Introduction
The law is not a new tool in the public health practitioner’s toolbox; it has been used for centuries to advance public health goals such as childhood vaccinations, tobacco control and prevention, and the creation of safe and healthy housing.Reference Goodman, Moulton and Matthews 1 A variation of an often-cited definition of public health law from Professors Lawrence Gostin and Lindsey Wiley states that public health law involves the “legal powers and duties of the state … to assure the conditions for people to be healthy … and the limitations on the power of the state to constrain the … legally protected interests of individuals for the common good.”Reference Gostin and Wiley 2 Legally protected interests include things such as the individual right to autonomy, privacy, and liberty. 3 In other words, public health law not only defines the jurisdiction, authority, and roles of public health practitioners, it also ensures practitioners’ powers are not unlimited.Reference Gostin and Wiley 4 While the law has been used to make significant improvements in the community’s health, it has also contributed to health inequities by creating and perpetrating systems that contribute to unequal distributions of power, resources, and support. 5 Many of the legal systems and structures have and continue to perpetuate inequities across the social determinants of health: education, food, housing, income, employment, transportation, and healthcare access.Reference Baciu 6
Given the pivotal role law plays in public health, there is a growing need and demand for public health law training among practitioners.Reference Bogaert 7 The field of public health currently faces multifaceted challenges including chronic diseases, global pandemics, climate change, and social inequities.Reference Fox 8 Moreover, the legal landscape, which is constantly evolving and rapidly changing, can be confusing, making knowledge of public health law even more critical. 9 Addressing these challenges requires a synergy between public health expertise and legal knowledge. 10 Various publications, surveys, and reports have underscored the importance of ensuring the public health workforce is trained in law and policy,Reference Bogaert 11 highlighting the urgency to integrate public health law into educational curricula.Reference Ransom and Yassine 12 Yet a significant gap exists. 13 Many public health practitioners lack formal education in law and legal principles, and only a small fraction of public health schools offer dedicated courses in public health law. 14
Recognizing this gap, ChangeLab Solutions, in partnership with Centers for Disease Control and Prevention (CDC)’s Public Health Law Program, developed and piloted a foundational public health law curriculum aimed at faculty in schools and programs of public health (SPPH). This article examines the curriculum’s development, implementation, and pilot findings. The findings from this pilot further support prioritizing public health law education in SPPH to better prepare the public health workforce for addressing social and structural health inequities. By equipping future public health practitioners with essential legal knowledge and skills, this curriculum seeks to enhance their capacity to address complex public health challenges and advance health equity by ensuring they understand their authority and the limitations on that authority to create change.
First, the article delves into the imperative for public health law training, describing the need for legal expertise in the field of public health and the consequences of its absence. It then outlines the methods employed in developing and implementing the pilot curriculum, detailing the curriculum’s structure, recruitment strategies, and faculty participation. Next, the article presents the results of the pilot, including faculty feedback on module structure, content, and delivery, as well as insights into student comprehension and impact on their future career paths. The discussion section analyzes the implications of these findings, highlighting the significance of integrating public health law into educational curricula and addressing the challenges encountered in doing so. Finally, the article discusses public health implications of this study, emphasizing the need for collective efforts from students, faculty, accrediting bodies, and public health organizations to prioritize public health law education and enhance the legal capacity of the public health workforce.
Need for Public Health Law Training
Given the law’s impact on health, there is a growing need from the field for public health practitioners to have knowledge and skills in public health law.Reference Ransom 15 In 2021, the Public Health Workforce Interests and Needs Survey and Harvard Business Review indicated that policy and legal analysis is a needed skill for public health practitioners in the field.Reference Varma, Long and Chokshi 16 Similarly in 2022, experts attending The Future of Public Health Summit identified “building legal capacity among public health practitioners” as an action item for their strategic plan to improve public health. 17 These findings are consistent with CDC’s pilot test surveys conducted from 2020 to 2023 in which 86% of state and local health department participants find public health law relevant to their current work and 85% intend to use public health law concepts for future professional project work.Reference Pella 18 Studies show that understanding the connection between law and health outcomes remains one of the primary knowledge gaps among the US public health workforce. 19
Despite the importance and growing demand for public health law training, public health law is not included in most academic public health programs. A 2020 environmental scan conducted by ChangeLab Solutions of SPPH across the United States found only 33 out of 190 (17%) SPPH have at least one course dedicated to public health law topics and only 13 out of 190 (7%) SPPH have one public health law course that is required for graduation. 20 Thus, few SPPH provide students with an opportunity to take a public health law course, and even fewer SPPH require students to take a public health law course to obtain a public health degree. The need and lack of opportunity for public health law training presents an opportunity to develop a foundational public health law curriculum for SPPH students. In response to this identified opportunity, ChangeLab Solutions (with funding from and in partnership with the CDC) developed and piloted a foundational public health law curriculum for faculty to use in SPPH in both undergraduate and graduate programs.
