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 Table of Contents    
EDITORIAL COMMENTARY  
Year : 2017  |  Volume : 42  |  Issue : 3  |  Page : 127-130
 

Teaching/Training and Practice of Public Health/PSM/Community Medicine


Director-Professor of Community Medicine and Director, Dr. Sushila Nayar School of Public Health, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India

Date of Submission29-May-2017
Date of Acceptance30-Jun-2017
Date of Web Publication3-Aug-2017

Correspondence Address:
B S Garg
Director-Professor of Community Medicine and Director, Dr. Sushila Nayar School of Public Health, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-0218.212073

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How to cite this article:
Garg B S. Teaching/Training and Practice of Public Health/PSM/Community Medicine. Indian J Community Med 2017;42:127-30

How to cite this URL:
Garg B S. Teaching/Training and Practice of Public Health/PSM/Community Medicine. Indian J Community Med [serial online] 2017 [cited 2017 Dec 15];42:127-30. Available from: http://www.ijcm.org.in/text.asp?2017/42/3/127/212073


Over the years, there have been various discussions pertaining to this specialty – What to call it - Preventive & Social Medicine (PSM) or Social & Preventive Medicine (SPM) or Community Medicine or Community Health or Public Health? Whether it is a clinical specialty? What all to include as part of curriculum for undergraduate and postgraduate teaching of the subject? How best to practice PSM/Community Medicine/Public Health?

This write up, an outcome of my perceptions and introspection as a teacher and practitioner of the subject, aims to create a forum for meaningful discussion on these issues. We need to realise that the medical fraternity, students and community at large have certain expectations from Public Health Professionals and it is high time that we introspect our social responsibility.

Let us examine what is Public health and Community Medicine.


   Public Health Top


Winslow (1923) defined public health as the “science and art of preventing disease, prolonging life, and promoting health and efficiency, through organized community effort for the sanitation of the environment, control of communicable infections, education of the individual in personal hygiene, organization of medical and nursing services for the early diagnosis and preventive treatment”.[1] It has subsequently been modified and expanded by many others. A committee appointed by the US Institute of Medicine to look into public health in the 21st century defined the mission of public health as “fulfilling society's interest in assuring conditions in which people can be healthier”. The American Society of Public Health defines public health as “involving a population-focused, organized effort to help individuals, groups and communities reduce health risks, and maintain or improve health status”.[2]

While public health has been defined in multiple ways, it has come to signify preventive and promotive work on a population basis. Majority of health care providers, in addition to their curative or clinical work, also perform some public health functions. However, there should be distinction between those who perform some additional public health functions and those who are primarily public health professionals. As the IOM study (2003) states “a public health professional is a person educated in public health or a related discipline and who is employed to improve health through a population focus.”[3]


   Community Medicine Top


It came in to existence when the Royal College of Physicians, London, decided to change its faculty of Public Health to faculty of Community Medicine in 1969-70. Immediately in many countries, the name PSM/SPM was changed to Community Medicine. In India too, Medical Council of India accepted the revised nomenclature and across most of the Universities, the departments of PSM/SPM were re named Community Medicine, without making any change in the teaching, training and practice.

In late 1980's, the same Royal College of Physicians, London decided that the faculty of Community Medicine will be renamed as faculty of Public Health Medicine. However, this time, most of the countries including India did not follow it.

So, what is Community Medicine?

  • Community Medicine is a branch of medicine dealing with health care issues affecting communities as a whole- (Oxford Living Dictionary)
  • Public health services emphasizing preventive medicine and epidemiology for members of a given community- (The American Heritage Medical Dictionary)
  • A branch of medicine that is concern with the health of the members of a community, municipality, or region. The emphasis in community medicine is on early diagnosis of disease, recognition of environmental and occupational hazards to good health and prevention of disease in the community (Mosby's Medical Dictionary, 9th ed.ition).


We accepted the glamour of the word Community Medicine without bringing any change on the teaching/training and in practice. However, the fact is that as Public Health Physician we have a specialized approach and intent towards the Public health, something unique to our specialty and hence I would like to use the word Public Health in this write up, now onwards.


