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The Future of Public Health Education

Public health in the United States in the early 1900s focused on improving sanitation, controlling infectious diseases, assuring the safety of the food and water supply, and providing immunizations to children with a workforce composed mostly of physicians, nurses, and biological scientists (Brandt and Gardner, 2000; Garrett, 2000; Mullan, 2000). Today’s public health challenges are much broader. Healthy People 2010 lays out a broad agenda for public health efforts aimed at increasing health-related quality of life and eliminating health disparities (U.S. DHHS, 2000). Koplan and Fleming (2000) outline 10 challenges for public health that include cleaning up the environment, eliminating health disparities, wisely using new scientific knowledge and technology, attending to children’s physical and emotional development, and aging healthily. Numerous authors have highlighted the importance of public health in addressing the effects of globalization (Lee, 2000; McMichael and Beaglehole, 2000; Barks-Ruggles, 2001; Kickbusch and Buse, 2001) and the impacts of an aging and increasingly diverse society (Brownson and Kreuter, 1997; Butler, 1997; Koplan and Fleming, 2000; Turnock, 2001).

These complex problems require multi-faceted public health actions based on an ecological approach to problem solving. Such an approach requires a well-educated interdisciplinary cadre of public health professionals who focus on population health and understand the multiple determinants that affect health. A cadre of professionals who also understand that successful interventions require understanding not only of the effects of biology and behavior, but also the social, environmental, and economic contexts within which populations exist. A cadre of profession-



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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century 3 The Future of Public Health Education Public health in the United States in the early 1900s focused on improving sanitation, controlling infectious diseases, assuring the safety of the food and water supply, and providing immunizations to children with a workforce composed mostly of physicians, nurses, and biological scientists (Brandt and Gardner, 2000; Garrett, 2000; Mullan, 2000). Today’s public health challenges are much broader. Healthy People 2010 lays out a broad agenda for public health efforts aimed at increasing health-related quality of life and eliminating health disparities (U.S. DHHS, 2000). Koplan and Fleming (2000) outline 10 challenges for public health that include cleaning up the environment, eliminating health disparities, wisely using new scientific knowledge and technology, attending to children’s physical and emotional development, and aging healthily. Numerous authors have highlighted the importance of public health in addressing the effects of globalization (Lee, 2000; McMichael and Beaglehole, 2000; Barks-Ruggles, 2001; Kickbusch and Buse, 2001) and the impacts of an aging and increasingly diverse society (Brownson and Kreuter, 1997; Butler, 1997; Koplan and Fleming, 2000; Turnock, 2001). These complex problems require multi-faceted public health actions based on an ecological approach to problem solving. Such an approach requires a well-educated interdisciplinary cadre of public health professionals who focus on population health and understand the multiple determinants that affect health. A cadre of professionals who also understand that successful interventions require understanding not only of the effects of biology and behavior, but also the social, environmental, and economic contexts within which populations exist. A cadre of profession-

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century als who understand that public health research must focus not only on secondary prevention and risk factor analysis, but also on evaluation of public health systems, on practice approaches and interventions, and on effective collaborations and partnerships with diverse communities. Public health professionals of the future will need to understand and be able to use the new information systems that provide the data upon which public health research and practice is based. They will need to be able to communicate with diverse populations, to understand the issues, concerns, and needs of these groups in order to work collaboratively to improve population health. Public health professionals must have the skills and competencies necessary to engage in public health practice at many levels: leadership, management, and supervisory. The committee reaffirms the importance of the traditional core public health areas of epidemiology, biostatistics, environmental health, health services administration, and social and behavioral sciences. However, the committee believes that public health professionals will be better prepared to address the major health problems and challenges facing society if they achieve competency in the following eight content areas: informatics, genomics, communication, cultural competence, community-based participatory research, global health, policy and law, and public health ethics. These eight areas are now and will continue to be significant to public health and public health education in programs and schools of public health for some time to come. These areas are natural outgrowths of the traditional core public health sciences as they have evolved in response to ongoing social, economic, technological, and demographic changes. For example, community-based participatory research (CBPR) is a contemporary approach to research that has its roots in the public health sciences of epidemiology and biostatistics, enriched by emerging community knowledge from the social and behavioral sciences. The following sections of this chapter provide an in-depth examination of these eight areas of critical importance to public health education in the 21st century. Competency in each of these areas will enable public health professionals to better function within the ecological model (discussed in Chapter 1), thereby contributing effectively to programs, policies, and research designed to improve the health of the public. For each of these areas we provide a brief definition and description, explore why each is important to public health, examine the minimum level of knowledge or understanding public health professionals should have about each area, and highlight potential ethical issues. INFORMATICS Capacity to perform the public health functions specified in The Future of Public Health (IOM, 1988), namely, assessment, policy development

