Schools of Public Health Research Paper

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This research paper is concerned with the history of schools of public health. It asks, ‘What are schools of public health and what do we know about them? Are we able to assess their contributions to improving the health of populations? What strengths and limitations have they demonstrated?’

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Broadly speaking, there are two views on the history of schools of public health. The more positive perspective sees schools of public health as key mechanisms underpinning progress in public health, providing the research evidence base and teaching practitioners. Advocates might point to the innovative work of Wade Hampton Frost in developing the science of epidemiology at the Johns Hopkins School of Hygiene and Public Health in the 1920s or Austin Bradford Hill’s seminal work with Richard Doll at the London School of Hygiene and Tropical Medicine on the link between smoking and lung cancer in the 1950s. With regard to teaching, Balinska (2000), for example, has argued the contribution of the National Institute of Hygiene, Poland, in training public health personnel for the Polish health service which had previously lacked a public health infrastructure. Thus, research and teaching undertaken in schools of public health have arguably made fundamental contributions to improvements in the health of populations over the past 150 years.

The alternative, more pessimistic perspective is that schools of public health have not fulfilled their potential to contribute to improving the health of populations. This view emphasizes the tensions between biomedical and social models of public health. It argues that since the early twentieth century schools of public health have been dominated by a narrow medical model and a focus on laboratory and other forms of scientific research rather than on the learning needs of public health practitioners and on wider social and political action addressing the determinants of health. Moreover, in global terms, schools of public health can be seen as yet another example of the top-down imposition of inappropriate health policy models from the rich developed countries to poorer developing countries.

There may well be elements of truth in both these perspectives; as evidence of the impact of schools of public health is scarce, it is difficult to come to a firm conclusion between them. Moreover, as with all aspects of evaluating complex systems, it is difficult to determine the specific contribution of schools of public health compared with other aspects of public health – national macroeconomic policy, primary health care, state public health services, nongovernmental organizations, international cooperation, and so on. If no definitive answer can be given, this research paper will at least seek to lay out the questions and explore the issues.

Many aspects of the history of public health are beset with definitional issues, but few more so than the history of schools of public health. What, in fact, is a ‘school of public health’? There is no universally agreed definition. In the U. S., there is now a generally recognized model. Schools of public health are those institutions that have met the explicit criteria for membership of the Association of Schools of Public Health. But there is no agreement on these criteria in the rest of the world. There are, for example, much more open criteria for membership of the Association of Schools of Public Health in the European Region. Thus, in Europe there is much greater diversity of participating institutions, including a number which may conduct public health research or offer postgraduate training in public health, but do not formally label themselves schools of public health. Some schools of public health are not even academic institutions but are operational public health service units attached to ministries of health. Table 1 summarizes the common functions as well as the extent of diversity of schools of public health.

Schools of Public Health Research Paper Table 1

As the table indicates, there is great diversity in the type of institutions labeled as schools of public health and there are a great many other institutions not so labeled that carry out many of the same public health teaching and research functions. The historian seeking to make sense of the history of schools of public health must accept this complex reality and the blurred boundaries between these diverse institutions. Moreover, schools of public health are located within very different national public health systems and local socioeconomic, cultural, and political contexts. Generalizations about schools of public health must therefore be made with some caution.

Historiography Of Schools Of Public Health

The history of schools of public health has been of continuing interest to a select group of public health historians, although never central to historical writing on the history of public health more generally. Within the English language literature, the most common approach to writing about schools of public health is celebratory accounts of the histories of specific institutions, usually in the U.S. More critical histories are relatively rare, and the most prolific historian in this area is Fee, who has written the history of one of the first U.S. schools of public health, the Johns Hopkins School of Hygiene and Public Health (Fee, 1987), and more general histories of schools of public health in the United States (Fee, 2003). In the UK, Wilkinson and Hardy (2001) have written the history of the London School of Hygiene and Tropical Medicine. Fee and Acheson (1991) edited a collection of papers on the history of education in public health in Britain and the U.S. There have been no general accounts of the history of schools of public health in Europe or globally.

