An Academic-Public Health Department Partnership for Education, Research, Practice, and Governance

Abstract

Public health departments and medical schools are often disconnected, yet each has much to offer the other. There are 4 areas in which the 2 entities can partner; in Atlanta, Georgia, the Morehouse School of Medicine (particularly its Prevention Research Center or PRC) and the Fulton County Department of Health and Wellness have demonstrated partnership in each area. With respect to teaching, the 2 have collaborated on clerkships for medical students and rotations for preventive medicine residents. In research, Morehouse faculty and health department staff have worked together on projects. In service, the 2 entities have been able to put into practice interventions developed through their joint research efforts. In governance, the health department has a representative on the PRC board, while the PRC principal investigator serves on the Fulton County Board of Health. Benefits have accrued to both entities and to the communities that they serve.

Medical schools and public health departments have historically had little contact with each other. The focus of medical schools has been basic and clinical research, clinical specialty care, and the education of medical students (with no more than an occasional graduate opting for a career in public health). Health departments, on the contrary, have provided population-based public health services, particularly to the underserved, and have only rarely been involved in research or clinical services (except, for a few health departments, ambulatory primary care services). With respect to student education, they may provide field practicums for graduate students in public health.

In Atlanta Georgia, Morehouse School of Medicine (MSM) and the Fulton County Department of Health and Wellness (FCDHW) have worked diligently to create a partnership that is beneficial to both parties and the communities they serve. The partnership has included public health education and training, public health research, public health practice, and governance. In this article, we describe the partnership and discuss the strengths, weaknesses, and benefits it has provided to the constituents of the medical school and the health department.

The Partners

On the medical school side, the partnership has been led by the MSM Prevention Research Center (PRC). The PRC was established in 1998 with funding from the Centers for Disease Control and Prevention (CDC). It primarily conducts Community-Based Participatory Research (CBPR), described as research that is conducted with, not on, communities in a partnership relationship.¹ In CBPR, the community participates in every phase of a research project, including identifying the research topic, framing the research questions, conducting the study, and interpreting and disseminating the results. At the time the PRC was established, many neighborhood leaders maintained a distrust of research and expressed apprehension about participating in a research partnership with an academic institution that would be unlikely to benefit their communities. It was the operationalization of the CBPR process that ultimately won them over.

The mission of the PRC is to conduct interdisciplinary community-based research on prevention in African American and other minority communities, train minority community-based researchers and public health practitioners, and demonstrate the value of community coalitions in conducting research.

The governing body of the PRC is the Community Coalition Board (CCB), to which all the partners belong, including academic, agency, and neighborhood partners, but by bylaw, neighborhood representatives hold the majority of seats and the chairmanship. The board’s neighborhood representatives are leaders of community organizations in the PRC partner neighborhoods. Academic partners are represented by a faculty member from the MSM and 2 other Atlanta universities. Seven public agencies, including the FCDHW, are also represented on the board. These agencies offer important services in the PRC partner neighborhoods, but their staff generally do not live there. The CCB serves as a policy-making board, not an “advisory board,” that has created an opportunity for community partners to have an active voice in directing the operations of the center and contributing to its sustainability.

The health department side of the partnership is represented by the FCDHW, formerly the Fulton County Health Department. With a workforce of more than 700 health care professionals and support staff, the FCDHW is the largest county health department in the state of Georgia. The director of the health department reports directly both to the 7-member Fulton County Board of Commissioners and to the state health officer. The Fulton County Board of Health, also with 7 members, serves primarily in an advisory capacity.

The FCDHW provides service during more than 350 000 constituent visits annually, an average of more than 1500 visits per workday. With a budget of $61 million, the health department provides the following services: limited primary care; behavioral health; adolescent and school health; screenings; immunizations; community health education; maternal and child health; communicable disease testing and treatment; environmental inspections; zoning and planning case review; and health impact assessments. It also administers 8 county-funded health center sites and 4 mobile units all located within high-need areas of the county.

