For the vast majority of us, the onset of the COVID-19 global pandemic in early 2020 was the beginning of an unparalleled time of uncertainty for the health of the nation and the capacity of our health care system. In the past, colleagues have weathered regional natural disasters, outbreaks of emerging infectious diseases, and terrorist attacks. Although the events were formidable and, at the time, the extent of their casualties unpredictable, the victims of September 11, 2001, and the anthrax attacks, for example, were treated by a limited corps of providers and institutions. In contrast, COVID-19 has affected all of us and its duration is unpredictable. The demands for a stronger public health system are echoing back from previous emergencies.1 How the medical community will reflect and adapt in the wake of this pandemic is unknowable, but an early lesson for medical students, physicians, and educators is clear: Public health content has a distinct and critical place across the continuum of medical education to prepare physicians to participate in, collaborate with, and advocate for public health systems.
Unique and Consistent Allies
Recommendations to secure a foundational position in medical education for public health, described by C.-E.A. Winslow as “the science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals,”2 date back for generations and are included in the 1910 Flexner Report.3 Public health includes quantitative sciences (biostatistics, epidemiology); social, behavioral, and environmental sciences; the study of health systems (health policy, financing, and regulation); clinical and community preventive services; leadership and communication skills; and contemporary disciplines and issues (e.g., informatics, genomics, preparedness) that together emphasize an ecological model of health. Medical education standards across the continuum of training, including policies and recommendations from the Liaison Committee on Medical Education, Accreditation Council for Graduate Medical Education, and specialty boards, have begun to include public health content, such as the application of biostatistics and epidemiology to evidence-based practice and quality improvement, social and behavioral sciences in the context of determinants of health, and the study of health care systems. The phrase “public health” is not necessarily included in this guidance, and public health systems—particularly the responsibilities and structure of the governmental public health systems in which physicians practice—are rarely mentioned. Content areas such as population health, social medicine, and health systems science overlap with public health, but we hope that our experience responding to COVID-19 will put to rest the instinct to dilute public health with alternative labels.
In 1988, the Institute of Medicine (IOM) reiterated Winslow’s perspective of public health by defining it as “what we as a society do collectively to assure the conditions in which people can be healthy.”4 In the wake of the September 11 terrorist attacks and subsequent anthrax attacks of 2001, the IOM articulated a vision for 21st-century public health systems that have governmental public health as the “backbone”; include the health sector (health care delivery system, public health, and health sciences academia); and broaden participation to include communities (e.g., schools, organizations, religious congregations), businesses and employers, and the media.4 Medical educators have similarly emphasized the importance of community engagement and interprofessional education. We wholeheartedly support this holistic perspective of health education but ask that public health entities and professionals not be grouped into a broad category of “community partners.” With shared primary missions to improve health, medicine and public health should be unique and consistent allies, working together with community partners to address society’s health challenges.
Calls to enhance public health content in medical curricula typically increase after significant threats to public health.5 A physician workforce that is knowledgeable about public health can better anticipate and contribute to public health interventions during a pandemic. The emergency preparedness and response capabilities for governmental public health agencies have been described in 6 categories: biosurveillance, community resilience, countermeasures and mitigation, incident management, information management, and surge management.6 At the time of crises, physicians contribute to surveillance efforts and echo public health messaging to patients from clinics and hospitals. Collaborating in public health emergency initiatives may also offer insights and experiences that promote physician resilience during emergencies7 and help to meet the needs of their patients, practices, and communities.
The medical and public health professions have not collaborated fully to meet health needs in the United States, in part due to differences in perspective and priorities. Treatment versus prevention, “reductionist” biomedical models versus bio-social-environmental landscapes, pure science versus efforts to translate evidence into policies—these have been some of the generalizations that have described the differences between medicine and public health. Cultivating meaningful partnerships between medical and public health communities to address more common threats to health through individual- and population-based interventions would improve the prevention and management of chronic diseases, injuries, and substance abuse; strategies to catalyze improvements in social determinants of health and achieve health equity; and the formulation of health-focused approaches to address global challenges like climate change.
To achieve more effective medicine–public health relationships in practice, medical education across the continuum must include explanations of public health systems, the responsibilities of physicians to their local and state governmental public health agencies, and opportunities for collaboration. Governing bodies that oversee each phase of medical education should ensure that public health systems are included in curricular requirements, beginning by building foundational knowledge in medical school, then exploring specialty-specific issues in residency and continuing education. With an enhanced appreciation of the relevance of public health to their practices, physicians are also more likely to seek out public health–related content, through informal channels and professional societies, and incorporate public health in their expectations of lifelong learning.
While a full and systematic assessment of our preparedness and response to COVID-19 will occur after this crisis, some conclusions are glaringly evident. Delays in testing have resulted in missed surveillance opportunities through the timeline of the U.S. outbreak, and the coordination of the response capacity in hard-hit areas has fallen short. Dangerous shortages of personal protective equipment have threatened the lives of health care and other essential workers. Minority communities have been disproportionately impacted. Public health agencies are frequent conveners of preparedness planning activities at local and state levels, when stakeholders identify and try to correct potential gaps in response capacities. Unfortunately, U.S. public health systems remain dangerously underfunded8 and frequently operate without the recognition and stature of the health care system. In many regions of the country, the public health infrastructure needs to be expanded to achieve the kind of coordinated testing, robust case identification, contact tracing, and follow-up to provide clinical guidance and inform policy decisions, such as loosening restrictions on daily life.
