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Public-Health Training for Veterinarians |
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONHISTORICAL CONTEXTTHE COMBINED MASTER OF...CHALLENGESREVISITING THE IDEA OF...REFERENCES |
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Key Words: public health • One Health • veterinary graduate education
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONHISTORICAL CONTEXTTHE COMBINED MASTER OF...CHALLENGESREVISITING THE IDEA OF...REFERENCES |
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Being admitted to the veterinary profession, I solemnly swear to use my scientific knowledge and skills for the benefit of society through the protection of animal health, the relief of animal suffering, the conservation of livestock resources, the promotion of public health and the advancement of medical knowledge.2
In spite of this worthy goal, the veterinary profession is vastly underrepresented in the public-health system. Nowhere is this more evident than in faculty and student bodies in public health schools and programs. Nationwide efforts to narrow the gap have implications for the success of One Health, an initiative that aims to improve integration of human, animal, and environmental health.
The objectives of this article are to describe the present integration of human and veterinary medical students’ education in the Combined Master of Public Health (CMPH) Program at Tufts University and to highlight outstanding challenges to that integration. To fully appreciate the unique philosophy and structure of this program, it is important to consider first its historical and environmental context.
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HISTORICAL CONTEXT |
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TOPABSTRACTINTRODUCTIONHISTORICAL CONTEXTTHE COMBINED MASTER OF...CHALLENGESREVISITING THE IDEA OF...REFERENCES |
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Born into an environment that already included robust health sciences schools, the Tufts veterinary school struggled in its first few years. As a private institution, the new veterinary school received little in the way of state funding; it could not exist on its own and depended heavily upon the faculty, staff, and resources of the medical school. In those early years, veterinary medical students joined their human medical counterparts in the basic sciences and systems courses that constituted the first two years of the curriculum. The concept of One Medicine was reduced to its most basic level, meaning that all students, including veterinary medical students, learned about human health. As summarized by Sol Gittleman, the university's provost for 21 years,
"Hospitality" was not an operational concept when the veterinary students found themselves sitting among the medical students in histology, biochemistry, physiology, and pathology. It soon became apparent that everyone was going to be unhappy. The Medical School faculty thought that the entire idea of One Medicine was no more than a fantastic Mayer conspiracy to provide the Veterinary School with courses and a faculty at no or little cost. The veterinary faculty saw immediately that insufficient comparative aspects were being taught in classes taught by Medical School faculty, who did not want to go the extra mile in supplementing their lectures. For their part, the veterinary students resented lecturers who emphasized only human physiology, microbiology, and diseases. Finally, the medical students simply announced that they were not interested in animal models.6
Over the next decade, the SVM increasingly found its financial footing. As a result of veterinary students’ and faculty members’ concerns that courses devoted almost entirely to human medicine and health did not meet their educational needs, the school gradually withdrew from the Boston campus and reestablished itself on a new campus 40 miles west of Boston, where it now stands.
The university environment into which the SVM arrived had a growing global perspective and also offered numerous opportunities for interdisciplinary scholarship, research, and service. In addition to Tufts College, with its highly respected Schools of Arts and Sciences, Graduate School of Arts and Sciences, and School of Engineering, the university was home to the School of Medicine, the School of Dental Medicine, the Sackler School of Biomedical Sciences, the Friedman School of Nutrition Science and Policy, and the Fletcher School of Law and Diplomacy.
In 1991 Tufts became the first university in the United States to establish a four-year MD/MPH program. Meanwhile, a number of graduates of the SVM, having pursued stand-alone MPH degrees at other universities, had moved into leadership positions in veterinary medicine and public health. Consistent expressions of interest in an MPH program arose from among the veterinary student body, and particularly from students enrolled in the SVM's International Veterinary Medicine certificate program and students with broad professional goals. Senior administrators of the medical and veterinary medical schools, pondering the possibility of a DVM/MPH program, were united in thinking, "Why not?" The SVM's curriculum had just been revised to include large blocks of elective time that could be used for MPH courses. The confluence of these factors, the fertile ground provided by Tufts through its strong interdisciplinary nature and entrepreneurial spirit, and the unqualified support of senior university administrators led to the establishment at Tufts University of the first DVM/MPH program in the United States. Begun in 1994, the DVM/MPH degree was incorporated into the already established MD/MPH degree program and renamed the Combined MPH (CMPH) Degree Program. Tufts’ CMPH program has just graduated its twelfth consecutive MD/MPH class and its ninth consecutive DVM/MPH class. As of 2007, 17 veterinarians had graduated from the program and 18 veterinary students were enrolled in it.
