Thread by @sdbaral

Public Health Practice Gems

#COVID19 has increased the general interest in public health.

So I thought it worthwhile to provide some framing for folks new to this field.

The goal is to provide an overview of public health:
1) Principles
2) Intervention Strategies
3) Actors

Public health practice is a service industry.

Similar to other service industries, the customer is always right.

If we don't understand our customer and empathetically address needs, people vote with their feet.

ie, PHP is Public Health Practitioner, not Public Health Police

Public Health Principles

Equity -- Given inequities across society, public health should aim to do more for those who need more

Social Justice -- Achieve balance between intervention burden and benefit

Participation -- public to be engaged in decisions that will affect them

Characteristics of ideal intervention strategies include being:
1) Evidence-based
2) Human-rights affirming
3) Efficient
4) Effective
5) Acceptable
6) Affordable
7) Practical
8) Accessible
9) Empathetic
10) Contextually Appropriate

The precautionary principle is commonly used in public health when we do not understand potential harms.

However, the precautionary principle should balance both potential benefits and harms of a particular decision.

Assessing the potential benefits in isolation is suboptimal.

Intervention strategies in public health are broad ranging from interventions focused at individual, network-level, structural, or policy levels including strategies based in:

Economics
Environmental Controls
Engineering
Education
Empowerment
Last consideration is Enforcement

Actors:
There are a lot of actors in public health but will write more tomorrow if there is any interest.

Competencies for Public Health Practice

Before I introduce actors in public health, I will introduce PH competencies which are a combination of skill, ability, and experience.

Broadly, there is generally a trade off between breadth and depth in training for these competencies.

Training for Public Health Practice

1) Most people entering PH practice have Master's level training and Doctoral level training not needed for public health practice
2) Competencies conserved irrespective of working at level of municipal, regional, national, or "global health"

Clinicians in Public Health

I will focus on MDs as I know them best, but many amazing RN and DVM in PH like @dtdangerfield and @pssinatl and will let them share.

Clinical training is focused on the management of individual patients with PH representing a lower priority for most

MDs can be thought of like pilots and the public health system like airspace management with many planes, many different types of planes, different companies, jurisdictions, etc.

All fails without pilots which highlights the necessity of their skills, but they are not sufficient

Public Health is its own specialty training for MDs (disclosure, that's me).

There are specialties that integrate PH training including Infectious Diseases, Medical Microbiology which are branches of internal medicine. Occupational health may branch off internal medicine or PH.

Clinicians may seek to gain competencies in PH through additional training including a Master's degree or another doctorate--will cover PH academic training next.

Finally, clinicians may also learn PHP through work opportunities in public health departments or programs.

Public Health Practice Training

The most common degrees focusing on PH practice at the Master's level is the Master of Public Health (MPH) and the Doctorate of Public Health (DrPH).

Can review specific criteria for both degrees on @CEPHtweets website:
media.ceph.org/documents/2016…

Master's Level Training

At accredited schools, MPH training includes training across a range of aforementioned PH competencies through classes, thesis, and experiential learning.

Clinicians, lawyers, industry, etc may do MPH to apply PH principles to their work or pivot careers

Doctoral Level Training

The DrPH is the "ultimate" training in public health practice. These are folks that are training to be leaders including training across a broader range of PH competencies.

Normally done part time by working people with significant baseline experience.

Research Oriented Public Health Training

At Master's level, these degrees have many names but normally have the word "Science" in them--Master of Science, etc.

At doctoral level, the most common degree is the Doctorate of Philosophy (PhD) but also Doctorate of Science (ScD).

Doctorate of Philosophy (PhD)

This is a research oriented degree generally offered at the departmental level with the focus of the research varying from epidemiology to immunology.

Even within epidemiology, there are many tracks and training normally organized accordingly.

PhD in Epidemiology

At @JohnsHopkinsEPI we have eight tracks of epidemiology that can be viewed here: jhsph.edu/departments/ep…

The training is normally quite specific with either the focus being on content areas such as Infectious Diseases or Cancer or on epidemiologic methods

Practice in PhD

There is recognition that many PhDs in Epidemiology go on to non-research public health roles, but generally limited integration of PH practice training during PhD.

However, interest growing in translational or consequential epidemiology. academic.oup.com/aje/article-ab…

What are strategies to judge the experience of the many messengers during #COVID19

Competencies are gained and not intuitive. Ie, sure the Neo of public health exists, but is not the norm. Can check what experience or training specifically in PH practice the messengers have.

Can check out pubmed.ncbi.nlm.nih.gov and type in name. Most names are unique enough that you will figure it our or can search by institution, etc.

Publications aren't everything, but they are the currency of academia. Even a few related articles before #COVID19 is helpful.

Since many may publish non-peer reviewed articles, Google Scholar is useful (scholar.google.com). Scientists argue a lot about productivity indices (h-index, i10-index, etc), but I wouldn't worry about it.

Just any related pieces before #COVID19 would be great--a low bar.

When reviewing papers, authorship order could also be helpful.

The authors near the beginning and end likely played more of a role. If someone only has middle author papers, it can be instructive.

Not always the case, but how it's supposed to work: icmje.org/recommendation…

Financial Conflicts

I have found the number of financial conflicts during #COVID19 to be dizzying.

We have rules around money from pharmaceutical companies, but less so for other financial conflicts.

If someone has a real or perceived conflict, ideally they should declare.