Non-Health Subjects in Community Medicine: How Much Healthy or Medicinal are They?

There has been a mushrooming of health care units globally, without having similar aim, approach, or even ethics, but invariably at all places they are called as hospitals or an equivalent word. The first concept of health centers was mooted by Lord Dawson in his Penn Report of 1920, which provided a comprehensive health care plan to cover the urban and rural areas.[1]These were the same mini hospitals that were built to provide preventive, promotive, and curative services to the people That time it was only medical care of the ill. But health management/ economics entered the boundary of the hospital as we started making health, a more broad-based science.

Health economics is commonly regarded as an applied field of economics such as health management. They draw theoretical inspiration principally from traditional areas of economics such as finance, industrial organization, insurance, and public finance or managerial texts. As per Fuchs,[2] policy-oriented research plays a major role and many important policy-relevant articles are published or read by physicians/researchers having direct involvement in health. The health economics has contributed much more than merely the application of econometric tools.[3] Health economics and management are well-developed subdisciplines in health sector financing, budgeting, management, or programming. A schematic flow chart is given below to make understand the components of health supportive sciences [Figure 1]. This also holds good for statistics or sociology.

Figure 1

Health Statistics, management, sociology, and economics arena.

It is now mandatory to understand the above issues; the boxes shaded with dots are essential for health. The unshaded boxes and line-shaded boxes represent the supportive services. It has been a newer trend to train nonmedical players for the line-shaded boxes of the above figure, without understanding the fact that they are extras and not players. The difference between them is, as between the heart surgeon and the scooter carburetor mechanic, both are pump mechanics but one deals with a living human being while the other in a dead machine. It is not that the statistics, management, sociology, or economics people should not be there, rather they are important, just like the head clerk in each administrators’ (or DMs’) office being the most valuable person but he is not the district magistrate. This might appear difficult for many to digest and they might have some points too but the statements given here are vital to understand.

The report of the health survey and development committee chaired by Sir Joseph Bhore emphasized upon the inadequate teaching of preventive medicine and public health in the medical student's undergraduate training, thereby highlighting the need and importance of public health education.[4] The public health initiatives over the years have contributed significantly to the improvement of several indicators, but morbidity and mortality levels in the country are still unacceptably high.[5] To take care of the health of large masses, more doctors with specialization in public health are required. On the other hand, day by day we are adding more and more allied subjects to medical sciences to have more theoretical or research base, rather than to have medical base. Engineering has taken its entry from the days of Program Evaluation and Review Technique/ Critical Path Method (PERT/CPM) to today’s imaging, robotics, and software medical science. PhD programmes have also been undertaken in the past in medical subjects with non-medical approach, eg, effect of nutrition in plastic surgery for students in MSc. Home Science, and these candidates being awarded a PhD (Plastic Surgery-Home Science). This appears to be pinching. Similarly political will is a key determinant of a nation’s public health orientation and is reflected in a nation’s health policy regarding population health.[6] It however does not mean that politics is medical sciences.

The statisticians are outstanding in their approach and barring few stray instances they have limited their area to research methodology. The health economist and management personnel have outgrown to medical science to prove their importance. Let us think of a PhD qualification. A medical graduate PhD in surgery cannot conduct surgery without MS in surgery. But this is being made muddy so far as community medicine is concerned. There are courses such as MPH (Master in Public Health) or master courses in epidemiology and others where nonmedical personnel are allowed to study and also after the course they join as epidemiologists. Examples are plenty when they join on the job of a community medicine specialists. The course organizers and Medical Council of India (MCI) has never cared for this. Thus, the specialty of community medicine takes a back seat. I have personal experience where I have taken informal interviews of these candidates, who on the chair show their inability to express even, “what is surveillance and how does it differ from survey.” For that matter “what is the difference between incubation period and communicable period.” Fortunately, now we are more concerned about communicable diseases, but days are not far when we will concentrate more on noncommunicable diseases, where medical or more precisely clinical knowledge will be required for diseases such as diabetes[7] and hypertension[8] or even newer infections.[9] Similarly, engineers do work on the area of networking/public health, and sociologists or nutritionists work in community or even community nutrition. In fact, when they work in collaboration with community medicine experts, they pretend to be superior to us. All of them joined these allied branches as they could not clear the PMT entrances, appeared tirelessly by them. That pinch of salty taste makes them, probably, to be more active to work in the area of community medicine because in no area of medical branch can they work with so easily. At the same time, I am afraid, some of us with the aim to portray self-magnanimity recoil multiple systems to help perish community medicine.

