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The country has witnessed the menace of two COVID-19 waves and stares at a third. While COVID-19 has been presented as an overarching public health calamity, the influence of medical doctors in the health policy response to COVID-19 has been particularly profound. This is symptomatic of our long-standing tendency to confound medicine with public health which permeates even the highest policy-making echelons.
If anything, both the scope and consequence of medicine in the overall health of the population is significantly limited. COVID-19 entails that this fact leaves the libraries and academia, and manifests as tangible policy measures that help consolidate public health in the country.
Reforming medical education
In the 1950s, a global consensus and a concomitant national consensus on the importance of socially-oriented physicians in population health resulted in the establishment of community medicine as a distinct medical specialty, both at the undergraduate and postgraduate levels. Vast swathes of the community medicine curriculum are devoted to tackling major public health challenges through a plethora of vertical disease control programmes which have always driven the national public health discourse. The larger medical curriculum has remained more or less stagnant since post-Independence.
Similarly, hardly any attempt has been made to reform the community medicine curriculum, from one that primarily provides technical inputs to technocratic health programmes — to one which can also take on the larger questions related to health policy and health systems, and inculcate critical thinking along lines that are divergent from clinical medicine.
Some experts have advocated the establishment of public health departments in medical schools, inspired by the COVID-19 pandemic. Community medicine, while frequently equated with public health, fails to embrace multiple facets of the multidisciplinary assemblage of competencies that is public health. Juxtapose the community medicine curriculum with that of any of the few bastions of socially-oriented public health courses, and the distinction becomes readily apparent. But proponents of community medicine have not been in denial of this essential distinction — eventually, community medicine is a medical specialty while public health is a multidisciplinary science. Since public health is a multidisciplinary science, why do we emphasise instilling public health competencies in medicine, and not so much for other allied fields such as engineering or anthropology?
Diagnosing what ails medical education
The pragmatic answer is that medical doctors, de facto, are likely to continue to be the most influential players in public health policy at least in the foreseeable future. This makes it imperative that medical doctors imbibe multidisciplinary public health thinking right since their formative days. Recent medical curricular reforms in India have laid a stress on inculcating clinical empathy, early clinical exposure, and at least ritualistically, on greater community exposure.
However, none of these confers the competencies necessary to critically assess the larger public health and health systems landscape of the country. For a medical curriculum to be steeped in clinical medicine and not inculcate a broader public health orientation is least desirable where health policy is largely shaped by doctors. At the postgraduate level, re-emphasising multidisciplinary public health principles would be equally important to ensure that we create not just community medicine technocrats but also well-rounded advocates of health system reform. While health-care reform is a complex process with numerous interacting elements, the role of formative medical education in it is quite often underrated. Countries such as Cuba demonstrate how a medical curriculum attuned to public health can strongly influence the whole philosophy of health-care provision in a country.
Ensure the safety of the community
Despite the considerable overlap between them, the non-substitutability of community medicine and public health cannot be ignored, at least in the current Indian context. Community medicine will always defend its exclusivity as being a fundamentally medical specialty meant only for doctors, and public health courses will rightfully need to be open to students from diverse backgrounds.
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A middle ground can be struck by upgrading community medicine to ‘community medicine and public health’ both at the undergraduate and postgraduate levels. This will involve revamping the community medicine curriculum through incorporation of or emphasising those areas of public health which are presently left out or under-emphasised, such as social health, health policy and health systems. At the same time, representation of experts other than doctors and from fields allied to public health will be essential in the refurbished ‘community medicine and public health’ departments.
Dr. Soham D. Bhaduri is a physician, health policy expert, and chief editor of The Indian Practitioner
