Public Health Professionals Research Paper

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Explanation Of Terms

Public Health

Public health was defined by Winslow in 1923 as

‘‘the science and art of preventing disease, prolonging life and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health’’ (Winslow, 1923: 1).

The 1988 Institute of Medicine report on the state of the U.S. public health system defined public health as ‘‘organized community efforts aimed at the prevention of disease and promotion of health.’’ The report also described public health as ‘‘what we, as a society, do collectively to assure the conditions in which people can be healthy’’ (Institute of Medicine, 1988: 40–41).

Public health is the science of protecting and improving the health of communities through creation of social conditions conducive to health, education, the promotion of healthy lifestyles, and research for disease and injury prevention. Public health involves the application of many different disciplines including epidemiology, biostatistics, anthropology, medicine, sociology, and public policy, to name a few.

Public Health Professionals

Broadly speaking, public health professionals are all those individuals who practice public health principles and methods in diverse areas such as program management, policy development, research, and surveillance. A recent Institute of Medicine study on educating public health professionals for the twenty-first century defines a public health professional as ‘‘a person educated in public health or a related discipline who is employed to improve health through a population focus’’ (Institute of Medicine, 2003: 30). The scope of work of public health professionals is large, and to some extent, not very strictly defined. Public health professionals may primarily focus on individual risk factors of disease and health conditions. Alternately, they may focus on social, environmental, and economic factors influencing health, such as income, education, housing, and so on. Another angle of addressing public health can be making the political landscape more committed to improving health of populations through appropriate policy development and advocacy. Finally, public health professionals can be primarily engaged in research – academic and operational – to build the evidence base for appropriate interventions and policies.

Public health professionals form an important part of the health workforce, together with clinical practitioners and other health professionals. The field of public health practice exists in most countries, although in different forms, and is developed to varying degrees. In countries such as the United States, UK, Australia, and Canada, the profession is well developed and widely recognized. In others, mostly developing countries of Asia and Africa, the profession is still struggling to establish an identity separate from and of equivalent standing as clinical medicine.

Public Health Practice/Service

According to the Public Health Function steering committee of the Institute of Medicine, the following are commonly presented as the 10 essential public health functions:

  1. Monitor health status to identify community health problems.
  2. Diagnose and investigate health problems and health hazards in the community.
  3. Inform, educate, and empower people about health issues.
  4. Mobilize community partnerships to identify and solve health problems.
  5. Develop policies and plans that support individual and community health efforts.
  6. Enforce laws and regulations that protect health and ensure safety.
  7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable.
  8. Assure a competent public health and personal health-care workforce.
  9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
  10. Research for new insights and innovative solutions to health problems.

Public health practice involves engagement of multiple sectors that influence health outcomes, such as education, legislation, and economics, among others.

Development Of Public Health As A Profession

Development of public health as a profession is closely linked with the history and development of public health as a field separate from medical practice. Historically, health has been dominated by a biomedical model. Early efforts to control and prevent infectious disease involved interventions like popular education, fumigation, disinfection, and vaccination. Responsibility for disease control and prevention was that of two groups – the medical officers (family doctors) and health officers. The doctors would diagnose the disease, advise patients about cure and prevention, and inform local health departments about occurrence of the disease. The health officers primarily included quarantine and sanitary officers who worked with the health departments and focused on aspects like sanitation of environments and isolation of patients. This group in some ways represented the earliest development of the public health professional cadre.

Legislative and administrative developments in the nineteenth century contributed to the establishment of the public health profession. Several public health laws were enacted, often led not by medical doctors but by lawyers and public service workers. Several initiatives related to sanitation and sewage disposal were connected to developments in engineering, not medicine. The individual responsible for establishment of the first sanitary commission (in the UK) – Edwin Chadwick – was a lawyer, who also made extensive observations on workers’ health in occupational settings. Demographers began using legislation on provision of vital statistics like birth and death rates to inform medicine and health issues. Early epidemiologists started drawing on geographical patterns of disease and impact of employment on health. Thus began the inclusion of nonmedical professional disciplines in addressing health and disease. Administrative developments included the establishment of a centralized department of health in the UK as well as the later establishment of the public health service in the United States. These bodies consisted of a number of qualified medical and scientific experts who started conducting investigations in communities, bringing back samples and data to the laboratory for analysis and relating disease to social and economic factors. Several health-related acts were passed in the UK, including one that made it possible to appoint medical officers of health, thereby further delineating the preventive medicine, or public health profession.