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THE COMBINED MASTER OF PUBLIC HEALTH PROGRAM AT TUFTS UNIVERSITY |
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TOPABSTRACTINTRODUCTIONHISTORICAL CONTEXTTHE COMBINED MASTER OF...CHALLENGESREVISITING THE IDEA OF...REFERENCES |
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The administrative home of the CMPH program is on the Boston campus, in the medical school's Department of Public Health and Family Medicine. Veterinary students apply separately to the CMPH program shortly after their acceptance into the DVM program; their applications and those of their fellow medical students are reviewed by a single MPH admissions committee. Students are notified of the status of their applications in late spring, so that those admitted to the program may take the required core course in epidemiology during the summer prior to their matriculation into the DVM program. This option helps to lessen the substantial academic burden that students frequently experience in their first semester of veterinary school.
The combined track offers two distinct advantages over programs with other structures. First, it allows students to integrate their public-health studies into their clinical training, so that each enriches the other. Second, busy clinicians often find that they cannot spare the time and expense of returning to pursue public-health degrees later on in their careers; the combined track saves them a year of valuable time.
Degree Requirements
Students must complete 44 credits of public-health coursework and earn four additional credits toward their MPH through work done toward the MD or DVM degree.
Curriculum
In the first two years of study, students in the CMPH program take most of the core and required public-health courses in place of weekly pre-clinical field or research electives pursued by other medical and veterinary medical students. Of the six core courses in the CMPH curriculum, five are taken in these two years: Epidemiology, Biostatistics, Public Health and Health Services, Introduction to Environmental and Occupational Health, and Social and Behavioral Sciences. Courses that are required but not included in the core curriculum include Introduction to Global Health, Public Health: Theory to Practice, Law and Public Health, Health Care Organizations: Budgeting and Management, Public Health Field Experience, and Public Health Rounds.
The Public Health Field Experience comprises an eight-week placement in a public, private, or volunteer health organization during the summer of the first year of study. Students are supervised by a director of field experience, located in Boston, and mentored by public-health professionals located in a number of local, state, national, and international organizations. The field experience is designed to meet the needs of the host agency while at the same time giving the student an opportunity to integrate his or her knowledge and begin to develop public-health skills in a public-health practice environment.
Public Health Rounds, a seminar required for all CMPH students, focuses on current topics in public health and is offered on a single Saturday in both fall and spring semesters of all four years of study. It is conducted as a panel presentation followed by seminars led by each panelist. Students have the opportunity to interact with individuals who are prominent in their fields and hold diverse and sometimes conflicting perspectives on the issue at hand. Public Health Rounds topics have included global warming, payment for performance, influenza, workplace risks for health workers, emergency preparedness, health development programs, and the food industry and obesity.
A sixth required course is the Applied Learning Experience (ALE), an advanced-level public-health practicum that is usually taken in the fourth year. The ALE gives students the opportunity to integrate and apply their knowledge and skills to propose a solution to an actual public-health problem. An accompanying seminar provides faculty and peer support as students develop their projects. Students frequently base their ALE projects on research conducted between their second and third years of medical or veterinary medical school. All ALE projects are evaluated by a panel of faculty members in April of students’ fourth year of study. Successful projects require students to draw on all the core public-health disciplines and to apply these to public-health practice.
ALE projects conducted by veterinary medical students have included the following:
Special four-week blocks are reserved for elective courses in the spring of students’ third and fourth years of study. Students are required to fulfill 12 elective credit hours; most elective courses qualify for two credit hours, and students take up to six courses to satisfy this requirement. Individual courses are offered, at most, once every two years; six or seven electives are offered each spring, although course offerings in any given year may vary. Elective courses are offered on both medical-school and SVM campuses and are open to all CMPH students. Elective courses offered in recent years have included the following:
In the past three years veterinary students enrolled in the Combined MPH program have had the option to include Veterinary Public Health, a required course in the veterinary medical curriculum, among their elective courses. This two-credit course integrates broad topics in the American College of Veterinary Preventive Medicine–recommended curriculum with the Ten Essential Public Health Services, the national framework for describing public-health practice developed by the CDC's National Public Health Performance Standards Program. Veterinary medical students are encouraged to view veterinary public health not as a haphazard collection of disease topics but as the contributions of their unique knowledge and experience to a range of generic public-health services that includes surveillance, disease investigation, program and policy development and evaluation, community mobilization, and research. Examples relevant to the veterinary medical curriculum are provided for each public health service. This approach to veterinary public health expands the appreciation of all veterinary medical students, including those enrolled in the CMPH program, for the diverse roles that veterinarians play in the public-health arena and for the range of topics that they address in addition to zoonoses. For veterinary medical students enrolled in the CMPH program, the framework of the Essential Public Health Services is further reinforced in courses taken in fulfillment of requirements for the MPH degree and offered by the medical school's Department of Public Health and Family Medicine.
