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EDITORIAL; Public Health School Belongs Here; Milwaukee Trumps Madison When It Comes; to Social Needs, Health Crises

Posted on: Sunday, 25 September 2005, 15:00 CDT

When it comes to public health problems in Wisconsin, Milwaukee is ground zero. It is the biggest city in the state with the largest and most diverse population, including a large number of poor bridled with serious health problems and, in the case of minorities, glaring disparities in health care.

These are reasons enough for Wisconsin to establish a school of public health in Milwaukee to address these problems firsthand while also training the army of public health workers who many experts believe will be needed more than ever in the future, if only as a means to control health care spending. The most logical place for such a school is at the University of Wisconsin-Milwaukee.

But it's the University of Wisconsin-Madison, not UWM, that has taken steps to establish a school of public health integrated with its medical school, despite being located in a city touted often as affluent and among the healthiest in the country.

The UW Board of Regents must not allow this to happen. Instead, the regents should begin working immediately with UWM to establish a school of public health on that campus.

Milwaukee, a city that can serve as a veritable laboratory in urban public health, is the better fit. Moreover, such a school would dovetail with UWM Chancellor Carlos Santiago's avowed mission to turn his school into a major research institution.

Public health is a field of science that over the years has often been relegated to second fiddle to its more glamorous, popular and well-endowed sister, the field of medicine.

About 95% of all health care spending in the U.S. goes toward medical care and biomedical research, leaving only 5% for public health, according to a 2002 report by the Institute of Medicine of the National Academies.

This is backward. And it is particularly backward for a state not to have a school of public health independent of a medical school. Minnesota, Illinois and Michigan, Iowa and Ohio all have such schools.

Wisconsin can take justifiable pride in the UW Medical School and the Medical College of Wisconsin in Wauwatosa, one of the largest private medical schools in the nation. Both are first-rate.

But by their very nature, medical schools have historically focused on diagnosing and treating disease as opposed to preventing it, which is the primary and almost sacred objective of schools of public health. Simply put, medicine deals with individuals while public health deals with whole populations of people, employing both hard sciences and social sciences.

The UW Medical School intends to make its case for an integrated school of medicine and public health to the Board of Regents soon.

This is more than a name change. UW Medical School officials say that they have been laying the groundwork for several years based on their belief that physicians and public health professionals need to lay aside their longstanding historical differences.

What is undeniably fueling this are the huge endowments more than $300 million each that the state's two medical schools received in 2004 when Blue Cross & Blue Shield United of Wisconsin became a for-profit company. The money was given to the schools to spend on public health initiatives.

But a number of people already involved in public health in Milwaukee harbor strong reservations about the UW plan. They should.

Such a school should come to Milwaukee because this is where the real hands-on urban public health research and outreach can occur and already does, thanks in part to UWM researchers.

In any case, to be accredited and qualify for federal public health research dollars through the National Institutes of Health and other agencies schools of public health must be independent of medical schools, according to Laura Razar King, executive director of the Council on Education for Public Health, the national accreditation body for public health schools and programs.

Accredition would be difficult

That ostensibly would mean UW would have to apply for an exemption for its new hybrid school, but King, who is scheduled to visit UW this week, says that is not going to happen.

"There will no exemptions or exceptions," she said in a telephone interview. "None."

Of the 37 accredited schools of public health in the nation, all but one are independent of medical schools, even those in the same university system. The exception is the School of Public Health at Yale University, which was established as part of the Yale School of Medicine in 1915 and has been grandfathered in.

It's no coincidence that of the accredited schools of public health in the nation, more than 60% are in larger cities. That's where most of the public health problems are.

Madison is the state's second-largest city, but the social and economic differences between it and Milwaukee are striking. As the Greater Madison Convention & Visitors Bureau boasts on it Web site, Madison is continually ranked by various publications and associations as among the healthiest, safest, most family-friendly and highest quality-of-life cities in the nation.

Last year, Milwaukee became one of the 10 poorest cities in the country, ranking seventh, according to estimates based on Census Bureau surveys. Even New Orleans, where the grinding poverty of its residents was recently laid bare by Hurricane Katrina, ranked better.

For Milwaukee, this dubious distinction was yet another blow to a city already reeling from such urban maladies as drug use, gun violence and homicides, a high incidence of lead poisoning and asthma among inner city children, and one of the highest teenage pregnancy rates in the nation.

Mayor expresses his frustration

In a strongly worded letter sent Friday to Phillip Farrell, dean of the UW Medical School, Milwaukee Mayor Tom Barrett questioned the decision to create a public health school in Madison.

Barrett said he was perplexed and frustrated that UW's decision "is being undertaken in a vacuum without the full participation" of his office and others, including the Milwaukee Health Department, Milwaukee-area legislators and the public. Barrett copied Gov. Jim Doyle, the UW-Madison chancellor, the president of the UW system and the regents on the letter.

Before he got the letter, Farrell called the mayor's office Friday to request a meeting.

Milwaukee's commissioner of health, Bevan Baker, said he would welcome a school of public health anywhere in the state. But he concedes there is a real benefit in having it located in the state's largest city, which would allow it to easily collaborate with his 300-person health department, the largest in the state.

Farrell pointed out in an interview that the UW Medical School has been busy reorganizing itself in the past few years to enable it to also function as a school of public health and consequently better deal with the health needs of all state residents, whether they live in Milwaukee or anywhere else.

Among other things, the school changed the name of its department of preventive medicine to the department of population health sciences and now offers master's and doctoral degrees in that area. It also created a Center for the Study of Cultural Diversity in Health Care to target minority health care problems.

