Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century (2003) / Chapter Skim
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Appendix D: Education of Public Health Professionals in the 21st Century
Appendix D: Education of Public Health Professionals in the 21st Century
Pages 222-261
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From page 222... ...
Gebbie, The Public Health Workforce: Key to Public Health Infrastructure, American Journal of Public Health, 89, 1999: 660-661. 2 Gebbie K, Hwang I
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From page 223... ...
Few have any work experience outside of academia, much less in city or state health departments. Not surprisingly, they have little interest in becoming engaged with the practical work of public health agencies.
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From page 224... ...
Certainly, there is no assumption that all members of a local health department will be graduates of an accredited school of public health. Salaries in public health are low and political pressures are often strong; many public health departments survive in a more or less permanent state of crisis, coping with the last budget cut and waiting for the next one.
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From page 225... ...
Public health leaders were generally people like Hermann Biggs or Josephine Baker physicians who, with lucrative private medical practices on the side, could devote themselves to the public's health as a largely voluntary activity. The rank and file of public health officers were simply practicing physicians who could be called out in times of crisis to assist in coping with epidemic diseases, but who were otherwise fully involved in caring for their own patients.
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From page 226... ...
Flexner found that Rose's concerns were widely shared by prominent leaders in public health. Indeed, the Massachusetts Institute of Technology and Harvard University had already put together an impressive curriculum for training health officers in communicable diseases, sanitary engineering, preventive medicine, demography, public health administration, sanitary biology, and sanitary chemistry.8 Students generally entered with professional degrees they could be engineers or physiciansand completed a two or three year course of additional study before receiving a certificate in public health.
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From page 227... ...
Wickliffe Rose asked Abraham Flexner to consult with medical school professors, members of the newly formed United States Public Health Service, the medical departments of the army and navy, state and city health departments, registrars of vital statistics, representatives of life insurance companies, and health managers of large industries. Flexner, however, preferred to rely on the advice of a few trusted friends and never consulted most of these varied experts.
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From page 228... ...
This central scientific school would be linked to simpler schools of public health to be established in every state; these state schools would focus on teaching rather than on research. The state schools would in turn be affiliated with medical schools and with state health departments and would offer short training courses for health officers already in the field.
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From page 229... ...
Some of the participants at the October conference and other public health leaders complained that Welch's version of the report was closer to the German than to the English conception of public health. In other words, the focus on research largely ignored public health practice, administration, public health nursing, and health education.
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From page 230... ...
They were well-endowed private institutions with high admission standards; they favored medical graduates, and often admitted rather distinguished mid-career people already experienced in public health. In the 1920s and early 1930s, the curricula of the schools tended to be heavily weighted toward the laboratory sciences: bacteriology, parasitology, immunology, and what was called "physiological hygiene," along with instruction in epidemiology, vital statistics, and public health administration.
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From page 231... ...
Smillie, Allen Freeman, and Huntington Williams, among others. This committee prepared 20 reports on the educational qualifications of 15 professional specialists, and ultimately distributed some 250,000 copies of these reports.~5 The idea of this very considerable effort was to inform state and local health departments about the types of employees they should be seeking and the kinds of qualifications appropriate for each, with the idea of creating national standards that, if used by the multiplicity of local health departments, could create some degree of uniformity across the nation.
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From page 232... ...
Of these 45, 10 were independent schools of public health, 20 were colleges and universities offering programs in public health nursing, and 12 were engineering colleges offering programs in sanitary engineering. Despite a great expansion of public health training facilities, there were still far from enough graduates to meet the demand.
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From page 233... ...
Thus, public health education in the 1930s tended to be practically oriented, with considerable emphasis on fields such as public health administration, health education, public health nursing, vital statistics, venereal disease control, and community health services. In this period, too, many schools developed field training programs in local communities where their students could get a taste of the practical world of public health and a preparation for their roles within local health departments.
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From page 234... ...
Schools of public health and public health training programs changed their educational programs to meet the various needs of the armed services as rapid training programs turned out large numbers of health professionals with a smattering of specialized education in high-priority fields. The research-oriented schools of public health, such as Hopkins and Harvard, maintained their research programs largely by recruiting foreign students many of them from Latin America to staff their laboratory and field programs; in those years, Johns Hopkins was said to resemble an outpost of Latin America.
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From page 235... ...
Thanks to studies by Haven Emerson and Martha Luginbuhl,2~ the Association was able to estimate how many full-time public health personnel were needed in the nation, the replacement rate of existing public health officers, and therefore the number of schools of public health that were really needed Shepard estimated in 1946 that between 5 and 10 additional schools of public health would be necessary to provide the public health workforce for the nation. The difficulty with instituting a system of licensing and credentialing was the low salaries involved in most public health positions.
