Journal of Public Health Medicine
Vol. 29, No. 2, pp. 144-148
Printed in Great Britain
The context and role of the US school of public
health: implications for the United Kingdom*
Raj Bhopal
Summary
Several UK medical schools have reorganized academic
public health in 'schools of public health' or 'health sciences'.
This paper considers the implications for the United Kingdom
of the US concept of schools of public hearth independent of
medical schools. These schools provide muttidisciplinary
research environments with scientists from laboratory and
population-based disciplines competing successfully for federal research funds on projects ranging from basic science
(e.g. biochemistry or genetics) to public health policy. Few
public health academics see the expenditure of a trillion
dollars per year on health care as a priority for public health.
These schools have excelled in research, but not in leadership
of service public health, so academic and service public health
goals have diverged. In seeking the research advantages of
the US system, the strengths of the UK one, including the
relatively close links between public health and medicine and
academia and service, together with a focus on applied work,
should not be lost.
Keywords: public health in USA, public health research,
training and education. School of Public Health
Introduction
Following the recommendation of the Acheson Committee that
the United Kingdom should establish more schools of public
health1 several medical schools have reorganized as 'schools of
public health', or 'health sciences', or like terms. This has
stimulated questions about the optimal organization of public
health sciences. The US school of public health model is worth
considering.
Schools of public health independent of medical schools
were promoted by the Rockefeller Foundation. The first such
institution was established in 1916 at the Johns Hopkins
University, Baltimore, USA. The London School of Tropical
Medicine and Hygiene was also funded by the Rockefeller
Foundation. The model was a combination of the German
research institute and the practice-orientated academic and
service public health system of the United Kingdom.
I observed three US schools of public health, at the
University of North Carolina, Johns Hopkins University and
Emory University (the first one in most depth) during
September 1996-June 1997, and made brief visits to the
Department of Health and Human Services in Washington, the
Centers for Disease Control in Atlanta, two state departments of
health and four local county departments of health to put the
work of schools into the public health context. The United
States is a massive and heterogeneous country, so these
observations and this paper have evident limitations, but
should suffice to spark discussion. A general discussion of
public health in the United States is followed by a description of
the three schools of public health. The implications for the
United Kingdom are then outlined.
Service public health in the United States
Public health in the United States is pluralistic, diverse,
complex and changing.2"4 Service public health is integral to
the political system. Agency heads, State Health Officers and
County Health Officers are political appointees, whose tenure is
generally short. The United States has been in an anti-public
service and anti-government phase which obviously affects
public health. The failure of President Clinton's health care
reforms has led to change in an uncontrolled way. The 'for
profit' managed care companies are in the ascendancy, and
absorbing privatized and public health care. The position of
public health is symbolized in the recent lengthy vacancy of the
post of Surgeon General, the equivalent of the Chief Medical
Officer in the United Kingdom.
There is a Secretary of State for Health at cabinet level in
government. The government Department of Health and Human
Services, which is responsible for policy nationally, conducts its
public health business through agencies, including the Centers
for Disease Control, the Health Care Financing Administration
and the National Institutes for Health.
The 50 State Departments of Health (or equivalent title and
functions) are independent, and perceived as the major force for
public health. State Departments work with county jurisdictions
where the public health services are mostly delivered. Control
Department of Epidemiology and Public Health, School of Health Sciences,
Medical School, University of Newcastle upon Tyne, Newcastle NE2 4HH,
UK.
Raj Bhopal, Head and Professor of Epidemiology and Public Health
Based on work done while Visiting Professor, Department of Epidemiology,
School of Public Health, University of North Carolina, Pittsboro St, Chapel
Hill, NC 27599 - CB 7400, USA.
This paper was commissioned by the editors.
© Oxford University Press 1998
THE US SCHOOL OF PUBLIC HEALTH
and co-ordination is sometimes by legislation, but usually
through offering services, and funding on a contractual basis.
There is tremendous heterogeneity in the conception of public
health.
Public health at the federal level is a mixture mainly of
research, policy making, surveillance activity and administration
of funds. Public health at state level is a combination of both
making policy and applying federal policy (usually after state
level modification), surveillance, contracting for public services
such as Medicaid (federal funds) and Medicare (a mixture of
federal and state funds), and research. For some 30 years, county
level public health in the United States, in particular, has been
dominated by the provision of health care services for people
ignored by the private sector. At present, much core public health
work, such as surveillance, health promotion, and health needs
assessment is subsidized from funds for clinical activity. As
clinical activity is devolved to the private sector, public health
staff at local level are being lost.
State Departments of Health and the Centers for Disease
Control are active in applied public health research. There are
many foundations and private agencies which do applied
research, thus obviating a reliance on schools of public health
for such work. The Centers for Disease Control have grown
enormously and their influence at state level is discernible.
