Addressing Gaps in Public Health Education to Advance Environmental Justice: Time for Action

At a time when environmental public health crises dominate headlines, ranging from the COVID-19 pandemic originating from a zoonotic source to extreme weather events linked to global climate change, we want to call attention to the erosion of environmental health (EH) content within master of public health (MPH) programs. The lack of EH content in MPH programs places the already strained public health workforce at risk for not adequately understanding the close interdependence of health on the environment and the major public health challenges of our time, from climate change to systemic racism.

A major contributing factor to the decline in EH curricula may be the revision of the Council on Education for Public Health (CEPH) accreditation standards for schools and programs in public health in 2016, which was done with the intention that graduates from all MPH programs would demonstrate foundational public health knowledge and competencies.¹ Yet five years later, the curricular revisions and course restructuring initiated by public health schools and programs in response to the revised CEPH requirements have resulted in a reduction of EH courses offered.²

Other contributing factors to the decline in EH content could be at play, including not understanding the foundational role of the environment in health and years of inaction on climate change, leading to a consequential lack of demand from students. However, interests of incoming students appear to be shifting as they are in other health professions seeking to add EH content to prepare their future workforce to be skilled in managing complex, interdisciplinary public health challenges of environmental origin.^3,4

The Association for Prevention Teaching and Research, via a working group on EH competency, reviewed these trends in public health education and expressed concern over this disconnect in the public health learning curriculum. Here we describe more fully the unintended consequences for graduate public health education of the CEPH accreditation revisions related to EH, the potential consequences for the public health workforce, and recommendations for reversing these effects and fostering innovative EH education for the next generation of public health professionals.

PROBLEM STATEMENT

CEPH serves as the US Department of Education’s approved accrediting body for schools and programs of public health.⁵ Previous CEPH accreditation criteria in 2011 required graduate public health education in five core areas (biostatistics, epidemiology, environmental health sciences, health services administration, and social and behavioral sciences).⁶ CEPH subsequently engaged in a multistakeholder accreditation review process focused on aligning academic training with public health workforce needs.⁷ This comprehensive process resulted in the current 2016 competency-based accreditation model, which requires foundational knowledge and competencies for undergraduate and graduate public health curricula.⁷

Specific to master’s-level public health education, there are 12 learning objectives covering foundational public health knowledge and 22 foundational competencies.¹ Explaining the role of environmental factors in a population’s health is required as a CEPH learning objective only. Learning objectives are less advanced than the CEPH-defined competencies designed as outcomes of graduate public health education.¹

As a consequence of these significant revisions, public health educational programs are no longer required to graduate a resultant public health workforce competent in EH. CEPH conducted a trend analysis of the prevalence of EH degree programs and courses among its accredited entities in response to public health faculty members and administrators expressing concern over this deficit.² At the time of the survey, 26% of MPH curricula did not require at least one standalone EH course. Among the programs that did not have a discrete EH course, some had reorganized to offer interdisciplinary courses (that might include EH content) as a tactic to meet the current accreditation criteria.

Between 2017 and 2019, EH concentrations or degrees were added to only nine accredited units for the MPH, whereas these concentrations or degrees were removed from 19 accredited units. The latter 19 MPH programs informed CEPH that they had discontinued an EH concentration offering for the following reasons: low or no student enrollment, challenges experienced in complying with the revised accreditation criteria, and insufficient faculty resources to teach this discipline.²

The decrease in EH offerings and the revised accreditation criteria pose several challenges for graduate public health education:

• 1.At the Association for Prevention Teaching and Research Council of Graduate Programs annual meetings, deans and directors have shared their challenges in meeting the criteria for CEPH competency areas because of the prioritization of EH content in their curricula. Thus, programs may choose to remove EH courses and replace them with courses related to CEPH accreditation requirements rather than attempting to meet the competencies through EH courses.
• 2.The current CEPH accreditation criteria deemphasize EH and may be inadvertently signaling public health programs to do the same.
• 3.The potential exists for a substantial percentage of current and future graduates to enter (and sustain) the public health workforce without sufficient EH knowledge and competencies to fulfill public health’s mission in the age of complex, widespread environmental public health challenges.

This shift in graduate public health curricula affects the EH education of other professionals within the public health workforce. For instance, all preventive medicine residency programs accredited by the Accreditation Council for Graduate Medical Education must include a graduate-level course in EH (or the equivalent) as part of the required MPH degree,⁸ and a specific EH course or a syllabus that reflects content equivalent to a free-standing course is required by the American Board of Preventive Medicine for eligibility to take the initial board certification examination. This foundational EH knowledge is considered critical to the practice of preventive medicine, as reflected in the 10% to 15% of board certification questions focused on EH content.⁹ According to the executive director of the American Board of Preventive Medicine, the absence of this requisite EH content has delayed approval of initial board certification applications for some recent preventive medicine residency graduates (C. J. Ondrula, oral communication, March 2021).

