The institutions strive to overcome a poor image while looking ahead to a new role in a managed-care environment
Sidebar : ACCREDITED SCHOOLS OF PUBLIC HEALTH
Once the poor cousins of medical schools, public health schools are coming into their own as universities create new programs or expand existing ones. The advent of managed care, which emphasizes cost-effectiveness, has focused the attention of many institutions on prevention, the traditional raison d'^Ðtre of public health.
CONSTANTLY CHANGING: While missions stay the same, public health programs continually evolve, says Columbia's Allan Rosenfield.
Many academics and researchers assert that schools of public health are at a crucial stage in their 80-year existence. (The first school, the Johns Hopkins School of Hygiene and Public Health, opened its doors in 1916.) New and reemerging infections such as hantavirus and tuberculosis-along with the continuing death toll from AIDS-put public health research in increasing demand. Managed-care organizations, which stress preventive medicine, also help focus attention on public health.
"It's a great time for schools of public health," contends Alfred Sommer, current dean of the Johns Hopkins school. "The revolution in health care has put a renewed emphasis on those disciplines that have their homes in schools of public health. It's a great paradigm shift that managed care has brought about in the health care cost crisis.
"As a doctor in a managed-care organization, I'm no longer responsible for just a patient," he explains. "I'm responsible for a population. I'm responsible for maximizing the health of the population I've contracted for. I have to think in those terms."
According to Sommer, public health is "based on maximizing the health of the population, vs. a doctor treating a single patient for an illness. It takes that broader view to maximize the health of the public, including the delivery of health services to a population."
Sommer gives an example of public health in action: A county in Maryland has a high cancer rate. Public health professionals might hunt for possible causes, and develop appropriate screening and prevention methods for the population at risk.
Schools of public health cover a wide variety of issues, from preventing infectious diseases to understanding how to deal with a health-care ethic that emphasizes prevention. At the same time, the schools are remaining true to their traditional education and research roots in areas such as epidemiology, environmental health, biostatistics, and community health.
BRANCHING OUT: SUNY's David Carpenter sees public health as going beyong disease prevention.
Carpenter contends that there should be more than the current total of 27 fully accredited schools of public health in the United States (see list on page 5). "It's surprising that we haven't had a rapid growth before now in schools of public health," he says, noting that some 10 or 12 new schools now are forming around the country. "I think there's a national realization that public health schools are important parts of our health care system, and need to be a part of doctors' training."
Many scientists see a need for greater interaction among schools of medicine and public health. "A number of joint meetings between the American Medical Association and the American Public Health Association have discussed the notion that medical students today increasingly need to know new sorts of things, such as societal determinants of disease, malnutrition, and drug abuse," Sommer points out. "There's a tremendous push to bring the public health perspective into medicine, and there's equally compelling argument to bring medicine into public health."
MULTIFACETED: Emory dean James Curran sees public health as applied and interdisciplinary.
The missions of medicine and public health are both very different and complementary, maintains Roger J. Pomerantz, a professor of medicine and director of the division of infectious diseases at Thomas Jefferson University in Philadelphia. Often public health researchers have joint appointments in medical schools.
"From an infectious disease standpoint, they look at an entire epidemic," Pomerantz says. "In a medical school, we look at clinical and basic research and clinical care of patients. We've never been good at tracking disease-we need schools to evaluate epidemics, how they spread, what are the factors involved, how they take hold in certain regions, and how to stem their tide. It's arguable that most of the progress against AIDS is from work at public health schools, and not medicine. We've learned how HIV is transmitted and about high-risk behaviors, for example."
While schools of public health aren't the only place for study and research in these disciplines, they provide a centralized home for curricula and research. Examples abound of recent headline-grabbing research that combines the disciplines of public health and medicine. In January, the National Cancer Institute announced it was ending a four-year study on the cancer-preventive effects of beta carotene and vitamin A supplements two years early. The project, headed by Gilbert Omenn, dean of the University of Washington School of Public Health and Community Medicine, focused on men at risk for lung cancer. Surprisingly, early results showed those taking the supplements had a 28 percent higher risk of lung cancer.
A MISSING LINK? Columbia's Marilie Gammon studies pesticide levels and cancer.
Not all schools of public health are focused on such groundbreaking research. Traditionally, state schools of public health are smaller, aimed at training state health officers, and are less research-driven. Larger, private institutions tend to stress research. Some schools that are just starting out are looking to combine both goals.