The Tufts CMPH program prepares generalists with a sound foundation in public-health disciplines and a population perspective that complements their clinical studies.
The program is characterized by three themes. Foremost among these is its dedication to interdisciplinary education. Located within the School of Medicine, the program draws its faculty from the wider Tufts community, including the Schools of Medicine, Veterinary Medicine, Engineering, Nutrition and Public Policy, and Law and Diplomacy. It also draws faculty members from the broad academic environment in the Boston area, including individuals with expertise in law and business, and from local and state public-health practice.
The program's second theme is global health. The university's Global Health Initiative promotes interdisciplinary education and research at Tufts, inaugurated a concentration in global health in the Tufts MPH program, and integrates Tufts courses with those of colleagues in Africa and Asia. The SVM's International Program offers a rigorous certificate in International Veterinary Medicine and has placed many DVM/MPH students in internships and externships in countries throughout the world.
A third program theme is active citizenship. Tufts Tisch College of Citizenship and Public Service supports a number of CMPH faculty and students as active citizens of a global community. The SVM has reinvigorated Dr. Albert Schweitzer's concept of "reverence for Life" to include non-human animals, as Schweitzer himself intended.7 Several DVM/MPH students have received the Schweitzer Fellowship for their community-based efforts to improve human and animal health.
Through these and other initiatives, the Tufts CMPH program increasingly incorporates a more current and timely One Medicine approach than was championed by Dr. Mayer almost 30 years ago. Nevertheless, numerous challenges remain for the education and training of veterinary medical students in public health. These challenges are not confined to Tufts University; they are challenges faced by the public-health profession, and will be addressed as such.
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CHALLENGES |
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TOPABSTRACTINTRODUCTIONHISTORICAL CONTEXTTHE COMBINED MASTER OF...CHALLENGESREVISITING THE IDEA OF...REFERENCES |
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How might the One Medicine/One Health approach be translated to the education and training of medical and veterinary medical students in public health, at Tufts and elsewhere? How might the perspectives of physicians, public-health professionals, and veterinarians be integrated more fully into the teaching of population health?
First, public-health courses can do a better job of integrating human and animal population health content. A required MPH course such as Environmental Health lends itself readily to this task. However, even required core MPH courses, such as Health Services, might well incorporate content that addresses delivery of and payment for services in veterinary public health, such as vaccination programs for rabies in companion animals or brucellosis in food animals. Courses in biostatistics and epidemiology teach universal principles and skills that may vary in their application, and, for this reason, such courses should incorporate examples from both human and animal population health. Elective courses should be of sufficient breadth to interest both types of students. This would represent an important step toward erasing the idea that human health and animal health, or public health and population health, are separate and unrelated to each other.
More veterinarians should serve as course directors for courses in public health or as guest lecturers in courses directed by other health professionals. This would help to ensure that the content of courses includes information relevant to the health of animal populations. Furthermore, increasing the representation of veterinarians on public-health faculties would foster a better understanding of the many ways in which human health and animal health are related. In order to achieve this goal, the veterinary profession, which largely turns out clinical practitioners, must be encouraged and supported to view its members as public-health practitioners in their communities and as integral members of the public-health system.
Veterinary medical faculty members should develop and offer more elective MPH courses that would interest a combined audience of veterinary and human medical students. Such courses might examine antibiotic resistance, nutrition policy in the United States and elsewhere around the world, food security, addressing the needs of animal populations in natural and man-made disasters, the role of animals in the development and maintenance of human resilience, and the financing and delivery of veterinary public health services, among other topics.