Methods
Curriculum Development
A group of curriculum consultants, in collaboration with ChangeLab Solutions, led the design and development of the curriculum and aligned it with existing public health law competencies. To inform the module content, the consultants conducted an extensive literature review on existing public health and public health law competencies and facilitated collaborative discussions with ChangeLab staff to formulate the pilot structure and content. The curriculum consultants expanded upon the content in the Public Health Law Academy, 21 online trainings that focus on the use of law and policy to improve population health outcomes for public health practitioners. Additionally, module pilot materials were informed by findings from the 2020 ChangeLab Solutions environmental scan and key informant interviews which focused on public health law training in SPPH. Finally, the modules were developed to align with public health competencies including Council on Education for Public Health Master of Public Health (MPH) competencies, the CDC Public Health Law Competency Module, and the Five Essential Public Health Law Services.
As a result of the findings from the environmental scan and extensive literature review, the curriculum consultants and ChangeLab Solutions developed six modules focused on defining public health law and explaining its role in shaping health outcomes and addressing inequities. As outlined in Table 1, the modules focused on: (1) introduction to public health law; (2) sources of public health authority; (3) limits on government power and preemption; (4) limits on government power and individual rights; (5) balancing government power with individual rights; and (6) legal epidemiology. Each module included an instructor guide with a script, suggested pre-class readings and videos, student engagement activities such as discussions and exercises, and additional resources on the subject matter. The education modules were designed to be integrated into existing public health courses. Figure 1, Curriculum Map: Public Health Law Map & Options provides four options faculty members could choose from in delivering specific modules. Delivery of all six modules was designed to take two weeks of course time, or approximately 8.5 hours. This did not include any of the pre-work recommended for students.
Public Health Law Module Topics and Aligned Competencies
Source: Curriculum Consultants: Max Gakh, Savita Malik, Amie Fishman
a Public Health Law Competency Model: Version 1.0 (Centers for Disease Control and Prevention, April 2016), https://www.cdc.gov/phlp/docs/phlcm-v1.pdf.
b Accreditation Criteria: Schools of Public Health & Public Health Program (Council on Education for Public Health, amended August 2021), https://media.ceph.org/documents/2021.Criteria.pdf.
c S. Burris et al., “Better Health Faster: The 5 Essential Public Health Law Services,” Public Health Reports 131, no. 6 (2016): 747–753. https://doi.org/10.1177/0033354916667496.
Curriculum Map: Public Health Law Modules & Options.
Source: Curriculum Consultants: Max Gakh, Savita Malik, Amie Fishman.
Recruitment and Participation
Recruitment of participants included promotion of the pilot at national public health conferences and leveraging existing ChangeLab relationships with faculty. Participants included faculty members with a range of professional degrees including JDs, PhDs, and MPHs, among others. Faculty across eight universities piloted the curriculum during the fall 2022 and spring 2023 academic semesters in a variety of undergraduate and graduate public health courses. Participants attended a kick-off and wrap-up meeting, as well as optional monthly office hours with ChangeLab staff and sometimes the curriculum consultants. Office hours allowed participants to ask questions related to the material, discuss successes and challenges, and share resources. All participants provided feedback via a qualitative survey and/or the group meetings. Faculty members that taught at least one module and provided feedback via a feedback form or group meetings received a $1,000–$2,000 stipend based on their level of participation.
Implementation and Adaptation
Instructors were free to implement some or all modules as aligned with the options in Figure 1: Curriculum Map: Public Health Law Modules & Options. Participants could adapt the modules to fit their existing class requirements and needs. Adaptions could be in the form of editing module materials to align with course descriptions or supplementing resources and activities already provided in the modules.
Results
Modules Taught and Faculty Training
During the fall 2022 and spring 2023 semesters, eight faculty members piloted the curriculum in public health programs; two of them taught it during both semesters. Modules 1–6 were taught by one faculty member, Modules 1–5 by another, and Module 1 by all faculty members. Among the eight piloting faculty members, two have doctorates. The instructors of modules 1–5 and 1–6 have Juris Doctor degrees.
