouridation led to improved oral health, and the decrease in motor vehicle deaths represented “the successful public health response to a great technologic advance of the 20th century” (Turnock, 2001). Indeed, the health of the U.S. population has improved dramatically during the 20th century because of public health efforts. And, without a certain level of health, people find it difficult to participate in many aspects of life, including family and community life, gainful employment, and participation in the political process. As we move into the 21st century it is important not only to celebrate the achievements of the past 100 years but also to identify and engage the new challenges to health, challenges that include globalization, scientific and technological advances, and demographic changes. One of our most pressing tasks is to prepare public health professionals to meet these challenges. Public health has the potential to continue to improve health during the coming century, but the extent to which we are successful depends in large part upon the quality and preparedness of our workforce. As Gebbie (1999) states, “[A]t the heart of all successful public health activities—in government agencies as well as in the private and voluntary sectors—are the public health workers.” To better understand what is needed to prepare public health professionals for the 21st century, the Robert Wood Johnson Foundation (RWJ) commissioned the Institute of Medicine (IOM) to
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century assess the past and current state of education and training (theory) for public health professionals and contrast it to future practice needs envisioned by the companion IOM study conducted by the Committee on Assuring the Health of the Public in the 21st Century. The committee’s findings will be used to develop a framework for how, over the next five to ten years, education, training, and research in schools of public health can be strengthened to meet the needs of future public health professionals to improve population-level health. The charge further specified that the committee should deliberate the following questions: What is the current status of training, curricula, and research efforts at accredited schools of public health? How has public health education evolved over time? What progress has been made in responding to the recommendations of the 1988 IOM report, The Future of Public Health? What does a systematic review of the capabilities of schools of public health reveal about their capacity to educate and train public health professionals who will meet future needs for assuring population health? Are the broad research agendas of schools of public health consistent with future needs to assure the health of the public? What role can national institutions and resources play in supporting well-trained public health professionals? What recommendations can be made to improve public health education, training, research, and leadership? In response, the IOM convened the Committee on Educating Public Health Professionals for the 21st Century. The committee is composed of experts in public health practice, academic public health, public health law, general graduate and continuing education, medical education, health professions training, public policy, social and behavioral sciences, occupational and environmental health, population-based and evaluation research, genomics, informatics, and communication. During the course of this one-year study the committee held five meetings (four included public information-gathering sessions); reviewed and analyzed key literature; and abstracted, analyzed, and synthesized data from catalogs and web sites of the accredited schools of public health (Appendix A). The committee also surveyed schools of public health (Appendix B) asking about progress made since publication of The Future of Public Health (IOM, 1988), and obtained written input from major public health organizations (Appendix C). This report presents the committee’s findings and recommendations for educating public health professionals for the 21st century. The following sections of Chapter 1 define the term “public health professional,”
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century discuss a general framework describing what public health professionals need to know and be able to accomplish, and explore how this framework guides responses to emerging public health challenges. PUBLIC HEALTH PROFESSIONALS Who are public health professionals? No single degree or certification characterizes this group. Public health has been defined in various ways. For example, Modeste (1996) defines it as the science and art of preventing disease, prolonging life, and promoting health and efficiency through organized community effort for the sanitation of the environment, control of communicable infections, education in personal hygiene, organization of medical and nursing services, and the development of the social machinery to ensure everyone a standard of living, adequate for the maintenance of health. The Future of Public Health (IOM, 1988) defined the mission of public health as “fulfilling society’s interest in assuring conditions in which people can be healthy.” Turnock (2001), elaborating on this description, identified the activities of public health as including “organized community efforts to prevent, identify, and counter threats to the health of the public.” According to the Association of Schools of Public Health (ASPH, 1999), public health encompasses a population-focused, organized effort to help individuals, groups, and communities reduce health risks, and maintain or improve health status. Each of these definitions has in common the understanding