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century and assurance, is principally dependent upon information. For example, assessment involves the collection, analysis, interpretation, and communication of information. Currently, this information comes from a wide variety of sources with attendant problems of fragmentation, lack of standardization, and redundancy. Policy development also is dependent upon current and reliable information and the ability to manipulate and display this information so that it is meaningful to those who make decisions about public health. Assurance requires information about access to health care services based upon community needs, which is monitored with community-level data. With increasing accessibility to more and more data, public health practitioners and researchers will find that a basic understanding of informatics, the use of informatics tools, and interaction with informaticians are essential to carrying out these functions. Public health informatics is defined as the systematic application of information, computer science, and technology to public health practice and learning (Yasnoff et al., 2000). Its scope includes the conceptualization, design, development, deployment, refinement, maintenance, and evaluation of communication, surveillance, and information systems relevant to public health. Public health informatics involves more than automating existing activities; it enables the redesign of systems using approaches that were previously impractical or not even contemplated. Public health informatics has immense potential not only to improve current public health practice, but to transform present-day capacity. The September 11, 2001, terrorist attack on the World Trade Center in New York City and the following anthrax distribution and deaths dramatically exemplifies the need for transformation and improvement. Of crucial importance is the collection of real time data on the occurrence of suspicious respiratory syndromes (e.g., possible early anthrax, plague, smallpox, or tularemia) to generate a more rapid and effective public health response (Rotz et al., 2000). For early response to bioterrorism, new data sources, such as emergency room, over-the-counter pharmacy data, absentee or 911 call data may supply potentially essential information. This type of surveillance will require an integrated approach, standardization, closer integration of public health and the health care system, and the timely capture of data. Improved surveillance systems are likely to tax the public health system’s capacity to process the growing quantity of health data required for public health improvement. Progressively, state and local governments are collecting and disseminating health status data at greater levels of detail, the number of reportable diseases is enlarging, and new developments in electronic laboratory reporting systems and electronic medical record systems will also increase the volume of data available to the public health system. Informatics methods and applications, such as decision support and expert systems, modeling and simulation techniques, can

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century help public health face this challenge by providing increased capacity to handle, analyze, and act on data that is likely to increase during the coming years. Health promotion and disease prevention is another aspect of public health that can be dramatically transformed by informatics. Methods and applications ranging from interactive guideline dissemination, preventive care reminders linked to the electronic medical record, computerized health risk assessments, and tailored messages can help health promotion and disease prevention interventions become more effective than ever before. Web-based systems are offering new strategies in health education. Applications can provide decision support for consumers, focusing on personalized goal setting, feedback regarding progress toward goals, and social support. Consumers of health care and patients managing chronic health conditions can make use of electronic portals to share coping strategies, provide emotional support, and exchange information on relevant health Websites. Consumer health informatics has been defined as the field of biomedical informatics that is concerned with this area. Informatics methods and applications are stimulating research and development in the use of information and communication technologies. In the broadest sense, consumer health informatics involves (1) analyzing, formalizing, and modeling consumer preferences and information needs; (2) developing methods to integrate these into information management in health promotion, clinical, educational, and research activities; (3) investigating the effectiveness and efficacy of computerized information, telecommunication, and network systems for consumers in relation to their participation in health and health care related activities; and (4) studying the effects of these systems on public health, the patient-professional relationship, and society. It is both inevitable and desirable that health promotion and disease prevention interventions become more available electronically, empowering consumers with enhanced control over their health. Public health professionals working to ensure the public’s health can help consumers by developing and increasing the availability of health-promoting technology based applications, and by safeguarding the confidentiality and security of the health data to which consumers are likely to be electronically exposed. A critical challenge for public health informatics is to educate the public health workforce in computing and communication technology applicable to public health activities. Some level of informatics training for both new and existing public health workers is essential. Just as every public health professional needs basic knowledge of epidemiology, a basic understanding of public health informatics is critical for effective practice in the information age (Yasnoff et al., 2000). The extent to which

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century information transforms the practice of public health will be determined, in large part, by the willingness of public health leaders to recognize the need for informatics training. Several initiatives have been undertaken recently to promote this recognition. The American Medical Informatics Association (AMIA) 2001 Spring Congress brought together the public health and informatics communities to develop a national agenda for public health informatics (PHI). The consensus of the session devoted to the topic of informatics training for the public health workforce was that the public health workforce urgently needed informatics knowledge and skills that could best be provided by a spectrum of educational programs (Yasnoff et al., 2001). Other, more detailed recommendations were to establish new and strengthen existing academic programs in PHI, develop a national competency-based continuing education program in PHI, adapt the American Association of Medical Colleges (AAMC) medical school informatics objectives to PHI, and support the Centers for Disease Control and Prevention (CDC) and other efforts to develop core competencies in PHI. CDC has established the Public Health Informatics Competencies Working Group to develop core competencies in public health informatics within the broader context of the Global and National Implementation Plan for Public Health Workforce Development with an initial focus on developing informatics competencies for the existing U.S. public health workforce. As of this writing, a document has been drafted identifying competencies for the three workforce segments defined by the Council on Linkages. Competencies are divided into two general classes. The first class includes competencies related to the use of information and computer sciences and technology to increase one’s individual effectiveness as a public health professional. Examples of these competencies include: electronic communication (use of IT tools for the full range of electronic communication appropriate to one’s programmatic area); on-line information access (use of IT tools to identify, locate, access, assess, and appropriately interpret and use on-line public health-related information and data); data and system protection (application of relevant procedures to ensure that confidential information is appropriately protected); distance learning (use of distance-learning technologies to support life-long learning); and strategic use of IT to promote health (use of IT as a strategic tool to promote public health). The second class of competencies is related to the development, deployment, and maintenance of information systems to improve the effectiveness of the public health enterprise.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century CDC also has made initial efforts to develop needed education programs through the public health informatics fellowship, a public health informatics course, and a cooperative effort with the National Library of Medicine to help train public health workers in the effective use of the information resources available on the Internet. Most current public health workers, lacking the knowledge and skills necessary to apply information and science technology, are unable to take advantage of its potential to enhance and facilitate public health activities (Lasker et al., 1995). For general public health practitioners, it may be adequate to have a basic understanding of well-established processes used in information systems development as well as an understanding of the roles public health practitioners should play in those processes. For public health professionals wishing to specialize, a higher-level proficiency in informatics is needed as it relates to project management; organizational behavior and management, information and knowledge development (data standards, security, privacy, and confidentiality); systems development, planning, and procurement; fundamental aspects of IT research, decision-making, and outcomes research. Facilitating advanced public health applications of information technology will require a cadre of public health professionals with advanced informatics training in addition to significant improvements in the basic technology literacy of the general workforce in public health, and ongoing training to continuously update information skills (Lasker et al., 1995). Ideally, public health informatics education would include developing degree and certificate granting programs, and instructional courses for public health agencies and collaborators. Informatics training is becoming increasingly widespread, although training varies by institution, some offering graduate degrees or certificates in informatics, others a course for graduate credit or continuing education. Several graduate programs in public health already offer an informatics course, and a few are offering degrees specializing in informatics. Efforts to provide informatics training through distance education also are increasing. The Association of Schools of Public Health (ASPH) has sponsored conferences on public health informatics and distance learning that focused on how people and technology can work together to positively impact public health practice. The User Liaison Program (ULP) of the Agency for Healthcare Research and Quality (AHRQ) has broadcast a Web-assisted audio teleconference series via the World Wide Web and telephone designed to help state and local policy makers make policy decisions and allocate resources related to health care informatics. Expansion of these and other efforts are important to provide the public health informatics education for the current and future public health workforce. Research efforts are also required to investigate the applicability of information science and technology to public health. Public health infor-

