CAREERS IN PUBLIC HEALTH

As a field of employment, public health offers a wide range of opportunities, requiring all levels of skills, and both technological and interpersonal expertise. Public health practice is distinguished within the general field of health practice by the regular interprofessional collaborations required for success. There are few (if any) tasks that need to be done in public health that are done by only one profession, and there are many challenges that benefit from the thinking of people trained with different world views. Public health is practiced in settings that range from the most sophisticated of laboratories in large urban centers to plain meeting rooms in small hamlets. As an additional challenge, any one public health worker may move from office to field investigation to legislative hearing in the course of a week's work. Individuals originally employed for a specific technical skill, such as the ability to perform a new laboratory test or explain a new vaccine, may, over the course of five or ten years, move into a completely different part of public health, drawn by shifts in community need, opportunity for advancement, or desire to continue learning.

Public health encompasses many familiar professions: medicine, nursing, social work, dentistry, pharmacy. But there are some roles that are less familiar: health educator, sanitarian, environmental engineer, disease investigator. Some people in these fields have chosen public health practice as a career at the outset, and obtained training in public health or a public health–related area as a part of their professional education. For others, public health represents a midcareer shift, perhaps associated with a desire to focus not on the treatment of disease but on its prevention. Many public health careers are at the technical level: laboratory technicians, radiation safety technicians; technical support staff in vital records and health statistics, or in communicable disease clinics and community outreach programs.

CORE PREPARATION

Preparation for work in public health can be obtained in a number of ways, and some specifics are discussed below. There is a core of material—a mix of knowledge, skills, and attitudes—that underlies all public health practice and ties together the multiple jobs that make up public health. First among these is an appreciation for the worldview of public health—the values and perspectives that shape how those practicing public health look at experiences and people. Practitioners of public health share an interest in populations and groups, in addition to individuals. That is, while they work with individual people on a regular basis, such people are seen as representatives of families, neighborhoods, or other clusters, sharing common risk factors, exposed to common threats to health, and with a shared potential for health promotion.

The public health worker has a strong bias toward prevention, rather than response after an illness or injury has occurred. One of the best examples of this is the implementation of immunization programs. Even in parts of the world where other public health and medical services are lacking, campaigns to immunize children against measles and polio are successful. The number of cases of vaccine-preventable diseases has dramatically decreased, and new vaccines are being developed to combat other conditions not now preventable. The prevention focus also includes secondary prevention; that is, the early diagnosis of disease so that treatment is prompt and complications are avoided. The development of screening programs for breast and cervical cancer, linked to referral and follow-up, are among recent advances in this aspect of public health. Health education for the community, enabling individuals to make their own decisions about preventive choices, has also flourished in recent decades.

Public health workers are also distinguished by their attention to systemic solutions rather than a series of individual ones. For example, to control waterborne diseases, the assurance that wells and public water systems are safely built and protected from contamination has been an important part of public health effort. Where this protection is lacking, individual households must arrange for treatment, or boil water before use. At the community level, public health workers have concentrated not only on providing individual health education, but on building health education into the school curriculum at all grade levels.

Finally, from an ethical viewpoint, people working in public health share a strong commitment to social justice and equity, balanced with an appreciation of the role of individual autonomy and decision making. It is possible to become passionate about public health from a perspective of enlightened self-interest (making the world safer so that I am safer). However, it is more likely that those who are drawn to careers in public health have an interest in assuring that all people in the community have equitable access to all kinds of health-related services. There is a role for overruling individuals when their actions put others at risk, such as the person with infectious tuberculosis who refuses to take medication or the restaurant owner who does not maintain cooking and storage facilities at proper temperatures. The enforcement is carried out, however, with attention to due process and using the least restrictive approach necessary.

RANGE OF INTERESTS

Although there is a core of interests, as described above, public health encompasses many specific program areas, and it is possible to develop a rewarding career within any one of them. The following discussion does not represent an exhaustive list of all public health programs, but does provide a sense of the range.

