By Curtis, LaShawn M Marx, John H
As stated in the Institute of Medicine report Who Will Keep the Public Healthy? the doctor of public health (DrPH) degree is offered for advanced training in public health leadership.1 The Association of Schools of Public Health (ASPH) classifies the DrPH as a professional degree, as opposed to the more academic, researchoriented PhD degree.2 As a professional degree, the DrPH is oriented toward practice (i.e., the strategic, interdisciplinary application of knowledge and skills necessary to execute the public health core functions of assessment, policy development, and assurance3) in public health settings, including community, state, federal, and international agencies.2 These descriptions of the DrPH degree are consistent with those presented on the Web sites of the 23 of 38 ASPH-accredited schools of public health that offer the degree.4 Based on these widely endorsed descriptions of the DrPH degree, it is appropriate to recognize it as the highest professional degree in public health. Unfortunately, despite the degree’s significance, there is currently no national competency model for DrPH training. In addition, the fieldwide leadership role of DrPH practitioners is relatively undefined. Vague Roles
Although an explicit statement of the specific leadership roles and responsibilities that DrPH professionals are expected to assume is noticeably absent from public health literature and discourse, the general role of public health practice leaders can be logically derived by reviewing the mission of public health as defined by the Institute of Medicine: “to fulfill society’s interest in assuring conditions in which people can be healthy.”5(p2) As such, through public health practice, DrPH professionals are charged with assuring conditions that will keep the public healthy. This is still a rather vague understanding of the role of public health practice leaders, which is particularly unsettling considering the significance of the DrPH degree and the relatively small number of practitioners who hold it. According to ASPH reports, only 130 public health students graduated with DrPH degrees in the 2004-2005 academic year, representing 2% of all public health graduates (i.e., those graduating with masters, other doctorate, and joint degrees).6
Some readers may reasonably argue that the 3 core public health functions and the 10 essential public health services7 provide sufficient guidance for the training of DrPH students and adequate insight into the role of DrPH professionals. However, we suggest that although the core functions and essential services are valuable for defining the scope and focus of public health, more effort is needed to clearly and specifically define the leadership role and responsibilities of DrPH professionals.
Varied Training
Two decades ago, Milton I. Roemer, MD, MPH, asserted that DrPH programs should prepare graduates for “their proper role” in society- serving the community as public health leaders and policymakers- and he proposed a DrPH training curriculum “addressed to the capabilities required for public health leadership.”8(pp25,28)
The need to clearly define both the role of DrPH professionals and core requirements for DrPH training remains no less critical today than it was 20 years ago, when Roemer published The Need for Professional Doctors of Public Health.8 Perhaps this need is even more important today, because our supply of preventive medicine physicians (who have long served as practice leaders in the public health field) is shrinking and the funding for preventive medicine training is dwindling.9
Unlike the master of public health (MPH) degree,10 no core set of competencies exists for the DrPH. Moreover, the organizing structures of DrPH programs vary widely across schools. Some public health schools offer schoolwide DrPH degrees (e.g., Johns Hopkins Bloomberg School of Public Health11), whereas others offer department-specific degrees (e.g., the DrPH program in the Health Policy and Administration Department at the University of North Carolina at Chapel Hill School of Public Health12).
It is worth noting that ASPH’s education committee and board created a DrPH subcommittee in 2006 that was charged with exploring the current status of DrPH education in schools of public health (E. Weist, MA, MPH, director, Special Projects, ASPH, written communication, April 2007). According to written communication with Weist, ASPH will soon be posting general information about the DrPH project on their Web site (http://www.asph.org). ASPH provided the following description of the recently launched DrPH project: the subcommittee aims to provide a mechanism for directors of DrPH programs in SPH [schools of public health] to interact and exchange information. The subcommittee is also currently seeking consensus on DrPH curricula in schools of public health and considering developing a set of core competencies for the DrPH. In keeping with the core competency consensus-building and development process that ASPH completed for the MPH, the DrPH subcommittee will not aim to prescribe a standard to which all DrPH programs should conform; rather, it will focus on offering a resource guide for those interested in improving the quality and accountability of DrPH education (E. Weist, e-mail communication). This initial effort to assess DrPH training on a national level has the potential to lead to the development of advanced training guidelines for DrPH students. However, leading public health agencies that work to assess the current status of DrPH education and training must be persuaded to engage stakeholders-including DrPH students, faculty, and national public health officials-to also help envision, define, and facilitate fulfillment of public health practice leadership roles for those earning DrPH degrees.