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From page 236... ...
They also stated that they could double the number of students enrolled if they had the necessary financial support for staff, basic operating funds, and construction. The applied fields most frequently in demand were public health administration, environmental sanitation, maternal and child hygiene, industrial hygiene, mental health, medical care organization, public health economics, public health nursing, and health education.24 Given this context, it seems hardly surprising mat We criteria for accreditation of schools of public health as implemented at mid-century seem undemanding by current standards.
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From page 237... ...
Perhaps the most interesting part of the accreditation of schools of public health was the evaluation of practical training and fieldwork. Schools had to be located close to local public health services that could be used for "observation and criticism" and these public health services had to be of sufficiently high quality "to make such observation fruitful."27 Indeed, all the accredited schools reported some sort of functional association with county or city health departments.
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From page 238... ...
The Department of Public Health at Yale provided surveys of town and city health programs in Connecticut at the request of local health departments. Each year, the students and faculty completed one such survey and presented their results to the local authorities.
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From page 239... ...
Gordon declared that "most important of all is to incorporate within the general fabric of public health a more adequate emphasis on social and economic factors...."30 Harvard instituted two core courses, one on "Human Ecology" and the other on "Community Organization," designed to "orient the public health program to the framework of modern society" by discussing such matters as "the problem of food supply in relation to world population" and "the influences of industry and transportation on human health."3~ The department of public health administration also offered a series of lectures and seminars on "the history of the public health movement" and "the cultural, social, and economic forces bearing on the evolution of the science of public health."32 Similarly, Columbia reorganized its curriculum around a single required course covering such topics as "the community and its needs," "the evaluation of health status," "the factors which influence the causation and control of disease," and "public health as a community service." At Pitts29 Iago Galdston, ea., Social Medicine: Its Derivations and Objectives. New York: The Commonwealth Fund, 1949.
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From page 240... ...
Winslow commented approvingly that the 11 schools of public health constituted "eleven experimental laboratories in which new pedagogic approaches are constantly being devised."34 The overall impression of the accredited schools of public health in 1950 was that they were doing a good job of preparing public health practitioners through courses and fieldwork, that the numbers of faculty and students were growing, and that curricular and research innovations seemed promising. The main complaints of the schools seemed to be lack of funding to pay faculty, expand space, and purchase equipment.
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From page 241... ...
In 1944, Thomas Parran, the Surgeon General, had drawn up a grand 10-year plan for his agency, the Public Health Service. Parran envisioned a remarkably complete health service, including public health and medical care, as well as health professional education and medical research: When peace returns, this country should so reorganize and develop its health resource that there will be available to everyone in the population all health and medical services necessary for the preservation and promotion of health, the prevention of disease, and the treatment of illness ....
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From page 242... ...
Liberals, conservatives, medical school deans, and researchers were all happy with the system, and members of Congress were pleased to bankroll such a popular and uncontroversial program.39 Schools of public health would have had no objection whatsoever to direct federal funding assuming only that it were relatively generous. But public health schools were generally lumped in with medical schools 33 Paul Starr, The Social Transformation of American Medicine.
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From page 243... ...
In the late 1940s and early 1950s, many of the most articulate and outspoken public health leaders were under attack, silenced, or were losing their positions and their influence. A DEEPENING CRISIS: PUBLIC HEALTH SCHOOLS AND DEPARTMENTS IN THE 1950S In the early 1950s, schools of public health were attempting both to maintain educational standards and to admit increasing numbers of students, in spite of the fact that most students were unable to finance 40 Marcos Charnes, "Problems Confronting Foreign Students Beginning Professional Education in the United States and in Adapting it to Practice at Home," in The Professional Education of Students from Other Lands, ea., Irwin T
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From page 244... ...
Averages, however, are misleading because they mask the wide variation between schools of public health and even between different departments within a particular school. What happened was that, if the faculty of a particular department was devoted mainly to teaching or to "service" (public health practice)
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From page 245... ...
At first, the school offered a three-month course for public health officers, then developed programs in venereal disease control, public health nursing, and health education all practice-oriented subjects. The school offered short training courses for armed services personnel and also took in foreign students during the war.
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From page 246... ...
The enterprise had been exhilarating, time-consuming, and expensive. "But it was a superb experiment" said McGavran, "and for two brief years the School of Public Health demonstrated to students, practitioners, and ourselves that there was a public health team."46 Thus, even a Director who strongly favored field training and distrusted departments devoted to research was unable to resist the pressures favoring research over practical training.
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From page 247... ...