At the heart of most public health programs are the people responsible for vital and health statistics and a continuing epidemiology program. These people, with skills in statistics, taxonomy, nosology, epidemiology, and research, continually accrue new information about communities and populations, analyze it, and provide it back to others in a form that makes it useful. The findings of these efforts provide the basis for other public health actions, as they identify newly emerging problems; shifts in the age, gender, or ethnicity of the population; or new experiences with historically important conditions. In addition, those in the vital records area provide a public service in the documentation of important life events (e.g., birth, death, marriage, divorce) and provide both summary information to policy makers and individual documents for the persons involved.

Control of infectious diseases has been important in public health since its inception. Common programs include those focused on tuberculosis, syphilis, gonorrhea, chlamydia, HIV (human immunodeficiency virus), and hepatitis. In the United States, each state has a long list of reportable diseases that are regularly monitored, with individual cases identified and often linked to treatment. States pool data on diseases of national interest and nations share similar information through the World Health Organization. In addition, those persons who might have spread the disease, and those who might have been infected, are identified. With tact, but a great deal of determination, these persons are located and linked to diagnostic and (if needed) treatment services. Making regular updates in the listing of reportable diseases and maintaining the relationships needed to assure comprehensive reporting from laboratories or clinicians are part of this effort.

Newer disease-control efforts have focused on environmental causes of various conditions and chronic diseases. Conditions that might be monitored, or be the subject of screening or risk-reduction programs, include lead poisoning, cancer, diabetes, obesity, heart disease, and occupational diseases. The epidemiology, care finding, and follow-up are similar to the infectious disease programs, but the laboratory backup needed is quite different, and the reduction of disease in the community often comes at a much slower pace. A broad-based community effort to reduce the disease risk associated with tobacco use, for example, began in the 1960s; and while deaths from lung cancer are declining, they remain high.

Maternal and child health is another major focus of public health. The range of programs in this area includes screening of newborns for conditions such as phenylketonuria, providing a full range of reproductive health services to men and women, prenatal and postnatal care, and programs to promote healthy growth and development. The support of good nutrition, particularly in pregnant women, nursing mothers, and very young children, has been a significant part of this effort. Injury prevention and violence prevention are among the newer components of comprehensive child health programs. School health education and comprehensive school health services, including on-site clinics, have also emerged as important components. In areas with limited medical care systems, this portion of the public health mission may expand dramatically, because failure to assure a healthy beginning to life has such severe negative effects later in life. Clinicians (pediatricians, midwives, obstetricians, pediatric nurses, dentists, nutritionists, and social workers, to name a few) are part of these public health program teams.

Mental health services are also a part of the public health enterprise. In some communities, treatment is primarily in community settings or inpatient facilities. The large hospitals built in the late eighteenth and early nineteenth centuries have come to symbolize some of the worst of public mental health policy. It is regrettable that the closure or downsizing of these institutions has not been accompanied by an increase in the community-based programs needed to support the chronically mentally ill on new pharmaceutical regimens. Contemporary approaches to public mental health include programs managed by those with expertise in suicide prevention, violence prevention, and substance abuse treatment and prevention. Some of these programs are managed separately, while others are integrated or coordinated with maternal and child health or chronic disease programs. The psychiatrists, psychologists, social workers, counselors, and substance abuse specialists working in these areas find that teamwork and collaboration are essential skills.

Environmental health is almost too broad a term for discussion in one paragraph. It includes programs that assure a safe supply of drinking water and food, proper disposal of human and industrial waste, and efforts to keep the air and soil free of contamination. These programs require the input of laboratory specialists in biochemistry and radiation physics, as well as field work by engineers, hydrologists, biologists, sanitarians, and others. Many environmental programs include the inspection and licensing of businesses, including restaurants, grocery stores, lodging facilities, and manufacturing plants. Oversight of the potentially hazardous chemicals used as pesticides in agriculture or other settings is also a part of this work. The ability to communicate successfully with people for whom health is not a central concern but a cost of doing business is a special skill in these circumstances.

