In a time of limited resources and public indifference, much needs to be done to modernize and maintain the profession of public health. Public health education must incorporate new knowledge and new strategies that will be needed to protect the public's health, as well as adapt and expand to meet new challenges and demands. The Institute of Medicine's (IOM's) Report Who Will Keep the Public Healthy is a timely and important contribution to the debate about the future of public health that identifies areas of new or expanding knowledge to which public health practitioners must have access.1 The report points out the need for a central organizing construct for public health education and to improve opportunities for practice-based learning. The ecological model promoted by the report is a robust and comprehensive model. The report fails, however, to clarify the authors' conceptual approach to education or to address the tensions inherent in the multiple perspectives and methodologies of the new core content areas it recommends. Although the executive summary notes in passing that, "Radical change is called for," the authors miss an opportunity to fully explain or justify this call.
We agree that fundamental, and perhaps even radical, change is necessary. In our view, however, three fundamental issues for public health education are raised but not addressed in the IOM report. First, the report calls for significant expanded content in public health education without giving attention to the already problematic balance between breadth and depth. Second, the report highlights new challenges and proposed solutions without discussing current and historic deficiencies in the public health infrastructure and educational system. Such deficiencies have been well documented in other IOM reports and elsewhere,2-4 but the failure to integrate a discussion of them into the current report diverts attention from chronic, fundamental, and unsolved problems. Third, implementation of the report's recommendations will require an investment of significant resources, but recommendations are directed exclusively to resource-starved public health educators and agencies. None are directed to other sectors of society, such as government, business, philanthropy, or the media, that could supply or influence the supply of such resources.
The IOM Report
The IOM report makes four major recommendations to educational programs that train public health workers at the graduate level. These are to
a. train all graduates in the ecological model of health determinants
b. train all graduates in eight new content areas in addition to the five currently recognized core public health disciplines:
1. Informatics
2. Genomics
3. Communication
4. Cultural Competence
5. Community-based Participatory Research
6. Global Health
7. Policy and Law
8. Ethics
c. expand supervised practice opportunities as part of the formal core curriculum, and
d. increase collaboration with policy makers, practitioners, communities, and other academic disciplines.
The Need for a Conceptual Framework
While the eight new content areas noted by the IOM for inclusion in public health curricula are important for every public health professional, the list of content areas is presented without any context or unifying theme to permit coordination with the existing education. These content areas originate in different disciplines, whose core assumptions and methodologies differ widely. The topics lend themselves to vastly different treatments. For instance, Genomics is a highly specialized topic within biomedicine-one that is generally new and that has definite but as yet unspecified implications for public health.5-7 Policy and Law, on the other hand, are two enormously broad areas of study and endeavor that have been central to public health education, although they have not been explicitly identified as part of the core curriculum. Further, cultural competency is perhaps better defined as a set of attitudes and skills rather than as an area of knowledge. Thus, even as the IOM report suggests an ecological model, it leaves unclear how these content areas can be integrated into a single framework.
The recommendation to add Genomics is particularly problematic. Currently, many public health students lack a background in the biological sciences. Public health practice has shifted away from physicians to include other professionals including nonscientists.8 The call for Genomics education implies that acquaintance with the biological underpinnings of health should be required of all public health graduates, but the report fails to take note of or address the lack of such a requirement in the core curriculum.
Ideally, this list of eight disparate content areas needs to be accompanied by a conceptual framework to include in public health education. Public health and public health education are undervalued2 (Association of Teachers of Preventive Medicine, unpublished data, 2003). Support and resources are diminishing even as new challenges force the profession to adapt2,3,8 (Association of Teachers of Preventive Medicine, unpublished data, 2003). Under these circumstances, increasing the scope of public health education, as the IOM suggests, can be done only by integrating the expanded curriculum into an effective, efficient, and holistic educational program. As presented, the recommendations add to deepening tensions within the public health educational model. Public Health education has largely been classroom and knowledge based, but there is a movement toward education primarily based on competencies rather than on knowledge.8,9 The eight new content areas intensify the challenge of presenting sufficient content and skill-based education within a single program. MPH programs cannot simultaneously add new content, increase practice experience, teach the current core curriculum, and maintain anything resembling their current length and cost. No one has identified any part of the current core curriculum that could be dispensed with.
Moving Ahead: Challenges and Opportunities Presented by the Report
Unsolved challenges, including the additional content highlighted by the IOM report, suggest that public health education needs to be reconsidered in a broader context if the opportunities presented by these challenges are to be identified and pursued. Table 1 lists some of the realities of public health education that the report evokes along with associated challenges and opportunities.
Recommendations
We believe that the IOM report identifies a set of knowledge and skills that, ideally, should be added to a public health education. The IOM report effectively draws attention to how much has to be done to truly prepare a public health professional. The reality is that the context for providing a public health education is often far from ideal, and the process is already strained. Additional expectations will add to that strain. New academic partnerships and resources will certainly be necessary if public health education is to flourish in the 21st century. To move forward, schools, programs, and students of public health will need to confront both challenges and opportunities so as to fulfill the mandates of this IOM report.
All groups involved in public health education, including schools, programs, the Council on Education in Public Health (CEPH), and those who practice public health, need to work together to address both the broad conceptual issues related to education and the political issues related to resources that will be available to public health generally.
We urge teaching programs to clarify for themselves and their students the conceptual framework of their education. It may be easier to focus on the new content areas, but, in our view, the other two major educational recommendations of the report-the need to teach the ecological model and the need to expand practice opportunities-should take priority, as these provide a framework around which to clarify the conceptual approach and to increase the effectiveness of new graduates in practice. Programs are also urged to work together to create a collective vision of what public health education should be, given current realities, and future possibilities. Finally, programs should experiment, innovate, and, where successful, share models that incorporate the new content areas into their own holistic framework of public health education.
From our vantage as former and current directors of graduate programs in public health, we see programs as uniquely positioned to foster collaboration with other disciplines and nonacademic partners, in keeping with the recommendations of the IOM report. Approximately one quarter of Master of Public Health graduates now get their degree from a program rather than a school of public health10 (Association of Teachers of Preventive Medicine, unpublished data, 2003). Programs exist in a wide variety of educational settings, including medical schools, schools of education, and allied health schools. They often develop in response to unmet workforce needs in their local communities. Because of their origins and location, they provide students and faculty with unique opportunities to collaborate with other academic disciplines and to work directly with communities and public health practice agencies. We urge policy makers and funding sources for public health education to support programs as laboratories for innovation.
We urge CEPH to move slowly in expanding the required core curriculum. The need to provide students with a context and framework for lifelong learning is more important than specific knowledge. CEPH should recognize the political and resource limitations on the one hand, and the controversies and changes in the profession on the other, and see in this environment the necessity for continuing innovation and experimentation. Creating new standards prematurely will only serve to inhibit such innovation and experimentation.
Those in public health practice should seek to create and foster a culture that values education in the workplace. In time, this could allow for the development of true academic public health practice settings, where students and new professionals can develop competencies in a supervised setting that allows for the gradual assumption of increasing levels of responsibility.
All stakeholders in public health should be mindful of the limited value society places on public health and should couple all demands for expanded education and training with demands that increased resources be made available to the profession, its educational partners, and its practitioners. Only if this second demand is met can the first be adequately addressed.
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