Public health education: Failing to see beyond ‘medicine’ no longer cuts it

When I started my medical education, I used to hear about a subject that most students joked about. Our seniors gave us the impression that this subject of the medical college is one of the most worthless subjects, if not the most. 

It does not help in conducting surgery, prescribing medicines, giving ward rounds, or even minor sutures when a patient gets a cut. The only utility of this subject, according to them, is knowing the organogram of a health center if someone is unlucky enough to stay there for long or to give some sanitation-related advice if someone ever requires it. That subject's name is Community Medicine. 

One senior, with a kind heart and the great intention to help me pass this subject, went steps ahead and told me to memorise the definition of 'public health' and 'primary health care' (which I did, and now use it to startle listeners often by reciting it in front of an amused audience), if I wanted to pass the subject with flying colours.

During our time, Community Medicine was taught in the third and fourth years. I found some truth in what my seniors told me about the subject. I learned later from many medical graduates that Community Medicine, as a subject, enjoyed a similar reputation in their respective medical colleges too. 

According to them, the pedagogy is boring, teachers are demotivated (the common perception is, Community Medicine teachers come to this field 'by chance,' not 'by choice,' as they failed to obtain a post-graduation in a 'reputed' clinical discipline), textbooks are unimpressive and outdated, and the topics covered in the subject are far removed from the actual professional needs. 

I was lucky, though, as when I reached my third year, a fresh Public Health graduate from a Belgian university joined as the head of the department and brought in a breath of fresh air to the department in terms of his teaching approaches. 

For the first time, as opposed to the common perception regarding Community Medicine, we were not asked to memorise anything, not a single word. For the first time, in my whole medical college life (and beyond), I encountered something called 'group work.' 

The new teacher divided the students into small groups and gave us some real-life problems that Public Health professionals may face in their careers. For example, he might ask, "Imagine you are working as a Medical Officer in an Upazila Health Complex, and one fine morning you find that a large number of diarrhea patients are coming to your hospital. What is the first thing you will do? What might be the successive steps to address the problem in the long run?"

In the fourth year, we were taken on an exceptional journey, part of the curriculum, but often neglected in many medical colleges--Residential Field Site Training (RFST). The whole class reserved a minibus and went to Palashbari Upazila Health Complex to gain first-hand training on field research. 

On my first day, I met a farmer working in a nearby field. When asked whether he uses a sanitary latrine, he glanced at me for a few seconds, held my hand, dragged me to a nearby hut - barely a roof over one's head. He said, "This is all I got from my ancestors. Now tell me, gentleman, should I sleep in it or build a toilet there?." 

The next day, I met a young mother, cooking rice, spinach, and lentils, holding her one-year-old child in her lap. Since Goiter is endemic in northern Bangladesh and is exacerbated by iodine deficiency, I asked whether she uses iodised salt for cooking. 

Again, there was the same blank gaze for a few seconds and an intense response, "Iodised salt costs Tk5 more per packet, which means about Tk50 a month. This amount is a two-day subsistence cost for my whole family. It means, mister, if I opt for iodised salt, my whole family has to starve for two days."

These experiences from the field turned the world known to me upside down for so many days. The famous 19th century physician and thinker Rudolf Virchow said, "Medicine is a social science, and politics is nothing else but medicine on a large scale." 

I realised it is not the medicine that we are learning in the medical college that can cure the overwhelming 'diseases' in the community; but it is the disenfranchisement of the people we need to cure first. This is not possible without addressing the social and political determinants of health, as Virchow rightly envisaged centuries ago. 

I made up my mind to pursue my career in Community Medicine but could not find a clue where it is taught. After much searching, I realised, Community Medicine is a 'misnomer' used in our medical colleges to represent a vast discipline called 'Public Health.' 

Later, I realised that medical colleges are more into 'medicine' than 'health.' Perhaps that is why some veteran medical educationists of our country considered Community Medicine a more appropriate name for a subject in the medical college rather than Public Health. 

I do not know the rationale behind such a naming principle, nor do I know its politics, should there be any. What I know is, this name is ambiguous at best and misleading at worst. This approach to naming ignores the right to 'health' of the people. It limits the mindset of the budding doctors to the confined remit of the 'medicine.' 

Needless to say, 'health' is a much larger concept, and medicine is just one tiny aspect of the study about restoration of health. According to the World Health Organisation's definition of health, it is the "state of complete physical, mental and social well being, and not merely an absence of disease or infirmity." 

Medicine pertains to only one aspect of health, i.e., the curative aspect, while other integral aspects are preventive, promotive, and rehabilitative aspects. So, emphasis should be shifted towards 'health' rather than 'medicine.' 

Secondly, students aiming for a higher study in Community Medicine will face a hard time identifying the mother discipline of this subject, which is Public Health. So, I propose to rename this subject in our medical curriculum as Public Health.

However, I sincerely agree that just changing the name of a subject will not go a long way to uphold the image and position of a subject. The Covid-19 pandemic showed us with a finger in the eye how important Public Health is in strengthening the health system, communicating health messages, promoting a healthy lifestyle, predicting the course of a disease, planning an evidence-informed pandemic response, developing a people-centered health policy, and leading an effective health sector. 

All of these are core functions of different sub-disciplines of Public Health, namely epidemiology, health economics, medical anthropology, health communication, health policy and systems, health management and administration, etc. 

Therefore, in medical colleges and beyond, the curriculum of this discipline should be revised to the current world standard, pedagogy should be improved to include a problem-based participatory learning approach, and career paths for the Public Health professionals in the government's health services should be defined and respected.

Public Health education should be reformed in such a way that attracts the budding health professionals to pursue it 'by choice,' not merely 'by chance.'

Dr Taufique Joarder is the Vice-Chairperson of Public Health Foundation, Bangladesh.