For this article, we define public health as “systematic efforts organized by society to protect, promote and restore the people's health. It is the combination of sciences, skills and beliefs that is directed to the maintenance and improvement of the health of a population or populations through collective or social actions.”1 Its core functions include health surveillance, health protection, disease and injury prevention, population health assessment, and health promotion.2 Public health measures act to reduce the impact of social, economic, and behavioral determinants on the health of populations.
We do not use the term public health to refer to the source of funding for medical services. In Canada, medically necessary health services are provided to Canadian citizens and landed immigrants through a series of provincially funded programs. Although the federal government provides a sizeable proportion of the funding, each province runs its own program within the broad parameters of the Canada Health Act.3
Background: A Confluence of Interest
In 1974, the Canadian government's white paper, A New Perspective on the Health of Canadians,4 proposed that changes in lifestyles or social and physical environments would lead to more improvements in health than would be achieved by spending more money on existing health care delivery systems. This report was followed in 1986 by the Ottawa Charter for Health Promotion5 and Achieving Health for All: A Framework for Health Promotion,6 which expanded on the white paper by focusing on the broader social, economic, and environmental factors that affect health. It also redefined health as a resource for everyday living and not an end in and of itself. In 1994, the Federal, Provincial and Territorial Advisory Committee on Population Health presented Canada's ministers of health with a document titled Strategies for Population Health: Investing in the Health of Canadians.7 This proposed a national framework for action on health disparities and the broad determinants of health, echoing and expanding on previous broad perspectives. In 2002, the Commission on the Future of Health Care in Canada8 stated in its final report:
The impact of determinants of health and lifestyle choices is well-known to governments and to health care organizations. Unfortunately, the key problem lies in turning this understanding into concrete actions that have an impact on individual Canadians and communities. In many areas in public health, the gap between knowledge and practice is still too great.8(p129)
The Canadian public health system (defined as the combined federal, provincial, and municipal services that support public health activities) has been undergoing a recent series of tests and has been being found lacking. The SARS outbreak in 2003,9,10 the Escherichia coli outbreak in Walkerton, Ontario,11 the increasing burden of chronic preventable disease12 and obesity,13 the risk of natural disaster,14,15 the possibility of a pandemic,16 and the increasing importance of global influences on health17 have led to concerns about the public health system. The public health system needs enhancement by training all health professionals to respond appropriately to threats to the public health. In the United States, the Institute of Medicine reports similar concerns and also recommends improved training in public health.18
The demands on medical practice are evolving. Whereas most provincial health programs rely on regional health authorities to assess needs and allocate resources at a regional level,19 changes in organization in many parts of Canada require physicians to respond to community needs and to assume responsibility for a practice population. To support this, physicians are remunerated by a mixture of capitation and fee-for-service payments. Physicians, therefore, have to be able to access and interpret information about a given community and to practice population health to orient their practice toward improving health and preventing disease. They must also continue interacting with regional health authorities, contributing to the information on which the authority can base allocation decisions. As a result, a number of medical schools are seeking to enhance teaching the aspects of public health that allow physicians to practice effectively.20
Responding to the World Health Organization's initiative, Towards Unity for Health,21 the Association of Faculties of Medicine in Canada (AFMC), which provides a national voice for academic medicine in Canada, launched its Social Accountability initiative in 2001. This initiative was charged to develop “an effective social accountability model for medical schools [to] … provide the basis for all partners to work collectively on meeting the needs of the Canadian population in a collegial and collaborative manner.”22 The initiative includes the Public Health Task Group, which is modeled on the Towards Unity for Health pentagon (see Figure 1) and includes representation from the Public Health Agency of Canada, Canadian faculties of medicine, medical students, the Medical Council of Canada (MCC), and the community. The task group will address the needs of the population and strengthen the public health system by ensuring that improvements are made to the education of health professionals. We describe its activities below.
Public Health Infrastructure in Medical Schools
Canadian medical schools are expected to teach public health as part of their curricula. The learning objectives for public health constitute a major portion of the Canadian licensing examination.23 The current objectives are presented in List 1. Most Canadian medical faculties include expertise in public health. In many, those charged with teaching public health also hold professional posts within the public health system.
Before 2006, there were no separate schools of public health in Canada. Unlike the United States, most public health academic programs were associated with the Canadian faculties of medicine. Graduate programs in public health focused on epidemiology, health promotion, and administration. Broad MPH degrees were rare. Since 2006, however, two schools of public health have been created, one in a university that has no medical school. Up to 16 other universities are currently developing proposals for schools of public health and formal MPH programs.