The Communities

The PRC’s primary partner communities are located within city of Atlanta Neighborhood Planning Units (NPUs) V, X, Y, and Z. These are 4 of the 25 NPUs into which the entire city is divided for the purpose of mobilizing grassroots input into the city’s initiatives. Each NPU consists of 5 to 10 well-defined neighborhoods. Each holds a monthly meeting, elects officers, receives reports from city officials, and votes on matters such as requests for zoning adjustments and liquor licenses. The total population of PRC’s partnering communities in NPUs V, X, Y, and Z is 55 757, with 89.3% (48 701) being African Americans. In these 4NPUs, 40.9% of African American families live below the poverty level.²

Fulton County has a population of approximately 1 million people, slightly less than half of whom live in the city of Atlanta. It covers a 535-square-mile area including approximately 88% of the city of Atlanta (the remaining 12% is in neighboring DeKalb County). In addition to Atlanta and a 105.6-square-mile unincorporated area, the county includes 13 cities and towns. Some provide their own public services such as police and fire protection, and the city of Atlanta has its own school system. However, the county’s entire population depends on the FCDHW for its public health services. The county owes its large size and elongated shape to having absorbed the destitute counties of Milton (to the north) and Campbell (to the south) during the Great Depression. However, the northern part of Fulton County is no longer destitute; on the contrary, it is now one of the wealthiest parts of the state, and its population is nearly all white. Hence, countywide demographics (median household income $57 000; population 44% black) do not describe the marked differences in population characteristics in different parts of the county.

African Americans are the largest racial/ethnic group in Fulton County (43.5%), followed by whites (40.8%), Hispanics (7.9%), Asians (5.6%), other/mixed races (2.0%), Native Americans (0.17%), and Pacific Islanders (0.3%).

Significant social and economic disparities exist for African Americans in Fulton County. The proportion of African Americans without a high school diploma is 2.7 times that of their white counterparts. African Americans are nearly 3 times more likely to be unemployed than whites, nearly 4 times more likely to be born below the poverty line, and, on average, earn less than a third of what white residents earn.

The Partnership

Academic-health department partnerships can take 4 forms: partnerships in education and training; partnerships in research; partnerships in public health practice; and partnerships in governance. The PRC-FCDHW partnership includes all 4. PRCs are encouraged to collaborate with both state and local health departments and many do so. Research studies mentioned in this narrative were approved by the MSM institutional review board.

Partnership in public health education and training

The MSM Public Health and Preventive Medicine Residency Program was established as a partnership between the medical school and the state health department, but the Fulton County Health Department assumed a major role early on when the County Health Officer became the chair of the Residency Advisory Committee. Core rotations took place at both the state and county health departments. In particular, the county health department served (and continues to serve) as an important site for an extended rotation in which the preventive medicine resident had an opportunity to apply elements of what he or she had learned in classroom exercises and in previous rotations (at any of several sites) in epidemiology, environmental health, health policy and administration, clinical preventive medicine, and social/behavioral aspects. Residents and students in other specialties occasionally rotated through the health department as well, particularly its sexually transmitted disease clinic.

The relationship between the medical school and the county health department was strengthened in 1996 when the Chair of the MSM Department of Community Health and Preventive Medicine assumed the simultaneous role of County Health Officer, spending half time in each position. With support from a CDC “Teaching Health Department” grant, an elective clerkship for senior medical students and practicum experiences for MPH students were established at the health department. The dual health officer-department chair arrangement was terminated in 1997 after the health officer-department chair failed to agree with the County Board of Commissioners on a matter concerning ambulance zones and the county hired a full-time health officer, but the relationship between the medical school and the health department continued. By 2005, the PRC had assumed the lead role for the medical school in partnering with the health department, now named the Fulton County Department of Health and Wellness. In 2006–2007, the PRC and the health department collaborated to secure a trainee (fellow) from CDC’s Public Health Prevention Service (PHPS). The PHPS program is a national program that provides experience in program planning, implementation, and evaluation through specialized hands-on training and mentorship at the CDC, as well as in state, local, and other public health organizations. The PRC-FCDHW partnership secured the fellow by submitting a joint application that proposed a supervisor at the medical school and another at the health department. A proposed project and opportunities for public health professional development were components of the application.

