Michael N. Bates, Rainer Fehr

Schools of Public Health in the United States of America Schools of Public Health in den USA

Some general, practical information on the structure and functions of schools of pubfic health in the United States is provided. The first such school was begun in 1916 and there are now 24 accredited schools in the U.S. with a total of more than 10,500 degree- students enrolled, producing more than 3,500graduates each year. All schools of public health contain departments or programs in biostatistics, epidemiology, environmental health, and health services administration. Other disciplines vary to some extent between schools. To maintain teaching standards, all schools are regularly reviewed and accredited by the Council on Education for Public Health. All schools offer at least the Master of Public Health degree and, most schools, doctoral degrees. In addition to

teaching, research is the other main focus of schools of public health. Research funding is usually obtained through a process of competitive grant application writing. Schools of public health maintain close cooperative linkages with each other, as well as with medical schools and departments of health. Graduates usually have no difficulty in obtaining employment. Keywords: Public Health, Health Sciences, Education, Postgraduate Training, USA

Dieser Beitrag gibt allgemeine und praxisbezogene Informationen iiber Aufbau und Funktionen der Schools of Public Health in den USA, wo die erste dieser Einrichtungen im Jahre 1916 gegriindet wurde. Heute gibt es dort 24 akkreditierte Schools mit insgesamt mehr als 10 500 Studenten und jiihrlich mehr als 3 500 Studienabschliissen. Alle diese Schools besitz en Abteilungen oder Programmefiir Biostatistik, Epidemiologie, Umwelt und Gesundheit sowie Gesundheitsverwaltung/-systemforschung. Andere Fachrichtungen variieren bis zu einem gewissen Grade yon einer School zur anderen. Um einen hohen Standard in der Lehre zu gewiihrleisten, werden alle Schools regelmii- flig vom Council on Education for Public Health iiberpriift und akkreditiert. Als Abschlufl bieten aUe Schools zumindest den Master of Public Health und in den meisten Fiillen auch einen Doktorgrad an. Neben der Lehre ist Forschung die Hauptaufgabe der Schools. Forschungsfi~rderung wird gew6hnlich im Wettbewerb um Fi~rderungs- mittel erreicht. Die Schools haben enge Kooperationskontakte miteinander sowie mit medizinischen Fakulti~ten und der Gesundheitsverwaltung. In der Regel finden die Absolventen miihelos eine geeignete Arbeitsstelle. SchliisselwOrter: Public Health, Gesundheitswissenschaften, Ausbildung, USA

Introduction

The purpose of this paper is to provide some basic, practical information on the structure and functions of schools of public health in the United States of America. It is hoped that the information may be useful in the planning and development of similar schools in Germany. In so doing, it is not intended to suggest that any of the features of U.S. schools of public health would necessarily be appropriate in countries other than the United States.

Although this paper is about U.S. schools of public health in general, particular reference is made to the school in the University of California at Berkeley (UC Berkeley). This is because the authors of this paper have both studied at that school and, therefore, have a more detailed and practical knowledge of its working functions than of other U.S. schools of public health.

History of U.S. Schools of Public Health

The purpose of public health has been defined as being to fulfill society's interest in assuring conditions in which people can be healthy [1]. The achievement of this objective requires the cooperation and input of a multitude of professionals in a wide variety of practical and academic disciplines. In turn, this requires a means by which such people may receive the necessary training, not only in their specialized fields, but also in a context that brings them together with the other disciplines with which, as public health professionals, they must necessarily interact.

In the United States, schools of public health are the primary focus of graduate education and training in public health. They are characterized by the multidisciplinary nature of their students, training programs and re- search outputs. Through this they provide a wide variety of professionals with a common vocabulary and understanding of public health perspectives and values.

The need for trained public health personnel was first recognized in the U.S. in the late 19th century. In the 1880s the Massachusetts Institute of Technology began teaching "sanitary sciences" and this lead was followed by medical schools at several other American and Canadian universities.

In 1916, the first U.S. school of public health was opened at Johns Hopkins University, followed shortly after by similar schools at Harvard, Columbia and Yale. These four schools trained specialists required for community health programs, including health officers, statisticians, epidemiologists, sanitary engineers, chemists, bacteriologists, public health nurses, and sanitary inspectors. By 1941 another four schools of public health had been established in public universities (including UC Berkeley).