Occupational health is a special subset of public health that is practiced in both the public and private spheres. Assurance that a workplace is safe for all levels of personnel it is expected, and it is supported by strong legislation (though implementation is difficult). Work includes development of ever-safer approaches to tasks, education of both workers and supervisors about best practices, and inspection and enforcement of laws. While the formal occupational health agencies are the most visible part of this effort, many large employers and some worker organizations have substantial investments in occupational health. Physicians, nurses, industrial hygienists, and a variety of engineers are typically involved in this effort.

Public health also includes programs related to the delivery of personal health services. Many of these programs are designed to assure that health services of all kinds are delivered safely. These include the licensing of hospitals, clinics, home health agencies, long-term care facilities, ambulatory surgical centers, and individual health practitioners. Staffing of these programs requires a combination of nursing, medical, environmental health, pharmacy, and engineering expertise. The programs are sensitive in that reimbursement for services is tied to successfully passing inspections, and the need for services is such that closure of an inadequate facility may seem to be a worse option than allowing it to continue operating under supervision. Another portion of work is related to the financing of care for particular groups. In some communities, this includes the management of large governmental programs, such as Medicaid, with a need for fiscal and management experts as well as health professionals. It may, however, also include smaller programs to serve a newly arrived refugee group or a small group with a particular condition that has become a matter of public health interest.

Advocacy and community development activities are both a traditional part of public health and a newer area for career development. Given the concentration of many public health problems in disenfranchised communities, the public health worker is often the one giving voice to otherwise unheard concerns. With an interest in assuring the conditions within which people can be healthy, public health has an overall mission to foster healthy people living in healthy communities—meaning an ongoing interest in how the community as a whole functions. Work with community groups such as civic clubs, voluntary health agencies, school support groups, and others is an essential part of public health. And since much of public health involves some form of governmental action, either in financing or program management, governmental advocacy is an important part of the effort.

Finally, there are many roles in public health for those with administrative skills. These include fiscal and personnel management, computer and information systems development and management, logistics and materials management, and general administration. In each of these areas, public health settings employ a full range of entry-level, technical, and professional staff. While these may be considered generic skills, their application in systems that are responsive to the community, and that must be able to respond during times of emergency or disaster, require unique skills and handling. This means that even the people employed for routine management or systems maintenance functions must understand the core concerns of public health and be a part of the overall effort.

JOB SITES AND SALARIES

Public health is practiced in all employment sectors, including government; private for-profit; private not-for-profit; and voluntary. The core of public health is the network of federal, state, and local governmental health authorities. At the federal level, the largest agency involved is the Department of Health and Human Services, with its well-known units: Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, Food and Drug Administration, Health Care Finance Administration, Health Resources and Services Administration, Indian Health Service, National Institutes of Health, and Substance Abuse and Mental Health Services Administration. Public health workers are also found in the Environmental Protection Agency, the Occupational Safety and Health Administration (Department of Labor), the Department of Agriculture, and the National Highway Traffic Safety Administration (Department of Transportation). All branches of the uniformed services have public health functions within their health programs. This list should not be taken as exhaustive: Anywhere there is a unit that is charged with preventing disease outbreaks, reducing exposure to hazards, preventing injuries, promoting health, assuring access to health services, or responding to the health aspects of disasters, public health is being practiced.

At the state and local level, the same range of services is provided, but the exact configuration of agency scope varies. Further, state and local jurisdictions have very different policies regarding the balance between direct provision of any assigned service and contracting for its performance with some outside organization. In some areas, for example, all maternal and child health services are conducted by private, not-for-profit agencies under contract to the health agency. In other areas, the public agency does almost no advocacy or community development, leaving that to the voluntary and private sectors.

There are jobs for public health workers in the private, not-for-profit sector, often in services funded with public grants and contracts. While many of these are the direct health services portion of public health, laboratory services, computer systems, and health education programs may also be set up this way. The voluntary sector includes both large and small organizations, such as those associated with a specific disease (cancer, diabetes), or a specific population group (women's health, children's health) or a specific intervention (against drunk driving, for gun control). While much of the work in these organizations is done by volunteers, most have at least a small staff supporting the communications network and developing materials for the volunteers to use.