There is a cruel paradox in the growing power and resources of
federal agencies in comparison with the increasing difficulties
of state and local public health.
Critique of US public health: reports of the
Institute of Medicine
Fragmentation of US public health, and the lack of common
purpose, has been debated most visibly by the Institute of
Medicine, a highly prestigious academic body and a part of the
National Academy of Sciences. The first report was published
in 1988,3 and the second in 1996.4 The first feared that the
'nation has lost sight of its public health goals and has allowed
the system of public health to fall into disarray'. Public health
was seen as assuring conditions in which people can be healthy,
and its core functions as assessment, policy development, and
assurance. The 50 States were identified as central. The need for
public health to work more closely with environmental health,
mental health services and to continue its role 'of last resort' in
the care of the indigent were among the issues identified.
The committee identified that schools of public health were
isolated from practice and devalued the training of public health
professionals. The reasons for this included the negative image
of public health practice. Recommendations to strengthen the
contribution of the schools of public health to public health
practice included the obvious ones of involving faculty and
students in public health agencies, and giving weight to public
health experience in recruiting students and faculty. The report
closed with words such as 'Public health is a vital function
which is in trouble' and by admonishing readers 'to get
145
involved in their own communities in order to address present
dangers, now and for the sake of future generations'.
The second report focused on the changing organization of
health care, especially managed care, the changing role of
government and the role of the community. The second report
gave a mixed message. First, it proclaimed great success for the
first report, particularly for its clarifications on the mission of
public health agencies, which, 'have been extraordinarily useful
in revitalising the infrastructure and rebuilding the system of
public health at all levels of government'. Second, it admits that
the core messages and core functions have been difficult to
translate for key stakeholders, including elected officials. In a
politically dominated public health system this is problematic.
The committee also found evidence of inadequate support of
governmental public health agencies and acknowledged that
core public health was endangered by privatization of health
care. No solution was offered except for public health to inform
legislature what it does. Both reports saw 'the public health
enterprise in the United States, as embodied in governmental
public health agencies as necessarily diverse in organisation
and function' (my emphasis on necessarily). Neither considered
the possibilities that the diversity is a problem, or that public
health needs federal government leadership more than
state leadership. These reports are from an academic body,
whereas public health in the United States is politically
embedded.
Academic public health
There are 27 schools of public health in the United States
providing multidisciplinary research environments, fertile for
developing the skills and careers, particularly, of non-medical
scientists. Academic posts are increasingly filled with basic
scientists, epidemiologists, demographers and social scientists
rather than public health practitioners. Schools of public health
compete successfully for federal research funds for projects
ranging from basic science (biochemistry or genetics) to public
health policy. Laboratory scientists and population scientists
are partners in the school of public health environment. Some
population science departments have basic science laboratories
within them. The academic vision of public health problems has
become more scientific with issues of theory, measurement and
method receiving close attention.
Academic public health is flourishing. A gap between
service and academic public health is widely recognized and,
from my observations, academic and service public health
inhabit different continents, with signs that practitioners are
migrating to academia, rather than the opposite. The concept of
local public health (to provide health care and public health
services) is starkly different from academic public health
(mainly research, and, increasingly, training for researchers).
One colleague informed me that in the 1950s the worlds of
practice and academia parted; practice towards clinical work,
academia towards research in traditional public health. With
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JOURNAL OF PUBLIC HEALTH MEDICINE
recent changes at local level, she said, it is beginning to look as
if academia was right.
Schools of public health emphasize research technique. In
contrast to the case in the United Kingdom, the Ph.D.
emphasizes course work as much as research. The Ph.D. is
the stepping stone to an academic career in public health, and
increasingly to professional posts in public health, particularly
as many involve research. The Master in Public Health
(M.P.H.) degree, which may be completed in as little as eight
months, is an entrance qualification to service public health, and
entitles the holder to the (esteemed) title of epidemiologist
There is a gulf between academic medicine and academic
public health, excepting specific research projects or common
responsibilities in education and training. Few public health
academics see the expenditure of a trillion dollars per year as a
public health issue. Certainly, public health does not take
responsibility for the problems of US medicine, except for the
services which are directly under its care, and to point to the
numbers of people without access to quality health care.
There are about 53 departments of preventive medicine or
public health (or equivalent titles) in the 126 medical schools of
the USA.2 None the less, preventive medicine is seen as a
specialty which is little known by medical students. Some
medical schools, including Duke University, some 10 miles
from the Chapel Hill School of Public Health, offer no
education in public health or epidemiology.
The American Board of Preventive Medicine, which
accredits training of physicians in public health related fields,
recommends three years of training which includes one clinical
year, and one for academic work, usually an M.P.H. degree.
