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Commonwealth:  A Journal of Political Science       Volume 14, Number 1      December 2008 
Special Policy Issue on Public Health             2008 PPSA/LORL, PA House of Reps.  ISSN 0890-2410 

 

 

 
Credentialing of the Public Health Work Force 

 
 

Bernard D. Goldstein, University of Pittsburgh 
 
 

Abstract 

Pennsylvania ranks last nationally among all states in the size of its 
public health workforce per capita.  More than a doubling of the current 
workforce would be needed for Pennsylvania to achieve even the 
national average.  For the foreseeable future Pennsylvania will depend 
even more heavily than other states on having a highly skilled public 
health workforce to overcome our shortages in numbers.  In this paper, I 
will discuss the efforts to at long last develop a core credential for the 
public health workforce and the potential impact this will have on 
ensuring a highly competent public health work force capable of 
responding to the public health challenges facing our state and our 
nation. I will also consider the relationship between public health and 
medicine including comparing the approaches toward credentialing.     

Public health is virtually the only professional field without a 
credential. After many years of committees, task forces, and a 
recommendation from the Surgeon General, the National Board of Public 
Health Examiners (NBPHE) was incorporated in December 2005.  Its 
volunteer board has seats allocated to a broad range of participating 
public health organizations. The first credentialing examination in 
August 2008, will test for knowledge of core and cross-cutting 
educational competencies that are relevant to the practice of public 
health. The driving forces leading to credentialing in public health 
include: 1) heightened recognition of the importance of the public health 
work force; 2) an increase in both the absolute number and percent of 
public health graduates who have no other credential; 3) increase in the 
availability of public health graduate education throughout the country; 
4) societal demand for credentialing and for professional accountability; 
and 5) improved delineation of the core and cross-cutting educational 
competencies underlying public health practice. 

 



138 CREDENTIALING OF THE PUBLIC HEALTH WORK FORCE 
 
 

 

Introduction 

Examination of the potential effectiveness of public policy requires 
consideration of the workforce that designs and carries out that policy. A 
notable aspect of the public health workforce that distinguishes it from 
virtually all other health or other professional fields is its lack of a formal 
credential in the general field of public health. I briefly describe the 
history and rationale for the new and long-awaited development of a 
national public health credential, as well as its potential impact on 
Pennsylvania.   

The first core credentialing examination in the field of public health 
is being offered in August 2008, by the National Board of Public Health 
Examiners (NBPHE). Successful examinees among the close to 900 
registrants for this new credential will receive the Certificate in Public 
Health (CPH), attesting to their competency in the core disciplines in 
public health (Gebbie et al. 2007; Goldstein 2008; National Board of 
Public Health Examiners 2008). Of the applicants, 6% are from 
Pennsylvania – only New York and California have a larger contingent 
among the examinees. Among the examinees, the largest employer group 
is government public health agencies.  

The new core public health credential has developed after literally 
decades of discussion and debate. Following a call by the U.S. Surgeon 
General in the late 1980s, both the American Public Health Association 
(APHA) and the Association of Schools of Public Health (ASPH) 
developed working groups to explore credentialing (Akhter 2001; 
Sommer 2000; Association of Schools of Public Health 2000). Similarly, 
the U.S. Centers for Disease Control identified credentialing as among 
the pathways to strengthen the public health workforce (Governmental 
Public Health Implementation Team 2004). A key figure throughout the 
more recent discussions has been Dr. Charles Mahan. Dr. Mahan, the 
original President of NBPHE, has a broad background as former 
Commissioner of Health of the State of Florida; former President of the 
American State and Territorial Health Officials (ASTHO); and former 
Dean of the University of South Florida School of Public Health (Mahan 
and Malecki 2004; Gebbie et al. 2007). His ability to bridge the gap 
between academia and public health practice has been crucial in moving 
the NBPHE forward, particularly as there has been tension between the 
public health practice and academic communities. 



Bernard D. Goldstein        139 
 

 

 

Public Health is not unusual in having tensions between practitioners 
and educators. The perception that academics are primarily interested in 
furthering research rather than responding to practical problems in the 
field extends to every academic program leading to practice (see, for 
example, a recent article in Solicitor’s Journal about the need for law 
school to be relevant to legal practice: Roberts 2008). A 1988 Institute of 
Medicine report on “The Future of Public Health” specifically enjoined 
schools of public health to be more responsive to the needs of public 
health practitioners (Institute of Medicine 1988). The result has been 
reluctance among the public health practitioner organizations to allow 
academia to take the lead in the credentialing of public health practice. 
This tension was resolved with the decision to move forward in 
developing a credential reflecting competency in the core and cross-
cutting disciplines that are the basis for the practice of public health, but 
not in the practice competencies themselves. The five key public health 
academic and practice organizations all participate in the NBPHE, 
including nomination of board members. These are: the American Public 
Health Association (APHA); the Association of Prevention Teaching and 
Research (APTR); the Association of Schools of Public Health (ASPH); 
the Association of State and Territorial Health Officials (ASTHO); and 
the National Association of County and City Health Officials 
(NACCHO). Eight additional board members have been selected by the 
NBPHE to ensure diversity of representation, including other major 
public health organizations. Seven of the current 20 members are now or 
recently have been members of state or local government public health 
departments, including six who have headed such departments. The two 
board members from Pennsylvania are Dr. Walter Tsou, former Health 
Commissioner of Philadelphia and former President of the American 
Public Health Association, and myself. The first NBPHE meeting was 
held in December 2005. The National Board of Medical Examiners 
(NBME), based in Philadelphia, is assisting in preparation of the 
examination. The goal of the NBPHE is:  

To ensure that students and graduates from schools and 
programs of public health accredited by the Council on Education for 
Public Health (CEPH) have mastered the knowledge and skills 
relevant to contemporary public health practice (National Board of 
Public Health Examiners 2008). 



