TEACHING OF PREVENTIVE AND SOCIAL MEDICINE IN MEDICAL COLLEGES
Item
- Title
- TEACHING OF PREVENTIVE AND SOCIAL MEDICINE IN MEDICAL COLLEGES
- extracted text
-
120
Indian Journal of Medical Education
should sweep us off our Feet !
We
do not want to think but we find safety
in applauding the achievements of our
ancients, we take pride in what we
have inherited. We have built a syst
em by which such heritages are wor
shipped within.the walls of " habit and
simple inertia
Any attempt to
change the existing state will be
seriously viewed and will be severely
condemned!,
.
/
1. January. 1962 ]
they have adopted were evolved out of i
experience and are sound. We should 3
have the courage to accept some of ■;
these methods for
analysing
outj
problems in medical education- The ;!
system of organising teaching institutes;
and workshops annually under the'
auspices of the American Medical
College have contributed considerably <
to the progress of medical education >
In U- S. A. I would venture to sug- ■
gest the introduction of similar teaching
tnslilutes and workshops to foster group.
The medical services to the commun
thinking- Thus, we will be able to
ity are found to conflict with the
define our problems and seek remedial.!
environmental anomalies and hence the
measures
At tfre same time we will
need for radical thinking and reorient
be laying the foundation for collective
ation of our educational system.
In
responsibility and nalional progress-?
vestigation into the selection procedures
Groups of people having common..:
pf students for medical colleges (taking
interest should collect and pool the data.,
note of their social background and
discuss information coming out of this
premedical education) proper evaluation
data in committees and moke available'
of the present training programme and
such information through the journal of
contents of current ■curriculum, the
medical education to others. Criticism.',
present examination system, opportun
from readers should further be pro-';
ities available
at present for the
cessed and policies and procedures-!
qualified physician to continue his
should be evolved and made readily\
education further are fields requiring
available through the medium of this .
our immediate attention Selection and
journal
Its role in such unexploreii
training of staff for the medical colleges
areas shall prove vital for our progress?
and
organising
the
administrative
Information regarding selection and'
machinery to increase efficiency should
location of medical centres facilities!
also .receive . prompt consideration. In
needed for establishment of such in'
addition, the progress of Medical Re
search in Medical Colleges should be stitutions, the type of education to be
given at the
premedical, medicals
carefully reviewed and the tempo of
graduate and post-graduate level, integ
research activities should be accelerated
ration of teaching and research and
such other problems when analysed
The Association of American Medic shall certainly belter medical colleges.
al Colleges has been a pioneer in. and provide the community with the
stitution in these fields.
The methods right type of doctor it needs to day.
RF_MP_8_E_SUDHA
J C
The Teaching of Preventive ‘32 Social Medicine in
Medical Colleges in Relation to Government’s
Health Plans
BY
Dr. K. G- KOSHI,
Dr. ISAAC JOSEPH.
Department of Preventive & Social Medicine,
Christian Medical College, Vellore.
The focal point in India's health
B’’programme is the primory health centre.
Ba. ? from which all health services are
£
expected to radiate into the rural areas.
LThis centre is staffed by a team of workS
ers headed by the doctor. In pursuence of their policy of prevention of
'disease and promotion of health both
£
' the Central and Stale Governments
Khave programmed to establish primary
Bj£>: health centres throughout the Country
K., by the end of the Third Plan. The
K;- authorities concerned with the organizefction and working of the primary health
Bp?.'' centre have corne up against numerous
Biproblems. administrative, as well as
t!
technical. However, this concept of
Kfr - integrated medical care has come to stay
K.
for the simple reason that no better
B‘
alternative Ims been suggested by anyK" one so far. The main problem in this
K' scheme is the training of the personnel
K-- incharge, but the success or failure of
Hk.; a health centre will ultimately depend
on the leadership of the doctor. How
to equip the doctor for his role in this
scheme ? Health and disease are the
result of constantly interacting forces
within the individual, the family and
the society on the one hand and the
physical, biological and social environ
ment on the other. The W. H. O.
has defined health as not merely the
absence of disease or disability but as a
state of physical, mental and social
well-being, in which the " total " man
is in harmonious, effetive and useful
adjustment with his ” total " environ
ment. T he practice of
preventive
medicine envisages the bringing about
of such an adjustment al various levels
from birth till death. There is nothing
static about this adjustment, which is a
continuing process.
The
planning
Commission realised the importance of
health in its programmes and has laid
emphasis on preventive medicine in the
third development plan. The health
121
122 / Indian Journal of Medical Education
programmes in'this plan can be grouped
as follows ;
1. Environmental Hygiene
Rural and Urban Water Supply.
and
2
Control of Communicable and
■..Noh-communicable Diseases.
3. Expansion
Health Centres.
of Hospitals and
4- Training of Health and Auxil
iary Personnel.
5-
Family Planning.
6. Extension of Health Services
such as Maternal & Child Health
School Health Industrial Health etc.
The importance ol health in Govern• ment’s development plans is obvious.
As plans are made for " man " and
•' not the other way about, it follows that
the health of roan is the prime requisite
. for the success of ell plans. More food
has to be produced, processed, transport
ed, stored, sold, cooked, served and
eaten.
Only a healthy population can
do this. The slogan "Grow More Food'
is no doubt important, but there is not
much point In producing more food, ifa good portion of it is to be consumed
only by the parasites that live in the
■ intestines of man 1 The importance of
national health in a developing economy
is obvious. The present move
for
physical fitness and the control and
eradication of acute and chronic diseases
Is based on a realisation of this concept.
There are various levels at which man's
health can be promoted and diseases
prevented. The most effective measure
for preventing disease is to attack it
. Ipng before It make sits appearance In the
Vol. 1, January, 1962
community. This can be brought about
by a programme of health promotion
and . education. The next effective
measure is to bring about specific
protection, which will include not only
a science of immunology, but anything
" specific ” generally for protecting
man against disease or disability and
may range from a fly trap to an antimalarial drainage scheme. The next
level at which diseases can be prevent
ed and dealt with is early diagnosis and
prompt and effective treatment. This
includes curative medicine in all its
aspects The earlier a disease is spotted
the better the chances for an uneventful
recovery to normalcy, and less the risk
to the community and less also the cost
of handling the disease situation. The
next level at which disease can be
tackled is the prevention of disability
and complications. This is in essence
an attempt to prevent things going from
bad to worse. The last level or activity
is rehabilitation where you deal with
damaged goods and give the patient a
new lease of life. The above is the
most logical concept of preventive
medicine, which has been evolved in
recent years It is obvious that if
measures ore taken at earlier levels
there would be no need to resort to
subsequen’ levels when disease and
disability have made- their appearance
and left their mark on the community.
It is also obvious that the most profit
able measure would
be to take
preventive action at the earliest level
commensurate with the resources, staff,
equipment and knowledge available.
The above
concept of promoting
health aud preventing sickness can also
be applied to man's physical, biological
and social environments. Eroded soil.
or polluted water supply or adulterated
foods or accumulation of solid, liquid '
and gaseous waste products, unfavour
able clltmatological factors, noise, , ,
The Teaching of Preventive & Social Medicine in Medical Colleges
123
consequences.
This is the main reason
why all the leading countries of the
world are watching with interest the
progress of India's development plans.
for much is at stake. The Community.
Development Project is in the main an
attempt to improve living standards by
helping the people to advance on
all fronts. All the nation building
department.
of
Government.
such
us Education. Health. Cooperation.
Agriculture & Food Production, Animal
Husbandry. Communications, Cottage
Industries
are
involved
in
this
Project and work
together under
a common
administrator the - Block
Development Officer. This concept of
development is based on the.experience
that no single activity like Health or
Education or Food Production can by
itself bring about improvement in the
standard of living of the rural popul
ation and that all these activities are
interdependent and linked one with the
other.
Health Services form one such
componentHowever health of the
people is a prime requisite for the
success of any Government plan, but a
successful health programme is linked
closely with the economic level, edu
cational standards, availability of food.
both in quantity and quality, state
of communications, the social back
ground of the people, their habits.
'1 be Community Development Pro activities, their philosophy of life and
ject launched by the Government of a host of other factors.
India in 1952 is the biggest social
Therefore, any health programme, if
experiment of its kind in the worldIt
it is to succeed, must go hand in hand
is an answer to the challenging situation.
with all other nation building activities.
which emerged in the wake of inde
This concept is the foundation on which
pendence and partition. I he standard of
the entire Community Development
living especially in rural areas was
Project is being built up.
deplorable and at sub-human levels
when compared to that of progressive
1 he immediate objective of medical
countries. Can this standard be raised education in India is to train enough
to comparable levels by democratic doctors ol comprehensive medicine to
methods ? If the answer io this question meet the present day needs of the rural
is 'Yes' it is a triumph for democracy. population and take up leadership in
If it is not. one dare net imagine the Lea'th programmes. They should get
vibrations or radio-active waste products
are examples of physically sick environ
ments. An environment teeming with
flies, mosquitoes, bugs. lice. rats, dogs
or infected foods, milk or water are
all examples of a biologically sick
environment so far as man's health is
concerned. Finally we can have a
sickness in ihe social environment. A
diseased society reeking with social evils
is an example. This aspect of man's
environment is indeed the root cause of
many of the problems which face him
today, of which health is only one.
Thus on the one hand we have the
"spectre" of disease in man as well as
in his environment and on the other we
have the l‘spectrum"of prevention. Such
a gigantic scheme calls for the services of
a team of workers consisting of various
disciplines such as medicine, public
health, nursing, health visiting, physical,
occupational and
recreational ther
apists. health .engineering, agriculture.
animal husbandry, entomology, social
science, education and so on, However,
it must be remembered that the ultimate
goal is to preserve and to promote
human health. Therefore, the doctor
of the future has an important role to
play in this total health scheme and
must needs be suitably trained to as
sume leadership in its working.
124
Indian Journal of Medical Education
January. 1962
It will ultimately
personal experience in the newer con health education.
cept of service through Community take over various special health pro
Health Centres, where preventive and grammes initiated by the Government.
curative services are integrated to pro Thus it is the focal point of all the
health activities of the area.
vide the basic health Facilities to the
people. The doctor will have first to
We may have the resources to es
know the community before he can
study its health problems and tackle tablish primary health centres all over
But unless we orient our
them. He has to have the cultural and the country
social background which alone will medical students to the concept of total
enable him to understand the people health services, we shall not be able
and their problems. The principle of to fulfil the objectives of the primary
integrated health services can be health centre.
adopted by larger hospitals also and
In order to Implement such a pro
ultimately by the teaching hospitals so
will be necessary
to
that the doctor of the future will be gramme it
trained to "teach as he treats ” He modify the present undergraduate curri
will seize every opportunity to educate cula so as to emphasize the importance
his patients so that diseases can not only of prevention and health promotion
throughout the entire medical course,
be cured but also prevented. He will
be concerned more with the maintenance and to inculcate in their minds the
of normal health than with the cure philosophy of comprehensive medical
and even prevention of diseases. He care.
must adjust himself to the needs of the
The curricula will have to be modi
rural people, otherwise he will meet
with resistance to "scientific" medicine. fied so os to include the following
For him a complete diagnosis includes courses:
clinical as well as social diagnosis and
1. Sociology and Human Ecology
therapy includes social therapy also.
This is the kind of doctor the country
2. Elementary Biostatistics
has been waiting for. ' The specialists
too will have to get adjusted to this
3. Field experience in family health
new concept of
integrated Health
core programme or case confer
Services.
ences.
The discipline of Preventive- and
4. Training for post-examination
Social Medicine in medical colleges
interns in comprehensive health
will, therefore, have to play an increas
care at approved health centres
ingly Important role in both under
graduate as well us postgraduate train
5. Participation in field research
ing in order to meet the above require
programme wherever possible.
ments.
The Primary Health Centre provides
both preventive and curative health
services. It is responsible for the health
of mothers, infants, pre-school and
school children, control of communicable
diseases, environmental sanitation and
Comprehensive medical care calls
for a knowledge of social and environ
mental factors of the population to be
served. Recent observation have shown
that the health status of a community is
inextricably mixed with the total en-
The Teaching of
^^ventive <fc Social Medicine in Medical Colleges
vironment. A course in Sociology and
Human Ecology is necessary for the
proper understanding of the various
factors which influence health and
medical care programmes.
A knowledge of elementary biostatist
ics is calculated to help the students
not only to a better understanding of
technical papers but also assist him in
planning short term field investigations
and help him to intelligently study and
present the data.
125
for the teaching of preventive and
social medicine. The students are ad
mitted to the 1st Year Integrated
M. B. B. S. class (Pre-medical) and
they are in the college for 6j yeats. 1
year pre-medical, 1 b$ years pre-clinical
3 years clinical and 1 year post-exami
nation internship. The teaching of pre
ventive and social medicine is spread
over the 6jz<j years of medical course.
In the pre medical year a course of
lectures on the objectives of medical
education, history of medicine, element
The family care programme and case ary sociology, concepts and philosophy
conferences will give the student an of preventive and social medicine and
insigjit to the health problems of the elementary biostatistics is given. During
area and help him to appreciate the the
pre-clinical period four to five
elfecls of environmental factors on inter-disciplinary conferences are arran
health and disease and also the limit
ged. This is usually given when the
ation under which a doctor has to work students have completed a section in
in a rural setting. It will also give him their physiology class. A patient with
a first-hand knowledge of the various a lesion in that section is presented and
agencies at work and how best to utilise the aetiology, epidemiology, prevention
their services in the furtherance of the and rehabilitation with reference to the
health programme.
case is discussed. During the clinical
period a course in enviromenual hygiene.
The post-examination internship is nutrition, epidemiology and control of
the most important part of the training communicable diseases and common
of the undergraduate, where the intern chronic diseases, vital statistics, prevent
gets personal experience in the various ive health services and public health
programmes connected with comprehen administrotion is given.
They also
sive medical care.
They work in a participate in a family care programme for
small hospital with limited facilities a period of 15 months. The post examin
and are encouraged to use their initi ation interns spend 3 months in the
ative and to be in full charge of the Department of Preventive and Social
care of patients, both out-patient and Medicine, In addition to Working in an
inpatient, under overall
supervision
approved health centre and taking
They are encouraged to follow-up the part in all its activities, the intern
patients both at the clinic and in their takes
part in field
investigations
own homes. In addition, they gain ex and is also trained in the maintenance
perience in maternal and child health. of medical records, coding and the pre
school health and in field investigations. sentation of reports. A seminar attend
They also gain experience in maintain
ed by the staff of the Preventive and
ing medical records, coding and present Social Medicine Department is held
ing reports of their work.
every week at the Rural Health Centre.
at which an intern presents a paper on
The Christian
Medical
College, a chosen public health problem
Each
Vellore, has the following programme intern gets this chance during his three
128
Indian Journal of Medical Education
months' stay at the health centre. An
attempt has thus been made to involve
the interns personally in. various aspects
of rural health service. This pro
gramme is working well and' we feel
that the interns are gaining greater con
fidence in their work-
There is scope for further improve
ment in the internship programme and at
the time of writing we are taking steps
towards this end. We feel that we
are moving in the right direction in this
aspect of the work of the Preventive &
Social Medicine Department.
With regard to the personnel already
in medical services it is necessary to
orient them to the philosophy of com
prehensive medical care. In their stu
Vol. I, January. 1962
dent days the emphasis was on curativa 3
medicine and tn most cases they have •>3
been working in dispensaries and hosplt-. '
als and bad no chance of working with J
public health personnel. For orienting ■
them it will be necessary to give inser- 3
vice training along with para medical ,51
workers who would be working with
them in the primary health centres. fl
Every state should have such orientation |
training centres so that all the health. |
personnel in their services would accept I
the philosophy of comprehensive medi- I
cal care, and work as a learn with the .1
participation of the people.
Thus equipped, our doctors wifi he
in a better position to meet the health
needs of lhe country.
Basic Health Concepts of Medical
Students on Entrance into Medical College
BY
P- MALHOTRA,
M. I- BELAVALGIDAD,
A. RAMA RAO,
Department of Social & Preventive Medicine,
Lady Hardinge Medical College, New Delhi.
INTRODUCTION
METHOD
Medical
education has undergone
much change and rapid advances have
been made in recent years. At the
present stage, we are trying to build up
tn our physicians a level of conscious
ness for prevention of disease at all
stages, from preventive inoculation.
early diagnosis and treatmentto rehabil
itation of lhe individual. For inculcat
ing this attitude in the physicians.
departments of Social hr Preventive
Medicine are being organised in all
Medical
Colleges
throughout
the
country.
The study on a group of 65 first
year medical students was conducted at
the Lady Hardinge Medical College in
July, 1960 within a week of students
joining the college, while they were
stilt adjusting to their new environment.
It is common saying in education
‘Start where lhe people are’ so for
organising a more effective teaching
programme we are interested in know
ing where the students are in their
understanding of health and disease on
entrance into a medical college-
A questionnaire consisting of 28
questions was designed for the purpose.
It was distributed amongst all the girls
present in the class and filled in within
an hour. The students’ response to the
questionnaire was good.
The questionnaire enquired into
students' basic concept of health and
disease as related to the individual.
family
and community, and also
recorded various basic factors such as
stale.
occupation, literacy status of
parents, social and relate activities of
the student herself.
293 ' Indian Journal of Medical Education
thunder Witter, Nobin Ch. Mookerjee,
Budden
Chunder Choudree, and
•Tames Pote).
They were examined
in Anatomy and Physiology, Chemis
try, Pharmacy and Materia Medica,
practice of Physic, practice of Sur
gery and operations.
After a seven
days’ examination Uma Charan Set,
Dwarka Nath Gupta, Raj Krishna
Dey and Nabin Ch. Mitra were con
sidered to have successfully answered
the tests. The examiners concluded
as follows : —
Vol. 1, July, 1962
Phillips’ Translation of the London
Phar macopoe ia.
Thomson’s Elements of Materia
Medica and Therapeutics
Dr. O’Shaughnessy’s Manual of
Chemistry
Cloquet’s Anatomy by Knox
Sir C. Bell’s Institute of Surgery
(just published)
Dr. Geo. Gregory’s Elements of
Medicine
Twining on the Diseases of Bengal
Cooper on Dislocations and Frac
tures, etc.
Clarke’s Commentaries on the
Diseases of children”!.
“The Ordeal through which these
young men have passed, is one of no
common kind, and affords a very
It would appear that a 5 th student,
gratifying measure of capacity and Babu Syama Ch. Dutt, also passed
acquirements. The result is such as out and was selected for the post of
to satisfy us with their average laboratory and medical Assistant at
knowledge of a solid and well ground the Opium Board at Patna.
ed character. We have unanimously
The Government approved of these
come to the decision of granting them
letters of testimonial, and we consider results and, accordingly a meeting
them competent to practise medicine was held in the College Theatre
and surgery. We beg to recommend presided over by Sir Edward Ryan,
them accordingly to the liberal con the theiV Chief Justice and President
sideration of Government, as the first of the General Committee of Public
Hindus who, rising superior to the Instruction, for the purpose of con
trammels of prejudice and obstacles ferring letters of qualification on
of no ordinary character, have distin these youngmen. A large number of
guished themselves by attaining to European and Indian gentlemen were
complete Medical Education upon present. Prizes presented by Baboo
enlightened principles. We corsider Dwarka Nath Tagore were also
Rs. 100/- p. m. at the outset of their awarded to the successful students
service as the most suitable rate of at the conclusion of the ceremony.
remuneration which might be in Uma Charan Set stood first and was
creased in progress of time according honoured for his distinguished career
to the extent of service and desert. with a gold watch presented by H.
