The dichotomy in regulating medical training by India's regulators, the National Medical Commission (NMC) and National Board of Examination (NBE) notwithstanding, the confusion among the academics and implementers about Public Health, Community Medicine and Family medicine is markedly reducing our chances to achieve significant success in our health parameters. The importance of these three disciplines; all critical to India's healthcare delivery system have most recently been highlighted the ongoing Covid-19 pandemic. Our response has largely been reflective of a one-dimensional approach combing the three together despite a clear heterogeneity of evolution and diversity of approaches not the least dictated by the politics of the nation states around the world.
The most commonly understood nomenclature for Public Health specialists in India currently is “Community Medicine” although we do not find a similar connotation to the term “community medicine” in academic medical discourse across the world. Unfortunately, though, Community Medicine itself appears to at cross roads with it being equated with family medicine, at least in some academic departments in India itself.
So, what is Public Health? A conglomeration of all organized activities that prevent disease, prolong life and promote health and efficiency of its people. Fundamental to this definition is the word “Organized”, “Prevent”, “Prolong” and “Promote” and missing are “treatment” or “medical” or “Medicine”. Does that therefore mean that “Community Medicine” and “Public health” are disparate entities joined together by an approach of conveniently tagging together two for lack of better understanding of the individual entity. As per the National Medical Commission, the objective of training in Community Medicine is “To create a skilled cadre of medical professionals having expertise in application of principles of Public Health, Community Medicine and applied epidemiology, contributing meaningfully in formulating National Health Policies & Programmes with a systems approach for overall human development”. Probably realising the limitations of Community Medicine in creating skilful public health professionals, the MOHFW created a task force to develop a focussed program catering to the academic needs of public health professionals through creation of a broad syllabus for Master's program in Public Health (MPH) in India. Unfortunately, though, the master's program is not currently covered by the National Medical Commission through their regulations raising concerns on their integration into academic departments largely run in India's medical colleges. And where does academic Family Medicine fit into Community Medicine or show up against the larger landscape of public health.
The Existing Confusion
Notwithstanding the fact that Community Medicine as an academic discipline is the cornerstone of the teaching and training programs in India's medical colleges at the undergraduate level, its practice continues to border on lack of clarity if not confusion. Probably the fact that India academicians understanding of academic public health has been largely restricted to running national programs has not helped either. However, the biggest contribution to this existing lack of clarity, apparently has been through recent creation of departments of Community and family medicine in newly opened AIIMS institutes across the country, a practice not followed by other medical colleges in India. Adding to this lack of clarity is the fact that large number of these institutions also run masters' programs in public health as well. This cocktail of specialities, so diverse in origin and practice being developed through a single academic department with little or no clinical experience sounds not only strange but also regressive.
For the record the departments of “Community Medicine” in India are capturing the theoretical component of the subject to a large extent by focussing on epidemiology of diseases and Biostatics. But the capacity to capture the clinical or practical component of its scope is limited. Contrary to our understanding of Community Medicine, Public Health has a much clearer interpretation not just because of the way it evolved but also because of a more clearly defined implementable. From a purely environmental sanitation phase to the period of the scientific control of communicable disease or use of legislation as a tool for Public Health, the evolution and emphasis has always been more practical than theoretical. Public Health has and continues to grow both in and outside the medical sector, as it should, against Community Medicine. This even though the theory of practice of Public Health may have moved from governments to individuals and institutions, but the implementation is still in the larger domain of Government policies and practices. Community Medicine lacks such applications. The current pandemic has probably captured this diversity in public health by recognising the involvement of engineers, aerosol scientists, medical professionals, biologists, social scientists and administrators. Contrast to Community Medicine and Public Health, Family Medicine thrives on the delivery of Comprehensive health care largely at primary to secondary healthcare level through a team approach based on competencies (both theoretical and clinical) different to a large extent from both. Therefore, a general clubbing together of these disciplines is not only of greatest disservice to just family medicine as a speciality but to primary care as whole.