Other factors that contributed to professionalization of public health included:

  • Setting educational standards for preventive medicine;
  • Creating public health journals (which contributed to establishing a professional identity for subscribers);
  • A registration system for health officers.

Disciplines like epidemiology and bacteriology enabled separation of public health professionals from medical doctors. In fact, the public health group started making certain demands, such as reporting infectious disease, on the medical doctors. This led to certain friction between the two groups, some of which we see even today.

The last century has seen a definite shift in the composition of public health professionals from only physicians to a diverse group with different backgrounds. For example, today we find many health administrators and environmental scientists working on public health issues; perhaps they outnumber physicians working in public health in certain countries. Public health is also leaning toward a broader understanding of health determinants such as behavioral sciences and economic factors.

Positioning Public Health Professionals In The Overall Health Workforce

Public health professionals try to prevent health problems from happening or re-occurring through implementing educational programs, developing policies, administering services, and conducting research, in contrast to clinical professionals, such as doctors and nurses, who focus primarily on treating individuals after they become sick or injured. They have an important role to play in designing health policy; implementing and evaluating health programs and health systems, and managing the health workforce comprising clinicians and paramedical professionals. They fulfill diverse roles – ranging from demographers and public health scientists to administrators and health communicators. Public health professionals serve unique functions as part of the health workforce and constitute an integral component of any modern health system.

Education And Training Of Public Health Professionals

Overview Of Public Health Education

In the last few decades, increasing demand for professionally trained public health professionals has led to emergence of several academic and other training programs for individuals aspiring to work in this field. While countries such as the United States and the UK boast well-established schools (and even associations of schools) of public health, developing countries such as Thailand have also established national schools of public health. Still others like India have recently launched initiatives to establish public health academic programs. In addition to public health programs, which typically admit students from various backgrounds, several countries also maintain the traditional residency programs in preventive and social medicine that are open for admission only to physicians.

Public health professionals require up-to-date information and training to keep up with the dynamic nature of this field. Further, education and training needs to be relevant to the context in which these professionals work. The context includes the health system, national policy structure, functions, and expected outcomes. For example, a community health administrator requires a set of skills and knowledge different from those required by a health advocate. Also, differences in distribution and determinants of health and disease among different population groups determines the types of skills and training required of the public health professionals.

Core Competencies Of Public Health Professionals

The U.S. Council on Linkages between academia and public health practice developed (in 2001) a set of core competencies for public health professionals. These were developed as a consensus set through collaborative work between various professionals and organizations, including public comments. The core competencies represent a set of skills, knowledge, and attitudes necessary for the broad practice of public health. The competencies are divided into eight domains. These domains are listed below with examples of specific skills therein:

  1. Analytic Assessment Skills (determines appropriate uses and limitations of both quantitative and qualitative data; identifies relevant and appropriate data and information sources; makes relevant inferences from quantitative and qualitative data).
  2. Basic Public Health Sciences Skills (identifies and applies basic research methods used in public health; applies the basic public health sciences including behavioral and social sciences, epidemiology, and prevention of chronic and infectious diseases).
  3. Cultural Competency Skills (utilizes appropriate methods for interacting sensitively, effectively, and professionally with persons from diverse backgrounds; identifies the role of cultural, social, and behavioral factors in determining the delivery of public health services; understands the importance of a diverse public health workforce).
  4. Communication Skills (communicates effectively both in writing and orally or in other ways; advocates for public health programs and resources; effectively presents accurate demographic and scientific information for professional and lay audiences).
  5. Community Dimensions of Practice Skills (establishes and maintains linkages with key stakeholders; accomplishes effective community engagements; develops, implements, and evaluates a community public health assessment).
  6. Financial Planning and Management Skills (manages programs within budget constraints; develops strategies for determining budget priorities; prepares proposals for funding from external sources).
  7. Leadership and Systems Thinking Skills (creates a culture of ethical standards within organizations and communities; promotes team and organizational learning).
  8. Policy Development/Program Planning Skills (states policy options and writes clear and concise policy statements; utilizes current techniques in decision analysis and health planning; translates policy into organizational plans, structures, and programs).