Module Structure and Materials
Overall, faculty were satisfied with the six module topics and structure of the content. The majority of faculty members reported the format of the individual modules, as well as the module series collectively, contributed to the effective learning of the material by students. Additionally, faculty expressed that having video presentations to supplement the assigned readings was helpful and that the materials allowed students to remain excited and engaged with the information.
Faculty also provided feedback to improve module structure, format, and materials. They felt more comprehensive slides and a clearer instructor’s guide would help them incorporate the modules into their lessons more cohesively. The slides had only provided simple text for some of the components of the training given copyright challenges. Faculty also mentioned how the module structures could be challenging depending on their class format or student academic backgrounds. One suggestion from faculty was to organize the module activities by the type of learning environment (in-person, online, asynchronous) to help ensure activities work in all settings. Another suggestion was to provide different versions of the script in the instructor guides geared for various academic levels (i.e., undergrad, graduate) to ensure the material is accessible at all levels. Finally, faculty expressed a desire for real-life case studies about current public health challenges and assessment and rubric materials to be added to the materials. Faculty noted that any assessment materials would need to be applicable to both asynchronous and synchronous classroom settings.
Module Content
Faculty noted that students found the content engaging, relevant to their coursework, and mostly understandable. However, a common theme communicated by faculty was students’ struggles with certain legal principles and concepts. Topics that students struggled with included preemption, jurisdiction, precedent, legislative process, authority, policy, and the idea that there is not a single answer to a legal question.
While there were challenges, one faculty member mentioned that the modules added to students understanding of how these concepts apply to the public health landscape. The faculty member stated, “Yes, it’s clear that most reach a eureka moment where they suddenly understand that all the things they’d like to do as public health practitioners are regulated by a complex structure of legal parameters and principles.”
Finally, faculty also recommended additional module topics such as:
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• Social determinants, health equity, systemic racism
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• Administrative law
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• Legal concepts of causation
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• Burden of proof
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• Judicial deference
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• Public health impacts of infrastructural and other less-typical public health laws
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• Public health ethics
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• Public health emergency law
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• Specific public health law topics like infectious disease, tobacco, chronic disease, injury, and the environment
Monthly Faculty Office Hours
Most faculty members highlighted the monthly optional office hours as a valuable source for support, peer learning, and new ideas. Comments from faculty members included:
“I loved having a group to discuss teaching PHL with! That type of peer mentoring has been an incredibly valuable experience. I incorporated several suggestions of others into my class … I would love to keep up with a teaching cohort!”
“I am one of those faculty members who does not have a JD and was relatively unfamiliar with public health law. I appreciate the resources provided and the resource suggestions shared on monthly calls from various experts was [sic] enormously helpful. I would recommend such calls, even if it is once or twice a semester in the long run.”
One faculty member suggested creating more collaboration spaces such as a shared document for frequently asked questions. Many shared a desire for a future space where newer and older faculty members could come together for mentoring and facilitated discussion.
Future Career Paths
Faculty members discussed how the modules served as a positive introduction to public health law concepts, and motivated students to dive deeper into the material, while exploring previously unconsidered career paths and interests in public health law. One faculty member noted that two students are doing doctoral dissertations using legal epidemiology and two MPH students applied and were accepted into the CDC Public Health Law Fellowship. Another faculty member noted that two students shared that this content will inform their career decisions after graduation. However, two faculty members noted that only having this content in one or two classes was not enough to influence or know if it influenced career paths. One faculty member shared that it would be good to provide more examples of how to learn about public health law for interested students.
Non-JD Faculty
Some faculty members without a JD noted that they experienced some challenges teaching the content and some had questions about their qualifications to teach the material. Faculty members without JDs only taught Module 1 during the pilot. One faculty member expressed that while the materials “immensely helped to deliver the content … at times it felt overwhelming to be able to answer students’ questions thoroughly” and that they felt “underprepared because it is not my field.” However, those that didn’t feel prepared were often able to seek additional support from other colleagues with JDs. Some non-JD faculty members noted it would be helpful to take the class before teaching it and to have a lawyer help support teaching the class. Like most faculty, they highlighted the desire for real-world applications and case studies as they felt less comfortable developing their own. Some noted that they wanted instructor materials that addressed the case studies and clearer instructor guides that included added nuances for faculty who might not be as familiar with the law. These faculty members also shared that their classes had lots of good discussion and interest around current topics and how public health law fits into those topics. One faculty member noted that having a certificate for undergraduate students in public health law could help make students stand out.