140 CREDENTIALING OF THE PUBLIC HEALTH WORK FORCE 
 
 

 

The sole focus of the NBPHE is on the core and cross-cutting 
educational competencies central to public health. The historic 
compromise that resulted in the NBPHE means that for at least the near 
future it will remain narrowly focused.  

An exceptionally important impact of the NBPHE will be the 
enhancement of continuing education (CE) in public health spurred by 
the examination and by recertification (Allegrante 2001). We anticipate 
that recertification will occur every ten years through both continuing 
education and re-examination. Among the CE efforts related to the 
examination is a study guide prepared by the ASPH (Association of 
Schools of Public Health 2008). Other organizations involved with the 
NBPHE, as well as HRSA-sponsored Public Health Training Centers, are 
also planning programs to help study for the examination. 

An important challenge faced by the NBPHE in accomplishing its 
goals is the issue of credentialing the current federal, state, and local 
health agency work force, many of whom are not eligible for the CPH by 
virtue of their not having received a graduate degree from a CEPH-
accredited school or program. Almost all of these individuals have a 
bachelor’s degree and have learned on the job. With the current broad 
availability of graduate education in public health, there seems to be no 
rationale that advanced public health education should not be a goal of 
anyone committed to a career in this complex and demanding field.  
Some state and local public health department employees are specialists, 
sometimes with their own graduate degree, e.g., an expert on informatics 
or a hydrogeologist. Such expertise is highly valuable and should be 
rewarded – but such specialists should not expect to be advanced to 
management positions without a broader grounding in public health 
achievable through graduate education to the master’s level.    

 

The Role of Workforce Credentialing In the Health Professions 

Health specialties, including public health, have at least some aspects 
of a guild – there is a body of specialized knowledge which must be 
mastered to function effectively. However, as with other modern 
professions such as law and engineering, entrance into health guilds is no 
longer through an apprentice system in which the first criterion is family 
kinship. Instead, entrance occurs through the progressive demonstration 
of mastery of core elements of the profession. This mastery is 



Bernard D. Goldstein        141 
 

 

 

demonstrated not only by graduation from an educational institution 
accredited to provide the core elements, but also by passing an 
examination testing mastery of the core elements. On-the-job education 
continues after credentialing in virtually all fields and is an important 
part of the professional development of the practitioner – there are few of 
us who would preferentially want our medical, dental, or legal case 
handled by someone who has just been licensed to practice medicine or 
dentistry, or has just passed the bar examination.   

The rapid pace of developments in virtually all modern professional 
disciplines has usually led to the requirement for re-credentialing based 
upon demonstration of continued mastery of core elements and the 
integration of newer information and competencies. My board 
certification in internal medicine (1969) and hematology (1971), both 
based upon required training in accredited programs and upon the 
passage of examinations, were received at times when no recertification 
was contemplated. Since 1990, new recipients of either of these 
credentials must be recertified every ten years. I am more recently 
credentialed (1979) by the American Board of Toxicology which now 
requires recertification every five years – a process which helps me keep 
current with the field and comfortable in my credential. 

Certain subspecialties related to public health do have credentialing 
examinations. Among these are health educators, environmental 
sanitarians, and industrial hygienists. For each of these specialties there 
are educational tracks that proceed through schools of public health. But 
alternative educational pathways are possible to achieve candidacy. One 
example is the Certified Health Education Specialist (CHES) which is 
administered by the National Commission for Health Education 
Certification, Inc, headquartered in Allentown, Pennsylvania. The 
NCHEC granted its first credential for certified health education 
specialist (CHES) in 1989. As of 2005, there were more than 12,000 
CHES holders nationwide (Airhihenbuwa et al. 2005). Of note has been 
the gradual transition from a highly controversial activity within the 
health education profession, to the current situation in which the majority 
of advertisements for health education jobs state that CHES is preferred 
or required. The NCHEC statement of the benefits of certification applies 
very well to the NBPHE (see Table 1, page 142).     

 



142 CREDENTIALING OF THE PUBLIC HEALTH WORK FORCE 
 
 

 

Table 1:  Benefits of Certification 

 
(adapted from: National Commission for Health Education Certification, 2002) 

 
Voluntary professional certification programs establish a national 
standard. They differ from state and local certifications and registries 
in that the requirements do not vary from one locale to another. 
National certification benefits practitioners and the public in that it: 

     Establishes a national standard  

     Attests to the individual's knowledge and skills  

     Assists employers in identifying qualified applicants  

     Provides a sense of pride and accomplishment  

     Promotes continued professional development  

     Enhances the ability of the profession to accomplish its 
public mission 

 

Receiving a credential has also been a pathway to achieving greater 
rewards for job performance. For example, the relatively new national 
teacher’s credential is now recognized by all states. Many states and 
school districts provide additional benefits to teachers holding this 
credential, including higher salaries and an enhanced ability to move to a 
new school district without losing seniority (All Star Directories 2002). 
Governmental agencies are also far more likely to provide support for 
continuing education or travel to a national meeting for those employees 
who are keeping up a job-related credential.   

