health care initiatives get a shot in the arm
While promoting education and research as relevant to India's health needs,
the Public Health Foundation will help meet those needs before and after the
trip to the doctor
As one whose training and activities span the spectrum of both clinical medicine
and pub lic health, I am often asked whether public health deals with subjects
other than sanitation and water safety. I hasten to clarify that while public
health does include those, it extends well beyond them. With the launch of the
Public Health Foundation of India by the Prime Minister on Tuesday, for the
first time there might be fewer asking me to
clarify the difference.
This innovative public-private partnership aims to establish a network of public
health training institutes across the country as well as assist in the growth of
existing ones. While promoting education and research as relevant to India's
health needs, this initiative will help meet those needs before and long after
the trip to the doctor.
This is the difference between public health and clinical medicine. In popular
perception, clinical medicine is the main or sole discipline associated with
health. Public health, however, is a distinct disciple. One definition is that
public health deals with the determinants and defence of health at the
population level, while clinical medicine deals with multiple maladies and their
remedies at the level of the individual patient. The difference is partly
numerical, with the ambit of public health covering large numbers across a
population, while clinical medicine renders its services to a sizeable but
smaller number of individuals. The difference is also qualitative, as public
health aims to elucidate and influence the social determinants of health as well
as to study and structure health systems as efficient channels for delivery of
health services, while clinical medicine focuses more on the biological
manifestations of disordered health.
To put it simply, clinical medicine deals with a patient when (s)he comes to a
healthcare provider with a health problem. Whatever happens before that patient
comes into that room to meet a doctor or a nurse is the arena of
public health, which tries to identify the sequential causal pathway of that
health problem, linking the social determinants that influence community
behaviours to the altered biology of individuals.
Whatever happens when the patient leaves the healthcare provider's clinical
consultation room is also the domain of public health. Whether essential drugs
and healthy foods are available at affordable prices, whether strong referral
and follow-up systems exist for after care and whether community health
services are geared to prevent recurrence or spread of that disease are all
matters which must engage the attention of public health.
Even the issue of whether that patient gets to see a proper healthcare provider
in time, even on the first occasion, is determined by the outreach and
performance of the health system, which comes under the purview of
public health. It is clear that this broad discipline covers a wide array of
non-personal factors which influence the health of individuals and applies a
broad range of social interventions (such as tobacco regulations and advocacy of
safe sex), preventive technologies (such as water safety and immunisation), and
health system innovations (such as the use of non-physician healthcare providers
and social insurance for healthcare financing) to improve the health of
This broad ambit makes it essential that education and training in public health
are multi-disciplinary in content and that the pathways of public health action
are multi-sectoral. Public health education must include subject areas like
epidemiology, biostatistics, behavioural sci ences, health economics, health
services management, environmental health, health inequities and human rights,
gender and health, health communication, ethics
of healthcare and research.
The students and practitioners of public health need not and should not be
confined to medical professionals. The public health community must expand to
include nurses, nutritionists, epidemiologists, social scientists, economists,
health communication specialists and even laboratory researchers in areas such
as environmental health or nutrition.
Such integrated multi-disciplinary training in public health is currently
provided only by a few MPH courses in India. The departments of community
medicine in medical colleges provide a part of such training in their M.D.
programme - but with only doctors being trained by teachers, who too are mostly
doctors. All included, the total number of even part-trained public health
professionals produced each year is around 350, which is woefully
inadequate for India's needs.
In the absence of adequately trained public health professionals, clinical
doctors have been mandated to perform public health functions in policymaking,
managerial and programme implementation roles. This mismatch between their
acquired expertise and assigned roles leads to a serious underperformance of the
health system. Even increased allocation of financial resources to the health
sector, essential as it is, cannot translate into health gains if the paucity of
suitable human resources continues to afflict public health.
There is, therefore, an urgent need to develop educational programmes to create
a large pool of trained public health professionals who can infuse strength into
the design and delivery of public health programmes, through
both government and non-government sectors. Till their numbers grow, there is
also need to enhance the knowledge and skills of persons currently performing
public health functions, through structured training, to enable
better performance. Policy- and programme-relevant research also requires to be
upscaled in quantity as well as quality. The advent of the Public Health
Foundation of India augurs well for the advancement of this agenda and
attainment of better health for the Indian people.
The writer is Head of Cardiology, All India Institute of Medical Sciences, New
Publication:Indian Express; Date:Mar 29, 2006; Section:Mumbai;