Public health scholars and professionals are often taught the “river story” to understand the role of the public health field in preventing disease and early death for entire populations rather than treating individual health problems one patient at a time. In the story, a physician explains the dilemma of the modern practice of medicine, saying: “There I am standing by the shore of a swiftly flowing river and I hear the cry of a drowning man. So I jump into the river, put my arms around him, pull him to shore and apply artificial respiration. Just when he begins to breathe, there is another cry for help. So I jump into the river, reach him, pull him to shore, apply artificial respiration, and then just as he begins to breathe, another cry for help. So back in the river again, reaching, pulling, applying, breathing and then another yell. Again and again, without end, goes the sequence. You know, I am so busy jumping in, pulling them to shore, applying artificial respiration, that I have no time to see who the hell is upstream pushing them all in.”1
This story illustrates how challenging it can be to focus attention “upstream,” to identify the root causes of health problems when under conditions of limited resources and massive need.2 It can be even more challenging to address the root causes occurring at a broad policy level that do harm instead of supporting health, wellbeing, and equity for individuals and communities. Regardless of their specific job descriptions, public health practitioners and researchers should have a robust understanding of how policies and politics intersect with public health, including the mechanics of the policymaking process and the influence on health outcomes. The public health workforce should also have the ability to identify and implement effective policies to promote public health. However, traditional approaches to public health training treat policy as a niche focus rather than a core component. The breadth of health-relevant policy issues has expanded beyond what is traditionally taught, yet it receives little attention in public health training.
Why Emphasize Policy in Public Health Training?
The COVID-19 pandemic has clearly shown how both policies and politics influence the work of public health researchers and practitioners as well as the life-saving benefits of good public health policy.3 It has also brought to light the challenges of weighing competing societal priorities, such as minimizing COVID-19 exposure risk, preventing social isolation, maintaining access to essential services, addressing financial impacts of the pandemic, and supporting civic engagement and voting access. The pandemic has given rise to the politicization of standard public health activities, such as infectious disease surveillance and risk communication. It is now clear that public health practice and research exist within a political context that cannot be ignored. Robust training in policy is needed to ensure the public health workforce can provide unbiased guidance based on sound science and implement effective and evidence-based solutions to public health threats.
Policy has long been considered a core element of public health practice. The 10 Essential Public Health Services framework describes core activities that protect and promote the health of all people in all communities.4 The framework directly calls on public health practitioners to use legal and policy skills to do so. Essential public health services are strongly influenced by political factors, even if they are not explicitly tied to policy. For example, public health professionals have had to navigate political opposition to communicating the health risks of COVID-19 and recommendations of evidence-based measures like wearing a mask in public. Development and distribution of a vaccine are also clearly scientific, logistical, and political challenges for public health professionals.
Schools offering a Master of Public Health degree are required to provide graduates with training in 22 foundational competencies of public health for accreditation by the Council on Education for Public Health (CEPH).5 Four of the CEPH competencies focus specifically on policy in public health, affirming the importance of policy knowledge and skills for public health practitioners. Schools of Public Health should strive to go beyond meeting formal accreditation requirements and provide rigorous and well-designed training in policy for public health students of all degree paths and disciplines.
How Can Public Health Education Build a Stronger Policy Skillset?
A range of strategies and opportunities are available for public health educators looking to increase the quantity and improve the quality of policy training for students.6 Incorporating readings and lecture content that connects public health issues to policy implications is an easily implemented and accessible strategy to strengthen existing courses. However, given the dynamic and applied nature of policy issues, policy training should be experiential and hands-on when possible. Course assignments or research projects can be designed to focus on timely policy issues that connect with student interests. When feasible, students should have opportunities to hear directly from diverse stakeholders discussing public health policy issues and skills. Public health educators can achieve this by inviting practitioners to give guest lectures, assigning students to attend public meetings and policy events. Public health students could also be paired with policy practitioners for theses, practicums, or class projects. Lastly, engaging with policy can take many forms and may reflect a range of ideological approaches. Educators should expose students to the full range of policy strategies available to public health practitioners and researchers, including collaboration and negotiation, providing data and analyses to inform policy decisions, direct policy advocacy, and legal action.6
While many public health educators are career academics and may have little personal experience engaging with policy, increasing faculty’s familiarity and experience with policy engagement would benefit both their research and their pedagogy. Schools of Public Health should value professional experience with public health policy during hiring decisions. Offering policy-focused professional development opportunities for faculty would also allow policy content to be effectively incorporated into all public health courses, not just those taught by policy-focused faculty.6
- Mckinlay, J. B. (1979). A Case For Refocusing Upstream: The Political Economy Of Illness. Patients, physicians and illness: A sourcebook in behavioral science and health. 9-25.
- Williams, D. R., Costa, M. V., Odunlami, A. O., & Mohammed, S. A. (2008). Moving upstream: how interventions that address the social determinants of health can improve health and reduce disparities. Journal of Public Health Management and Practice, 14, S8-17. https://doi.org/10.1097/01.PHH.0000338382.36695.42
- Collins, F. (2020, June 23). Public health policies have prevented hundreds of millions of coronavirus infections. NIH director’s blog. https://directorsblog.nih.gov/2020/06/23/public-health-policies-have-prevented-hundreds-of-millions-of-coronavirus-infections/
- Centers for Disease Control and Prevention. (2020, September 22). 10 essential public health services. https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html
- Council on Education for Public Health. (2016). Accreditation criteria: Schools of public health & public health programs. https://media.ceph.org/documents/2016.Criteria.pdf
- Hearne, S. A. (2008). Practice-based teaching for health policy action and advocacy. Public Health Reports, 123(2), 65–70. https://doi.org/10.1177/00333549081230s209
- Freudenberg, N., & Kotelchuck, D. (2001). Political competencies and public health leadership. American Journal of Public Health, 91(3), 468. https://doi.org/10.2105/ajph.91.3.468b
The author thanks Megan Ray and Shannon Monnat for inputs and edits on earlier versions of this brief.
About the Author
Claire Pendergrast is a Ph.D. student in the Department of Sociology, a Graduate Associate in the Center for Policy Research, and a Lerner Graduate Fellow for the Lerner Center for Public Health Promotion at Syracuse University (firstname.lastname@example.org).