 

Why Now? 

An obvious question is, after all of these years of discussion, why is 
it now time to develop a core public health credential? I suggest there are 
at least five reasons: 

 

 



Bernard D. Goldstein        143 
 

 

 

1)  Change in the Educational Background of Public Health 
Graduates 

The background of those receiving public health degrees has 
changed dramatically. At one time, schools of public health restricted 
admission to those who already had an advanced degree in medicine or 
another health field. This was liberalized over time to a matriculation 
requirement that specified either an advanced health degree or a 
minimum number of years in practice. Currently, any such requirements 
have virtually disappeared. While no national statistics have been kept, 
there can be no question that the overwhelming majority of those 
completing graduate education in accredited schools and programs of 
public health now have no other certifiable credential beyond that of 
their MPH degree. For example, only 20% of the University of 
Pittsburgh Graduate School of Public Health’s most recent matriculates 
had another degree, while in 1992 it was 50%. 

These graduates are younger and presumably will have more time in 
their careers than those who entered after first receiving a medical or 
other health degree. Until now, they have been virtually alone among the 
graduates of academic health programs in not having a credential 
attesting to their mastery of the core competencies relevant to the 
practice of their health discipline.   

2)  Increase in the Opportunity to Obtain Graduate Education in 
Public Health 

The increase in number of accredited schools and programs in public 
health in recent years has been phenomenal, outstripping that of virtually 
any other major academic health science field. During the past decade 
there has been a one-third increase in the number of accredited schools of 
public health to the current 42 and more than a doubling of accredited 
programs in public health to the current 69. Further increase in programs 
and schools is anticipated along with a continued increase in enrollment. 
For example, student enrollment in the University of Pittsburgh GSPH 
has increased from 400 to over 700 in the past decade. As a comparison, 
during this period there has been relatively little change in the number of 
new matriculates in American medical schools, and until the past three 
years, a significant decline in applicants.  

 



144 CREDENTIALING OF THE PUBLIC HEALTH WORK FORCE 
 
 

 

3)  Increasing Awareness and Complexities of Public Health 
Challenges 

Public health is in the midst of a transition. There is growing 
recognition of the need to improve the public health infrastructure, 
including development of a highly competent public health workforce 
(Gebbie and Turnock 2006; Gebbie et al. 2002; Baker et al. 2005). In the 
past it has largely been an unseen discipline, responsible primarily for 
preventing adverse health events through actions often grouped under the 
heading of sanitary engineering. Winslow, a leader in early 20th Century 
public health and the founder of the Yale School of Public Health, was 
fond of pointing out that a grateful patient cured of a disease is a 
commonality in medicine, but it would be unusual to express gratitude to 
the public health expert for your wellness. However, today there are 
many public health issues that again have caught the public’s attention. 
These include emerging infectious diseases such as SARS and avian flu, 
the threats posed by bioterrorism, the obesity epidemic, the health of 
aging “baby boomers,” the prevention of chronic diseases, and the health 
impacts of global climate change. For each of these, the public is aware 
of the need for an expert workforce to address the potential for major 
societal impacts that extend far beyond individual health effects.    

There are other increasingly recognized societal issues that can be 
readily approached through the wide lens of public health. Among them 
are health disparities between our majority and minority populations; the 
growing number of uninsured; the health and societal impacts of urban 
sprawl; and the broad spectrum of global health and sustainability issues. 
Equity is at the heart of many of these issues, some of which, such as 
environmental justice, are framed in language that specifically 
recognizes that societal inequality is a root cause. All are issues that 
extend across usual disciplinary boundaries and that require a systems 
approach. Cross-disciplinary systems approaches characterize public 
health, in contrast to the reductionism that is at the core of subspecialty 
medicine. 

4)   Emergence of a Public Health Core Curriculum 

The NBPHE examination will rely on the core and cross-cutting 
competency processes developed by the ASPH, the Council of Linkages, 
and others (Association of Schools of Public Health 2005; Calhoun et al.  



Bernard D. Goldstein        145 
 

 

 

2008; Council on Linkages between Academia and Public Health 
Practice 2005; Moser 2008). The agreement among the major public 
health organizations that led to the creation of the NBPHE is built upon 
an agreement that there are core educational credentials that underlay the 
practice of public health. This recognition has developed through 
multiple complementary approaches by the various academic and 
practice organizations in the field. The Council on Education in Public 
Health (CEPH), the accrediting body in the field, requires that there be 
full courses in five core public health areas. These are epidemiology, 
biostatistics, environmental health, behavioral and community health 
sciences, and health policy and management. Determining what 
constitutes a core course suitable for accreditation has led to much 
discussion among academic and practice organizations. The CEPH board 
is itself made up of representatives from APHA and ASPH as well as 
others chosen to represent specific interests (Council on Education for 
Public Health 2008). Determining core competencies upon which core 
coursework should be based is a common issue in accreditation of 
educational institutions. In 2001, the ASPH embarked on a major effort 
to develop core competencies in the five core disciplines. Core curricular 
activities have increasingly represented collaboration between academia 
and public health practice. Particularly notable has been the core 
competency activities of the Council of Linkages, a coalition of 
representatives from 17 public health organizations that work to further 
academic/practice collaboration, particularly in workforce training and 
competency activities (Council on Linkages Between Academia and 
Public Health Practice 2005). The NBPHE test writers took into account 
all of these core curriculum activities pertinent to their area of test 
development. In addition, the examination will test for a variety of cross-
cutting competencies that were added following the recommendations of 
an Institute of Medicine committee (Institute of Medicine 2003). These 
cross-cutting competencies are: communications and informatics, 
diversity and culture, leadership, public health biology, professionalism, 
program planning, and systems thinking.   