Physicians wishing to specialize in public health may take postgraduate training in community medicine, which is a five-year specialty program (including internship) comparable with that of surgery, pediatrics, and other medical specialties. This training program generally meets the requirements for work as a medical officer of health.
The Role of the Public Health Task Group
The Public Health Task Group noted the concern around the teaching of public health and undertook the following four main steps to address it.
* Reaching agreement on common overall objectives for teaching in the area of public health.
* Obtaining baseline information on the programs that were being provided across Canada.
* Obtaining an inventory of resources available at each university.
* Creating a support system for supporting public health teaching in undergraduate medicine programs.
Creating common objectives
The MCC provides the national certification examination for medical practice in Canada. All provincial medical licensing bodies require members to have successfully completed the MCC exams. In recent years, the MCC objectives have been drawn up to reflect the competencies required to address clinical presentations of illness. This diminishes the place of public and population health, which go beyond the clinical situation and aim to prevent illness and, thus, should be applied before clinical presentation. Building on the existing MCC standards, documents from the Association of American Medical Colleges,24 and academic texts,19 the Public Health Task Group created a proposed set of population health objectives for undergraduate teaching that can be used by all medical schools in Canada. Published as a committee report in 2005,24 these objectives were submitted to the MCC for adoption. The major changes are shown in List 1. Because this continues to be a work in progress, more changes are being proposed and the document continues to be refined. However, the involvement of all schools in this process of defining a common agenda is central to the reform process.
Survey of baseline information on Canadian programs
The revised objectives were also circulated to the 17 medical schools in Canada. A survey was then conducted to determine the schools' awareness of the objectives and to identify their needs.25 Eleven responded to the survey. Nine stated that they were aware of the revised objectives but that implementation of these objectives was impeded by lack of curriculum time (eight schools), inadequate faculty resources (seven schools), need for curriculum buy-in or support (four schools), and lack of the necessary tools and supports (three schools). The barriers as perceived by the responding medical schools were
* lack of faculty (critical mass);
* inadequate support for local champions;
* high cost of developing resources and learning modules;
* high cost of creating appropriate field placements;
* inadequate methods of student assessment;
poor image as an attractive specialty/few role models.
Most of the education on public health occurs in the preclinical years. This and the discontinuity of educational exposure across all four years were seen as weaknesses in the medical curricula.
Obtaining an inventory of resources
Subsequent to the baseline survey, in 2006 another survey of the 17 medical schools ascertained methods and materials used in teaching public health to undergraduates; 13 schools responded. No single textbook is used by all the schools, although one Canadian reference book19 was mentioned by most of those who reported that they used a textbook. A wide and ever-changing variety of key articles were provided to students as potential reading material, but no key review articles were included. A number of Web sites and other online materials were also mentioned by a few of the schools. In response to specific questions, the availability of public health trained educators, faculty development in public health concepts for all teachers in medical school curricula, and the development of resource material targeted to the agreed-on objectives were seen as needs which the Public Health Task Group or a Public Health Educators Network (see below) might address.
Creating a support system for supporting public health teaching in undergraduate medicine programs
Reviewing the survey findings, the AFMC Public Health Task Group noted the need for a forum where public health educators could share expertise and resources as well as develop teaching tools and materials. Such a forum would support public health teachers. The Public Health Task Group recognized that these resources should go beyond simply undergraduate education and could be used for faculty development and eventually could support postgraduate training in public health for some specialties such as family medicine and pediatrics, as well as in other professions. The task group summarized its vision for how to move public health education forward in a report to Canadian medical school deans at the annual AFMC conference in May 2006; the report was also published.26
Concurrently with completing the survey on resources (above), the AFMC Public Health Task Group sought and obtained funding from the Public Health Agency of Canada for the creation of a Public Health Educators Network. The network consists of one representative from each of the 17 medical schools. As expected, each medical school designated their representative to be the faculty member who was responsible for teaching public health in the curriculum. The purpose of the network is to provide mutual support, share documents, and develop new resources for use by the collective.
The inaugural meeting was held in March 2007, and 15 of the 17 schools attended it. At the meeting, there was a continued interest to further define the objectives, to share resources, and to collectively create new resources. Annual meetings have been planned, but much of the work will be done electronically. The AFMC has agreed to host a forum through which resources can be shared securely. As the Public Health Educators Network's role increases, the role of Public Health Task Group will diminish accordingly.
