COMMENTARY
A Call to Action: Training Public Health Students to Be Effective Agents for Social Change In the 21st century, we face enormous public health challenges that differ fundamentally from those of the last century, because these challenges involve widespread societal change and complexity. To address these challenges, public health professionals need to be able to place their work in a larger social context, understand local and global perspectives on a deeper level, and effectively engage a wide variety of stakeholders. To confer these skills, we need to change the way we train our students. We present two examples of low-cost innovative approaches to teaching public health that promote active engagement with individuals across a wide range of backgrounds and fields and that train students to be effective agents for change. (Am J Public Health. 2015; 105:S34–S37. doi:10.2105/ AJPH.2014.302356)
Hilary Godwin, PhD, and S. Jody Heymann, MD, MPP, PhD
FOR PUBLIC HEALTH TO succeed in the 21st century, we need to create fundamentally new approaches compared with those pursued in the 20th century. Some of the greatest global successes (e.g., small pox eradication, soon to be followed by polio, hopefully) were massive efforts that required immense ingenuity, commitment, courage, and effectiveness, but these efforts still did not involve much social change. For instance, the technology of immunization has not changed how people work, how much they earn, or where and how they live. Areas in which we had remarkable, but partial, success in the 20th century included addressing motor vehicle accidents and tobacco-related deaths. Public health succeeded in dramatically reducing illness, injury, and death in high-income countries, saving millions of lives. At the same time, the globalization of the economy facilitated dramatic increases in tobacco use and poor quality diets in low- and middle-income countries; the latter situation resulted in a marked rise in the rates of obesity and diabetes, although malnutrition is still widespread. When we look to the greatest population health challenges of the 21st century, whether addressing tobacco globally or addressing climate change, there will be no simple solutions. Reducing the extent of risk and preventing the massive amount of morbidity and mortality associated with social, economic, and environmental risks require
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addressing social factors both globally and locally. We need to train public health leaders by providing students with the opportunity to: (1) develop the skills needed to successfully address problems that require societal change to solve, and (2) address social, economic, and environmental problems as part of a global community. We need to help all public health students develop these skills, including students in resource-constrained environments. We describe two examples of approaches taken while training students and public health practitioners to address climate change, a problem that the World Health Organization highlights as one of the greatest threats to health that requires deep societal responses on a global scale.1 We purposely selected two examples of approaches, one local and one global, that can be applied in public health schools and programs around the world and do not require substantial financial resources. A primary innovation of the approach in both of these examples was that the format and content of the trainings were driven by local public health needs identified by our partners, and the courses were then designed using a collaborative, consultative process. In addition, the courses were unusual in that they provided our students with opportunities to engage directly with important stakeholder groups and to learn how they approach challenging, multidisciplinary problems. Although many high
profile innovations in teaching in recent years focused on using technology, often in an asynchronous mode, to deliver training to large numbers of students and professionals, both of the examples discussed herein illustrate the important benefits of promoting direct interactions in relatively small group settings. We discuss why synchronous engagement was critical to learning and crossfertilization between groups in each of these examples and how low cost-technological solutions could be used for synchronous engagement between institutions in different countries.
STUDENTS ENGAGING LOCALLY TO AFFECT SOCIAL CHANGE In the future, the biggest opportunities to improve health will arise through implementation of public policies and programs at scales that benefit health.2,3 Engaging in local climate action planning activities provides both students and public health professionals with an opportunity to simultaneously build critical skills and to have a tremendous impact on the future health of their local communities. In a recent survey, the Pew Research Center found that Americans were relatively unconcerned about climate change compared with individuals from almost all of the other countries surveyed.4 Individuals who are not concerned about climate impacts are unlikely to change their behaviors to reduce greenhouse gas emissions or build
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resiliency to the impacts of climate change. Likewise, without popular support, politicians are unlikely to push forward regulations that promote climate change mitigation and adaptation. Public health professionals are uniquely positioned to develop and deliver messages about the effects of climate change on health to the general public and to work with vulnerable communities and other stakeholders to build resiliency to the health impacts of climate change. Unfortunately, many public health professionals do not understand how their skills can be leveraged in the context of climate action planning. Although a growing number of public health students now take classes on climate change, those same students also need to learn how to convey technical information effectively to diverse audiences and how to actively engage diverse stakeholders in planning activities. To address these issues, we developed a partnership between the Fielding School of Public Health (FSPH) at the University of California Los Angeles (UCLA) and the Division of Environmental Health in the Los Angeles County Department of Public Health (LACDPH) to propel regional climate action planning. One of LACDPH’s top priorities is to build their capacity to monitor health effects, integrate preparedness, and improve climate response; educating their staff about the public health effects of climate change was an essential first step in this process. To address these needs, faculty and doctoral students at FSPH met with the climate action planning team from our local health department to determine how to develop training modules that would break the complexities of climate and health into manageable action areas.