Medical education should also prepare physicians to advocate for public health policies, programs, and infrastructure that will improve and protect the health of their patients and communities. Advocacy has been incorporated into medical curricular standards,9 and credible physicians engender trust in science, even in the face of complex political environments. At a minimum, all physicians should be knowledgeable about policies that will affect the health of their patients, communities, and practices and consider them when they vote. Governmental public health and health-related policy can be political, however, and some physicians may hesitate to become directly involved. At the turn of the 21st century, for example, physicians were less likely to vote than the general public.9 Still, specialty societies are facilitating advocacy efforts, not only to promote specialty-specific interests but also to educate and inform policymakers and the public about a broader scope of issues that impact health.
Learning in the Moment
This is a teachable and learnable moment for medical learners across the continuum to become better acquainted with public health. Medical educators, who are already innovating and collaborating on delivering instruction virtually, are encouraged to integrate public health into their efforts. Academic Medicine readers may enjoy Brandt and Gardner’s clear and succinct narrative of the relationship between medicine and public health in this country10 and Frieden’s description of the future of public health.11 For brief, introductory presentations on specific aspects of public health, the Centers for Disease Control and Prevention’s e-learning series, Public Health 101,12 is a convenient resource. To appreciate potential opportunities for engagement at the local and state levels, the National Association of County and City Health Official’s report, The Forces of Change in America’s Local Public Health System,13 and the Association of State and Territorial Health Official’s Profile of State and Territorial Public Health14 provide recent assessments of local and state health departments across the country, including areas of programmatic focus.
What Is Essential
Too often, the public health and clinical care systems and professionals operate in parallel rather than in synergy, but a key public health-related principle in Flexner’s report was that “collaborations between the academic medicine and public health communities result in benefits to both parties.”3 The IOM identified 3 levels of physician engagement with public health: (1) “All physicians,” because practices intersect public health; (2) physicians in practices or specialties with public health needs; and (3) physicians specializing in public health.3 During this crisis, we have been reminded of what is “essential.” We have witnessed that in addition to advising the public, workplaces, schools, and communities, public health plays a crucial role in health care delivery, providing data and giving guidance for infection control, testing, and clinical care in all settings, from laboratories to emergency medical services and home care. Pandemic COVID-19 provides all of us, whether we are on the frontlines of the response or are sidelined from our usual practice and finding ways to provide material and moral support to frontline colleagues, laser focus that “all physicians” are indeed part of public health systems and that the capacities of public health systems impact our patients, communities, and practices. Widespread availability of public health content in medical education across the continuum can help facilitate solutions to daunting challenges like climate change, firearm injury prevention, health inequities that contributed to disparities in COVID-19 morbidity and mortality, as well as pandemic preparedness, as we live and work in a global society. Our collective challenge is to transform this teachable public health moment into a learnable moment for medical education.
1. Interlandi J. The U.S. approach to public health: Neglect, panic, repeat. The New York Times. https://www.nytimes.com/2020/04/09/opinion/coronavirus-public-health-system-us.html?action=click&module=Opinion&pgtype=Homepage
. Published April 9, 2020 Accessed May 11, 2020
2. Winslow CEA. The untilled field of public health. Mod Med. 1920; 2:183–191
3. Maeshiro R, Johnson I, Koo D, et al. Medical education for a healthier population: Reflections on the Flexner Report from a public health perspective. Acad Med. 2010; 85:211–219
4. Institute of Medicine. Training Physicians for Public Health Careers. Washington, DC: National Academies Press, 2007. https://www.nap.edu/catalog/11915/training-physicians-for-public-health-careers
. Accessed May 11, 2020
5. Carney JK, Schilling LM, Frank SH, et al. Planning and incorporating public health preparedness into the medical curriculum. Am J Prev Med. 2011; 414 suppl 3S193–S199
6. Centers for Disease Control and Prevention. Public Health Emergency Preparedness and Response Capabilities. Atlanta, GA: U.S. Department of Health and Human Services, 2018. https://www.cdc.gov/cpr/readiness/00_docs/CDC_PreparednesResponseCapabilities_October2018_Final_508.pdf
. Accessed May 11, 2020
7. Madrigano J, Chandra A, Costigan T, Acosta JD. Beyond disaster preparedness: Building a resilience-oriented workforce for the future. Int J Environ Res Public Health. 2017; 14:E1563
8. McKillop M, Ilakkuvan V. The Impact of Chronic Underfunding of America’s Public Health System: Trends, Risks, and Recommendations. Washington, DC: Trust for America’s Health, 2019. https://www.tfah.org/wp-content/uploads/2020/03/TFAH_2019_PublicHealthFunding_07.pdf
. Accessed May 11, 2020
9. Earnest MA, Wong SL, Federico SG. Perspective: Physician advocacy: What is it and how do we do it? Acad Med. 2010; 85:63–67
10. Brandt AM, Gardner M. Antagonism and accommodation: Interpreting the relationship between public health and medicine in the United States during the 20th
century. Am J Public Health. 2000; 90:707–715
11. Frieden TR. The future of public health. N Engl J Med. 2015; 373:1748–1754
12. Centers for Disease Control and Prevention. Public Health 101 Series. https://www.cdc.gov/publichealth101/e-learning/public-health
. Accessed May 1, 2020
13. National Association of County and City Health Officials. The Forces of Change in America’s Local Public Health System. Washington, DC: National Association of County and City Health Officials, 2018. http://nacchoprofilestudy.org/forces-of-change
. Accessed May 11, 2020
14. Association of State and Territorial Health Officials. ASTHO Profile of State and Territorial Public Health, Volume Four. Arlington, VA: Association of State and Territorial Health Officials, 2017. https://www.astho.org/Research/Profile-of-State-Public-Health/Volume-Four
. Accessed May 11, 2020