Out of Challenge Comes Opportunity
Public health does itself a huge disservice by not investing in the organization and empowerment of the small number of practice leaders actually trained in the field. The absence of high national standards for DrPH training is disconcerting because training standards can be an important step in establishing the legitimacy of the advanced leadership, and of practice training and experience of DrPH practitioners. One suggestion for addressing both the absence of clearly defined, profession-level leadership roles for DrPH practioners and the lack of standardization of DrPH programs is to organize DrPH professionals, training, and leadership development around one of public health’s biggest challenges: the impact of social inequalities on health.
Assuming that the training and expertise of public health practice leaders should be applied to changing and improving the American public health system, there are compelling grounds for focusing the preparation of DrPH professionals on issues of social inequality. In relation to socially rooted causes of health and illness, this should generate public health efforts that address issues of social inequalities that are detrimental to the public’s wellbeing. Furthermore, issues of social inequality and its negative impact on population health are complex. Attending to these issues requires a sophisticated understanding of the different “publics'” needs and resources, as well as leadership skills to both collaborate with key stakeholders (government officials, business leaders) and to mobilize action for social change-public health’s trained practice leaders are particularly suited for this charge.
Social Determinants of Health-Centered Training
Should one of the primary leadership roles assigned to DrPH practitioners be to advance the field’s efforts to address socially rooted causes of health and illness, the following points are offered for consideration:
1. Future public health practice leaders need to have a thorough understanding of, and be encouraged to grapple with, unique features of American society that present fundamental and persistent challenges to public health practice, including American ideological individualism, market capitalism, and the political nature of public health.
2. Because many of the solutions to redressing social and health inequities require confronting and challenging social policies and norms, DrPH practitioners need to be well versed in the evolution of health policy and, in particular, of social policies that affect the population’s well-being.
3. DrPH training should adequately prepare students to collaborate with those in other fields, including education, law, and economics, the primary practice areas and political agendas that impact the public’s well-being.
4. DrPH programs and practitioners should emphasize ecosocial approaches to public health practice and focus on the structural determinants of health, rather than on traditional intervention strategies that primarily focus on specific diseases and related individual and lifestyle risk factors. This recommendation is not intended to discredit interventions targeted at changing the health behaviors of individuals. Rather, it recognizes that, based on the core competencies model,9 masters-level students are more than adequately trained to sustain traditional public health programs, which provide important public health services, including vaccination, screenings, and risk behavior prevention education. 5. DrPH training should be practice oriented, with special emphasis on developing students’ leadership and management skills.
It is recognized that DrPH programs at several schools of public health likely provide courses and practical learning experiences that cover some of the topics recommended here. However, to facilitate the mobilization of DrPH students and professionals and to ensure that practice leaders are adequately prepared to address what is arguably the field’s most immense challenge (i.e., eliminating health disparities, which involves attending to broader issues of social inequalities) the goals and standards of DrPH training should be defined and coordinated on a national level.
In addition, efforts to clearly delineate profession-wide leadership roles for those with DrPHs and to develop national DrPH training goals, standards, and, perhaps, curriculum guidelines, should (1) be led by DrPH practitioners, students, and faculty, (2) draw on existing DrPH curricula models in accredited schools of public health, and (3) support the development of a national forum for DrPH students and practitioners to network, mobilize, and use professional and practical resources to identify and promote the best strategies for addressing social inequalities that threaten the public’s well-being.
Conclusions
The title of the Institute of Medicine’s report asks, Who Will Keep the Public Healthy? Given public health’s mission to fulfill society’s interest in assuring conditions in which people can be healthy, and because social environments lacking basic resources- largely as a result of social inequalities-“present the highest public health risk for serious illness and premature death,”13(p114) perhaps the better question is, Who will lead the change that is required to make the public healthy? We propose that DrPH students and professionals, as public health’s practice leaders, be trained and called upon to direct and advance the field’s efforts to address socially rooted causes of health and illness. The focus of this recommended leadership role may be dismissed by some, including some DrPH students and professionals, as overly ambitious or too far removed from the traditional scope of disease prevention and health promotion. However, it should be much more difficult to dismiss the absence of national-level standards for and coordination of DrPH training. It should be as equally difficult to disregard the need to define clear profession-wide leadership roles for the few professionals receiving degrees for advanced leadership in public health practice.