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century matics research is essential to help set priorities for resources and ensure that new ideas are adequately tested prior to implementation. Academic researchers in public health have important roles to perform at the cross-roads between informatics and public health. The focus of public health on prevention, communities, surveillance, and longitudinal analysis introduces unique opportunities for informatics research (Yasnoff et al., 2001). Academic researchers in public health possess the expertise to help guide a research agenda and priorities for allocation of resources that concentrate on unique public health concerns that could have a substantial impact on public health practice. Contributions of this expertise to multidisciplinary research collaborations can increase the chances that this complex research will be successful and relevant to public health. Specific research agenda items suggested at the American Medication Informatics 2001 Spring Congress include assessing informatics tools as they relate to real-time data acquisition; data mining for population data; assessing informatics tools for managing temporal, spatial, or multilevel data; developing methods of measuring the cost of informatics and the benefit that accrues from its use; determining the informatics aspects of a preventive health record for the community; studying the ethical issues needed to guide confidentiality policy; and determining the value and impact of the use of uniform coding and common clinical vocabulary on public health activities (Yasnoff et al., 2001). Uniform coding, the use of existing national standards, and identifying priorities for the development of new data standards are of great importance to public health informatics research. Representation in collaborations such as the Public Health Data Standards Consortium (PHDSC) is yet another significant role for public health academic researchers. Cross-fertilization between government and academia and local and state agencies can stimulate interest and capacity to support new innovations in the use of technology in public health practice. An example initiated by CDC is the national network of Centers for Public Health Preparedness (CPHP) to strengthen bioterrorism and emergency preparedness at the front lines by linking academic expertise and assets to state and local health agency needs. A number of centers are currently providing public health professionals with connections to online resources and the opportunities to learn technology-based skills that can be applied in their work setting. The critical challenge of educating the public health workforce in computing and communication technology applicable to public health activities will require collaborative action involving those working in the field; professional associations; local, state, and federal government agencies; library and information service providers; and programs and schools of public health.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century We live in an information age that is transforming the ways in which we engage in actions to improve health. Public health professionals of the 21st century must learn about public health informatics and understand how this science contributes to the core functions of assessment, policy development, and assurance activities. Public health professionals must be prepared to understand and use these new information technologies to most effectively work to improve the health of the public. Another major area of scientific and technological development is the field of genomics. The following section discusses this important area. GENOMICS We have entered an era in which the genetic factors in common and complex diseases are becoming well understood and in which important new preventive and therapeutic approaches will derive from improved understanding of genetics and genomics. Research in genetics— the study of single genes and their functions and effects—has provided increasingly detailed information about both the basic biology and the phenotypic manifestations of several disorders that are caused by abnormality in the number of chromosomes present (such as Down syndrome, Trisomy 18 and Turner syndrome). Such also has been the case in a somewhat larger number of disorders caused by deletions or additions of fairly large segments of chromosomes (such as “cri-du-chat” syndrome and 22q11 deletion syndrome), and for several thousand conditions caused by mutations in single genes (such as cystic fibrosis, sickle cell disease, Tay-Sachs disease, hereditary hemochromatosis, Marfan syndrome, Prader-Willi syndrome, and hereditary hemorrhagic telangiectasia). Having one of these thousands of disorders often has significant impact on the health, and even life, of an affected individual and, frequently, on other family members. Certain of these “chromosomal” or “single-gene” conditions (such as Down syndrome and hemochromatosis) are relatively common in the general population in the United States, but even they occur in only one of several hundred individuals. Others (such as sickle cell disease among African Americans and Tay-Sachs disease among Ashkenazi Jews), while rare in the general population, are more common in specific population groups. Nonetheless, the overall frequency of chromosomal and single-gene conditions as a group is low in the general population in the United States. Moreover, there have been relatively few effective therapeutic interventions for chromosomal and single-gene conditions. Because of the relative rarity of chromosomal and single-gene conditions and the limited effective therapeutic strategies for them, genetics has not played a significant role in most individuals’ health care, and therefore, genetics has been a relatively minor part of medicine.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century Genetics has traditionally played an even smaller role in public health. Not only has it been relevant to the health of relatively few people, but there have been almost no effective preventive strategies for chromosomal and single-gene conditions. The major exception to this has been newborn screening (prenatal genetic screening has also been widely practiced; however, it differs importantly from newborn screening in that it is used early in pregnancy to detect major chromosomal abnormalities and birth defects). In the almost 40 years since its inception, newborn screening has become an important public health activity in all states of the United States and in many other developed countries. However, genetics has now evolved into genomics, the study of the entire human genome—the approximately 35,000 genes that humans possess. Because genomics encompasses not only the actions of single genes but also the interactions of multiple genes with each other and with the environment, genomics has far wider applicability to health and disease than does genetics alone. With the arrival of the era in which we will have the ability to understand gene-environment interactions comes not only the era of genomic medicine, but of genomics-based public health. Understanding genomics, therefore, is essential for an effective public health workforce. Consider for instance, Table 3-1, which is based upon preliminary figures from the CDC, and shows the 10 leading causes of mortality in the United States in 2000. Genetic factors play a significant causative role in at least 9 of these 10 leading causes of morbidity in the United States—injury is the only possible exception. (However, this may hold true for injuries; since genetic factors often play a significant role in the individual host’s response to trauma, they play a significant role in determining whether a specific injury proves fatal to a specific person.) Although it has been widely known that genetic factors played a role in conditions like those in Table 3-1, until recently the precise identity of those factors was not known. However, we have entered an era in which we are rapidly identifying these factors. Moreover, we also are beginning to be able to design new effective therapeutic and preventive strategies based upon this knowledge. One might assume that it is only in the United States and other developed countries that genomics is on the brink of making major contributions to health. That is not the case. A recent report on genomics and world health (WHO, 2002) points out that genetic research has the potential to lead to major advances in combating such important global diseases as tuberculosis, malaria, and HIV/AIDS in the developing world within the next three to five years. If understanding genomics is essential to today’s and tomorrow’s public health workforce, what is the appropriate level of understanding of genomics that programs and schools of public health should endeavor