Broadly speaking, Public Health, Community Medicine and Family Medicine should be seen as three entirely different disciplines with little overlap much like other broader specialities in academic medicine taught in medical colleges across India. And this clarity has to be extended to every medical college, whether regulated by the NMC or not. Just looking at the overlap and seeing it as merging of these entities into one single discipline is a visual trap falling into which needs to be resisted by the academic departments of India's medical colleges. If this trap is not avoided, we will continue to create half-baked professional with little skills and competencies to deliver.
While Public Health as a discipline needs to be opened up to everyone from legislators to administers to engineers to environmentalists to lawyers, as is beginning to happen, the implications need to focus on policy from water to sanitation to poverty to corruption to trade and fiscal measures, nutrition and education and similar others and the role of these in influencing health. Public Health should be the building block of academics, not just at graduate or post graduate level but also in school curriculum. Restricting it to medical colleges is the greatest disservice to the interests of this nation striving to achieve health developmental goals at par with the developed countries of the world. Without bringing Public Health into the realm of our thinking and doing, the larger objective of organized activities that prevent disease, prolong life and promote health and efficiency of its people cannot be fulfilled. This pandemic has been a shining example of that, wherein large intervention efforts have failed because of a lack of a public health policy on dealing with large scale infection led disasters and an emphatic shift in the medicalisation of health in last few decades. Institutionalising Public Health will be the way forward. The Medical colleges can also be encouraged to run public health institutions through multidisciplinary teams.
The departments of Community Medicine need to continue as the primary domain of medical professionals, use epidemiology of diseases and inferential biostatics as tools to function at fundamental levels of academics, research and service delivery (through medical colleges) while integrating veterinary, human, and environmental medicine and delivering on the emerging concept of “One Health”. The academics will need an integration of basic expertise in microbiology/virology, public health, livestock, management, environmental health (with a focus on zoonotic diseases) and outpatient care to develop cross cutting integrated curriculum. With the way the world is evolving and newer threats of communicable diseases are emerging, these departments will be excellently placed to mitigate their impact.
The departments are also expected to function as the hubs for research on One Health. As such the research priorities in Zoonotic diseases and environmental health seem to suffer from the fact that research priorities keep varying and are largely based on the current contextual situations. The department also needs to work out through an outpatient unit taking care of patients falling under the domain of clinical care under “One Health”. These Outpatient units will also function as sentinel sites for picking up newer infections, potential epidemics and pandemics backed by the academic and research expertise vested in these departments.
The academic departments of Family medicine are needed in all medical colleges. A clinical discipline tasked in teaching and training of a health care delivery model that provides quality healthcare services ranging from health promotion to prevention, treatment, rehabilitation, and palliative care across geographies through emphasis on the development of a primary care team. The capacity of Family medicine to deliver comprehensive primary and secondary healthcare is vastly under-utilised resulting in a largely technology dependent, urban friendly hospital-based healthcare with a definite skew towards tertiary care. This may not serve India's national interests. If anything, Family Medicine has fully developed connotations across the world as also in our country as post graduate courses in family medicine are already being regulated by the National Board of Examination (NBE). What will probably been needed is extending the regulation to graduate curriculum through its inclusion in MBBS course by the National Medical Commission.
To produce a doctor of first contact of the community while being globally relevant, the time period allotted to Community Medicine under the NMC regulation, currently completed in three and a half years can be broken down into three parts. While the first and the smallest part can host public health, the other two larger halves can host Community Medicine and Family Medicine respectively.
India will be able to serve its large health interest, it is able to bridge the dichotomy of regulation in academic medicine and unclog the three disciplines of public health, Community Medicine and Family medicine into separate academic departments.
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3. Raina SK, Kumar R, Galwankar S, et al A health care delivery model focusing on development of a cadre of primary care physicians-Recommendations of Organized Medicine Academic Guild J Family Med Prim Care. 2019;8(2):330–335
4. DNB – Family Medicine. Last accessed: 16:09:2021 Available online at: https://nbe.edu.in>curriculum