We further recommend that, at the E. Lord Auckland.
end of five years, they should under
These four students wore, without
go another examination and that for
the purpose of frequent and habitual delay, appointed as Sub Assistant
reference they be supplied, before Surgeons to the hospitals at Dacca,
quitting the College, with the Murshidabad, Patna and Chittagong
at Rs. 100/- p. m.
following works : —
f From the report of the examiners (dated
Calcutta, the 21st November 1838) to Mr.
H. T. Prinsep, Secretary to tho Government
of India.
Integration of Teaching of Preventive and
Social Medicine with Clinical Subjects with Special
Emphasis on Medicine
BY
R. SHARMA, Reader in Preventive and Social Medicine, &
R. M. KASLIWAL, Professor and Head of the Department
of Medicine, S. M. S. Medical College. Jaipur.
For the past few decades a great must be placed on first of these than
interest is being taken in developing has been the case in the past.” In
a rational approach to tho teaching of the second medical education conpreventive and social medicine. Confe frence held in 1955 it was once again
rences and seminarshave been held to accepted that this subject requires
find ways and means to introduce this special emphasis in the medical curri
newer concept of preventive medicine culum.
in the medical curriculum.
This new subject of preventive and
In India, the importance of such social medicine now includes some
courses which are quite different
teaching was first emphasised in tho
than those of the old subject of public
report of Bhore Committee on reorga
nisation of medical care and health health and hygiene. Now it includes
programme in 1946. In connection subjects like epidemiology, human
with undergraduate medical curricu ecology, domiciliary medicine, bio
lum, it was recommended that statistics, and sociology in addition to
“undergraduate medical education in subjects like environmental hygiene
the past has been concerned perhaps and puplic health administration. Its
too much with tho curative aspect of main objective is to acquint students
medicine. Preventive medicine must with tho importance of positive
now come to the forefront and the health, elfcct of socio-environmental
duty of medical profession should be factors on the causation, progression.
largely to prevent rather than cure and treatment of diseases, and indivi
disease. Tho promotion of health, dual and community measures avai
the prevention of illness and the lable for their control and prevention.
treatment of disease should all bo dealt
To achieve these objectives it has
in the curriculum but greater emphasis been pointed out that the teaching
289
300
Indian Journal of Medical Education
given by the preventive and social
medicine department has to be inte
grated with the training programmes
of other departments, particularly
the clinical departments. In the draft
syllabus submitted by Dr. Taylor at
the medical education conference
held in 1955, for teaching of preven
tive and social medicine, some of the
major fields in which such integration
could be attempted have been
outlined. Similarly, Grundy
&
Mackintosh have also suggested fields
for collaborative teaching in preven
tive & social mediciire with other
clinical subjects.
Vol. 1, July, 1962
and indviduals.
While discussing
the question of integrated teaching,
the study group of teaching of social
and preventive medicine of Western
Pacific region of the World Health
Organisation, has pointed out disad
vantages of such unplanned integra
tion. It has been pointed out that
there are many subjects in social and
preventive medicine, which could
never fit into an integrated teaching
programme, like biostatistics, public
health administration etc. However,
there are some subjects which could
be better covered by coordinated and
collaborative teaching with the help
of clinical faculties.
In some medical schools in the
United States, experiments are being
Some of the methods which could
conducted for total integration of effectively be used for integrated
teaching in all the medical subjects. teaching of social and preventive
Western Reserve University School medicine with the clinical subjects,.
of Medicine probably was the first can be grouped as follows :
medical school where such an inte
grated course was started.
There,
(1)
Clinico-social conference
medical course has been divided into
I
three phases; first, which deals with
(2)
Case study
normal structure, function, growth,
and development, second with’altera(3)
Comprehensive
care
pro
tions in these normals and the study
gramme
of diseases, and third with clinical
application
of material covered
(4)
Family care and advisory
during first and second phases. It is
services
believed that this type of integrated
system of teaching will give the
(5)
Participation in ‘urban and
student a better grasp of the basic
rural health unit activities.
medical services and the fundamental
principles of scientific medicine.
Clinico-Social Conference ;
Similar experiments are also being
■ done in some of the other medical
schools in the United States, and in
other countries. That similar inte
grated courses are not to be introdu
ced in other medical schools without
taking into consideration the local'
conditions, requirement, and resources
has been stressed by various groups
For such conferences a medical or a
surgical case could be selected from
the wards. The patient should have
some social problems, which could
help in pointing out the importance
of social factors in the causation and
treatment of disease. Medical social
worker should visit the family and
collect all the relevant data. The
Integration of Teaching of Preventive.and Social Medicine
301
case should be presented in the class Comprehensive Medical Care Pro
gramme ;
by a senior student. Medical social
.worker should discuss the social
In India there does not seem to be
history and later clinical aspect of
the case could be discussed by the any medical school with such a
programme.
This programme was
clinical teachers,' while the causation,
prevention and control and the im first organised at Colorado Medical
portance of socio-economic factors in School in United States. This was
causation, and social agencies which with the objective of providing a
could help in treatment and rehabili complete medical care to families in
tation could be brought out by the one selected population. A chronic
teachers in Preventive and Social disease patient was selected and
Medicine. Such conferences could assigned to a medical student during
be arranged in the first year of clinical his posting in the General Medical
training, and could be held once a clinic, organised by cooperation of
week. These will bring out the four clinical departments, medicine,
importance of environmental factors paediatrics, psychiatry and obstetrics
in causation and problems in the & gynaecology. Students in small
groups were posted in the clinic for
treatment of the casse.
12-18 weeks. Cases were to be
followed by them through home
Case - Study :
visits. In case help was required
from any extamural agency, students
During their posting in the OPD were expected to visit that as well
or in ward each student could be to complete their records. Once a
assigned one case, of chronic disease week C.M.C. conference was held and
for collection of complete socio- students were required to present
environmental and similar other data their cases. Discussion on the socioby home visits. On first visit he environmental factors, family pro
could be accompanied by the medical blems, clinical prognosis & rehabilita
social worker or a teacher of preven tion of the cases were held. This
tive and social medicine department, required well planned coordination
or both could visit the family sepa between the curriculum of all the
rately. Both should collect data four subjects. Here, in addition
regarding
socio-economic ’ status, to the staff of the four departments,
occupation, housing condition, atti help was also sought of a Public
tude of family members towards Health Nurse and a social worker.
patient’s illness, etc. After student
has completed such study he could Family Care & Family Advisory
present this case in the clinics held
Services ;
in the ward or OPD, in which one of
the staff members of preventive
Such a family care programme
medicine could also be present. was first started in Pennsylvania
Programme could bo planned in such University^ School of Medicine in
a way that each student during his Philadephia.
Each student was
posting in the ward would work up assigned a selected family. He was
one such case and present before the expected to visit the family once
class.
weekly or more often according to
802
Indian Journal of Medical Education
the necessity. He was introduced
as a student-doctor. During his
weekly visits he collected information
regarding occupation, family pro
blems, attitudes, etc. He kept a
complete record of all the important
events in the family. Weekly or
fortnightly seminars are held to
bring out the medico-social problems
in the families. Students also helped
their patients in getting them
examined by the physicians in OPD
and help in follow-up of patients in
their houses.
Social worker was
also present in the discussion to
help in bringing out social aspects of
the problems.
Such family follow
.up was to be continued throughout
all the four years of medical studies.
These family care programmes could
be valuable in a number of ways as
reported by Merton. Some of them
are :
Vol. 1, July, 1962
6 months to 1 year. This could be
better given in second term of 3rd
year and first term of 4th year, because
it is felt that by this time students
would have had enough training in
the basic and clinical subjects to
participate eifectively in such a
programme. During seminars other
specialists cculd also be invited, in
case some problems of their speciali
ties were going to be discussed.
Similar programmes, with two
families, one with pregnant mother
and the other with chronic disease
patient are being carried out at
Christian Medical College,Vellore and
at some other medical schools in
India. These family care program
mes differ from case study and
Comprehensive Medical Care pro
gramme in two aspects, one that
it provides longer period of follow
up and secondly, it also provides
1.
Because it gave training in opportunity for the students to
total family care, i.e. in being a participate in the medical and health
family physician.
care of families themselves.
2.
Because it gave an insight into
All the clinical specialities could
the influence of emotional factors
and social factors on medical be included in such a programme, if
selection of cases was properly done.
problems.
we feel such a family care programme
3.
Because it maintained or deep
should be better based on selection
ened their interest in patients
of case from the indoor wards, with
as people.
whom student has worked in the
4.
Because it helped them to learn hospital. It is felt, that as the
how to establish good relation student was taking care of the
ship with patients.
patient in the hospital, he would be
more interested in his follow up and
Although as mentioned earlier,' his family. Lecturers in clinical
such follow-up was being done in subjects could even work as precep
Pennsylvania School of Medicine for a tors for small groups of students.
period of 4 years, wo feel that a
majority of students lose their
Case selection should be better
interest in families as soon as they done with the help of a medical
complete their preclinical courses. social worker, who should visit the
We are in favour of keeping the family prior to selection. Seminars
experience limited to a period of could be held once fortnightly or
Integration of Teaching of'Preventive and Social Medicine
weekly as time permits. During
this period students could also
contact teachers in preventive and
social medicine and in
clinical
subjects for any help and guidance
required.
Participation in Rural and Urban
Health Units :
At present, except 2-3 months of
internship in the Rural Health unit
students during their clinical years
arc not posted at these health cen
tres. For providing students an idea
about the total care programme of
integrated preventive and curative
medicine at the health centres it
might be desirable to establish urban
health centres with departments in
each of preventive & social medicines.
Students could be posted in such a
centre for a period of 1-2 months.
They could see the working of the
health centre, and also learn about
domiciliary and preventive health
services provided at such a center
specially for mothers, infants and
toddlers. They could also visit the
voluntary health organisation, if any,
.in the area.
These special projects discussed
above would definitely help in bring
ing out the importance of socio
economic factors in causation of
diseases, importance of attitudes of
patients and family members towards
illness, care of healthy indviduals
for promotion of health, various
special preventive health services to
be provided for infants, children and
pregnant mothers, importance of
environmental sanitation and proper
nutrition in control and prevention
of prevalent diseases, and similar
other ideas regarding other preven
tion practices.
303
However, to give students an idea
that curative and preventive practi
ces are parts of same -medical care
programme and differ only in their
being applied at different stages in
the natural history of illness, it
would be better if didactic courses
in clinical subjects could also be
co-ordinated in such a way that
students would be able to get a
complete picture of total medical
care in a proper perspective. Special
instances,, where such coordination
could be attempted are
Communicable Diseases ;
At present this subject is covered
by two departments, Medicine and
Preventive & Social Medicine. While
Medicine covers the clinical signs
and symptoms and treatment part of
individual diseases, Preventive &
Social Medicine department covers the
community aspect of disease, epide
miology and measures for control
and prevention. It could be better
if this subject could be covered by a
coordinated programme of taking
diseases according to . mode of
spread. First, the department of
preventive & social medicine could
discuss the morbidity and mortality
and details of routes of transmission
of such diseases as a group. Then
clinical aspects could be covered by
medicine department. In the end,
again, preventive and social medicine
department could take up the epide
miology and control of such diseases.
Tuberculosis is a subject which is
at present covered piece-meal by
the departments of medicine, preven
tive medicine and Tuberculosis.
Why ? Could this be not covered by
a better planned and coordinated
teaching programme,
where
all
aspects of T. B. could be covered in
a meaningful manner?
804
Indian Journal of Medical Education
Similarly courses in parasitology
and entomology could also bo
coordinated.
Students could also bo involved in
field surveys where they could
examine stools, urine, blood, etc.
This would enable them to see for
themselves the problem of common
communicable diseases.
They should also be posted in Iso
lation Hospital for a period of 1 or 2
weeks where they could be required
to do the laboratory examination and
immunization themselves.
Maternal Health :
Here coordination in teaching
should bo attempted in such a way
that the importance of preventive
practices like prenatal, natal & post
natal care in clinics & in houses
could be effectively brought out.
Students could also be given chances
of domiciliary visits with
the
paramedical staff and for domiciliary
midwifery.
Child Health:
In the United States more than
50% of the Paediatrician’s time is
spent in medical supervision of
healthy children and in other preven
tive practices like health counselling
and immunization.
Our students
should also be given an idea regarding
importance of such preventive prac
tices in addition to the regular
teaching of diseases prevalent in
childhood.
Family Planning;
Department of preventive medicine
could discuss the demographic basis
Vol. 1, July, 1962
of family planning while the details
of methodology could be perhaps
better covered by Obstetrics and
Gynaecology department. But once
again this has to be adequately
coordinated, so as to explain the
details of family planning programme
effectively.
Nutrition ;
While various nutritional diseases
are covered by the medicine depart
ment, such teaching could be supple
mented by the diet & nutrition
surveys to be conducted under the
guidance of preventive medicine
department. This would help in
bringing out the diet pattern, planning
of diet according to local eating
habits and within limited finances.
Similarly teaching in other subjects,
like mental health, venereal diseases
could alsc\be coordinated.
In addition to such coordinated
teaching, efforts should also bo made
to have inter departmental co-opera
tion in the research schemes. There
are various aspects of research pro
gramme in which the department of
preventive & social medicine could
be of help, particularly in field
research tregarding epidemiology of
chronic diseases. It could help in
planning, methodology of study and
later in assessment of results.
Finally it would be worth while
mentioning that the termintegration
means the infiltration and later
adoption of aspects of one subject into
teaching of another related subject
and since it has been generally accep
ted that the preventive attitude
should prevail at least from now
onwards on the curative practices,
Integration of Teaching of Preventive and Social Medicine
ultimate goal of such integration of conditions and resources available.
preventive and social medicine teach Till sufficient teachers are available,
ing with clinical subjects is that it may not be possible to have
every clinical teacher would become complete integration, but in any case
teacher in preventive and social attempts must be made for partial
integration, as suggested, by introduc
medicine also.
ing various special projects and by
Methods & special fields discussed planned coordination in teaching of
for coordinated teaching have to be other subjects. It could be helpful
properly selected according to the to have a curriculum committee in
facilities available, in different medi each medical college, to implement
cal colleges. As pointed out earlier, such integrated programmes.
it has to be planned according to local
A Review of the Teaching Programme in Preventive
and Social Medicine in Various Medical Colleges
in India with Recommendations
BY
N. JUNGALWALLA,
Deputy Director General of Health Services, New Delhi.
introduction
In the field of Medical Education,
there is hardly an educationist or
administrator, planner or politician
in the country who has either not
tpoken or is not aware of social medinine and socialized medicine. Yet we
tannot escape from the fact that the
Cedical student who has to study the
subject in the undegraduate course
end has a university examination to
pass before graduation in most of the
Indian Universities, does not have a
tH curriculum.
I
Preventive and Social Medicine is not
3 mere collection of techniques; it is
mere a philosophy, an attitude of
Bind which must necessarily per
meate throughout the medical curri'O»lnm. The age-old segregation of
.’Preventive and Curative Medicine
Im had deleterious consequences. It
6m generally been accepted in the
put, both by medical faculties as well
why students, that only minimun at
tention need be given to the study of
Jewentive and social medicine in the
wriod of undergraduate study.
Although much talk is going on
regarding the maxim that “prevention
is better than cure” the medical edu
cators and administrators still persist
that preventive medicine can well be
left to the public health services
since the general practitioner is
preoccupied with the urgent and
endless demands of curative medicine.
Therefore undergraduate training in
preventive and
social medicine in
most medical colleges is only of mini
mal importance. The root cause of
such thinking is the outmoded idea
aboutthe scope of preventive medicine.
Integration of preventive and Cura
tive Medicine into Medical Care.
Even when it is recognised that
preventive medicine includes both
personal health services and non-personal environmental sanitation, it is
still argued by some that the personal
preventive services should be the res
ponsibility of the public health
services for which special training is
given.
It will bo extremely unfortunate if
preventive and curative personal
120
Indian Journal of Medical Education
Vol. II, January,
health services are separated from Previous attempts to draw up
each other either in concept or in
standard curriculum.
practice. The concept on which such
Several attempts have been mad
a tendency of separation is based is
erroneous. It assumes that there is in the past to draw up a standai
a clear dividing line between health curriculum, more so during the hi
and ill-health. Barring a few specific five years. Unfortunately, it is M
infections there is indeed no clear-cut yet actively and urgently implement
boundary between health and ill- ed in all the medical colleges. Hi
health. Thus, to separate preventive following are some of the attempt
from curative care is to attempt to made in the past to draw up a stand
divide the indivisible.
The only ard curriculum, course content
logical and beneficial
conclusion is syllabus and time table
to integrate preventive and curative
services into a single service of
(1)
All India Medical Education,
‘medical care'.
Conference 1958 (Course-Content I
Dr. Carl E. Taylor).
The need for a standard curriculum
In spite of the acceptance of this
new discipline in most medical col
leges in this country since 1955,
there is as yet no generally accepted
curriculum throughout India. With
16 States, 36 Universities and over
62 medical colleges, variations exist
between States, Universities and
even between affiliated medical col
leges of the same University.
(2)
Report by Curriculum Con
mittee of the Indian Public Healt
Association (1958),
(3)
(1959)
The Medical Council of Indi
(4)
Discussions at various medic
educational conferencess by Rock
feller Foundation, W.H.O. Sool
East Asia Region 1954-1957).
(5)
Medical Education Conference
Andhra Pradesh (1957-61)
The basic reason for these varia
tions is the fact that it is a young Plan of Study
discipline. In some places, the staff,
equipment and other facilities are not
Objectives: Stated broadly, tl
adequately provided. The reactions objective of this study was to asse
of the faculty and students are not the present curriculum of the tead
yet favourable for accepting this new ing of Preventive and Social Medioii
discipline which needs and must in in various colleges/in India-the coun
tegrate with a several other subjects. content, the number of hours devote
This has to be done throughout the to this subject, nature of exam
undergraduate medical course and nation and the type of integratie
several modern methods in teaching with other departments, etc.
techniques in the college, hospital
and field centres have to be evolved,
It was intended to make the stud;
adopted and improved.
as far as possible, representative i
A Review of the Teaching Programme
121
the whole of India. To achieve this,
all the colleges in India were chosen
for the study.
Analysis of data obtained from 12
Medical Colleges
There is no uniformity in approach
in teaching the subject of Preventive
and Social Medicine. From an ana
lysis of the replies received from 12
A questionnaire was sent to all medical colleges on the subject
the colleges chosen for the study. (table 11, it is seen that in six of them
It was intended to get information the teaching begins in the first year
regarding extent of the teaching but is continued throughout the fiveprogramme, through which years of year course in only five of them,
the M. B. B. S. course does teaching whereas the sixth terminates teaching
extend, subject breakdown for each the subject after the fourth year. In
year, details of examination' organi five other colleges, though the sub
sation of field programme, details of ject is begun in the third year, it is
participation, internship period and carried through the rest of the course
any suggestions for improvement of in only 3 of them ; and two others
the curriculum. The answers to the cover the subject only for a period
In only one college
questionnaire received from only of two years.
12 medical colleges are analyzed and the subject is begun in pre-medical
and continued throughout the course.
tabulated.
Source of Study
Table I
Duration of teaching in Preventive and Social Medicine in 12 Medical
Colleges in India.
Year of Commencement
of teaching the subject
1 Year of completing teach- (Number of Medical
Colleges
ing the subject
1
|
1
Pre-Medical
5 th Year
1st Year
4th Year
1
5
1st Year
5th Year
3rd Year
4th Year
2
3rd Year
5th Year
3
Infopnation on the total hours of
leaching for the entire undergraduate
course' was lacking from all the
colleges who responded.
Assuming
a total of approximately 5,000 hours
for the entire course (calculated on
the basis of 4| years’ course, with
30 working weeks a year, 6 working
days a week and 7 working hours a
day), the time allotted to the subject
of Preventive and Social Medicine
ranges from 2 to 8 per cent of the
total curriculum time and in 60 per
cent of these institutions, it is more
than 5 per cent.
