Practicing Public Health

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Until the COVID-19 pandemic most people were only vaguely aware of the field of Public Health. During the pandemic a great deal of factional distortion and misrepresentation warped the public perception of this vital field.

Public Health is largely responsible for the increase in lifespan in the U.S. from 47.3 years in 1900 to 78.7 in 2010. In 1900 several infectious diseases including influenza, pneumonia, and tuberculosis were among the top causes of death, but in 2010 they were notably absent. The progress against infectious diseases is largely a story of the development of effective sewage and water treatment along with pasteurization of milk. These are all preventative measures rather than treatments. In this sense, Public Health involves creating environments where disease doesn’t happen and we now take these achievements for granted.

The podcast Transforming Your Health and Extending Your Life explores the creation of public health which has created civilization as we now experience it.

What follows is an approximate transcript of this podcast interview with Dr. Amy Hicks, Chair of Health Sciences at Bob Jones University.

[01:02] Mike Gray: Well, we welcome today Dr. Amy Hicks to the program, and Dr. Hicks has a very interesting educational arc. Welcome, Amy.

[01:14] Amy Hicks: Thank you so much. I'm very happy to be here with you. I've been looking forward to getting to come talk about my field and also get caught up with you.

[01:23] Mike Gray: Yeah, it's been too long.

[01:25] Amy Hicks: It has been.

[01:26] Mike Gray: That's what happens when you're not in the classroom every day. You kind of lose touch with people who matter. So, your BS is in what area?

[01:36] Amy Hicks: My Bachelor of Science is in Premed. I came here in the early 90’s and completed a bachelor's, like I said, Bachelors of Science in Premed. So, my house was the science building here. Of course, you were one of my favorite teachers and taught me how to think like a scientist. But I think I was very similar to other students that I still see coming in now that they're interested in medicine in some form. And the only two things they know about are I could be a doctor or I could be a nurse. And so that's kind of where I came in. And I thought, well, I would prefer a doctor. So that was my route at the time.

[02:18] Mike Gray: At some point, your desires or realities, whatever it was, changed. You ended up going to Wake Forest for a PhD in what?

[02:30] Amy Hicks: I did. So, my transition time, I guess, and finding a new career came after college. I didn't figure it out in college. That might have been better and more streamlined if I had, but I worked in various jobs in hospitals and doctor's offices for a couple of years after I graduated with my bachelor's. And I realized I did not want to be a physician. Maybe it was just the practices that I found myself in, but I found it pretty tedious, and I wanted something that was new and changing.

So, whether for the better or not, I'm not sure if my PhD was new and changing, but I got a PhD from Wake Forest School of Medicine in Winston Salem, North Carolina, in biochemistry. Not what most people probably think about when they think of exciting and new. But my research was specifically in the field of cancer immunology. And I looked at the role that the innate immune system in particular plays in the body's defense against cancer cells. So, I loved that. And what that taught me about myself was that I liked hands on learning, and I liked discovering new things. So that part of research really fit my personality to find new things as opposed to just learning old things.

[03:58] Mike Gray: So, at that point, some people would really draw a line between a research type person and a teaching type person. Of course, graduate school is populated mostly with research types who, if they're pressed into service as teachers, are not necessarily really effective in that role. So, what did you intend to do with your biochemistry training?

[04:26] Amy Hicks: That's a good question. That makes me think of when I went to Wake Forest for an interview, actually, Wake Forest was very big on putting people into research, especially they wanted you to have high career ambitions, to become a top line researcher, work at a really high-level school. And when I first went into interview, I told them, I want to be a professor. I want to teach. And they looked a little bit disappointed in that, but they accepted me anyway. And so, I went to grad school with the thought that I would probably teach somewhere someday. I loved the science of biochemistry, but I did not see myself working in a lab for the rest of my life.