The students also learned how to present the materials in a way that would inspire the staff within the health department to actively engage in our local climate action planning process. The result was a 16-part interactive workshop series for staff at LACDPH. Each workshop focused on a specific aspect of climate and health (e.g., effects on vulnerable populations, or the effects of climate change on water quality and scarcity in our region) and consisted of (1) a 20 to 30 minute presentation (given by a faculty member or student from UCLA), and (2) a 50 to 60 minute brainstorming activity, designed to engage the staff and students in the climate action planning process (e.g., identifying existing strengths or programs within LACDPH and potential partners at other organizations that could be leveraged to promote resiliency, or developing SMART [Specific Measureable Assignable Realistic and Time-related] objectives for building resiliency5). Each workshop was typically attended by 20 to 30 staff, representing a wide range of departments and backgrounds (e.g., vector control, public health nursing, emergency response, and water quality). For the brainstorming activities, the participants broke into groups of five to eight people with individuals from different subdisciplines and then reported back to the larger group. We intentionally directed participants to group with individuals who they did not normally work with for the brainstorming sessions, to promote cross-fertilization and teambuilding between staff and students and between staff from different units within the health department. Staff from the health department who had participated in one or more workshops were surveyed
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midway through the workshop series to evaluate whether they found the workshops beneficial. All of the workshop respondents indicated that the workshop had either “fully” or “somewhat” met the following objectives: (1) the workshop increased their knowledge of climate change and its health effects on populations, and (2) the brainstorming allowed them to use the information acquired in the presentation section of the workshop, with 90% and 80% of the respondents rating goals 1 and 2 as “fully” met, respectively. Notably, 80% of respondents indicated that they planned to use the information and skills acquired during the workshop in their daily activities. The brainstorming activities proved to be a particularly critical component of the workshops, illustrating how important the synchronous interactions were to the workshop participant. This was evidenced by reports from staff who initially elected to participate in the workshops via webcam; they felt that they were “missing out” by not being able to work collaboratively on the problemsolving activities. Each of these individuals elected to participate in at least one of the subsequent workshops in person. In addition, many outstanding suggestions arose during the brainstorming activities, several of which the department is now in the process of implementing or have been incorporated into the department’s climate action planning documents (http://publichealth.lacounty. gov/eh). One of the important innovations of the workshop series was that it provided our doctoral students who were working on climate change with a substantive opportunity to work directly with mid-career public health
professionals and to learn from them. All too often, doctoral students are tightly focused on conducting their own research and do not get to interact substantively with public health practitioners who bring important perspectives to public health problems and a wealth of real-world experience. The opportunity to work directly with staff from LACDPH provided the doctoral students who participated in the workshop series with invaluable insights into perspectives of public health professionals and the constraints that health departments face. In this workshop series, the participating doctoral students not only learned to craft a presentation that was appropriate for practitioners, a skill that will serve them well throughout their careers, but they also participated directly with the staff in the health department in the problem-solving activities and learned first-hand how to use critical active engagement strategies to elicit “buy-in” from important stakeholders. As a result of the workshop series, several of these doctoral students are now collaborating with staff at LACDPH to perform vulnerability assessments for specific climate and health impact areas. Each of these students has expressed a desire to work at the interface of policy, climate, and health after they graduate. Their active engagement in the collaboration with LACDPH has uniquely prepared these students to play a leadership role in this arena in the years to come.