Today there are 24 accredited U.S. schools of public health located in 8 private and 16 public universities. They have a combined enrollment of more than 10,500 students obtaining degrees (including 16 % from foreign countries) and employ more than 1,900 faculty members. In 1989 - 90 the schools together produced more than 3,500 graduates [2]. On a per capita basis this would be equivalent to a current enrollment of around 3,000 German students in schools of public health, with about 1,000 graduates per year.

Each school has an explicitly stated purpose, or "mission", from which it begins. These are broadly similar across the schools. To quote Joyce Lashof, M.D., former Dean of the Berkeley School of Public Health [3]:

The basic mission of the School of Public Health is to provide leadership in the field of education, research and service in all aspects of public health. Public health, as a

field, is devoted to the promotion of health and the prevention of disease through the identification of the factors affecting the health of population groups and the determination of how best to bring about change necessary to assure the maximum well-being of all people. Accomplishing this mission requires the joint efforts of professionals from many disciplines directing their attention toward understanding the biologic, environmental, and social factors involved in the causation of disease and the maintenance of health.

Structures of Schools

As mentioned, one of the major features of U.S. schools of public health is that they are multidisciplinary and therefore they each involve a number of separate, but interrelated, academic teaching units or departments. Some of the academic disciplines are common to all U.S. schools of public health (see next section). However, outside these core subject areas there is considerable variation in terms of the other disciplines that are taught in different schools. In addition, there is no single administrative structure that is common to all schools. This is illustrated with two models:

In the first model the major disciplines are each represented by separate academic departments of equal status. Some departments may then be divided into a number of subspeciality areas (programs). This is the most common administrative structure found in U.S. schools of public health. An example is Johns Hopkins School of Public Health, which has 10 indepen- dent academic departments [4] (Table 1). Some of these departments contain several programs. For example, the Department of Environmental Health Sciences contains six separate programs (Environmental Chemistry & Biology, Toxicological Sciences, Environmental Health Engineering, Physiology, Occupational Health, and Radiation Health Sciences). Most departments have fewer programs than this.

Table 1. Academic departments of the Johns Hopkins School of Hygiene and Public Health (1991-92).

Biochemistry Biostatistics Environmental Health Sciences Epidemiology Health Policy and Management Immunology and Infectious Diseases International Health Maternal and Child Health Mental Hygiene Population Dynamics

The Berkeley School of Public Health represents a different, less common, model [3]. There are only two major departments, Social and Administra-

tive Health Sciences and Biomedical and Environmental Health Sciences. Both of these are divided into a number of separate programs (Table 2).

Table 2. Program areas within the two main departments of the School of Public Health at the University of California, Berkeley (1990-91)

Social and Administrative Health Sciences

Biomedical and Environmental Health Sciences

Behavioral Sciences Community Health Education Health Policy and Administration Maternal and Child Health Public Health Nutrition Genetic Counseling Unit

Biomedical Sciences Biostatistics Environmental Health Sciences Epidemiology Forensic Science

The second model may be most appropriate when individual academic units are small and duplication of some administrative structures would be inefficient.

In both of these models there may be other programs that cut across the established departments in order to bring together a multidisciplinary group of people with a common purpose that does not fit easily into any of the regular departments. For example, there is a Program in Public Health Economics at Johns Hopkins that is jointly offered by the Depar tments of Health Policy and Management, International Health, and Population Dynamics.

Major Disciplines Related to the breadth requirements (see below) there are a number of disciplines that are common to all schools of public health:

1. Biostatistics Biostatistics is concerned with the application of statistical principles and methods to problems in the biological, medical and health sciences. It involves a broad knowledge of biology and a more detailed knowledge of statistics.

2. Epidemiology Epidemiology is the study of factors that determine the distribution of disease in human populations. Its main purposes are to discover the causes of disease, to evaluate methods of disease prevention and to assist in planning and evaluating the effectiveness of public health programs.

Epidemiology and biostatistics are, together, often regarded as the foundation sciences of public health.

3. Environmental health sciences This discipline brings together the sciences that deal with the effects of biological, chemical and physical agents in the environment (including the workplace) on human health. Potentially it can include a large number of separate disciplines, such as are listed above under the example of Johns Hopkins. Occupational and environmental epidemiology are included in this department in some schools.

It should be noted that environmental health sciences are different from environ- mental sciences. The latter are more concerned with the effects of agents on the natural environment. These are not usually included in schools of public health. However, there may be considerable collaboration between departments of envi- ronmental health and departments of environmental sciences, because of overlapping interests.