Because of its association with social justice and services to the disenfranchised, and its role licensing and overseeing private businesses, it is common to think of all public health being practiced in the public or voluntary sector. However, many industries employ public health workers. They may be focused on the occupational health of the employees, or they may be part of the quality assurance function, as they are in large fast-food chains. In the for-profit health industry, they may be providing epidemiologic services or health education services parallel to those in the public sector. The pharmaceutical industry employs people with public health training in a variety of functions; one of the important issues for these workers is maintaining their collegial ties with others in the public health workforce while continuing to work in places that may come under the scrutiny and even criticism of their colleagues.

Of the various areas of health employment, public health is often listed near the lower end of the income scale. Certainly compared to some of the surgical specialties in medicine, public health is far from a way to make a fortune. Because so many public health workers are in government employment, it is difficult to make rapid changes in compensation packages when there is a shift in competition for workers. The countervailing benefit of stable employment with a good benefit package, however, appears to be of less importance in a world in which people expect to change jobs many times over a career. While it sounds a bit Pollyannaish, the compensation that appears to be most important to public health workers is the satisfaction of contribution to the community, and to the well-being of many individuals.

GETTING INTO PUBLIC HEALTH

One of the simplest entry points into public health is through one of the health professions such as medicine, nursing, or dentistry. Completion of basic preparation in any of these fields may meet minimum qualifications for entry-level positions in public health. In nursing, for example, graduates with a bachelor's degree in nursing have the basic preparation necessary to function as a public health nurse. However, specialization in public health is often necessary and may be obtained through additional study. The Master of Public Health (M.P.H.) degree or its equivalent takes an additional year or two of study, often combined with work in the field. In medicine, one recognized credential is board certification in preventive medicine, though many pediatricians, infectious disease specialists, obstetricians, family physicians, and others add the M.P.H. to their specialty training if public health becomes their area of interest.

The M.P.H. degree may also be an added specialty for those with credentials in engineering, environmental science, biology, or chemistry. The title "sanitarian" is used to designate a group of professionals with basic scientific education who have completed supervised practice in environmental health.

The first degree earned by a public health professional may be in almost any professional or academic area. There are some who enter public health at the entry level with a technical or bachelor's degree in a laboratory science, health education, computer systems, or statistics (to name a few). These individuals may eventually find it valuable to add the M.P.H. or other graduate degree as a way of increasing depth of knowledge and meeting requirements for advancement. The M.P.H. provides a common opportunity to learn more about the core of public health, and to learn how to apply existing skill and knowledge to a public health program area.

The role of volunteers has been mentioned, but should also be identified as a career path opportunity. A number of those practicing public health as a full-time career began their involvement as a volunteer, either in a community agency or within a specific program area. An interest in public health that developed around an initial interest in stopping HIV infection, getting access to breast cancer screening, or controlling pesticide use may lead to a job in one of these areas, and eventually to the wider field of public health. Others have had their first direct exposure to public health through a classroom assignment or internship. Many public health agencies are eager to share what they do with students from all levels, and they develop opportunities for experience that may be as short as a day, or as long as a year or two. This is an excellent way for someone interested in public health to discover what public health careers are all about.

Promoting the physical and mental health of a community and preventing disease, injury, and disability are rewarding goals. Achieving them is the focus of a career in public health, requiring not only technical skills but commitment, patience, and appreciation of the value of each individual within the context of a community. There is almost no area of interest in human health that is not represented on the public health workforce, and there are no two jobs in public health that are identical, as each is shaped by the community with which it works. Whether the beginning, middle, or culminating portion of a life's work, it is an area of opportunity.

Kristine Gebbie

(see also Accreditation of Public Health Training Programs; Association of Schools of Public Health; Certification of Public Health Workers; Communications as a Career; Council on Education for Public Health; Epidemiologist; Finance as a Career; Health Educator; Laboratory Technician; Nongovernmental Organizations, United States; Nurse; Public Health Nursing; Research in Health Departments; Sanitarian; Social Work; Training for Public Health; Vital Statistics )

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