Educated Citizenry or Workforce Pipeline Development? Questions for the Future of Undergraduate Public Health in the United States

The spring of 2020 will undoubtedly be associated with COVID-19 lockdowns, hospital surges, death, and political turmoil. But as COVID-19 began to fundamentally reshape the relationship between public health and the public in the United States, another public health milestone occurred: the spring of 2020 represented the first time that more undergraduate public health degrees were awarded in the nation than master’s degrees. In 2020, 18 289 undergraduate public health degrees (UGPHDs) were conferred compared with 18 044 master’s degrees (Figure 1).¹ This milestone at this critical moment offers an opportunity to assess the degree and its growth over the past two decades, and to pose key questions for its future.

FIGURE 1—

Growth of the Undergraduate Public Health Degree: United States, 2000–2020

Source. National Center for Education Statistics.¹ Includes Classification of Instruction program codes 51.22XX (Public Health), 26.1102 (Biostatistics), 26.1309 (Epidemiology), 44.0503 (Health Policy Analysis), and 51.0504 (Dental Public Health).

A DUAL IDENTITY FOR UNDERGRADUATE PUBLIC HEALTH DEGREE

The Institute of Medicine’s 2003 “Who Will Keep the Public Healthy?” report recommended for “all undergraduates to have access to education in public health.”^2(p20) It led to a dual identity for the undergraduate degree going forward: (1) to advance public health literacy and an “educated citizenry” to integrate public health into whatever fields graduates enter, and (2) to provide more intentional public health workforce preparation to ensure an adequate and prepared staff for the nation’s governmental health agencies.^3,4

From 2019 to 2020, conferrals of master’s degrees in public health grew 1%, compared with 7% for UGPHDs. Prior to the COVID-19 pandemic (academic year 2019–2020), master’s degrees in public health saw the first sustained year-to-year drop in applications since data have been recorded, whereas conferrals of UGPHDs continued to grow, although the pace of acceleration slowed substantially.⁵ However, COVID-19–related interest in public health and a temperamental economy yielded an all-time high pool of graduate public health applicants beginning in March 2020, providing a reprieve from the expected stagnation of graduate applications.^3,5–7 Although demographic changes and economic pressures are still expected to reduce the number of high school graduates, undergraduates, and thus master’s degree students in the medium term,⁷ the immediate future of academic public health in the aftermath of the pandemic faces much uncertainty.^8,9

Conferrals of UGPHDs now eclipse those for master’s degrees, but only a small percentage of the governmental public health workforce—even among new entrants—has a bachelor’s or master’s degree in public health.¹⁰ Data from the Associations of Schools and Programs of Public Health (ASPPH) show that a relatively small percentage of those with either undergraduate or graduate degrees in public health end up in governmental public health practice.¹¹ ASPPH data on undergraduates show that first jobs out of school were in for-profit organizations (38%), health care (27%), academic institutions (10%), government (10%), and all others (15%).

BIG QUESTIONS REMAIN

We offer some big questions for students, academics, and researchers to consider for the identity of the undergraduate public health degree.

• 1.What are public health undergraduate programs preparing students to do?

Reports from the Institute of Medicine and ASPPH have long laid out a vision wherein master’s-trained students represent the future leadership of the governmental public health workforce.^2,4 However, data indicate that most public health graduates at any degree level do not go into governmental public health, and particularly at the undergraduate level. Thus, the identity of the undergraduate degree becomes paramount, especially as vision documents for the field and accreditation requirements for the degree are aimed at preparing students for the governmental public health workforce. However, if most undergraduates go into the private sector or health care and not government, and with some going on to further education in health care or graduate public health,¹² shouldn’t that affect how we prepare students for a future career? Can this milestone perhaps serve as a call for needed changes in the field to attract graduates with public health training to governmental public health?

• 2.Can undergraduate public health help combat systemic racism and improve health equity?

The twin pandemics of COVID-19 and systemic racism threaten the health and well-being of the public. Undergraduate public health may be well positioned to train a generation of graduates to bring hard and soft skills to antiracist efforts, although formal commitment to doing so from schools, programs, and faculty is in the nascent stages. A long-time focus within public health on social determinants and social justice theory, along with a newfound public interest in equity and health equity issues, have created substantial opportunity for public health graduates. These opportunities are consonant with both identities of the degree: to produce an educated citizenry in whatever fields graduates pursue and, by preparing a public health workforce within government, to effect change in the racism and equity space.