One impact of the NBPHE will be to provoke continued discussion 
and improvement of these educational competencies. Inevitably, those 
who believe that their area of emphasis has been inadequately covered in 
the examination will work to change the core curriculum and the core 
competencies on which the examination is based. As is clear from the 



146 CREDENTIALING OF THE PUBLIC HEALTH WORK FORCE 
 
 

 

experience of physician educators, building a competency-based 
curriculum can be challenging but is worth the effort (Albanese et al. 
2008). 

5)  Increased Societal Emphasis on Professional Accountability, 
Including Institutionalization of Rewards Based Upon Credentials 

Professional accountability is a central aspect of modern society. 
Work forces with almost any pretensions to a basic core of knowledge or 
a responsibility to the public have developed credentials that are based 
on the demonstration and maintenance of this knowledge and of a skill 
set. This pervasive societal demand for credentialing and for professional 
accountability inevitably has implications to the public health workforce, 
which has been virtually the only major health field without a central 
credentialing activity.  

The National Organization for Competency Assurance (NOCA) is a 
national membership group of credentialing organizations that was 
formed in 1977. It has rapidly grown. Its web site in June 2008 lists 90 
credentialing organizations offering 212 credential programs (National 
Organization for Competency Assurance 2007), mostly for workers in 
health professions. There are even more health credentials – for example, 
the American Board of Medical specialties, which consists of 24 
medical/specialty certifying boards, is not a NOCA member. 

The importance of assurance and accountability in public health is 
also reinforced by a separate national movement under way to develop 
standards for accrediting of public health departments (Public Health 
Accreditation Board 2007). Sixteen states, not including Pennsylvania, 
have been funded to explore the accreditation process with a goal of 
developing criteria that will begin to be applied in 2011. As Pennsylvania 
has relatively few local health departments, the accreditation activity is 
of somewhat lesser importance to our Commonwealth than to other 
states. The two activities of credentialing and accreditation are 
complementary – issues related to the quality of the workforce, which are 
central to credentialing, are also important to the criteria for accreditation 
of local health departments. 

 

 

 



Bernard D. Goldstein        147 
 

 

 

The Relationship Between Medicine and Public Health 

Any consideration of the role of the public health workforce must 
take into account the fact that our country is far more oriented toward 
treatment than prevention of disease. Various cost figures are used to 
attempt to describe the relative amounts spent on prevention versus 
treatment of disease, with treatment accounting for more than 90% in 
virtually all estimates. These estimates are complicated by the various 
definitions of prevention. An egregious example is that of a director of a 
National Institute of Health who defined heart transplantation as a 
preventive measure because it prevented heart failure (Rall 1994).  
However, there is clarity and agreement that we are not achieving 
societal health goals. Despite the highest per capita spending rate on 
health among all countries, we do not rank close to the best in usual 
metrics of health such as longevity, where we rank 47th (United States 
Central Intelligence Agency 2008b), and infant mortality, where we rank 
43rd (United States Central Intelligence Agency 2008a). The amount of 
uninsured is over 40 million and continues to climb; and despite 
improvements in some areas, major health disparities remain between the 
disadvantaged and advantaged in our nation (Agency for Healthcare 
Research and Quality 2006).   

In considering the relationship between medicine and public health 
in achieving national health goals, it is important to note that there is 
some degree of overlap among all of the health professions. From a 
policy perspective, a key issue is to enable the overlap to function 
effectively in accomplishing beneficial societal goals while minimizing 
the negative aspects of redundancy and organizational conflict. At one 
extreme, medicine can be described as reactively responding to an 
individual who has already developed a specific disease, and public 
health as proactively providing for the wellness of populations. The 
standard World Health Organization definition that guides public health 
is: “Health is a state of complete physical, mental and social well-being 
and not merely the absence of disease or infirmity” (World Health 
Organization 2008).  

Note that in the discussion above I have used the term “medicine” 
very broadly to include all of the components of health care, including 
nursing, pharmacy, dentistry, etc. Below I will define medicine more 
narrowly as those aspects of health care performed or directed by 



148 CREDENTIALING OF THE PUBLIC HEALTH WORK FORCE 
 
 

 

physicians. I do so in order to consider the issue of credentialing by 
contrasting the requirements for physicians, and their role in society, 
with those of public health practitioners. 

The overlap between public health and medicine in achieving health 
occurs in many ways, ranging from the medical subspecialty of 
preventive medicine to the bedside actions of physicians who act to treat 
or inform patients in ways to prevent further problems. A useful 
classification of preventive activities considers primary prevention as an 
approach that totally avoids a risk of adverse health consequences (e.g., 
prevention of smoking); secondary prevention as early detection and 
intervention to prevent disease (e.g., the detection and treatment of 
asymptomatic high blood pressure); and tertiary prevention as preventing 
complications of the disease or its treatment. Both medicine and public 
health are involved in all three types of prevention, with medicine 
focusing more on detection and treatment, and public health on primary 
prevention through policy as well as detection.  An obvious overlap is in 
the example given for secondary prevention: detection of high blood 
pressure can occur in the physician’s office during a routine visit, or 
during outreach to populations in the community organized by medical 
groups, such as hospitals, or by public health authorities working alone 
or with community-based organizations. Similarly, primary prevention of 
smoking can occur through a physician’s advice to a pre-teen, or through 
a broad panoply of public policy initiatives, legal activities, and outreach. 
The Commonwealth’s Department of Health maintains an active 
program in alerting the public about the benefits of screening for high 
blood pressure as well as many other preventable diseases. The 
Department of Health has been particularly active in tobacco prevention 
and cessation, working with programs in each county. Most of our state’s 
tobacco funding, however, goes to the medical research community in 
part because of erroneous testimony by the head of a major Pennsylvania 
cancer institute that cigarette smoking was not preventable (Snowbeck 
2000). 