So, I said, I like learning new things, but I also want them to be practical things that are useful. And I looked at some of those around me, some who spent a lifetime analyzing the crystal structure of a protein, and I did not want that. That seemed so mundane and frustrating to me. I wanted something that made a difference in my lifetime in the health of people. So, I knew I wanted something more interactive with other people, and I also wanted the opportunity to train others to love science as much as I did. So, I had my sight set on being a professor.

[05:46] Mike Gray: Okay, but then there was another turn in the road, right?

[05:48] Amy Hicks: Yes, there was.

[05:49] Mike Gray: What was that?

[05:51] Amy Hicks: Well, I did something that you're not supposed to do if you are going to have a career in research. And that was I had four children. No. Even one child. No. I remember actually faculty members that I had in grad school that didn't have any children until they were, like, almost 50 because it interfered with their career. And so I had my first child at the end of grad school. I actually defended my dissertation two weeks before he was born. So that was very interesting.

I never intended to leave the workforce, and it was a very difficult decision for me to leave the workforce and to stay home. Eventually that happened one day when I picked up my son. He was about six months old, probably. I picked him up from the babysitter, and he reached for her instead of me, and my heart broke and I knew I had to spend more time with him. And so, at that point, I went part-time. My advisor, I had finished my PhD, and I was in my first postdoctoral fellowship, and my boss very kindly let me go back to working, I think three days a week. And then when my second son was born, I made the decision to take a couple of years off until they were a little bit older. Well, that couple years turned into seven years. Three years after my second son was born, I found out I was having twins. And I remember I just burst into tears at the doctor's office, and I said, I'm never going to work again. And she just looked at me full of pity, because at the time, my boys were four and two, and I had twins coming. And she said, oh, you'll be working, you're just not going to get paid for it. Yes. So, I was home for about seven years, and those were wonderful years, but they were also that death knell for any remaining idea that I might have had of going back into research and running my own lab. I knew that that was past and that was okay because it wasn't what I wanted to do.

[08:00] Mike Gray: But eventually you decided to go back to school to train in a different area than biochemistry. So, more school!

[08:13] Amy Hicks: I did, yeah.

So, I loved school. I was one of those kids that every fall, as soon as August came, I was so excited to get back into school. And so, during that time, I decided, well, let's get some more schooling while my kids are little, and I can't work or I choose not to work. I never actually totally left the work field. I did stay involved in my career peripherally. At the time, I attended weekly conferences where oncologists presented on patient cases just to try to stay up in my knowledge of oncology, I worked as an adjunct faculty member teaching an anatomy and physiology class. I co-founded a networking group that was focused on raising the awareness of biotechnology in our area in the Piedmont of North Carolina. But to be honest, I often felt a little lost because I didn't know what I was going to do with a degree that had meant so much to me. And I loved having that degree, but I didn't know how it was going to fit into my future.

Around the 6th year of staying home is the first time I remember really being exposed to the field of public health. Looking back, I don't think I really knew what it was. Even as somebody who had been immersed in the medical field, I didn't really have a good understanding of what public health was. But the more I looked into it, it seemed like it married my interest of science, along with my desire to work with a larger public and really my desire to be innovative in problem solving. All of those things are necessary in public health. So, almost on a whim at the time, I enrolled in a Master of Public Health program, and I immediately knew that that was the field for me. That was what I was created to do. It was what I loved to do. And I found that my PhD in biochemistry was not a waste. It gave me a solid foundation for understanding all those physiological processes that are going on at that micro level. And it gave me a great training in the scientific method that gives me a vision for how public health should be conducted, that it's not some soft science that should be less rigorous, but it should be practiced and taught just as rigorously as any other science.

[10:35] Mike Gray: So, you're currently the Chair of Health Sciences at BJU. And Health Sciences is a big umbrella term that includes, what?