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century TABLE 3-1 Causes of Death in the United States, 2000   Cause of Death Percentage of All U.S. Deaths 1 Heart disease 29.5% 2 Cancer 22.9% 3 Cerebrovascular diseases 6.9% 4 Chronic lower respiratory diseases 5.1% 5 Injury 3.9% 6 Diabetes 2.9% 7 Pneumonia/influenza 2.8% 8 Alzheimer disease 2.0% 9 Renal disease 1.6% 10 Septicemia 1.3% Based on preliminary data. Derived from information obtained on http://www.cdc.gov/nchs/data/nvsr/nvsr49/nvsr49_12.pdf. to provide to their students? All public health students should learn to “think genomically,” to be able to apply an understanding of genomics to a variety of public health issues. Two groups have provided valuable considerations of “core competencies” in genomics and genetics that help pinpoint what this might mean in terms of public health education. The National Coalition for Health Professional Education in Genetics, a coalition of more than 120 health professional organizations, has promulgated a set of competencies in genetics and genomics (Jenkins et al., 2001). The CDC also convened an interdisciplinary group that produced a set of competencies in genetics and genomics specific to the public health workforce (CDC, 2001d). These competencies supply a particularly worthwhile set of guideposts for public health education. The competencies are recommended for all public health professionals, and thus one might consider these the competencies that programs and schools of public health should provide all of their students. These are the abilities to: apply the basic public health sciences, (including behavioral and social sciences, biostatistics, epidemiology, informatics, and environmental health) to genomic issues and studies and genetic testing, using the genomic vocabulary to attain the goal of disease prevention; identify ethical and medical limitations to genetic testing, including uses that don’t benefit the individual; maintain up-to-date knowledge on the development of genetic advances and technologies relevant to an individual in his/her specialty or field of expertise and learn the uses of genomics as a tool for achieving public health goals related to that person’s field or area of practice; identify the role of cultural, social, behavioral, environmental, and genetic factors in the development of disease, in disease prevention, and