Public health credentialing can also be considered in relation to 
physician credentialing. The latter occurs in a stepwise fashion that 
begins with passage of three different examinations, known as the U.S. 
Medical Licensure Examinations, which are virtually required by every 
state before licensure. The first examination tests for knowledge of the 
basic science of medicine and is usually administered after the second 



Bernard D. Goldstein        149 
 

 

 

year of medical school. The Step 2 examination tests for knowledge 
expected to be obtained in the core clinical disciplines and is usually 
taken in the fourth year of medical school prior to graduation. The 
required Step 3 examination is aimed at examining for skills necessary 
for clinical encounters. While there is some variation among states, 
virtually all require passage of Steps 1, 2, and 3 or their equivalent (there 
are alternate examination pathways developed by osteopathic physicians 
and for foreign medical graduates). The new credentialing process in 
public health is comparable in some ways to Step 1 of the USMLE in 
that it tests for core knowledge on which public health practice is based. 
But, as it is not required for licensure, the NBPHE credential is in other 
ways similar to voluntary board examinations in medical specialties. 
These provide evidence of knowledge in the field and facilitate 
recognition that can lead to further practice opportunities – but are not 
required for licensure to practice. As with the NBPHE, eligibility to sit 
for specialty medical board examinations usually requires some element 
of accredited training, e.g., eligibility for the American Board of Family 
Medicine certification examination includes an MD or DO degree from 
an accredited institution and at least three years of training in a family 
medicine residency program accredited by the Accreditation Council for 
Graduate Medical Education.  

Organized medicine is not unified in its consideration of public 
health. There is both a reaching out to schools of public health and an 
aggressive assertion that public health is a medical specialty. The NBME 
credentialing process has led to further exploration of the roles of 
medicine and public health in this country. The American Medical 
Association (AMA) reacted negatively to the credentialing of public 
health professionals. At the AMA’s 2007 Annual Meeting, a resolution 
was passed that specifically names the NBPHE. The basic premise of the 
resolution is that public health is a specialty of medicine and that 
certifying public health practitioners would mislead the public into 
believing they are physicians (American Medical Association 2007). 
Ironically, this resolution was passed within a few weeks of an Institute 
of Medicine report decrying the lack of physician involvement in public 
health (Institute of Medicine 2007; Goldstein 2008). 

Physicians do play an important role in public health, and those 
board certified by the American Board of Preventive Medicine have been 
particularly valuable (Institute of Medicine 2007; Goldstein 2008). But, 



150 CREDENTIALING OF THE PUBLIC HEALTH WORK FORCE 
 
 

 

as discussed below, there are far too few whose training makes them 
eligible for board certification in Prevention and Public Health to 
respond to our nation’s public health infrastructure needs. 

The role of public health in physician education has recently begun 
to be explored in a standard questionnaire given to medical school 
graduates (Division of Medical Education 2007). The only specific 
question about “public health” in this questionnaire is subsumed under 
the heading of “Evidence Based Medicine.” Of the responding students, 
32.1% stated that the instruction was inadequate. The only other question 
in the category of “evidence based medicine” receiving such a high level 
of inadequate as a response was the related category of “role of 
community health and social service agencies.” In essence, a third of 
medical school graduates felt that their training in public health or in 
community related activities was inadequate.   

Further training of future physicians in public health is highly 
desirable, and there are efforts under way to accomplish this goal 
(Institute of Medicine 2007; Maeshiro 2008; Hernandez and Munthali 
2007). But the major determinant of the medical field chosen by a future 
physician is their residency program. Unfortunately, residency programs 
in preventive medicine and public health represent a tiny fraction of total 
approved residencies. There are only about 130 approved preventive 
medicine residency positions, out of over 20,000 new residency slots 
each year nationally. Even with this small number, many of the 
preventive medicine residency positions do not fill. In comparison, there 
are over 5,000 MPH graduates each year. 

Public health leaders have often considered medical education to be 
part of the problem.  Roemer (1986) has stated: “After one has seen the 
failures to provide public health leadership in country after country, 
Province after Province, one begins to regard training in clinical 
medicine, training to be a clinical physician, as more of an obstacle than 
a preparation for the role of public health leader.” To be effective in 
preparing for roles in public health, physicians need to transcend their 
medical education, not just supplement it.   