[10:46] Amy Hicks: A little bit of everything, really. We have a variety of career endpoints in our division, so some of those are really prescribed. Students come in, and if they get through that program, they know exactly what they're going to do. So, for instance, Premed, which is my former bachelor's, is now under my division. And so, I have very, very motivated students who come in knowing they want to be a doctor. They have a great acceptance rate into medical school and that's their career is laid out for them. We have students who want to go into clinical medicine, who want to go into therapy. For instance, communication disorders is in our division. So, students who want to go on into Speech Language Pathology or audiology. We have also students who want to go to PA school, pharmacy school. But then we have the opposite side of that, students who are interested not in clinical medicine and working in healthcare, but in students who are interested in community health. We have students who, for instance, major in nutrition, students who major in public health. So all of those are kind of under the umbrella of the Division of Health Sciences. And we're very excited too, because we're introducing two new Master's programs in the fall. We have a Master's of Speech Language Pathology that's going to be offered. We've got our first cohort of students enrolled and ready to go. And then we're also starting a Master's in Public Health, two new programs which will keep us all hopping, I'm sure.

[12:20] Mike Gray: Yes. So, but you're already hopping, as I understand it. You're Assistant Director of the Center for Community and Global Health. Is that in your spare time? What's the purpose of that center?

[12:35] Amy Hicks: Well, I hate to be bored. I remember sitting in freshman orientation, and Dr. Gunter Salter was teaching that one class, and he said something—the only thing that has stuck with me from freshman orientation—where he said, boredom is the disease of a small mind, and if you're willing to think—or he didn't say this—what I took from that is—if you're willing to think, you will never be bored. And so, the Center for Community and Global Health, our mission vision statement is that we exist to improve the health of vulnerable populations locally and globally, et cetera, but we utilize multidisciplinary, innovative, and evidence-based interventions. And what that means is that we're the research arm of the School of Health Professions research and interventions. And so, we work very closely with people in the community, with people in our community here in Greenville and also people around the world in order to help those who are the least seen. And I really take that to be a very biblical command that throughout the scriptures we see constantly this admonition to look out for refugees, for the strangers, foreigners, as some translations would say, for widows, for the fatherless, for all of those who are disadvantaged, most at risk. And that's a big part of public health. But that's what the center for Community and Global Health exists to do.

[14:11] Mike Gray: Lots going on there. Probably we should get a little more precision—because it's so big here—about this idea of public health. I think for many Americans, the COVID pandemic was their first sustained contact with the field of public health. Can you give us a succinct sense of what public health is? I guess there is a sense in which it kind of explains itself, but I think it's maybe even a polarizing term right now. The public is involved and health is involved, but what's the interaction look like?

[14:51] Amy Hicks: Absolutely. So public health in the United States is a victim of its own success. We don't tend to see public health. It's running seamlessly under the surface until it isn't, like in COVID.

So, we don't see how much of our lifespan, our life expectancy, and our health outcomes are actually completely due to public health. Since 1900, in the United States, the life expectancy of the average American has increased by about 35 years. About five of those years are due to advances in medical treatment, and about 30 of those years are due to advances in public health. So, things like clean water, things like childhood vaccines, we don't see children dying from polio anymore. But that was a scourge across the country when I was a kid. Yes.

[15:50] Mike Gray: Okay. I'm that old. I got vaccinated with both different kinds of vaccines because one was supposed to be like, you don't have to worry about going to the old swimming hole anymore. And it's like, oh, wait, it isn't working as well as we thought, so there's this other vaccine. So, I was greatly relieved that there was essentially no chance to spend the rest of my life back then in an iron lung, right?

[16:16] Amy Hicks: Yeah. And as a mother, I never was concerned that my children were going to die of measles. But that throughout history has not been the case. But even advances like automobile safety that ticked my grandma off so bad when seatbelts became mandatory law, which we take for granted now. But advances in vehicle safety are really part of public health because there was such a high crash fatality.  

So throughout each of these kind of eras that we've gone through in the United States, public health has improved life expectancy, but it's done so in ways that people haven't really noticed and that we've certainly grown beyond noticing now.