This fall, 29 students are attending the first classes of the newly established school of public health at Allegheny University of the Health Sciences-the first in Philadelphia. The new school, which now offers a master's in public health, will concentrate in disciplines such as biostatistics, epidemiology, environmental and occupational health, and health management and policy. The school, however, has yet to get accredited, a process that takes several years and requires an institution to prove its academic mettle.
Acting dean William Welton contends that the time is ripe for a school of public health in a major metropolitan area such as Philadelphia. "It [a school of public health] provides us opportunities to think of old problems in new ways.
"There will be more opportunities for integration across scientific disciplines," he points out. "The question is, how do we integrate the work in science labs in a medical school with the work of epidemiologists, behavior specialists, [and] statisticians with community-based physicians?"
Improving the population's health will require education, general understanding of how diseases occur, and a knowledge of health systems, in addition to direct medical intervention, he says. "Many of the nation's public health tenets are changing. It's a challenge for public health schools to change what and how they teach, and their research.
"From our standpoint [as a new school], it's both an opportunity and problem," he says. "We can identify what programs need to be emphasized, and how we should structure our programs and school."
While overall missions may stay the same, university public health programs are continually evolving. "[Today's schools] have an increasing role to play in assessing the outcomes and quality of care, in conjunction with managed-care organizations and academic medical centers," says Allan Rosenfield, dean of the Columbia School of Public Health.
Columbia's research agenda is broad, including such topics as environmental health, AIDS, tobacco use, and teen pregnancy. "Issues change-certainly health policy and health care reform, the uninsured, Medicaid changes-all have generated great interest," he notes.
SUNY-Albany stresses a hands-on approach to public health, according to Carpenter, who also is a research physician for the state department of health. "We've evolved a unique approach to education. We are the only school that mandates practical experience in our professional program, patterned after what medical schools do.
"Graduate education is in-depth study in a narrow field, subject-specific. Professional instruction is in the range of relevant basic disciplines, working in an apprentice fashion. The state department of health perceived that students from schools of public health couldn't hit the ground running. We adopted a different philosophy." At present, half of the Albany school of public health's resources come from the university, and half from the department of health.
At Emory, Curran says, the program stresses three features: interdisciplinary and applied research, along with a population perspective. "For example, researchers are examining poor health, drug use, and AIDS in poor women in Atlanta. Others are looking at asthma in the inner city, which involves environmental health toxicologists and epidemiologists."
CONNECTED: The AIDS work of Harvard's Max Essex bridges basic research, medicine and social concerns.
Essex, chairman of the Harvard AIDS Institute, says: "If you understand AIDS, you understand public health." He notes that AIDS efforts combine basic research and preventive medicine, in addition to social and behavioral concerns. "A researcher in AIDS research at a public health institution would be more likely be doing vaccine research or behavior modification."
He notes the "greater awareness of the need for preventive medicine in the U.S., perhaps more so than anywhere else. We came to the realization that we were spending 14 percent of gross national product and not getting any healthier. Other countries were spending far less."
Managed care's effects on the health care system bode well for the future of schools of public health, says Essex. "Part of the health-care revolution was the realization that we can't continue to spend more on high-tech medicine and drugs to treat heart disease and cancer. It slapped medicine in the face to set up new pricing structures."
Despite the boost public health received from the managed-care revolution, researchers in the field complain that the area of public health is underfunded. They cite a lack of public awareness about the importance of the roles of public health practitioners and researchers, and say that major funding agencies are often more disease- or crisis-oriented. Prevention research, they point out, lacks glamour.
When it comes to appropriating dollars, funders look at the "sexy technologies; public health has few sexy technologies," stresses Edith Leyasmeyer, dean of the University of Minnesota's school of public health. "It's a challenge to sell concepts. Prevention is behind-the-scenes work," she notes.
NEW FOCUS: Johns Hopkins Alfred Sommer says the health care revolution of the 1990s puts attention on public health.
It's not the same as "when we reorganize health care funding or increase understanding of the molecular biology of a virus to develop a vaccine against a disease," Sommer points out.
BOOSTER: Jefferson's Roger Pomerantz points to the contributions of public health in the fight against AIDS.
Unfortunately, the funding gaps between medicine and public health probably result from the image of public health as less scientific, says Pomerantz. "It is easier to understand, and people tend to think of it as less important, though that isn't the fact."