that public health focuses on the health of populations, that is on population-level health which addresses issues pertaining to the health of large numbers of people, involves a definable population, and operates at the level of the whole person. Therefore, a public health professional focuses on population-level health. But which professional categories are included? Must a person have a degree in public health to be viewed as a public health professional? People who work as professionals in public health have received education and training in a wide range of disciplines including medicine, nursing, dentistry, social work, allied health professions, pharmacy, law, public administration, veterinary medicine, engineering, environmental sciences, biology, microbiology, and journalism. Few of these professionals have a specific public health degree. A definition that requires a public health degree would, therefore, exclude a large number of individuals who are key to improving the health of the public. Well then, what about identifying the specific professions that engage in public health activities? As noted above, professionals who work in public health come from diverse disciplines, for example, medicine, nurs-
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century ing, dentistry, social work. They receive their education and training in many different academic settings. However, most professionals so educated do not work in public health, they work in a wide variety of settings. Therefore, it is not possible to define a public health professional solely on the basis of degree or training received. What about using the organizational setting in which work is performed to identify those who are public health professionals? This criterion would include people who work for the local, state, and federal official public health agencies. Do we also include voluntary organizations? Some voluntary organizations contribute significantly to the public’s health, for example, the March of Dimes and Mothers Against Drunk Driving. Other voluntary organizations do not. There are also health care delivery organizations such as hospitals and clinics to consider. Some of their work clearly involves public health activities such as providing immunizations and mounting stop-smoking campaigns. However, the primary function of health care delivery organizations is to provide medical care to individuals rather than providing programs oriented to population-level health. Organizational setting, therefore, cannot be used to define a public health professional. After much deliberation, the committee arrived at a definition that combines the various elements discussed above; 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. Nearly all public health professionals encompassed by this definition would have earned at least a baccalaureate degree. These public health professionals contribute to improving the health of the public in numerous ways. They develop and implement programs designed to prevent the spread of infectious diseases (e.g., AIDS and tuberculosis). They conduct research aimed at determining effectiveness of health intervention programs and at translating the results of other research (e.g., basic research) to solve real-world health problems. Public health professionals work with policy makers to translate science into practical policies. They work with communities to address the wide range of community-identified public health problems. Public health professionals also are critical to assuring that the public health system is prepared to respond to immediate challenges and threats such as those faced following the terrorist attacks of September 11, 2001. To function most effectively, public health professionals must be well educated and trained. They must have a framework for action and an understanding of the ways in which their activities affect the health of individuals and populations, and of the multiple determinants of health. The following section provides and explores such a framework.
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century DETERMINANTS OF HEALTH Why are some people healthy and others not? It seems a simple question. The answers, however, are complex and have to do not only with disease and illness, but also with who we are, where we live and work, and the social and economic policies of our government, all of which play a role in determining our health. To understand how to improve health, we first must understand the determinants of health and how they interact. Our views of health, what it is and how to measure it, have evolved over time. Until about the mid-20th century, health was measured with negative indicators, that is, in terms of mortality and disease rates. Populations with lower mortality rates were considered healthier than populations with higher mortality rates. We continue to use mortality or disease rates as broad indicators of health in a society, for example, by comparing populations according to their infant mortality rates, or their rates of heart disease, tuberculosis, or HIV/AIDS. In the 1950s, however, efforts to redefine health were initiated. The World Health Organization (WHO) put forth a new view of health as “a state of complete physical, mental, and social well being, and not merely the absence of disease or infirmity” (WHO, 1948). The WHO definition required a much broader view of health, and concomitantly, an evolution of thinking about the determinants of health. Lalonde (1974), in a Canadian white paper, presented a framework for health that included environment, lifestyle, human biology, medical care, and health care organization as major determinants of health. The concepts and ideas presented in this white paper