Reforming Community Medicine in Line with the Country's Health Priorities - Let's Make it Relevant and Rational.

Community medicine (CM) is a very critical and important discipline in medical science from the country and citizens' perspectives. However, the felt need of people and policymakers is toward classical clinical disciplines. This may be attributed to the nonclarity about the role of CM experts and their tangible contributions to general community health. Further, young experts are facing despondency due to perceived identity crisis[1] coupled with threats from competing disciplines.[2]

Debates and discussions, on both formal and informal forums, are going on about the current situation of discipline. Over the past two decades, several stalwarts have written a number of editorials/articles about it too. From all these, a consensus emerges; that a reform in CM[3] is required, and the Indian Association of Preventive and Social Medicine (IAPSM) is looked on to take the lead.[4] Being an apex professional body, IAPSM has decided to shoulder this responsibility and has started the reform process by initiating situational analysis of the current scenario of the subject.

Based on the debates/discussions, review of literature, and personal interactions, three key issues are identified: (1) changing focus of expertise from time to time, (2) ambiguity about roles and functions of CM experts, and (3) quality of teaching and training in under/postgraduate (PG) studies. Although these three problems are listed separately, they are interlinked and require in-depth analysis for facilitating the reforms.

CHANGING FOCUS OF EXPERTISE OF SUBJECT

CM has witnessed great metamorphosis, as reflected in its varied nomenclature, namely, the Public Health, Preventive and Social Medicine (PSM), Community Health, Community and Family Medicine, CM, etc. The changes in CM discipline over the period can be attributed to the changing epidemiological scenario of public health problems and advancement of knowledge and skills to manage them. Let's try and describe the metamorphosis of the subject from conventional Public Health to advanced versions.

Public health version 1.0 – Conventional Public Health

It was a period of Hygiene and Sanitation, largely focusing on the environment, where personal hygiene, water, sanitation, healthy housing, and surroundings were dominating community health measures. Environmental management was the key principle, and safe water, as well as sanitary waste disposal, was key strategies in protecting people's health. This approach; targeting public at large, with few individualistic approaches such as quarantine and isolation, can be referred to as Conventional Public Health.

Public health version 2.0 – Preventive & Social Medicine

Discovery of germ theory, better understanding of the dynamics of disease transmission, newer knowledge, and skills for prevention and control of diseases; set the ground for up gradation to the second version where the approach was to focus on disease control. With better control over environmental factors, the role of social factors in health were also realized and interventions addressing social determinants were also included. The Conventional Public Health thus transformed to version 2.0 and came to be known as PSM in medical science. Epidemiology discipline became the torch bearer, and PSM experts largely identified themselves as epidemiologists who helped methodological understanding of causation of diseases and their control. Approach shifted from the earlier “public as a general” to interventions targeting “specific vulnerable groups and causative factors.” Specific protection measures such as spraying, growth monitoring, breastfeeding, oral rehydration therapy, immunization, disinfection, contraception, and personal protective equipment were adopted as key strategies in this version, further supported by environmental health management and interventions addressing social determinants.

Public health version 3.0 – Community Medicine

Improvement in effective clinical care leads to early identification of cases/carriers, reduced transmission of diseases, and reducing suffering as well as mortality. This created a felt need for taking clinical medicine in closer contact of the community as reflected in the acceptance of the Primary Health Care (PHC) approach to achieve Health for All by 2000 by the World Health Assembly of World Health Organization (WHO) at Alma Ata (1978). With the Alma Ata declaration, came the need for transforming PSM to CM, the Public Health version 3.0. Here, the approach focused on preventive, promotive, and primary clinical care with effective health-care delivery system for addressing local public health problems besides working on environmental and social factors (including behavior). This version requires working of CM experts in close liaison with the health system. Planning, organization, and monitoring of these activities demand good understanding and skills of management science.