• 3.Will undergraduate public health help rebuild the public health workforce?

From the Great Recession up until COVID-19, best estimates indicate that state and local health departments lost a net 40 000 jobs.¹³ Since COVID-19, a dramatic increase in the temporary and contract workforce has potentially offset these losses, although questions remain about whether a temporary workforce will become a permanent one going forward. In addition, voluntary separations from public health agencies are at an all-time high—the Great Resignation has changed the employment landscape in many fields across the United States.¹⁴ The impact of this macroeconomic movement on public health remains uncertain. Yet a fundamental question emerges: will undergraduates be part of the rebuilding of the public health workforce? If so, will this require a curriculum retool to meet emerging governmental needs in the post–COVID-19 era? Implicit in this is the question, can health departments attract graduates away from the private sector and health care?⁶

• 4.Will there be a substitution effect for undergraduate versus graduate degrees in public health?

Substitution effects in hiring—for example, preferentially hiring a holder of a bachelor’s degree rather than a master’s—have long been observed, most notably in fields like education as a cost-cutting measure. Although recent evidence does not suggest widespread substitution effects in public health, especially in government agencies,¹⁵ there remain open questions about whether an UGPHD looks as appealing as a master’s degree from the perspective of an employer, such as those in health care or the private sector more broadly. If such a substitution effect does emerge, will it manifest more in one degree identity over the other? And ultimately, what might be the impact of such a substitution effect on the practice of public health (e.g., the depth of knowledge and skills), especially in specialized fields like epidemiology?

• 5.What is the value of an undergraduate public health degree?

The monetary benefits of a bachelor’s degree broadly are demonstrable, although inequitable distribution of student loan debt has created disparities by race, ethnicity, and class. Yet the advantages of an UGPHD versus other undergraduate degrees are less well characterized. If the public health degree is considered under the Institute of Medicine’s broad social goals of an educated citizenry, UGPHD outcomes might be compared with humanities or other field-based types of study such as sociology, anthropology, or political science. However, if UGPHDs are within the realm of workforce preparation as a specific discipline, such as nursing or other allied health degrees, outcomes may be less favorable. A final point in the consideration of value is that motivations matter to job satisfaction, perhaps as much as compensation.⁶ As such, assessments of value to any degree should consider both the monetary and nonmonetary benefits of the degree and potential employment outcomes.

• 6.What is a reasonable upper bound on the expected number of undergraduate degrees in public health each year?

As conferrals of undergraduate degrees eclipse those of master’s degrees, questions about an upper limit naturally arise and diverge across the two identities. Compared with other undergraduate humanities degrees, public health, at 18 000 degrees, is modest in size and has some room for growth. In 2020, for example, undergraduate degrees for sociology were at 29 000, and computer science and political science had 40 000 each; however, in the realm of workforce preparation there is a large gap for public health degrees compared with nursing (160 000) and business (170 000).¹

The ratios of undergraduate to graduate degrees further accentuate the distinctions across the two degree identities and raise questions about intended professional trajectories. Among profession-focused degrees, in 2020, ratios for bachelor’s versus master’s degrees were 5 to 1 for nursing, 2.8 to 1 for computer science, and 1.4 to 1 for business degrees; however, for humanities-based degrees a distinctly different picture emerges, with ratios of 22 to 1 for sociology and 23 to 1 for political science degrees.⁷ Although it seems functionally impossible to have 20 UGPHDs awarded for every one master’s degree in public health, it may be plausible to see a ratio of 2 to 1 or even 3 to 1, contingent on employment outcomes and loan repayment options.^3,12

CONCLUSIONS

Undergraduate public health education is clearly here to stay, and needs to be a core part of academic public health’s plans for the future. It represents potential for much-needed strengthening of the field and capacity to improve the health and health equity of the public, in terms of both a better understanding of public health among the broader workforce and more public health–trained people to help rebuild the governmental public health workforce.