encouraged analysis and exploration of the importance of individual risk factors to health. Evans and Stoddart (1994) developed a more complex model. They argued that a framework for determinants of health must provide for distinctions among disease, health, functioning, and well being. Further, such a framework should consider both behavioral and biological responses to social and physical environments. A 1999 IOM report proposed a model of determinants that illustrated how individual characteristics and environmental characteristics influence health-related quality of life (symptoms, functional status, health perceptions, and opportunity). Individual characteristics were identified as biology, life course, life-style and health behavior, illness behavior, and personality and motivation; environmental characteristics were characterized as social and cultural influences, economic and political factors, physical and geographic factors, and health and social care (IOM, 1999). Kaplan and colleagues (2000) proposed a multilevel approach to health determinants that included pathophysiological pathways, genetic/ constitutional factors, individual risk factors, social relationships, living
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century conditions, neighborhoods and communities, institutions, and social and economic policies as the major forces having an impact on health. They argued for an approach that builds bridges between levels, rather than emphasizing one level of determinants over another. There are numerous models that display the contextual, layered understanding of both individual and population health (Dahlgren and Whitehead, 1991; Kaplan et al., 2000). The committee finds it most useful for present purposes to embrace the concept proffered by Kaplan and colleagues, Grzywacz and Fuqua (2000), and others; that is, there are multiple determinants of health that are related and linked in many ways. A model of health that emphasizes the linkages and relationships among multiple factors (or determinants) affecting health is an ecological model. An example of the ecological model can be found in Figure 1-1. It is important to note that the committee is not recommending any single model, but rather emphasizing the concept that there are linkages and relationships among the multiple determinants of health. An ecological model assumes that health and well being are affected by interaction among multiple determinants including biology, behavior, and the environment. Interaction unfolds over the life course of individuals, families, and communities, and evidence is emerging that societal-level factors are critical to understanding and improving the health of the public (IOM, 2000). For example, epidemiologic evidence demonstrates that social support improves the prognosis and survival of people with serious cardiovascular disease; social engagement and networks slow the rate of cognitive decline in aging men and women; and more socially integrated societies appear to have better overall quality of life and lower rates of mortality from all causes (IOM, 2002). Other research demonstrates that public health outcomes are associated with neighborhood cohesiveness, stability and trust, and evidence supports the view that major variations in health among countries is a result of environmental, economic, and social and behavioral factors (IOM, 1997; Beaglehole and Bonita, 1998; Kickbusch and Buse, 2001). While an ecological model addresses the interactions and linkages among determinants of health, an ecological view of health is a perspective that involves knowledge of the ecological model of determinants of health and an attempt to understand a specific problem or situation in terms of that model. For example, thinking about automobile fatalities from an ecological view would include thinking about automobile design, road design, age for licensing of drivers, use of drugs (prescription and otherwise) while driving, blood alcohol levels, enforcement strategies and traffic safety education. An ecological approach to health is one in which multiple strategies are developed to impact determinants of health relevant to the desired health outcomes. For example, an ecological approach to the reduction of tobacco use would include alteration in physi-
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century SOURCE: The Future of the Public's Health (IOM 2003). NOTES: Adapted from Dahlgren and Whitehead, 1991. The dashed lines between levels of the model denote interaction effects between and among the various levels of health determinants (Worthman, 1999). a Social conditions include, but are not limited to: economic inequality, urbanization, mobility, cultural values, attitudes and policies related to discrimination and intolerance on the basis of race, gender, and other differences. b Other conditions at the national level might include major sociopolitical shifts, such as recession, war, and governmental collapse. c The built environment includes transportation, water and sanitation, housing, and other dimensions of urban planning. FIGURE 1-1 A guide to thinking about the determinants of population health. cal environment (smoke-free workplaces and public places), alteration in social environment (social marketing of tobacco prevention as a priority), and individual behavior change (smoking cessation classes). The committee believes that understanding the ecological model of determinants of health is necessary to develop, implement, and evaluate the effectiveness of interventions designed to improve health. As McMichael and Beaglehole (2000) state,