The PHPS fellow recruitment involved a 3-phase process. First, placement site applications were reviewed by the program and, if successful, were invited to participate in open recruitment. During this second phase, telephone dialogue between placement site applicants and fellows was designed for fellows to learn more about the proposed field assignments in which they were interested. Fellows then provided the program with sites they would like to invite to an interview day. During this third phase, potential placement sites and fellows engaged in face-to-face discussion regarding the “fit” of their interests with the site. Subsequent to this phase, a 2-year match was assigned by the PHPS.

The first PRC-FCDHW fellow was placed from 2007 to 2009. The fellow’s role was central to supporting a small media campaign (FCDHW) to promote breast and cervical cancer screening primarily among African American women in Metropolitan Atlanta. This placement was the first match of a PHPS fellow across the 32-member (at that time) CDC PRC network. The current PHPS fellow (2012–2014) has, among her primary roles, the coordination of the center’s 2012–2013 Community Health Needs Assessment. An additional role for the PHPS fellow is participating in developing, testing, and publishing a CBPR curriculum for training early-career researchers as well as lay people. Her health department responsibilities include coordinating activities of the Safe Kids Fulton County Coalition, in which she conducts child injury prevention education classes and inspections at the request of the health department as well as external partners. Training support for the fellow includes mentorship and professional guidance from researchers at the PRC and practitioners at the FCDHW, participation in professional meetings, and access to educational events at the medical school.

Partnership in public health research

Our first PHPS trainee participated in a tobacco control study that tested the impact of a smoking cessation training program on the implementation of smoking cessation guidelines by practicing physicians. The study was primarily conducted through the PRC.² Health centers of the FCDHW served as recruitment sites for participants in a PRC research project that demonstrated the efficacy of an educational intervention to promote colorectal cancer screening.³ From 2001–2005, the MSM and the FCDHW collaborated on the execution of a REACH (Racial and Ethnic Approaches to Community Health) grant from the CDC. The project studied approaches to preventing cardiovascular disease among African Americans and consisted of a set of educational and motivational interventions directed at smoking prevention and cessation, dietary improvement, and other cardiovascular disease risk factors. The health department was the grantee, and the MSM conducted the evaluation on a subcontract and also provided institutional review board clearance for the study.

Partnership in public health practice

A particularly productive type of partnership occurs when an academic institution and a health department collaborate to implement an intervention whose efficacy has been demonstrated by research at the academic institution. We provided a demonstration of this in 2008–2009 when faculty and community health workers from the PRC worked with health educators from the health department to implement the educational intervention to promote colorectal cancer screening mentioned in the “Partnership in Public Health Research” section. When conducted by the PRC-health department team in county senior centers, the intervention was successful in increasing the percentage of participants screened for colorectal cancer.⁴

In 2005, the CDC offered a new round of funding for REACH, this time with a focus on practice rather than research. The MSM PRC became the grantee with the FCDH Was the subcontractor. The focus of the program was prevention of breast and cervical cancer mortality among African Americans, and the health department worked with community-based organizations in Fulton County to promote screening, using evidence based interventions. Another example of a practice partnership was the small media campaign to promote breast and cervical cancer screening mentioned earlier, in which the jointly sponsored PHPS fellow played a lead role.

Partnership in governance

Approximately 75% of local health departments in the United States have an associated board of health.⁵ The responsibilities of the boards range from governance (hiring and firing the agency head; approving the budget) to advisement. Board members may be appointed by elected officials or may be ex officio (for instance, the superintendent of schools or the county coroner may by law serve on the board).

The 7 members of the Fulton County Board of Health are appointed by the superintendents of the Atlanta and Fulton County Schools Systems; the mayor of Atlanta; the chair of Fulton County Board of Commissioners; the full Board of Commissioners; the Atlanta City Council; and the Fulton County Grand Jury. The grand jury appointee must be a physician. Members serve staggered 4-year terms. The Board of Health serves in an advisory capacity to the director of the FCDHW. The Fulton County Grand Jury requires that its appointee be nominated by one of the local medical societies. In 2011, the Atlanta Medical Association nominated, and the grand jury appointed, the Principal Investigator of the PRC to the Board of Health.