4. Health Services administration This involves the study of the structures, dynamics, financing and administration of health and medical care systems. There is usually a focus on improving the efficiency and effectiveness of existing systems, as well as improving access to health care for disadvantaged groups.

Other major areas of public health focus found in virtually all schools of public health are [5]: - Public health practice and program management (23 schools) - Health education/Behavioral science (24 schools) - Occupational safety and health (24 schools) - Nutrition (20 schools) - Biomedical and laboratory sciences (19 schools)

Table 3 shows the areas of specialization of students in U.S. schools of public health in fall, 1990 [2].

Table 3. Areas of specialization of students obtaining degrees in the 24 U.S. schools of public health, fall, 1990 (Data from reference 2).

Area or discipline Number Percent

Biostatistics 610.5 5.8 Epidemiology 1,648.5 15.6 Health services administration 2,772.0 26.3 Public health policy and program 790.0 7.5 management Health education/behavioral sciences 1,199.0 11.4 Environmental health 1,519.5 14.4 Occupational safety and health 233.0 2.2 Nutrition 252.5 2.4 Biomedical sciences 280.0 2.7 Other disciplines 958.0 9.1 Nonspecialized (general public health) 283.5 2.7

Total 10,547.5 100.0

M a i n t a i n i n g S t a n d a r d s : T h e A c c r e d i t a t i o n P r o c e s s

Since 1945, graduate education in U.S. schools of public health has been subject to a process of accreditation to ensure uniform standards of quality across the schools. Since 1974 the accreditation process has been adminis- tered by the Council on Educat ion for Public Heal th (CEPH) , which was established by the Amer ican Public Heal th Association and the Association of Schools of Public Health.

The CEPH reviews any organization that applies for accreditation as a school of public health. The process of accreditation requires the applicant first to conduct a self-evaluation study and to submit the results to CEPH. This is followed by an on-site survey by a team of qualified peer reviewers to validate the self-study document. Twenty-four U.S. schools of public health have successfully undergone the accreditation process.

Each accredited school is reviewed at least every seven years and individual programs are reviewed at least every five years.

Degrees Offered Schools of public health involve study at a graduate level. That is to say, they offer advanced degrees to people who already have at least a first university degree and usually some work experience in an area of public health. All schools offer master's degree programs and most schools, doctoral degrees.

The Master of Public Health (M.P.H.) is the most common master's degree program, and is offered by all U.S. schools of public health.

1. The M.P.H.

The M.P.H. is a professional degree designed to provide a practical know- ledge of public health, to aid a person working directly in some branch of the field. The M.P.H. usually involves a minimum of 24 semester units (12 units is usually considered to be a full program of work during a semester). However, this generally only applies to students who enter the program with a prior doctoral degree in medicine, dentistry, or veterinary science. Students with other qualifications usually take up to two years (four semesters) to complete an M.P.H. The rationale for this difference is that on entering the program such students need to spend the extra year acquiring the background knowledge that physicians, dentists and veterinarians have already obtained during their training. This rationale is becoming increasingly outmoded: People with scientific backgrounds frequently have a wealth of public health knowledge and experience that is comparable with that of the physicians. Also, the expansion of the body of knowledge in public health is such that it is increasingly difficult to cover an adequate amount in a period of one year.

The M.P.H. degree curriculum has both breadth and depth requirements. To satisfy the depth requirement, each student is generally expected to pursue one chosen area of specialization (e.g., epidemiology, public health nutrition, or health services administration) in which they concentrate their study. This means that there are almost no "general" public health students; virtually everyone has a specialized area of concentration (Table 3). However, to satisfy the breadth requirements of the curriculum all students are required to have or to obtain a general understanding of the fundamental areas of knowledge that bear on the field of public health. This enables them to interact effectively with other public health professionals. The fundamen- tal areas of public health in which CEPH considers that every student should have some training can be broadly defined as follows:

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(a) Biological, physical and chemical factors that affect the health of a community;

(b) concepts and methods of relevant social and behavioral sciences; (c) distribution of diseases or conditions in populations, and factors that

influence this distribution; (d) collection, storage, retrieval, analysis, and interpretation of health data;

and (e) planning, policy analysis, and administration of health programs.