Although these core competencies were developed in the United States, a close review indicates that these general sets of skills are applicable to public health professionals across countries. Such a listing can guide curriculum and content development of public health education and training programs for public health professionals. They can also be used as a framework for hiring and evaluating staff (Institute of Medicine, 2002).

Structure Of Academic Programs/Training

Public health education is provided through both on-the campus and distance-based models. It is well established as a formal academic program in several developed countries, and is gaining a foothold in parts of the developing world. On-the-job training for staff employed in public health systems is another common modality of public health teaching.

Formal Academic Programs

Public health degree programs at undergraduate, graduate, and postgraduate levels are offered in many universities, in particular, in North America, Europe, Australia, and New Zealand. The purpose of the undergraduate or baccalaureate programs is to prepare graduates for entry-level professional practice in a variety of public health settings. The purpose of the master’s level graduate programs is to prepare advanced professionals and managers for public health. The purpose of doctoral or postgraduate programs is to conduct research that advances the theoretical foundation of public health practice and healthcare delivery. Public health academic programs can be broadly divided into programs that are professionally oriented and those that are academically oriented.

Professional degrees generally have a greater orientation toward practice in public health settings. The Masters in Public Health (MPH), Doctor of Public Health (DrPH), and Masters in Health or Hospital Administration (MHA) are example of degrees that are geared toward those who want careers as practitioners of public health in traditional health departments, managed care organizations, community-based organizations, hospitals, consulting firms, international agencies, and state and federal agencies, among others.

Academic degrees are more oriented toward students wishing to seek a career in academics and research rather than public health practice. Examples of academic degrees are the Masters of Science (MS), Doctor of Philosophy (PhD), and Doctor of Science (ScD) in subjects like immunology, genetics, and biostatistics.

Although it is possible to learn about public health practice through work experience, many public health positions require a degree in public health. A formal academic degree enables public health professionals to gain knowledge of the factors that influence local, national, and global legislative and social polices; apply broad-based, state-of-the-art quantitative and qualitative skills needed for problem solving; develop multidisciplinary and collaborative strategies for solving health-related problems; and enhance communication skills by working with diverse populations, and to be positioned for a leadership role in health promotion and disease prevention (Institute of Medicine, 2003).

Informal Training

In several countries, formal public health academic training is not commonly available. Several governments provide inservice short-term training programs to health sector employees. These are typically provided by national health institutes, nongovernmental organizations, and international health agencies.

Continuing Public Health Education

Like any other profession, in public health as well, continuing education and training at repeated intervals is very important for professionals to keep abreast with developments in the field. This is crucial especially in today’s world where the public health community is faced with several new challenges such as chronic disease burden and health in disaster situations.

Many of the established public health schools offer opportunities for taking continuing education credits through on-site and distance-based courses. These meet the educational needs of working professionals – health practitioners, educators, scientists – who seek expanded skills, new credentials, career advancement, and an enhanced quality of working life.

Areas Of Specialization

In addition to the general bachelor’s or master’s level public health degree, some professionals proceed to specialize in specific disciplines. These include health policy and management, epidemiology, biostatistics, behavioral science and health education, health communications, occupational safety and health, environmental health sciences, international and global health, public health preparedness, oral health, family health, and research methodology. This creates a cadre of specialists to work in specific areas of the public health system.

Careers In Public Health

Public health careers inherently interest individuals who derive satisfaction from working to improve health of populations. The public health field challenges professionals to confront complex health issues like chronic disease control, health system reforms, health financing, and protection from occupational health hazards, to name a few. Working in public health can also be enriching due to its multisectoral nature. Professionals in this field come from a diverse array of backgrounds – educators, economists, lawyers, doctors, and so on. Leadership opportunities abound in this field in both national and international organizations.

Public Health Workplaces – Public Sector, Private Sector, Nongovernmental Agencies

Public health professionals work in both the public and private sectors. Many public health graduates begin work in the public sector in local, state, or central health departments. The jobs available at health departments range from food safety inspectors to health educators; from policy analysts to epidemiologists. Other public health professionals work in university systems as researchers and teachers. Those interested in working for a nonprofit organization can find jobs in health advocacy, policy, or research for international organizations such as the Red Cross or Medicins Sans Frontiers (Doctors without Borders), or local non-profit organizations that focus on specific health issues. Another group of organizations is the international agencies like the World Health Organization, UNAIDS, and UNICEF. These bodies recruit public health professionals with diverse backgrounds to serve on international health projects. Public health professionals are also in demand in the private sector – to work on clinical research for pharmaceutical companies or as managers and experts for health insurance companies.

Examples of professional paths are as follows:

  • Health policy and management: academic/management/ legislative policy adviser;
  • Epidemiology: research/state-level or district-level/pharmaco-epidemiologist;
  • Behavioral sciences and health education: mental health researcher/health educator/behavioral scientist;
  • Health communications: communications specialist/ journalist;
  • Occupational health: corporate medical director;
  • Social health work: nongovernmental agencies, international humanitarian bodies.

Other Professionals In Public Health

Public Health Nursing

The American Public Health Association defines public health nursing as the practice of promoting and protecting the health of populations using knowledge from nursing and social and public health sciences. Public health nursing is population-focused, community-oriented nursing practice. The goal of public health nursing is the prevention of disease and disability for all people through the creation of conditions in which people can be healthy (Demetrius, 2004). Public health nursing practice is considered to include the core functions of public health: assessment, policy development, and assurance activities. Community health nursing, often used synonymously, is a synthesis of nursing practice and public health practice, applied to promoting and preserving the health of populations. Public health nursing degree programs at various levels are offered in selected universities globally. Developing countries that are faced with a shortage of health workers should aim to explore the potential of utilizing public health nurses to serve several core public health activities. There are examples of such initiatives, such as the auxiliary nurse midwives in South East Asia who provide basic clinical, health promotion, and health education services and support local health centers in monitoring population health.

Public Health Lawyers

Public health law is a form of public health policy that integrates concepts from law, medicine, health care, and public health. Public health law typically includes certain public health interventions of a legal nature. Thus, implementation of public health law is an essential element in ensuring population-level health, especially through governmental entities. It provides public health professionals with the legal basis for their practice and defines the scope of their practice. In recent decades, public health law has developed as a specialization – both for general lawyers and public health practitioners. International legislation such as international health regulations and public health treaties call for legal expertise in public health, at both national and international levels (Gostin, 2000).

Health Economists

Scarcity of resources in the public health sector and the need to prioritize makes economics of health an important area of work. The aim of health economists is often to inform decision makers on choices they make to maximize health benefits to the population. This involves improving the level and distribution of population health within the resources available in an equitable manner. Health economists are engaged in several areas of public health practice including evaluation of health programs, study of health financing, and health systems development.

Emerging Roles Of Public Health Professionals

Emerging Public Health Threats

Re-Emerging Infectious Diseases

Emerging diseases include outbreaks of previously unknown diseases or known diseases whose incidence in humans has significantly increased in the past two decades. Re-emerging diseases are known diseases that have reappeared after a significant decline in incidence. Changes in human demographics, behavior, land use, and so on are contributing to new disease emergence by changing transmission dynamics, bringing people into closer and more frequent contact with pathogens. In addition to the continual discovery of new human pathogens, old infectious disease enemies are ‘re-emerging.’ Natural genetic variations, recombinations, and adaptations allow new strains of known pathogens to appear, pathogens to which the immune system has not been exposed and is therefore not primed to recognize (e.g., influenza). Furthermore, human behavior plays an important role in re-emergence. Increased and sometimes imprudent use of antimicrobial drugs and pesticides has led to the development of resistant pathogens, allowing many diseases that were formerly treatable with drugs to make a comeback (e.g., tuberculosis, malaria, and nosocomial and food-borne infections).

Public health professionals are faced with the challenge of preventing, identifying, and controlling spread of these infectious diseases. This involves strengthening basic and applied research on the diseases, identifying better control strategies for infections (like tuberculosis, malaria, and selected zoonoses) that continue to challenge global health, and maintaining national and international expertise to respond to future threats by supporting scientific exchange and training.

Chronic Diseases And Conditions

In 2004 Brownson and Bright aptly described

‘‘the origins of modern public health can be traced back to infectious disease epidemics of now uncommon diseases such as cholera, plague, and leprosy. As these diseases were controlled through a combination of improved sanitation and hygiene, the discovery of antibiotics, and vaccination programs, chronic diseases such as heart disease, cancer, and diabetes became increasingly prevalent over the twentieth century. Today, heart disease, cancer, and stroke are the three leading causes of death, accounting for almost two-thirds of all deaths’’ (Brownson and Bright, 2004).

Chronic disease prevention and control of risk factors requires urgent attention. This subject also throws up unique challenges for public health professionals who have traditionally worked on (infectious) disease control. For example, chronic disease control requires policy interventions that go beyond the scope of the health sector and that need cooperation with other sectors like trade and finance. Control of risk factors like tobacco use, alcohol consumption, and obesity demand a set of multisectoral strategies. And conditions like road traffic injuries require an understanding of broader development issues like urban planning and transport systems. The political commitment and innovative policy development required for chronic disease control and prevention add to the complexity of this field (World Health Organization, 2005).

Health Management In Disaster Situations

Emergencies and disasters affect the health and well-being of populations – large sections may be displaced or may be subject to risks of epidemics, infrastructure may be destroyed or compromised, and huge economic losses may be incurred. Disasters can be of several types, such as natural disasters (earthquakes and tornadoes), politically unstable situations (war, riots), and pandemics or large epidemics of infectious diseases. Disasters affect population health in multiple ways, through injuries and death, increase in endemic diseases and breakout of epidemics, emotional stress, and breakdown of health service delivery systems, to name a few. Globalization, increasing world population, and environmental deterioration make people across several continents vulnerable to the health impact of disaster situations. Public health professionals are called on to serve nationally and internationally in such situations. Therefore, it becomes crucial to improve the capacity of the international public health and humanitarian community in emergencies. Efforts are being made at the international level by agencies like the World Health Organization in order to strengthen the public health and the personal and operational skills required by public health professionals to work as part of public health response teams in emergency settings. Public health professionals deployed by such agencies for health activities in disasters are under immense pressure to work safely and effectively in interagency and national country teams, so that humanitarian health is delivered in a predictable manner and that, ultimately, health action in crises is improved.

Bioterrorism

The potential threat of use of biological and chemical agents has led to recent calls for public health preparedness in this area by the international community. The first to respond to an attack with a toxic substance having immediate effects are likely to be the police, fire departments, and emergency medical personnel on or near the scene. In contrast, the first to respond to an initially undetected attack with an infective or toxic agent having only delayed effects are more likely to be regular healthcare providers, including nurses, physicians, and hospital accident and emergency personnel, who may be located in widely separated places. While chemical weapons can place a great burden on public safety personnel, and biological weapons on the public health infrastructure, they can both place an extraordinary burden on the local health-care delivery system. Public health professionals are likely to be called on to support activities like assessment of the risks, managing the risks (introduction of risk reduction and control measures), monitoring activities, and communicating the risks. International and national agencies have begun to identify capacities that need to be developed in a section of the public health community so that these professionals can provide such support, should the need arise.

Health Management

Public health professionals are often called on to serve in supervisory and management roles. This may involve managing actual implementation of health interventions or managing public health teams which in turn are responsible for field operations. Not many public health professionals are traditionally trained in management principles like human resource management, finances and accounting, principles of ethical management, and cultural and diversity issues. However, understanding management principles becomes critical for professionals who are called on to play diverse roles, such as chief executive officers of national health agencies, managed health-care leaders, and health insurance specialists. Several disease control programs are funded through international agencies – working on such projects also requires a solid understanding of management principles. In fact, emphasis on ‘de-medicalization’ of public health partly draws from the need to have such a diverse range of skills among public health professionals (Boedigheimer and Gebbie, 2001).