Wider accounts of the history of public health in the nineteenth and twentieth centuries only briefly mention the development of schools of public health. The recent collection on The History of Public Health and the Modern State (Porter, 1994), for example, includes no references to schools of public health in the index and only occasional mention in the text. The history of schools of public health must often be pieced together by infrequent references in other histories, for example, from the histories of Western philanthropy in the developing world, and of the Rockefeller Foundation in particular (Farley, 2004). The special issue of Studies in History and Philosophy of Biological and Biomedical Sciences on the Rockefeller Foundation and public health introduced by Lowy and Zylberman (2000) contains a number of relevant articles. The history of schools of public health in Asia, Africa, and Latin America has been largely neglected with no specific histories of schools of public health in these regions in the English language literature (though there has been much relevant and related work on the history of social medicine in Latin America (Porter, 2006)).

Prehistory Of Schools Of Public Health

The public health movement emerged in nineteenth century Europe and the U.S. as a response to the social and health problems of industrialization and urbanization, not least epidemic diseases such as cholera. In France major educational reforms included the creation of a new medical academy in Paris with a department of hygiene. Leading French hygienists such as Villerme used epidemiological methods to demonstrate that the causes of ill health were primarily social. Virchow in Germany similarly demonstrated the social determinants of disease although he advocated a more progressive political program to address the issues. Villerme, Virchow, and many other continental European public health activists were doctors, but in Britain the first wave of public health activity was led by a broader multidisciplinary group of social reformers. Chadwick and other early British public health activists saw sanitary science, not medicine, as holding the solution to public health issues, and academic institutions and training played little part in the early British public health movement. During the course of the nineteenth century, medicine became increasingly dominant within British public health with the appointment of medical officers of health at a local and national level, and the establishment of the diploma in public health as a medical qualification to practice public health. But as British medical training was mainly located outside universities, so too was public health training.

In the late nineteenth century, a series of revolutionary scientific discoveries in Germany and France established the new sciences of bacteriology and microbiology. Koch and his associates in Germany identified the causative organisms for anthrax, tuberculosis, cholera, and a host of other infectious diseases while Pasteur and his followers developed vaccines for anthrax and rabies among other infectious diseases. New research institutes sprang up, most notably the Pasteur Institute (1888) in Paris (to be followed by a network of Pasteur institutes across the world), Koch’s Institute in Berlin (1891), the Lister Institute (1891) in London, and the Rockefeller Institute for Medical Research (1901) in New York. Although not labeled schools of public health, these medically orientated research institutes focused attention on infectious diseases as the major public health issue of the day. Thus, the success of their research contributed to the increasing dominance of medicine within the public health field. Professors of hygiene and public health were appointed in many European universities, often in medical schools, but not usually in distinct schools of public health.

The growth of academic public health first in Europe and then more widely was part of a wider public health movement and the evolution of what we today might call a public health system. Thus there was concurrently an incremental growth in public health legislation, the appointment and extended responsibilities of state public health officers, and the emergence of academic public health journals, national associations, and international conferences.

The Rockefeller Foundation And Schools Of Public Health

Any history of schools of public health must address the central role played by the Rockefeller Foundation in the development and dissemination of the concept in the twentieth century. The Rockefeller Foundation was established in 1913 by the oil magnate and philanthropist John D. Rockefeller with an original endowment of $35 million increased to almost $183 million by 1927. Its public health work followed on from the hookworm eradication campaign in the American South, conducted by the Rockefeller Sanitary Commission of 1909, and broader Rockefeller support for education and medical research. The Rockefeller-commissioned Flexner reports on medical education in the United States and Canada (1910) and Europe (1912) led to major reforms of medical education and further Rockefeller support for the development of medical schools.

The success of the anti-hookworm campaign in the American South led to two interconnected strands of Rockefeller public health activity. The first strand, initiated by Wickliffe Rose, organizer of the Rockefeller Sanitary Commission, identified the need to develop the professions of public health and to establish new institutions to train these practitioners. Rose worked with Flexner of the Rockefeller General Education Board and organized a meeting in October 1914 bringing together a group of 20 public health representatives and Rockefeller trustees. Rose’s vision was of a central scientific school linked to simpler education-focused schools of public health in each U.S. state. Flexner excluded the most influential nonmedical public health educators, William Sedgwick from the Massachusetts Institute of Technology and Edwin Seligman from Columbia University. William Henry Welch, professor of pathology at Johns Hopkins University, then re-drafted Rose’s plan into one for an ‘institute of hygiene’ with a much stronger biomedical and laboratory science emphasis and without Rose’s proposal for a network of state schools.

The Welch plan was adopted and the first U.S. school of public health following this model was endowed by the Rockefeller Foundation at Johns Hopkins in 1916, opening its doors to students in 1918. The Rockefeller Foundation subsequently funded further North American schools of public health at Harvard (1922), Toronto (1924), and Michigan (1940). The Harvard school is particularly noteworthy as it replaced a Harvard-MIT School for Health Officers which had preceded the Johns Hopkins School and gave the same attention to sanitary engineering as to medicine. Other U.S. universities, notably Yale and Columbia, continued with a broader philosophy of public health, but increasingly Johns Hopkins was the model for other U.S. schools of public health.

The second strand arising out of the anti-hookworm campaign in the American South was the internationalization of the Rockefeller public health work. In 1913 the Rockefeller Foundation established the International Health Commission (later the International Health Board) with Rose as director to extend the hookworm campaign internationally. The International Health Board became increasingly involved in wider international public health activity. One central aspect of this was the support of schools of public health outside the U.S. on the Johns Hopkins model with a strong emphasis on biomedical and laboratory science and on administrative and organizational methods. In 1913 Rose visited London and met with hookworm experts at the London School of Tropical Diseases, amongst other public health figures. The International Health Board was particularly interested in developing collaboration in British-controlled territories. Following the disruption of the First World War, renewed contacts in 1919 led to Rockefeller Foundation support for an expanded London School of Hygiene and Tropical Medicine. Rockefeller Foundation funding was granted in 1922 and eventually totaled $2 million. The new school’s charter was agreed in 1924 and it officially opened in 1929.

From Britain the Rockefeller Foundation went on to establish similar institutions in Prague, Warsaw, Copenhagen, Budapest, Belgrade, Zagreb, Calcutta (now Kolcata), Manila, Sa˜o Paulo, and Tokyo. Between 1913 and 1950 the Rockefeller Foundation spent $25 million building, equipping, and supporting a total of 22 public health schools and institutions in 17 countries. In comparison, the Rockefeller Foundation spent $60 million during this period on disease control programs out of a total expenditure on public health and medicine of $335 million (Shaplen, 1964).

This creation of an international network of schools of public health was part of a wider Rockefeller Foundation strategy of developing the science of public health. A key part of this strategy was to develop an internationally minded body of public health experts. Thus, these schools displayed not only the Rockefeller Foundation’s philosophy of the science of public health modeled on Johns Hopkins, but also its objective to develop local public health experts. Lo¨wy and Zylberman (2000) report how the direction of the Sa˜o Paulo School of Hygiene was first entrusted to an American expert from 1919 to 1921, but then transferred to a Brazilian doctor who had been educated at Johns Hopkins and was an enthusiastic supporter of American methods. This development of local expertise was supported by the Rockefeller Foundation’s fellowship program which enabled promising young public health officers, doctors, and scientists to come to the U.S., and learn the science of public health, and then return home to implement and diffuse this science.

All the Rockefeller-funded schools of public health provided the basic training required in laboratory-based disciplines such as bacteriology. They also taught the administrative methods used in the wider Rockefeller approach to public health: collection and analysis of data, and the organization of health services at local and national levels. This model of public health training was part of a wider strategy to foster the development of state public health services on a Rockefeller Foundation model, linked to ‘scientific’ programs of disease control. Moreover, the Rockefeller Foundation sought to transfer responsibility for schools of public health as rapidly as possible, preferring to fund buildings and equipment and leave recurring costs to national or local authorities (Lo¨wy and Zylberman, 2000).

During the interwar years, the Rockefeller Foundation worked closely with the League of Nations Health Organization on the promotion of international public health, but remained the better resourced and more influential body in shaping the development of schools of public health. After the Second World War, the United Nations and its subsidiary bodies, in particular the World Health Organization, increasingly took responsibility for such international public health work. The Rockefeller Foundation shifted its resources to different priorities including education, agriculture, and development, and the International Health Board was abolished in 1951.

Social Medicine

The concept of social medicine was another important influence on education for public health in the interwar period. Its origins lay in the concerns of progressive nineteenth-century doctors that medicine must be concerned with the social determinants of health and have a political role in creating just and healthy societies. Most famously, Virchow’s report on the 1848 outbreak of typhus fever in Upper Silesia identified the solution to the outbreak not in medical terms but as ‘education, liberty and prosperity.’ In the U.S. the most notable initiative, led by Winternitz, dean of the medical school at Yale, was the creation of the Institute of Human Relations to integrate medicine into research on health inequalities; but this ultimately foundered partly due to students opting for ‘high tech’ rather than social medicine. In the UK social medicine was rooted in the work of social investigators and pressure groups concerned about the health gap between rich and poor in the economic depression of the 1930s. John Ryle was appointed the first UK professor of social medicine at Oxford in 1942; UK social medicine, however, was increasingly concerned with clinical epidemiology and medical statistics rather than the socioeconomic determinants of health, and increasingly alienated from the practice of public health. Most UK universities modified their departments of public health slightly, but without fundamentally changing their approach. In continental Europe, Rene´ Sand was appointed professor of social medicine at Brussels University in 1945, and like others in social medicine he wanted to integrate medicine’s social role into the training of doctors. Sand’s influence, however, was probably greatest in the 1920s and 1930s when he played a critical role in the promotion of the new discipline, especially in Latin America where he worked for the International Health Board (see the section on Latin America later in this research paper).

Postwar Expansion Of Schools Of Public Health

The World Health Organization (WHO) was established as the international health agency of the United Nations on 7 April 1948. Among its early priorities was support to national governments with the education and training of doctors, nurses, and other health professionals, including public health practitioners. This support took a number of forms including the provision of WHO teaching staff to local education institutions. Between 1952 and 1957, 86 WHO visiting professors were appointed to 42 schools in 20 subjects (World Health Organization, 1958). Of these appointments, 31 were in preventive medicine, public health, epidemiology, and statistics. The functions of the WHO visiting professors included the reorganization of departments within the schools, the teaching of students, and the inauguration of research projects, but their paramount duty was to train local staff so that at least one person would be capable of taking over when WHO assistance ended. WHO sometimes assisted well-established institutions, for example, seven WHO staff were provided to enable the All India Institute of Hygiene and Public Health in Calcutta to establish a diploma course in public health. This led to the Institute becoming a recognized international training center in public health.

According to the WHO, the number of schools of public health increased from 100 institutions in 42 countries in 1965 to 121 institutions in 44 countries in1972, to 216 institutions in 54 countries by 1985 and to 375 institutions by 2006. Table 2 illustrates the distribution of schools across WHO regions in 2006 and the countries with the earliest school establishments for each region.

Schools of Public Health Research Paper Table 2

North America

There were two distinct phases of public health education in the United States: 1914 to the mid-1930s when schools of public health were mainly established and funded by the great philanthropies, and the period of federal and state funding from the mid-1930s to the present (Fee, 2003). The latter commenced with the New Deal and Social Security Act of 1935 which provided federal grants to states for public health, required states to establish minimum qualifications for health personnel, and recommended at least 1 year of graduate education at an approved school of public health. In 1936 the American Public Health Association (APHA) reported that 10 schools offered degrees or certificates; by 1939, 45 institutions were offering 18 different degrees, certificates, and diplomas in public health.

In 1941 representatives from Columbia, Harvard, Johns Hopkins, Michigan, North Carolina, Toronto, and Yale met to organize the Association of Schools of Public Health (ASPH). At the end of the Second World War, the Committee on Professional Education of the American Public Health Association took over the job of monitoring the standards of public health education. The first standards for accreditation were undemanding, but these became more rigorous over time. At the same time there were continuing changes in the curriculum, in particular the impact of social medicine led to greater inclusion of the social and economic context for public health. Since 1974 the ASPH transferred responsibility for accreditation to the independent Council on Education for Public Health. The number of accredited schools of public health continued to increase, most recently from 24 in 1999 to 38 in 2007. This is still a minority of the estimated 300 plus institutions offering some type of graduate degree in public health in the United States.

State funding first provided as part of the New Deal increased in the 1950s. The 1957 Hill-Rhodes Act resulted in over $30 billion in support to health professions’ schools, including public health. Over the second half of the twentieth century there was increased funding for biomedical research; in particular, National Institutes of Health grants which were seen as a politically acceptable way to fund medical schools, and for which schools of public health also had to compete. The federal research funding streams were increasingly important to schools of public health as the philanthropic foundations lost much of their enthusiasm for funding public health education in the postwar period. A few schools, especially Johns Hopkins and Harvard, grew large and prosperous, but the majority struggled. Within the schools, laboratory sciences generally thrived, whereas public health practice and teaching suffered, and the number of students fell. Since the 1950s the Pan American Health Organization also moved away from sending foreign students to study in the U.S., further reducing student numbers and schools’ income. Since the 1960s some schools of public health lost their independent status and were absorbed into other parts of their universities.

Schools of public health were affected as were other parts of academia by the swings in the wider U.S. political climate, from the increasing political conservatism of the 1950s, to new growth in the 1960s, and then further cuts or threats of cuts in the 1970s and 1980s. In the late 1980s the Institute of Medicine (IOM) published a landmark report on The Future of Public Health (Institute of Medicine, 1988). Although the focus was on public health practice, the report made a number of recommendations for schools of public health; for example, education programs should be more integrated with state agencies and more targeted on the needs of practitioners. The years since the IOM report have seen continued expansion by schools of public health, yet fundamental tensions remain. A number of commentators have identified the continuing tensions between medicine and public health, and Fee (2003) has highlighted the continuing divide between schools of public health (mainly research institutes with scientists and researchers with PhDs) and state public health departments (lacking in skills and qualifications).


There is no published history of schools of public health in Europe comparable to Fee’s work on the United States, so the history must be pieced together from a number of sources. The starting point must be an understanding of the impact of the wider history of Europe, in particular, the Second World War, postwar devastation, reconstruction, and the advent of the Cold War.

The increasing wealth of western European states and the prevailing ‘welfare state’ approach has supported investment in public health systems including schools of public health. Western European schools of public health have been historically diverse with some departments of public health within schools of medicine, some attached as training arms of state ministries of health, and some more akin to the U.S. model of an independent school of public health within a university. Since the 1970s a number of new schools of public health have been established, including the Nordic School of Public Health serving the Scandinavian countries. In the UK postgraduate training in public health, which had been commonly restricted to doctors, has been opened to nonmedical students since the mid-1990s.

Soviet-dominated Eastern Europe experienced much more stagnant economies and relatively under-resourced public health systems. Here the predominant model has been separate departments of social hygiene and public health within a university of medicine, although some schools of public health were attached to ministries of health. The fall of the Iron Curtain in 1989 and the implosion of the Soviet state and its satellites led to widespread economic and social dislocation, and to disruptions to public health systems in the post-Soviet world. The resulting grave deterioration in public health led to increasing Western intervention to renew the public health infrastructure in Eastern Europe and the former Soviet Union. This included twinning arrangements between Western and Eastern European schools of public health.

With increasing European integration, there has been increasing pan-European cooperation on public health training. The Association of Schools of Public Health in the European Region (ASPHER) was founded in 1966; the number of schools of public health has continued to increase with both the foundation of new schools and the transition of other institutions into independent schools of public health. By 1999 ASPHER had 72 members, although these are only a small part of the 500 public health training initiatives identified in the European Union by that time. Most recently, there have been developments toward a common European Master of Public Health degree.

The Developing World

Public health in the developing world was strongly shaped by the legacy of colonialism and colonial health systems, and continuing poverty, inequality, and conflict in the postwar world. A key turning point was the 1978 Alma Ata Declaration on Primary Health Care which stressed the need for community-based, affordable, and accessible health care for all. Alma Ata pushed the issue of public health in the developing world up the global agenda, and thus shaped the context for a continuing growth in the number of schools of public health.

Latin America

The development of schools of public health in Latin America has been closely associated with U.S. domination of the region, and the role of U.S. interests including the Rockefeller Foundation. Rockefeller Foundation support for schools of public health in Latin America was closely bound up with wider Rockefeller activities such as its hookworm eradication campaigns in Latin America between 1918 and 1940.

Ten schools of public health opened in eight Latin America countries between 1922 and 1976 (World Health Organization, 1985). The first opened in Mexico City in 1922 funded by the Department of Health in Mexico City. This was followed by the school of public health in Sa˜o Paulo established in 1925 with support from the Rockefeller Foundation. There was then a substantial gap before schools of public health opened in Chile in 1944, Venezuela in 1958, Argentina in 1960, Peru in 1963, Colombia in 1964, and Cuba in 1976.

Just before and during the Second World War, American influence was strengthened by an increased number of fellowships and grants offered by U.S. government agencies, private philanthropies, and universities (Cueto, 1995). Cueto reports that these institutions offered so many fellowships that Latin Americans could ‘shop around’ to determine which fellowships would suit them best, while many in the U.S. considered that the supply of good candidates from Latin America was being exhausted. Thus, the ties of Latin American public health organizations with U.S. institutions was evident. Notably, the National Institute for Public Health, Mexico, is the only non-U.S. member of ASPH. Increasingly, however, schools of public health in the region are developing their own links. The Associacion Latino-America de Escuelas de Salud, established in 1974, increased to 25 members in 1999 and to 58 in 2007.

The influence of European social medicine, and the work of Sand in particular, influenced Latin American social medicine from the 1920s and 1930s into the postwar years. Departments of social medicine developed in Lima, Peru, Rio de Janeiro in Brazil, and at the University of Chile where Salvador Allende, future president of Chile, developed a Marxist approach which profoundly influenced the subsequent development of Latin American social medicine. Following the Second World War, Latin American social medicine became increasingly distinct from academic public health in its emphasis on political and social transformation, as opposed to the public health emphasis on disease control, sanitation, nutrition, and other factors often more narrowly aimed at improving labor force productivity.

South East Asia And The Western Pacific

The development of schools of public health in the South East Asian and the Western Pacific regions is closely linked with the history of colonialism and the emergence of the post-colonial world after the Second World War. The Rockefeller Foundation was very involved in public health work in China since the 1910s and instrumental in setting up the Peking Union Medical College in 1917, and its department of public health in 1921. The first diploma in public health course in Peking was in 1929, although there was no formal school of public health until 1952. After the Communist victory in 1949, six medical universities established schools of public health on the Soviet model. By 1979 there were 14 schools of public health in China. In British-controlled India there were early schools of public health in Bombay (1915) and Calcutta (1921). By 1979 India had the largest number of schools of public health in Asia with 35 in total. By contrast, Japan and Pakistan each have only one school of public health, founded in 1939 and 1949, respectively. In 1985 there were 80 schools of public health in Asia and the Pacific, a relatively small number for a region containing almost a third of the world’s population. The Asia-Pacific Academic Consortium for Public Health was launched in 1984 with five members, and grew to 25 members in 1999, and to 55 members in 20 countries in 2007.

Africa And The Eastern Mediterranean

As in Asia, the development of schools of public health in Africa and the Arab world is embedded in the history of colonialism and post-colonialism. Prior to the Second World War the training of public health personnel in Africa was commonly limited to addressing those tropical diseases of concern to colonial administrations. No schools of public health were established in Africa and the Arab world until after the Second World War. The first opened in Egypt in 1950 and in Nigeria in 1951. According to the WHO, Egypt has opened the most schools of public health in these regions with nine established between 1950 and 1973, followed by Nigeria with six between 1951 and 1967. Six other schools were established in other African countries beginning with Uganda (1967), Tanzania (1974), Benin (1977), Sudan (1977), Ghana (1980), and Ethiopia (1982). The public health indices of Africa are among the worst in the world, and Africa’s public health infrastructure is limited by its complex history of colonialism, conflict, maladministration, and, most recently, structural adjustment programs imposed by the World Bank and the International Monetary Fund. Many countries still lack public health infrastructure, in particular training in public health. To address these needs the Rockefeller Foundation in the 1990s supported an innovative Public Health Schools Without Walls project. There is no African association of schools of public health.


Inevitably, this history of schools of public health is partial and selective, dependent on where historians have researched and written. We know a great deal about some aspects of this history, particularly relating to schools of public health in the United States where most of the historical work has been done. We know far less about the histories of schools of public health in the developing world. The role of the Rockefeller Foundation in the period 1913–45 has been extensively studied; we know much less of the postwar role of the WHO and other international organizations in the postwar history of schools of public health.

We can make some general points with confidence. Despite some fluctuations over time, there has been a long-term worldwide increase in the number of schools of public health and other institutions offering postgraduate public health training. Although there are an increasing number of schools of public health in the developing world, their number and resources have never been proportionate to the large populations and higher levels of health need found there. The poorer developing world continues to struggle with a lack of sufficient public health professionals, particularly given the continued ‘brain drain’ of such professionals to the developed world.

There remains great diversity in schools of public health structures, resources, functions, and relationships to wider local public health systems. Even the international network of Rockefeller-funded schools, which were intended to follow the Johns Hopkins model, in time developed into quite diverse institutions. Indeed, there is no universal definition or set of criteria for defining exactly what counts as a school of public health.

Several fundamental tensions have run through the history of schools of public health. Foremost among these has been a tension between medical and multidisciplinary conceptions of public health. The work of the Rockefeller Foundation since 1914 can be seen as part of a process of medicalization of public health. Such medicalization was challenged by the new public health in the 1970s, the emergence of the Alma Ata approach to primary health care, and new disciplines such as health promotion. Some such as White (1991) have argued the need to ‘heal the schism’ between medicine and public health, whilst others have seen the multidisciplinary challenge to the medical model as essential if public health is to adequately address the political nature of public health action. The latter perspective is linked to a critique of laboratory or epidemiological studies which masked immense socioeconomic and gender inequalities. Such concerns were particularly exposed in tensions between Rockefeller-model schools of public health and the emerging field of social medicine in Latin America since the 1930s.

A second and related tension reflects concerns most fully articulated by Fee in the American context regarding the gap between the research orientation of schools of public health and the training needs of service-oriented public health practitioners. Fee argues that U.S. schools of public health have become mainly research institutes where students learn the art of preparing grant proposals and writing scientific articles while local public health departments are staffed by people with little public health training. It is difficult to assess how widespread this gap may be globally, although it clearly applies to some degree in some other developed countries such as the UK.

The most fundamental question about the extent to which schools of public health have contributed to improving the health of populations is of course the most difficult to answer. Advocates will point to the many scientific and epidemiological discoveries that have been made by researchers in schools of public health, the education of generations of public health practitioners, and the number of public health leaders who have emerged from the schools. Critics will point to academic disassociation from the political activism and community engagement that are central to seriously addressing critical public health issues.

Ultimately, the assessment of the contribution of schools of public health cannot be separated from the assessment of wider public health systems – the interconnected networks of international organizations, government ministries, professional bodies, and local departments of public health services. Where public health systems have broken down, as in Eastern Europe and the former Soviet Union in the 1990s, the health of the population has suffered. Where economic development and social justice have gone hand in hand with the development of public health systems, as in much of Western Europe in the postwar era, the health of the population has significantly improved. Schools of public health have only ever been a small part of the complex chain of causality for the health of populations.


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