"Even though public health in general has had as much an impact on the health of the nation as anything "[it was] never well-funded," says Columbia's Rosenfield. "The bulk of federal support goes to medical schools."
Public health schools therefore are looking for alternative sources of funds. One such source is the Centers for Disease Control and Prevention Cooperative Program, which began in 1981 as an agreement among CDC, schools of public health, and state and local health departments to conduct research in public health. Funding has grown from $400,000 in its first year to more than $9 million today.
Scott Becker, assistant director of the Washington, D.C.-based Association of Schools of Public Health, says the program assists schools to integrate applied public health into the curriculum by allowing faculty to work on projects within the community. Typically, a partnership is built in with public health agencies. It also assists CDC in reaching out to the public health communities. Faculty whose appointment is in a school of public health may apply.
For example, the University of Washington, Johns Hopkins, and Columbia are working on a joint project to examine the effectiveness of skill-building support groups in helping high-risk HIV-negative women from contracting the virus and other sexually transmitted diseases compared with women in a control group.
Omenn notes that the cooperative program-a mechanism for competitive, peer-reviewed research funding-is "important and should grow."
Yet Omenn comments that CDC is not a major funder of external research and that public health needs more sources of such money. Several NIH institutes-such as the National Cancer Institute, the National Institute for Child Health and Human Development, and the National Institute on Aging-sponsor public health-related research.
Those funding woes will not go away, despite rising demand for public health professionals, according to many public health deans and researchers. Donald Mattison, dean of the University of Pittsburgh Graduate School of Public Health, points to "grappling with a menu of population-based problems that are always evolving." One such problem, he contends, is "dealing with a culturally diverse-and aging-population with a variety of health and social problems."
According to Mattison, the focus of the federal health-care investment has traditionally been on care of the sick, rather than on prevention. "We're still in that mode, and it's too early in this transition to prevention-it hasn't percolated into the consciousness of the decision-makers that these are the skills they will need."
Among the future challenges for public health, he says, are understanding how to develop better measuring techniques and indices, and encouraging students in research despite fiscal restraints. He asks, for example, how schools will be able to train students in a broad range of public health fields when faced with a lack of resources and federal funds.
Dean Stephen Gehlbach of the University of Massachusetts School of Public Health in Amherst sees health services as moving to the forefront of public health research. He calls it the "other end of health care"-how to deliver services in a cost-efficient manner. "For example, more efficient management of health centers, cutting down on overuse of technologies, what preventive services should be provided in an HMO [health-maintenance organization], and the cost-effectiveness of medical treatments.
"These are different [areas] from what public health has been historically involved in," he notes. Columbia epidemiologist Marilie Gammon is a veteran of population-based studies. "When I started out 20 years ago, few people [in the public] had heard of epidemiology," she recalls. "Now it makes that front page of the New York Times. It's become much more applied. People can relate to many of these types of studies because they concern their lives.
"The challenge will be to continue to do good work and get funded," she notes.
ATTENTION-GETTER: Judith Jones of Columbia sees challenges ahead in securing funding.
Jones is currently director of the Robert Wood Johnson Foundation's National Initiative for Head Start, based in Princeton, N.J. Her work focuses on outreach, education, and prevention. "We're hoping to better understand what works [by] identifying helpful interventions. We're trying to strengthen families, change community norms."
Epidemiologist Sylvia Furner, associate dean of the University of Illinois' School of Public Health in Chicago, contends that public health schools are even more important today than they were 20 years ago: "The area [of public health] emerging in Chicago is the creation of programs for health and well-being. We have programs in which we go into schools and instruct students, parents, and teachers about the risks of asthma, for example.
"Our profile is low," she acknowledges. But she notes that "the issues of managed care and issues of access to health care are becoming more visible. [Public health] schools with community involvement will be more visible and effective.
"I think right now is when we [schools of public health] will begin to get noticed," Furner says. "The importance of preventive medicine and access to such care is becoming more visible. We train two kinds of students here-public health professionals, who run the applied programs, and scientists, who do more basic research."
Such disciplines will have to merge to create effective schools of public health, according to a 1988 Institute of Medicine report (The Future of Public Health, Washington, D.C., National Academy Press). As schools are created, they must incorporate more community interaction into their programs, says Carpenter. "I think hands-on, practical training is what's needed," he states. "Schools have not for the most part been part of the [public health] agencies that practice the professions." However, he notes, "It's starting to shift."