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century Public-health researchers and practitioners, and those in the political and public realms with whom they interact, must take a broad view of the determinants and, indeed, the sustainability of population health. This is an ecological view of health; an awareness that shifts in the ecology of human living, in relation to both the natural and social environments, account for much of the ebb and flow of diseases over time. Public health professionals must be aware of not only the biological risk factors affecting health; they must also understand the environmental, social, and behavioral contexts within which individuals and populations operate in order to identify factors that may hinder or promote the success of their interventions. They must be aware of the multiple factors that influence health and how those factors interact in order to evaluate the effectiveness of their interventions. They must understand the theoretical underpinnings of the ecological model in order to develop research that further explicates the pathways and interrelationships of the multiple determinants of health. With such knowledge, well-educated public health professionals will be able to design better interventions and contribute to improving the health of the public. They will also be able to more effectively address the challenges of the 21st century. The following section explores major challenges to which public health professionals will need to respond in the coming century. CHALLENGES Globalization Globalization has been defined as “the process of increasing economic, political, and social interdependence and global integration that takes place as capital, traded goods, persons, concepts, images, and values diffuse across state boundaries” (Yach and Bettcher, 1998). According to McMichael and Beaglehole (2000) globalization is “a mixed blessing for health.” Increased travel, trade, economic growth, and diffusion of technology have been accompanied by negative social and environmental conditions, a greater disparity between rich and poor, environmental degradation, and food security issues. Additionally, there is cause for concern about drug resistant strains of emerging and re-emerging diseases (e.g., HIV/AIDS, tuberculosis, hepatitis B, malaria, cholera, diptheria, and Ebola). The health of the U.S. population is increasingly affected by globalization and its accompanying environmental changes. Throughout history the movement of people and goods has impacted the health of populations. Plague was spread via trade routes, measles and smallpox traveled from Europe to America with explorers while in return the Europeans received syphilis, and the slave trade fostered the spread of hookworm and leprosy (Lee, 1999). Never before, however, has the world experi
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century enced the level of interaction that exists today. War, famine, and drought have created vast numbers of refugees; since 1990, more than 48 million people have either become refugees or been displaced within their own countries (IOM, 1997). Travel between countries has also increased. In 1996 there were more than 400 million U.S. border crossings (Barks-Ruggles, 2001). These major movements of people, coupled with the re-emergence of major infectious diseases, make it increasingly clear that the U.S. population is not immune to the threat of these emerging and re-emerging infections around the world. As the subtitle of a Barks-Ruggles (2001) article asks, “When Congo sneezes, will California get a cold?” In addition to the movement of people, there has been a tremendous increase in the exchange of products and food, some of which is contaminated. Kickbusch and Buse (2001) reported on a cholera outbreak in Latin America that was traced to contaminated water from the ballast tanks of a Chinese trade vessel. The water, dumped in Peruvian waters, was contaminated with Vibrio Cholerae which infected the local seafood. Within weeks there were reports of a cholera outbreak in Peru and by the end of the epidemic almost 10,000 people across Latin America had died. As this example illustrates, diseases can be carried, not only by humans, but also by other mediums including water, plants, animals, food, and soil. In 1998 422,000 cargo-bearing aircraft underwent inspection after landing in the United States (Barks-Ruggles, 2001). Along with the transmission of microbes and viruses, the increase in international trade is fostering the distribution of products associated with major health risks, for example, alcohol and tobacco. It is estimated that the fourth major cause of disability worldwide is alcohol. By 2025 annual tobacco-related deaths are expected to be about 10 million and the majority of these deaths will be in developing regions (IOM, 1997). Public health professionals have a major role to play in addressing the health effects of globalization, but to do so effectively they must have sufficient knowledge and understanding to intervene in a manner that will produce improved health outcomes. This requires an understanding of the ecological model of health and of the linkages and interactions among the determinants of health. With such knowledge public health professionals will be able to develop programs and policies that maximize health outcomes in the complex environment of globalization. Scientific and Medical Technology Advances in science and medical technology have made major contributions to improved health. During the 20th century antibiotics and vaccines, along with improved sanitation and hygiene, led to a dramatic reduction in deaths from pneumonia, tuberculosis (TB), diarrhea and enteritis, smallpox, poliomyelitis, typhoid, cholera, and rabies. Today, how