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century in health promoting behaviors; and the impact of these factors on medical service organization and delivery of services to maximize wellness and prevent disease; participate in strategic policy planning and development related to genetic testing or genomic programs; collaborate with existing and emerging health agencies and organizations, and academic, research, private, and commercial enterprises, including genomic-related businesses, agencies and organizations and community partnerships to identify and solve genomic-related problems; participate in the evaluation of program effectiveness, accessibility, cost-benefit, cost effectiveness, and quality of personal and population-based genomic services in public health; and develop protocols to ensure informed consent and human subject protection in research. There are also competency sets developed for particular types of public health professionals including public health leaders and administrators, and public health professionals in clinical services evaluating individuals and families, in epidemiology and data management, in population-based health education, in laboratory sciences, and professionals in environmental health. Few, if any, public health education programs have developed comprehensive curricula in genomics. Genomics is not only new, but also changing as rapidly as any area of bioscience. This combination presents a particularly daunting challenge to designing curricula. Schools and programs need to integrate a largely new content area while, at the same time, recognizing that what is currently known, even at the cutting-edge frontiers of that content area will be woefully out of date and/or incorrect early in their students’ professional lives. Thus, public health curricula in genomics may need to focus on creating a framework of appreciation for the importance of genomics and a basic understanding of the topic. It has long been widely agreed in the field of genomics that its ethical, legal, and social implications (ELSI) are important for society at large and, particularly so, for health professionals. In educating students about genetics and genomics, programs and schools of public health have a responsibility to consider these issues. Some of these ELSI issues are included in each of the two organizations’ sets of competencies cited above. Undoubtedly new issues that we cannot yet foresee will arise in this area during the professional lives of today’s students. Thus, it is important that schools of public health constantly update their curricula in all areas of genomics, including the ELSI issues. Ethical, legal, and social issues are important to many areas in the education of students of public health, including genomics. Therefore, it is important that consideration of these issues not be an afterthought or

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century mains have been embodied in a set of core legal competencies, prepared by the Center for Law and the Public’s Health with support from CDC. A critical area in public health policy research is engagement with law. Within the ecological model of health, laws and legal practices may be important constituents of the “fundamental social causes of disease” that broadly determine population vulnerability and immunity from illness (Link and Phelan, 1995; Sweat, 1995; Burris et al., 2002; Sumartojo, 2000). Public health research seeking to understand the relationship of multiple determinants of health will be enhanced by integrating law and legal practices into research on individuals, partners, communities, and whole populations. Because laws are used as structural interventions to regulate individual behavior and to change social and material conditions that endanger health (Blankenship, 2000; Hemenway, 2001; Schmid et al., 1995), law is also an important tool for intervention in public health, and here research has a vital role to play. Research in public health can help to document how health policy is made (and the process influenced) (Backstrom and Robins, 1995; Mittelmark, 1999), as well as the difference between law on the books and law in practice (Boden, 1996; Cotton-Oldenburg, 2001). The challenge is not only to recognize law as a part of the universe of factors to be studied, but also to develop and support methods that are appropriate to the study of law’s operation in a population over time. The operation of law cannot often be studied in experimental designs. More attention to and respect for observational studies, rapid assessments, qualitative methods, and modeling is essential to expanding the public health research base in law. Major barriers to increasing law-related research in public health are lack of funding and faculty incentives for efforts to make research more useful in the policy process (Nutbeam, 1996). Historically, funding for law-related research in public health has been minimal. In recent years, the CDC has made an important commitment to funding public health law research, but awareness of and support for this field of work remains rare in the National Institutes of Health. Ethics, too, play an important role in politics and policy development as elsewhere in practice. Ethics are a tool through which public health professionals can interrogate their own values, formulate policy goals, and articulate a rationale for change in policy. Gostin suggests that [p]ublic health ethics . . . can illuminate the field of public health in several ways. Ethics can offer guidance on (i) the meaning of public health professionalism and the ethical practice of the profession; (ii) the moral weight and value of the community’s health and wellbeing; (iii) the recurring themes of the field and the dilemmas faced in everyday public health practice; and (iv) the role of advocacy to achieve the goal of safer and healthier populations (Gostin, 2002).