(Table II).
122
Indian Journal of Medical Education
Vol. II, January, 1863
Table II
Curriculum h<-urs for Preventive tmd Social Medicine during
undergraduate medical course in a few medical colleges of India.
Curriculum time for Preventive and |
Social Medicine
(Percentage of total curriculum hours) 1
A Review of the Teaching Programme
123
About the nature of subjects
taught in different medical colleges
and the years in which these subjects
are taught, only nine out of twelve
colleges responded. Table IV below
sums up the situation.
Number of Colleges
1
Less than 2 +
Table IV
Contents of teaching the subject of Preventive and Social Medicine in
several Medical Colleges.
2+
1
3+
Nil
Subject
Taught
•
Number of
College53
1
1|
Subject
Taught
Number of
College 8
History of Medicine
4
Preventive Medicine
Growth and Development
3
Socio-Cultural patterns of Life
(India)
1
4
Biostatistics
5
Medical Statistics
4
Social Anthropology and
Eugenics
Elementary Sociology
4
Public Health Administration 4
2
Family Planning
2
4
Administration of Hospitals
5
4+
5 4-
1
6+
1
1
7484Elementary Psychology
1
Not known
. Personal Hygiene
A break down of the hours allotted
to the teaching of this subject under
didactic teaching and practical work
(includes class-room practicals, tutorials, seminars, field visits, clinical
work in infectious diseases hospital )
is furnished in Table III.
The didactic teaching ranges from 30 per
cent of the total curriculum, hours
for the subject to 70 per cent.
Table III
Didactic teaching in relation to total curriculum hours allotted to
teaching of Preventive and Social Medicine.
Diadactic teaching (percentage of total
curriculum hours) for Preventive
and Social Medicine
Less than 30 +
30 +
40 +
50 +
60470 +
Not known
Environmental Sanitation
Nutrition
Principles of Epidemiology anti
Natural History of Disease
Medical Aspects of Human
Ecology
1
Health Education
3
Mental Health
1
6
7
Communicable Diseases and
their contiol/prcvcntion
Number of Colleges
I
1
3
*
!
i
From this table it can be seen that nutrition and epidemiology. Fewer
majority of the institutions still institutions teach the subjects like
conform to the traditional teaching History of Medicine. Growth and
of Hygiene by laying emphasis ’ Development, Medical Aspects of
mostly on subjects relating to com Human Ecology, Elementary Socio
munity medicine like environmental logy
and
Psychology,
Social
sanitation, communicable diseases and Anthropology and Eugenics, etc.
their control,'prevention, statistics,
Table VI
Allocation of Marks for the University Examination:
System of Examination :
Duration of Rural Internship Programme
Information was available from
nine college
*
on the system of exami
Information on the allocation of
nation. One cf them had examina
tion in Preventive and Social Medi marks was available only i t the case
cine in the ird year, two in the 4th of five colleges which is furnished ii
year and the remaining six in the Table V.
5th year.
Table V
'
125
A Review of Teaching Programme
Vol. II. January, 1963
Indian Journal of Medical Education
124
Period of Internship
•
Number of Colleges
4 Weeks
1 -
6
2
2
8
10
Details of Marks allotted to the subject in University Examination
1
„
2
12
Details of Break-up of total marks given
under col. 2
Number
of
colleges
Total
marks
allotted
Theory
1
2
3.1
3.2
____3.3___
1
50
-
-
-
1
150
100
2
200
150
1
300
100
Day to day
Viva |
class work
50
1
50
|
50
Terminal
Examination.
3.4
Integrated Teaching with Other
Departments
Remarks,
Only five colleges have furnished
information under this heading and of
4
them, only four have integrated
teaching programme with other
departments. The subjects in which
the teaching is integrated is furnished
bolow.
Table VII
The exami
*
nation in ft
& S. M. isB
part of
Medicine
Intergrated Teaching
Department of Preventive and Social Medicine
integrating teaching with
I
1
Number of
Colleges
—
—
—
—
Anatomy
3
75
75
Pediatrics
3
i
In four of the five colleges, the ges only, of which only one collegB
examination in the subject is done provides for both urban and run!
separately from the examination in internship of 2 and 10 weeks duratkw
Medicine, but in only one college it respectively. Rest of the collegB
is part of Medicine
provide only for rural intemAfe
Internship Prrrgnmme •
ranging from 4 to 12 weeks u pet
.
,.
details below.
information on internship pro- w«»
•u”lied bv nine eolle-
s
z
■■
Physiology
2
Psychiatric Medicine
2
Tuberculosis
2
Internal Medicine
1
Surgery
1
Obstetrics and Gynaecology
1
126
Indian Journal of Medical Education
Vol. II, January, I9R
127
A Review of Teaching Programme
Multiple Integration
Table IX
Table VIII
Various types of participations in teaching of Preventive and
Multiple Integration in Teaching Preventive and Social Medicine with other
departments.
Number of Number of departments with which
Colleges
integration done
Names of
Departments
Types of Participation
By other departments with Preventive and Social
Medieine.
6
By Preventive and Social Medicine with other
departments.
3
Joint teaching by these departments.
5
1
6
Anatomy, Physiology.
Paediatrics, Tuber
culosis, Surgery,
Gynaecology
1
4
Tuberculosis, Medicine
Paediatrics, Psychiatry.
I
4
Anatomy, Physiology,
Paediatrics, and
Psychiatry
1
1
Anatomy
1
Nil
From the above it is seen that
multiple integration is more frequent
with the Departments of Paediatrics,
Psychiatry and Anatomy and rarely
with Internal Medicine, Gynaecology
and Surgery.
Type of Participation.
Out of 12 colleges only seven furni
shed information regarding the type
of participation. Three, types of parti-
Social Medicine
-
cipations were found in these insti
tutions.
In six colleges, other departments
participate in the teaching of Preven
tive arid Social Medicine; in three
colleges the Department of Preventive
and Social Medicine participates with
the teaching in other departments and
in five colleges there is joint teaching
and clinical conferences.
Recommended Curriculum
From the foregoing analysis it is
' realized that the medical colleges in
India still support and emphasize the
older concept of hygiene and public
health in the teaching of preventive
and social medicine.
An outline
: enrriculum provided below is an
attempt to invoke comments on the.
. contents of teaching of Preventive
I and Social Medicine.
Emphasis is
I’ on integrated teaching to demonstrate
to the student the unity of a given
topic despite its radial interests and
relationships The integrated teach
ing in the pre-clinical phase relate to
•be study of normal man not only
Number of Colleges
with reference to the physical
structure and function but also co
ordinated with the psychological and
socio-economic principles depicted in
the bio-social sciences like Sociology,
Human Ecology and Social Anthro
pology, thus relating in the mind of
the student the individual and group
approach complementary to each
other. Similarly, during the clinical
phase of learning attempt to inte
grate the teaching with the pre-clini
cal phase is made by teaching sub
jects like preventive paediatrics as
against social psychology of the preclinical phase, etc.
The following
table gives the outlines of the recom
mended curriculum.
128
Vol. II, January, 1963
Indian Journal of Medical Education
1
Years
Years
Didactic
Pre- First
Cli
nical
Practicals,
Seminars, Participating
Tutorials, Depn rtments.
Demonstra
tions, Field
Visits, etc.
Pre- First
Cli- year
nieal
Biological Causes
2
1
I
Social Causes
History of Health Practi
ces in India
Responsibility of a Physi
cian to Society
1
1
1
1
4
P. and S.M.
The practice of Medicine
2
jMedicine
Medical Statistics (IA)
10
6
Second Medical Statistics (IB)
year
Elementary Psychology
8
6
8
3
Psychiatric
Medicine
Fundamentals of Perso
nal Hygiene; Exercise,
rest and work - Skin
in relation to health
4
1
Physiology
Normal Diet
1
Biochemistry
3
Physiology
“
'P. and S.M.
1
Medicine
1
1
f 1
b
1
1
1
1
1
J
Bacteriology
2
P. and S.M.
do
Elementary Sociology
Introduction - Society
culture and Individual
- Health and disease,
a socio - cultural phe
nomenon - Hospital as
a Social organization.
Evolution of Medicine.
Supernatural causes and
Physical
causes
of
disease
Subjects to be taught |
Teaching Hours
Subjects to be taught
Teaching Hours
Practicals,
Seminars, 1Participating
Tutorials, 1Departments.
Didactic' Denionstra-I
I
i tiers, Field
(Visits, etcJ
Recommended Curriculum
1
129
A Review of Teaching Programme
Table X
1
P. and S M.
|
do
Personal Hygiene.
Medicine
Concepts of Health and
| Normalcy and Eugenics.
1
Man and his Environment
Life cycle of man-Heredi
ty and health (normal
and abnormal)
6
Physiology
Dimensions of Growth
1
Paediatrics
Definitions f Public Heal
th implications of here
dity.
Principles
of
Eugenics.
Role of
i Environment.
4
P. and S.M,
Third 1
yea
Climate and health Air
ventilation and atmos
pheric pollutionConcept of Ecology, water
supply, sewage dispo
sal, Refuse disposal.
housing. Village and
town planning, Rat and
insect control, work 1
and health
1
131
A Review of Teaching Programme
130
Vol. II, January, 1963
Indian Journal of Medical Education
Table XI
Teaching Hours
1
Years
Pre- Third
year
Clinioal
Abstract Table of Curriculum hours of teaching Preventive and
Practicals,
Seminars, Participating
*
Tutorials, Department
Didactic
Demonstra
1 tions, Field
________________________!
Visits, etc.
Class
Didactic
(hours)
Practicals, Tutorials.
Demonstrations, Field
Visits, Seminars and
Revision, (hours)
Examination
Total hours
(hours)
Nutrition
Diet
2
Nutrition survey, Food
planning. Diseases trans
mitted by food, food
control programme
4
Deficiency Diseases and
planning . of special
diets
2
1
1
1
1
1
1
>
I
1
1
1
J
Biochemistry
12
P. and S.M.
Vital Statistics
7
2
42
23
15
2
40
Third year
49
39
2
90
Fourth year
83
30
8
127
39
53
8
100
Grand total
227
150
22
399
In the recommended curriculum, Preventive and Social Medicine is
allotted about 8 per cent of the Curriculom hours for the total course, and
of which 4.5 per cent is for didactic and 3.5 per cent for practicale, etc.
It is considered that this is a fairly well-balanced distribution;
5
P.- and S.M.
2
8
do
[Communicable Diseases
42
46
Medicine,
Bacteriology
V.D., T.B..P
and S.M.
[Preventive Medicine
23
6
Medicine,
Paediatrics
and P & S.M.
Social Medicine
39
53
P. and S.M.
ofDis-
33
Fifth year
10
Clini Fourth (Natural History
year | ease
cal
First year
Second year
Medicine
Medical Statistics (II)
Fifth
year
Social Medicine
! Subjects to be taught
144
Indian Journal of Medical Education
Vol III, January, 19M
voluntarily opted for medicine we mendablo step in this direction by
Family
Students :
have examined them more closely. exempting all those students froa
in Practice
Medicine
Whatever we have been able to fish college fees whose parents do not psy
any
income-tax.
However,
such
pocr
BY
out of the pooled up data has already
DR. B. K. MAHAJAN
been presented in the accompanying students often face many difiicultia
during their training and we hare
tables.
Professor
enquired into them in a subsequent
Family traditions were for long a study.
Dr. N. R. MEHTA
very dominant influence in our
Junior Lecturer
Out of the present student-pops-®
society, ciicumscribing the vocational
Preventive & Social Medicine, M. P. Shah Medical College, Jamnagar, area into which one could move. lation of the college nearly 28'/.
They no longer seem to do so now. girls; 20/! seats are reserved for the:
during admissions. However,
Businessmen,
Government officers show
a very unequal distributiesB
and craftsmen are contributing three
amongst the different social sectca.®
times as many students to the
Introduction
ourselves to practical work in this
medical college as professional per Educated persons above the incosK
paper.
In India, the
methods
sons like doctors, engineers and level of Rs. 250/- per month Eg
Medical education has been often adopted for practical work are
lawyers. Medical education is a new sending almost half as many girls eg
criticised for overemphasis on disease traditional.? evolved, new or copied
boys.
This is a very substantaCK
enterprise in Rajasthan and it seems
daring the three years of clinical after experience in U. S. A. and U.K.
number and should be taken uaB
to be attracting people from all
study. Instead of this undue con
sign of social awakening because tSi®, centration in the later years of Reporting on these methods, Frazer
walks of life.
Brockington W. H. 0. consultans
now the only career open to wests
nedical study, it has been suggested (1962) has categorised them at
was marriage and a doctor’s life w|Sj
certainly considered too hazard®®. that the students should he introduc follows
It is interesting to observe the
ed more overtly to the concept that
®!
*
largo number of students coming for them, particularly in Rajasth
Leal th is a precarious equilibrium
1.
Social case studies or the allot
from the lower socio-economic strata, On the other hand, amongst the lowBr Between, the person and his physical,
ment of cases and families.
classes
plying
small
trades,
girls
quite in contrast to the situation in
far behind the boys, showing AtB Biological, social and psychological
the past when it was more or less a
tavironments and that patients are
2.
Project, that is, survey or
privilege of the well-to-do classes taboo which still exists here agsMB people with their own likes and
epidemiology studies.
alone. The income group below Rs. women’s education. Out of neas^®: dislikes, hopes and fears and ways
sixty such students only twoarogsa^
3.
Assignment to services.
250/-per month can claim almost
life
(Warren
1962).
and even their parents are employ
®*
half our student population today.
4.
Demonstration visits.
®-'This is indeed a very significant fact. in the medical college itself.
In most of the medical colleges in
5.
Demonstration of general practice
Such students on graduation should
India the subject of preventive and
find themselves quite at ease in the
w«ul medicine is taught throughout
Work on social: case studies may
In conclusion, we have tried tcH
rural surroundings were the citythe medical course. Introductory involve
oriented doctors always hesitate to back on our own careers. How diS
the beginning, the teaching goes
cult
it
is
to
make
out
whether
fc
go. Perhaps an effective way of
into full swing in the clinical years The follow up of the normal : —
resolving tho acute shortage of choice was an outcome of judioffl
. with the actual practice given during
doctors in the remote areas would be decisions or just a matter of htri J-fetanship. Although tho teaching
a.
The family
to encourage more and more students accidents. But we do hope that!
'
clinical years consists of didactic
b.
The pregnant woman.
with a rural background to take up the future there would be toM
hertares lecture-demonstrations and
c.
School children.
choice
and
less
chance
in
the
nukhL
medicine. The Government of Rajas
i poetical work, we propose to confine
d.
Students.
than has already taken one com- of careers.
145
Study by Undergraduate
An Experiment
of Social
I
’ 146
Indian Journal of Medical Education
The follow up of the sick :
a.
b.
c.
Ward cases.
Out patients.
Health centre patients
(b)
(c)
(d)
"vol. Ill, January, 19C4
Number
family.
of
students
per
Provision of transport.
Availability
facilities.
of
family study by undergraduate students
4. Study
physical,
biological
social and psychological environments
and find how the adjustments and
failure of man take place in
i
them.
treatment
;
5. Give physical check-up to all
members of family.
Follow up of the family should be
done wherever practicable and this
is practised in different ways Preparation of students :
'
6.
Follow up weekly or fort(Mahajan 1963). Family care or
■ightly to suggest measures to be
family health service constitutes the
The students before allotment were taken on the observation made for :field practice of comprehensive not only told but also given in writ
medical care In the curriculum of ing to realise that: —
a. Health promotion.
the undergraduate students, family
b.
Disease prevention,
study takes six months to an year
1. Healthy or sick person is mem
c.
Early diagnosis and prompt
or even longer- This lends itself to
ber of family and family isi
treatment.
experimental study. An attempt is
unit of society.
d.
Limitation of disability or
made to present the observations on
spread of disease in individual
experiments conducted at the M. P.
2. Domiciliary approach to heallk
family or society.
Shah Medical College in family study.
problems has a special place ie
e.
Rehabilitation.
our country apart from beinf
essential for doctor-patient
Objectives of the Experiments
relationship,
Preparation of families :
' 1. To assess the organisational
3. Environments-physical, biologi
problems involved, like staff, trans
Four different areas were selected
cal, social and psychologies!
port, nature of practice field,
fcr study one after the other. Public
have important role in determi
*
equipment, etc.
ing the balance in favour ci Health nurse of the hospital staff
visited the families before the
health or disease.
2. To evaluate the usefulness of
stadents did, to explain the purpose
such programme.
4. Proper keeping of records is u to the head of the family or the
essential prerequisite fre Housewife. She could not pay repeat
3. To determine the feasibility of
ed visits with the students.
successful medical practice.
accommodating such studies in the
college curriculum,
In the actual conduct of th
experiments, the students are expect Haipunent:—
4. To ascertain the reaction of cd to do the following : —
students assigned for such studies
. One or two students were assigned
and the response of the families.
1.
Study the composition of th tooee family and they were provided
family and find its relation to socie^ wish lhefollowing prepared schedules
Wfill up
Methods and Procedures
2.
Ascertain the economic stats
I- House-hold schedule.
Methods adopted in all the experi and problems.
■
ments were essentially the same but
differed in following aspects : —
(a)
Area selected.
4.
Individual infant schedule.
5.
Individual toddler schedule.
6.
Individual
schedule.
school
ch id 1
Time of visit was 3 to 5 p.m. for
the first few weeks as provided in the
college time table till the schedules
were completed.
For follow up,
students had to visit the families at
least once a week at the time con
venient to student and the family
but more often if need be, to, attend
to any problem.
Results
Experiment No. 1
Each of the 12 students of the fourth
clinical term was allotted a family of
some member of the staff residing in
the college campus. The class chosen
consisted of clerks, compounders,
dressers, etc. This was done for
better co-operation and also to
obviate the need for transport which
the department did not have at the
time. It was not possible for the
lecturer and/or the professor-the only
teaching staff-to accompany students
each time nor was the public health
nurse or medical social worker
always
available during visits.
Heads of the families being members
of college staff and quite familiar with
the students took the family care
service lightly. Schedules presented
were poor.
Students showed no
enthusiasm and no seminar worth
the name could be held.
Experiment No. 2 : —
3.
Take a critical view of th ■' 2. Individual woman Schedule,
habits and customs in relation ti
■ X Individual man schedule.
health.
Next batch of 25 students was
allotted families in the nearby village
14S
Indian Journal of Medical Education
situated at a distance of J of a mile
from the medical college.
Two
students were assigned together to
two families to which they explained
the programme of study. Still the
cooperation given was poor, part ially
due to usual averseness and remain
ing busy with tlr ir own activities
but mainly for want of a person
keeping in touch with them during
the programme. Need of public
health nurses or medical social
worker was felt still more for
motivation of families and of more
teaching staff for supervising and
guiding the students.
Lack of
transport made the matters worse
and the experiment was a failure.
Experiment No. 3
Vol III January, 1961
They filled the schedules after they
were well set with the families, i
Students with aptitude for such .!
study were encouraged and named as
leaders and the study’ went on very •
well. After about 3 months study’ j
seminars were held in which two |
student partners presented their fami- M
ly under the chairmanship of one other ’
student in the presence of the professor- j
and lecturer. Sometime the staff mem- i
bers from other departments were I
also invited. Students took lively ■
part in discussion. A few of the
interesting cases discovered by them .
were a leprosy patient, a case of
essential hypertension, a typhoid case
and anaemia cases apart from cases
of diarrhoea, dysentery and influenza.
Brief summary of two families pre
sented by students is appended
alongwith the impressions of such
study given by students.