At Berkeley, to satisfy these requirements, all M.P.H. students are required either to have had prior training, or to take at least introductory courses, in the following areas:

- general public health (including its history, development, and main areas of focus)

- health and medical care systems - epidemiology - environmental health - biostatistics

Students are also encouraged to pursue their particular interests by taking courses in departments outside the School of Public Health. In M.P.H. programs at some schools students may be required to complete a thesis on a research topic.

2. Doctoral degrees (Ph.D. and Dr.P.H.)

Most schools of public health have departments or programs that offer doctorates, and, overall, these constitute about 10 percent of degrees awar- ded by U.S. schools of public health. The two main doctoral degrees are the Doctor of Philosophy (Ph.D.) and the Doctor of Public Health (Dr.P.H.). The Ph.D. is intended to be an academic degree involving original research, leading mainly to a career in teaching and/or research, whereas the Dr.P.H. is intended to be a professional degree with a more practical, less research- oriented focus. However, over time, these degrees have become increasingly similar.

The program for both doctorates involves an initial period of course work focusing on the main subject area of interest. The purpose of this work is to ensure that the students have sufficient knowledge and expertise to pursue their chosen research topic.

When it is considered that the student has completed sufficient course work for his or her particular program of study, then the qualifying exam may be undertaken. This is an individualized exam that may involve written papers and/or an oral examination by a committee of several professors. The student must prove competency in his or her major field, as well as in two "minor" fields. For example, a doctoral student in epidemiology would probably have biostatistics as one of the minor fields and, as the other, perhaps toxicology, microbiology, or any one of a large number of other disciplines. Provided the qualifying exam is passed students will be advanced

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to candidacy for the doctorate. It is at this point that they begin their re- search or, if necessary, continue the process of defining their research topic.

The research program (leading eventually to the doctoral dissertation) is the most important component of the doctoral degree. The research is overseen by a committee of three to five professors, drawn from different academic departments. There is no general specification as to how long doctoral research should last or what it should involve. However, on average, a doctoral program takes four to five years of work, and it is generally accep- ted that the research should advance scientific knowledge. One practical criterion used by some professors for judging the sufficiency of doctoral research is that the resulting dissertation should be the equivalent in content and quality of at least two or three papers published in the peer-reviewed scientific literature.

The final stage of the doctoral degree is when the dissertation has been reviewed and approved by the committee of professors. In some schools or programs doctoral candidates are also expected to publicly defend their dissertations.

3. Joint degree programs

In at least some schools, joint degree programs are offered. This involves combining study for an M.P.H. with study for another degree offered outside the school of public health. For example, a student might also study for a Master of Business Administration (M.B.A.), a Master of Public Policy (M.P.P.), or a Doctor of Medicine (M.D.). Inevitably these joint programs extend the time taken to obtain either degree. However, the potential career benefits of these degree combinations are obvious.

Faculty Full-time faculty usually hold the title of Professor, Associate Professor, or Assistant Professor. In almost all cases, faculty hold a doctoral degree, usually a Ph.D. or an M.D. For example, in the School of Public Health at Berkeley in the period 1987-1988, of 52 full-time professors, there were 8 with an M.D., 39 with a Ph.D. or a Dr.P.H., one M.D./Ph.D., and four with other doctorates [3].

In addition to the full-time professors, there were about 60 part-time faculty, usually with the title of Lecturer or Adjunct Professor.

Students In fall, 1990, there were 11,386 students enrolled in the 24 accredited schools of public health in the U.S. Of these, 63 % were women and about 16 % were foreign. About 70 % were enrolled in master's degree programs, 23 % in doctoral programs, and less than 7 % were in non-degree programs [2].

The largest program area in schools of public health was health services administration, with over 26 % of students. This was followed by epidemiology

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with 16 % and environmental health sciences with 14 %. Over one-third (36 %) of students were part-time and the remainder full-time.

Some general student trends have been noted over the last several decades. In the 1960s the typical student in U.S. schools of public health was a white male, in his early thirties, and medically trained. The trend since then has been for more women students, more racial diversity, and fewer students with prior medical training. Students now come from a wide variety of backgrounds. This trend has been accompanied by a tendency for masters' programs to be expanded from one to two years.

As is normal at U.S. universities, all students pay enrollment fees. These may range from one or two thousand dollars a year at some of the public universities to more than U.S. $15,000 at the private universities. Normally foreign students at public schools pay considerably higher fees than Ame- rican citizens at the same schools.

