Educated public health professionals are essential for ensuring the public’s health and well-being. Fortunately, public health has been attracting more and more students who hope to devote their careers to addressing the wide range of health challenges we face in the 21st century. Between 2000 and 2010, enrollment in schools of public health increased by 57 percent. In parallel, tuition for public health training programs has continued to rise. Between 2002-03 and 2009-10, the cost for an in-state master’s degree at a school of public health rose by 72 percent.
Yet this influx of students and tuition dollars does not always directly support the salaries of the faculty who are responsible for teaching the next generation of public health leaders. How are schools of public health funded, and how can we ensure their continued health and vitality as the field continues to expand?
In the early 20th century, the first independent schools of public health were funded privately, mostly by the Rockefeller philanthropies. Yet by the 1950s and 1960s, as schools expanded and needed additional funds to cover costs, public health schools increasingly looked to the National Institutes of Health (NIH) and other federal agencies for funding. By 1961, 61 percent of schools’ total expenditures came from federal government sources.
The resulting competition for federal grant money influenced the way schools of public health structured themselves. As the enterprise of medical and public health research expanded, schools sought research funding to build robust faculties that could engage in both research and teaching. A 2003 National Academies Press report on public health education summarized the situation that emerged:
“If a particular department within a school was devoted mainly to teaching or to public health practice, the numbers of faculty stayed stable or gradually declined. If the department was devoted to research, and was reasonably successful at funding that research, the department grew, sometimes at an impressive rate.”
Historian Elizabeth Fee has sharply critiqued the effect this funding structure has had on public health education and advocacy. When faculty must devote their energy to raising the better part of their salaries, while also covering the resources that makes public health research possible—graduate research assistants, administrative assistants, students and equipment—other activities, such as teaching and public outreach, become difficult to sustain. Fee asserted that this system affects the quality of the scholarship and public engagement produced by public health schools: “It is only on rare occasion and more or less by accident that schools of public health harbor public intellectuals or effective public advocates for the public’s health.”
This seems unduly harsh and in conflict with ample evidence of extraordinary teachers, communicators, and advocates for the public’s health associated with schools of public health. Nonetheless, the current approach to financing these schools lacks structures to function as a kind of insurance policy that teaching and advocacy are as highly valued as research activities.
Faculty who work at grant-driven “soft money” institutions are paid primarily to conduct research. These sources of funding do not necessarily compensate faculty for the time they commit to the university community, including educating students and working on the committees that are critical to the health of institutions of higher learning. This set of circumstances is not unique to public health; recent debate has underscored the exigencies of rethinking this funding and promotion structure in academia more broadly.
Today, schools of public health remain heavily dependent on federal research funding at a time of deep budget cuts. Biologist Michael Eisen has written, “[W]e are in one of the worst periods of scientific funding I—and my more senior colleagues—can remember. People aren’t just worried about whether their next grant will get funded, they’re worried about whether a career in academic or public science is even viable.”
Sequestration and federal budget cuts mean that only about 15 percent of NIH grant applications are now being funded, the lowest rate in the history of the agency. In this climate, remaining heavily dependent on successful grant applications is an increasingly perilous strategy. In fact, Dr. Francis Collins, director of the NIH, warned against universities relying too much on NIH money, asserting that researchers were in danger of turning into “grant-writing machines.”
In this environment, public health research that focuses on the social determinants of health is especially vulnerable. When money is tight, researchers may compete for limited funds by aligning their work with current trends such as molecular analysis and personalized medicine, and strategic research priorities set forth by the individual institutes and centers comprising the NIH. It becomes particularly hard to fund scholarship that deviates from these prevailing trends, notably research focusing on social forces such as inequality, poverty, and racism, which affect disadvantaged populations and population health overall. Students, in turn, may be deprived of the opportunity to study the health of vulnerable populations and the social determinants of disease when the work of experts in these areas is not supported.
This situation foregrounds essential questions about the values and priorities of schools of public health. The education of students is one of the core missions of schools of public health; the challenge is to align institutional funding structures with this core mission.
If the priorities of institutions of higher education do not always perfectly align with the vagaries of federal grant funding, schools of public health must consider alternative funding approaches. Harvard’s School of Public Health, for instance, has launched a $450 million capital campaign to diversify its income and place itself on a more stable financial footing. One goal of the campaign is to endow more professorships, on the reasoning that this strategy “will enable more researchers to pursue their own intellectual avenues in a tight federal-funding environment.”
In seeking to support education and research that addresses the fundamental causes of disease, public health advocates should also seek to build partnerships with new allies and sectors. The authors of an analysis of the impact of New York City’s 1975 fiscal crisis on public health concluded that developing broad coalitions could help protect urgent public health work in the face of budgetary constraints. “Perhaps the principal lesson is that if the public health community is to advocate effectively against budget and policy decisions that damage health, it will need to identify constituencies that can bring new clout into the political arena.”
Financially supporting teaching, research, and advocacy that deviate from prevailing paradigms and confront systemic injustices is no small undertaking. Indeed, it is hard to imagine a greater task—or a more urgent one. We need to find a more sustainable funding model to support public health faculty and students who take on this challenge. As the Dean of the Columbia University Mailman School of Public Health, Dr. Linda Fried, and several colleagues recently observed, “We can either accommodate the status quo or confront political and economic power in the name of the public’s health.”
Edited by Dana March