STUDENTS LEARNING AS PART OF A GLOBAL COMMUNITY Just as local collaborations are essential to students’ professional development, opportunities to learn together with students from
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other countries are also critical. We need to ensure that every student, whether educated in a school that has students attending from around the world or educated in a school that primarily has students from a single state or country, has the opportunity to engage with the men and women with whom they will be working with in the future to find global solutions. Past models for providing a global education have been limited in a series of ways. Smaller public health schools often do not have a global student body. Public health schools in low-income countries often do not draw students from highincome countries. Public health schools in high-income countries vary tremendously in the number of students they have from other countries. Moreover, even those schools whose student body comes from multiple countries typically have only one or two students from most countries in any one classroom. As a result, the voices and experiences from these countries may come across as less nuanced or may not receive adequate attention. We need to find ways to: (1) bring together students from diverse settings so that all perspectives can be heard equally, (2) reach students being trained in low- and high-income countries, and (3) create global communities that connect students in schools whose student bodies are primarily from one nation with students in schools from other nations and with students from schools that are truly global. To address these needs, we conducted pilot “collaborative classes” with a partner institution in another country. The simple model for the collaboration included:
d
d
d
d
d
Instructors at each of the institutions ran the class at their home institution and assigned grades to the students at their own institution; A syllabus was developed jointly between the instructors at the two institutions (typically via Skype [Microsoft, Redmond, WA] calls, in the months leading up to the course) that leveraged the complementary strengths and expertise of the instructors; One of the two instructors developed a presentation (typically using Powerpoint [Microsoft]) and lectured on the material for each topic; An electronic copy of the presentation was shared with the other instructor in advance (to allow for time to download large files) and each instructor projected the presentation in their own classroom; and The oral portion of the lecture was shared across the two classrooms via live Internet transmission (e.g., using Skype). The lecturer indicated when to advance to the next slide, and the students or instructor on the other campus notified the lecturer when they had a question.
We used this approach to conduct a joint class with Masters students and advanced undergraduates at the Higher Institute of Environmental Sciences (HIES) at the International Bilingual Academy Yaounde, in Cameroon. The focus of the course was on a comparison of the environmental health challenges and opportunities in Cameroon and California. The approach used was not without challenges. Because of the time difference between the two locations, the class had to be offered from 8 to 10 AM at UCLA, which meant that enrollment by our own students was reduced. In addition,
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because Cameroon is bilingual, the class was conducted in both English and French, which required constant translation of the lectures and questions and meant that the amount of material that could be covered in each class session was limited. Finally, we experienced significant technological challenges; despite the decision to go with the simplest possible technology. HIES does not have their own generator, and hence, when there was a blackout (which was fairly often), we would lose contact. Likewise, the Internet connection was not very stable, and sometimes even a strong rain event could significantly impair transmission. These complexities were not just frustrating, but also required significant flexibility on the parts of both instructors because sometimes the instructor who was not scheduled to lecture on a particular day was left with a full classroom on their own end and with no connection to the lecturer on the other campus. Nonetheless, the advantages were tremendous. The two instructors for the course had complementary expertise, and hence, were able to offer content to the students at the other institution that they would not otherwise have received. The instructors from our institution were professors of environmental health, and the lead instructor from Cameroon was an internationally recognized expert in agroforestry. Neither institution had instructors present on their own campus in the field covered by the partner institution, and significant demand existed in each of the institutions for classes in the expertise area represented by the partner. Notably, the instructors had an established collaboration and a good understanding of the needs and strengths of their partner
instructor and institution. As a result, we were able to work together to develop a syllabus and approach to instruction that allowed us to leverage each other’s expertise and develop a course that focused on providing examples of how different expertise could be used to develop multifaceted solutions to a common problem. Likewise, the comparative nature of the course (i.e., exploring the strengths and challenges in both countries) allowed us to have a richer and more nuanced discussion of environmental health issues than would have been possible with only a single country perspective. The Cameroonian students were sometimes frustrated to learn about the limitations of the US systems (e.g., how bipartisan politics and industrial influence in the United States has thwarted passage of national climate legislation), but were also sometimes fascinated to learn about our own challenges (e.g., that California produces the majority of fruits, vegetables, and nuts in the United States, but that our food security is threatened by our current drought and by California’s heavy reliance on water from other states to produce those crops). The lessons for the instructors were often momentous as well. When covering climate change in classes at UCLA, we often discuss how Africa and other parts of the developing world face the greatest threats to health as a result of climate change, even though the United States has produced the majority of greenhouse gas emissions to date. In the joint class with HIES, the synchronous nature of the class and the ability of the students in each country to interact and talk directly to each other was critical. The US students were deeply moved by the discussions
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with the African students and sobered by the revelation that Cameroon is already experiencing dramatic impacts from climate change, whereas in the United States, we are still struggling to convince people that climate change is real and that we all need to change our behaviors to prevent more damage. Both Cameroonian and US students have requested additional courses like this one. One suggestion that the American students provided for how the course could be improved in the future in their end-of-quarter course evaluations is that additional mechanisms be put in place for direct interactions between the US and Cameroonian students.