Application and Admission Procedures

Application to U.S. schools of public health is a complicated and competitive process. Invariably, there are more applicants than positions for students in the schools. Since these are all graduate schools, applicants must hold at least a bachelor 's degree or its equivalent from a reputable institution, and have attained a good grade point average. Many schools prefer students who have already worked for some time in a field of public health.

Table 4 shows the areas of study for undergraduate (bachelors') and graduate degrees prior to beginning public health study for a sample of 1,610 graduates in 1986 from U.S. schools of public health [6].

Table 4. Areas of study for prior degrees for a sample of 1,6101986 graduates of U .S. schools of public health (Data from reference 6).

Bachelor's degree Post-graduate degree Area No. Percent No. Percent

Humanities 75 4.8 9 1.8 Social sciences 334 21.5 90 17.6 Biological sciences 891 57.3 349 68.3 Physical sciences 121 7.8 21 4.1 Other 133 8.6 42 8.2 Unknown 56 - 13 -

1,610 100.0 524 100.0

Students must supply evidence of their academic and professional achievements, as well as several references. A short essay or statement of purpose may also be required. All applicantsmust take the Graduate Record Examination (a national examination required for anyone intending to do graduate study in the U.S.), and applicants from countries where English is not the national language may be required to take the Test of English as a Foreign Language.

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Normally each individual program will have an established quota of students that it will accept. Applicants generally only apply for entry to the program in the specia- lized area of their choice.

Student Personal Advisors

It is standard procedure in U.S. universities, including schools of public health, for every student to be assigned a personal advisor on the faculty. Usually this is a professor with interests related to the student's main area of focus. The advisor is available if the student has either academic questions or problems, or personal problems that are interfering with his or her academic progress. Some students meet very seldom with their advisor, whereas others may have regular meetings. This system has been shown to be very successful: It gives faculty an insight into student problems and issues, helps to eliminate the feeling of anonymity and loneliness that students may feel, especially when first attending a large university, and reduces the chance that students may suddenly "drop out" because of frustration and dissatisfaction.

Teaching

At almost all schools of public health, teaching takes place within the hours of 8:00 am and 6:00 pm, Monday to Friday. Regular classes in the evenings, or on weekends, are rare. However, there is an increasing demand for "nontraditional" educational programs and three schools now schedule the majority of their classes in the late afternoon or evening [2]. Many students maintain part-time jobs during their study; some even continue with full- time employment. However, because of the heavy workload entailed by most courses of study, full-time employment tends to be much less common. When it occurs, the time taken to complete the degree is often considerably extended.

Most classes run for a full semester (16 weeks) and each one is assigned a number of credit units that usually corresponds to the number of hours per week of formal teaching for that particular course. A full-time student work load would usually be defined as no less than about 12 units per semester, although some students, depending on their abilities, may take up to about 20 units.

Generally, classes are in lecture format, although they usually have an informal style and students may ask questions at any time. Credit is also given for attendance at regular seminars and for laboratory work. For most classes a grade is awarded (i.e., A, B, etc.). The basis for this is very variable according to the preference of the teacher. Some may put a lot of emphasis on the results of a final, and perhaps a mid-term, exam. However, it is increasingly common for more emphasis to be placed on the results of assignments and projects carried out during the semester. In fact, many classes have no end-of-semester examination.

At the graduate level students are expected to be largely self-sufficient and self-motivated. For this reason, classes tend to be no more than a guide to

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study and students are expected to supplement material covered in the classroom with additional reading and study.

Professors generally have "office hours", which are several hours set aside at a specified time each week, during which students from their class(es) may consult them.

Professors are frequently assisted in their teaching of a class by teaching assistants (TAs). These are usually advanced students who have successfully taken the same class in a previous year. They assist by preparing materials for the class (e.g., handouts and overhead transparencies), conducting tutorial classes (e.g., in biostatistics, where students often need extra help), preparing and grading exams, sometimes conducting the regular class for the professor, and generally making themselves available for consultation with the students. In return, the TA is paid a small salary. Some students rely heavily on this income.

Also frequently available are "course readers". These are collections of articles and papers from the published literature that are essential to a proper understanding of the course topic. The original collections of papers are often compiled by TAs, and copies are made available (at some charge), often from "copy shops" around the campus. The great benefit of the course readers is that each student does not have to spend a lot of time individually seeking out and copying the relevant literature.

