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US changes dose to treat public health malaise

Revised curricula will emphasise leadership and time spent away from the lab. Jon Marcus reports

Poor Kate Winslet. Or more precisely, poor Erin Mears, the character Winslet played in the Steven Soderbergh film Contagion (2011).

Awkward and shy, the junk food-addicted public health investigator struggles to her dying breath to persuade politicians and government officials of the need for quarantine and other measures to prevent the spread of a mysterious lethal disease.

Now, as anxiety mounts about real-life threats such as bird flu, a top US graduate school of public health is leading a drive to arm students with the skills they need not just to squint into microscopes in the quiet of a lab, but also to influence policy and decision-making in government and business.

Developed with advice on leadership training from the Yale School of Management, the curriculum, being launched this autumn by the Mailman School of Public Health at Columbia University, marks the biggest change in US public health education in a century.

The Harvard School of Public Health is expected to make similar revisions to its curriculum next year.

First-year students at Columbia will consider historical and present-day case studies, work in teams, weigh competing points of view, write policy briefs, plan public outreach and learn such skills as persuasion, team-thinking and public speaking.

The public health professional "can no longer sit in his or her office and have big thoughts in isolation", says Sandro Galea, the Mailman School's chair of epidemiology, who led the overhaul.

Although the curriculum has many elements, it is the leadership component that is receiving the most attention.

"What Columbia has done by focusing on producing leadership skills moves the field collectively closer to what it needs, which is the ability to impact change," says Ian Lapp, associate dean for strategic educational initiatives at the Harvard School of Public Health.

The subject's constant presence in the news, not to mention popular culture, means that more Americans than ever are going into public health. US graduate programmes are attracting twice as many applicants as they did 10 years ago - 49,227 in 2010 according to the Association of Schools of Public Health, the last year for which data are available.

Meanwhile, a larger than usual wave of retirements and factors such as the involvement of the likes of the Bill and Melinda Gates Foundation in public health will create the need for an estimated 250,000 new public health professionals in the next decade, Columbia says, due in part to spending by philanthropies on global health initiatives.

The number of accredited schools of public health in the US has jumped from 29 to 49 since 2000, with 30 more in the pipeline, according to the Council on Education for Public Health.

Antiquated medicine

Until now, the basic system of US public health education has not changed substantially since it replaced the private apprenticeship model in 1910 as a result of the Flexner report - at a time when industrialisation and urbanisation were still relatively new. So were germ theory, vaccination and immunisation.

Major reports in 2002 and 2003 by the US Institute of Medicine urged schools of public health to update their curricula. A council of public health officials said there was a need for students to learn financial management, planning and cultural competence - and that these were not being taught.

"We found gaps," says Denise Koo, director of the Scientific Education and Professional Development Program Office at the Centers for Disease Control and Prevention. "Schools of public health didn't consistently teach surveillance, for instance. They weren't necessarily exposing their epidemiology majors to other departments. And they didn't offer enough practical experience."

By the time an international commission was convened by the Gates Foundation in 2010 to review the education of future health professionals, it found "a slow-burning crisis".

Public health education continued to rely on "fragmented, outdated and static curricula that produce ill-equipped graduates", the commission wrote in a paper, "Education of Health Professionals for the 21st Century", published in The Lancet. Graduates were not being taught how to apply the knowledge they acquired and there was "tribalism" among specialists who worked in isolation from (even in competition with) each other.

David Dausey, chair of public health at Mercyhurst University, agrees that public health schools have focused too narrowly. When he attended graduate school in Yale, Dausey says, the subject of epidemiology was further split into "chronic" and "infectious".

He says that "American schools of public health have stayed divided in their own little cliques" because they have been rewarded for narrowly focused research.

"There is a history in academic schools of public health of departmental autonomy that's driven in large part by the heavy emphasis on individual investigator-driven projects," Galea says. "And that carries over to the rest of the culture."

The problems exist across the board, the Gates commission concluded.

"If you've seen one school of public health's curriculum, you've seen practically all of them," Lapp says.

Cost-effective treatment

It is not only these reports that have propelled Columbia's reforms. There is increasing pressure from employers who need graduates ready to work in teams and advocate for policy, and who face a projected shortfall of trained public health professionals.

Students and their families also want to know what they are getting for their spiralling tuition costs.

"We're not the first people to notice this," says Melissa Begg, Mailman's vice-dean of education. "The people who employ our graduates have been talking about it. And when we looked at our (master's in public health) graduates, the most successful ones have the broadest skill sets."

Yet public health education "has not changed that much", Lapp argues.

"What schools [such as] Columbia have recognised is that we cannot produce only graduates with technical skills. We have to produce graduates who can communicate the public health agenda and be agents for change."

The Columbia experiment is under way after taking two years and $5 million (£3.2 million) to develop. And the Association of Schools of Public Health has convened a task force to recommend by 2015 how matters should proceed for the next 100 years.

Many other schools are not waiting for the results and are already reviewing or revising their curricula.

"We're moving to a more practical level," says Lisa Sullivan, associate dean for education at the Boston University School of Public Health. It is not alone. The University of Michigan School of Public Health is testing an interdisciplinary core curriculum. And the University of North Carolina Gillings School of Global Public Health last semester began requiring an interdisciplinary introductory course.

"Certainly employers and students drive it, but we're also seeing across the field this realisation that the curricula we have in place are not necessarily getting the job done," says Dausey, whose students shadow food and restaurant inspectors and other local health officials as part of their course.

"You can lecture until you're blue in the face," he adds. But, like Erin Mears, "we have to actually be doing things".

At Columbia, the response to the changes has been notable, with applications for the class that will pioneer the curriculum up 20 per cent, according to the university.

"What Columbia has done and Harvard is doing is challenging the status quo," Galea says. "It's a bold experiment. We don't know how this is going to work. But there's going to be no appetite for going back."

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