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LESSONS LEARNED AND FUTURE OPPORTUNITIES We discussed only two of the many ways that innovative strategies could be used to train future public health leaders who will be able to develop and implement solutions to the challenges we collectively face in the 21st century. Many other equally exciting approaches are being developed by a broad range of public health faculty at our own institution, and at many other institutions as well. We hope these examples illustrate some important themes: d
Addressing complex social and environmental determinants of health requires working effectively with policymakers, as well as with programmatic and civil society leaders. This is a skill that needs to be core to our curricula if our students are going to be effective in the greatest challenges of the 21st century. Every school of public health has a local community with leaders with whom they can work. Learning from and giving to
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the communities we are a part of strengthens the education students receive. To do this effectively means transforming how we understand the classroom. Although public health education needs to become more deeply engaged in our local communities, many of the greatest challenges for public health are fundamentally global. The dramatic transformation that has occurred in low-cost communications technology has placed global partnerships and teaching within the reach of all schools, regardless of resources. What this requires is a willingness to invest time, a recognition of what we all have to learn from each other, a respect for what everyone brings to the table, and an understanding that solutions require partnerships. Creative and innovative learning opportunities can arise if we work collaboratively with community partners to determine what types of courses and content best meet their needs. In a world of sophisticated technology, sometimes simple, lowcost solutions and direct engagement with stakeholders in applying research to solving pressing problems can provide the richest learning experiences.
We recognize that, although they did not require substantial monetary resources to implement, the examples we described both required significant time and energy on the part of faculty and students. At the core, these approaches were dependent upon developing lasting collaborations, whether globally or locally. We need to ensure that these types of efforts are recognized and rewarded within our systems for evaluation and advancement. Institutions must provide
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administrative and financial support to help facilitate these types of initiatives, when possible. For instance, our University provided summer fellowships for three of the doctoral students working on the climate action planning collaboration with our county health department, although the students were not working on traditional research projects because engagement in the local community is an institution-wide priority. Finally, we note that as we engage in more innovative training strategies, we need to be mindful to develop and implement strategies that allowed us to assess whether these programs and projects were having desirable effects. In the long run, the success of these initiatives will be measured by the change that our students will be able to make both locally and globally as they develop into the public health leaders of tomorrow. j
About the Authors Hilary Godwin and S. Jody Heymann are with the Fielding School of Public Health, University of California, Los Angeles (UCLA). Correspondence should be sent to Hilary Godwin, PhD, Department of Environmental Health Sciences, UCLA Fielding School of Public Health, 66-06B CHS, BOX 951772, Los Angeles, CA 90095-1772 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted September 22, 2014.
wish to acknowledge the leadership and camaraderie on these projects provided by Zac Tchoundjeu, PhD, and Rene Jiofack, PhD, at HIES; by Angelo Bellomo, MS, Charlene Contreras, Melina Bakshi, MS, and Elizabeth Rhoades, PhD, at LACDPH; and by Patrick Allard, PhD, Sabrina Adelaine, MS, Katherine Reich, MA, Bryan Moy, MPH, Sharona Sokolow, MPH, Tamana Rahman, MPH, and Tyler Watson, MPH, at UCLA. Support for three of the doctoral students (Bryan Moy, Tamana Rahman, and Tyler Watson) who worked on the collaboration with LACDPH was provided by the UCLA Graduate Division through the Graduate Summer Research Mentorship Program.
References 1. Kovats RS, Menne B, McMichael AJ, Corvalan C, Bertollini R. Climate Change and Human Health: Impact and Adaptation. Geneva, Switzerland: World Health Organization; 2000. 2. Cole BL, Fielding JE. Health impact assessment: a tool to help policy makers understand health beyond health care. Annu Rev Public Health. 2007;28:393--412. 3. Milio N. Making healthy public policy; developing the science by learning the art: an ecological framework for policy studies. Health Promot. 1987;2(3): 263---274. 4. Kohut A, Wike R, Horowitz JM, et al. Climate Change and Financial Instability Seen as Top Global Threats. Washington, DC: Pew Research Center; 2013. 5. Tempest E. How to draw up SMART objectives that will work. Nurs Times. 2012;108(41):37.
Contributors H. Godwin and S. J. Heymann worked collaboratively to conceptualize the article. H. Godwin developed the initial draft of the article; both authors contributed substantially to revisions to and editing of the article.