It is normal procedure at Berkeley at the end of every course for each student participant tO be asked to complete a course evaluation form. In this they have the opportunity to rate both the course and the teacher (on a scale of one to five), and have the opportunity to make suggestions for course improvements in future years. Results of these assessments (in which the students are not identified) are made available to the professor after final course grades have been assigned.

Research

As well as teaching, the other major emphasis in U.S. schools of public health is on research and publication of the results of that research. Although some research funding may be available from school sources, the amount of this is limited and most research funding is obtained from organizations outside the schools, such as the National Institutes of Health. This is usually sought and obtained through a process of competitive grant application writing. As the availability of research funds has been decreasing in recent years, because of a general decline in the overall state of the U.S. economy, this process has become increasingly competitive. This lack of funds can have a detrimental effect on research, particularly for doctoral students if they must spend a significant proport ion of their time writing grant applications, or otherwise searching for funding sources.

In writing grant applications in the United States it is quite normal, and accepted by funding agencies, that in addition to the direct costs of the research a further fixed percentage is added to cover overheads (the normal operating costs of the universities or institutes). This could be another 50 - 75 % of the actual costs of the research. The actual percentage varies from university to university. For that reason, universities welcome large research grants, and professors who secure these gain a great deal of prestige.

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Unlike the situation in German universities, U.S. professors are not necessarily paid a full salary by their university. They are often dependent on obtaining research funds to pay at least part of their salary costs, and those of their co-workers. The proportion of a full salary paid to professors varies from university to university, and may be as low as 20 % at some institutions. Professors are expected to make up the difference by obtaining research funds or by consulting.

Analogous to the position of Teaching Assistant is the position of Research Assistant (RA). These positions, which also carry a small salary, are usually funded out of research grant money obtained by professors. RAs assist professors with aspects of their research and, in some cases, this research may even be the student's doctoral research.

Libraries Fundamental to the operation of a school of public health is a dedicated public health library, which is kept up to date with the latest journals and books. At Berkeley at least, copies of all doctoral dissertations are kept in the library for ready reference.

Such libraries usually have on-line or CD-ROM access to bibliographic data- bases, such as Medline. Students are usually permitted to use these directly.

Linkage with Other Organizations No school of public health is self-sufficient. The field of public health has become so diverse and so complex that it is essential for its practitioners to forge links with other organizations with some interest in the field. Foremost among these are other schools of public health, medical schools, other university departments outside the school of public health', and the depart- ment of health.

(a) Medical Schools Many U.S. schools of public health are situated on campuses that also have medical schools, usually because the school of public health evolved out of a public health department of the medical school. However, it is by no means essential for there to be a medical school on the same campus. Several U.S. schools of public health, including the University of California, Berkeley, and the University of Massachusetts, have no medical school on the same campus, and this is not seen as any disadvantage. However, in the case of Berkeley strong ties have been forged with the School of Medicine at the University of California at San Francisco (UCSF), across the San Francisco Bay. This arrangement works very well. The two schools complement each other without either one dominating the other, and there are many collaborative research and training projects. For example, many medical graduates from UCSF come to UC Berkeley to obtain M.P.H. degrees. Also, some professors hold joint appointments at both UCSF and Berkeley.

(b) Departments of Health The School of Public Health at UC Berkeley is located very near to, and cooperates closely with, the California Department of Health Services

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(CDHS). This is an arrangement that works extremely well. Both the school and the CDHS contain expertise that the other lacks, and there is a constant interchange. The CDHS also employs many students on research projects. In addition to being a source of student income, these serve as valuable practical training in public health and have been the source of many doctoral dissertation and master's thesis research projects.

(c) Other Schools of Public Health Because they have a common purpose, the schools of public health form a "network" throughout the United States. They have, since 1953, been officially linked through the Association of Schools of Public Health (ASPH), which has a broad function of coordinating developments and monitoring trends in public health issues, as well as representing the concerns of the schools to the U.S. Congress and Administration.

More specifically, the ASPH has stated that its functions include [5]:

- providing a focus and a platform for the enhancement of academic public health programs;

- assisting its member schools in the development and coordination of national health policies;

- serving as an information center for governmental and private groups and individuals whose concerns overlap those of higher education for public health; and

- assisting in meeting national goals of disease prevention and health promotion.

In addition to this formal association, there are innumerable other direct linkages, both formal and informal, between schools of public health, particularly in the form of joint research projects. Public health research questions often involve action on such a scale (e.g., thousands of interviews in many different centres) that it is beyond the resources of any one school to do that alone.