Because it's in Madison, the school has an impressive array of assets it can tap into for public health, Farrell noted, including the State Laboratory of Hygiene, which began operations in 1903 on the UW campus to function as the official lab for the State Board of Health.

But UWM wouldn't have to build a school of public health from the ground up, either. The framework is already here.

"We already have a virtual school of public health," argues David Petering, a professor of chemistry at UWM and director of the Marine and Freshwater Biomedical Sciences Center at UWM, which is part of the National Institute of Environmental Health Sciences.

As Petering and others note, UWM has a strong program in toxicology, which is critical in identifying problems of contaminated water, air and food; a respected College of Nursing; a School of Allied Health Sciences; and a strong social sciences faculty focused on urban society.

Petering and Jeanne Hewitt, an associate professor in the College of Nursing and an epidemiologist, have been advocating a school of public health at UWM for several years, based on what UWM faculty are already doing in the community.

"Outreach is nothing new to us," said Hewitt, who is associate director for the Institute of Environmental Health at UWM.

UWM involved already with clinics

The best example of this is probably the rapidly growing Sixteenth Street Community Center on Milwaukee's near south side. The clinic's location allows the staff there, including UWM faculty and students from a variety of disciplines, to serve a relatively poor and largely Hispanic immigrant population, and a smaller number of Hmong and African-Americans.

John Bartkowski, chief executive officer of the Sixteenth Street Health Center, is one the most staunch and vocal proponents of establishing a school of public health at UWM.

" You'd have no problem finding the resources there to start a school," says Bartkowski, who obtained his doctorate in public health from the University of Illinois-Chicago because no in-state schools offered the degree years ago.

Bartkowski believes that if such a school is created, it should not be part of a medical school because the two professions have contrasting missions.

Bernard Goldstein, dean of the University of Pittsburgh Graduate School of Public Health, agrees. Goldstein, who got his undergraduate degree from UW-Madison, is chairman of the Communications Committee of the Association of Schools of Public Health.

A physician himself, Goldstein says that because physicians focus on curative care and public health professionals on preventive care, it's in the best interest of both professions to have independent schools.

Goldstein's own experience has been that when public health professionals are part of a medical school, they end up in a secondary, almost supportive role to the medical school people.

That doesn't mean, Goldstein said, that schools of public health should not work closely with medical schools, as his own faculty and students do with the University of Pittsburgh School of Medicine.

Role for the Medical College?

Although the private Medical College of Wisconsin, unlike UW, has no plans to create a school of public health, it is planning to expand its public health focus and already collaborates with UWM and other Milwaukee-area colleges.

If a school of public health is established in Wisconsin, Santiago said, "It makes sense to have it located in a community with the largest population and the greatest problems, including health care disparities."

Michael Bolger, president of the Medical College of Wisconsin, believes that the wisest approach would be for medical schools and other schools to collaborate first before creating a school of public health in Wisconsin, wherever it would be located.

"But if UWM wants to create a school of public health, we'll collaborate," Bolger said. "We'll do what we can."

Santiago believes that if UWM were to get a school of public health, it should pool resources with other area schools, including the Medical College. As he points out, UWM worked with the Medical College to establish a doctoral degree in medical informatics, which deals with medical information technology and is exploring creating a number of joint graduate degrees in public health with the Medical College. UWM researchers also collaborate regularly with Medical College researchers.

"But a school's a bigger animal," said Santiago, who came to UWM from the State University of New York-Albany, where he was provost. Albany has had a school of public health since 1985, and Santiago was involved when the school underwent reaccreditation.

Santiago believes a school of public health could be established at UWM with a minimal faculty of about 25, including current UWM faculty members, and an annual budget of $10 million.

"The core pieces are here," Santiago said, although he added that establishing a public health school could be a financial challenge for UWM.

In his letter to Farrell, however, Barrett said he saw no reason why this couldn't happen.

"Yes, resources to initiate a professional school of public health in Milwaukee may be too much for UWM to bear alone," he wrote. "But together with the UW Medical School, the Medical College of Wisconsin and philanthropic interests, a Wisconsin School of Public Health, located in Milwaukee, could and should become a reality."

It's also clear the initial investment could eventually produce large dividends through federal and private public health grants.

As Petering points out, UWM's Marine and Freshwater Biomedical Sciences Center has a yearly budget of about $300,000 but attracts federal grants of more than $2 million.

An even better example is Pittsburgh's Graduate School of Public Health, which more than doubled its external funding since 2001 to almost $80 million today.

Madison is already on the plus side of a huge gap in research dollars compared to UWM. Madison, the fourth biggest research institution in the country, spent $721.2 million in research in 2003. UWM spent about $27.2 million.

Recently released figures showed that 82 cents of every research dollar in the state was spent on the Madison campus. Along with other efforts to beef up research at UWM, a school of public health could help narrow that gap and help Milwaukee's struggling economy to boot.

Patrick Remington, a physician and a professor at the UW Medical School with 20 years of service in the field of public health with the state and federal government, doesn't dispute that there has been a deep divide between medical schools and schools of public health over the past century.

But attitudes are gradually changing, he says, because both sides realize the only way to achieve their mutual goals is, in effect, through a marriage.

UWM's Hewitt disagrees.

"The really strong schools of public health are independent of medical schools," she says. "I still feel passionately that the need is here and it should be in a separate school independent of a medical school."

So do we. The Board of Regents should simply look at which school would exist in the best urban laboratory for public health in the state.

The answer is Milwaukee, not Madison.

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This special editorial and the related article below were reported and written by Jerry Resler for the Editorial Board.

Copyright 2005, Journal Sentinel Inc. All rights reserved. (Note: This notice does not apply to those news items already copyrighted and received through wire services or other media.)

Source: Milwaukee Journal Sentinel

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