 

 

 



Bernard D. Goldstein        151 
 

 

 

Medical and Public Health Education in Pennsylvania 

Pennsylvania is active in public health education. The Drexel 
University School of Public Health was founded as the Allegheny 
University School of Public Health in 1996. The School’s founding dean, 
Dr. Jonathan Mann, was a charismatic leader in public health who 
developed the World Health Organization’s Global AIDS program.  His 
vision of the interrelationship between human rights and human health 
was central to his development of a then unique model of public health 
education, in essence a “school without walls” in which the students 
learned in a case-based learning format and spent a significant amount of 
time in the community performing both their research and service hours.   
Although he died in a plane crash in 1998, Dr. Mann’s vision has 
persisted in the successor Drexel University School of Public Health.  
Under the leadership of the current dean, Dr. Marla Gold, an infectious 
disease physician and expert in HIV/AIDS, Drexel in 2007 received full 
accreditation as a school of public health from CEPH. Students and 
faculty continue to focus much of their work in the regional 
communities. The School has thrived with an exponential increase in 
class size, expert faculty, and in research funding. 

The University of Pittsburgh Graduate School of Public Health 
(GSPH) was founded in 1948, largely in response to the occupational and 
environmental health issues of western Pennsylvania. The founding dean, 
Dr. Thomas Parran, who had been Surgeon General under Presidents 
Roosevelt and Truman, established a focus on research to advance public 
health. The GSPH remains a public health research powerhouse, ranking 
third among 42 schools of public health in competitive funding from the 
National Institutes of Health. Only Johns Hopkins and Harvard Schools 
of Public Health receive more total NIH funding, but the GSPH exceeds 
them in funding per faculty member. Its annual NIH funding total also 
exceeds three of the six Pennsylvania medical schools.  In recent years 
its public health practice components have achieved national recognition, 
including the Center for Public Health Practice headed by Margaret 
Potter, JD, and the Center for Minority Health, headed by Stephen 
Thomas, PhD. The new GSPH Dean, Dr. Donald Burke, has an 
exceptional record of leadership in global health issues, particularly 
emerging infections, and is the UPMC-Jonas Salk Chair in Global 
Health. 



152 CREDENTIALING OF THE PUBLIC HEALTH WORK FORCE 
 
 

 

Pennsylvania is fortunate to have six allopathic medical schools, 
slightly above the national average in number (with 4.2% of the 
population we have 4.9% of the 129 accredited medical schools). We 
also have two osteopathic medical schools of the 25 in the United States.  
Two of the allopathic medical schools (University of Pennsylvania and 
the University of Pittsburgh) are leading research institutions, ranking in 
the top ten in terms of receiving NIH grants, and propelling Pennsylvania 
to be fourth highest among all states in terms of NIH funding. We 
received $1.4 billion in NIH funding 2007, equivalent to 6.8% of the 
total (National Institutes of Health 2008).  

Recently, there has been a movement in academic medicine to obtain 
support for increasing the number of medical students. At the state level, 
bills have been introduced to increase funding for medical education in 
Pennsylvania. Of note is that a driving force in the expressed need for 
more medical school graduates is the perceived shortage of primary care 
physicians. The American Association of Medical Colleges has 
campaigned for federal funding on this basis. This is also a major 
rationale for the new allopathic medical school proposed for Scranton 
which has received $35 million in state funding and intends to admit its 
first class in Fall 2009 (Sonderman 2006; Pennsylvania Medical Society 
2008). Not all agree. Goodman and Fisher (2008) argue that the 
perception that there is a physician shortage is a symptom of the 
underlying problems in our health care system, and that increasing the 
number of physicians will not be helpful. Central to this and other 
arguments about physician numbers has been the concern not only about 
the relative lack of primary care physicians, but also the declining 
interest among medical students in general care (Forrest 2006; Garibaldi 
et al. 2005). The reasons range from the focus of health care resources on 
specialized physicians, to burnout among primary care practitioners from 
seeing too many patients in too little time. As primary care physicians 
are at the forefront of preventive medicine to individuals, and in such 
settings as Community Health Centers (Rosenblatt et al. 2006; Iglehart 
2008), their decline in number, and the increasing demands on their time, 
make organized medicine even less likely to be the locus of needed 
preventive activities thus increasing demands on the public health 
workforce.    

The increasing recognition by academic medicine of the value of 
academic public health is evident in Pennsylvania.  Of the six allopathic 



Bernard D. Goldstein        153 
 

 

 

medical schools, two are associated with schools of public health on the 
same campus offering master’s and doctoral degrees (Pittsburgh and 
Drexel), and three of the four other medical schools have accredited 
programs of public health offering the MPH degree.  Of note is that two 
of these medical school public health degree programs are relatively 
recent – the programs at both the University of Pennsylvania and at 
Thomas Jefferson Medical School being accredited in 2006. This 
represents the recent nationwide surge in public health educational 
programs at universities with medical schools. Of the 69 degree granting 
graduate educational programs accredited by the Council on Education 
for Public Health, 38 have been accredited since 2000. Not all of the 
programs that are on a campus with a medical school are closely 
associated with the medical school. Temple University, whose MPH 
program was accredited in 1985, is at the College of Health Professions. 
Similarly, New York University’s accredited program in public health is 
on its main campus in a Department of Food, Nutrition and Public Health 
rather than on the medical campus. 

The only Pennsylvania university that has an allopathic medical 
school but does not offer an accredited graduate degree in public health 
is The Pennsylvania State University. Although there have been moves 
in this direction, it is unlikely to occur at the Hershey campus due to the 
recent appointment of a Senior Vice President for Health Affairs and 
Dean of the Penn State College of Medicine who has a track record of 
opposition to public health educational programs. 

