Public health advocacy must be taught
The COVID-19 pandemic gave contemporary meaning to 19th-century physician Rudolf Virchow’s famous observation that medicine is bound by politics. We have long understood that the solutions to public health problems lie not only with the best available science, but also in bold policies for social reform. Indeed, the field’s greatest achievements—from sanitation infrastructure and workplace safety to seat belt laws and tobacco control—are all products of policy change, informed by public health research and catalyzed by the concerted efforts of advocates. Yet, in the decades preceding the pandemic, public health and our academic institutions have increasingly distanced themselves from their roots in political activism and accepted a more neutral, scientific identity.
As our society struggles through the evolution of COVID-19, the crucial question is: are we preparing the next generation of public health practitioners to not only investigate what harms health but to also advocate affirmatively for what is needed to advance health, particularly for groups plagued by structural inequities?
The 10 Essential Public Health Services: A solid foundation
Policy development and the ability to “create, champion, and implement policies, plans, and laws that impact health” (EPHS No. 5) are among the 10 Essential Public Health Services (EPHS)—a widely recognized framework which outlines the activities necessary to protect and promote public health. Since its inception by a federal working group in 1994, the EPHS model has served as a foundation for the standards by which public health is taught and practiced. Schools and programs of public health in the U.S. are accredited based on criteria for foundational knowledge and competencies that all graduates must demonstrate. These include assessing students’ ability to “Advocate for political, social, or economic policies and programs that will improve health in diverse populations.”
The EPHS represents an important guiding vision, but there is a clear disconnect between what public health professionals should be able to perform to be effective and what is currently being taught and fostered in our schools of public health. Few public health students will graduate with the advocacy skills emphasized in the EPHS because required courses in policy and media advocacy are markedly absent from most graduate-level curricula. Schools and programs of public health in the U.S. excel in teaching rigorous research methods and preparing their students to carry out the “Assessment” functions of the EPHS (EPHS No. 1 & 2). Yet, they lack the same comprehensive training in “Policy Development” and the advocacy skills necessary to move their science into public policy action (EPHS No. 3-6). Accrediting agencies give wide latitude to schools in meeting the required advocacy competencies delineated in EPHS. Schools routinely map these competencies to general courses on community health, public health leadership, and health administration which may or may not include discrete advocacy skill building. This is a mistake.
Of the 68 accredited schools of public health in the U.S., not one requires an advocacy course to graduate with a Master of Public Health (MPH). For those institutions, such as Boston University, Johns Hopkins University, and the University of California, Berkeley, that do offer a health policy advocacy course or concentration, they remain elective additions to core curricula and not a requirement for degree completion. Even fewer accredited schools of public health offer practice-based degree tracks in policy advocacy de-coupled from healthcare management.
A handful of accredited and non-accredited colleges and universities now offer various graduate degrees in healthy policy with an advocacy course requirement, including a Master of Science in Health Policy at Johns Hopkins and a Master of Science in Health and the Public Interest at Georgetown University, as well as several stand-alone certificate programs specific to health advocacy. However, while these programs bear similar titles, their focus ranges widely from population-level policy and practice change to individual-level patient navigation of the health care system.
The disconnect between what is needed and what is taught is reflected, not only in the way we educate our public health workforce, but also in the activities we use to reward and incentivize those doing the teaching—namely, research and publication. Success for most public health academics is defined not by their demonstrable contributions to improving public health, but by their numbers of peer-reviewed publications in high-impact journals. Hiring and promotion for academic faculty is assessed within broad categories of research, teaching, and service, but most institutions rely heavily on easily quantifiable measures of success, such as the number of research publications a faculty member has and the amount of grant funding they secure. Metrics for research impact are closely tied to the number of times a study is cited by other authors. However, only a small fraction of academic research will ever permeate the realms of policy and practice, leaving a gap between existing public policy and what their evidence shows is needed.
EPHS Revised: Bringing health equity to the fore
In recognition of changing contexts, and deepening health inequities across the U.S., the EPHS were revised and re-launched in September 2020. Importantly, the revision centers health equity where it once revolved around research. An outcome-based goal, “Equity,” now sits as both an end and a means for carrying out public health’s mission. The positioning of equity as a core
value explicitly calls on the field to “actively promote policies, systems, and overall community conditions that enable optimal health for all.” Yet, schools of public health have not kept pace with this change. Schools of public health must support research that goes beyond documenting inequities to elucidating how to eliminate them. And, as COVID-19 has so painfully illustrated, eliminating inequities, in particular racial inequities, requires serious attention in our schools of public health.
If we want health equity to be more than an aspiration on a teaching diagram, advocacy must be taught and required as a core skillset for graduation from accredited schools of public health.
Make the EPHS real: Teach and reward public health advocacy
As the Institute of Medicine (IOM) wrote nearly two decades ago in their 2003 report, “Should schools wish to be significant players in the future of public health and health care, dwelling on the science of public health without paying appropriate attention to both politics and policy will not be enough.” Simply publishing data with broad recommendations for others to take up will not satisfy public health goals. It’s imperative that our academic public health institutions be held accountable to their accreditation standards and equip the next generation of practitioners with the skills to execute all 10 EPHS and address the root causes of inequity through policy change.
As we mark another calendar year of the pandemic, it’s time to re-think how we teach and train our public health professionals to meet the challenges to come. In the face of fierce public opposition to protective public health measures and conflicting private interests, public health students must be prepared to engage in the politics of health equity. We can start by designing and requiring policy and media advocacy breadth courses, distinct from healthcare administration, to train students to bring public health science to bear on public policy. We should require our faculty to demonstrate how their research has contributed to improving health and health inequities: How has their work been used? What was the outcome? We must also create pathways that reward faculty for their efforts beyond publication and create clear metrics of success in terms of health outcomes. For that, our schools of public health should evaluate whether their actions are successful in providing graduates and faculty the skills and experience to deliver the 10 Essential PH Services.
Rudolph Virchow was prescient in the 19th century. We must put his wisdom into action if we are to end health inequities in the 21st century.