Harvey D, Shaff J, Hurley J, Resnick B, George C, Thorpe R, Bowie J. DrPHers building back better the public health leadership pipeline. HPHR. 2021;35.
The public health workforce is dependent on well-trained and diverse professionals that possess the necessary knowledge, competencies, and leadership to advance the field of public health and address the urgent and persistent problems faced by individuals and communities. Communities that have been historically marginalized and disadvantaged rely on respected and trusted leadership willing to understand and confront the vestiges of enduring racist cultural perceptions and beliefs that prevent optimal and equitable health and healthcare. DrPH programs have created opportunities for students to gain foundational and concentration-specific competencies and leadership to apply their learning towards research, intervention, and policy solutions that transform health inequalities leading to health equity.
In the US, structural racism is a root cause for many of the system-level health inequities that are occurring. Our nation needs steadfast and effective leadership to manage ongoing mitigation and surveillance efforts to address public health challenges, which is why it is important for schools and programs of public health to offer competency-based training. In 2017, the Johns Hopkins Bloomberg School of Public Health redesigned its DrPH program from exclusively departmental-based DrPH degrees to a schoolwide DrPH Program. This program is largely a part-time, online program, a design that is overwhelmingly favorable to working mid-career professionals. In this paper, we highlight three examples of DrPH students on different pathways working in distinct arenas to advance health equity and social justice and exhibiting the utility of their DrPH training to bridge science, academic- and practice-based evidence, and translate this evidence to action.
There has been a no more important time in the recent history of the United States for all Americans to fully understand the role of public health in society. The pandemic of the COVID-19 coupled with the racial and social injustice worldwide shed light on several longstanding key structural problems. In the US, structural racism is a root cause for many of the system-level health inequities that are occurring. One key approach to addressing these persistent public health problems is the training of the next generation of public health professionals. In recent years there has been an increase in the number of Doctor of Public Health (DrPH) degree programs across the country that have reimagined how to train leaders in practice and research translation and to be at the ready when there is a need for a quick and nimble response. Part-time DrPH programs tailored for working professionals with a focus on practice and leadership allow for real time transition of knowledge to practice and have been instrumental in advancing public health and academic-practice collaborations throughout the pandemic.
In the age of COVID-19 and beyond, our nation needs steadfast and effective leadership to manage ongoing mitigation and surveillance efforts to address public health challenges, which is why it is important for schools and programs of public health to offer competency-based training. In 2017, the Johns Hopkins Bloomberg School of Public Health (BSPH) redesigned its DrPH program in alignment with Council on Education for Public Health (CEPH) revised criteria and shifted from exclusively departmental-based DrPH degrees to a schoolwide DrPH Program. The earlier department-based programs were full-time and onsite, with inconsistent curricula and competency requirements across departments that did not align with public health practice. Over time, it became apparent that to prepare leaders to respond to real-world public health challenges and advance the field, a consistent program in a part-time, online format conducive to mid-career professionals with concentration areas relevant to public health was needed. Thus, the DrPH curriculum was designed to meet these needs, through a common core of foundational competencies across six domains — 1) Leadership, Management & Governance, 2) Ethics, 3) Data and Analysis, 4) Communication, 5) Policy and Programs, and 6) Education and Workforce Development, and across 10 concentration areas including a customized track to allow flexibility to address areas of need as they develop. One concentration of relevance to the pandemic and the country’s social unrest is Health Equity and Social Justice (HESJ). HESJ aligns with the aim of the DrPH to engage with communities, work in multidisciplinary teams, and deploy research methods, practice activities, and policy-oriented outcomes; here again, demonstrating the nimbleness needed to shift from traditional siloed systems and bureaucratic structures to processes and strategies that can be leveraged across sectors and disciplines to eliminate racial and ethnic health inequalities. Students in other concentration and track areas are also addressing diverse issues and exploring creative solutions to promoting health equity and social justice.
We highlight three examples of DrPH students on different pathways working in distinct arenas to advance health equity and social justice and exhibiting the utility of their DrPH training to bridge science, academic- and practice-based evidence and translate this evidence to action. In each of these cases, the impact of systematic disparities is intentionally emphasized and illustrated.