   Situation Analysis of the Teaching and Training of the Subject in Medical Colleges Top


In India, the curriculum for public health education was designed several decades ago and very few changes have been made since then. There is a need to review the curriculum urgently in light of the broader changes in the society as highlighted in the Calcutta declaration on Public Health.[4]

Public health is multi-disciplinary in its precept and multi-sectoral in practice. Several sub-specialties, such as epidemiology, environment and occupational health, health management, health economics, public health nutrition and communicable and non-communicable diseases form an integral part of the Public Health discipline.[5]

The Christian Medical College (CMC), Vellore and Mahatma Gandhi Institute of Medical Sciences, (MGIMS), Sevagram have their own model for teaching, training and practice of Public Health. Few years back, the Government of India decided to promote integration of primary, secondary and tertiary health care by involvement of medical colleges and invited CMC, Vellore and MGIMS, Sevagram to present their models. Afterward, it was decided that the Centre for Innovation in Public Services, Hyderabad will coordinate to promote the models of MGIMS and CMC Vellore at 5 different Government Medical Colleges in the States of Gujarat, Punjab, Andhra Pradesh, Tripura and Assam. Accordingly, the process was started but it has slowed down due to certain administrative issues. We have to promote community innovations for teaching of community medicine, as being developed and done at CMC Vellore and MGIMS Sewagram. Of particular mention are Village Adoption Programme at both places for teaching. At the same time, we have to provide clinical training and practice to medical students with community medicine department as lead department like Community Health and Development (CHAD) Hospital at CMC Vellore and General Out Patient Department (GOPD) at MGIMS Sewagram as innovative approach. Similarly, the departments in other medical colleges should also strengthen their urban and rural health training centres as well as should develop examples of show casing good public health practices.

Notwithstanding or waiting for any MCI endorsements, we need to assert ourselves as Public Health Physician by promoting the practice of public health - both in field and hospital settings. This will help create a unique image of ourselves amongst medical students, fraternity and community. At present many departments at various medical colleges function in isolation, without any clinical or health service responsibility. The intricacies of today's public health problems necessitate partnerships, sharing and collaboration between public health, clinical practice, health systems and communities. The major responsibility of teaching institutions should be to assure a system of lifelong learning and training that is based on models that support and enhance the practice of public health.[4]


   Situation Analysis on the Practice of the Subject Top


The Public Health/Community Medicine/Preventive and Social Medicine is an important and distinct discipline and a well-developed specialty in all undergraduate medical education as well as in postgraduate training programmes. However, the politicians, bureaucrats, and even medical professionals do not attach adequate importance to it, perhaps due to poor leadership, lack of motivation/confidence of the public health professionals and poor visibility/clarity. Even in medical colleges, clinician are the role model and public health is not viewed by students as an attractive career choice. We have to work hard to build up the credibility of the subject, first within our own institution. The IAPSM/IPHA should come forward to develop some guidelines in this direction.

There is no public health cadre in the health system in many states in our country. Very little or no consideration is given to qualified public health professionals in promotion, placements and postings at different level in the health system. They are treated on par with general medical doctors. The doctors with no public health qualifications and competence occupy many top-level positions at central, state and district levels where public health competencies are desirable. There are no promising career opportunities and prospects for the public health professional hence the young graduates are not attracted to the discipline.

The Medical Council of India has failed to promote the discipline of Public Health/Community Medicine and the time has arrived when we should have the Public Health Council, which already exists in many countries, in order to improve the teaching, training and practice of public health in India. In this era of globalization and market economy, the public health education must address the societal needs and values such as Human Rights, Democracy, Equity, Social Justice and Gender and Ethics. This would require coordinated inputs from all stakeholders - policy makers, health professional, academic institutions and communities.


   Education andTraining: Key Issues and Concerns Top


  • There is a lack of good community-oriented, field-based programmes for demonstration and participatory education in many medical colleges. Most medical colleges have no/minimum linkage with the health care system and play a limited role in public health services delivery and in fostering academic-health system partnerships[6]
  • Teaching learning (TL) support, equipment and supplies in most of the medical institutions are not inadequate and do not receive priority
  • TL methods and settings are limited. Opportunities for student centered and lifelong learning, e-learning, telemedicine and other modes of open and distance learning have not been adequately explored
  • The programmes do not explicitly address the development of attitudes and values for practicing public health with empathy, compassion and care[6]
  • Student assessments are designed to test cognitive skills. Public health skills and attitudes and values are not often assessed
  • Faculty development for teachers to deliver the education and facilitator skills to impart the public health competences are not regularly organized.



   New Courses and Players Top


Over last few years, there has been an increasing trend to have Masters in Public Health Programme in more and more Institutions. At present more than 40 Public Health Institutions are offering MPH to medical and non-medical graduates, which is not approved by the Medical Council of India. There is no uniform accreditation standard/guidelines for the MPH programme. Need for this programme and its advantages/drawbacks over the existing Diploma in Public Health and MD in Community Medicine, particularly in the Indian context and scenario, requires discussion and debate at IAPSM/IPHA forum.

Similarly, there is a move to create a new discipline of Family Medicine with Public Health, without due discussions and deliberations. While the discipline of Family Medicine is well developed in many developed and developing countries, there are limited guidelines for the same by Medical Council of India and National Board of Examinations. While the integration of public health and Family Medicine is a welcome step, we should move cautiously with assessment of our strengths and weaknesses and in consideration of the societal health needs.