Public health education, although widely variable in Canada, needs to be enhanced. As outlined by Naylor,9 and similar to calls from the IOM,18 there is a need for improved public health education of medical practitioners. Medical schools in Canada face common barriers, and addressing these collectively makes the most sense. The work by the AFMC Public Health Task Group, and the creation of the Public Health Educators Network, represent a major step forward among these medical schools. Because of limited resources, there is recognition that no one school can or should “go it alone.” There is general acceptance that the status quo is not acceptable, that now is the time for change, and that we are all stronger through such collaborative action. In terms of limitations, the authors recognize that we are early into the process, and we see this as a work-in-progress.
The creation and redefinition of educational objectives has formed the first step in the process; each of the universities must share in the common vision and agree with the overall outcomes. This does not interfere with the uniqueness of each individual curriculum, and there is no desire to force uniformity. Rather, the process aims to provide a common base from which each curriculum can build its own most suitable features.
Presently, the objectives are general, to allow for this flexibility. Several schools have expressed a desire for greater precision in the definition of the terms and concepts used in the objectives. In particular, the verbs used in the detailed objectives, because they reflect the level of understanding and anticipated action, may need to be more specific. Discussions have helped clarify the content and have led to better understanding of the issues. However, it is recognized that trying immediately to define the details is likely to block initiation of the process of change. It is accepted that the process will be iterative and that consensus on the details will evolve over time.
Finally, strong modules for teaching public health to undergraduate medical students can provide a basis for modules for continuing education, faculty development, and, possibly, teaching modules in some postgraduate programs. The network hopes that the development of generic modules will serve multiple audiences and thereby lead to greater efficiencies, faculty support from all sectors, and, eventually, strengthening of the public health system. Members of the network have already expressed their appreciation of the collegiality developing between the various medical schools, and they feel that sharing information and resources is the way of the future. Support and the leadership of the deans are also seen as necessary factors in enhancing the teaching of public health in the medical schools.
Note added in proof. Since the manuscript was accepted for publication, the Medical Council of Canada has published new educational objectives for the Population Health Section. These new objectives are very similar to those proposed by the AFMC Task Group in List 1. Information on the new objectives can be found at the Website cited in reference 23.
The authors wish to acknowledge the Public Health Agency of Canada for its financial assistance with the creation of the AFMC Public Health Task Group and the Public Health Education Network. The authors also wish to acknowledge the contributions of the 17 medical schools in Canada and the members of the AFMC Public Health Task Group and the Public Health Education Network for their contributions to the process. Finally, the authors wish to acknowledge Sue Maskill, Barbie Shore, and Ian McDowell for their review of the article and constructive comments.
1 Last J. A Dictionary of Epidemiology. 4th ed. New York, NY: Oxford University Press; 2001.
5 World Health Organization; Health and Welfare Canada; Canadian Public Health Association. Ottawa Charter for Health Promotion: First International Conference on Health Promotion. Available at: (www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf
). Accessed December 14, 2007.
7 Federal, Provincial and Territorial Advisory Committee on Population Health. Strategies for Population Health: Investing in the Health of Canadians. Available at: (www.phac-aspc.gc.ca/ph-sp/phdd/pdf/e_strateg.pdf
). Accessed December 14, 2007.
12 Klein-Geltink JE, Choi BC, Fry RN. Multiple exposures to smoking, alcohol, physical inactivity and overweight: Prevalences according to the Canadian Community Health Survey Cycle 1.1. Chronic Dis Can. 2006;27:25–33.
13 Shields M, Tjepkema M. Trends in adult obesity. Health Rep. 2006;17:53–59.
14 Hartling L, Pickett W, Brison RJ. The injury experience observed in two emergency departments in Kingston, Ontario during ‘ice storm 98.' Can J Public Health. 1999;90:95–98.
16 Butler-Jones D. Canada's public health system: Building support for front-line physicians. Can Med Assoc J. 2007;176:36–37.
18 Institute of Medicine. Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century. Washington, DC: National Academy Press; 2003.
19 Shah CP. Public Health and Preventive Medicine in Canada. 5th ed. Toronto, Canada: Elsevier Press; 2003.
20 Donovan D, Xhignesse M, Grand'Maison P. Integrating public health and medicine [WHO working paper]. Geneva, Switzerland: World Health Organization, 2005.
24 Association of American Medical Colleges. Medical Schools Objectives Project. Learning Objectives for Medical Student Education: Guidelines for Medical Schools. Available at: (www.aamc.org/meded/msop/msop1.pdf
). Accessed December 14, 2007.