With the third batch of32 students
Experiment No. 4
we selected lower class and poor
Fourth study was made in an are
* ;
families living in insanitary chawls
situated close to collego hospital. of Jamnagar town. This area was
This was done again to do away with selected because it was served by •
Maternity & Child Health':
the transport and for easy avail a
ability of curative service from the M.C H. centre aided by Government,:,’
privately managed. Thej
hospital when needed. Heads of the though
families were taken into confidence management was informed that ifa
extended cooperation their
by teaching staff and were fully they
explained the purpose of the service centre and surrounding area could be j
by students.
Students were also converted into a training urban health ':
advised to bo friendly and familiar unit of this department. We left the
*!'
first and. then start filling the selection of families to the lady medic
schedules
They should attend to officer and medical social worker of:
curative need if any promptly and the health centre but the responsM
help them in getting examined or in was not good. Then we sent ths
obtaining medicine and milk, etc. for hospital public health nurse sad;
the babies or pregnant mothers. This social worker of the family planning.'
time each batch of two students was training centre of the medical college!
allotted one family.
They helped to motivate the families. Professor :
the families in treatment of their and lecturer also accompanied tie
ailments, got them milk from well students to individual homes. Ml
baby clinic and gave their children students were allotted 10 families i»’
batches of two in one street near the:
B.CG. and small-pox vaccination.
Family study by undergraduate students
M. C. H. centre. Transport was pro
vided. During visits after introduc
tion, when the students went alone,
they were not welcome. In spite of
the staff going with the students
later on, there was no co-operation
from the families. The students too
felt frustrated and the experiment
was almost a. failure.
Discussion
149
No. 3. Family allotted should have
an antenatal case, a growing child or
some chronic illness as T. B. (Prasad
1962).
3.
Ready curative services were
not provided which is key to practice
of preventive or integrated medicine.
In Pondicherry students go to fami
lies well equipped for such service.
They are provided with kits contain
ing standard medicines, food supple
ments, vaccination kits etc. (Dutta
1962).
It will be seen from the above four
experiments that the family study
was a success only in the third experi
ment where the student found it a
4.
Families al lotted wore not well
matter of pride to make the study. The prepared and not taken into confidence
staff felt contented and families felt before the students visited them. No
grateful for the service. As regards the public health nurse or social worker
achievements of the avowed objecti was available to accompany the stu
ves of these experiments we could dents. Medical officer of the unit
assess the organisational problems area or of the department along with
involved in such study, evaluate social worker or public health nurse
nsefulness of this study, determine should be available throughout the
the feasibility of accommodating the study or at least till the students are
: study in time table and gather well set with the families. Lack of
impressions of the students.
continuous supervision and insu fficient
preparation of families lead to student
The failure in the other three frustration because of too limited
experiments are attributed mainly to staff as pointed out by Carl Taylor in
. organisational problems stated his report (1959).
below
5. There was no transport in ex
:
1. Area selected for families, periment. No. 2. This is essential for
village or town was random and was taking students into the field.
not regularly served in any form by
this department.' It should bo rural
As regards usefulness, it could be
or urban field practice area, server! seen from experiment No. 3 that this
by the staff of the department of is one very important way to teach
S'.preventive and social medicine as practice of integrated medicine
’ possessed by G. S. Medical College (Refer Appendix 1 & 2).
It was
i Bombay (urban), All India Institute found that such studies could be
! of medical science (rural) or medical accommodated in the time table. One
college of Pondicherry (rural).
afternoon has to be kept for such
study and visit should be arranged
2. Families selected were not at the time when most of the mem
seedy with problems in experiment bers of family are available, i e., after
No. 1 as they were in experiment the school time or office hours.
Family study by undergraduate students
Vol. Ill, January, 1964
151
Our tha- ks are also due to of normal families : An experiment
management and staff of Gulab Kun- in Medical Education”, The Lancet,
: verba M. C. H. Centre and the village pp. 263-05 Feb- 3/1963
Headman of Nawagam for their
hours.
cooperation.
Mahajan, B K., “ Organisation of
Assessment of the students reaction
department of Preventive and Social
was made (Appendix 2). We feel
References
5.
Seminar presentations of fami
Medicine in an undergraduate medi
that only a few of the students have lies at intervals are very instructive
| Brockington F. “Report on teach- cal college”,, Med. Edu. Bull, WHO,
liking for such a study, even in the and liked by the students. Specific
SEA Regional office, Vol. VIII, No. 1
face of difficulties but majority take hour has to be provided in the time ' ; ing of preventive and social medicine P. 27, April’ 63
! in Indian Medical Colleges”, SEA/
to it if facilities of transport, treat
‘ Med. Educ./29, WHO, SEA Regional
ment and cooperation of the families table for that.
and guidance by staff are available.
(> Report of studies should be I \ office, P 35, 10 Oct.’ 02
Prasad, B G., “The use of rural
They liked the seminars very much srutinised by staff and given marks I
training health centre in the teaching
as it enhanced both their theoretical to be counted in the university.
Datta, S. P. “ A note on training of of undergraduates and intefnes”,
’
and practical knowledgeA full
undergraduates in Family Advisory Med. Edu. Bull., WHO, SEA Regional
separate university examination in
7.
Great care is necessary to j Services at urban health centres”, office Vol. VII, No. 1 P. 6, Oct. 62
preventive and social medicine with
Med. Edu. Bull., WHO, SEA, Regio
ensure that the students have under- j
definite marks for such family study
nal office, Vol VII No, I, page 19,
stood the significance of preventive J
Oct.
’ 62
sheets will procure almost cent per examination.
j
Taylor, Carl “Report on visits to
cent response.
I Border J., Lovell E. A. Marvin department of Preventive and Social
Medicine”, Health Division, T. C. M.
8.
The study should last for one ■
V. M., and Warren M. D. “ A study P. 3, July - Aug.’ 59
year in the IV and V clinical terms, j
Conclusions and recommendations
150
Indian Journal of Medical Education
Head of the family, if he be a shop
keeper,has to be contacted at suitable
4- Two to three preliminary group
discussions with students should be
held to explain to them the purpose
of the study and method of writing
the schedules.
|
I
Summary
1. As pointed out by Frazer
APPENDIX : I
Brockington in his report, this valua
Experiments for family strdy u J
ble technique (family study) should part of practical work in the subject of j
Summary of 2 seminar presentations in 3rd experiment
not be used unless there is adequate preventive and social medicine were I
£
Family No- 1
Presented by Shri
staff. Some members of the teaching
conducted in M.P.Shah MedicalCollege, K Minkad Y. R-, and partner.
on right side, suspected to be filarial
staff and public health nurse or
Jamnagar with 4 successive batches;
in origin and confirmed on blood
medical social worker have to bo
of students in different practice fields.
examination. Improved with Hetrazan.
there most of the time with the stu The experiments failed in 3 casesaad
General:- A poor family (college Repeated check advised. Role of
E atreeper) consisting of 5 members with
dents in the field.
succeeded in one. The reasons fee
mosquitoes in filariasis and danger to
failure are explained. Organisation^ I E income less than Rs. 25/- p. m. per other members explained.
K iicad, living in a small tenemented
problems involved and usefulness td K-house. No piped water supply.no
2. I’racticc field should be care
the study have been assessed in
2. Wife
Age 22, working in
fully selected. Urban or rural, it
K huthrooin, used common basket type
teaching by this mothod-the practirui
T. B. Hospital, though given B. C. G.
should ba near the college and be an
hslrioes. Lot of mosquitoes and fly
of comprehensive medicine to th® «
vaccination had cervical lymphB lending in vicinity.
area within the health unit served by
-fl
adentis.
Advised treatment.
Un
the staff under the professor of pre students.
Acknowledgement
1
ventive and social medicine. Families
8 All members of the family had vaccinated children accompanied her
to T. B Hospital. Advised not to do
selected should have some health
Weare grateful to Dr. A.D. Jose|fc1 ■ Snae ailment or other.
so but get them B. C. G. vaccination.
problem or chronic illness.
Dean, M. P. Shah Medical Collet Fhividual
Jamnagar for providing facilities fit
3. Son
Age 2, poorly built and
3. Students should go well equip
• L Head of the family
Ago
25
such study and permitting publiar
ped with curative and preventive
y«us, bad a swelling in the scrotum ill nourished. Procured him milk
of the article, after geius
regularly from, well baby clinic
kits, A kit should be planned for tion
through it.
>3
such service.
Vol- ITT, January, 1964
Indian Journal of Medical Education
Child had small-pox 4 months ago.
Parents’ negligence explained.
4. 6-month old child
Unpro
tected against ^mall-pox, was vacci
nated.
5.
Brother of No. 1, ago 10 had
chronic ulcers on forearm and contracture oi left ring and index
fingers. Suspected to be a case of
leprosy; confirmed by skin biopsy.
Treatment with DDS tablets started
and danger of spread to other mem
bers and neighbours explained Exa
mined all other members carefully for
detection of any early case.
Family No. 2
Presented by Shri
Khakhar H. P., and partner.
General
Poor family of 4 mem
bers living in one tenement of the
same chawl as No. 1 with identical
environment.
2. Elder brother
Age 28 years
had ulcers in tho mouth, which
improved on oral and parenteral
administration of Vit. B complex.
Advised change of diet.
3. Wife of No. 2
Age 22, had
two abortions and one full term
normal delivery Found to bo preg
nant at first visit, advised to attend
antenatal clinic which she did. Found
anaemic, given treatment, aborted,
Full investigations regarding Rh.
factor and syphilis started.
4. Sister of No 1 and 2: Age17 suffering from sore throat and
tonsillitis. Had 5 attacks in last3
years. Treated with sulpha drugs
and advised removal of tonsils to
which she submitted after persu
asion.
5. Father of No 1 and 2:- Age
52 wore goggles, on inquiry he did so
for photophobia and watering of eyes.
He was a case of chronic trachoma
with trichiais and enteropion of both
Individuals
eyes and corneal opacity in left eye.
1,
Chief wage earner
A clerk Depilation of eyelashes done and
age 25, had small-pox marks on the advised operation for entropion.
Given auroomycin ointment.
face.
APPENDIX :
If
Students impression on family study as given by Shri Khakhar II. PPatel, S. A. and Mankad, Y. R. in the 3rd experiment
The thing that struck us most
during family study was ignorance
and apathy on the part of most people
in matters of health and sanitation.
A few who were conscious, were
indifferent or had poor economic
means.
Simple principles of maintenance
of health like personal hygiene,
balanced diet, food hygiene, cleat
water, open air, timely immunisation
and regular health check up were
unknown.
We were often confronted with
resistance to our approach by way of
blunt refusals, but by patience and
persuasion, we could win over.
Family study by undergraduate students
In many families, found cases of
With all the above achievomentsf
communicable and deficiency diseases we were left with certain feelings o,
such as leprosy. T. B., Trachoma, disappointment narrated below-.Filariasis, bleeding gums, ulcers in
the mouth, anaemia, etc, who n?ver
1.
Most disappointing was our
came up for treatment. We got them inability to offer treatment for even
treated and prevented complications minor illnesses when demanded in
in them and spread to others- We house itself. This very often estranged
got some of them protected by our relations with family.
immunisation against small-pox and
tuberculosis.
2.
In matter of sanitation and
nutrition, even when we could
We taught them proper storage of motivate families to improve them,
water, disposal of wastes, food they were unable to do it simply
hygiene and protection from insects because of poor economic conditions,
like flies and mosquitoes. Pregnant for which we could do nothing.
women and children started visiting
antenatal and well-baby clinics.
3.
We feel that 8-10 visits for
two hours are inadequate to do any
thing positive. If more visits pre
It provided an excellent oppor ferably in morning hours are arranged,
tunity to learn technique of approach we can do a better job and learn more.
to the family. We experienced the
need of human relationship, specially
doctor-patient relationships. We got
4.
Very often we needed teacher’s
experience of medical practice out guidance or Public Health Nurse’s
side tho hospital and learnt how assistance on the spot, but because,
preventive medicine can be practiced of their other engagements that was
with clinical methods.
not available.
TEACHING OF PREVENTIVE MEDICINE IN HOSPITAL CLINICAL SETTING
Dr V. C. Jain
Chowk, Lucknow, U.P.
The developing concept of comprehensive will it be possible to inculcate in him the
medical care emphasis has shifted, in theory, preventive and epidemiologic approach to
from curative to preventive aspect of dealing disease in the community. To achieve this
with disease. This has resulted in the insti co-ordination between clinical and preven
tution of social and preventive medicine as tive medicine, the following points may be
a new subject in the teaching of medical considered:
undergraduates. The Indian Medical Coun
cil has laid down the curriculum for this
subject. But curriculum content is fulfilled Immunisation Clinic
to varying extents in individual teaching
Many of the common childhood diseases
centres, depending upon resources available. are preventable through an immunisation
The Council has stressed a combined clinico- clinic in the out-patient department. Through
preventive bias in teaching this subject such a clinic, the student can be given
This goal however is seldom achieved practical training in routine immunisation,
because of fragmentary approach.
which he is supposed to practice in the
The departments of Social and Preventive community. The science of disease pre
Medicine usually impart training to the vention through immunisation is developing
undergraduates through didactic lectures, at a rapid pace and several new procedures
field demonstrations and practical training at have recently been developed such as
the rural health training centre and its measles and mumps immunisation. Apart
subcentres. These departments usually have from the practical training of the under
no representation in the clinical out-patient graduate, such a clinic can cater to research
sections of the teaching hospitals. Due to needs for immunisation techniques at the
this fragmentation, the medical student is post-graduate level.
probably not able to see this new subject in
its proper perspective, and therefore may
regard his training in social medicine as Nutrition Clinic
almost synonymous with training for practice
Morbidity among children in India, as in
in village.
many other developing countries, is due to
There is another aspect which calls for defective nutrition, which again is partly due
better co-ordination between preventive and to economic reasons and partly due to ignor
clinical medicine. The majority of students ance. Cases of Kwashiorkor, hypoproteinacoming to medical colleges aim at becoming emic oedema, rickets, scurvy and marasmus
general practitioners or medical officers. are quite common in a pediatric out-patient
As such their interest is mainly focused to department of a hospital as well as in general
achieving efficiency in clinical subjects. practice. The pediatrician engaged in
Therefore, any subject taught which is not teaching medical students about the diagno
linked with clinical medicine may be regard sis and treatment of cases, has little time to
ed as a hurdle to be crossed to reach the goal. teach the preventive aspects in individual
As such, he will study social and preventive cases. Such cases can well be referred to
medicine only to pass the examination and the nutrition clinic, where the student can
not to put what he learnt into practice. learn about the social and preventive
Therefore, if the future doctor has to become aspects of nutrition disorders. The same
a successful uOnuiiuiiity physician, then his centre can be utilized to teach about y>e
training in clinical and preventive medicine nutritional needs in regard to the changing
has to be carried on side by side. Only then patterns of growth and development during
"32 - c iu
Teaching of Preventive Medicine in Hospital Clinical Setting
159
A centre, catering to study of these aspects,
can provide facilities for social and epide
miologic investigation in the family. This
will inculcate in the student the collective
approach for early detection and control of
disease and the concept of clinical epidemio
Centre for Social and Epidemiologic logy, when he goes to practice in the com
Study of Patient and Family .
munity. At the post-graduate level, such a
According to the new concept, family has hospital-based service can form a nucleus
now become the unit of medical study, as for organisation of epidemiologic research
this allows disease to be investigated in all its on various diseases such as rheumatic fever
aspects, viz., clinical, epidemiologic and and diabetes mellitus, both in the hospital
social.
population and in community. By treating
With better understanding of multiple preventive medicine not as a fundamental
causation of disease, and discovery of screen science taught in paraclinical training but by
extending
it to out-patient clinics, better
ing tests to detect disease in pre-pathogenic.
phase, the social and epidemiologic approach co-ordination between this and clinical
has assumed greater importance. For subjects can be obtained. Only then the
example, Diabetes can be detected in the pre student will see it in its proper perspective.
diabetes phase. Gout, phenylpyruvic oligo The didactic lectures, field demonstrations
phrenia and others can be detected in the and training at rural health training centreX
‘carrier’ stage and genetic counselling can be all have their role to play, but an integration '
rendered in several conditions such as of the training at the clinical setting of a
mongolism.
teaching hospital has its own significance for
the proper development of this subject.
various stages froiWmfancy to adolescence.
Some Pediatric departments do have such
clinics but its service is seldom co-ordinated
with that of the department of Preventive
Medicine.
Clinical Conference Demonstrations in the Teaching of
Social and Preventive Medicine
BY
Dr B. G. Prasad, Professor and Dr S. B. Nayar, Lecturer
Department of Social and Preventive Medicine, King George's Medical College, Lucknow
Medicine. She deals with the case with
Introduction
particular reference to the social background
In 1958, a full-time Department of and other environmental implications of
Social and Preventive Medicine was esta the disease. The spread of infection (in
blished at the King George’s Medical case of an infectious disease like tubercu
College, Lucknow. The teaching of Social losis and smallpox), the socio-economic
and Preventive Medicine to the medical - history, the emotional conflicts, the socio
students was extended over the preclinical, economic problems and the effects cn
clinical and internship periods.
personality created by the disease are also
• Clinical conference .demonstrations are dealt with. Finally she explains what
held once a month in the preclinical years measures can be taken by way of social
to illustrate to the students the social therapy and rehabilitation with particular
origins of disease, its' multiple causation, reference to the case.
the natural history of a disease process, the
In his concluding remarks the Professor
levels of prevention (Leavell and Clark, of Social and Preventive Medicine tries to
1958), and the total aspect of medicine.
focus the attention of the students on the
salient features of the case history as related
to the patient, his family and the community,
Presentation of a case
At these conferences the socio-clinical
presentation of illness is attempted, and
selected patients are presented with their
families. The professor of Social and
Preventive Medicine introduces the subject
with particular reference to the significance
of the disease or disability in the community.
A senior demonstrator of the department
introduces the case, deals with its clinical
aspects and explains the natural history of
the disease process and the levels of preven
tion. According to the nature of the
subject, the anatomical and/or physiological
aspects of the disease are dealt with by the
demonstrators of the department concerned.
y a case is connected with any speciality,
for example, pathology and bacteriology
as in ankylostomiasis or orthopaedic surgery
as in poliomvelitis needing rehabilitation,
a staff member of the concerned department
also participates in the conference.
. I’he medico-social asoects of the case is
•:'.en explored by the medical social worker
ot the Department of Social and Preventive
L
and points Gut the lesson les mt iruni the
failure of medicine in the case under conside
ration. He examines the chain of causation
to show where it could have been broken
and concludes by stressing the need for
prevention and early treatment.
Demonstrations Held
a,
Ten important social illnesses were1;
demonstrated during 1962-63, viz., rickets,
tuberculosis, blindness from smallpox,
diabetes and poliomyelitis in the first year;
and leprosy, venereal diseases, ankylotomiasis, hypertension and psychoneurosis
in the second year. Each of these illnesses
illustrated the importance of certain levels
of prevention. For instance, while in
rickets, promotion of health through nurtition is the main level of prevention, in
tuberculosis, health promotion, specific
protection, early detection and prompt
treatment are the three important levels of
prevention. On the other hand specific
protection is the main level of prevention
INDIAN JOURNAL OF MEDICAL EDUCATION
LOL. IV, OCTOBER 1964
.in smallpox, while specific protection and
rehabilitation are the important levels of
prevention in poliomyelitis. A few illustra
tions of the case presentations are given
below:
humiliation to bim.^Later she deserted
him for another man in spite of pressure
from her parents to make her stay with him.
She had one child by him whom she took
away. When he decided to remarry he
would choose none but a woman with a
pigeon chest. It was thus that he adjusted
himself in his marital life. He had two
normal children by his second marriage,
aged 4 and 2J years.