We have also seen entry of many players, other than medical colleges, in the field of Public Health such as Public Health Foundation of India (PHFI), Institute of Health Management and Research (IHMR), Tata Institute of Social Sciences (TISS), etc. While they all have their own strength, limited efforts have been made towards the collaboration/integration of these institutions with existing public health, teaching/training and practice institutions. IAPSM and IPHA have to come forward, partner with these institutions and ensure that teaching, training and practice of public health in the country is regulated and imparted in a manner which is in consonance with the government policies, community needs, and also help in discharging the social responsibilities. While we have recently witnessed some positive movements in this directions through various IAPSM initiatives. All public health professional should contribute and strengthen this movement.

In summary, the following are the needs of the hour:

  • Promote-Partnerships/interaction between academic institution and the health system/facilities at appropriate levels to facilitate education, service and research through information exchange, programmes implementation and exchange of students and faculty.[2]
  • Promote- greater community involvement and other community development activities through discussion, collaboration and focused action by developing clear concepts and different models for testing out the most appropriate mechanisms and modalities[4]
  • Promote- practice based teaching with inter sectoral linkages among the various health determinants so as to cater and respond to the broad, diverse, and multidisciplinary needs of the health system. Teaching learning to focus on inculcation of the public health skills alongside epidemiological skills for understanding of disease dynamics for effective control, need-based health planning and program management which would help create skilled future public health managers.[7]


Recommendations

  • The definition of public health should be revised to make it simpler. There should be uniform nomenclature of the subject all over the country for the discipline preferably as Public Health which will give us a distinct identity
  • Curriculum Revision: There is an urgent need to review both undergraduate and post graduate curriculum in public health. It should focus also on topics such as health management, health economics, leadership development, public health laws and ethics, health system and policy research, guidance and counselling, public health nutrition, gender, behavioural science, information technology and environmental science. I am glad that IAPSM has started working in this direction however we should act fast. We should make a competency based curriculum which lays emphasis on skill building for effective teaching. We have to develop our field practice area, develop partnership with health system and promote practice based learning
  • Skill Based Public Health Training: We must have provision of specific time frame for skill building both at undergraduate and postgraduate levels. All departments of PSM/Community Medicine in Medical colleges and other Public Health institutions must have a close collaboration with the local/district health system in order to provide an exposure to public health practices to students[3]
  • Quality of Training: The training should be student-cantered, problem-oriented, integrated, community-based and need-oriented with electives. Modern learning methods should be utilized[2]
  • Integration between Clinical Practice and Public Health: The Community Medicine departments of medical colleges should be more involved in integrated teaching with clinical disciplines and should also be involved in the delivery of services in the teaching hospital and in primary health care settings, such as in immunization, guidance/counselling, biomedical waste management and infection control. At the same time the Clinical disciplines should also be involved in the teaching of Public Health
  • Greater Community Involvement in Public Health Development Activities: This should be achieved through discussions, collaborations, focused action and by developing clear concepts and different models for testing out the most appropriate mechanisms and modalities. This will help the academic institutions in discharging their Social Accountability[4]
  • Public Health Council of India: It should immediately be set up to develop accreditation guidelines for the public health education for all categories of health professionals, for all types of related courses and institutions.


 
   References Top

1.
Winslow CEA - The untilled filled of Public Health; Mod Med; 1920,2: 183-91.  Back to cited text no. 1
    
2.
Institute of Medicine of the National Academies, Who Will Keep the Public Healthy: Educating Public Health Professionals for the 21st Century. Washington, DC: National Academies Press, 2002:9-12.  Back to cited text no. 2
    
3.
Garg BS and Zodpey Sanjay- Status Paper on Public Health Courses in India, WHO India Country Office, New Delhi, 2006.  Back to cited text no. 3
    
4.
WHO- Future Directions in Public Health- Calcutta & Beyond, WHO regional office for SE Asia, New Delhi, 2004.  Back to cited text no. 4
    
5.
WHO- Public Health Education in India: Issues, Challenges and Way Forward. Report of National Consultation, New Delhi August 2005, WHO India Country Office, New Delhi, 2005.  Back to cited text no. 5
    
6.
WHO-Networking of Public Health Institutions, Report of Intercountry meeting, WHO regional office for SE Asia, New Delhi, 2003.  Back to cited text no. 6
    
7.
Atchison, Christopher MPA; Boatright, Daniel T. PhD; Merrigan, Daniel EdD, MPH; Quill, Beth E. MPH; Whittaker, Carol MA, MPA; Vickery, Antigone R. MPH, CHES; Aglipay, Geraldine S- Demonstrating Excellence in Practice based Teaching for Public Health; Journal of Public Health Management & Practice: January/February 2006-Volume 12-Issue 1-p 15–21.  Back to cited text no. 7
    




 

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