The third year (practicum year) is highlyflexible.A fourth year
of independent work is needed for certification.2 In practice,
training is often shorter. Funding of training is problematic and
authorized residency positions remain unfilled.2
The School of Public Health of the
University of North Carolina at Chapel Hill
The University of North Carolina is a state university with over
23 000 students. The mission statement emphasizes the role of
service. The mission of the school of public health includes
improving the health and well-being of the population. The
school of public health is organized as eight departments and
five inter-disciplinary programmes. (One department, Nutrition, is jointly with the Medical School.) The school has more
than 160 full-time academic staff (faculty), plus many honorary
(adjunct) faculty, and large numbers of research and support
staff. Departments are strong and enjoy autonomy in research
and teaching.
This world-famous school is only 57 years old. Responding
to the need for a centre for training of public health
professionals a division of public health in the Medical
School was established in 1935. A desire for independence
for the division grew, and in 1940 the school was created.5
Practice-based disciplines such as public health nursing and
educationflourished,as did international activities and teaching
of overseas students. The school became involved in matters
such as control of venereal disease and health education of
black Americans. The school was rooted in the community and
its problems. Departments of biostatistics and maternal & child
health were added in the late 1940s.
In 1953 the Dean led a review of the nature and purpose of
public health, defining it as 'the scientific diagnosis and
treatment of the body politic' and identifying the community as
public health's patient. The purpose of the school was teaching
and being a resource for the community. The Dean's view was
that 'You are not training research people. You are training
people that know the value of research.' This was contentious.
The 1950s saw funding for research becoming plentiful,
making the above policy unsustainable.
By the 1960s the research-orientated departments dominated. By the 1970s students were complaining about the
courses and there was criticism that the school was neglecting
its responsibilities to state public health problems. A self-study
attributed this to the quest for research funds. Research remains
the highest priority. Practice is seen as desirable when it
coincides with teaching or research interests, but not when
it interferes with the primary goals. Success in research is the
route to tenure and above average-salary awards.
The school offers an undergraduate bachelor in science in
public health degree and seven postgraduate degrees. For a
Master of Public Health in epidemiology two years of work is
the norm, though the course can be done in 12-18 months, with
no requirement for field training or service.
The Doctor in Public Health (Dr.P.H.) and Ph.D. degrees
require substantial course work (lasting approximately two
years, six courses) and directed research over two years beyond
master's level (in practice, students try tofinishtheir research in
6—12 months). The dissertation must demonstrate both original
work and mastery of the methods of the discipline. Thefinaloral
examination is a public defence of the dissertation. There is
supposedly a distinction between the Dr.P.H. and the Ph.D., the
former being designed for those in, or aiming for, leadership
roles in practice and the latter for researchers. Often the research
done for the Dr.P.H. is no different from that done for the Ph.D.
The School of Hygiene and Public Hearth at
Johns Hopkins University
Established in 1916, this was the first such school in the United
States. The idea of combining the research orientation of the
German schools of hygiene with the practice of public health of
the United Kingdom is encapsulated in the title and underlies
the combination of both laboratory and population science
departments. The mission of the school emphasizes education
of both scientists and public health professionals, and the
discovery and application of knowledge to improve health
around the world.
THE US SCHOOL OF PUBLIC HEALTH
The school consists of ten departments and many crossdepartmental groupings called centres. The departments
include biochemistry (one of the three in the university
campus) and molecular microbiology and immunology.
Individual departments are large; for example, epidemiology
has some 40 academic staff and about 500 persons associated
with it. As with Chapel Hill, departments are largely
autonomous. The school's focus is on research degrees
(M.S.P.H., M.Sc, Ph.D., D.Sc. and the Dr.P.H.), which,
unlike the M.P.H., are departmentally based.
The laboratory-based departments share the school mission,
but clearly their values and goals are not the same as those of
population-orientated departments, though the close proximity
permits interaction of students and academics (research students
do courses in both laboratory and population-based sciences).
The Rollins School of Public Health at
Atlanta, Georgia
The Rollins School of Public Health at Emory University,
Atlanta, was founded in 1990. It is within the heart of the
Emory University campus, and is close to the Centers for
Disease Control and many health care facilities. There are six
academic departments and five centres. None are laboratory
based. There are about 70 full-time academic staff.
A school of public health was encouraged by the university
and the Centers for Disease Control. The move from the
medical school of several of the founding departments of the
school was accomplished co-operatively. Before the school was
created there were about 20 M.P.H. graduates per year, now
there are about 150.
This school puts explicit emphasis on the community.
Students are expected to do 'practicum', that is, work in the
service context, and faculty are encouraged to serve the
community. The Centers for Disease Control, on the doorstep,
is one of the major institutions which makes this a reality,
particularly as it emphasizesresearch.There are no institutional
strategies to safeguard such multi-agency and multidisciplinary
work.