THE ENVIRONMENTAL HEALTH WORKFORCE AND CREDENTIALING

Our public health system relies on well-trained EH professionals who need to understand essential issues such as the effects of a changing climate on health and need a technical understanding of issues such as food safety. Given that EH professionals account for about 10% of the local (approximately 14 700 employees) and 7% of the state (approximately 6800 employees) health department workforce, they represent a significant proportion of the governmental public health workforce.^10,11 Educational preparation is a timely issue, with 26% of EH professionals working in US health departments potentially retiring over the next 5 years¹² and only 6% of current students pursuing degrees focused on EH content.¹³

The National Environmental Health Association recently collaborated with the Centers for Disease Control and Prevention and Baylor University on a mixed-methods investigation called the Understanding Needs, Challenges, Opportunities, Vision and Emerging Roles in Environmental Health (UNCOVER EH) study. The authors conducted a survey of more than 1700 EH professionals with accompanying focus groups and identified six major priority areas for EH practice: drinking water quality, wastewater management, healthy homes, food safety, vectors and public health pests, and emerging issues. The authors suggested that current academic training in EH is insufficient to meet the extensive demands of the EH workforce, and educational reform was prominent in their recommendations for practice.¹⁴

The authors of a recent commentary on the alignment of public health academia, professional certification, and public health practice noted the many similarities between the accrediting bodies of schools and programs in public health: CEPH (the credentialing body for public health professionals), the National Board of Public Health Examiners (NBPHE), and the Public Health Accreditation Board (PHAB; the accrediting body for state, local, and tribal health departments). NBPHE offers a certified in public health credential and has certified more than 6000 people since 2008.¹⁵ In 2014, NBPHE embarked on a job task analysis to survey the public health workforce about essential functions and competencies necessary for the public health workforce. PHAB chose to use the 10 essential public health services and three core functions of public health (assessment, policy development, and assurance) as a starting point for its standards.

Although NBPHE and PHAB both have content areas related to EH and human disease risk, the accrediting body for academic public health does not have a competency related to EH.¹⁵ Put simply, we now have public health students who are not required to take an EH course or demonstrate attainment of any EH competencies but who may need this knowledge and these skills to become certified in public health or enter the workforce.

In addition to formal education, once professionals enter the workforce, the registered environmental health specialist and registered sanitarian credentials support professional preparedness through initial competency examinations and continuing education. However, these credentials are inconsistent in their scope, level of training, and requirements within and among states, tribes, and territories. A national standardized format for the two credentials would improve consistency in EH workforce training.¹⁶ Thus, a robust set of EH CEPH competencies would ensure that graduates are prepared to meet these credentialing requirements.

ENVIRONMENTAL JUSTICE

The COVID-19 pandemic has highlighted the significance of the environment for the health of all communities. In many ways, it has provided a new lens for appreciating the wide-reaching impact of the social, natural, and built environment on health. Within this expanded view of the environment, the pandemic has exacerbated inequities that have been ingrained in our society for too long (e.g., poor-quality housing, unfair zoning practices, inadequate workplace safety, deliberate indifference to drinking water contamination). For example, communities of color are more likely than their White counterparts to live near industry, breathe polluted air, and ingest lead-contaminated water.^17–19 When this undue burden of exposure to environmental hazards (and the resultant adverse health outcomes) occurs, often in communities of color, it is due to structural racism and highlights the important work of environmental justice advocates in bringing these inequities to light.

We have also tragically observed that COVID-19 cases and deaths are more likely among people of color, those living in poverty and overcrowded conditions, and those of low socioeconomic status.²⁰ Challenges associated with climate change adaptation will also further expose vulnerabilities along racial and ethnic lines as marginalized and low-income communities cope with flooding, extreme heat, vector-borne diseases, and other emerging threats if no action is taken to minimize these structural inequities.²⁰

How do we expect to combat structural and environmental racism when we are not sufficiently preparing our public health workforce to do the indispensable work of environmental justice? Our public health students must be taught that the “fair treatment and meaningful involvement of all people regardless of race, color, national origin, or income”²¹ is critical in working with communities to assess their health with respect to environmental hazards, create EH promotion and disease prevention efforts, and develop and evaluate EH policies. Through our EH classes and programs, we must reinforce application of essential public health services to significant EH threats to understand, address, and prevent environmental health injustice and promote health equity.

