When You've Seen One Health Department...
When You've Seen One Health Department...
Local Public Health in Washington State
Patricia W. Wahl
Dean and Professor of Biostatistics
School of Public Health and Community Medicine
University of Washington
Background
When
I became Dean of the School of Public Health and Community Medicine at
the University of Washington, I brought to the job little knowledge of
public health as it is practiced in the real world. My career as a faculty
member in the Department of Biostatistics had been spent within the walls
of the ivory tower, focused on research and teaching. Although I had served
as the School's Associate Dean for a number of years, my duties and responsibilities
in that role were concentrated on the internal administration of the School.
To gain a better understanding of public health at the community level and to learn how graduates of our School might be employed, I decided to visit a few local health departments in our state. In planning this venture I was wisely counseled by Mark Oberle, a former CDC medical epidemiologist and now our School's Associate Dean for Public Health Practice, who served from 1987 to 1990 as our School's liaison to the public health agencies in this state. I asked Mark to select a few "representative" health departments to visit, but he claimed there was no such thing. To get a complete picture, he insisted, we would have to visit all of them. Accordingly, we made the commitment to visit all 34 local health jurisdictions in the state of Washington.
After announcing our intention at the annual meeting of the Washington State Public Health Association in 1999, we proceeded to work with each of the health departments and districts to schedule visits. Our state-wide tour took almost two years, with the bulk of the visits being made during the summers - a good time for academia but less so for our agency hosts.
Description of Visits
On some visits we were accompanied by a faculty or staff member from the School; at other times a student would join us. The most frequent participant was Rolf Christensen, a dentist and public health student, so we also learned about oral health problems and the surprising lack of fluoridation in many parts of the state.
Because we set no specific agenda for our visits, the format of each visit could be determined by the department or district. The length of each visit varied considerably - from a couple of hours to a full day - as did the variety of people who met with us. Sometimes we saw only the agency administrator, although more frequently the meetings included key staff and, occasionally, community partners. On several occasions our visits were timed to coincide with local Board of Health meetings.
Most meetings consisted of a brief presentation about our School of Public Health and why we were making the visit, but the majority of the time focused on hearing from the agency staff. Of particular interest to me was the organizational structure within each department or district and its relationship with the local Board of Health and the community. I was also interested in what particular services fell under the agency's responsibility, and what local health problems were of most concern. Additionally, we queried everyone about how they had become involved in public health, their educational preparation, and what additional training and educational opportunities would be of most interest.
We learned that most people were aware of our School of Public Health and were generally positive about the public health science research done by our School. But - and there was always a but - generally it was felt that much of our research was of little use to public health practitioners and had little impact on the health of their communities. It became apparent that our research findings were not being disseminated in a way that was useful, either for communication to the local Boards of Health and the community or for developing and evaluating community interventions.
While our School's expertise was widely recognized and respected, and
our academic programs highly valued, they appeared to be neither accessible
nor of benefit to local public health. Most of our academic programs require
students' on-campus presence for a minimum of two years. Time and financial
constraints of public health staff and their agencies prevent extensive
time away from work. In addition, most of the staff desired only a course
or several courses on a specific topic, not an entire degree program.
Visit Impressions
Repeatedly
demonstrated was the old adage "When you've seen one health department,
you've seen one health department." Most departments or districts
were a microcosm of their community and reflected local political, social,
and cultural environments. Organizational structure, responsibilities
and services, resources and health problems reflected local influences
and were as variable as the geography of Washington state. Clearly, urban
and rural, eastern and western Washington departments would be expected
to vary; however, there were often considerable differences in departments
of similar size and geographic location. Also, no single model or organizational
structure could be considered uniformly best, although those agencies
with a physical separation of environmental health from the rest of public
health suffered from a lack of efficient, effective, and comprehensive
public health response. Logically enough, communities in which health
and human services and public health were combined or worked together
seamlessly appeared to provide better service than those in which the
various governmental entities were not only more distinct but less cooperative.
Local Boards of Health that respected and valued the work of public health and supported it with resources contributed significantly to the health of their local communities. Other community partners, including doctors and hospitals, local government, private business, and citizen groups, often greatly assisted in expanding the capacity of public health in their community.