Acknowledgments We wish to thank our partners at both the Los Angeles County Department of Public Health (LACDPH) and at the Higher Institute of Environmental Sciences (HIES) in Cameroon, as well as the students and faculty at UCLA and HIES who participated in these projects. We particularly
Godwin and Heymann | Peer Reviewed | Commentary | S37
A Call to Action: Training Public Health Students to Be Effective Agents for Social Change In the 21st century, we face enormous public health challenges that differ fundamentally from those of the last century, because these challenges involve widespread societal change and complexity. To address these challenges, public health professionals need to be able to place their work in a larger social context, understand local and global perspectives on a deeper level, and effectively engage a wide variety of stakeholders. To confer these skills, we need to change the way we train our students. We present two examples of low-cost innovative approaches to teaching public health that promote active engagement with individuals across a wide range of backgrounds and fields and that train students to be effective agents for change. (Am J Public Health. 2015; 105:S34–S37. doi:10.2105/ AJPH.2014.302356)
Hilary Godwin, PhD, and S. Jody Heymann, MD, MPP, PhD
FOR PUBLIC HEALTH TO succeed in the 21st century, we need to create fundamentally new approaches compared with those pursued in the 20th century. Some of the greatest global successes (e.g., small pox eradication, soon to be followed by polio, hopefully) were massive efforts that required immense ingenuity, commitment, courage, and effectiveness, but these efforts still did not involve much social change. For instance, the technology of immunization has not changed how people work, how much they earn, or where and how they live. Areas in which we had remarkable, but partial, success in the 20th century included addressing motor vehicle accidents and tobacco-related deaths. Public health succeeded in dramatically reducing illness, injury, and death in high-income countries, saving millions of lives. At the same time, the globalization of the economy facilitated dramatic increases in tobacco use and poor quality diets in low- and middle-income countries; the latter situation resulted in a marked rise in the rates of obesity and diabetes, although malnutrition is still widespread. When we look to the greatest population health challenges of the 21st century, whether addressing tobacco globally or addressing climate change, there will be no simple solutions. Reducing the extent of risk and preventing the massive amount of morbidity and mortality associated with social, economic, and environmental risks require
S34 | Commentary | Peer Reviewed | Godwin and Heymann
addressing social factors both globally and locally. We need to train public health leaders by providing students with the opportunity to: (1) develop the skills needed to successfully address problems that require societal change to solve, and (2) address social, economic, and environmental problems as part of a global community. We need to help all public health students develop these skills, including students in resource-constrained environments. We describe two examples of approaches taken while training students and public health practitioners to address climate change, a problem that the World Health Organization highlights as one of the greatest threats to health that requires deep societal responses on a global scale.1 We purposely selected two examples of approaches, one local and one global, that can be applied in public health schools and programs around the world and do not require substantial financial resources. A primary innovation of the approach in both of these examples was that the format and content of the trainings were driven by local public health needs identified by our partners, and the courses were then designed using a collaborative, consultative process. In addition, the courses were unusual in that they provided our students with opportunities to engage directly with important stakeholder groups and to learn how they approach challenging, multidisciplinary problems. Although many high
profile innovations in teaching in recent years focused on using technology, often in an asynchronous mode, to deliver training to large numbers of students and professionals, both of the examples discussed herein illustrate the important benefits of promoting direct interactions in relatively small group settings. We discuss why synchronous engagement was critical to learning and crossfertilization between groups in each of these examples and how low cost-technological solutions could be used for synchronous engagement between institutions in different countries.
STUDENTS ENGAGING LOCALLY TO AFFECT SOCIAL CHANGE In the future, the biggest opportunities to improve health will arise through implementation of public policies and programs at scales that benefit health.2,3 Engaging in local climate action planning activities provides both students and public health professionals with an opportunity to simultaneously build critical skills and to have a tremendous impact on the future health of their local communities. In a recent survey, the Pew Research Center found that Americans were relatively unconcerned about climate change compared with individuals from almost all of the other countries surveyed.4 Individuals who are not concerned about climate impacts are unlikely to change their behaviors to reduce greenhouse gas emissions or build
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resiliency to the impacts of climate change. Likewise, without popular support, politicians are unlikely to push forward regulations that promote climate change mitigation and adaptation. Public health professionals are uniquely positioned to develop and deliver messages about the effects of climate change on health to the general public and to work with vulnerable communities and other stakeholders to build resiliency to the health impacts of climate change. Unfortunately, many public health professionals do not understand how their skills can be leveraged in the context of climate action planning. Although a growing number of public health students now take classes on climate change, those same students also need to learn how to convey technical information effectively to diverse audiences and how to actively engage diverse stakeholders in planning activities. To address these issues, we developed a partnership between the Fielding School of Public Health (FSPH) at the University of California Los Angeles (UCLA) and the Division of Environmental Health in the Los Angeles County Department of Public Health (LACDPH) to propel regional climate action planning. One of LACDPH’s top priorities is to build their capacity to monitor health effects, integrate preparedness, and improve climate response; educating their staff about the public health effects of climate change was an essential first step in this process. To address these needs, faculty and doctoral students at FSPH met with the climate action planning team from our local health department to determine how to develop training modules that would break the complexities of climate and health into manageable action areas.