The PRC CCB was described earlier. The FCDHW has a permanent seat on the board as one of the agency members. The PRC considers that the CCB is a policy-making board whose wishes must be acted upon by the faculty and staff of the center if at all possible; it is not considered to be an advisory board whose advice could be heeded or ignored. It does not have legal authority over the center, however; this authority ultimately rests with the president and the board of trustees of the school of medicine.

Discussion

The 37 PRCs in the United States are encouraged by their main funder (CDC) to work with health departments, and many do. In 2010, 36 of the 37 reported some joint activity with a state or local health department. The activities ranged from committee representation to research leading to publication in a scientific journal.⁶ Hence, PRCs may be seen as major contributors to the academic health department movement across the United States.

Examples exist in each of the 4 domains of the partnership: research, practice, education/training, and governance. Perhaps, the best example is represented by the colorectal cancer screening intervention, which was developed through a PRC research project (with the participation of the health department) and then put into practice by the health department (with the participation of the PRC). We have named the intervention EPICS (Educational Program to Increase Colorectal Cancer Screening) and are testing alternative approaches to its dissemination nationally with the support of a National Institutes of Health grant. Participating in research benefits the health department by offering it access to cutting-edge developments in the field; participating in practice benefits the academic institution by offering the opportunity to see the products of its research efforts put to good use. Both of these benefits are intangible, but the more tangible mutual benefits of staff/faculty development are not insignificant.

The education and training initiatives have also proven mutually beneficial. Medical student clerkships, MPH practicums, and resident rotations at the health department have offered students important public health experiences. Many of these same students and residents receive portions of their education and training in the PRC. Most importantly, several of the graduates have assumed key positions at the health department.

Regarding governance, there are differences in the FCDHW seat on the PRC CCB as compared with the PRC representation on the Fulton County Board of Health, as pointed out earlier. But the 2 representatives play important counterpart roles: the health department representative brings a public health practice perspective to the PRC CCB, whereas the PRC principal investigator brings an academic perspective to the board of health. There are important differences, however, as shown in the Table.

TABLE.

Board of Health and Community Coalition Governance Comparison

	FCDHW Board of Health	MSM PRC Community Coalition Board
Status	PRC representative appointed for a 4-y term, with a limit of 2 terms; successor might or might not represent the PRC	Health department has permanent seat on the board
Board authority	Board established by state law; advisory	Board established by the PRC; policy making but without legal authority
Method of selection	Democratic roots: the majority of members appointed by elected officials	The majority of board comprises local leaders who are volunteers; they may represent community organizations, but they are not elected

Abbreviations: FCDHW, Fulton County Department of Health and Wellness; MSM, Morehouse School of Medicine; PRC, Prevention Research Center.

A potential weakness of the partnership is represented by the difference in the size and scope of responsibility of the 2 partners. The health department has a vastly larger budget and staff than the PRC and is responsible for protecting public health throughout the county. County residents count on the health department to provide essential services. If the partnership were to dissolve, the health department would have less to lose than the PRC. Nonetheless, the partnership has not been one-sided; the contributions and the benefits have been fairly evenly divided.

The main strength of the partnership could probably be described as the partners’ similarity of mission. Both are concerned largely or entirely with attempting to improve the health of the underserved (although it must be acknowledged that the health department serves all the people of the county, whether underserved or not). It is this shared focus that keeps the partnership intact.

Partnerships between academic institutions and public health departments are varied,⁷ ranging from cases in which the health department and the medical school are closely tied together through contracts and partnerships dealing with teaching, research, and service⁸ to the more common arrangement in which an occasional student passes through the health department. Political considerations may limit the extent to which structures can overlap. Ultimately, the success of such a partnership depends on the extent to which leadership at both the health department and the academic institution desire its success and appreciate the mutual benefits. We have described a partnership between a medical school, primarily its community-based research center, and a local health department. The partnership has accomplished a great deal and each partner has had an influence on the other, but each has maintained its autonomy.