And so public health, you mentioned it can be polarizing. It absolutely is polarizing, which is a shame. It's been used by both sides of the political spectrum to kind of hammer the other side. But public health is a science. It's a field of practice. And what makes it polarizing is a fairly American phenomenon. Not to say that it's not in other countries, but in America, we very much value our individuality. We value our autonomy. We value limited government. And so, when you have a problem like COVID, that puts public health directly up against some of our core values. Because public health focuses on the greater good. It doesn't focus on individuals. It focuses on communities, on populations, on the public.

So, when you go to a doctor, your doctor is treating you, but a public health professional is treating your whole community. And so that individualism versus the greater good can kind of bump up against each other. Public health also a key aspect of it is when you go to the doctor, it's typically to be treated for something that's wrong with you. I know we have our annual checkups, and we are more and more concerned in the US about prevention, but that hasn't always been the case. We go to the doctor to be fixed of something. Public health looks at why do people get sick in the first place and how can we stop it? So, an example of water, water quality, you mentioned polio, which is water transmitted. And when I work in other countries, one of the things that we're looking at is water quality because public health hasn't advanced to the same degree in all countries, and children still die of waterborne diseases. So public health looks at prevention rather than being reactive. We don't want to wait and treat everybody. We want to keep them from getting sick in the first place.

And so sometimes what that means, like in the example with my grandma getting irritated about having to wear seatbelts, is that people are asked to voluntarily, hopefully give up some of their own rights in order to prevent that sickness in the first place temporarily, not forever. And then I would say the other part about public health—so we said that it's focused on communities, it's preventative. And the other part of public health is that it really focuses on disparities. Why do some groups live 10-20 years less than other groups? And so public health seeks to address that.

[19:57] Mike Gray: So, I guess that leads to the question of how do those things get addressed? What do public health professionals in particular get involved in? What's the practical level of this? When they show up for their job? What do they do?

[20:16] Amy Hicks: That's a good question. Sometimes students in undergraduate programs particularly, can feel very overwhelmed by, what does this mean I'm going to do? Because public health is so vast, no one person covers all of the field of public health. It's very, very extensive. So, what a person does really depends on their community. Where do they work, as well as their skill sets. There is a place in public health for every skill set.

Public health involves advocacy and policy change. It involves politics. And so there are lawyers, there are advocates who instruct on policy. And so that would be one form of public health. Public health involves working with communities as a health educator. So, for instance, we do health education in Ghana, one of the places that we work, because we work in child nutrition and we go into Ghana, we work with school systems in order to identify how many of their children, what percentage are malnourished, how many are at risk? And then when you find those children, we come up with, what do you do about it? What do you do when you have this child who's malnourished? What do you do when 15% of the students in a school are malnourished? And one of those things is health education. Simply talking to teachers about what are the signs of malnutrition, what are the consequences of malnutrition, how do you address it? We work with families to talk about what a balanced diet looks like at every childhood stage. So that would kind of fall under health education.

You're not going to have to do that in the United States. In that way, we have the opposite problem of increasing childhood obesity. So, health education is still an important part of helping to lower obesity in children through educating people on how active should kids be? What are the dangers of screen time? Anytime you see messages about that, that's public health education. We also have interventions. This would be similar maybe to a family physician working with a patient where you go into a community, and you start an intervention aimed at a particular problem. So, you work specifically with people who are at risk for, say, cardiovascular disease, and you do teaching classes. You need better access to health care. So, it's a very wide field. And sometimes that can be like I said, it can be frustrating because there's so much you could do.

[23:05] Mike Gray: You painted a good picture, I think. When this gets into the classroom, particularly a classroom that's centered on powerful ideas that are broadly applicable, can you give us an example of one of the core concepts that need to be grasped? Not a definition memorized, but the actual idea, thoroughly understood and embraced to the level where creative application of that idea is expected of the student in ways that are, of course, achievable to an undergraduate student or in the master's program to master's level student. Do you have an example, concrete example of a concept?

[23:55] Amy Hicks: I do.

[23:56] Mike Gray: An idea we could say for those in the audience who are not used to the term concept?