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century While the content of public health ethics will continue to develop, the committee believes that ethics are an important and heretofore neglected element of a thorough education in policy. Finally, policy training in programs and schools of public health also can be enhanced by considering human rights and their relation to health. As used in public health circles, human rights cut across law, ethics, and advocacy. When evoked in terms of the various international human rights conventions and national constitutions, they are a species of law (Burris, 2002). As deployed in efforts to secure just and effective public health policies, they are a tool of advocacy (Gostin and Lazzarini, 1997). Jonathan Mann argued that human rights could also take the place of an ethics for public health (Mann, 1997). While much work remains to be done to develop the public health potential of human rights analysis (Gostin, 2002), a human rights perspective has already become an important part of international health practice. ETHICS1 Public health raises a number of moral problems that extend beyond the earlier boundaries of bioethics and require their own form of ethical analysis (Callahan and Jennings, 2002). Ethics, in general terms, are “values or standards designed to shed light on the relative rightness or wrongness of actions based on moral principles, professionally endorsed and practiced” (Modeste, 1996). Public health is confronted with a wide array of ethical issues and questions, including issues involving: advances in technology and how they will be applied to improve the health of populations (e.g., information technology and genomics), the decisions we make about what and how to communicate, the ways in which we interact with diverse populations, the extent to which we develop partnerships and collaboration for public health programs and research, and resource allocation for provision of care. The ethical basis for the practice of the health professions has been well studied by both health professionals and ethicists for some time. A statement of public health practice ethics has only recently been produced, and very little attention is paid to public health ethics in educational programs. Few schools of public health have trained ethicists on faculty, despite the fact that 22 of the 25 responding schools of public health report teaching ethics. To foster appropriate thinking and action 1   Much of the material in this section is abstracted from the commissioned paper prepared for the committee by James C. Thomas, M.P.H., Ph.D.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century in public health, with its immense potential to influence populations, research and teaching in ethics as they apply to public health must be strengthened. Callahan and Jennings (2002) have described the scope of issues in public health ethics as encompassing four general categories: health promotion and disease prevention, risk reduction, epidemiological and other public health research, and structural and socioeconomic disparities. They further identify different types of ethical analysis: professional ethics, applied ethics, advocacy ethics, and critical ethics, and they encourage all schools of public health to promote the teaching of ethics. The American Public Health Association (APHA) has recently adopted a public health code of ethics (see Box 3-1). This code is based upon certain identified values and beliefs of public health including: a belief in the interdependence of people and between people and their environment, the importance of addressing root causes of health and illness, the utility of the scientific method for gaining information, and the importance of acting on reliable information that is in hand when the resources are available to do so (Thomas et al., 2002). Public health ethics differs from medical ethics, which is typically concerned with an individual who is ill or disabled. Part of the ethical equation in medicine is whether withholding a treatment is tantamount to failing to rescue a person when rescue is possible. Moreover, the risks of introducing an intervention may be more palatable in view of the suffering that is likely in the absence of the intervention. In the case of public health prevention,2 however, the person or population is not necessarily ill or disabled, and the potential benefits of an intervention are less salient to those who might experience them. Even after an intervention to prevent an illness or injury is in place, benefits are often invisible or at least not in the forefront of people’s minds. Seldom do people think, for example, of the illnesses they did not get because they were vaccinated, or the cavities they did not have because the water supply was fluoridated. The hidden nature of some prevention benefits places an extra burden on public health professionals to clarify to the public the benefits of an intervention and how those benefits outweigh the risks of not intervening. 2   Prevention can be categorized into three types: primary, secondary, and tertiary. Primary prevention, to which this statement refers, is the prevention of an illness or a disability. Secondary prevention is the treatment of a curable illness, and is designed to limit the progression of an illness or a disability. In the case of irreversible conditions, tertiary prevention is prevention of the progression to a more serious illness or disability, or the postponement of death.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century BOX 3-1 Principles of the Ethical Practice of Public Health Public health should address principally the fundamental causes of disease and requirements for health, aiming to prevent adverse health outcomes. Public health should achieve community health in a way that respects the rights of individuals in the community. Public health policies, programs, and priorities should be developed and evaluated through processes that ensure an opportunity for input from community members. Public health should advocate for, or work for the empowerment of, disenfranchised community members, ensuring that the basic resources and conditions necessary for health are accessible to all people in the community. Public health should seek the information needed to implement effective policies and programs that protect and promote health. Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community’s consent for their implementation. Public health institutions should act in a timely manner on the information they have within the resources and the mandate given to them by the public. Public health programs and policies should incorporate a variety of approaches that anticipate and respect diverse values, beliefs, and cultures in the community. Public health programs and policies should be implemented in a manner that most enhances the physical and social environment. Public health institutions should protect the confidentiality of information that can bring harm to an individual or community if made public. Exceptions must be justified on the basis of the high likelihood of significant harm to the individual or others. Public health institutions should ensure the professional competence of their employees. Public health institutions and their employees should engage in collaborations and affiliations in ways that build the public’s trust and the institution’s effectiveness. SOURCE: Thomas et al., 2002. Reprinted with permission of Am J Public Health, 2002; 7:1057–9. The public health focus on populations also differs from the medical focus on interactions between a patient and a care provider. With a population perspective, public health institutions think in terms of healthy populations and communities as well as healthy individuals. The health of a community includes the quality of interactions among community members (consider, for example, the prevention of violence) and among institutions serving the community (e.g., the need for collaboration to achieve complex goals). A community perspective thus highlights the interdependence of individuals and organizations. This stands in contrast to the importance given to autonomy in medical ethics, in which the concern is principally to prevent a patient from being abused by a care provider who wields much power. Although personal autonomy remains

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century an important consideration in public health ethics, it is counterbalanced by concern for the well-being of a whole population and a realization that not everyone affected by a particular public health action will agree with it. Thus, in public health the personal choices and preferences of some will be overridden by a greater concern for the well-being of a whole population. Policies and practices affecting a population are typically designed and implemented by government and other organizations, raising the question of how an agency develops and maintains an ethical compass. Is it through policy-making, or, in the case of governmental agencies, through legislation? Does it include understandings within a community that transcend legislation (e.g., a concern for equal access that is not legally mandated)? How are ethical conundrums resolved or decisions made in an organization that includes employees with different perspectives and sensibilities? An important part of public health ethics is sorting through ethical issues in a group setting. The combination of a population perspective and institutional action presents a particular ethical danger to public health. “Population” and “institution” are abstract concepts, neither of which bears a human face. The ability to sympathize with another is a fundamental aspect of being able to think and act ethically towards that person. Personal interactions can lead to sympathy. However, interactions between an institution and a population occur in such a way that sympathy is not a common element of the interaction. To an epidemiologist, the population may be represented as a data set. Even to a public health ethicist, thinking about a population may be an exercise in wrestling with other abstract concepts such as the distribution of scarce resources. All too frequently such an exercise does not stem from direct interaction with those who will be most affected by a decision regarding those resources. From the perspective of the individual in the community, the public health institution also lacks a human face. In this situation, however, the primary concern resulting from the impersonal nature of the institution is not the ethical treatment of the institution by individuals but the ability of individuals to trust the institution. A widespread absence of trust can severely limit the effectiveness of the institution. Ethical treatment of an individual and community by the institution, however, builds trust. In this way, the ethical functioning of a public health institution also affects its effectiveness in accomplishing its mission. Public health needs both scholars who can articulate the unique aspects of public health ethics and public health practitioners who understand and operate within the ethics structures of the field. Nancy Kass (2001) discusses a six-step ethics framework for public health that can serve as an analytic tool used to help consider ethical implications of