Incomplete and inefficient treatment, combined with the collapse of public health systems in Abkhazia, have helped create strains of bacilli that are resistant to antituberculosis drugs. Used with permission of Aurora Photos. Copyright by Serge Sibert/Cosmos/ Aurora.
References
1. Committee on Educating Public Health Professionals for the 21st Century, Board on Health Promotion and Disease Prevention, Institute of Medicine. Gebbie K, Rosenstock L, Hernandez LM, eds. Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century. Washington, DC: National Academies Press; 2002.
2. What Is Public Health? FAQs. Washington, DC: Association of Schools of Public Health. Available at: http:// www.whatispublichealth.org/faqs/index.html#student_faqs5. Accessed December 11, 2006.
3. Council of Public Health Practice Coordinators. Demonstrating Excellence in Academic Public Health Practice. Washington, DC: Association of Schools of Public Health. Available at: http:// www.asph.org/userfiles/demex-aphp.pdf. Accessed May 22, 2007.
4. Search for a Program. Washington, DC: Association of Schools of Public Health. Available at: http://www.asph.org/ document.cfm?page=753. Accessed December 11, 2006.
5. Committee on Assuring the Health of the Public in the 21st Century, Board on Health Promotion and Disease Prevention, Institute of Medicine. The Future of the Public’s Health in the 21st Century. Washington, DC: National Academies Press; 2002.
6. Ramiah K, Silver G, Sow M. Association of Schools of Public Health 2005 Annual Data Report. Washington, DC: Association of Schools of Public Health. Available at: http://www.asph.org/ userfiles/ADR%202005.pdf. Accessed December 11, 2006.
7. What Is Public Health? Washington, DC: Association of Schools of Public Health. Available at: http://asph.org/ document.cfm?page=300. Accessed April 22, 2007.
8. Roemer MI. The need for professional doctors of public health. Public Health Rep. 1986;101:21-29.
9. A Public Health Crisis: The Shortage of Physicians Trained in Preventive Medicine. Washington, DC: American College of Preventive Medicine. Available at: http://www.acpm.org/finalproof_90.pdf. Accessed April 22, 2007.
10. Association of Schools of Public Health Education Committee. Master’s Degree in Public Health Core Competency Development Project Version 2.3. Washington, DC: Association of Schools of Public Health. Available at: http://www.asph.org/userfiles/Version2.3.pdf. Accessed December 11, 2006.
11. About the DrPH. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health. Available at: http://www.jhsph.edu/academics/ degreeprograms/drph/about. Accessed December 11, 2006.
12. Degrees and Certificates. Chapel Hill: University of North Carolina at Chapel Hill School of Public Health. Available at: http:/ /www.sph.unc.edu/student_affairs/ degrees_and_certificates_52_140.html#drph. Accessed December 11, 2006.
13. Taskforce on Community Preventive Services. The Guide to Community Preventive Services: Social Environment. Atlanta, GA: Centers for Disease Control and Prevention. Available at: http:// www.thecommunityguide.org/social. Accessed October 23, 2006.
LaShawn M. Curtis, MPH
John H. Marx, PhD
About the Authors
LaShawn M. Curtis is enrolled in the Doctor of Public Health Program in the Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA. John H. Marx is with the Department of Sociology and the Graduate School of Public Health, Department of Behavioral and Community Health Sciences, University of Pittsburgh, Pittsburgh.
Requests for reprints should be sent to LaShawn Curtis, MPH, University of Pittsburgh, Graduate School of Public Health, 207C Parran Hall, Pittsburgh, PA 15261 (e-mail: [email protected]).
This editorial was accepted June 4, 2007.
doi:10.2105/AJPH.2007.119313
Contributors
The authors worked together to conceptualize and develop the topic. L. M. Curtis drafted the editorial and contacted and reviewed cited sources. J.H. Marx reviewed drafts and contributed to the writing.
Acknowledgments
The authors thank Megan L. Kavanaugh for her thoughtful review and feedback on drafts and Howard S. Berliner, Bernard D. Goldstein, Martha Ann Terry, and Christopher R. Keane for their valuable comments. The authors also thank Elizabeth Weist for sharing information on the DrPH subcommittee of the Association of Schools of Public Health education committee.
Copyright American Public Health Association Sep 2008
(c) 2008 American Journal of Public Health. Provided by ProQuest LLC. All rights Reserved.
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