The students also learned how to present the materials in a way that would inspire the staff within the health department to actively engage in our local climate action planning process. The result was a 16-part interactive workshop series for staff at LACDPH. Each workshop focused on a specific aspect of climate and health (e.g., effects on vulnerable populations, or the effects of climate change on water quality and scarcity in our region) and consisted of (1) a 20 to 30 minute presentation (given by a faculty member or student from UCLA), and (2) a 50 to 60 minute brainstorming activity, designed to engage the staff and students in the climate action planning process (e.g., identifying existing strengths or programs within LACDPH and potential partners at other organizations that could be leveraged to promote resiliency, or developing SMART [Specific Measureable Assignable Realistic and Time-related] objectives for building resiliency5). Each workshop was typically attended by 20 to 30 staff, representing a wide range of departments and backgrounds (e.g., vector control, public health nursing, emergency response, and water quality). For the brainstorming activities, the participants broke into groups of five to eight people with individuals from different subdisciplines and then reported back to the larger group. We intentionally directed participants to group with individuals who they did not normally work with for the brainstorming sessions, to promote cross-fertilization and teambuilding between staff and students and between staff from different units within the health department. Staff from the health department who had participated in one or more workshops were surveyed
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midway through the workshop series to evaluate whether they found the workshops beneficial. All of the workshop respondents indicated that the workshop had either “fully” or “somewhat” met the following objectives: (1) the workshop increased their knowledge of climate change and its health effects on populations, and (2) the brainstorming allowed them to use the information acquired in the presentation section of the workshop, with 90% and 80% of the respondents rating goals 1 and 2 as “fully” met, respectively. Notably, 80% of respondents indicated that they planned to use the information and skills acquired during the workshop in their daily activities. The brainstorming activities proved to be a particularly critical component of the workshops, illustrating how important the synchronous interactions were to the workshop participant. This was evidenced by reports from staff who initially elected to participate in the workshops via webcam; they felt that they were “missing out” by not being able to work collaboratively on the problemsolving activities. Each of these individuals elected to participate in at least one of the subsequent workshops in person. In addition, many outstanding suggestions arose during the brainstorming activities, several of which the department is now in the process of implementing or have been incorporated into the department’s climate action planning documents (http://publichealth.lacounty. gov/eh). One of the important innovations of the workshop series was that it provided our doctoral students who were working on climate change with a substantive opportunity to work directly with mid-career public health
professionals and to learn from them. All too often, doctoral students are tightly focused on conducting their own research and do not get to interact substantively with public health practitioners who bring important perspectives to public health problems and a wealth of real-world experience. The opportunity to work directly with staff from LACDPH provided the doctoral students who participated in the workshop series with invaluable insights into perspectives of public health professionals and the constraints that health departments face. In this workshop series, the participating doctoral students not only learned to craft a presentation that was appropriate for practitioners, a skill that will serve them well throughout their careers, but they also participated directly with the staff in the health department in the problem-solving activities and learned first-hand how to use critical active engagement strategies to elicit “buy-in” from important stakeholders. As a result of the workshop series, several of these doctoral students are now collaborating with staff at LACDPH to perform vulnerability assessments for specific climate and health impact areas. Each of these students has expressed a desire to work at the interface of policy, climate, and health after they graduate. Their active engagement in the collaboration with LACDPH has uniquely prepared these students to play a leadership role in this arena in the years to come.
