The Covid-19 lockdown began in Massachusetts the week I submitted my dissertation to become a doctor of public health (DrPH).
When I had gone back to school in Boston three years before, after working as a policy analyst at the National Institutes of Health, I could never have imagined graduating during a health crisis like this. I had studied pandemics, of course, but only as history lessons. Suddenly I — like everyone around the globe — was living through one.
I was fortunate to be able to contribute to the response. A week after I submitted my dissertation, I began volunteering for local health departments throughout Massachusetts, supporting contact tracing and creating communication materials. This work led to a full-time job coordinating the Covid-19 response for a small Native American reservation.
One of the many things I have learned over the past year is that my career prospects in public health departments are limited. My DrPH is similar to a Doctor of Nursing Practice or a Doctor of Physical Therapy — degrees for people trained to be leaders in the field, not professors in academia. Yet despite my degree, I do not qualify for many senior positions, since many jobs in health departments around the country require a Doctor of Medicine, or MD.
The silent assumption is that public health and medicine are the same: If you can treat one person, then you can treat a group of people.
It’s not that simple. As President Biden plans to improve the U.S. public health system, a first step should be removing from public health jobs the requirement to be a medical doctor.
The fundamental difference between medicine and public health is the unit of analysis. Medicine trains practitioners to evaluate the health of each person individually, while public health trains practitioners to improve the health of groups of people.
What is best for each person may not be best for the public. Consider the CDC’s recommendation on Covid-19 boosters. Boosters improve a person’s protection from Covid-19, making them a good choice for individuals. But are they the best choice for society? Would society be more protected by giving more doses to other countries?
While questions like those are not easy to answer, the “best” decision varies greatly depending on whether one is looking out for individuals or for society.
The educational backgrounds of public health leaders matter. Yet many of these jobs require MD degrees. While there is no comprehensive database, a quick glance indicates that something is amiss. Nearly two-thirds of state public health officers, who ultimately oversee each state’s Covid-19 response, are medical doctors. The nation’s top public health officer, CDC Director Dr. Rachelle Walensky, is a medical doctor, just like 16 of the previous 18 CDC directors.
Some areas have codified medical requirements for public health positions. I work in California, where state law requires every county health officer, including the state public health officer, to be a board-certified doctor. The director of the Nashville Department of Health “shall be a doctor of medicine” according to the city statute, which is the same requirement for the City Health Commissioner of New York City.
Historically, it made sense for medical doctors to also be in public health positions. They were often the first to recognize unusual disease patterns in their patients, a telltale sign of a looming health problem. Many of the most influential public health pioneers were medical doctors. John Snow, a London medical doctor, discovered the source of a cholera epidemic and became the father of epidemiology. Rudolph Virchow, a German medical doctor, coined the term “social medicine” and was one of the first to note the significance of social factors on health.
In the last 100-plus years, however, public health has become a distinct profession separate from medicine. Disease monitoring has improved, especially with electronic health records, so millions of people can be analyzed almost instantly. Unusual patterns of disease can be identified in a spreadsheet. New statistical techniques have identified further causes of health conditions, such as social determinants of health. It is now widely accepted that nonclinical factors, like where people live, work, play, pray, and more determine more of individuals’ health status than the health care they receive.
The last 21 months have proven that the U.S. needs to improve its public health workforce. To address this issue, President Biden plans to spend $6.5 billion, which is money sorely needed. Removing requirements to be a medical doctor for senior public health leaders is a costless first step to improving the U.S. public health system. America deserves the best public health doctors.
Eric Coles is the president of the DrPH Coalition and the tribal public health officer for the Tule River Indian Tribe of California.
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