ENVIRONMENTAL BURDEN OF DISEASE AND RELATED THREATS

From the epidemiological triangle, we know that the environment is a critical component of disease and a foundation of both epidemiology and public health. Likewise, EH and public health are interconnected foundational pillars that must work together to improve the health of communities and address the tremendous environmental burden of disease (Box 1). In addition, we must understand historical environmental events so that we can recognize where we both failed and succeeded in acting swiftly, interprofessionally, and in an evidence-based manner. As educators, it is incumbent that we do not sacrifice meaningful EH content because of an already packed curriculum but instead set EH competencies that ensure public health professionals can effectively prepare for and efficiently respond to EH threats and disasters.

BOX 1—

Major Causes of Morbidity and Mortality Attributable to the Environment

1. Cardiovascular disease 2. Infectious and parasitic diseases 3. Cancer 4. Respiratory disease 5. Road traffic accidents 6. Unintentional injuries 7. Neonatal conditions 8. Mental and behavioral disorders

Source. Prüss-Ustün et al.²²

Addressing current and future challenges facing our public health workforce requires competency in toxicology and environmental sciences, among many other areas in EH. The COVID-19 pandemic will force public health leaders to rewrite the textbooks on emergency preparedness and response, infectious disease prevention and control, and vaccination development and administration programs. We will need to rethink how the structures of our physical and social environments influence disease transmission, necessitating a nuanced understanding of topics including bioaerosols, ventilation systems, and even transportation and workplace design.

Since the beginning of the pandemic, public health professionals of all backgrounds have been reengaging with their EH roots as they work directly on the front lines of pandemic response. Public health leaders had to examine how the environment can be changed to lessen transmission through the difficult decisions to close schools and workplaces, issue stay-at-home orders, and require mask use. Facing a deadly novel virus with sparse epidemiological evidence meant that policies had to be grounded in basic environmental science, expert opinion, and principles of environmental justice to reach those most at risk.

This acute need for an academically trained and competent public health workforce equipped with basic EH knowledge, skills, and competency is gaining recognition at the federal level. Within his American Rescue Plan, President Biden immediately called for 1.6 million new public health workers, specifying that 250 000 jobs be devoted to addressing public health crises and “environmental drivers of sickness.”²¹ We echo this plan in our call to action for public health programs to reinvigorate their EH courses to meet this need. We must ensure that every public health graduate is competent in basic environmental health science, is grounded in the importance of environmental justice, and is prepared to meet the challenges set forth by President Biden.²³

CALL TO ACTION

For these reasons, the Association for Prevention Teaching and Research calls on schools and programs in public health and preventive medicine to maintain existing EH content and develop such content if previously eliminated or never offered.²⁴ We also emphasize the need to ensure that EH content is evidence based and inclusive of past, current, and future EH threats. At the same time, educators need to develop a strategy ensuring that all MPH graduates receive education and training in EH to prepare a competent public health workforce that is ready to address environmental issues. To increase interest and demand, we need to do a better job of explaining the role of the environment in the health of all communities. Preparing our students to understand EH will be critical to counter the pending shortages in the public health workforce.

The reason for teaching EH is not only to ensure the competency of the workforce; it is critical to our students’ understanding of the drivers of health inequities and the fundamental work of the environmental justice movement. As educators, it is our duty to develop future public health practitioners sufficiently prepared to respond to the world’s pressing public health issues, many of which are environmental in origin or involve a significant environmental component. At this moment in our history, we must rededicate ourselves to advocate for those most affected by environmental threats, to promote health equity, and to address structural and environmental racism.

As leaders in public health, we need to work together to advocate that the next revision of the CEPH foundational competencies explicitly include EH. CEPH acknowledges that EH is a foundational learning objective, but environmental health needs to be reflected in the competencies as a value statement to emphasize the indispensable nature of EH knowledge and skills in terms of public health practice. If accreditation standards are revised to more explicitly incorporate EH-related competencies, schools and programs will be incentivized to include EH content that incorporates higher-level learning objectives.

We also need to ensure that EH content is broadly included in the certification in public health examination and other appropriate credentialing and professional examinations for the health workforce. Finally, we need to share our expertise to make it easier for schools and programs to develop rich and engaging EH content. We can collaborate to create examples, case studies, resources, and open access coursework that can be adapted and shared widely via our professional associations (e.g., the Association for Prevention Teaching and Research, the American Public Health Association, the American College of Preventive Medicine, the Association of Environmental Health Academic Programs, and the National Environmental Health Association) to promote high-quality education in EH.

In summary, this past year has been a time of tremendous challenges and adaptations for our public health workforce. Now we urgently need our graduate public health education system to adapt as well. We call on educational leaders to recalibrate our public health educational priorities and emphasize EH to best prepare our future workforce for the inevitable environmental threats we face now and will face for generations to come.