Implications for the United Kingdom
With the divergent health systems and politics of the United
Kingdom and the United States it is hard to make generalizations but some implications seem clear. The US school of
public health environment is a powerful means of focusing on
research. The Rockefeller Foundation's dream has been
achieved in thisregard.The challenge of developing the critical
mass of researchers (so necessary to Ph.D. programmes requiring
advanced course work) is achievable in the school of public
health environment. Focusing on research, the school of public
health becomes integral to the university with less of the tension
which exists between vocational and academic missions.
The school of public health provides an environment to
147
strengthen non-medical public health (an acknowledged need
in the United Kingdom) and draws in public health scientists
from many disciplines. Clearly, non-medical public health
scientists perceive themselves as much more highly valued in
the school of public health than they are, or would be, in the
school of medicine. Working across disciplines is somewhat
eased by having diverse groups of public health scientists from
chemists to sociologists in the same administrative structure,
yet all subscribing, at least in theory, to the public health vision
(though interdisciplinary divides remain).
Schools of public health are large enough to offer a career
path for professional researchers. For example, the epidemiologists form a professionalized self-contained group. By
contrast, many epidemiologists in the United Kingdom perceive
themselves first as statisticians, physicians, public health
specialists or social scientists.
There is a price to be paid for these benefits. An independent
large school of public health, focusing on research, develops its
own agenda which potentially distances it from the world of
medicine, which is increasingly important to the public health
goal, for example, in taking over the delivery of preventive
health services in the United States (as in the United Kingdom).
For reasons that may be peculiar to the history of public health
in the United States, but may be an attribute of changing
priorities, the school of public health environment also seems to
distance public health scholars from the world of service public
health. Certainly, the vision, goals and day-to-day work of
many public health practitioners are so different from those of
the academic in the school of public health that this is not
surprising. What is more surprising is the relative lack of
interest in the fortunes of service public health and in assisting
in the renewal of the local public health function.
The UK system of academic public health is substantially
founded on applied research relevant to health policy and
planning, and medical and public health practice. With the
National Health Service (NHS) increasingly embracing
research through its research and development initiative, this
model is likely to be strengthened. (The danger is that applied
work is done at the expense of more basic public health
research.) The US model, although trying to blend the best of
the German and the UK approaches, has clearly veered towards
non-applied research. The highest accolades are reserved for
research done with funds from the National Institutes for
Health, which have a preference for basic research with longterm goals. In evaluating and implementing the Acheson
Committee's recommendation to increase the number of
schools of public health, UK universities, medical schools,
the NHS and the public health fraternity should consider the
above potential long-term implications of a move to the US
model.
A school of public health model truer to the UK tradition
may be focused around service and applied research, rather
than more basic research. Yet, the US school of public health
captures the spirit of the strategy fostered by the research
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JOURNAL OF PUBLIC HEALTH MEDICINE
assessment exercise of the Higher Education Funding Council:
selectivity, critical mass, and the need to focus on research of
international importance largely funded through national
research councils.
Increasing the independence from the medical school of UK
academic departments working on public health issues is likely
to foster the career development of non-medical public health
researchers and, on the US precedent, likely to lead to growth.
In seeking the advantages for research of the US approach the
strengths of the UK system, including the links between service
and academia, public health and medical care, and due
emphasis on applied work, should be safeguarded.
Acknowledgements
It is impossible for me to give due thanks to the hundreds of
people who opened their doors and minds to me. They are
primarily responsible for my developing an understanding of a
complex health and public health system in a relatively short
period of time. The following people are a few of the many who
helped: Dr Peter Hill, who commissioned a report on this
subject; Dr Carl Shy, who hosted my visit and shared his
experiences; Drs Trade Bennett, Vic Schoenbach, Lenore
Kohlmeier and Steven Wing for continuing dicussions; Dr
David Ballard for hosting my visit to Emory University and for
insights into US research culture; Drs Ebenezer Israel and
Rashid Chotani for hosting my visit to Maryland State Health
Department, Baltimore, the Johns Hopkins School of Public
Health and to county health departments; Dr Tim Aldrich
for educating me about public health at State level; Dr Beth
Joyner for educating me about county level public health
and for organizing county health department visits. To these
and to the many others in the United States, I give my heartfelt
thanks.
References
1 Committee of Inquiry. Public health in England. London:
HMSO, 1988.
2 Forum for leadership in the specialty of preventive
medicine. The specialty of preventive medicine. Leadership
in medicine for the 21st century. Washington, DC:
American College of Preventive Medicine, 1996.
3 Committee for the Study of the Future of Public Health
(Institute of Medicine). The future of public health.
Washington, DC: National Academy Press, 1988.
4 Stoto M, Abel C, Dievler A. Healthy communities: new
partnerships for the future of public health (Institute of
Medicine). Washington, DC: National Academy Press, 1996.
5 Korstad RR. Dreaming of a time. Chapel Hill, NC:
University of North Carolina, 1990.
Accepted on 4 November 1997