Pennsylvania is also fortunate to have excellent accredited public 
health graduate programs that are not associated with universities with 
medical campuses. East Stroudsburg University and West Chester 
University both offer fully accredited MPH degree programs. East 
Stroudsburg University’s program also represents the changing trends in 
public health education. In the past, there was a separate accreditation 
pathway for graduate programs that focused on health education. CEPH 
changed their rules to establish the same core public health requirements 
for all accredited programs. These are the core disciplines on which the 
NBPHE is based.   

 

 



154 CREDENTIALING OF THE PUBLIC HEALTH WORK FORCE 
 
 

 

Professional Licensing and State Health Leadership 
in Pennsylvania 

Pennsylvania’s Department of State has oversight function over 27 
professional licensing boards and commissions with the goal of 
protecting the health, safety, and welfare of Commonwealth citizens. The 
15 health-related boards alphabetically range from chiropractic to 
veterinary medicine and include medicine, dentistry, nursing, pharmacy, 
physical therapy, etc. – but not public health. In addition, there are a 
dozen business-related boards including accountancy and cosmetology 
(Pennsylvania Department of State 2002). Again, the field of public 
health is not among those covered by Pennsylvania licensing boards and 
commissions. 

Pennsylvania is one of many states that have removed the 
requirement that the head of its state health department must be a 
physician (Pennsylvania Public Law 518 of July 2, 1996, Vol. 115, 
Section 4, p. 4-55). At the same time, the law created the new position of 
Physician General with the stated goal that this individual would serve as 
the primary advisor on medical issues to the Governor and to the 
Secretary of Health (id, p. 4-56) when the Secretary of Health was not a 
physician. Our first non-physician Secretary of Health was Robert 
Zimmerman, who has an MPH degree and had a long and respected 
career as a public health professional. Robert Muscalus, D.O., became 
the Commonwealth’s first Physician General in February 1999. He left 
the position in March 2005. Our current Secretary of Health, Calvin 
Johnson, MD, MPH, is a physician, who also has excellent public health 
experience. New Jersey also changed its laws in 1990 to allow a non-
physician to be its Commissioner of Health. The New Jersey experience 
has differed from Pennsylvania in that law has been the background of its 
two non-physician Commissioners of Health. Its first non-MD lawyer 
was appointed as Commissioner of Health in 1992 – as is Governor 
Corzine’s present appointee. Both had extensive experience in legislative 
activities related to health care, but neither has any educational 
background or direct experience in public health or health care 
organizations. New Jersey has also appointed one physician during the 
time period that non-physicians have been eligible. In this case the 
physician was an internist with extensive practice and hospital 
experience, but with no public health background. However, New Jersey 
does have a State Board of Health that has statutory authorities and 



Bernard D. Goldstein        155 
 

 

 

oversight responsibilities. Pennsylvania, like many other states, no longer 
has a similar State Board of Health. 

 

Implications to Public Health in Pennsylvania 

Pennsylvania presents a microcosm of the major public health 
challenges facing our country. We have large urban areas which share 
many of the characteristic health disparities found in disadvantaged inner 
city areas. Yet Philadelphia and Pittsburgh are remarkably different 
demographically; Pittsburgh is notable for its aging population, with 
Allegheny County said to have the second oldest population of any 
county in the state. There is also a relative lack of a migrant Hispanic 
work force in Pittsburgh, reflecting the fact that job creation, which has 
been slow, has tended to be at the middle or upper end of the wage scale. 
Eastern urban areas in our Commonwealth must put more resources 
toward meeting the health challenges of poor documented and 
undocumented immigrants. Problems such as HIV/AIDS and violence 
tend to be more evident in Philadelphia than Pittsburgh. The rural parts 
of our state provide yet other challenges to public health that differ from 
those of our two major urban areas. It has become clear that rural health 
issues go well beyond access to care (Meit, 2005). 

It has been conventional to describe the “three Pennsylvanias” as 
being Philadelphia, Pittsburgh, and a “T” of rural counties that extends 
across the north and central parts of the Commonwealth. This can be 
helpful in looking at Pennsylvania’s public health needs. However, it 
does not tell the whole story. For example, reviewing the prevalence of 
smokeless tobacco use is an informative means of further distinguishing 
among the distinct cultural factors that affect public health in our state. 
Among the nine Pennsylvania health districts, male use of smokeless 
tobacco, as expected, is lower in cities than in rural areas. Yet the major 
gradient is east-west. The estimated prevalence of male users of 
smokeless tobacco in 2002-03 was 16% in Pennsylvania’s Southwestern 
Health District and 15% in the Northwestern Health District as compared 
to 3% and 2% in the Northeastern and Southeastern Health Districts. 
Allegheny County had an estimated prevalence of 6%, three times higher 
than that for Philadelphia County. The Northcentral and Southcentral 
health districts, at 10% and 8%, were in between, confirming that there is 



156 CREDENTIALING OF THE PUBLIC HEALTH WORK FORCE 
 
 

 

a geographical component whose cultural influences on the use of 
smokeless tobacco transcend usual urban-rural differences.   