Second, the scope of the intersection of veterinary medicine and public health must be expanded beyond the obvious—the prevention and control of zoonotic diseases—to incorporate essential public-health services such as financing and delivery of veterinary preventive and public-health services, surveillance, epidemiologic investigation of disease occurrence, community mobilization, public-health policy and program development, program evaluation, assurance of high-quality veterinary public health services, and research. The mention of avian influenza may provide the "Eureka!" moment for people who do not regard veterinarians as public-health professionals, but veterinarians should not allow their broad role in public health to be defined by a few easily recognized topics such as avian influenza and rabies.
Third, all health professionals should promote and encourage a team approach to the education of public-health professionals. Many of mankind's most pressing global challenges—the development of antibiotic resistance, global warming and its effect on climate, food insecurity among millions of the world's people, and the emergence or re-emergence of infectious diseases, including zoonoses—will require creative solutions from teams of individuals with diverse knowledge and skills and the capacity to work together. This kind of thinking and its application are best developed when students are inculcated with it during their earliest training. Medical and veterinary students must also learn to work together in teams—for example, in study groups, during field experiences, and on research projects or the Applied Learning Experience of the Tufts CMPH program. Faculty who teach these students must also make a greater commitment to team teaching and to sponsoring a team approach in their research. The NIH Roadmap Initiative and its team approach to problem solving represent a model that should be adopted as a goal for other publicly and privately funded research.8
Fourth, educational programs in public health should foster entrepreneurship among veterinarians seeking positions in public health. The sad fact is that many veterinary graduates of public-health programs still have difficulty finding positions that are devoted wholly or in part to public health. Two decades ago this might have been entirely attributable to the lack of veterinarians trained in public health, but this is no longer the case. With 17 public-health degree programs now open to enrollment by veterinary students or graduate veterinarians, veterinarians with public-health degrees are being turned out faster than a public-health system with limited opportunities for veterinarians can absorb them. What this sector needs is to adopt the approach described by Gittleman:
The idea of "academic entrepreneurship" was a notion very few people in higher education had heard of. Businessmen might have understood the psyche of the visionary who is absolutely convinced that he cannot fail and who fearlessly takes risks in the face of dangers he dismisses. These high-stakes gamblers, when they encounter rules and obstructions, will ignore them, because their optimism and certainty have convinced them that the vision they see is the only goal.6
For Mayer, Tufts was the instrument given him to achieve his goals for higher education. For veterinary students, the public-health degree is the instrument they have earned to elevate their professional goals beyond clinical practice. In their education and training, they must be encouraged by public-health faculty to knock on doors that appear closed to them, whether by intent or by oversight, and they must be empowered to convince skeptical employers that, as public-health professionals, they are as skilled as their non-veterinarian counterparts. Veterinarians need not cede public health to others; they can make enormous contributions to public health through the application of their own unique knowledge and skills.
Fifth, all health professionals, including public-health professionals, should openly acknowledge the importance of studying and understanding the health of animal populations for their own sake. One recent example is the colony collapse in bees, which has already posed a serious threat to agri-business and may affect human population health directly, should pollination levels fall low enough to disrupt the food supply. Acknowledging the importance of non-human populations will also require acknowledging that public health has defined itself rather narrowly. Human activity is dramatically changing and threatening the ecology of the planet. The models and tools needed to understand these changes and to discover how to prevent or mitigate their impact have yet to be developed. Very little is understood about the health and disease of the non-human populations that share our environment, and we write them off as less important than human populations at our peril.
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REVISITING THE IDEA OF ONE MEDICINE/ONE HEALTH |
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TOPABSTRACTINTRODUCTIONHISTORICAL CONTEXTTHE COMBINED MASTER OF...CHALLENGESREVISITING THE IDEA OF...REFERENCES |
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Footnotes |
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Joann M. Lindenmayer, DVM, MPH, is Associate Professor in the Department of Environmental and Population Health and liaison to the Combined MPH Program, Cummings School of Veterinary Medicine, Tufts University, 200 Westboro Road, North Grafton, MA 01536 USA. E-mail: Joann.Lindenmayer{at}tufts.edu. Her research interests include veterinary public health systems development, surveillance, and investigation of diseases at the human–animal interface.
Anthony L. Schlaff, MD, MPH, is Associate Clinical Professor in the Department of Public Health and Family Medicine and Director of the MPH Program, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02110 USA. His research interests include community-oriented primary-care models and methods, community organizing and outreach for health promotion and disease prevention, and physician–community coalition building.
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