While young, his parents put him to work
as an apprentice in a tailor’s shop and he
earned about Rs 2.50 per day from tailoring.
Conclusion: This patient with his wife
and their two normal children brought out
several points of interest to the students.
1. The importance of nutrition in
promotion of health, and the disability
left by rickets, were clearly brought out in
the demonstration
2. It could be shown that rickets is an
acquired condition and not hereditary as,
the children born to the parents, both of
whom had suffered from rickets, were
normal.
3. The patient had married a woman
who was deformed by rickets. He had to
abandon the normal ways of getting the
necessary emotional adjustment in married
life, and had to go to the extreme of choosing
a partner who had a similar deformity.
4. The case also demonstrated that he
could rehabilitate himself in life in spite of
the deformity by taking up a suitable pro
fession like tailoring.
' 26
1.
Case Presentation on Rickets
A.G—aged 35 years, male; Muslim, tailor
by profession, separated from the first wife,
having three children, one by the first and
two by the second wife. He complained
of marked weakness for the last 30 years
and a chest deformity which was present
since childhood. General examination
revealed a marked deformity of the spinal
column presenting a pigeon chest with
lordosis and kyphosis.
Past history was suggestive of debility
and lowered body resistance, with recurrent
attacks of pneumonia [and bronchitis.
History of present illness revealed the
following facts:
The patient in early childhood developed
pyrexia, which lasted for about 1J-2
months; together with this he also developed
pain in the bones and weakness in both the
upper and the lower limbs. His mother,
who was working as- a maid servant in
Calcutta, took him to various quacks,
Voids and Hakims, but with no relief. In
the meantime two bony projections one
in the back, in the region of the upper
thoracic spine, and the other over the sternum
were noticed. His mother again consulted
some quacks who advised her to press
the bony protrusions by applying heavy
weights. She tried this with stones but 2. Case Presentation on Blindness
finding no improvement had to give it up.
from Smallpox
These deformities went on increasing and
R. J., a boy of 18 years, Hindu, a student
gave him the pigeon chest.
in the Blind School, unmarried, lost his
Social aspects: The illness of the patient eye sight in childhood due to smallpox.
was neglected in the initial stages because He had 3 sisters and 2 brothers. His
of poverty, ignorance and lack of health father was a postman of very meagre income.
education. The ignorance of the patient’s
About 14 years ago when there was an
mother was revealed when she applied epidemic of smallpox in his locality in
heavy stones on the chest of the patient to Lucknow city, the patient got an attack of
lessen the bony protrusions.
smallpox and was bedridden for about
The disability left by the illness created 2 months. He was vaccinated against
a lot of problems for the patient as he could smallpox only once at the age of 6 months
not Jive an active, productive and happy (primary vaccination) but revaccination was
lift1 He was prnotic,r'td!y upset in h»<s marital not done. During his illness the patient
life as well. Whenever there was a quarrel, was not given any treatment because of the
his first wife called him a female, because belief that any treatment would aggravate
of his chest protrusion and this was a great the disease. His cousin, living in the same
CLINICAL CONFERENCE DEMONSTRATIONS IN PREVENTIVE MEDICINE
house, had died earl® of smallpox in the
Lme epidemic. Without proper treatment,
patient developed pustules in the eyes
resulting in corneal ulcer, sloughing of the
eyes (panophthalmitis) and blindness.
Social aspects: The patient’s elder sister
who had never been vaccinated against
smallpox, had died in an earlier epidemic.
After that the parents used to get their other
Children vaccinated before the age of 6
months. But during the epidemic in which
r. J. became ill, they did not know that
smallpox was prevalent in the locality.
When they knew of the epidemic and had
a case in the house, they did not know that
revaccination was necessary for protection,
and especially so in an epidemic.
First, R. J’s cousin, became ill with
smallpox. But the parents did not have
enough space in the house (two rooms and
two families living) to segregate him. Pro
per treatment also could not be given because
of ignorance and- financial limitation.
R. J’s father was a postman getting Rs 80
p.m. and the only earning member in the
family. The cousin died, while R. J.
became infected and lost his eyesight.
Being the eldest son in the family he was
the main hope of the parents. But from
then onwards he became a burden.
27
(i) The psychological tension created
in the family by the oldest male child, the
future bread winner of the family, handi
capped for life.
(17) The financial burden on the parents
in giving the patient suitable vocational
training. Besides attending the Blind
School, the patient attended a music academy
where loss of eye sight was no bar. The
parents had to spend more money on him
then they would have, had the boy been
without a disability and reading in a normal
school.
6. A discussion on social therapy revealed
to the class the functioning of therorganizations for the physically
handicapped and what vocationil
training can do for the blind.
Case Presentation on Poliomyel- \ ■
itis
A. K. aged 9 years, Hindu, student of the *
3rd standard, complained of disability in
the left leg, following an attack of polio
myelitis, for about 8 years. General
examination revealed weakness in both the
legs.
Past history revealed that the patient at
the zge of 9 months had an attack of fever
for about 10 days. For about three months
Conclusion: The case of R. J. with following the fever the child was completely
blindness and pock marks on the face disabled. At that time it was found out
suggested to the students the following that the boy had.lost motor power in the
left leg. He was taken to an allopathic
points:
doctor who diagnosed him to be a case of
1.
How a costly experience with a killing poliomyelitis. Since that time he had
disease taught the parents, the resorted to allopathic as well as homeopathic
necessity of primary vaccination. treatments. He had been having regular
2.
The ignorance about illness and lack massages throughout for the last 5 years.
of health education was revealed For nearly 8 months he was in plaster at -r
in the fact that the patient was intervals to correct the deformities of the
not given revaccination during an lower limbs. For about 3 years he had —C
epidemic, especially as there was electric treatment after which he showed ■
some improvement. He could manage to
another case in the house.
walk with some difficulty without any —
3.
Specific protection by primary walking aid from one end of the room to
'
vaccination and revaccinations can the other. He had been given callipers
prevent smallpox in a community. for walking but could not use them properly
Poor living conditions prevented isola and due to instability he fell down and
tion of an infectious case like fractured the left humerus. At the time
of presentation in the class he could walk
smallpox.
3- The case was also suggestive of the well with the callipers on.
Social aspects: In spite of the fact that
problems that were the after-effects
A. K’s parents belonged to the lower middle
of the disease, viz.,
3.
v 28
INDIAN JOURNAL OF MEDICAL EDUCATION
VOL. IV, OCTOBER 1964
and the neelfta have family case
income group, A. K.’s illness was not
neglected by his parents. When he became
work facilities.
ill the father was getting a pay of Rs 150
4.
The need for prevention of polimyep.m., which increased to Rs 250 p.m.
litis in the community through
when the case was investigated. He had
immunisation in infancy and child
four children to support. A. K. was the
hood.
only male child in the family.
5.
In spite of the poor economic circum
From the time the boy was 9 months old,
stances of A.K.’s. parents, efforts
the parents had been giving him some
were made by them to rehabilitate
treatment or other. They had borrowed
A.K. physically and emotionally as
Rs 1,500 for the boy’s treatment. They
far as possible.
had to do without some of the basic needs
of life for a long time in order to repav the
These are just a few illustrations of the
loan in instalments.
cases presented in the class. All the case
A survey of the economic conditions reve illustrations mainly aim at bringing out the
aled how poverty prevents people from causes of illness other than the biological, the
environmental
conditions, the after-effects.
getting proper treatment. The parents
were not able to give him continuous treat of illness, and what could be done to alleviate
ment, or even, better type of callipers. the same through social therapy and proper
The case showed the need for rehabilitation ' exploitation of the existing facilities. In
of the physically handicapped. The these case demonstrations the students were
parents were trying to teach him music made to realize that a complete diagnosis
and put him in schools of better standard includes clinical diagnosis plus social diagno
so that he would be accepted by others. sis, and therapy includes social therapy.
They had been careful to see to his emotional
It was thought that the presentation of
rehabilitation also. Earlier the patient was certain living examples of people with
shy and sensitive and used manifest feelings illnesses and handicaps, who might have
of inferiority on his dealings with others. been saved untold suffering but for a little
One of his complaints was that he could care, proper education and utilization of
not take revenge on those who insulted him proper facilities, would serve a useful pur
on his physical disability. Later, he tried pose. The importance of prevention in the
to over-compensate his limitations—he was daily work of a medical student would be
leader of the locality among his friends, stressed as well as the application of the five
intelligent in his studies and smart in his levels of prevention i.e., health promotion
social relations. But because he had been (including health education), specific pro
trying to over-do, he had to repress a lot tection, early detection and prompt treat
of his emotions. These he found vent for by ment, limitation of disability, and rehabilita
complaining to his parents. He urged them tion. Each of the above cases brought out
to provide him with the best of treatment certain levels of prevention, which could
which they could ill-afford. The result have been practised and the disease prevented
was that the mother started continuing her or interrupted. The case demonstrations
studies to take up a career so that she could could make it possible for the student to
also earn to give the boy a better techmeal look at the natural history of any disease as
education.
a process that can be averted, interrupted,
Conclusion: The case of A. K. demons" or delayed at various noints in its evolution.
He could also appreciate that prevention
trated the following points:
includes not only prevention of ‘occurrence’
1. Lack of economic security which but also prevention of ‘progress’. Early
prevents people from getting proper detection or diagnosis of a disease and its
treatment was also prevention. The demon
treatment.
2. The need for adequate rehabilitation strations also impressed on the student
that the question to be asked was not only
for the physically handicapped.
‘what is the treatment?’ but also ‘what are
3. The need for emotional rehabilitation the causes?’ and ‘if preventable, then why
through proper case work therapy not be prevented?’
CLINICAL CONFERENCE DEMONSTRATIONS IN PREVENTIVE MEDICINE
Summary
j The purpose and importance of the .
monthly clinical conference demonstrations
ju the teaching of Social and Preventive )
Medicine during the pre-clinical years is to !
enable the student to see the patient as a
person and try to focus his attention on the;
wider objectives of medicine in the com-J
in unity.
2. The clinical conference demonstration
is a joint presentation by several teachers, of a
patient with his family, in which the sub
ject of the conference is introduced, the case
is clinically and socially presented, the levels
of prevention with specific reference to the
case are given, and social diagnosis and social
therapy are discussed.
29
REFERENCES
1.
Leavell, H. R. and Clark, E. G., Preventive
Medicine for the Doctor in his Community.
McGraw-Hill, New York, 1958.
2.
Prasad, B. G., Social and Preventive Medicine
in the Undergraduate Medical Curriculum.
Med. Ed. Bulletin (WHO Regional Office'
for South East Asia), Vol. 3, 1959.
Prasad, B. G., Family Studies by Students,
Innovations at Lucknow. The Lancet,
October, 1, 757, 1960.
Prasad, B. G., Field Training for Intern in
Social and Preventive' Medicine. J. Ind.
Med. Assn., Vol. 35, 465, 1961.
Prasad, B. G., 'Social Medicine Teaching in
a Rural Health Centre, in India’, Epide
miology, Reports on Research and Teaching
1962, edited by J. Pemberton, Oxford
University Press, London, 1963.
s which the cliniion centres showf combined progtetrics and social
veloping countries.
edical education is
tedical colleges to
argcry, paediatrics
which the patients’
he tognosis, treatcat^) is now fre-
The Practical Approach to the Teaching of
Preventive and Social Medicine to the
Undergraduates—the Plan of Action of the
J. Medical College, Poona.
B.
N.S. DPODHAK
*
& P.V. SATIIR
**
Much That was being taught in the traditional ‘Hygiene and Public Health’
ant role to play in |’
■cine as well as in S tomedieal students was outmoded. With the rapid advances in medical and allied
sciences
the practice of medicine required different skills and education. Il was
t and conducting of
of instructions in £ realised that with the emergence of modern society and technological advances,
m and assessment, ft something of fundamental importance—the human approach—was being
majority of instances K forgotten in a preoccupation with research and diagnostic excellence. Spccialisential in adequate | zition in medicine weakened the doctor-patient relationship, and the neglect of
listration. Medical t human values in medicine was recognised by clinicians such as Ryle who
" medical education & introduced the term ‘Social Medicine’ to describe a new discipline.
The last 15 years have constituted a period of transition in the teaching of
r medical education ft
Ith to organise such B preventive medicine. The scope of preventive and social medicine is so wide that
various ideas—some of them vague—were. tried out and the teaching of this
subject at different colleges would disclose a surprising variety of content and
have an additional
method. This teaching was not a smooth task. There was no recognition of the
to the developing
new discipline by many clinicians. There was much philosophical talk on
developed countries
positive health when illness was rampant. Transformation of ‘public health’ to
tations.
■preventive medicine’ was hampered by a shortage of qualified and suitable
' teachers, and teaching was also affected by the fact that students were admitted
; in progressively increasing numbers. Administratively, there was more of
I hindrance than support, more of ridicule than help, and much unrewarding
. paper work. While these conditions still prevail to a varying extent at some
■ places, there is a general improvement. The new discipline is, however, far from
I suture. There arc unwarranted moves for empty educational reforms such as for
■ change of the name from Preventive and Social Medicine to Community Medicine.
; We are presenting here our approach that has gradually evolved since 1955.
: Principles
Some important guiding principles should be borne in mind in the teaching
of preventive and social medicine. These arc:
(a)
The aim of teaching should be the development of concepts, and acquiProf. & Head of the Deptt. of P.S.M., ** Reader, Preventive and Social
Medicine, B.J. Medical College, Poona.
39
NIHAE BULLETIN
TEACHING
sition of skill and knowledge for practice, not in isolation but integrated with
the practice of general medicine or its specialities.
(b)
With this in view, the training of the students should be done not only
in the class-rooms (which has to be continued), but also by demonstration and
participation.
(c)
Development of communities where preventive and social medicine is
practised should bean essential activity for teaching purposes. This would remove
the notion from the mind of students that this subject is to be studied only for
passing examinations; and that the principles of preventive and social medicine
are good but have no place in practice. Just any geographical area with a
public health service will not do. The community services in the area should be
specially developed for training which should be the primary responsibility, and
the services (and the area) should be expanded as necessary for teaching.
(d)
The aim of teaching should not be to turn out public health specialists,
but good practitioners of medicine who arc aware of community conditions,
their duties towards the community, and responsibilities in the national health
problems and programmes. These students, after passing, may become general
practitioners and either start private practice or man the primary health centres,
or take up specialities.
(r) Preventive medicine is not the only important subject, it has no existence
without curative medicine. The preventive aspects of medicine are only a part
of good medical care.
Background Information
medical services of tl
operation at the Armthe State Directorate
institutions, a cluste
neighbourhood of Po
from the various depa
The establishment of
up this speciality as a
in training the medic
research activities of 1
them to undertake in
responsibility to junio
Bredinical Period
The newly admitted
cine through the specia
purpose of impressing <
periodic health check-t
practical applications <
from explanations no f
A course of introdi
students. These lecture
before they start the cli
of 40 each and semifor
tion to medicine, ecolo.
and social medicine, fu
The teaching of preventive and social medicine to students in the B.J.
Medical, College, Poona, located in a fairly developed area, presents certain
handicapsand also advantages. The handicaps arc that the number of students
Clinical Period
admitted every year is as large as 200, which poses difficulties in paying
During all the six c
personal attention to the students, and increases the load of teaching as it
are trained in various si
becomes imperative to form many small batches of the students. Moreover,
tion,
medical statistics
about 80 per cent of the students have an essentially utban upbringing with no
and control of comm
personal experience of the way of life in the villages. The trend of such students
community health servi
is also to settle in large towns and cities after graduation and, therefore, they
programmes including
have a mental barrier in appreciating the needs of the rural population, poor
health activities, etc. In
environmental sanitation, their traditional customs and beliefs, and of the
inadequacy of medical and health facilities, etc. In the past there was no sepa- ' examples which have a
rate examination in preventive and social medicine at the final M.B.B.S ' socio-economic develop:
in statistics, data on phy
examination. This created problems in teaching, but now there is a separate
selves is made use of. T
examination together with medicine, surgery, and midwifery and gynaecology.
Because of this the students are now better motivated, and this is being made\
Extramural teaching
use of to achieve the aims of teaching as explained later.
demonstrations, e.g., n
At the same time certain circumstances arc favourable. The students are; through the visits and de
of class-room lectures to
familiar with the problems of urbanisation and industrialisation, and the
resultant social and health problems, The fairly developed public health and •
Considering the impc
40
’• '
> •’***
'■■■
*
<•
.....
TEACHING OF P.S.M. IN THE B.J. MEDICAL COLLEGE, POONA
grated with
me not only
stration and
medicine is
Duld remove
ied only for
al medicine
area with a
ea should be
isib A, and
thing.
h specialists,
conditions,
tional health
eome general
ealth centres,
no existence
e only a part
s in the B.J.
csents certain
er of students
ties in paying
teaching as it
s. ^^reover,
ngifl^^’ilh no
such students
herefore, they
rulation, poor
s, and of the
: was no sc pafinal M.B.B.S
e is a separate
1 gynaecology,
is being made
le students arc
ition, and the
♦lie health and
medical services of the Poona Municipal Corporation, the facilities and co
operation at the Armed Forces Medical College, the facilities and support of
the State Directorate of Public Health, the presence of several well developed
institutions, a cluster of rural health centres situated on good roads in the
neighbourhood of Poona, constitute our assets. There is also good co-operation
from the various departments in the college and the Sassoon General Hospitals.
The establishment of postgraduate courses has attracted junior teachers to take
up this speciality as a career, which creates an academic environment and helps
in training the medical students. Involvement of the staff members in the
research activities of the department provides the training which will enable
lhem to undertake investigations independently. The gradual delegation of
responsibility to junior staff has produced satisfactory results.
Preclinical Period
The newly admitted students are introduced to preventive and social medi
cine through the specially designed Students Health Service which serves the
purpose of impressing on them the wider functions of a doctor and the value of
periodic health check-ups, early detection of disease, immunization and other
practical applications of the principles of preventive and social medicine. Apart
from explanations no formal teaching is undertaken during the first term.
A course of introductory lecturesis given to the First M.B.,B.S. 2nd term
students. These lectures aim at orienting the students in medical practice even
before they start the clinical curriculum. The students are divided into batches
of 40 each and semiformal teaching is carried out. The topics include introduc
tion to medicine, ecology, concept of health and disease, scope of preventive
and social medicine, functions of a doctor, medical social work, etc.
Clinical Period
During all the six clinical terms extending over three years, the students
arc trained in various subjects such as the principles of environmental sanita
tion, medical statistics and biostatistics, general epidemiology, epidemiology
and control of communicable and preventable non-communicable diseases,
community health services, community development, nutrition, national health
programmes including family planning, occupational health, international
health activities, etc. In all these courses, care is taken to provide illustrative
tramples which have a direct bearing on real-life situations as related to the
focio-economic development, sanitation, etc. For example, in the practical work
in statistics, data on physiological variations collected from the students them
selves is made use of. The findings of the health check-up are used similarly.
Extramural teaching is done as much as possible through field visits and
demonstrations, c.g., most of the training in environmental sanitation is
through the visits and demonstrations. In most of the courses the proportion
of class-room lectures to the practical and field work is 1 to 2 or 1 to 3.
Considering the importance of communicable diseases in India, at present
41
NIHAE BULLETIN
and in the near future, intensive teaching is done in this subject. In addition to
lectures on epidemiology, bedside clinics are taken in the infectious diseases
hospital of the Poona Municipal Corporation, and the students examine and
maintain systematic records about the clinical aspects, epidemiology, and
prevention (including health education) of the common communicable diseases.
It is impressed upon them at this time that in order to practise good preventive
medicine they must be good clinicians, and conversely if they want to be good
family doctors they must also practise preventive medicine by taking care of the
other members of the family of the affected patient, and the community at large.