The example of smokeless tobacco is just one of many that support 
the concept that local knowledge is crucial to responding to public health 
needs. It would be inappropriate to assign the same priority to smokeless 
tobacco in eastern as compared to western Pennsylvania. The Allegheny 
County Health Department must confront health problems related to an 
Appalachian life style that are not all that common in Philadelphia 
County. Similarly, there are large Hispanic immigrant populations in 
cities in the eastern half of our Commonwealth. Such populations present 
challenges to public health authorities ranging from classical migrant 
health issues to the need to be sure that public health messages are 
understood by those to whom English is not a native language. Major 
programs to address rural public health issues have been developed at the 
Pennsylvania State University, which houses the Pennsylvania Office of 
Rural Health, and the University of Pittsburgh-Bradford. However, 
despite the local nature of many public health issues, there is a 
commonality in the core competencies needed to address these issues.  
These are the core competencies that are the basis for the NBPHE 
credentialing examination.  

Pennsylvania stands out from other states in its relative lack of an 
identifiable public health workforce. A HRSA-sponsored study (Gebbie 
2000) showed that in public health workforce per capita we ranked last 
among all 50 states and the District of Columbia. The difference was 
substantial: the public health workers per capita for Pennsylvania was 
37/100,000 population while the average for the entire country was 138 
and for our region was 174.  Put another way, we would have to almost 
quadruple our public health workforce simply to achieve the national 
median, and more than quadruple it to achieve the median for our region.  

A major reason for Pennsylvania’s relative scarcity of identifiable 
public health workers is the lack of local health departments. Nationally, 
there are approximately 3,000 local health departments (Salinsky and 
Gursky 2007) – only seven of which are in Pennsylvania. Most of our 68 
counties are covered by the state Department of Health which has 
regional offices in various locations throughout the state. I am unaware 
of any systematic study of whether our state’s organizational system is 
better for public health than are more usual organizational systems in 
which there are many local county or municipal health departments in 



Bernard D. Goldstein        157 
 

 

 

addition to a state health department. However, the disparate and 
fragmented local and state public health organizational structure and 
responsibilities has been considered to be both a symptom of what ails 
public health, and a cause of its problems.   

More information about Pennsylvania’s state public health workforce 
is available from a 2007 ASTHO study (Association of State and 
Territorial Health Officials 2007).  The average age of a PADOH public 
health professional is 49, slightly older than the national average of 47 
years. One of the problems facing Pennsylvania and the nation is an 
expected turnover of the existing public health work force – 23% of the 
nation’s public health workforce is eligible to retire by 2012 (Association 
of Schools of Public Health 2008) and for Pennsylvania the number is 
29% (Association of State and Territorial Health Officials 2007).   
Secretary Calvin Johnson has noted this issue for Pennsylvania and has 
led the Department in dealing with a variety of public health workforce 
issues. He has made recruiting and retaining a highly skilled public 
health workforce one of his primary goals, along with developing 
initiatives to improve workforce accountability (Pennsylvania 
Department of Health 2007). 

In addition to the failure to obtain adequate funding for Tobacco 
Cessation and Prevention, a glaringly evident symptom of the weakness 
of public health as a policy force in Pennsylvania is the 2003 repeal of 
the motorcycle helmet law, a repeal that was supported by Democratic 
Governor Edward Rendell. The dire predictions of the public health 
community have been more than borne out with data demonstrating a 
32% increase in head injury deaths and a 42% increase in head injury-
related hospitalizations (Mertz and Weiss 2008). Despite the highly 
publicized statement after his motorcycle incident by head-injured 
Steeler quarterback Ben Roethlisberger that he would have worn a 
helmet had that been the law, and despite newspaper editorials 
throughout the state supporting reinstitution of universal motorcycle 
helmet laws, any change in our state’s motorcycle helmet coverage is 
unlikely.   

One way to determine what is needed in any system is to stress the 
system. In essence, the post 9/11 anthrax outbreak and continued threat 
of bioterrorism, along with the need to meet emerging infections such as 
SARS and avian flu, has provided this stress. Studies of the ability of the 



158 CREDENTIALING OF THE PUBLIC HEALTH WORK FORCE 
 
 

 

public health system to respond to an emerging natural or terrorist 
biothreat have provided ample documentation of the need for a 
transformation of public health. In addition to fragmented lines of 
authorities, there is a patchwork of capabilities and a workforce that 
already has too much to do with too little resources and too little training 
(Gursky 2005). Any public health emergency will require a highly 
trained workforce capable of a knowledgeable and flexible response. It 
also will require a surge capability that will allow rapid response without 
sacrifice of other public health functions. Substantial criticism has been 
directed at current preparedness activities as diverting resources and 
workforce from existing and necessary public health activities – for 
example, in recent congressional testimony the head of the Association 
of Public Health Laboratories called the national post 9/11 
biosurveillance system a “parasite” on public health laboratory function 
(Downes 2008). 

In the words of one observer, for preparedness to deal with natural or 
terrorist biological threats, public health should be considered a sector 
that needs to become a system (Gursky 2005). Training and sustaining a 
skilled workforce has been identified as one of the key challenges to 
ensuring public health preparedness.   

Pennsylvania’s public health workforce needs are substantial.  New 
county and regional health departments are under consideration as are 
state initiatives to bolster the public health workforce. Providing a 
national core credential for the public health workforce will not by itself 
transform public health in Pennsylvania so it can effectively protect the 
public against all health challenges – but it is a necessary step toward a 
vibrant public health workforce responsive to longstanding public health 
threats and to the emerging problems of our times.    

  Acknowledgments. I thank my colleagues at the National Board of 
Public Health Examiners and at the University of Pittsburgh Graduate 
School of Public Health Center for Public Health Practice for their 
insight and their dedication. Jessica Kanzler and Michael Bazaco 
provided valuable assistance in preparing the manuscript.  

 

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