(d) Other university departments It is common for researchers in university departments outside the school of public health to have interests with a public health relevance. For example, engineers may have interests in the control of water and air pollution; chemists and biochemists an interest in the environmental fate of chemicals; and social scientists, a concern with the impact on health of a multitude of social, political and economic developments. All of these issues, and many more, have a direct public health relevance. Therefore it is common for professors from outside the school to teach courses in the school and for the reverse to occur. Similar considerations apply to research projects, which may cut across a number of university departments.

E m p l o y m e n t o f G r a d u a t e s

In 1987 the ASPH carried out a survey of the employment status of individuals who graduated from U.S. schools of public health between

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January and August, 1986 [6]. A response rate of 68 % was obtained for 2,567 survey forms sent out. Of the responders 82.1% were employed, 11.5 % were obtaining further education, and 6.4 % were unemployed. The distribution of employment areas is set out in Table 5. About 60 % of graduates were employed by hospitals, universities, health departments and the federal government.

Table 5. Areas of employment in 1987 of a sample of 1,322 graduates of U.S. schools of public health in 1986 (Data from reference 6).

Type of employing organization No. Percent

Association, foundation or voluntary agency (e.g., American Heart Association) Health insurance Community health center or clinic Consulting company Federal government Health department (state or local) Health maintenance organization Group practice (fee-for-service) Health systems planning agency Home health agency Hospital International agency/institute Long-term care facility Psychiatric facility Regulatory agency Research Industrial or commercial company University (teaching, research or administration) Other or unknown

Total

56 4.3

15 1.1 48 3.7 70 5.3

126 9.6 187 14.2 49 3.7 23 1.7 5 0.4 9 0.7

253 19.2 17 1.3 11 0.8 14 1.1 20 1.5 33 2.5 72 5.5

219 16.7

95 7.2

1,322 100.0

Alumni Association

At Berkeley, graduates of the School of Public Health may join the Public Health Alumni Association, which publishes a directory of members. For a small fee, they receive a regular newsletter which helps to maintain their linkages with the school and to keep them in touch with the progress of their fellow graduates.

In addition, the Alumni Association is a useful fund-raising source for the school.

Conclusion

This paper has described, in a very broad and general sense, the characteristics of U.S. schools of public health. The situation in these schools is one of great

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dynamism, flexibility, cooperation, and an ability to adapt to changing circumstances, combined with excellence in teaching and research. There is no one model that is "correct" for all schools of public health. Each school must adapt itself to local circumstances and concerns, and take advantage of available resources.

Acknowledgements

The authors gratefully acknowledge suggestions from A.-B. Kobusch and technical assistance from A. Ingram. This work was partially supported by funding from the German Academic Exchange Council.

References [1] Committee for the Study of the Future of Public Health Division of Health Care

Services, Institute of Medicine. The Future of Public Health. Washington, D.C: National Academy Press. 1988.

[2] Levin M. U.S. Schools of Public Health: Data Report on Applicants, Students, Graduates and Expenditures 1989 - 90 with Trends Analysis for 1974 - 75 through 1989 - 90. Association of Schools of Public Health. Washington, D.C. 1991.

[3] University of California, Berkeley. Graduate School of Public Health 1990- 91 Announcement. Berkeley, Ca. 1990.

[4] TheJohnsHopkinsUniversity.SchoolofHygieneandpublicHealth. Prospectus and Application Materials for Academic Year 1992- 93. Baltimore, Md. 1991.

[5] Association of Schools of Public Health. Graduate Education for Public Health: A Guide to Career Planning for Students and Professionals. Washington, D.C. 1991.

[6] Magee, JH. Employment Patterns for 1986 Graduates of the U.S. Schools of Public Health. Association of Schools of Public Health. Washington, D.C. 1987.

Dr. Michael N. Bates, Epidemiology Program, Department of Biomedical and Environmental Health Sciences, School of Public Health University of California, Berkeley, CA 94720, U.S.A. sowie Zentrum fur Gesundheitswissenschaften, Universit~it Bielefeld 4800 Bielefeld i

Dr. Rainer Fehr, Institut ftir Dokumentation und Information, Sozialmedizin und 6ffentliches Gesundheitswesen (IDIS), Westerfeldstr. 35-37, 4800 Bielefeld 1

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