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century ever, misuse of antibiotics has resulted in emergence of drug-resistant bacteria. According to Turnock (2001): the emergence of drug-resistant strains has reduced the effectiveness of treatment for several common infections, including tuberculosis, gonorrhea, pneumococcal infections, and hospital-acquired staphylococcal and enterococcal infections. During the last decade of the 20th century, major scientific and technological advances were made in human genetics. The Human Genome Project officially began in 1990 (Collins, 1999). By the fall of 1998, technological improvements and rapid progress led project leaders to promise the complete DNA sequence of the human genome by 2003 (Fink and Collins, 2000). Current achievements include identifying more than 10,000 genes and developing, for use in medical practice, more than 600 tests that will identify gene variants associated with diseases (Khoury et al., 2000). Further advances in genomics may identify the cause of many diseases, thereby allowing us to better understand how to prevent those diseases and promote health. Collins and McKusick (2001) predict that by 2020, gene-based “designer drugs” will be marketed for many conditions. These major advances are accompanied by important ethical, legal and social questions. For example, if advances in genetics allow us to identify genes that are responsible for particular diseases, how will we ensure that individuals with those genetic traits are not discriminated against in the workplace or when trying to obtain insurance? Clayton (2000) writes: legislators to date have said almost nothing about how and when tests for mutations that predispose individuals to develop diseases that become symptomatic only after infancy should be incorporated into clinical and public health practice. They have, however, become quite concerned that information about genetic risk factors will be used to interfere with individuals’ access to employment and health insurance. Burris and colleagues (2000), writing about public health surveillance of genetic information, state that to be ethical, these surveillance data must be protected, and promote the health of the population, and their collection must be acceptable to the population. Suggested safeguards include: informed consent, protection of individual autonomy, confidentiality of testing results, limitation of workplace and insurance company testing, and education of both health practitioners and the general public (Khoury et al., 1999). Ensuring that the benefits of advances in genetics are shared globally is a major challenge. Pang (2002) writes that, “the relatively rich product pipeline of genomics-based drugs will mean a tremendous increase in the
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century demand for clinical trial sites, many of which will be in the developing countries.” This raises ethical questions relating to informed consent, standard of care, and continuing availability of the drug being tested after completion of the trial. Communication and information technologies are other areas in which major advances have occurred. Growing numbers of people have access to the Internet, providing for rapid exchange of information. Such exchange has the potential to improve population health, for example, through the spread of accurate health information. However, there is also the potential for dissemination of misleading or incorrect health information that would have a negative impact on the public’s health. When used properly, however information technology provides tools that facilitate linking of information about the health of the public with data specific to the care of an individual patient as well as provides clinicians and patients with access to the knowledge that they need to ensure optimum health outcomes (Brennan and Friede, 2001). Further, public health informatics (i.e., the systematic application of information, computer science, and technology to public health practice, research, and learning [Yasnoff et al., 2000]) provides an opportunity for the automation of common tasks (such as real time physician alerts on emerging disease trends detected by surveillance systems) and for improved communication among the many components of the health care and public health systems. One of the challenges of these new communication and information technologies relates to the confidentiality and security of the systems. As stated by Yasnoff et al. (2000), “[I]nformation systems are correctly perceived by the public to be a double-edged sword.” As with advances in genetics, a balance needs to be achieved between individual privacy and the public good. While scientific advances in the biomedical field have greatly improved the health of the public, McGinnis and Foege (1993) report that about half of all causes of mortality in the United States are linked to social and behavioral factors and accidents. For example, the leading cause of mortality in early to middle adulthood is unintentional injuries, the majority of which are due to motor vehicle accidents; the links between modifiable risk factors (e.g., obesity, hypertension, diet, smoking, and sun exposure) and heart disease, stroke, and cancer have been well demonstrated (Emmons, 2000). Several studies have shown the relationship between unintentional injuries and certain risk factors, for example, accessibility to firearms, use of alcohol and tobacco, and use of seat belts (Turnock, 2001). Other research has shown the influence of psychological risk factors on disease; for example the management of diabetes is influenced by coping skills