STUDENTS LEARNING AS PART OF A GLOBAL COMMUNITY Just as local collaborations are essential to students’ professional development, opportunities to learn together with students from
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other countries are also critical. We need to ensure that every student, whether educated in a school that has students attending from around the world or educated in a school that primarily has students from a single state or country, has the opportunity to engage with the men and women with whom they will be working with in the future to find global solutions. Past models for providing a global education have been limited in a series of ways. Smaller public health schools often do not have a global student body. Public health schools in low-income countries often do not draw students from highincome countries. Public health schools in high-income countries vary tremendously in the number of students they have from other countries. Moreover, even those schools whose student body comes from multiple countries typically have only one or two students from most countries in any one classroom. As a result, the voices and experiences from these countries may come across as less nuanced or may not receive adequate attention. We need to find ways to: (1) bring together students from diverse settings so that all perspectives can be heard equally, (2) reach students being trained in low- and high-income countries, and (3) create global communities that connect students in schools whose student bodies are primarily from one nation with students in schools from other nations and with students from schools that are truly global. To address these needs, we conducted pilot “collaborative classes” with a partner institution in another country. The simple model for the collaboration included:
d
d
d
d
d
Instructors at each of the institutions ran the class at their home institution and assigned grades to the students at their own institution; A syllabus was developed jointly between the instructors at the two institutions (typically via Skype [Microsoft, Redmond, WA] calls, in the months leading up to the course) that leveraged the complementary strengths and expertise of the instructors; One of the two instructors developed a presentation (typically using Powerpoint [Microsoft]) and lectured on the material for each topic; An electronic copy of the presentation was shared with the other instructor in advance (to allow for time to download large files) and each instructor projected the presentation in their own classroom; and The oral portion of the lecture was shared across the two classrooms via live Internet transmission (e.g., using Skype). The lecturer indicated when to advance to the next slide, and the students or instructor on the other campus notified the lecturer when they had a question.
We used this approach to conduct a joint class with Masters students and advanced undergraduates at the Higher Institute of Environmental Sciences (HIES) at the International Bilingual Academy Yaounde, in Cameroon. The focus of the course was on a comparison of the environmental health challenges and opportunities in Cameroon and California. The approach used was not without challenges. Because of the time difference between the two locations, the class had to be offered from 8 to 10 AM at UCLA, which meant that enrollment by our own students was reduced. In addition,
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because Cameroon is bilingual, the class was conducted in both English and French, which required constant translation of the lectures and questions and meant that the amount of material that could be covered in each class session was limited. Finally, we experienced significant technological challenges; despite the decision to go with the simplest possible technology. HIES does not have their own generator, and hence, when there was a blackout (which was fairly often), we would lose contact. Likewise, the Internet connection was not very stable, and sometimes even a strong rain event could significantly impair transmission. These complexities were not just frustrating, but also required significant flexibility on the parts of both instructors because sometimes the instructor who was not scheduled to lecture on a particular day was left with a full classroom on their own end and with no connection to the lecturer on the other campus. Nonetheless, the advantages were tremendous. The two instructors for the course had complementary expertise, and hence, were able to offer content to the students at the other institution that they would not otherwise have received. The instructors from our institution were professors of environmental health, and the lead instructor from Cameroon was an internationally recognized expert in agroforestry. Neither institution had instructors present on their own campus in the field covered by the partner institution, and significant demand existed in each of the institutions for classes in the expertise area represented by the partner. Notably, the instructors had an established collaboration and a good understanding of the needs and strengths of their partner
instructor and institution. As a result, we were able to work together to develop a syllabus and approach to instruction that allowed us to leverage each other’s expertise and develop a course that focused on providing examples of how different expertise could be used to develop multifaceted solutions to a common problem. Likewise, the comparative nature of the course (i.e., exploring the strengths and challenges in both countries) allowed us to have a richer and more nuanced discussion of environmental health issues than would have been possible with only a single country perspective. The Cameroonian students were sometimes frustrated to learn about the limitations of the US systems (e.g., how bipartisan politics and industrial influence in the United States has thwarted passage of national climate legislation), but were also sometimes fascinated to learn about our own challenges (e.g., that California produces the majority of fruits, vegetables, and nuts in the United States, but that our food security is threatened by our current drought and by California’s heavy reliance on water from other states to produce those crops). The lessons for the instructors were often momentous as well. When covering climate change in classes at UCLA, we often discuss how Africa and other parts of the developing world face the greatest threats to health as a result of climate change, even though the United States has produced the majority of greenhouse gas emissions to date. In the joint class with HIES, the synchronous nature of the class and the ability of the students in each country to interact and talk directly to each other was critical. The US students were deeply moved by the discussions
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with the African students and sobered by the revelation that Cameroon is already experiencing dramatic impacts from climate change, whereas in the United States, we are still struggling to convince people that climate change is real and that we all need to change our behaviors to prevent more damage. Both Cameroonian and US students have requested additional courses like this one. One suggestion that the American students provided for how the course could be improved in the future in their end-of-quarter course evaluations is that additional mechanisms be put in place for direct interactions between the US and Cameroonian students.