[24:02] Amy Hicks: Sure. I do try to structure all of my courses to minimize lectures. Just standing up there, droning on and on. I rarely have students memorize definitions and come back and write a definition on a course, on a test. Of course, anybody in any field needs to be able to use the vocabulary of their field. So, they need to know those definitions. But more than that, they need to understand the concepts and make them their own. They need to know how to think, like, in my case, a public health worker.

And so, I structure my courses with a lot of active learning. And so that active learning sometimes means case studies where they're given a case, and they have to go back and research it. In my Introduction to Public Health course, I assign a disease to a group of students. So that disease might be breast cancer. That disease might be heart disease. It might be childhood obesity. But I assign a group that disease, and they have to go back. They have to research and then come back and present to the class what are the risk factors for that disease. So, what is your typical person who has that disease? What have they done? Have they smoked? Likely. Are they overweight? Is obesity tied? But then we don't just stop there. We look at the underlying causes and say, okay, so why are some groups more likely to smoke? What does education have to do with your likelihood of smoking? What does education have to do with the diet that you eat that makes some groups more likely to be a . . .

[25:45] Mike Gray: A particular kind of education?

[25:47] Amy Hicks: Yes. [But also] actually being educated. Okay, that too. Yes. So those social determinants that determine, like it says in the title, what we do, finished high school or didn't finish high school.

[26:04] Amy Hicks: If you did not finish high school, your life expectancy is probably 20 years less than somebody who went to college on a population level. And so, I asked them to look into that. Why is that? What groups are more at risk? Why are they more at risk? And then when they have analyzed that disease down to the population level, then they come back and say, I make them tell me. Okay, what are research, published, evidence-based interventions that work in this? What are some gaps in our knowledge? And so, they have to go back and really own that entire disease, but not so much at the medical level, but at the population level to understand disparities and understand the interventions that they would actually be involved in.

So let me give you another example. I teach a class called population health management, and one of the topics that we discuss in that class is homelessness and the impact that homelessness has on the health and the economy of an entire community. So, it's well known that homelessness, the higher the rate of homelessness, the worse the outcomes for the entire community and the more the hospital system has to spend. So, health care becomes more and more unsustainable when you have homelessness. And so, to get them to really understand the problem of homelessness, I take them on a field trip and we go to the bridge here in Greenville where it became a crisis in the upstate. And we have a guest.

[27:43] Mike Gray: You want to explain?

[27:44] Amy Hicks: Yes, I will. So there's a bridge in one of the poorest sections of town that has a lot of housing instability. And this bridge became kind of the focal point for homelessness in Greenville County, meaning that there were some people living under the bridge that were homeless. And a news report was done on these individuals. And out of an, outpouring of love and compassion, churches and other groups started coming down to that bridge and giving things out.

[28:20] Mike Gray: I remember that.

[28:21] Amy Hicks: Yeah. So they gave out things that were important, like food, toiletries, et cetera, clothes. But then out of their abundance and generosity, some people started thinking, well, they're humans just like I am, so maybe they would like the same things that I would like. And so at Christmas, people started bringing down Christmas trees. And at the Super Bowl, people started bringing down televisions so that people could watch this with good intentions. But that had a huge problem. It backfired. And more than 100 people soon were living under that bridge because word got out. This was a place; it was kind of luxury living for homelessness. So, fights broke out, people ended up in the hospital, and the police had to disperse that as an area of homelessness.

So, students go down there. I have them learn from the director for the Greenville Homeless Alliance, and she talks about what's the impact of homelessness on the individual, on the community, and why are there good ways to address it and bad ways to address it, and what can you do as a public health professional or a healthcare worker? So, I try to make something jump off the page that otherwise would become pretty boring and just faceless. But when we put a face to it, then that concept sticks.

[29:47] Mike Gray: Sounds like it takes a lot of imagination and creativity to create an environment like that for students. What have been some formative influences on your approach to teaching and learning since there's so much emphasis on what people in the profession call active learning? I've said multiple times, I don't think there is any other kind.