As a result of these dynamics, all the service-oriented departments that had failed to grow in over a decade of federal support the departments of health administration, health education, maternal and child health, mental health, public health nursing, and public health nutrition were bundled into a single department of community health practice and administration. The same dynamics were at work in other schools of public health.
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From page 248... ...
This industrial mode of research organization was easily adaptable to other forms of laboratory research and, in time, to other quantitative public health disciplines. The system of research funding, however, did not work well for field research, public health practice, public health administration, the social sciences, history, politics, law, anthropology, or (at least at this juncture)
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From page 249... ...
Stebbins, "Contributions of the Graduate School of Public Health Past, Present, and Future," American Journal of Public Health, 47, 1957, 1508-1512. 53 Roger M
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From page 250... ...
And the health departments were in a sorry state. In the 1950s, federal grants-in-aid to the states for public health programs steadily declined with the total dollar amounts falling from $45 million in 1950 to $33 million in 1959.
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From page 251... ...
The Congress raised the ceiling on the formula grants, provided grants-in-aid for training to state health departments, and authorized special training grants, fellowships for faculty development, and construction grants for schools of public health. New Life in the Sixties The federal government now began to reverse the damage that had been done to public health by providing traineeships, formula grants, and project grants to develop new curricular areas.
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From page 252... ...
New faculty appointments were made in such fields as medical care organization, social and behavioral sciences, public health administration, human ecology, radiation sciences, population studies, and international health. The newly created Agency for International Development (AID)
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From page 253... ...
Community mental health centers were financed by the federal government and locally controlled, thus largely bypassing the states. Many of the other programs of the 1960s and 1970s would be created as independent ventures, thus directly or indirectly weakening the role of the states and of state health departments.
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From page 254... ...
. Environmental protection agencies, like He neighborhood health centers and the community mental health centers, were organizationally independent of state health departments, although they were clearly important agencies for the public's health.
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From page 255... ...
They were offering degrees in such fields as environmental health, health management and administration, nutrition, public health nursing, and health education. Somewhat to the distress of accredited schools of public health, most employers did not distinguish between accredited and non-accredited programs.69 By 1975, there were some 43 graduate programs in health administration offered in schools of public or business administration and 15 graduate programs in nutrition offered by departments of home economics, education, and human development.
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From page 256... ...
In the volume published from that conference, Cecil Sheps, then Vice Chancellor of the University of North Carolina, noted that leading schools of public health were wondering "seriously and agonizingly" about their future.7~ The participants offered a generally gloomy assessment of public health education. According to Russell Nelson of the Johns Hopkins Medical Institutions, corridor talk at his campus said that public health was dead.
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From page 257... ...
there was a fairly general belief that solutions to societal problems were being sacrificed on the altar of scientific research.76 Some of Me threatened funding cuts were restored, but the trend in Me 1970s was toward ever more reliance on targeted research funding, thus exacerbating Me problems to which Ramsey had referred. In 1976, the Milbank Memorial Fund issued its extensive report, Higher Education for Public Health.77 The Milbank Commission, chaired by Cecil Sheps, asked the usual questions: Why was there not a closer relationship between professional education and professional practice?
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From page 258... ...
They should also serve as regional resources by assisting faculties in medical and other health-related schools to develop teaching programs and research in public health. Different schools would serve as national centers of excellence for specific fields but "should avoid setting up special programs in every new area simply because funding is available." Instead, faculty should become involved in the operation of community health services in areas relevant to their areas of academic responsibility, thus offering supervised field experience for aspiring public health practitioners.
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From page 259... ...
Twelve years after the Milbank Commission Report, the Institute of Medicine issued its own landmark report, The Future of Public Health.85 This documented the bleak landscape of many public health departments across the country. Half of the state boards of health had disappeared; important programs had been taken away from health departments; and public health was "in disarray." The prose of this report was often vivid: "The most frequent perception of the health department by legislators and citizens was of a slow and inflexible bureaucracy battling with chaos, fighting to meet crises, and behaving in an essentially reactive manner....
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From page 260... ...
Schools of public health should establish firm practice links with state and local health departments so that more faculty members could undertake professional responsibilities in those agencies, conduct relevant research, and train students in practice situations. lust as had the Milbank report, so too the Institute of Medicine report urged schools of public health to serve as resources to government at all levels in the development of public health policy, to assist other types of institutions in educating public health practitioners, and to take better advantage of such university resources as schools of business administration and departments of physical, biological, and social sciences.
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From page 261... ...
Previous efforts to design truly effective systems of public health education generally foundered because of lack of political will, public disinterest, or paucity of funds. Since September 11, 2001, however, the context has changed dramatically.
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