Of great concern to me was how little of the public health workforce had any formal education in public health. A recent survey of our state's public health workforce(1) found that less than ten percent had any public health education. While we hoped to meet graduates of our programs and to learn first hand how well their educational experience had served them, there were few such opportunities. MPH graduates or others in related public health disciplines were seldom found except in a few large health departments. Most frequently we encountered graduates of our undergraduate environmental health program, coupled with repeated requests for more of these undergraduates.
A surprising observation was how many of the urban and even rural health departments around the state are challenged by large numbers of ethnic communities. These multicultural communities consist of farm workers from Mexico and Central America, immigrants from Russia, Ukraine and other Eastern European countries, plus many more from Southeast Asia. Previously, I had assumed that only the larger western Washington cities faced extensive communication challenges, cultural differences, and even cases of multiple antibiotic-resistant TB and other emerging diseases.
Our visits began during a stressful period for the public health system in Washington State, as massive staff and service cuts were being implemented due to the repeal of Washington's Motor Vehicle Excise Tax, a major funding source. It was disheartening to observe the lack of adequate, stable funding provided to the local health agencies. Many departments depended on grants and one-time funding and lacked sufficient infrastructure resources to provide the essential services needed to assure the health of their communities. The categorical or restrictive nature of much of the funding contributed to a lack of flexibility to respond to local health crises.
In the face of all this, then, we were overwhelmed by the dedication
and commitment of the public health workers. In spite of the daily challenges
they faced - resource shortages, on-the-job learning, mastering new technologies,
and more tasks than staff or time to do - everyone expressed enthusiasm
for and pride in their work. I regretted the time we took from their busy
days and remain deeply appreciative of their willingness to meet with
us. There were several small departments in which the two people who met
with us were basically the entire workforce, and I felt it might have
been better for me to answer the phone rather than talk about educational
opportunities they might never have the time to access.
Impact of Visits on School
These visits have not only served as a first hand learning opportunity for me; they have also influenced the School's strategic plan and resulted in some concrete changes.
To
better prepare graduates for careers in community and public health practice
as effective problem-solvers, innovators, advocates, and leaders, the
School is developing a new MPH
in Community-Oriented Public Health Practice. In addition to receiving
a solid foundation in the core disciplines of public health, students
will develop a variety of additional competencies. Graduates will be able
to work in an interdisciplinary team, to understand management and organization
in a health agency setting, and to develop policy and mobilize local community
partners. Proficiency with the new technologies will be emphasized in
order to manage the escalating volume of health information. The program
will integrate learning and practice through experiential fieldwork coupled
with problem-based learning, using specially designed case studies based
on public health issues within the community. With new University funding
to expand our graduate student enrollment, this new program will be offered
starting Fall 2002.
The School will continue its other academic programs with emphases on research methodology and a high level of technical competence. With over eighty percent of the School's funding derived from research grants and contracts, the majority of its faculty, and thus its programs, will continue to reflect strong research excellence. However, as a professional school, the School must find ways to translate its research findings and apply them to the benefit of the public health profession and the health of the population in our state and region. To that end, the School is engaging the faculty and departments in a revision of the School's promotion guidelines with a goal of recognizing and rewarding faculty for public health practice activities.
Recent funding from the Health Research Services Administration and the Center for Disease Control and Prevention, awarded to our Northwest Center for Public Health Practice,(2) will assist the School in making its educational resources and expertise available in the state and throughout the Northwest. (3) Jack Thompson, director of the Center, is co-chairing the workforce development committee of the state's Public Health Improvement Plan to broaden and coordinate the state's public health workforce development agenda. (4)
Large changes in traditional educational institutions do not come easily,
but small increments made as part of a larger plan, reflecting evolutions
in higher education and in the US health care system, will allow the School
of Public Health and Community Medicine to expand its professional role
while maintaining its research excellence.
References
- Reder S, Gale JL, Taylor J. Using a Dual Method Needs Assessment to Evaluate the Training Needs of Public Health Professionals. J Public Health Management Practice. 1999;5(6):62-69.
- Omenn GS, Oberle M, Gale J, Hoover JJ, Tapp J. The Northwest Center for Public Health Practice. Am J Public Health. 1993;83(12):1788-1799.
- Bekemeier, B. A Public Health Workforce That Works. Northwest Public Health. 2001;18:6-9
- Washington State Department of Health. 2000 Public Health Improvement Plan. Olympia, WA:2000.
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