JD Faculty
The faculty members with JDs noted some difficulties with teaching the content. It was difficult to teach classes with a mixed population of law students and public health students due to different levels of background knowledge related to both public health and law. Some concerns were shared about faculty without JDs teaching public health law. One faculty member noted that detailed rubrics for scoring would be helpful to ensure consistency. Detailed rubrics would also make it easier for those without JDs to ensure no issues are missed on assessments. One faculty member shared that those without a JD could use a law student as a teaching assistant in the class. Faculty with JDs also shared that it was very important to teach non-law students what are reliable legal sources, some basic legal issue-spotting skills, and when to consult a lawyer.
These faculty members also shared that the content overlapped with what they were already teaching, but that the modules were a good foundation for people that want to use a portion of it for a class. One faculty member shared that the modules gave them a different way to explain things and often had simpler language which made it more approachable. Another faculty member noted that the curriculum was very similar to the Public Health Law Academy (as noted above), which they also assign to their class. The similarities made it challenging to not repeat the same information in their lectures. Finally, one faculty member noted that the modules (which were developed for 8.5 hours of teaching content) did not include enough information for a semester-long three-credit course and similarly that more in-depth information was needed for some of the modules.
Discussion
This pilot curriculum will help address the need for upcoming public health practitioners to have a foundational understanding of public health law and how to apply it to their work. Results from the pilot showed students found the material engaging and provided faculty with strong foundational content and resources to teach fundamental concepts of public health law. The pilot highlighted the need to ensure curriculum materials are adapted based on the teaching method (in-person, online, asynchronous), students’ academic levels (undergraduate or graduate), and the background of the students (public health or law).
Piloting this curriculum in SPPH helped identify some potential barriers that might hinder effective training delivery such as limited resources for instructors teaching public health law. For example, resources could include adding JD faculty to staff to help develop and teach public health law courses or to serve as collaborators in this work. This observation reinforces evidence from ChangeLab Solutions’ environmental scan, in which researchers found that 67% of public health schools and programs did not have a faculty member with a JD. 22
There are several ways to help ensure that faculty teaching public health law are supported. Results from this study demonstrated that providing a collective learning space for those teaching public health law to ask questions, share resources, and troubleshoot could contribute to faculty’s confidence in teaching. Offering supplemental support and training can also help faculty that are less experienced with the material feel more comfortable. Additionally, establishing partnerships with law school faculty or other legal communities could serve as additional supports and encourage collaboration between public health programs and other entities with legal expertise.
The curriculum consultants implemented several updates to the curriculum in response to the feedback provided by faculty during the piloting phase. They updated the instructor guide with the goal of making it easier to follow and included case studies for each of the six modules. Future revisions should include recent court cases and information about the changing sociopolitical landscape as suggested by faculty that participated in the pilot and the 2020 environmental scan and key informant interviews. 23
Public Health Implications
Increasing current and future public health practitioners’ capacity to understand and apply public health law concepts is crucial to improving population health and health equity. 24 Law is a tool that has been used since the field’s inception to impact public health both positively and negatively. 25 As the field of public health has faced many recent challenges to its authority to protect the community’s health, understanding public health law is even more critical.Reference Looker 26 The public health law curriculum piloted by ChangeLab Solutions highlights how public health law knowledge and concepts can be included in SPPH curriculum at a foundational level to equip future public health practitioners.
Ensuring students gain an understanding of public health law in SPPH could be addressed by adding more public health law courses in SPPH and incorporating public health law as a core public health competency for accreditation. Requiring the integration of public health law concepts into SPPH curriculums would improve students’ ability to understand and address structural inequities and improve health outcomes. To provide students with a comprehensive public health law course, findings from the piloting phase reveal that additional administrative resources such as funding and increased hiring of JD faculty, as well as non-JD faculty training and support in public health law are needed. The findings from this pilot can be used to inform faculty, academic institutions, and public health organizations about specific strategies and initiatives they can implement to enhance the legal capacity and skills of the public health workforce.
Acknowledgements
The authors would like to thank Max Gakh, Savita Malik, and Amie Fishman for their work in leading the development of the modules and their collaboration throughout the project. We would also like to thank Don Benken, Samantha Bent Weber, Abigail Ferrell, and Matthew Penn for their review and partnership in this work. Additionally, Nessia Berner Wong, Alexis Etow, and Rachael Bennett for their review and support throughout the drafting process.
Disclosure
The work discussed in this article was supported, in part, by the Centers for Disease Control and Prevention (CDC) of the US Department of Health and Human Services (HHS). The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement by, CDC/HHS or the US Government.