Health Information Technology

Public health informatics, a hitherto practically unknown field, is defined as the systematic application of information and computer science and technology to public health practice, research, and learning. This field includes a focus on applications of information science and technology that promote health of populations; and a focus on disease prevention and operations largely within a governmental context. Medical and health practitioners have been using computers, networks, and databases for a long time. However, the concept of public health information systems is still relatively new in most parts of the world. Few public health professionals receive formal training in informatics. They are not fully aware of the nature and purpose of informatics in health, nor of the potential, if any, of information technology to improve and even transform public health practice. Drivers of change forcing public health professionals to be conversant with the development, use, and strategic importance of computerized health information systems include emerging public health issues, growth in managed care, and the information technology revolution. Countries with a well-established public health infrastructure are beginning to recognize the potential of this emerging field in public health practice. Public health professionals of the future will have to familiarize themselves with this emerging branch, which can play a key role in maintaining, updating, and analyzing information related to the health status of populations, thereby informing policy development. Mortality and morbidity data, vital statistics systems, and public health surveillance of health conditions can all benefit through applications of information technology. Some examples of applications include networking for public health officials, use of data analysis for policy objectives, and national-level health surveys (O’Caroll et al., 2003).

Achievement Of Overall Development Goals

The Millennium Development Goals (MDGs), endorsed by all United Nations Member States at the 2000 Millennium Summit, provide ambitious targets for reducing poverty. Health is at the core of the MDGs. Three of the eight Development Goals, eight of the 18 targets, and 18 of the 48 indicators are health related. The MDGs do not provide a comprehensive list of health targets (e.g., lacking indicators for reproductive health, reduction in noncommunicable disease, and HIV treatment). However, they are an important milestone in progress toward health for all. Public health agencies, both national and international, have incorporated achievement of the health-related targets along with the overall MDG targets. Public health professionals will be required to be familiar with the health related MDG targets and to engage in health programs that aim to support attainment of these targets.

Public Health Leadership

Public health professionals are challenged with ensuring the provision of public health services in an environment of change that requires adequate preparation in the discipline of public health and the leadership ability to mobilize communities. Public health professionals with leadership skills are required to guide other professionals forward during times of uncertainty and to ensure that the public health needs of various and diverse populations are met. Leadership is the ability to influence a group to move forward toward a mutually agreed on community goal. Leaders are focused on moving the public health agenda forward toward a healthier nation. Public health leadership requires a desire, a commitment, and adequate public health preparation and experience to effectively lead.

Critical leadership skills for public health professionals include communication; public health practice experience; understanding of public health values, history, and methods; cultural competence; negotiation skills; organizational management; and public health emergency decision-making abilities.

Looking Ahead

Challenges Of Globalization

Public health continues to be challenged with change: increased technology, international integration of economic and human resources, and emergence of developing countries are powerful forces in global markets and powerful changes in social structures. Globalization in the world economy in general has led to globalization of public health efforts, as can be seen through international public health treaties and international health regulations. This presents increased opportunities and challenges for public health practice.

Multi-Sectoral Nature Of Public Health Practice

Increasingly, multiple sectors outside the health sector are being identified as stakeholders in health policy development and implementation. This includes not only the public sector but also agencies from the private sector. Law, finance, trade, and telecommunications are examples of sectors within governments with which the health sectors are required to collaborate on various aspects of public health. Numerous legislations and regulations impact health of populations, likewise public health interventions call for economic and legal interventions for successful implementation. Thus, the public health professionals of tomorrow will be expected to have a wider understanding of determinants of public health beyond the health sector. Another challenge will be to work in close collaboration with multiple sectors, something that the traditional medical infrastructure, and even the health system to some extent, has not focused on, yet.

Migration Of (Public) Health Professionals

Migration of health workers is an important factor contributing to global shortages in the health-care delivery systems. Although no specific information is available about movement of public health professionals, they obviously constitute a component of this migratory workforce. In particular, a lack of formal academic programs and a scarcity of well-remunerated positions lead to the migration of young professionals interested in training, research, and practice in public health, from developing countries to developed countries. Thus, the issue is two-pronged – public health professionals themselves are in short supply in certain countries, and they must deal with the lack of other health-care workers in the delivery systems. Recent global reports and initiatives have begun addressing this issue within the overall context of shortage of health workers due to various factors (World Health Organization, 2006).

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