David Harvey holds the rank of Captain in the Commissioned Corps of the US Public Health Service and currently is the Deputy Director of the Division of Sanitation Facilities Construction at the Indian Health Service (IHS) in Maryland. With the Commissioned Corps he has experience as a hospital facility manager at St. Elizabeth’s Hospital in Washington, DC, as a field engineer with the IHS in Nevada, and with the Environmental Protection Agency in Washington, DC where he worked on the Water Security Initiative, coordinated the National Tribal Drinking Water Program, and was the Arsenic Drinking Water rule manager. Prior to joining the public sector, he worked for a water treatment equipment supply company in New Jersey and a private engineering consulting firm in Bilbao, Spain assisting with the supply, delivery, and installation of equipment for a municipal water company in Shanghai, China. He is a registered Professional Engineer in the State of Maine holds a Bachelor of Science degree from the University of Maine, a Master of Science degree from the University of Connecticut both in Civil Engineering, and a Master of Public Health degree from Johns Hopkins University Bloomberg School of Public Health. In 2019 he was named by Johns Hopkins University as a Bloomberg American Health Initiative Fellow and is currently pursuing a Doctor of Public Health Degree focused on Environmental Health. In 2020 he co-led the Navajo Water Access Coordination Group to help increase water access on the Navajo Nation.
The health benefits associated with access to safe water in protecting health are widely acknowledged within the field of public health (CDC, 2021). In 1959, Congress authorized the Surgeon General to provide essential sanitation facilities including domestic and community water supplies to serve American Indian and Alaska Native (AI/AN) communities (Public Law 86-121). The Congress further prioritized the need for water facilities serving these communities in the 1974 Indian Health Care Improvement Act and in the 1988 amendments to the Act, stating it was in the “interest and policy” of the United States that all Indian communities and homes be provided with safe water supply systems “as soon as possible” (Public Law 100-713).
The Indian Health Service (IHS) has made progress towards improving water access (IHS, 2017) however, gaps in access still exist in some AI/AN communities (IHS, 2019). These gaps have been widely recognized during the COVID-19 pandemic especially on the Navajo Nation where IHS data showed that over 9,600 Navajo tribal homes, about 37,000 people or over 20% of the Navajo Nation population, lacked access to piped water at the start of the pandemic.
In April 2020, in the Navajo Nation, positive COVID-19 cases approached 700 per 100,000 population, a rate greater than 48 States, and the highest per capita death rate than any other US State. Additionally, epidemiological evidence indicated that a lack of in-home piped water access could be a determinate contributing to the high incidence of COVID-19 infections (Rodriguez-Lonebear et al, 2020). Under these circumstances, the leadership of the Navajo Nation requested support from the Center for Disease Control and Prevention (CDC) and the IHS to increase safe water access quickly.
This resulted in a team of US Public Health Service Commissioned Corps Officers being deployed to assess the status of safe water hauling locations, recommend and implement approaches to reduce barriers to water access and provide a means to safely haul smaller volumes of water for drinking and cooking. The mission resulted in the installation of an additional 59 safe water access points, more than doubling the number of points on the Navajo Nation and reducing the round trip driving distance for residents living in homes with no piped water to 17 from 52 miles. This intervention, in addition to aiding hand washing, is hoped to also reduce the risk of waterborne illness and the associated hospital and clinic visits on the overburdened IHS healthcare system.
J. Sam Hurley currently serves as the Director of Maine Emergency Medical Services (Maine EMS) for the State of Maine. He has served in EMS since he was 16 years old where he began as a volunteer firefighter in rural North Carolina. After completing his undergraduate studies at the University of North Carolina at Chapel Hill as well as obtaining his license and working as a paramedic, he relocated to Atlanta where he attended Rollins School of Public Health at Emory University and earned a Masters in Public Health while he worked full-time as a paramedic for Grady Health System. After completing his MPH, he also obtained a Masters in Emergency and Disaster Management from Georgetown University. In 2017, he began working as the EMS Program Manager for the District of Columbia Department of Health in Washington, D.C. and recently took the role of State EMS Director in 2019 in Maine. Mr. Hurley is currently completing his second year as a DrPH student in Environmental Health focusing on Health Security.
