We are all public health

I view librarians of most types as part of the public health workforce. The circle of essential public health services (Figure 1) divides public health work into ten essential areas. One of these is to “inform, educate, and empower” people about health issues [1]. Clearly this role fits the training, expertise, and inclination of most librarians. Also, Banks et al. have shown the competencies of health sciences librarianship and public health to be complementary and have offered examples of libraries' collaborations and services to public health that suggest librarians can be considered full members of the public health workforce [2].

Figure 1.

Ten essential public health servicesSource: US Department of Health and Human Services. Public health in America: public health functions project. [Web document]. Washington DC: The Department, 1995. [rev. 1999; cited 14 Feb 2007]. <http://web.health.gov/phfunctions/public.htm>.

Public health agencies serve as a voice of authority. A case study by Berkelman suggests that information provided by public health departments via telephone may not consistently be of high quality [3]. Public health touches all individuals every day as they eat, drink, breathe, and live with partners or pets. It is crucial that public health workers base decisions and regulations on the best evidence. Librarians can provide that authoritative information.

Health sciences librarians have another public health role: to keep clinicians up to date on the latest information from local public health agencies and to promote feedback loops between local practitioners and local public health. Public health decision makers set the parameters in which health care workers practice. Librarians can ensure that the public health guidance to the practitioners whom they educate and serve is based on the best evidence.

All public health is local, but the will to improve public health information access and evidence-based practice is often at a more removed level. Several local, national, and international efforts to enhance public health information are described in this issue of the Journal of the Medical Library Association. In 2001, when colleagues and I reviewed National Library of Medicine–funded outreach grant reports in preparation for a public health outreach forum, sustainability was a major concern [4]. As you read this issue, consider what progress has been made in the past few years and the past fifty years. Are the concerns outlined in 1955 by Herman (described below) still with us? Have organizations taken the actions necessary to ensure sustainability of information resource access and continuation of evidence-based practice?

In 1955, Flora Herman, librarian of the Florida State Board of Health, introduced Medical Library Association members to public health libraries as a type of medical library [5]. All but 8 states had a state public health library. The average state health department library had about 4,000 volumes, was subordinate to the division of health education, had a full-time nonprofessional librarian with perhaps an assistant, and was either a central library or decentralized reference-only library with the various bureaus housing discipline-specific collections. It served not only public health personnel, but also physicians, nurses, lawyers, teachers, and consumers with a variety of materials and services, including loan of materials to any member of the medical or allied health professions and pamphlets to lay people. Counties were responsible for funding their own collections but could freely borrow items from the state health department library.

Fifty-plus years have brought fewer changes than one might expect. What has not changed is the negative—the struggles with funding, staffing, time, and political whims—as well as the positive— the emphasis on personalized service. Inadequate budgets and dependence on grants or disease-specific categorical funding make it difficult to maintain a balanced collection of essential resources. Scattered agency bureaus and departments with local collections often weaken the central collection. Electronic access to journals and some core texts has reduced the geography problem for those who can afford them, but it has created new issues in terms of Internet protocol access and vendor negotiations about multiple sites. Service remains the public health library's most important function, and Herman's examples of extending the library to patrons who cannot or will not come to the library, no mean feat in 1955 with only microfilm and photostat services, resonate today.

So what has changed? Certainly the amount of relevant public health research available for those with money and time to obtain it has increased. Sadly, the number of state public health libraries has decreased from the forty Herman reported. In 2004, when I examined the Websites of all state public health agencies looking for libraries, only twenty-four states advertised either their own library, resource collection, or relationship with a library. Some were in a specific department, while others pointed to libraries in the state hospital or other state resources [6]. This figure was not an exact enumeration, as at least one state health department library known to me could not be identified from the Website. Physical libraries notwithstanding, these agencies generally offered a virtual library of information to meet the needs of a diverse audience—health care providers, politicians and policymakers, business and industry, community-based organizations, and the general public.

Herman stated that a public health library in a large city possessing outstanding libraries with cooperative interlibrary loan might need just a few reference works, monographs, and a five-year file of unbound journals. The ever-widening domain of public health and the explosion of information resources mark this as a historical statement. To put this in perspective, version 2.0 of the Core Public Health Journals List, released in October 2006, contained 607 titles [7]. When I was manager of the New York City Department of Health & Mental Hygiene's Public Health Library from 2002 to 2005, we had 174 current subscriptions and retained all older issues, a much richer collection than Herman proposed, but still we relied heavily on interlibrary loan and physically traveling to other libraries that were open to the public. For a recent description of a state public health library collection, see Rethlefsen's article on the Minnesota Department of Health's library in this issue.

Today, librarians focus less on public health libraries and more on providing public health information. Herman reported that only thirteen professional public health librarians in the United States were working in state public health libraries. In 1999, the Public Health/ Health Administration (PH/HA) Section of MLA removed the word “Libraries” from its name to encourage membership by those who worked in public health, but outside of standalone public health libraries. In 1998, the PH/HA Section had 112 members, in 2007, it had 175.

Access to information resources and information professionals is only part of implementing evidence-based practice. Fulfilling knowledge management needs is another role that librarians could help address. The public health workforce is rich in tacit knowledge that it finds difficult to share effectively. The orientation of new practitioners and succession planning for those leaving the field are insufficient to manage the need to share local, internalized knowledge. Knowledge gaps abound. New people with classroom knowledge but no local savvy need to get up to speed, while others with vast reservoirs of experience in the community require updating in technical skills. Public health personnel are too busy responding to crises and dealing with day-to-day mandated functions to get “out of the house” and learn methods to improve their practice. Local networking is one way people try to keep up. Maintaining technical expertise is also a challenge as the wealth of existing information may not be accessible due to lack of time, funds, or knowledge of what might be available.

Educational demands on the public health workforce are daunting. A public health educator, for example, must be able to perform challenging tasks varying from motivating change in an individual's personal smoking behavior to explaining to a large audience with varied scientific expertise how environmental mutagens prevalent in the community might affect the genetics of a variety of organisms. While health sciences libraries clearly play a role in the formal education and information literacy of the public health workforce, other libraries should also support public health. Public, municipal, and state libraries are also essential to the education and development of the public health workforce in most communities. Where health sciences librarians are not available to practitioners, we need to help practitioners identify and better use the resources available through these other types of libraries.

Public health is about action, so I leave you with thoughts on ways that I feel that librarians can advocate to improve to public health workers' access to information.

1. All health sciences libraries, particularly hospital libraries, should allow on-site access by local public health workers.

2. All communities should have a library or group of libraries committed to partnering with local public health officials to provide health information to benefit the overall health of the community.

3. State or other centrally funded electronic resource packages should include public health information and be promoted to the public health workforce as a resource.

4. All government, state, and municipal libraries should have access to DOCLINE to quickly obtain materials.

5. Libraries with large public health collections—such as Centers for Disease Control and Prevention, National Library of Medicine, World Health Organization Library, or their regional networks—should provide Loansome Doc–type services to unaffiliated public health workers.

6. Vendors of public health knowledge resources should place their materials online and make them available for reasonable, pay-per-use purchases.

Implementing these suggestions will take both will and effort at many levels. Individual librarians today can embrace their role of informing, educating, and empowering others to improve public health by continuing the dialogue initiated by their colleagues who have contributed to this issue of the journal.