Amy Hicks: I know exactly what you mean.

Mike Gray: And it's obvious from the examples that you've used. These are not students sitting passively in a seat, listening to information, being dispensed by the teacher. That they're having to own what they're learning and apply what they're learning as they're learning it. So, what have been some of the formative influences that steered you that direction?

[30:39] Amy Hicks: That's a good question. So, I feel like I'm very much still in progress of getting this down.

[30:48] Mike Gray: You always will be.

[30:49] Amy Hicks: Yeah.

[30:50] Mike Gray: I can tell you as somebody who’s further down. And that's inspiring, actually, that it doesn't get old.

[30:57] Amy Hicks: No, it doesn't.

[30:58] Mike Gray: You always got another opportunity. Next time this course comes around, or maybe even while the semester is going, like, let's just reformulate things.

[31:07] Amy Hicks: Yeah. Some things I've tried have fallen flat on its face and I thought, well, that didn't work, so let's try that again next year a different way. So, trial and error is one way, but I think the way that I became really aware of this, a couple of different influences. So, I was fortunate enough to sit under your teaching in undergrad. And I remember coming in my freshman year, biology, very deer in the headlights. I'd always been the top of my class at a small private school, and then I came into this big lecture hall, and there were all these kids who were smarter than I was, and it didn't matter how much I was a good memorizer. The tests were not just write it, fill in the blanks. And that kind of blew my mind at first. But I loved that it made me question things, and it made me feel like I was actually becoming an expert. So just the feeling that it gave me to think like that. I want to give my students that to ask questions, to look for logical conclusions.

And then as a faculty member, I came in that very first summer before classes, and I was able to take the Summer Institute in Teaching Sciences again with you. I'm very thankful that I was able to do that before my first semester of teaching, because it really cemented in my mind that I did not want to just stand up there and give lectures, but I needed this to be something that intrigued them. We talk about stories in SITS. That you give stories because people learn from stories, and they do. We absolutely learn from stories. So, I try to build stories into it. I try to put a face on things. When we learn about Global Health, most of the students in that class have never been outside the country, and they have no concept of what the rest of the world looks like. So, we watch a lot of videos. We do case studies. We have people come in that talk about the cultural context of another country. Both Introduction to Public Health and Global Health are classes that I frequently have. Students come back and say, that totally changed my outlook on life. It changed how I view the world. And so that's what I'm shooting for. That's what I want them to do.

Probably one of the most impactful things that ever changed how I teach, though, had nothing to do with science and had nothing to do with public health. It was during those seven years that I was at home with my kids. I pretty early got involved in a women's Bible class and 100 moms would show up every Thursday for this class. And the way they taught was unlike anything I had ever seen in learning about faith before. The women who taught this were so practical and they were so deep thinking. And then after a couple of years, I started teaching in it and I realized that no matter how hard I tried, nobody learned as much about that lesson as I did. The teacher learns way more than the student ever learns. And so how I took that into the classroom is I want them to have to go teach something and I want them to have to learn it for themselves and then come back and tell the class. Because if I stand up and tell them, they're going to forget it in 5 minutes, but if they have to go do it, then they're going to remember.

[34:41] Mike Gray: Yeah, it's pretty powerful. And even the idea that learning how to think deeply about any domain, including Bible study, is eye opening. Obviously, scripture is more eye opening than anything else. At least it has that potential that we're talking about. An approach to life as much as even that we're talking within higher education right now, really talking about a more rewarding way of approaching all of the things that we could potentially be drawn to learn about. And I'm always comforted by the fact, since life is short, that I'll have eternity to explore all kinds of things and I'll be a much better learner than I am now. I plan to use the time that I have exploring other areas that I know nothing about right now, but that would be mind expanding and it might change my burden for or view of other people and their needs.

This has been very helpful. Maybe we'll have another opportunity to chat about the thinking of practitioners of public health. But thanks for being here today, Amy.

[36:04] Amy Hicks: Oh, my pleasure. I have enjoyed it a lot.