At this time the students clearly see that preventive and curative medicine are
not watertight compartments.
The spacious museum of the department is generally well made use of by
the students. With a number of actual specimens, models, photographs and
charts, it serves the purpose of giving information to the students in addition to f
arousing interest. Entomological specimens, etc., arc displayed on a revolving ;
stage under a microscope so that the students can revise them any time.
As a part of health education in the hospital or on the occasions such as
world health day, college functions, etc., special health exhibitions are
organised. The students actively participate on all such occasions and explain
to the public for long hours not only what the exhibits are meant to convey,
but also many other points that arise.
TEACHING
additional staff is bcir
participation in the he
zations, health educat
child health, etc.
Examinations
There is no doubt
a subject forms a part
teaching of prevents
matter—should not b
reforms in the general
examinations. Till tha
can be made use of in
of each term in theor
set in these examinath
can deal with by mi
students are made t
particular situation.
clearly about a prot
coherent expression.
In short, the exam
direct the studies and
Sassoon General Hospitals
The students learn what they commonly see. Naturally they learn more
of the hospital practice of medicine which is mostly the specialists dealing
with an episode in the course of an illness. The practice of preventive
and social medicine can be taught only if the hospital practice
is made comprehensive. Some progress has been made in this direction
because of the establishment of the following services at this teaching
hospital which recently celebrated its centenary, viz., antenatal and postnatal g
clinics, well baby and child welfare clinic, diabetic clinic, family planning clinic,
medical social service department, immunization centre, cancer detection
centre, genetic clinic and counselling, hospital health education, etc. In order to
improve the quality of management of the patients at the out-patient depart
ment and of training of medical students a scheme of general practice ol
medicine will be shortly introduced in the hospital. However, it would be a long
time before our hospitals are able to provide truely comprehensive medical .
care.
Urban Health Centre
For demonstration of community health services, comprehensive and inte
grated medical care, continued care, etc., an Urban Health Centre has been
established recently very near the college with the co-operation of the Poona
Municipal Corporation. The activities at this centre are being developed and
42
Rural Training Centrt
Teaching of prev«
students, unless it is ir
trated. The students
social factors that n
determine the patient’
them to the social cor
best compromise betv
social circumstances a
The Rural Training
nictrcs from Poona on
control of the centre
Medical Officer in cha
used to belong to the '
a proper orientation o
Health Services in the
five and social medicir
All the students art
post •examination com
year. It is decided to e
when after orientation
TEACHING OF P.S.M. IN THE B.J. MEDICAL COLLEGE, POONA
In addition to
'ectious diseases
s examine and
femiology. and
icable diseases.
ood preventive
ant to be good
ing care of the
(unity at large.
medicine are
nade^se of by
and
in addition to
jn a revolving
time.
asions such as
diibitions are
is and explain
mt to convey,
y learn more
ialists dealing
of preventive
ital practice
his direction
his teaching
tnd postnatal
anni^k clinic,
:er Wtection
. In order to
tient departal practice of
aid be a long
osive medical
ve and inteitre has been
of the Poona
veloped and
additional stalf is being provided. Senior students arc posted at the centre for
participation in the health services such as school health check-ups, immuni
zations, health education, morbidity surveys, nutritional projects.and research,
child health, etc.
Examinations
There is no doubt that the interest of the students markedly improves when
a subject forms a part of the final examination. Although we believe that the
teaching of preventive and social medicine—or any other subject for that
matter—should not be examination-oriented, it would involve basic and radical
reforms in the general system of education in our country to do away with
examinations. Till that time this examination-oriented motivation of the students
can be made use of in directing their studies. Examinations are held at the end
of each term in theory, practicals and oral. The questions and the problems
set in these examinations arc, however, not the usual type which the students
can deal with by memorizing a passage from a book or class notes. The
students arc made to think for themselves and apply their knowledge to a
particular situation. These examinations also train the students to think
dearly about a problem, to make a decision, and to develop the habit of
coherent expression.
In short, the examinations are essentially used as an educational tool to
direct the studies and to provide self assessment.
Rural Training Centre
Teaching of preventive and social medicine will be meaningless to the
students, unless it is integrated with the practice of medicine and so demons
trated. The students should be able to witness and experience some of the
social factors that may initiate or influence the disease process, and may
determine the patient’s reaction to the disease. It is also essential to expose
them to the social consequences of the disease, and to demonstrate what is the
best compromise between the theoretically ideal and what is possible in the
social circumstances and in a particular individual.
The Rural Training Centre is situated at Sirur, Poona District, about 66 kilo
metres from Poona on Poona Aurangabad road. The administrative and technical
control of the centre is entirely with the B.J. Medical College, Poona. The
Medical Officer in charge of the Centre, of the rank of a District Health Officer,
used to belong to the Public Health Department in the past. However, to ensure
a proper orientation of the training programmes and the establishment of Basic
Health Services in the area, a lecturer or a reader of the department of preven
tive and social medicine is now given the charge of the rural training centre.
All the students are posted at Sirur for a period of 3 .months during the
post-examination compulsory internship. Four such batches arc trained in a
year. It is decided to extend this rural training to 6 months from the next batch
when after orientation course the students would be posted continuously at
43
NIHAE BULLETIN
several primary health centres, including Sirur, for practice of comprehensive
medical care. Good hostel and mess facilities are provided at Sirur.
The internship programme is so arranged that there is an integrated approach
for preventive and curative services. The interns arc responsible for giving
medical relief at the five (to be extended to six) subcentres. They continue to
develop the skill and practice of history-taking, diagnosis and treatment of the
sick, on their own, which helps them to become good general practitioners later.
They have to take the decisions themselves. The interns are, however, not
completely deprived of guidance and consultation with the specialists. They are
made aware that many simple and effective measures can be easily taken to
prevent disease. Each week a specialist in medicine, pediatrics, general practice,
and at a set frequency a specialist in tuberculosis, dermatology, surgery, mid
wifery and gynaecology, etc., visit the main centre at Sirur and at the sub
centres when the interns can refer or bring difficult cases for consultation in
diagnostic and/or management problems. All departments in the college, and
some general practitioners in Poona, participate and the standard of the services
is maintained fairly high.
The interns also get a first-hand knowledge of the pattern of basic health
services in the rural area. Through participation and demonstration they learn
about the various National Health Programmes, M.C.H. services, school health,
immunizations, nutrition programmes, sanitation, etc. They also participate in
research activities to get acquainted with the methods of epidemiology and
research techniques. Health education is routinely done by them as they go in
the villages and meet the people.
Summary
Some of the principles of teaching preventive and social medicine to the
undergraduate medical students and the scheme of training them at the B.J.
Medical College, Poona, have been outlined. Efforts are being made to develop
strong urban and rural field practice areas to demonstrate the principles and
practice of preventive and social medicine. Such field programmes in compre
hensive medical care are most important for the training of future doctors.
Unless such an integrated practice becomes a rule there will be no worthwhile
progress in the teaching of preventive and social medicine.
Teaching of Com
Undergraduate M
Christian Medical
This Paper deals wit
programme that give the si
“Community Medicine”.
At the Christian Medic
nised into a Department ol
name of the department w
mainly because our attemp
of the faculty, as well as
phrase “Community Healt
away the association thal
exclusion of health promo
We also consider the u
medical college to the end
The teaching of the “c<
periods—(i) the first period
of 3 months (12 weeks)
Community Health.
The First Period
This may be further
mainly didactic); and (b)
involvement in a Family B
The introductory phas
elements of sociology, culti
those aspects applicable to
In addition to this there is
examination for internal as
is no University examinatii
The definitive phase of
Advisory Health Service.
♦ Prof. & Head of the
Deptt. of Community
__
--v quarts C" |
’ . Utuic PariS* ■
>rd-^f^'
'hich could
P°ss’ble
kgh cost ? *
>g a packed lu-^.
wh«theyr^£
tes, but rather
1
conditions. tC 1
th? tv™
**
Teater for a for^.
twenty-five.^
rrrent to patiesa 1
ehabilitation—tjg
‘f Pensions »-,>
■•sistance Board.
rorandum on
■ut to remunencht
ery different fraa patient who paa
earns normal fcj.
of patients eam^
m stifle initiadvr,
ingle man with q.
working a tweznwither complk>
*
addition
S. 8d. To mrnp
r
*
“ the formulx is
ons and NariaaJ
■lly for the paries
ig over £2 a wax.
■cnefits for a wifi
■able to Natioaal
he initial stages),
■nee contributkc
ngs, the dispro, the contriburicc
Mot surprisingly.
cually prohibited
which might lewd
on State funds.
y of Health in
•itional Insurance
sickness benrik.
s and Natxxsd
helpful, but
tai cases of bard.mir of earning-
t0 hospital and who has dependants drawing
Asshtance may find that the Ministry of Health and
—, Assistance Board are eaqh claiming from his
. board-and-lodging and for dependants ’ allowance
’ rt of the National Insurance Advisory Comthe Question of Long-term Hospital Patients
glared that there must be a point where a
earnings become inconsistent with his receiving
insurance benefit, and the committee concluded
was no evidence at the present time that the
..“limit of 40s. a week was acting as a disincentive.
we have no doubt that the £2 limit acts as an
in the initial stages of work outside hospital when
**
a
?"!
are low and depend on the patient’s efforts. The
considered that the limit “ should remain at
*'®SSfings per week for the present ”. It obviously
that changes would be necessary, and I consider
the present circumstances further consideration'
f which no
by I.T.O.
"^busalten*?"
'
.j
'
j
* Unlike short-term illness, long-stay patients are not
for work today and fit for full-time employment
It will require time to re-establish the habit
T^rnal work, and in most cases failure will result. We
to teach patients to assume normal responsibilities—
mv their National Insurance contributions, to pay
if due, to pay for all or part of their keep,
transport costs, and their meals at work—but this
await the third stage of rehabilitation when the
-utieat draws a full economic wage. If the Ministry
7 Health (1958) and the National Insurance Advisory
rMvninee believe in the therapeutic value of work, as
say they do, then together with the N.A.B. some
yK-mr must be devised which will encourage patients
swork.
Social Resettlement
j
j
The Medical Research Council (1959), discussing the
aasditions of resettlement of schizophrenics, says:
Brown et al. (1958) pointed out that, apart from the
dnical state of the patient on discharge and his success in
■curing employment, the finding of suitable accommodatian was of paramount importance. It is unreasonable to
expect a patient who has spent many years in the artificial
■nosphere of hospital to settle immediately in the
■mmunity when he obtains employment.
As the
Wustrial training of a patient may take a considerable
so too may his social training. Together with
tedustrial training and resettlement must go social
■fcibilitation. Clark and Cooper (1960) describe an
ttperiment in Cambridge which they call a psychiatric
Mfway house.
Their hostel was financed by S.O.S., a charitable organisa—• (with aid from the Cambridge Mental Welfare Association
■dthe county council). They conclude that such a house is of
•due to a limited group of people and suggest that, for a
••dim ent area of 360,000,16 places would be adequate. They
only patients who were in work or capable of finding
•Moyment within a month and who were deemed capable of
•™eving independent social life (in lodgings at least) within
Sj“®“nths. Possibly these requirements are rather'rigid, and
were more flexible, there might be more patients suit. ■•for admission; but it speaks well for the selection that 10
rf 19 schizophrenics were discharged in the first year.
757
Especially in view of the Mental Health Act (1959), I
consider that the social reorientation and re-education of
patients should be undertaken jointly by the hospital and
local authority. In Bristol we have discussed possibilities
with representatives of the housing and the health com
mittee. I would like to see developed on the hospital estate
(but removed completely from the hospital—on the opposite
side of a main road) a row of 6-8 standard council houses
such as patients may expect to live in on discharge; these
houses would be built by the local authority and be
jointly administered by hospital and local authority.
With a minimum of supervision—e.g., a male nurse and
his wife in one of the houses—discharged patients still
undergoing industrial rehabilitation would occupy these
houses as tenants, paying rent and learning again how to
live socially acceptable lives. These proposals are still
in the embryo stage; but the hospital management com
mittee favour the scheme, as does the chairman of the
local authority’s housing committee.
If such a scheme of industrial and social rehabilitation
were supported by the goodwill of the great national
voluntary organisations, then at last there would be some
real hope for the successful reintegration of the long-stay
patient into the community.
My thanks are due to those people whose goodwill and enthusiasm
have made this experiment possible—particularly to Mr. John P.
Turley, director of Messrs. Tallon Ltd., and managing director of
I.T.O. (Bristol) Ltd., without whom the project would not have
come into being.
Charlton, E. P. H. (1959) The Place of Work in the Treatment of Mental
Disorder; p. 29. London.
Clark, D. H., Cooper, L. W. (1960) Lancet, i. 588.
Medical Research Council (1959) Report for the Year 1957-58. H.M.
Stationery Office.
Ministry of Health (1958) Memorandum of Recovery of Part Cost from
Hospital Patients going out to Work. H.M. (58) 72.
Ministry of Health (1959) Memorandum on the Rehabilitation of the
sick and injured.
National Insurance Advisory Committee (1960) Report on the Question
of Long-Term Hospital Patients. H.M. Stationery Office.
Stanley, R. (1959) The Place of Work in the Treatment of Mental Disorder;
p. 39. London.
• It appeared likely that a proportion of these patients could ..,
v
restored to life in the community provided that their social I
^chaviour was such as to permit of their being discharged from --------taspital and of free association with healthy people.”
4
THE LANCET
MEDICAL EDUCATION
1, I’60
Medical Education
FAMILY STUDIES BY STUDENTS
Innovations at Lucknow
B. G. Prasad
M.D. Lucknow, D.P.H., D.T.M.
PROFESSOR AND HEAD OF THE DEPARTMENT OF SOCIAL AND PREVENTIVE
MEDICINE, KING GEORGE’S MEDICAL COLLEGE, LUCKNOW, INDIA
The undergraduate student should see health and
disease in their natural setting. This helps him to learn to
look beyond the individual patient, to the family in which
that patient lives, to his work and play, and to his social
and cultural background. The student has to realise that
the unit of his work is the family—not merely the sick
person who first appears at the clinic.
In India the undergraduate curriculum is overloaded
with diagnostic and therapeutic medicine of the hospital
type. Few colleges give the student opportunities to work
and observe in health centres, or with general practitioners
or in families. He remains so preoccupied with clinical
and laboratory findings that he gives little thought to the
human, psychological, biological, physical, and social
factors operating in the family or in the community. In
medical education, therefore, provision has to be made
for the study of man in disease in addition to the usual
study of disease in man.
■* /
“ ( LI&HARY )£ ;
758
October 1, 1960
PUBLIC HEALTH
One of the suggestions made at the 1959 W.H.O.
conference on mental health was that students should
follow one family through health and disease over a num
ber of years.1 Departments of social and preventive
medicine can suitably take the initiative in such a family
study programme.
HOW AND WHEN
At Lucknow the teaching of social and preventive
medicine is spread over the preclinical and clinical years.
A rural health centre at Sarojini Nagar is being developed
to give field training to undergraduates and'preregistration
graduates, and a family-study programme is being intro
duced for the undergraduates. At present we have a fiveyear course (after intermediate science examination in
physics, chemistry, and biology has been passed) and
during his third and fourth years the student acts as family
adviser to two families—one family with a mother and a
growing child and another family with a case of a chronic
disease. The study will help the student (1) to get a better
understanding of the relation of health and disease to the
total life of the family, (2) to observe normal growth and
development and any departure from it, and also the means
for maintaining normal health, and (3) to appreciate the
economic, social, and emotional situations created by
disease and disability. The department has on its staff a
medical social worker to help and guide the students in
this programme.
Some recommend 1
2 34that students in their'preclinical
years should be given families for study; but this is not
generally favoured in India1 and I think it inadvisable.
The student’s average age on entry in 1959-60 was 19-7
for men students and 18-3 years for women, and at this
age they are not "mature enough to create and maintain
good rapport with the families. They would not be able to
give the medical advice, or arrange the medical relief for
which the families would ask; yet they might start playing
the role of a doctor, which would be undesirable both for
them and for the family.
In the preclinical years it is better to give some intro
ductory lectures and then hold clinical conference
demonstrations (as is now done in Lucknow once a
month5) at which selected patients are presented with
their families, in cooperation with other departments.
Such a conference is essentially “ preclinical ”—i.e., it is
concerned with the circumstances and^condition of the
patient more than with his disease. In the analysis with
which the conference concludes the chain of causation is
examined to show where this could have been broken The
aim is to lead students to think in terms of maintaining
normal health, of the social causes operating in disease,
and of the need for prevention, early detection, and early
treatment.
A SUCCESSFUL PROJECT
In 1958 and 1959 the fourth-year students at Lucknow,
who number about 160 per year, were each allotted a
family having a registered case of pulmonary tuberculosis
and were asked to write a medical and social history of the
case. Before they did this they were given a schedule of
study showing what information they must seek, and they
attended a demonstration at which a case was presented in
accordance with this schedule. Health visitors from the
tuberculosis department introduced the students to the
1. World Health Organisation Conference on Mental Health, Helsinki.
Abstr. J. Ind. med. An. 1959, 33, 196.
2. Gout, K. N. Ind. J. publ. Hlth, 1958, 2, 40.
3. Vengsarkar, S. G. ibid. p. 245.
4. Patnaik, K. C., Holmes, E. M. ibid. 1959, 3, 269.
5. Prasad, B. G. J. King George't med. Goll. din. Soc. 1959, 42, 1.
X3k show
families, and the students consulted the d
records of the cases. Each case-history was evalua
^ylabclk
me and the student was called to clarify points <
(he quali'
history and discuss the study. Occasionally he was
^old pay le.
to revisit the family or consult the records again. ,!
If t
The students on the whole did an excellent
iadividi
some made instructive sketches to show the envircqjBo
in which the families were living. Their interest wwm , Fixed lega
confined to writing the medicosocial case-histories:
/ sal woul
necessary they examined the sputum of patients M
je designed
contacts, and took the contacts to the tuberculosis dhfc
for screening, Mantoux testing, and b.c.g. vacdn«fcfc
•Wa
legal ar
A few patients who had defaulted from the clinic g
*
persuaded by the students to revisit it for the usualcteti
igft contain'
up. Some of the students, going beyond their task, viaw
M (for ft
the neighbouring families to find out whether there vck
other cases of tuberculosis and what was being donafe
'
ample
them.
JMa • whole mil,
I am grateful to Mrs. S. B. Nayar, medical social worker
i
department, for helping in the preparation of the schedule of
study, and to Prof. A. Leslie Banks, W.H.O. visiting ptetKKf
in social and preventive medicine at this college, for his sugjoriHt
and encouragement.
Mil reco.
iadividua
teds to the
isnilable,
Public Health
MILK COMPOSITION
An interdepartmental committee was
May, 1958, under the chairmanship of Dr.
vice-chancellor of Exeter University, “ to
composition of milk sold off farms in the United
from the standpoint both of human nutrition
animal husbandry and to recommend any
other changes that may be desirable ”. Its
published last week.1
LEGAL DEFINITION
The committee finds that the definition of
Food and Drugs Act (1955) is inadequate in
milk composition. The suggested statutory
‘ Cows’ milk ’ means the secretion, excluding
which can be gained by normal milking methods
lactating mammary gland of the healthy, normally
RECOMMENDATIONS
The committee’s main conclusions and
tions are as follows:
Because milk is important in the human diet
virtue of its content of solids other than fat
collectively as s.n.f.), the consumption of
maintained and, if possible, increased. Small
fat fraction of milk are less important
in s.n.f. The evidence of a link between either
ischaemic heart-disease and the consumption of
though suggestive, is not conclusive, and much
the problem is urgently needed.