Imagine asking someone about their race and ethnicity when you have never been coached on how to do so. To promote standardization and consistency in data collection, Mr. Hurley developed an asynchronous online course that helps to facilitate that education. The training is based on years of research funded by the U.S. Department of Health and Human Resources aimed at standardizing race and ethnicity language within the hospital system but has been repurposed for the emergency medical services (EMS) clinical environment (U.S. CMS, 2021).
When most public health researchers consider embarking on an investigation into our nation’s health system, it rarely is centered around emergency medical services. As Patterson describes in his 2006 commentary from the Journal of Rural Health, EMS is the “red-headed stepchild” of the healthcare system (Patterson, 2006). There may be some that view the field in this light; however, it is important to remember that the EMS system in America forms one of the cornerstones of our contemporary system – facilitating access during an emergency, transferring patients between facilities, and new modalities that have the capacity to bring the health system to the patients.
It is imperative that we, public health researchers, keep EMS in mind when we are considering research, interventions, and monitoring as millions of Americans interact with the EMS system on a yearly basis (NEMSIS, 2021). Lessons learned from other aspects of our healthcare system warrant application within the EMS field as well to strengthen the quality of the care rendered. EMS clinicians (EMTs, Advanced EMTs, and paramedics) serve as the primary workforce within the EMS system. However, unlike traditional healthcare environments, they are asked to function as the lead clinician, phlebotomist, nurse, environmental services, and registrar all in the span of a single interaction with a patient. In traditional healthcare environments, each of those positions receives specialized training on how to do their respective job. Specifically, many registrars are explicitly educated on how to ask questions about patients’ racial and ethnic identity; however, most EMS clinicians don’t receive that as part of their training courses (Bhalla, Yongue & Currie, 2012).
The course was designed using Thomas, Kern, Hughes, and Chen’s six-step approach to Curriculum Development for Medical Education. Members of the EMS community in Maine were interviewed as part of the curriculum development to better understand the needs of the EMS clinicians and how to meet them where they were in their understanding of race and ethnicity. By in large, the clinicians expressed concerns about not having training on how to ask race and ethnicity questions, the rationale for needing such information, as well as how to deal with situations where people were uncomfortable. The course, now completed and to be implemented over the next two to three months throughout the State of Maine, explores racial disparities, contemporary research highlighting the need, communication techniques, and even gives the learner an opportunity to simulate their new skills in an online patient encounter simulation. As a result, over 5,000 EMS clinicians as well as emergency medical dispatchers across the state will have access to this training.
This new course serves as an example of how DrPH students, like Mr. Hurley, are weaving public health theory and concepts into everyday public health practice to try and improve health outcomes – embodying the translational nature of a robust DrPH program (Hasnain-Wynia & Baker, 2006).
Jaimie Shaff is a second year DrPH student in Health Equity and Social Justice at the Johns Hopkins Bloomberg School of Public Health. Jaimie currently serves as the Chief Data Scientist for the NYC Department of Health and Mental Hygiene’s COVID-19 Response and Jaimie also serves on the Diversity, Equity, and Inclusion Council for Doctors Without Borders USA. As a multi-racial Asian-American, Jaimie’s DrPH work is focused on identifying opportunities to identify and support the health needs of the growing populations who cannot easily check any one box to indicate their racial identity. Jaimie holds an MPA in Public and Nonprofit Management from the New York University Robert F. Wagner School of Public Service, and an MPH in Epidemiology from the Harvard T.H. Chan School of Public Health.
Since February 29, 2020, New York City (NYC) recorded over 850,000 COVID-19 cases and over 31,000 COVID-19 deaths. Early efforts to contain the outbreak focused primarily on people traveling from Asian countries, which persisted as the virus spread across Europe. Investigations of SARS-CoV-2 specimens from the early weeks of the pandemic suggest the sequences of virus circulating in NYC to be most like those in Europe (Bushman et al., 2020).
Asian communities have experienced an incredible volume of stigma and hate after the outbreak began in China, which has increased over the past year. Asian-owned businesses experienced a slowdown prior to social distancing measures, suggesting a prolonged economic burden on these stigmatized populations (Olumhense, 2020). Stop Asian American and Pacific Islander (AAPI) Hate, an organization that has been tracking hate incidents nationally throughout the pandemic, received 3,795 reports between mid-March 2020 and February 2021 (Stop AAPI Hate, 2021). The NYC Commission on Human Rights reports an increase in hate crimes and bias incidents, some classified as violent crimes (NYC Commission on Human Rights, 2021). In the weeks following that report, the United States experienced the murders of Asian women in Georgia and the brutalization of Asian people, particularly the elderly, across the country.
Racialized language, including the reference to SARS-CoV-2 as the “Chinese virus,” weaponized latent race-based fear and discrimination (Chiu, 2020). Despite the common misconception that Asian communities don’t experience the same adverse health outcomes as other communities of color, we are learning more about the numerous health disparities experienced by Asian heritage groups both in NYC and the greater United States (Cho, 2014; Lee, 2015). These misconceptions, and the harmful narrative labeling Asians as the “model minority,” not only serve to divide communities of color and justify stereotypes against other minority groups – they also result in a dearth of directed or culturally/linguistically appropriate support for AAPI communities (Wu, 2013; Purnell, 2018).
Several important factors contribute to the mental health of Asian communities, which provide important context to designing effective culturally responsive interventions. Acculturation mismatch, intergenerational culture conflict, perceived discrimination, and racism are associated with adverse mental health outcomes among Asian communities, and impact Asian heritage groups in different ways (Chau, Bowie, & Juon, 2018; Lui, 2015). Additionally, studies have demonstrated the clinical utility of idioms of distress, which vary by Asian culture and context (Hinton & Lewis-Fernandez, 2010). These factors are not included in screening and diagnostic tools most used by providers in the United States yet are essential to accurately measuring mental health outcomes and in turn providing culturally relevant care (Kalibatseva & Leong, 2011; Yang & WonPat-Borja, 2007).
The COVID-19 pandemic provided an opportunity to build the capacity of NYC public health workers to recognize the complex relationship between culture, community, and health, and to remain vigilant regarding the societal tendency to utilize “success” among Asian communities to shift blame onto other communities of color experiencing rather than the structures that perpetuate the inequalities. To address the impact of COVID-19 on Asian communities we held an informational session in Spring 2020 to introduce NYC public health responders to the impact of the pandemic on Asian communities. This session served to inform participants of the ways the model minority myth is used to create divisions between communities of color and provided a platform for a facilitated conversation on allyship. The session also highlighted the need for disaggregated data by Asian subgroups, not only for COVID-19 but other health outcomes as well. As we work towards recovery efforts, we acknowledge the need to investigate disparities by ancestry group, improve data availability, and provide culturally and linguistically responsive care. In order to improve public health efforts supporting Asian heritage groups, we must expand data collection standards to allow for disaggregation of data.
The public health workforce is dependent on well-trained and diverse professionals that possess the necessary skill, talent, and leadership to advance the field of public health and address the urgent and persistent problems of its citizenry. These three examples, from the BSPH DrPH program, reflect the integrated learning in DrPH programs in schools and programs of public health. Their experiences also demonstrate the depth of their competence, approaches, and perspectives to analyze and address the public health problems they encountered and to formulate practical and meaningful solutions. Their strategies were consistent with their advanced DrPH training designed to assess, recognize, and adapt to rapidly changing and complex circumstances, including confronting racial and ethnic health disparities, while also seeking the necessary collaborators to formulate the best possible and most equitable outcomes. As the global space, we occupy continues to shift demographically, environmentally, economically, politically, and socially, DrPH programs are well-positioned to train the next generation of public health leaders. Our aim in the BSPH, not only within the HESJ concentration, but in all concentrations and tracks is to promote a DrPH program of academic excellence and integrity that will prepare future leaders to cultivate social and institutional changes and scalable solutions to equitably address the health, health care, and safety of the public they serve.
Earning a part-time DrPH online has allowed these three mid-career professionals to earn an advanced degree with flexibility but has been admittedly challenging, particularly during the COVID-19 pandemic. The BSPH DrPH program is constructed on the foundational CEPH DrPH, and multiple concentration competencies distributed through a blend of didactic coursework, applied integrating experience and dissertation research. All three HESJ cases are examples of how the applied integrating experiences allows blending of didactic learning with efforts to transform health inequalities in local communities. The evidence base in Case #1 for the safe water hauling recommendations was informed by the review of IHS health data completed by Harvey as part of his practicum requirement. The project described in Case #2 was borne out of Mr. Hurley’s educational plan development requirement in the Teaching, Learning, and Leading Course, a component of the DrPH core curriculum. The work done in Case #3 was part of Shaff’s required Practicum and the NYC COVID-19 response to raise awareness of the impacts on Asian communities.
Charles Ko, Alice Welch, Jennifer Hoenig, Lauren Martini, Scott Harper, the Navajo Water Access Coordination Group
David E. Harvey is a part time DrPH Student at the Johns Hopkins University Bloomberg School of Public Health and a Bloomberg American Health Initiative Fellow. He is a Commissioned Corps Officer of the US Public Health Service. His work has primarily focused on improving and maintaining access to safe water in American Indian and Alaska Native communities. He holds bachelor and master’s degrees in civil engineering and is a registered professional engineer in the State of Maine.
Jaimie Shaff is a third year DrPH student at the Johns Hopkins Bloomberg School of Public Health in the Health Equity and Social Justice track. Jaimie completed her MPH in Epidemiology at Harvard and her MPA in Public and Nonprofit Management at New York University. During the COVID-19 pandemic, Jaimie served as the Chief Data Scientist for the New York City Department of Health and Mental Hygiene. Before serving in the NYC Health Department, Jaimie worked in the global health sector and serves on the Diversity, Equity, and Inclusion Council for Doctors Without Borders USA.
Sam Hurley is a third year DrPH student at Johns Hopkins University’s Bloomberg School of Public Health within the Health Security Track of the Environmental Health Program. He holds an MPH from Emory University’s Rollins School of Public Health and an Executive Masters in Professional Studies in Emergency and Disaster Management from Georgetown University. He has extensive experience within the healthcare field along the eastern seaboard (Georgia to Maine). In addition to his studies, he serves full-time as the State EMS Director for the Maine Bureau of Emergency Medical Services (EMS). He is passionate about further exploring the nexus of clinical medicine, public health, and emergency management/public safety.
Dr. Resnick is the Assistant Dean for Public Health Practice and a co-director of the custom track of the DrPH at the Johns Hopkins Bloomberg School of Public Health. She focuses on the translation of research to practice and on the governance, financing and capacity of the U.S. public health system.
Dr. Christine Marie George is an Associate Professor at the Johns Hopkins Bloomberg School of Public Health in the Department of International Health. She is an environmental epidemiologist and environmental engineer whose career focuses on identifying transmission routes for environmental exposures and the development of water, sanitation, and hygiene (WASH) interventions to intervene upon these identified transmission routes. Dr. George serves as the co-director of the Johns Hopkins Health Equity and Social Justice DrPH concentration.
Dr. Thorpe is a Professor of Health, Behavior and Society at the Johns Hopkins Bloomberg School of Public Health. As a social epidemiologist and gerontologist, his research focuses on how key social determinants of health such as race, socioeconomic status, and segregation affect health and functional outcomes among men, particularly U.S. men. Dr. Thorpe is the co-director of the Johns Hopkins Health Equity and Social Justice DrPH concentration.
Dr. Bowie is the Bloomberg Centennial Professor in the Department of Health, Behavior and Society at the Johns Hopkins Bloomberg School of Public Health. She is Chair of the Schoolwide Doctor of Public Health Program. Her research portfolio focuses on the development of partner-engaged interventions to address community factors that contribute to health disparities and health equity.