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century and family stresses; other research demonstrates that acute stress may trigger myocardial ischemia (IOM, 2001a). Despite the many achievements of research, much remains to be accomplished. The vast majority of the nation’s health research resources have been directed toward biomedical research endeavors that cannot, by themselves, address the most significant challenges to improving the public’s health; comparatively few resources have been devoted to supporting health research on social and behavioral determinants of health (IOM, 2000). Scrimshaw et al. (2001) point out that only 1 percent to 2 percent of the U.S. health care budget is spent on prevention and that a like imbalance exists between funding for basic biomedical research and population-based prevention research. Without also addressing the social and behavioral determinants of health we are missing some of the most significant opportunities for improving the public’s health. Demographic Transformations Major demographic changes are taking place in the United States. The median age of the U.S. population is now 35.3 years, the highest level ever recorded. By 2030 it is estimated that about 20 percent of the population (or 69 million people) will be over age 65, compared with 13 percent today, and the most rapidly growing group of older persons is aged 85 and older (Day, 1996). Population aging has been accompanied by longer lifetime exposure to potential toxic agents (e.g., tobacco and high fat food), lack of exercise that can lead to osteoporosis, sarcopenia (muscle thinning), and inadequate cardiac conditioning (Butler, 1997). The elderly tend to suffer from multiple chronic diseases, geriatric conditions, and mental health conditions such as depression and cognitive decline (Blazer, 2000). A major challenge before us is to better understand how to prevent, delay or mitigate the effects of these diseases, thereby increasing the chances for healthful, functional aging. As Koplan and Fleming (2000) put it “[I]n addition to achieving a longer lifespan for the rapidly growing aging population, increasing their healthspan must be a priority.” Another major demographic change occurring in the United States is increasing racial and ethnic diversity. White non-Hispanic people make up about 73 percent of the U.S. population but by the year 2020 the U.S. Census Bureau projects that the proportion will drop to around 64 percent because minority ethnic and racial populations are growing at a faster rate (Day, 1996). By 2050 it is expected that the Hispanic population will reach 81 million, the African American population will reach 62 million, and the Asian and Pacific Islander group will reach 41 million (Brownson and Kreuter, 1997). Cultural diversity enriches the United States, but it also presents ma-
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century jor challenges. Large racial and ethnic health disparities exist and are reflected in increased rates among minorities of heart disease, cancer, accidents, diabetes, HIV infections, chronic liver disease and cirrhosis, chronic nephritis, and homicide (Turnock, 2001). Access to health care and treatment is uneven: Twenty percent of African Americans and 30 percent of Hispanics lack a usual source of health care compared with less than 16 percent of whites; and minorities are less likely to receive medical treatments such as bypass surgery, mammogram and follow-up diagnostic testing for breast cancer, antiretroviral therapy for HIV infection, and routine medication to prevent asthma-related hospitalizations (U.S. DHHS, 2002a). Improvements in health have yet to be felt equally by all populations in U.S. society. Improving health outcomes for all components of American society, closing the gaps in access to health care, and assuring equality in quality of care are major challenges for the 21st century. SUMMARY The effects of globalization, scientific and technological advances, and demographic changes are profound. Yet the extent to which these effects are salutary or detrimental to the public’s health depends on our responses to many changing variables. Responses that advance the health of the people of the United States and of the world depend on many factors that are beyond the purview of this report. However, public health professionals can be a formidable force for the development of positive outcomes. The committee believes that well-educated public health professionals have an ecological view of the determinants of health. These professionals will help shape programs and policies that address the myriad health issues associated with globalization. They will be able to design and conduct research that contributes to a better understanding of the social and behavioral determinants of health, to develop culturally sensitive programs aimed at reducing racial and ethnic disparities in health, and to contribute to the debate on the ethical use and dissemination of new technologies. The beginning of the 21st century brings new public health opportunities and challenges. This first chapter has defined public health professionals, discussed an ecological view of health and its determinants, and described challenges that face public health as we move into the 21st century. Chapter 2 reviews the history and current status of public health education in the United States. In Chapter 3 the future of public health
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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century education is explored. Chapter 4 describes the role of schools of public health in that future. The contributions to public health education of other schools and programs are described in Chapter 5, while Chapter 6 addresses the role of public health agencies in educating public health professionals. Chapter 7 is the conclusion to this report.
Representative terms from entire chapter: