AJPH PERSPECTIVES

The Public Health Practitioner of the Future

The requisite capacities and Paul Campbell Erwin, MD, DrPH, and Ross C. Brownson, PhD
capabilities of the public health
practitioner of the future are
being driven by multiple forces See also DeSalvo, p. 1205.
of change, including public

I
health agency accreditation, n the April 2016 issue of climate change, health in all administration, we believe that
climate change, health in all AJPH, DeSalvo et al. pro- policies, social media and the five capacities and capabilities
policies, social media and in- posed a “Public Health 3.0” informatics, demographic tran- we describe will remain relevant
formatics, demographic tran- upgrade to “boldly expand sitions, and globalized travel. We and critical for the public health
sitions, globalized travel, and the scope and reach of public also described possible approaches practitioner of the future.
the repercussions of the Af- health” as a means of addressing to measuring, tracking, and un-
fordable Care Act. social determinants of health, derstanding the effects of these
We describe five critical ca- the high cost of health in the forces of change on public health
pacities and capabilities that United States and the country’s practice, including the use of
REQUIRED CAPACITIES
public health practitioners can relatively low ranking in terms evidence-based public health,
of life expectancy, and persistent practice-based research, and pol-
AND CAPABILITIES
build on to successfully pre- Our five critical capacities
gaps in health status.1 The icy surveillance.
pare for and respond to these and capabilities are as follows:
necessary components of this Here we describe five critical
forces of change: systems systems thinking and systems
upgrade would include en- capacities and capabilities that
thinking and systems methods, methods, communication
hanced leadership (with local public health practitioners can
communication capacities, an capacities, an entrepreneurial
public health agency directors build upon to successfully pre-
entrepreneurial orientation, orientation, transformational
being the “lead health strate- pare for and respond to these
transformational ethics, and ethics, and policy analysis and
gists” in their communities); forces of change. After a brief
response.
policy analysis and response. new partners (elected leaders, description of these capacities and
Equipping the public health businesses, people from sub- capabilities, we provide addi-
practitioner with the requisite populations at the greatest risk tional commentary on what they Systems Thinking and
capabilities and capacities will for poor health); accredita- will mean for public health aca- Systems Methods
require new content and tion (of governmental health demia, taking into consideration Three decades before Peter
methods for those in public agencies); technology, tools, the Framing the Future initiatives Senge popularized “systems
health academia, as well as and data; new metrics of success; of the Association of Schools and thinking” in The Fifth Discipline,
and an adequate and reliable Programs of Public Health5 and René Dubos described systems
a recommitment to lifelong
funding stream. In his Shattuck the revised accreditation criteria thinking, without naming it, in
learning on the part of the
Lecture in 2015, Frieden de- of the Council on Education his discussion of the internal and
practitioner, within an in-
scribed a future of public health for Public Health (CEPH).6 The external environments related to
creasingly uncertain and po-
that involved closer working earlier-cited articles on forces of human diseases: “Any event in
larized political environment. relationships with clinical change were written and ac- the outer world which impinges
(Am J Public Health. 2017;107: medicine, particularly regarding cepted for publication prior on an individual modifies,
1227–1232. doi:10.2105/AJPH. the prevention, control, and to the 2016 US presidential however indirectly and slightly,
2017.303823) treatment of infectious and election; however, although the balance between his various
chronic diseases.2 the forces of change are them- organs and functions”7(p122);
In a recent editorial3 and selves evolving under the new moreover,
review4 on macro trends af-
fecting public health practice, ABOUT THE AUTHORS
we identified several “forces of Paul Campbell Erwin is with the Department of Public Health, University of Tennessee,
change” that are exerting an Knoxville. Ross C. Brownson is with the Prevention Research Center in St. Louis and the
Washington University School of Medicine, Washington University in St. Louis, St. Louis,
impact on current governmental MO.
public health practice: the 2010 Correspondence should be sent to Paul Campbell Erwin, MD, DrPH, Department of Public
Patient Protection and Afford- Health, University of Tennessee, 1914 Andy Holt Ave, Knoxville, TN 37996 (e-mail: perwin@
utk.edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.
able Care Act (ACA), public This article was accepted March 29, 2017.
health agency accreditation, doi: 10.2105/AJPH.2017.303823

August 2017, Vol 107, No. 8 AJPH Erwin and Brownson Peer Reviewed Commentary 1227
AJPH PERSPECTIVES

any factor that upsets the are used to vary the properties of (i.e., newspapers, television, and management business philoso-
equilibrium of [the] internal and a system as a means of estimat- radio) will further challenge phy, can be characterized as
external environments can
ing the effects of proposed in- the public health practitioner’s a multidimensional construct of
become a determinant of diseases.
As all components of both systems terventions or policies. choice of communication organizational behavior, with
are interrelated, any disturbance In agent-based modeling, platforms. measures of proactiveness, in-
in either of them—even though computer simulation is used to Public health, Teutsch and novativeness, and risk taking.15 In
minor and not damaging in itself— study complex systems from the Fielding surmised, is ultimately the health arena, this three-factor
can set in motion secondary effects
“bottom up” by examining how a “knowledge organization,” entrepreneurial orientation scale
which become destructive to the
organism.7(pp110–111) the individual or organizational and the information it seeks to has been used in studies involving
elements of a system (agents) communicate must be able to rise not-for-profit hospitals, health
In the past two decades we function as a result of their above “the cacophony of voices” care executives, health care staff,
have seen other descriptors or properties, environment, and in ways that are effective and nursing home management, and,
aspects of systems thinking, for interactions. In public health, credible.13(pp295–296) This will most recently, the use of elec-
example as it applies to the in- agent-based modeling has been necessitate identifying new edu- tronic health records to improve
teraction of multiple diseases used most frequently to study cational competencies, as “the treatment of substance use dis-
within a population (syndemics)8,9 infectious disease epidemics older models of health education orders.16,17 In many ways, en-
or to research frameworks that and the dynamics of disease are inadequate.”13(p296) In the trepreneurial orientation relates
offer a “novel solutions-oriented transmission, and its integration context of translating research to concepts that should be fa-
approach to complex problems” of geographical information into practice and policy, Woolf miliar to the public health
(the intervention-level frame- systems and social network et al.14 labeled new educational practitioner.
work).10(p1270) information has allowed great- competencies “strategic com- Proactiveness is an important
Bringing systems thinking er visualization of systems munications” and emphasized element of strategic thinking.
further into the current and fu- modeling. the critical importance of defining The concept of innovativeness in
ture work of the public health the target audience, developing entrepreneurial orientation relates
practitioner requires an un- the correct message, and using this to similar constructs in imple-
derstanding of how systems Communication process as the basis for selecting the mentation science, particularly
thinking is being supported by Capabilities appropriate medium to use: harkening to Everett Rogers’
Every generation seems to lay seminal work in Diffusion of
a variety of systems methods.
claim to the “information gen- The most effective Innovations.18 Risk taking, partic-
Common among these methods communication efforts are not
eration” moniker. For the public ularly in often risk-averse govern-
are social network analysis, sys- a distraction from, but instead are
health practitioner of the future, seamlessly integrated into, the mental agencies, is perhaps the most
tem dynamics modeling, and
it is less about the nuts and bolts lives of their target audiences, unfamiliar of the three entrepre-
agent-based modeling.11 Social
of communication platforms reaching them where they are, neurial orientation dimensions
network analysis, probably the considering the people, places,
themselves (Twitter feeds, Face- vis-à-vis public health practice.
most commonly applied method and media they interact with
book walls, blog posts)—the Achieving an entrepreneurial
among the three, focuses on the daily, and understanding the
“how” of communications—and information sources and formats orientation will push the educa-
relationships among sets of actors more about the “why.” That tion and training of the future
they trust.14(p472)
that may include individuals or being said, although 91% of local public health practitioner outside
agencies. Network analysis al- health departments have access to Teaching these new methods the usual domain; entrepreneurial
lows users to visualize a network smartphones and at least basic of communication, especially orientation is much more likely to
and employ statistical tools to Internet services are almost uni- sifting “noise” from “substance,” be a focus of business courses.
model relationships (e.g., do versally available, the “what” of will require new approaches to Currently, however, there are
certain network characteristics communications remains a chal- curriculum design for those in 27 accredited schools or programs
predict strong collaboration?). lenge for many; for example, academics (e.g., partnering with of public health that provide a dual
Arising from management access to research libraries or academic programs in commu- or joint MPH/MBA,19 and they
science, system dynamics mod- online full-length journal articles nication and information). It will may be incubators of innovations
eling is based on the notion that continues to be limited.12 Pur- also require new training mo- in the application of entrepre-
complex system behaviors (e.g., poseful communications must be dalities for the current public neurial orientation concepts in
prevalence of an infectious paramount, because otherwise it health workforce. public health practice. This is not
disease) result from the in- will simply not be possible to to advance the notion that public
terrelationships of feedback manage, digest, or make use of health simply needs to be run like
loops, stocks (e.g., people, disease the enormous amount of in- Entrepreneurial a business to be successful; rather,
counts), and flows (e.g., in- formation available. The current Orientation it is a push to use certain skills,
cidence rate) within a bounded climate of distrusting and even Entrepreneurial orienta- techniques, and approaches that
system. Computer simulations vilifying traditional media tion, which has its roots in have been successful in other

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 AJPH PERSPECTIVES

TABLE 1—Requisite Capacities and Capabilities of the Public Health Practitioner of the Future

Cross-Cutting Areas and Relevant Examples of Opportunities for

Public Health Domains for Public Critical Core Content for a 21st- Critical Core Content for a 21st- Achieving Foundational
Capacity or Capability Health Undergraduate Education Century MPH Degree Century DrPH Degree Competenciesa
Systems thinking and Systems thinking: students should Systems thinking regarding the Effects of local, state, tribal, Integrating systems thinking with
systems methods have an introduction to the factors, dynamic interactions among actors, regional, national, and global systems methods (e.g., agent-based
including socioeconomic, sectors, and organizations with trends, complexities, and modeling) across the core public
behavioral, biological, and which public health professionals interdependencies on health health curriculum and partnering
environmental factors, that affect interact to achieve health systems and the various factors that with practitioners to make this
human health and contribute to improvements influence dynamic health situations integration applicable in real-world
health disparities; they should also and future population health settings
have an introduction to the outcomes; characteristics of
fundamental characteristics and complex systems, the role and
organizational structures of the power of system stakeholders,
US health system and differences system-level interventions, and
between that system and those in systems thinking tools
other countries
Communication Networking: students should have an Public health–specific Communication strategies for Designing, implementing, and
capacities and introduction to the basic communication and social disseminating both evidence-based evaluating a population-based
capabilities concepts of public health–specific marketing, including technical and practices and practice-based project, program, or intervention
communication, including technical professional writing and the use evidence on health policies and that makes use of social media as
and professional writing and the of mass media and electronic practices to diverse audiences to both a platform for communication
use of mass media and electronic technology inform and influence individual and a tool for public health
technology and community behavior and education and promotion
organizational and community
policies; communication with
people and communities across the
entire range of academic and
health literacy levels
Entrepreneurial Critical thinking and creativity: Concepts of project implementation Foundations of organizational Establishing interprofessional
orientation students should have an and management, including behavior, dynamics, design, and educational teams with academic
introduction to the concepts of planning, budgeting, human theories to develop effective programs in business, economics,
population health and the basic resources, assessment, and organizations and methods and management science to
processes, approaches, and evaluation to diagnose and evaluate enhance core public health
interventions that identify and organizational problems and curricula
address the major health-related strengths; research drawn from
needs and concerns of populations multiple sources for the design of
innovative approaches to creating
or enhancing programs, policies,
and systems that improve
population health and create the
evidence base for practice

Continued

settings to advance the practice of partners to address health attention has been focused on the base for public health; every action
public health. How can the public inequities? ethics of public health practice must be amplified, ameliorated,
health practitioner be proactive (e.g., through attention to health and contextualized through trans-
in addressing newly emerging equity); we bring these concepts formational ethics, or every positive
communicable diseases, be in- Transformational Ethics together in describing trans- step in population health will be
novative in designing campaigns Public health practitioners have formational ethics. It will not be met with negative repercussions for
to improve influenza vaccination, been inculcated with concepts of enough for the public health subpopulations (i.e., what will
or better understand risk taking transformational leadership during leader to understand, facilitate, benefit the most may hurt those
when aligning with community the past two decades, and greater translate, and create the evidence already most in need).

August 2017, Vol 107, No. 8 AJPH Erwin and Brownson Peer Reviewed Commentary 1229
AJPH PERSPECTIVES

TABLE 1—Continued

Cross-Cutting Areas and Relevant Examples of Opportunities for

Public Health Domains for Public Critical Core Content for a 21st- Critical Core Content for a 21st- Achieving Foundational
Capacity or Capability Health Undergraduate Education Century MPH Degree Century DrPH Degree Competenciesa
Transformational ethics Ethical decision making as related to Biological, environmental, Human rights frameworks and Assessing the effects of structural
oneself and society: students socioeconomic, behavioral, principles as a foundation for bias at the organizational,
should have an introduction to cultural, and other factors that ethical practices and decision community, and societal levels that
basic concepts of legal, ethical, affect human health, influence the making; ethical concepts and gives rise to health inequities and
economic, and regulatory global and societal burden of principles related to public health applying the Public Health Code of
dimensions of health care and disease, and contribute to health and the strategies for identification Ethics24 in formulating ethics-based
public health policy and the roles, disparities; legal, ethical, economic, and analysis of ethical issues approaches to achieving health
influences, and responsibilities of and regulatory dimensions of equity
the different agencies and branches health care and public health
of government policy; the roles, influences, and
responsibilities of the different
agencies and branches of
government; approaches to
developing, evaluating, and
advocating for public health
policies
Policy analysis and Health policy, law, ethics, and Legal, ethical, economic, and Evidence-based policy development, Assessing multiple dimensions of the
response economics: students should have an regulatory dimensions of health analysis, and translation processes, policy-making process, including
introduction to basic concepts of care and public health policy; including the role and impact of the roles of ethics and evidence;
legal, ethical, economic, and the roles, influences, and scientific information, legal advocating for political, social, or
regulatory dimensions of health responsibilities of the different and regulatory approaches and economic policies and programs
care and public health policy and agencies and branches of constraints, ethical issues, and that will improve health in diverse
the roles, influences, and government; approaches to varied stakeholder interests populations; evaluating policies
responsibilities of the different developing, evaluating, and with respect to their impact on
agencies and branches of advocating for public health public health and health equity;
government policies identifying new ways of
communicating about policy that
are better tailored to political
ideology
a
Revised accreditation criteria of the Council on Education for Public Health.

Another way of framing this distribution are permissible only inequities are lessened. Had the the ability to identify and ana-
is simply that population health if those worst off are made necessary investments been lyze policy changes and their
improvements may be accom- better off.”20(p709) made in drinking water in- impact in the context of un-
panied by worsening health in- Although Bryant’s conceptu- frastructure in Flint City, certainty. Consider the shifts
equities unless the public health alization of health as social justice Michigan, 20 years ago—which, that are occurring vis-à-vis the
practitioner of the future con- was applied in the framework no doubt, would have re- earlier-described forces of
ceptualizes public health (writ of international health service quired a greater investment in change as this commentary is
large) as social justice. More than development (particularly in the communities in greatest being written:
40 years ago, John Bryant low-income/low-resource need—would the city be expe-
merged the Rawlsian concept of countries), it can serve as a model riencing the even more costly d The Affordable Care Act: the
justice with Nicholas Rescher’s for transformational ethics in impact of lead intoxication now? ACA is on the precipice of
formulations on distributive public health practice: whatever being repealed and replaced.
justice to propose a principle improvements can be made in d Public health agency accredita-
of health care system develop- the health of the public should Policy Analysis and tion: with the largest proportion
ment: “Whatever health ser- be made equally for all; de- Response of local health departments
vices are available should be partures from equality of op- Among the most important serving rural populations that
equally available to all. De- portunity, access, and outcomes skills of the public health are predominantly White
partures from equality of are permissible only if health practitioner of the future will be and represent a significant

1230 Commentary Peer Reviewed Erwin and Brownson AJPH August 2017, Vol 107, No. 8
 AJPH PERSPECTIVES

segment of the disaffected, physical education,21 and most We believe that the critical lifelong learning on the part of
antigovernment electorate, recently a sentinel surveillance content areas from Framing the the practitioner.
will there be sufficient drive system has been established to Future and the revised CEPH
CONTRIBUTORS
to elevate the governmental detect the effects of policy competencies match up well with The authors contributed equally to the
presence in health? changes on public health prac- what we have described as the conceptualization and analysis of ideas
d Health in all policies: market tice.22 Identifying policy necessary capacities and capabil- presented in this article, and both con-
tributed substantially to drafting, editing,
forces, with deregulation changes through these surveil- ities of the public health practi- and revising the article.
and governmental restraint, lance systems, and responding tioner of the future (examples are
are already overriding con- effectively and appropriately provided in Table 1).24 ACKNOWLEDGMENTS
siderations about health despite an uncertain environ- New professional develop- This article is adapted with permission
from Erwin PC, Brownson RC. The
(e.g., the Keystone Pipeline). ment, will require the public ment and training approaches future of public health practice. In: Erwin
d Climate change: those in health practitioner to meld all of are also needed for practitioners PC, Brownson RC, eds. Scutchfield and
several executive cabinet po- the skills described here: systems already in the workforce. Only Keck’s Principles of Public Health Practice. 4th
ed. Boston, MA: Cengage Learning; 2016.
sitions (secretaries and other thinking and analysis, commu- between one fifth and one third
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