Both the fat and s.n.f. contents of milk
gradually over the past thirty years in
though there has been little change in Scotland.
s.n.f. may continue unless steps are taken
milk producers could improve the composition
by changes in herd management if they were
incentive. .
The dairying industry therefore should aim
maintain but also to improve the S.N.F. content
and both statutory and marketing means should
this end.
A girl of
tonsill
diphthe
*»aublis
brothci
*d snathe:
fflothe:
?t 10 a ,
,*
Cattle a
ether c
f comprehensive
irur.
■grated approach
isible for giving
They continue to
treatment of the
petitioners later.
e, however, not
lists. They are
easily taken to
“eneral practice,
y, s'^hry, midand at the sub
consultation in
the college, and
of the services
of basic health
.tion they learn
school health,
participate in
■iemiology and
i as they go in
edicine to the
n at the B.J.
le to develop
r inches and
s in^Jbipre.ure doctors.
i worthwhile
Teaching of Community Medicine to the
Undergraduate Medical Students at
Christian Medical College, Vellore
V. BENJAMIN
*
AND K.G. KOSHl
**
This Paper deals with only those aspects of the teaching and training
programme that give the student some insight into the parameters involved in
“Community Medicine”.
At the Christian Medical College, the Department of Hygiene was reorga
nised into a Department of Preventive and Social Medicine in 1955. In 1965, the
name of the department was changed to “Department of Community Health”
mainly because our attempt to explain our service programme to other members
of the faculty, as well as to general population seemed easier if we used the
phrase “Community Health”. The word medicine was avoided in order to keep
away the association that this word has with therapeutic procedures to the
exclusion of health promotional activities.
We also consider the undergraduate period as the period from the entry into
medical college to the end of the compulsory rotating internship period.
The teaching of the “community medicine” may be further divided into two
periods—(i) the first period, first year to final year, and (ii) the second, the period
of 3 months (12 weeks) of compulsory internship with the Department of
Community Health.
The First Period
This may be further divided into (a) an introductory phase, (first year;
mainly didactic); and (b) a definitive phase where there is learning through
involvement in a Family Health Advisory (Family Doctor) Service.
The introductory phase is a didactic course in the history of medicine,
elements of sociology, cultural anthropology and social psychology; especially
those aspects applicable to the ecological factors affecting the health of mankind.
In addition to this there is a course in elements of Biostatistics. We hold an
examination for internal assessment in this course at the end of first year. There
is no University examination in these subjects.
The definitive phase of the first period is involvement in the Family Health
Advisory Health Service. To quote from the introductory notes to this pro• Prof. & Head of the Deptt. of Community Health, ** Prof. & Consultant,
Deptt. of Community Health, Christian Medical College, Vellore.
45
NIHAE BULLETIN
gramme, as given in the book in which the record of work in this programme
is to be recorded by the student:
(7) Environmental
“The fundamental objective of this programme is to enable each student to
(8) Nutrition.
obtain practical experience in the practice of those prime essential elements for
(9) Personal hygie
medical practice, the maintenance of good health, and the promotion of better
(10) Specific disease
health. In addition to this, broad objective, there arc other specific objectives.
(11) Mental hygiene
These are:
(12) Family Plannin
(1)
To study the effects of. pregnancy upon the patient and the family.
The student is expe
(2)
To observe the growth and development of children.
ted in the record book,
(3)
To learn the importance of observing a patient in his own natural
(1) Broad based co
environment, and thus gain an appreciation of the neccessity of including
(2) Demographic a>
in the medical history, significant facts relating to the environment and
having a bearing on health and disease.
(3) Environmental c
(4)
To develop an appreciation of the manner in which a patient’s illness,
(4) Socio -economic
not only affects, but is also influenced by the family.
(5) Dietary habits a
(5)
To gain a knowledge of the factors in home or community which may
(6) Immunity status
lead to physical or emotional illness or prevent the carrying out of
(7) Summary of the
prescribed treatment.”
ning of the prog
With these objectives each student is assigned two village families; as far as
(8) Recommendatio
possible one of the families will be where there is an expectant mother, with
(9)
Summary
of the
children, and the other in which there is a chronic disease problem, or sonic
months: a critical ess
other health problem.
Selection of families will be from among the families with whom the depart
ment has already established contact through the Department’s Rural Health
Service Unit. Visits are made to the families once a week, and an effective 1|
hours beginning from 4.00 P.M. is usually available. Senior staff of the Depart
ment, demonstrators, social workers, and public health nurses also accompany
the students; and 6-8 students are assigned to a staff-member who acts as
staff-advisor.
The village from which these families are chosen, will be one where there is
a Maternal and Child Health Centre. Thus the facilities of such a centre for
weighing or simple investigations are available to the student.
Since the students are at the beginning of their clinical course when they
start on this, a series of classes are held for 45 minutes at each session to covet
some of the knowledge and skills that will be required in this.
The following topics are covered:
(1)
Community organisation and development.
(2)
Principles and techniques of interviewing.
(3)
Principles and objectives of pre-natal care.
(4)
Principles and objectives of child health supervision.
(5)
Growth and development.
(6)
Principles of infant feeding.
46
Five terms (each of
terms, there are weekly
intervening period being
faculty and the class ft
established pattern. Hen
presents in addition to ti
the family. These discuss
live action in-between we
the Rural Health Unit st;
referrals made by the st
problems requiring refen
student who is by the tim
posted to one of them.
Another related prog
conference. During the se
pediatrics department, a
hospitalised patients along
staff of the Department <
findings are discussed in
This is carried out with
Medicine, and Surgery als
collaboration with the Deg
TEACHING OF COMMUNITY MEDICINE
s programme
■ch student to
elements for
ion of better
c objectives.
amily.
own natural |
of including
onment and
ent’s illness,
«/hic^.may
-g 9 of
s; as far as
jther, with
■n, or some
(7)
Environmental sanitation.
(8)
Nutrition.
(9)
Personal hygiene.
(10)
Specific disease protection.
(11)
Mental hygiene.
(12)
Family Planning.
The student is expected to record his findings in the proformas incorpora
te in the record book. The record covers the following:
Broad based community survey of the village.
Demographic aspects (family size, age, sex, occupation, etc.).
Environmental conditions.
Socio-economic data.
Dietary habits and rough estimates of intake.
Immunity status of the individuals.
Summary of the health needs of the family (as envisaged at the begin
ning of the programme).
(8)
Recommendations or suggested plan to meet these needs.
(9)
Summary of the health status at the end of the assignment (i.c. after IS
months: a critical essay of achievements and failure giving reasons.)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Five terms (each of three months) are given to this. During the first two
'
' terms, there are weekly visits. Thereafter there are only fortnightly visits, the
, intervening period being utilised for presentation of families by turn to the
: faculty and the class for discussion. Case presentation at the bedside is a well
!I established pattern. Here, the student is expected to do a similar thing, but he
I presents in addition to the clinical problem in the family, all other aspects of
| the family. These discussion sessions are quite popular with the class. SupporI live action in-between weekly or fortnightly visits by the student is provided by
re there is
[ the Rural Health Unit stall—mainly public health nurses-who act on specific
:entrc for
referrals made by the student, and countersigned by the staff adviser. Major
problems requiring referrals to the general hospital arc to be arranged by the
/hen they
student who is by the time familiar with the clinical units, and is concurrently
to cover
posted to one of them.
he departal Health
ffective 1J
e Depart■ccompany
(10 acts as
Another related programme is the Interdepartmental clinieo-social case
. (inference. During the second clinical year, while the students are posted to the
pediatrics department, a student is expected to pay a visit to the home of the
hospitalised patients along with the pediatrician and one of the members of the
staff of the Department of Community Health, and the case and home-visit
endings are discussed in the presence of the faculty of the two departments.
This is carried out with Departments of Obstetrics and Gynaecology and
I Medicine, and Surgery also, but the most consistent attempts have been in
collaboration with the Department of Pediatrics.
...
>■■■'' ■
N1HAE BULLETIN
The student is encouraged to engage himself in health education, immuniza- r
tion, and motivation for family planning, nutrition education. He is given as '
much back-up support as is possible by fhe Departments service unit which I
is the Rural Health Centre. But the student ’ also comes to face the realities of •
limitation in respect of resources, and the indifference to “change” in mosl 1,
people.
f
During this phase it is hoped that the student learns to deal with the clinical !
problem, as a problem, in a human being as a person in a family, which is ■
placed in a community of families.
tea
Part I : (All) At the Rura
during which they are ]
week at a time. From
specific programmes in
Part II: (By some only)—c
The programmes are:
i. At Leprosy Research
ii. In survey and researc
iii. At C.S.I. Hospital, N
The Second Period—The Internship Programme
Time available 12 weeks (Three months)
Programme in Detail :
Practice Units:
Part I. Rural Health Centr
(1)
Rural Health Centre with 3 extension centres
(Hagayam—adjacent to College Campus)
(2)
Kavanur Rural Health Centre
(20 miles away from College)
(3)
Leprosy Research Sanatorium, Karigiri
(16 miles away from College)
(4)
Mobile Dispensary—Twice a week
(5)
Participation in Urban Health Unit programmme
(6)
C.S.I. Hospital, Nagari, Chittoor Distt., A,P.
(62 miles away from College)
Residential Facilities:
Provided at Bagayam, Kavanur, Karigiri and Nagari.
Number of Interns at any one time:
10—12
Objectives of the Training Programme:
To equip the physician:
i.
To think in epidemiological and social categories;
!
ii.
To understand the part played by health services and how such serviced;
are based on epidemiological principles;
iii.
To look at every clinical problem with a preventive bias and as a challenge I
to preventive and community health action;
iv.
To comprehend his social role in relation to the individual, the familj L
and the community; and
v.
To achieve these within the framework of the limitations in resources tha:
actually face him in practice in present day conditions in the country.
The Programme in Outline:
The assignments are divided into two parts—one part of which is taken b)
all (6 weeks) and the other part (6 weeks) is taken by some.
48
(1) O.P.D. Services—7:
Saturday)
(2) Inpatient care—(24
(3) Casualty type of set
(4) Elective surgery und
One afternoon—general
One afternoon—reconst
(5) Maternal and Child
(6) School health progra
to teachers—one aftern
(7) Leprosy clinics—3 1
(These are clinics run si
location in the village c
(8) Tuberculosis clinic
problems of ambulatoi
Tuberculosis Control Pt
(9) Participation by pt
trainees (medical.and pa
exclusive ofpreparation.
(10) Participation in P
specialists —mainly Ge:
surgical and obstetric
week).
(11) Participation in Far
O.P.D. and Maternal an
educational (motivation
special emphasis.
(12) Participation in Ob.
attached to Rural Hea
Centre).
teaching of community medicine
i, immunizae is given as
:e unit which
te realities of
ige” in most
h the clinical
ily, which is
Parti: (All) At the Rural Health Centre anil Hospital, Bagayam 6 weeks—
during which they are posted to the Kavanur Rural Health Centre for one
week at a time. From the Rural Health Centre they will also be posted for
specific programmes in the Urban Community Health Programme.
Part II: (By some only)—one of the following programmes—6 weeks.
The programmes are:
i.
ii.
iii.
At Leprosy Research Sanatorium, Karigiri; and
In survey and research project (Epidemiological and/or field projects); or
At C.S.I. Hospital, Nagari, Chittoor District, Andhra Pradesh.
Programme in Detail:
Part I. Rural Health Centre Programme :
v si^hservices
as a challenge
jal, the family
. resources that
(try.
ich is taken by
(1)
O.P.D. Services—7:30 A.M. to 12:30 P.M. (6 days) (Monday through
Saturday).
(2)
Inpatient care—(24 beds) daily.
(3)
Casualty type of service (on call duty)—one interne/day.
(4)
Elective surgery under Rural Health Centre conditions—
One afternoon—general surgery
One afternoon—reconstructive surgery for leprosy.
(5)
Maternal and Child I-Icalth Clinics—4 afternoons.
(6)
School health programme—Chequered carrier—mainly health education
to teachers—one afternoon a week.
(7)
Leprosy clinics—3 half days.
(These are clinics run simultaneously with other clinics, but in a different
location in the village or community).
(8)
Tuberculosis clinic—one afternoon a week. (Includes participation in
problems of ambulatory care of tuberculosis and significance of National
Tuberculosis Control Programme).
(9)
Participation by preparing and leading discussion for all staff and
trainees (medical.and pnra-medieal) on Health Promotional aspects—/J hours
exclusive ofpreparation.
(10)
Participation in Rural Hospital Practice Seminars, led by clinical
specialists—mainly General Practitioner approach to medical, pediatric,
surgical and obstetric problems. (Usually after dinner sessions—1 hour/
week).
(11)
Participation in Family Planning activities—largely integrated into the
O.P.D. and Maternal and Child Health Clinic services, and organised group
educational (motivation oriented) programmes. IUCD programme has
special emphasis.
(12)
Participation in Obstetric practice—(Labour room and lying-in section
attached to Rural Health Centre, Bagayam and Kavanur Rural Health
Centre).
49
NIHAE BULLETIN
for the definitive di
more than an aid U
The history-tak
something largely n
is made to correc
possible to achieve t
therapeutic action a
Part II:
Through a progr
(1)
Posting at the Leprosy Research Sanatorium—(6 weeks) involves helping and surgeons from t
with diagnosis of the various types of leprosy, detailed study of complication
such a thing is poss
of leprosy, and some involvement in epidemiological studies in leprosy.
(2)
The Urban Health Unit has ante-natal, post-natal and child health
(i) Regular “R
clinics, and a school health programme. Internes are posted to these.
specialists, help in sb
(3)
The survey and research posting: In this posting, two internes are made and how a sim
encouraged to choose some subject for investigation. They are given some
and so on can be orj
guidance in the choice of the subject for enquiry by allowing them to choosef
(ii) Therapy: It
from a panel of subjects already carefully thought out by the Departments
is done both at an ir
of Community Health and Biostatistics. Care is taken to choose such of
sultation, and at a gr
those enquiries that lend themselves to some conclusions or a sense of
tions. Only in this v
accomplishment within a period of 6 weeks. At the end of the assignments
community member:
they present a consolidated report of the work and its possible conclusions
produce the illness ar
or implications to all the other internes and other staff of the department.
can be taken in futun.
In this way it is hoped that even those who do not have this specific assign
medication given is ti
thing that matters is a
ment will gain some insight into research methodology applied to field
problems.
limitation. It is str
(4)
The posting at Nagari is mainly to give experience in running a small generally neglected as
hospital and dealing with the clinical problems with limited facilities. The
It is possible to co
Hospital is ideally placed for such an experience. In addition, the Hospital
patients to see: while
have to be made mor
also provides experience in community health work, running ante-natal and
initiates the educatior
child health, leprosy and tuberculosis clinics. It is essentially a hospital
based on community health programme.
initiating any therape:
(iii) Early diagm
Commentary on the programme
medical practice. Th
health
clinics and thro
The training programme shown in outline is designed to try and fulfil the
(internes) take a leadin.
objectives mentioned earlier. This attempt may also be considered at two
public
health nurses a
levels, viz. (A) at the individual level, and (B) at the community level.
(iv) Surgical Pract
(A) At the individual level: Diagnosis involves careful history taking and
senior
surgeons
help
a high degree of clinical skills to make as accurate a diagnosis as possible. All
procedures (eg. gastroje
good clinical teaching emphasise this; but the increasing tendency to depend
equipment at the Rura
heavily on laboratory tests for diagnosis is discouraged. Laboratory tests arc
By turns, one to two weeks is spent at the Kavanur Rural Health Centre,
where they participate in O.P.D. services, M.C.H. services, leprosy clinics and
family planning.
Health education is emphasised throughout the period and internes have to
organise and carry out health education on various topics to groups of patients
and their relatives in the ward and the O.P.D. (thrice a week).
not considered un-necessary; but rather efforts are made to use only such of
those that help to confirm a clinical or give the clue to the difference between
two or three provisional diagnoses. It is postulated here that most of the tests
done in a big hospital set-up are for purely academic reasons and not essential
50
(2?) At the Common
prehensive approach to
and identifying the vari<
I EACHING OF COMMUNITY MEDICINE
Ith Centre,
clinics and
les have to
of patients
ves helping
amplication
uro^^
iiili^Pealth
lese.
nternes are
iiven some
to choosef
’epartmcnts
ose such of
a sense of
assignments
conclusions
lepartment.
ific assign
ed to field
ting a small
lities. The
te Hospital
e-natal and
a l^pital-
1 fulfil the
ered at two
1.
taking and
ssible. All
y to depend
y tests are
only such of
ace between
>f the tests
ot essential
for the definitive diagnosis, and that the laboratory tests have tended to become
more than an aid to diagnosis.
The history-taking includes a complete socio-economic history. This is
something largely neglected in traditional history taking and a definite attempt
is made to correct this deficiency. Only when this is done adequately it is
possible to achieve the objective of making a community diagnosis and planning
therapeutic action at a community level.
Through a programme of weekly grand-rounds and discussions, pediatricians
and surgeons from the main teaching hospital emphasise and demonstrate that
such a thing is possible.
(i)
Regular “Rural Hospital Practice” seminars, led by the various
j specialists, help in showing how a practical approach to clinical problems can be
I made and how a simple laboratory for essential tests with simpler techniques
I and so on can be organised.
J
(ii) Therapy: It is emphasised that therapy includes health education which
is done both at an individual level, at the doctor-patient encounter during con
sultation, and at a group level through organised group talks and or demonstra. lions. Only in this way can we make the patient, his relatives, and other
I community members become aware of what factors ‘conspired’ together to
produce the illness and what preventive action could have been taken, and what
, can be taken in future to prevent a recurrence, or minimize the disability. The
I medication given is thus looked upon only as a “sugar coat” on a pill; the real
I thing that matters is awareness and knowledge about prevention and disability
| limitation. It is stressed that the doctor has a leading role to play in this
generally neglected aspect of therapy.
It is possible to consider such an activity difficult for a doctor who has many
patients to see: while this is a legitimate difficulty, the fact remains that doctors
have to be made more aware of its essential importance, and be the leader who
initiates the educational activity as a prelude to other agencies taking over and
■ initiating any therapeutic activity at the community level.
(iii) Early diagnoses and anticipatory action is a sine quo non in good
medical practice. This is practised through the various antenatal and child
health clinics and through the health-maintenance clinics. The house-surgeons
(internes) take a leading role in running these clinics and they are helped by the
public health nurses and midwives.
(iv) Surgical Practice—In this area of great glamour for young graduates,
lenior surgeons help the house surgeons carry out relatively major surgical
procedures (eg. gastrojejunostomy) under limited resources of personnel and
equipment at the Rural Hospital.
(B) At the Community Level: (i) Epidemiological approach—Since a com
prehensive approach to health problems is well-nigh impossible without analysing
ind identifying the various factors that interact, an attempt-aCgivihg an insight
51
C6866
l/? '
/'/
NIHAE BULLETIN
TEA<
as to how to go about making such an analysis for purposes of community
action is made through short term investigations and surveys using accredited ■ challenge remains. The t
research methodology including statistical methods. The statisticians and I humble attempt to meet thi
social workers play a major role by assisting in this activity. This is, in a way,
practical epidemiological approach, which is also a largely neglected discipline
Samples oj the special pt
in present-day medical curricula and traditional house-surgeoncy training pro I. motion seminars for interns
grammes. A list of some of the various problems on which studies have been
Illustrative of the specia
done is given below.
i discussed at health promoti
(ii)
Communicable Disease Control and Illnesses : Though every health
problem has a community component, the communicable-diseases offer examples
(i) Epidemiology of fun.
of definite clear-cut community action which the doctor as the leader of the
double blind theraprutic
health team can initiate and maintain. Experience is provided in a leprosy |
(ii) Evaluation of the pr
control programme, and in the ambulatory tuberculosis treatment programme, i
(iii) An enquiry into the
and activities of contract-tracing, immunization on a mass scale where applicable
family planning and fam
are all emphasised and practised.
