Sea Change: Viewing student health as public health

Julio Frenk, MD, PhD, MPH, MA / March 13, 2017

AS a college president with a long career in public health, the term “student body” takes on a particular meaning when addressing student health and wellness. From a public health perspective, students are viewed as individuals as well as a population that can be examined in the aggregate with an eye towards anticipating and preventing challenges.

These two ideas — a holistic approach involving whole groups and the idea of proactively preventing problems before they start — are the essence of public health. This view can be particularly valuable in addressing the mental, emotional, and behavioral health of students for a variety of reasons, not the least of which is the cost of not doing so. If colleges and universities only react episodically to mental health issues on campus, we create a knowledge gap that inhibits our planning for needed capacity; we miss the opportunity to support students at risk, and we negatively impact important university goals, from graduation and retention rates to our ultimate responsibility to develop healthy, constructive citizens.

Seeing the Big Picture, Starting Upstream

Rather than looking at incidents of mental health challenges one student at a time, the public health professional tries to understand patterns by looking at the entire population of students. Those populations are, of course, formed by individual people, so a population perspective doesn’t mean that we don’t pay attention to individual characteristics, especially when a person requires care.

But to understand and develop the strategies and techniques for intervention, we need to look at the entire population, including those who may not exhibit any symptoms or lack access to care.

This is particularly important in addressing the mental health of young adults.

We need to treat those who are ill and protect those who have high-risk factors. We also need to understand the difference between what is an outright diagnosis of mental illness, and what is part of the normal human condition that can become problematic when environmental factors disrupt the equilibrium separating healthy from unhealthy responses.

When someone is facing a challenge and seeks care, we of course have to respond with high-quality, accessible, and affordable services. But in public health, we proactively start a step before, and we try to stop problems before they become manifest. When we know they will occur regardless of our efforts, we try to be prepared.

These premises lead to a strategy based on four components that are extremely relevant in addressing the problems we’re seeing in the health and wellness of university students. These interrelated areas are: promotion, prevention, protection, and preparedness.
Health promotion is the proactive effort to empower people to lead healthy lifestyles. In the college setting, this can include facilitating physical activity, engagement in athletics, and participation in community-based activities. We know that all of these have very important effects in reducing issues of isolation that can lead to a number of mental health problems. Other “wellness” strategies involve mindfulness, balance and stress reduction, regular sleep and good diet, as well as activities that take students outside of their own individual pursuits.

Prevention means adapting specific measures to address risk factors that can lead to disease. Specific prevention in mental health is complicated because of its etiology. The causes are very complex, so it’s not so easy to find specific preventive measures like a vaccine—though we are learning more about effective ways to intervene before mental health manifestations occur, including drug and alcohol abuse.

Protection, from a public health perspective, means keeping students from harm. This is particularly relevant on college campus when it comes to sexual assault, acts of violence and forms of bullying and harassment, as well as controlling access to alcohol and other addictive substances.

Closely related is preparedness to respond to extreme incidents like active shooters on campus, and making sure there are procedures in place to keep students safe.

Adding to these cornerstones of public health is the culture of measurement—using metrics to assess the phenomenon itself, as well as trends over time.

For example, in the case of emotional distress, this involves everything from examining how common it is to understanding the risk factors that predispose the appearance of the problem. And, of course, we must measure the effects of our interventions. If we’ve done something, did it work? Did it not work? And to what extent? Measurement is the common foundation to the four pillars of public health.

Sharpening the Focus
Like any approach, there are challenges in adopting a public health framework to student health and wellness that must be identified and addressed, the first being an understanding of the boundaries of the problem. Mental health includes a whole spectrum of situations.

On one end, there are discrete, specific diagnoses like depression, but there are also mental health formations from other diseases. And this works both ways. When someone is given a diagnosis of a very serious disease like cancer, for example, it triggers a mental health consequence such as anxiety. In the opposite way, emotional problems act as triggers for a variety of somatic problems. Every non-mental health problem has a mental health dimension.

Then there are the usual behavioral and emotional aspects of human existence that aren’t necessarily categorized with a diagnosis, such as being in a bad mood, having an explosive temperament, or being sad for a variety of reasons.

We don’t necessarily have to medicalize these conditions, but if we don’t pay attention to them, they can escalate into full psychiatric diagnoses. We need to have a comprehensive view so that we can understand the different elements that go under the rubric of mental health, and treat them accordingly.

Fortunately, there has been great progress made in our scientific understanding of the root causes of many of these issues.
The second challenge we must overcome, for a variety of very practical, as well as moral reasons, is stigma. Stigma interferes with people seeking help; it interferes with management of the problem; and it interferes with measurement.

From a public health perspective, the single most important priority we have on campus is to de-stigmatize mental health problems. Part of this effort involves normalizing emotional issues so that we capture those at risk, as well as those who are ill.

College student face enormous pressures that can trigger deep emotions; they can be upset, angry and very worried about a variety of issues including academics and relationships. Acknowledging this helps students reach out and get help without the fear that a diagnostic label will necessarily follow. This is where counseling becomes so important as a step in preventing progression to a much more clearly defined psychiatric diagnosis.

The same approach is needed with substance abuse. To the extent that we can avoid criminalizing the person who’s abusing substances, and treat him or her as a person who needs help, we are able to bring in a lot more people who may not have come forward in the past. I think we’ve made progress in this area, but the challenge now is the increased demand for those services.
Finally, collaboration and shared learning are critical components to our full application of public health strategies in student mental, emotional, and behavioral health.

When we evaluate interventions, we should share that knowledge. We can’t afford to rediscover things that have worked elsewhere, or worse, to make mistakes that others have made but kept to themselves.

Fulfilling the Social Compact

Higher education involves a social compact where multiple parties have both expectations and responsibilities. This includes an obligation to society as a whole — which, in part, finances higher education through taxes and philanthropy, and gains from it in the form of a well-prepared citizenry. For college administrators, this compact involves assuming responsibility for the overall success and wellbeing of their students in addition to their education. Seeing student health through a public health lens will help society achieve this vital aspiration.

Julio Frenk is the president of the University of Miami and the former Minister of Health of Mexico. Prior to joining UM he served as dean of the Harvard T.H. Chan School of Public Health.