Evolution of Public Health from hygiene to the stage where it is closely linked with “Sustainable Development” can be better understood by a stepladder model [Figure 1]. While our subject successfully evolved from version 1.0-2.0, we are stuck to version 2.0 in spite of the need and time to change to version 3.0, that is, as a “CM.” This probably is because PH/PSM/CM is a multidisciplinary subject. Addition of newer sciences saw different experts describe varied roles and functions during different stages of evolution. This created a scenario where experts in PH/PSM/CM need to be master of everything under the sun (including the sun)! This confusion can be best understood by referring to the genesis of the faculty of CM of the Royal Colleges of Physicians, United Kingdom (UK),[5] from the faculty of Public Health and its subsequent change to the faculty of Public Health Medicine. They passed through the same confusion and identity crisis, which we are experiencing now. They tried to address it but failed.[6] However, we need to learn from it to succeed. Carrying baggage of all the previous versions is the cause of all confusion and identity crisis.

Figure 1

Step ladder model: Evolution of public health/community medicine

IAPSM, at one of it's conference, decided to change the nomenclature of the discipline from PSM to CM without defining core areas for teaching/training/implementation, key roles and functions, or developing strategies to change.[3] Hence, currently, CM is lingering somewhere between versions 2.0 and 3.0 with heavy baggage of version 1.0. We need to follow the path travelled by the conventional clinical science during its evolution. With the advancement of knowledge/skills, instead of growing vertically only, it has expanded horizontally as different specialties within the broader domain of clinical science. Similarly, we need to establish CM as one of super/subspecialty within larger domain Public Health instead of just trying to grow vertically by mastering all aspects of Public Health Science. For the same, let's define CM and identify “few” core areas of expertise within “many” areas under Public Health Science. CM can establish its unique position as specialist branch in public health which is having medical background and skills in preventive, promotive, and primary care with a “good” understanding of allied Public Health disciplines. With this USP, we can be experts in managing Community Health problems through effective health programs and health services. It's time we work with the health system and create our space as health system leaders within the larger domain of Public Health. If we succeed, it will clear the clouds of confusion and aptly answer the question “What is CM all about?”

CONFUSION REGARDING THE ROLES AND FUNCTIONS OF COMMUNITY MEDICINE EXPERTS

Historically, three different models/concepts of CM can be traced, as followed in the United States of America (USA), South Africa, and the UK. In 1919, Dr. Ernst Christopher Meyer, from Rockefeller Foundation, New York, USA, proposed CM as a solution to meet the needs of medical care for the middle class, as the then existing health care was very costly and well accessible only to the rich and poor classes.[7] In 1940, two young South African physicians, Sidney and Emily Kark, set up a system of health service delivery for rural and tribal population that previously had received little benefit from Western medicine. This model was known as Community-oriented Primary Care.[8] In April 1976, UK reorganized the British National Health Services; thereby creating CM - “a service specialty which deals with population or groups rather than individual patients”; keeping Medical Officer of Health at the center of focus.[9] These specialists were expected to (i) organize health and allied services for the community; (ii) set priorities in communities using epidemiology and biostatistics, and (iii) address social determinants of the disease. The USA model aimed to increase access to care and promote equity; UK model was designed for managing urban health, whereas South Africa model was a blend of public health strategies and primary care.

Meanwhile, between mid-1960 and mid-1970, the WHO was pondering to comprehensively address the health needs of the world's people as large numbers were not having access to care, especially in the developing countries. Vertical programs of preventive interventions were not resulting in desired health outcomes. Based on various successful models of primary care; including that of one from India, the WHO came up with the concept of PHC – a strategy to provide basic Health services that meet the health needs of the Community.[6] The WHO's PHC model can be called a blend of all above three models.

While CM should evolve in response to the changing local health needs and expectations, it has got typecasted into academics. Majority voices in IAPSM are in the favor of including primary care, preventive and promotive services in the community as core areas of functioning of CM along with a liasioning role with specialist medical care, conventional public health, and other sectors as shown in Torch Light Model [Figure 2], which is an effort to describe role of CM in the spectrum of health care. With collective wisdom, we need to fix core areas of our expertise under MD (CM) so that better clarity and uniform understanding about roles and functions of CM experts can be developed for India.