All of these science branches are the important tools of community medicine, which cannot be denied at all. The economists, statisticians, management, nutrition, and sociology personnels have provided lots of models and tools of academic importance. But not a single statistical model contributed anything in family planning or not a single sociometric tool or nutritional technique improved health.[10111213] Important legislations such as use of seat belts in cars leading to reduction of motor vehicle injuries; The Census Act 1948; the Registration of Births and Deaths, Act 1969; the International Health Regulation 2005; the Medical Termination of Pregnancy (MTP) Act 1971; the Maternity Benefit Act 1961, and others have all contributed toward improving public health[14] without limiting the boundary of community medicine. It is high time we save the existence of community medicine as a medical subject; else it may disappear as dinosaurs, such a huge animal lost to eternity!!

In the UK, specialist accreditation in public health is provided by the faculty of public health. Specialist accreditation is through participation in a 4-year program analogous to specialist training for doctors. Specialist trainees must pass an examination, demonstrably achieve certain skills and submit a portfolio of work. However, specialist training in public health is also open to nondoctors. In most countries, the MPH program is only available for physician graduates (MBBS, MD, DO, or equivalent). Based on the accreditation of the Council on Education for Public Health (CEPH), an MPH or MSPH is not a clinical degree.[15] In India MPH degree, is a 2-year course or a postgraduate diploma of 1 year, which is open to candidates with a bachelor's degree in any discipline from a recognized university, with at least 50% marks. But preference is given to applicants having a graduate/bachelor's degree in any of the following fields—medical, dental, physiotherapy, nursing, and paramedical sciences; veterinary sciences; management; natural sciences (including biology); social sciences and social work; engineering; law; commerce or accounting; communication; and others. Relevant work experience in health or development sector will be an advantage but not mandatory.[15] This gives scopes to many other branches other than medical sciences. The paradox is more interesting. An MPH degree holder may be a graduate in engineering/agriculture/law, but the recognition is given by the MCI the master of the medical universe. In India therefore, most people doing MPH are graduates of lateral branches such as veterinary sciences, management, natural sciences (including biology), social sciences and social work, engineering, law, commerce or accounting, communication, since there after they become equivalent to Doctor of Medicine, although they could not get through PMT, examination any “n𔄙 times they appeared. It would have been better if these degrees would have been recognized by a body of community health, giving degrees as MPH (community agriculture)/MPH (community sociology)/MPH (community agriculture), and so on. By this the candidates’ basic degree is respected and he/she does a master degree in same subject. But we are all sure the education in different medical specialty is managed by God in India, so people do survive with distributing, recognizing, and practicing such degrees. On the other hand, public health careers within and between any of these disciplines varies widely, which makes delivery of primary health care to the community impossible. Public health and medicine have been mutually dependent and interact with each other, in the past and in modern times.[16]

The health services include approaches to prevention, promotion, treatment, rehabilitation, and palliative care, and these services must be sufficient to meet health needs, both in quantity and in quality. Services must also be prepared for the unexpected—environmental disasters, chemical or nuclear accidents, pandemics, and so on.[17] All these activities toward attaining universal health coverage can be effectively performed by none other than a community medicine physician. Honestly, it is difficult to imagine medicine without the practice of public health and the understanding that with each patient, there is an opportunity to impact overall community health. Primary health care is the foundation of community medicine that encompasses all three components preventive, promotive, and curative. Only curative community-based care is the forte of family medicine specialists. Medical MPH will be more able to identify the determinants of health and disease in the community, understand the epidemiology of disease, estimate the burden and patterns of disease in communities to prioritize health needs, use systematic approaches to develop, implement, and evaluate public health policies, programs, or services, communicate effectively to multiple audiences and also has the ability to correlate data epidemiologically and use data more effectively to identify and solve public health problems. A nonmedical MPH may be specialized in one or more of the above nonmedical areas, but cannot relate it to determinants of health and disease or even diagnosis, prevention, and cure of a community problem. Thus, let us carry along with the nonmedical colleagues of ours but do not designate them as either physician nor give them place at a chair which is meant for doctors. Attempts have been made by different statisticians to claim as head of the department of community medicine and each time they have been denied since they are not doctors (Physicians).

Hence, I feel that public health and medicine are integrated and nonmedical MPH or a simple physician will not be effective in managing and effectively caring for the overall health and well-being of a community as a medical MPH. It is high time the Indian Association of Preventive and Social Medicine (IAPSM) raise the voice unanimously to retain the sanctity of community medicine. There is nothing to be frustrated as to why do we change the name of our subject, because with time we have to change, else all of us would have remained as apes…not humans.

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