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century proposed interventions, policies, research, and programs. The six steps are as follows: What are the public health goals of the proposed program? How effective is the program in achieving its stated goals? What are the known or potential burdens of the program? Can burdens be minimized? Are there alternative approaches? Is the program implemented fairly? How can the benefits and burdens of a program be fairly balanced? Thomas, in the paper prepared for this committee, identified seven areas for education in public health ethics. First, are the values and beliefs inherent to a public health perspective. A list of these was developed in conjunction with the Public Health Code of Ethics (Thomas et al., 2002). They are presented on the Web at www.apha.org/codeofethics and include: a belief in the interdependence of people and between people and their environment; the importance of addressing root causes of health and illness; the use of the scientific method for gaining information; and the importance of acting upon reliable information when the resources are available to do so. Secondly, education in public health ethics should address ethical principles that follow from the values and beliefs outlined above. The Public Health Code of Ethics consists of 12 ethical principles (see Box 3-1) that address the relationship between public health institutions and the populations they serve. Other codes of ethics for epidemiology and health education provide additional information more specific to these practices (located on the Web, respectively, at www.acepidemiology.org/policystmts/EthicsGuide.htm and www.sophe.org/). Public health mandates and powers is another important component of education. Students should understand the legal mandates given to public health institutions and the powers available to them to meet the mandates and the potential abuses of these powers. It is also important to know that the powers of non-public-health organizations, such as some private companies, affect the health of the public and to consider how public health ethics might extend to them. Further, ethical tensions within public health should be included in an understanding of public health ethics. Some ethical questions arise frequently because of an underlying, irresolvable tension between ethical principles. One that is common in public health is the tension between the need to protect the health of an entire community and the need to honor the rights of individuals in the community. This tension is brought to the fore when an individual claims that a public health regulation violates his or her rights. Examples of how some of these situations have been handled can be helpful in navigating future conflicts.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century It is important to review historical ethical failures and triumphs. One ethical failure in public health was the study of syphilis that was conducted by the Public Health Service and the Tuskegee Institute. Students should be aware of this study and what went wrong. It is also important to provide examples of ethical triumphs and more modest failures. An exclusive focus on “monstrous” failures can lead some to believe that ethics are not a concern for “normal” people such as themselves. Two other areas to include are the history and purposes of research ethics institutions and the application of ethics to specific topics such as informatics and genomics. Institutional Review Boards (IRBs) currently review research proposals to ensure that they are consistent with rules and regulations concerning human experimentation. It is imperative that public health researchers and practitioners know how to interact with such boards and appreciate the value of this review system. In terms of specific topics, much of contemporary practical ethics is driven by new technological developments. The use of information about individuals that can be managed through sophisticated electronic systems, and in some instances acquired through genetic tools are two that bear directly on public health and affect nearly every public health practitioner. Students need to be informed of the prevalent ethical standards for using these tools. “Ethical analysis can further understanding in every area of public health practice” (Levin, 2002), and it is essential that programs and schools of public health incorporate the teaching of ethics. However, the barriers to teaching ethics are substantial and, if not required, it is likely that ethics will not be taught in any meaningful way. Requiring ethics instruction in the curriculum does not necessarily mean requiring a free-standing course. A free-standing course entitled “ethics” might unintentionally convey the notion that ethics stands apart from other topics in public health, as opposed to the notion that it permeates every topic. Conversely, sometimes ethics teaching is best received when it is not billed as ethics. For example, a course may include instruction in how to interact with community members and thus communicate the importance of community input without appealing to it explicitly as an ethical principle. There are dangers in not creating a free-standing course in ethics, however. In the absence of a required course, individual courses are likely to include an ethics lecture or two. Unless there is some coordination among courses, they are likely to cover similar material. A student may thus sit through three lectures on the Tuskegee study of syphilis or the functions of an IRB, but never learn to reason through tensions between individual interests and the good of the community or how to avoid unethical conflicts of interest. An uncoordinated ethics curriculum can easily be neither broad nor deep; it can be an inch wide and an inch deep. However a program or school chooses to integrate ethics, a necessary first step is to identify competencies in public health ethics. Once the core

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century competencies are identified, a curriculum committee can ensure that they are covered within the required courses, regardless of whether a topic is labeled as ethics when it is taught. The committee recognizes that teaching ethics in programs and schools of public health requires faculty educated to do so. This means that faculty will, themselves, require education in ethics, and schools and programs will need to provide professional incentives and rewards that encourage and value ethics as a subject of teaching and research. Ethics is most stale and irrelevant when it is solely academic. Ethics is something less than ethics when it is not put into practice. Putting ethics into practice means that ethics should not be limited to a list of rules and regulations. Although these often represent the encoding of the ethical values of an institution, they are seldom adequate to address all situations, and they will never obviate the need for individuals and groups to have skills in reasoning through ethical conundrums. It is also important that classroom teaching on ethics be linked to practical, real-life situations. Ideally, this might involve site visits to various neighborhoods or discussions with study participants. To counter the dehumanizing potential of a population perspective, mentioned above, public health students need to interact with individuals who are most affected by a particular ethical decision. Regardless of whether ethics is taught explicitly, ethical values are communicated though teaching, mentoring, public health research and interventions, interactions between the school and other institutions, and more. If not taught explicitly, the accidental teaching of ethics is likely to be inconsistent and nonsystematic, and may perpetuate unethical actions. To promote ethical practices and to prepare students for the multitude of ethical decisions they will confront, students must be taught ethics in an intentional way. The means by which this is done, whether in a free-standing course or integrated into the curriculum, is less important than the identification of competencies along with a system of ensuring that these competencies are fully covered in the curriculum. To facilitate the teaching of ethics, schools and programs must institutionalize incentives for faculty to develop interest in ethics and the ability to teach the topic. For the teaching of ethics to be credible and vital to students, ethical education must include a practical component, most likely in the field, and schools and programs of public health education must personify a high ethical standard. Law is another emerging area for public health scholarship, and while ethics and law are often discussed as related fields, each deserves attention in its own right. However, law overlaps with ethics, in that public health laws themselves should be ethical, as should the implementation of those laws. Since law can influence the social and physical environ-