Figure 2

Torch light model: Expansion of medical care to health care and role of community medicine

TEACHING AND TRAINING OF UNDERGRADUATE AND POSTGRADUATE STUDENTS

Defining CM and describing roles and functions of its experts requires to be supported with the alignment of teaching and training of undergraduates (UGs) and PGs. Bhore Committee (1946) highlighted the importance of the then Preventive and Social Medicine, which was reiterated in the recommendations of the first Medical Education Conference (1955).[10] Although the learning objectives for UG students and curriculum for MD (CM) are well defined, with list of competences, it has failed in delivering the desired goal and objectives. Broadly, teaching/training of CM has two fault lines – “syllabus” and “methods”. The current syllabus has many redundant topics, not in alignment with the expected roles of medical UGs/PGs. CM being a multidisciplinary subject, clarity is required about what to learn, how much to learn of allied disciplines. This has led to overemphasis on certain subjects (statistics, entomology, sociology, environment, etc.) and underemphasis on some others (communication, clinical skills, etc.) during the training.

The Medical Educational Institutes have the dual responsibility of producing capable medical graduates/PGs and providing quality medical care to the people. Both go hand in hand as skills of medical teachers/students are upgraded by way of getting involved in medical practices (services at hospitals) and hands-on exposure. Medical profession being service oriented, “learning by serving” should be at the center of teaching/training strategies, especially the PG training. Thus, for good teaching/training, CM department must be actively involved in delivering services to the community. Currently, at most CM departments, teaching, and training of the subject are largely classroom based. Lack of support and vision of college management along with poor capacity of the faculties have complicated the situation further. At some medical colleges, practicing models are seen, but there is no uniformity. Standardized practicing model of CM with universal practice is one of the solutions to the prevailing confusion about the subject. Even the WHO has organized at least four workshops during 2009-10 for reviewing the curriculum,[11] teaching/training,[12] and recommending measures[13] to improve[14] it in South Asia Region.

As a part of reforming CM, IAPSM recently carried out PG teaching/training need assessment study through online survey in May 2017 with the aim to understand aspirations and perceptions of PGs about teaching/learning opportunities during their training. Total 368 PGs/young CM experts participated in it. Salient findings are as below: 73% joined the course as a first or an alternative choice. More than 50% are interested to work with health system as a manager/consultant. 21% and 13.4% are interested to pursue career as teachers and researchers, respectively. 77% emphatically mentioned that current teaching/training is not as per their aspirations. Developing Health Management competencies have been put higher up than clinical and research skills. However, teaching and training opportunities for health management skills during MD training are below their expectations.

WAY FORWARD TO REFORMS-IAPSM VISION

We need to make CM Department, a practicing department across the nation, with well-defined list of core areas of expertise, key roles, and functions of the CM Experts. For the same, we need to prepare a list of essential services models and develop one which is feasible to be implemented across all colleges, thereby creating a universal image of the subject. Below are some of the initiatives planned to be completed in the next year and a half, by collective efforts and wisdom.

Defining the CM discipline

Describing roles and functions of CM experts

Revising UG syllabus/curriculum

Preparing and publishing multi-author book for UGs as per syllabus recommended by IAPSM

Making PG teaching/training curriculum rational and relevant to country and current time

Recommending list of essential services to make CM department a Practicing department

Preparing technical/operational guideline for Urban Health Training Centre and Rural Health Training Centre.

The National Health Policy-2017, envisages the development of a National Medical Services, in the line of civil services.[15] This is the apt time to initiate the reforms to maximize the gains. IAPSM can only be a facilitator as it is neither a regulatory body nora legal authority. Actual reforms can happen only when all CM departments across the country, take up the consensus recommendations of IAPSM and put in wholehearted efforts to fully implement them.