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LESSONS LEARNED AND FUTURE OPPORTUNITIES We discussed only two of the many ways that innovative strategies could be used to train future public health leaders who will be able to develop and implement solutions to the challenges we collectively face in the 21st century. Many other equally exciting approaches are being developed by a broad range of public health faculty at our own institution, and at many other institutions as well. We hope these examples illustrate some important themes: d
Addressing complex social and environmental determinants of health requires working effectively with policymakers, as well as with programmatic and civil society leaders. This is a skill that needs to be core to our curricula if our students are going to be effective in the greatest challenges of the 21st century. Every school of public health has a local community with leaders with whom they can work. Learning from and giving to
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the communities we are a part of strengthens the education students receive. To do this effectively means transforming how we understand the classroom. Although public health education needs to become more deeply engaged in our local communities, many of the greatest challenges for public health are fundamentally global. The dramatic transformation that has occurred in low-cost communications technology has placed global partnerships and teaching within the reach of all schools, regardless of resources. What this requires is a willingness to invest time, a recognition of what we all have to learn from each other, a respect for what everyone brings to the table, and an understanding that solutions require partnerships. Creative and innovative learning opportunities can arise if we work collaboratively with community partners to determine what types of courses and content best meet their needs. In a world of sophisticated technology, sometimes simple, lowcost solutions and direct engagement with stakeholders in applying research to solving pressing problems can provide the richest learning experiences.
We recognize that, although they did not require substantial monetary resources to implement, the examples we described both required significant time and energy on the part of faculty and students. At the core, these approaches were dependent upon developing lasting collaborations, whether globally or locally. We need to ensure that these types of efforts are recognized and rewarded within our systems for evaluation and advancement. Institutions must provide
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administrative and financial support to help facilitate these types of initiatives, when possible. For instance, our University provided summer fellowships for three of the doctoral students working on the climate action planning collaboration with our county health department, although the students were not working on traditional research projects because engagement in the local community is an institution-wide priority. Finally, we note that as we engage in more innovative training strategies, we need to be mindful to develop and implement strategies that allowed us to assess whether these programs and projects were having desirable effects. In the long run, the success of these initiatives will be measured by the change that our students will be able to make both locally and globally as they develop into the public health leaders of tomorrow. j
About the Authors Hilary Godwin and S. Jody Heymann are with the Fielding School of Public Health, University of California, Los Angeles (UCLA). Correspondence should be sent to Hilary Godwin, PhD, Department of Environmental Health Sciences, UCLA Fielding School of Public Health, 66-06B CHS, BOX 951772, Los Angeles, CA 90095-1772 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted September 22, 2014.
wish to acknowledge the leadership and camaraderie on these projects provided by Zac Tchoundjeu, PhD, and Rene Jiofack, PhD, at HIES; by Angelo Bellomo, MS, Charlene Contreras, Melina Bakshi, MS, and Elizabeth Rhoades, PhD, at LACDPH; and by Patrick Allard, PhD, Sabrina Adelaine, MS, Katherine Reich, MA, Bryan Moy, MPH, Sharona Sokolow, MPH, Tamana Rahman, MPH, and Tyler Watson, MPH, at UCLA. Support for three of the doctoral students (Bryan Moy, Tamana Rahman, and Tyler Watson) who worked on the collaboration with LACDPH was provided by the UCLA Graduate Division through the Graduate Summer Research Mentorship Program.
References 1. Kovats RS, Menne B, McMichael AJ, Corvalan C, Bertollini R. Climate Change and Human Health: Impact and Adaptation. Geneva, Switzerland: World Health Organization; 2000. 2. Cole BL, Fielding JE. Health impact assessment: a tool to help policy makers understand health beyond health care. Annu Rev Public Health. 2007;28:393--412. 3. Milio N. Making healthy public policy; developing the science by learning the art: an ecological framework for policy studies. Health Promot. 1987;2(3): 263---274. 4. Kohut A, Wike R, Horowitz JM, et al. Climate Change and Financial Instability Seen as Top Global Threats. Washington, DC: Pew Research Center; 2013. 5. Tempest E. How to draw up SMART objectives that will work. Nurs Times. 2012;108(41):37.
Contributors H. Godwin and S. J. Heymann worked collaboratively to conceptualize the article. H. Godwin developed the initial draft of the article; both authors contributed substantially to revisions to and editing of the article.
Acknowledgments We wish to thank our partners at both the Los Angeles County Department of Public Health (LACDPH) and at the Higher Institute of Environmental Sciences (HIES) in Cameroon, as well as the students and faculty at UCLA and HIES who participated in these projects. We particularly
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