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century ment in ways that are important to health, it is much more than a set of rules; law also encompasses the institutions and practices that bring these rules to daily life. Understanding this ethical perspective of law and using law in this way requires much more than mastery of regulations about specific businesses (restaurants, water systems) and the administrative procedures through which they are administered, though these are important. It brings to the forefront the use of law to influence choices made by individuals through the rewards or penalties that accrue. SUMMARY Each of the eight content areas discussed in this chapter is important for the future of public health and public health education. Understanding and being able to apply information and computer science technology to public health practice and learning (i.e., public health informatics) are crucial competencies for public health professionals in this information age in which we are vitally dependent upon data and information. Genomics is helping us understand the causative role of genetic factors in leading causes of morbidity in the United States, information that is important to the ecological model public health professionals must use to better understand how to improve health. Public health professionals must be proficient in communication in order to interact effectively with multiple audiences. They also must be able to understand and incorporate the needs and perspectives of culturally diverse communities in public health interventions and research. New approaches to research that involve practitioners, researchers, and the community in joint efforts to improve health are becoming more necessary as we recognize the importance of the impact of multiple determinants on health, for example, social relationships, living conditions, neighborhoods, and communities. Understanding global health issues is increasingly important as public health professionals are called upon to address problems that transcend national boundaries. Public health professionals must also understand how best to inform policy makers as they develop policies, laws, and regulations that have an impact on the public’s health. Finally, public health professionals must be able to identify and address the numerous ethical issues that arise in public health practice and research. Therefore, for each of these eight emerging content areas, the committee recommends that: competencies be identified; each area be included in graduate level public health education; continuing development and creation of new knowledge be pursued; and opportunity for specialization be offered.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century The committee has highlighted the importance of these eight areas because it believes that they are and will continue to be central to public health for some time to come. It is beyond the charge of this committee to prepare curricula for educating public health professionals in these areas, yet it is crucial that such curricula be developed. As our understanding evolves, and as conditions change, other new knowledge and skills will be identified that will need to be incorporated into public health professional education. The committee emphasizes that it is important that public health education not “freeze” with the focus as identified in this report. Rather, the committee believes that the progress made in understanding and incorporating these eight important areas into public health practice, education, and research will enable us, in the future, to identify other new and emerging areas that must be addressed. The committee also believes that it is important to enhance the development of the profession of public health, with some advocating the use of credentialing and certification as approaches to workforce development. Credentialing is a formal process used to ensure that persons practicing in a profession meet minimum standards (Modeste, 1996). Certification is “a process by which a quasi-governmental agency or association grants recognition or licensure to a person who has met certain qualifications specified by that agency. For example, the National Commission for Health Education Credentialing (NCHEC) certifies health educators. CDC and other public health agencies and organizations such as the National Association of County and City Health Officers (NACCHO), ASPH, and APHA are examining the feasibility of creating a credentialing system for public health. Their efforts are focused on credentialing based on competencies linked to the essential public health services framework. Many issues that need to be pursued in this area are beyond the scope of this report. Certification, however, relates to the education of public health professionals. Within the various professions in the world of health and illness, the process of certification is common. In some cases, such as medicine and nursing, specialty certification is available only to those who have first qualified for a license to practice that is granted by a state authority. The specialty certification attests to skills beyond the legal minimum that apply to a limited set of patients (e.g., pediatrics), conditions (e.g., infectious diseases), or interventions (e.g., anesthesia). There are also areas of practice for which there is no required state licensure but for which members of the practice field have created certification as a way of attesting to minimum or common capacities. In public health, perhaps the best known is the Certified Health Education Specialist (CHES). In environmental health, there is also the mixed model of the registered sanitarian, who may be certified by the National Environmental Health Association but is required to achieve a state license in some states.

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Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century The range of individuals entering M.P.H. programs, many with no previous health-specific education and with no access to the public health-related certifications currently in existence, makes this group likely candidates for a certification program. Defining specific criteria for such certification as well as designating a responsible organization to carry out out the process is beyond the scope of this report. However, the committee believes that voluntary certification for the M.P.H. graduate would enhance the profession. Therefore, the committee recommends the development of a voluntary certification of competence in the ecological approach to public health as a mechanism for encouraging the development of new M.P.H. graduates. This chapter has described the future of public health professional education, no matter the site at which that education is obtained. Chapter 4 discusses the role of schools of public health in educating public health professionals, while Chapter 5 discusses the roles of other schools and programs. Chapter 6 focuses on the state, local, and federal public health agencies.