(iv) Epidemiology of Kv
Opportunity is also provided in the optimal use of other agencies through i
(v) Study of the commur
the above two programmes. A good community health practitioner should i
Health Centre.
know the agencies in his community and learn how to use their help.
(vi) Survey on sickness
(iii)
Follow-up and continuing care : In traditional hospital practice, this
over.
again is a neglected sphere. In a health centre set-up, or in a general practi '
(vii) Study of a small ep
tioner basis this is given importance, and here again the use of public health
(viii) Health education nurses, health visitors and midwives for follow-up care is encouraged, demons
(ix) Opportunities for he
trated, and we hope, appreciated.
(x) The role of public he
(iv)
Round Table Discussions and Seminars : Since the period of house(xi) Preventive and healt
surgeoncy is short, to ensure that various aspects of houllh promotion uro al
(xii) Mental health pion
least thought of and discussed, a series of health promotion seminars on various
subjects are conducted weekly, and here the house-surgeons read a short paper Comments:
on the assigned subject and lead a discussion. Senior doctors, public health
The Department’s teachir
nurses, social workers and other para-medical workers participate in these
i tions which have not alwa
discussions, and again emphasise the team approach.
Departments of Preventive at
The science of medicine is fast becoming thought of as a Social Science. Ii onwards, and one of the i
this is so, there has to be far reaching changes in the kind of medical education through the educational pr
given at the undergraduate level and in the training period thereafter. How I The qualities and skills of the
| broadly, here in Vellore we e
ever, the science and art of being a good doctor still continues to start with
the doctor-patient encounter in the privacy of the consultation room, and will most clinical problems with c
continue to be so. What is needed is to enlarge the concept of medical practice thus seen in a patient some p
and to realise that dealing with sickness in the individual without a conceit ■ the family of the patient, and
for prevention and community factors that have a bearing on the state of health - appropriate reporting or refer
of individuals and communities, is practising sub-standard medicine. It is also panchayat, etc. He should
necessary to galvanise the imagination and energies of young medical graduate! public health components of;
The objectives of the fami
to the satisfactions of enlarging their vision and scope of health care on i
comprehensive basis, even in situations where resources are limited. The need much ever since the beginniny
for this is so obvious but our capacity and our willingness to meet this need ii been some change in the objet
what is lacking. Whatever the blocks, and whoever is to be blamed—th: period 1955-1965, the stated <
follows :
52
TEACHING 01- COMMUNITY MEDICINE
' community
1 accredited
sticians and
s, in a way,
1 discipline
lining prohave been
very health
er examples
,der of the
a leprosy
irogranune,
a^^cable
es through
rer should
ictice, this
eral practi
ce health
demons-
challenge remains. The training programme at the Rural Health Centre is a
humble attempt to meet this challenge. .
Samples of the special projects curried out by house-surf’eons mu! health pro- •rum seminars for interns :
Illustrative of the special projects carried out by house surgeons and subjects
trussed at health promotion seminars are :
(i) Epidemiology of fungus infections of the scalp in an Orphanage and a
double blind theraprutic trial with Criseofulvin.
(ii) Evaluation of the programme of the Rural Health Centre for Leprosy.
(ill) An enquiry into the attitude, knowledge and practice of methods of
family planning and family size limitation.
(iv) Epidemiology of Kwashiorkor with special reference to family size.
(v) Study of the community response to the services rendered by the Rural
Health Centre.
(vi) Survey on sickness and health levels of rural populations aged 50 and
over.
I (vii) Study of a small epidemic of Typhoid in a nearby village.
(viii) Health education -General principles and tools.
(ix) Opportunities for heatlh promotion in hospital, home and community.
(x) The role of public health and vital statistics in health promotion.
, (xi) Preventive and health promotional aspects of the problem of Cancer.
i (xii) Mental health promotion.
of houseon are at
on various
Comments :
tort paper
die health I
The Department’s teaching programme has been based on certain assumpe in these Ims which have not always been explicitly stated. Historically speaking
Departments of Preventive and Social Medicine were being set-up from 1955
lienee. If I .wards, and one of the objectives of medical education was the evolution,
'/rough the educational process, of five to six years, of the “basic doctor’’.
eduction
re qualities and skills of the “basic doctor” were never sharply defined, but
er.WPlowbroadly, here in Vellore we envisaged a person who would be able to deal with
start with
rust clinical problems with confidence and bring to bear on the health probleih
and will
seen in a patient some plan of action to prevent such problems at least in
al practice
t: family of the patient, and initiate some action at the community level by
a concern
qropriate reporting or referral to the health authority/municipal corporation/
of health
pnehayat, etc. He should at least think of the preventive possibilities and
It is also
graduates p.blic health components of the problem.
The objectives of the family health advisory service has not changed very
care on a
The need ■ruchever since thebeginning of the programme in 1956. However, there has
is need is ken some change in the objectives of the internship programme. During the
med—the period 1955-1965, the stated objectives of the internship programme were as
fcllows:
53
NIHAE BULLETIN
I.
To encourage the physician to give equal importance to preventivi
medicine and public health practice's to diagnostic and curative services.
2.
To realise that reasonably scientific medical, surgical, obstetric an,'
pediatric practice is possible even without the resources of specialist person
nel (for consultation) and laboratory facilities that are usually available it
a teaching hospital.
About the year 1965, we redefined the objectives as already stated earlier
There were other assumptions also, when we launched on this programs
in 1955-56. Some of these were :
(i)
That the entire faculty of the medical college and hospital were reasoc
ably familiar with the concept of the ‘basic doctor’;
(ii)
That the entire faculty believed in the wisdom and desirability of bein:
deeply involved in producing such a basic doctor to meet the health needs«
society; and
(iii)
That the entire faculty would, as far as possible, and as often as possite
high-light the preventive and community aspects of the disease problems 1
they discuss them in the class room or at the bedside, and not consider th:1
as the sole responsibility of the department of community health.
Family Planning
1.
GUPTA, p.b., Popn
2.
ENKE, STEPHEN, *
Research Institute
Human Fertility
Countries”, Scien
3.
SIMON j.l. “The X
Population Studu
These abstracts deal
The experience of the last fifteen years has not really borne out the validit;' examined this question fr
Gupta contends that
of these assumptions. This is regrettable. We do not presume to analyse it
causes of this here. It is, however, pertinent to observe that there has been n. in the educational status
violent opposition from the faculty to these concepts or programmes, but on!1 vation for adoption of
an indifference to the Department’s programme, conditioned by the influen; unless the growth of po;
of the need that other faculty members feel for their responsibility to impart tl. need for providing for idea of excellence in their own speciality to the student. The net result is th: all efforts at economic
table relationship betwee
we have not really succeeded in producing the ideal “basic doctor”.
We have also come to realise that there is room for more drastic modify t »o far as fertility is cone
tion of the curriculum as well as the teaching programme if we are to produ. R lily in USA in the first p.
the kind of physician who will emotionally accept his role as a social enginet '■ standard living through
with the skills necessary to function with professional satisfaction as a genet. This could be a relevant
practitioner, even in the set-up of (he primary health centre. To do this nw ‘ lher motivation can be j
effectively, there will be need to give him some of the managerial skills. T even in non-industrial ei
product of the present medical course is still heavily individual patient orienie »uch environments one
whereas, if the health needs of the community are to be realistically met, » nient of living standard
those who claim that ev
need a doctor who is more community health oriented. Just as the student
present gets satisfaction from seeing the individual patient diagnosed at vation can be produced
cured, we should provide the melieu for developing skills to diagnose commun. planning programme. 1
health problems and to solve them, and derive professional satisfaction Ire the question, for the ab<
doing so. Schemes and plans are afoot to try and reorganise the traini: P concerned are already
programme towards this end, by greater involvment of the medical college ini. which cannot be generr
by him only when educ;
delivery of comprehensive health services of community.
54
Abstracts of Current Literature
•ce to preventive I
ative services.
f
il, obstetric and |
pecialist person- j
illy available in |
y stated earlier. |
this programme I
Family Planning and Economic Development—Abstracts of
Three Recent Publications
I.
al^fere reason- I
GUPTA, P.B., Population Policy in India. Bulletin of the Socio-Economic
Research Institute, Calcutta, Volume 3, pp. 1-9, 1969.
KNKII, SH-PHHN,
Human Fertility
often as possible |
ease problems as |
lot consider this |
,ealtb.
"Birth Control for Economic Development—■ Reducing
can Raise Per Capita Income in Less-Developed
Countries”, Science, Vol. 164, No. 3881 pp. 798. May 16, 1969.
rability of being |
e health needs ol I
3.
Simon J.L. "The Value of Avoided Births to Under-Developed Countries”
Population Studies, Volume XXII, No. I, March, 1969.
These abstracts deal with three publications in which the authors have
* out the validity examined this question from three different angles.
Gupta contends that a rise in the levels of living, which includes improvement
le to analyse the
here has been no io the educational status of the population, is the key to the generation of moti
ammes, but only vation for adoption of family planning methods. He contests the view that
by the influence unless the growth of population is arrested by the curtailment of fertility, the
ility to impart the need for providing for an ever increasing population would make nonsense of
net result is that ill efforts at economic planning and asserts that there is no unique and inevi
table relationship between population growth and economic development. Also,
ctoj^.
4^ic modifies- io far as fertility is concerned, as has been demonstrated in the decline in fertiwe are to produce t Sty in USA in the first part of the 19th century, he feels that improvement in
a social engineer, itandard living through industrialisation is not necessary for reducing fertility.
lion as a general : This could be a relevant field for reserch in India; it has to be found out whe
To do this more ther motivation can be generated through improvement of standard of living
gerial skills. The even in non-industrial environments. From recent studies or knowledge from
al patient oriented, such environments one can identify atleast two contributory factors-improve
distically met, we ment of living standards and advancement of general education. He questions
as the student at those who claim that even in the absence of economic and social progress, moti
nt diagnosed and vation can be produced by mass communication methods as a part of family
iagnose community planning programme. This, in the view of the author, would be simply begging
1 satisfaction from the question, for the above information will fall on deaf ears, unless the couples
ganise the training concerned are already motivated. Motivation is an urge felt by the individual
;dical college in the which cannot be generated by propaganda alone. It is an attitude attained
by him only when education brings in comparative freedom from traditional
55
VOL. V, OCTOBER 1965
44
INDIAN JOURNAL OF MEDICAL EDUCATION
a temporary system of reservation of quotaj
(M.M.S.), degree in 5 years' time for the three divisions may be introduced,
after passing his higher secondary reserving 65 per cent of seats for the clinical
examination, the period being the
division and allotting 15 per cent to the
same as for the 1st postgraduate basic medical and 20 per cent to the public
degree (M.Sc.) in Science faculty. health divisions. We have, however, to face
The MM.S. degree shall be con the challenge of the rapidly developing
sidered equivalent to the M.Sc. medical sciences. A fundamental change
degree of the Science faculty.
• in our outlook of medical education jj
2.
It is likely to provide more personnel called for. No stop-gap arrangement to
for pre-clinical, para-clinical and meet any immediate demand will be
public health services.
adequate.
3.
It will significantly reduce the load of
The author has invited criticisms ani\
subjects to be taught, whereby
quality of learning would improve. comments on his proposals. Readers are
requested to send their comments to the Editor.
One apparent drawback of the present Efforts will be made to publish them in the
scheme is that the proposed compartment'Medical Education Forum' section of the
glisation may cause a drop in the net turn ensuing issues of the Journal—Editor.
over of clinicians. To meet this difficulty
Bed-side Teaching of Social and Preventive Medicine:
‘Operation Kalianpur’
BY
Dr P. D. P. Mathur and Dr C. M. S. Siddhu
Department of Social and Preventive Medicine, G.S.VM. Medical College, Kanpur
The relationship of a doctor to the patient
The feeling of a majority of medical men
here that ‘Social and Preventive Medicine’ and his family has been the basis of medical
i, merely a fashionable terminological practice for centuries. The doctor had
venation of ‘Hygiene and Public Health’ direct and personal contact with the prob
does not seem to have undergone a signi lems, anxieties, culture and the socio
ficant change with the passage of years. economic aspects of his patients. The
The mention of this department still tends complex life of today has adversely affected
to bring unpleasant memories of milk and these earlier relationships. The demands
water purification, sera, vaccines and latrines. of an individual in matters of health, disease
True, these sections are integral parts of the and disability will, however, always remain
aubject, but the emphasis has remarkably personal. Hospital training alone seems to
be lacking in emphasising the value of
changed.
A prodigious amount of literature has early diagnosis and preventive measures.
True education is largely self-education.
accumulated on the teaching of this subject.
An irrefutable fact that has evolved from these Learning is more important and lasting than
controversial arguments is the importance teaching, and direct experience is of greatest
of grinding into the undergraduates the importance in undergraduate training. An
concept of Medical Care, often designated environment conducive for the under
M Comprehensive Medical Care to empha graduates to learn the methods and acquire
sise its magnitude. Consequent upon com the habits of self-education is necessary.
prehensive Medical Care being regarded by More demonstrations in dairies, slaughter
the Bhore Committee, Mudaliar Committee houses, or primary health centres are not
“d WHO as the only panacea for health, enough for permeating into students the
•specially in an under-developed country modem trends in medicine and the elements
“ke ours, the scheme of Health Centres was that determine all the aspects of medical
“Wght into being. But to date, success and health services of the future.
* still eluding us. Why?
This brings into focus the problem of
A sound programme is as good as the producing doctors familiar with the modem
Personnel who operate it. The medical concept of medical care. The responsibility
Personnel running these health centres were of training undergraduates in this new
^trely produced by our medical colleges. discipline was rightly accepted by the
can our present doctors properly departments of Social and Preventive Medi
^nne overall responsibility of patients cine. But just as Internal Medicine cannot
|j“eo they themselves are ill-equipped with be learnt without examining cases in the
concepts, principles, and practice of wards, the principles of Medical Care cannot
«cal care? Medical colleges have train- be imbibed unless the students become an
^*
frfti
primarily in the art of curative integral part of the programme providing such
They are not fully conversant care. ‘Practical experience in comprehen
the social implications of medical sive care is essential if the student ordinarily
and the social responsibility of the confined within the closed system of the
profession. It is difficult for them hospital, is to grasp concretely its principles.
rile social gap between medical The unit of clerkship should be a training
^°°logy and medical care.
health centre, rural or urban, possibly both.’
45
■ 46
INDIAN JOURNAL OF MEDICAL EDUCATION
VOL. v, OCTOBER 1965
!
JJP-SIDE TEACHING ^^SOCIAL AND PREVENT! re medicine
47
n nartment visits twice a week to the Centre provided, that villagers believe that round
staff reviews the case, modifies the treatment
•P inspect, guide and solve our many worms help the process of digestion and
if necessary, and helps the student in proper.
problems.
lice help in keeping the hair biack, and to
ly advising the patient. During all this,
special emphasis is laid on preventive and
Thus, the students, to theirgreat advantage cure marasmus, villagers mercilessly brand
social aspects of the disease, and on the sociox3re responsibility for the care of the their infants lightly, with red-hot irons, on
economic and cultural background of the
patients and their families. They are the scalp and back.
family. The population are instructed to
allotted a round of duties which contributes
4. No amount of lectures can produce
carefully keep their cards bearing family
I0 the working of the Centre. All the time, the impact that is produced on the student
and individual numbers, so that taking out
work of the students is kept under super by himself practising preventive measures
their individual cards does not become a
vision by the teaching staff.
on a case. An example is the successful
time-consuming job. Our patients have;
The construction of a students’ hostel, Scabies Eradication Programme in which
extended their full co-operation in this
M.O.H.’s house and office block is nearing the students played a major role. Again, the
matter. At a later date, when sufficient
completion. When these are ready, the students participated in a vaccination pro
Kalianpur Training Health Centre is data has accumulated, morbidity measure
students will reside at Kalianpur for one full gramme.
situated four miles away from G.S.V.M. ments will be introduced to the students.
month. It is hoped that with these buildings
5. Students are able to appreciate the
Medical College, Kanpur. At the moment,
In addition to this routine work, once a
completed, additional staff sanctioned and high cost of medical care in a poor country
we have for accommodation part of the
other aids received, future plans, already like ours, and this helps in modifying their
P.H.C. building, two examination rooms, week all the students attend Maternity and
suggested by Dr Susser and Dr Siddhu approach to disease.
one lecture room and one laboratory. Out Child Welfare Clinic, while the working of
in their preliminary report to W.H.O. will
6. With meagre diagnostic aids available
door clinic is conducted in the varandah, these is explained to them by the staff.
materialise.
in health centres, students are trained to
where open country air partly compensates Every week, each student makes a visit to a
for lack of electric fittings. The laboratory ‘Chronic Sick’. A register of such cases
We feel that even in this short period of make presumptive diagnosis, which enhances
in
the
defined
population
is
maintained
at
the
is equipped for conducting preliminary in
six months this new project has shown their confidence and gets them used to
vestigations, viz., blond, urine, stool and Centre. Cases desired by us to be kept
results. Certain shortcomings in the medical working in more modestly equipped clinics.
sputum. The hours of working are from under observation are visited by the students.
training hitherto observed with hospital
7. The students get an opportunity of
After
each
round
the
students
report
to
us
the
9 a.m. to 1 p.m. Since training all the
clerkship alone for practical training of the following up each case. Thus they can
condition
of
the
patient,
family
problems
students of a class (about 150) is a formidable
undergraduates, now seem to be compen critically evaluate their prognosis of the case
task, 48 students of the 1st Professional exa and needs and prognosis. If warranted,
sated for by this new discipline, e.g.,
and
the value of the services rendered.
mination have been selected. Four of these one of the staff visits the case along with the
E ‘Conception of Disease in a Commu They are also able to appreciate that medical
ranging from middle of 3rd year to middle student in charge.
nity’ is a difficult thing to achieve. During responsibility does not end until the patient
of 4th year, are posted at the Centre each
During his one month’s posting each
hospital training students are able to see is restored to his normal role, or is resettled.
month. Usually, one lecturer, one M.O.H.- student carries out an epidemiological
only a small fraction of the medical problems
8. The students are able to better under
cum-lecturer and two demonstrators com exercise under guidance of the staff. So far,
of our country. Here at the Centre they get stand the problems of care and readjustment
prise the teaching team. Thus four staff records of the following diseases from 1959
an inkling of 'he more important and bigger of patients in their own homes when they
members and four students daily reach the to 1962 have been _______
j the students in.
studied by
F10 °f1116 problem. Thus the students are are discharged from hospital during the
Centre at 9 a.m. in a motor van. For
Medical College group of hospitals!
enabled to get a true conception of disease convalescent period or as a ‘Chronic Sick’.
auxiliary staff we have a sanitary inspector, ’ <■'Septic »»
Meningitis, m...
Typhoid,
.u_:j c
Small-pofiB
—ii
*• >t affects a person, his family and the
a health educator and a fitter mistry.
and Diphtheria. From each study tHB community. They observe the true range
9. Intimate contact between the studentsstudents write a dissertation and submit®
morbidity of a community, and are thus and the suffering population helps in build
A limited population of Kalianpur Block it for correction. Each student also studied®
c
correct the erroneous impression ing of social ties between them, and acclima
has been selected for our experiment— a family by doing a multi-purpose survey®
ealed by the highly selected cases of a tises the students to rural health services.
Shed No. 1 of Criminal Tribe Settlement,
and submits his report for checking an»B
The missionary zeal, the discipline of team
hospital.
(Population 400) and village Bairi (Popula discussion.
This enables them to haW®
work and the social affiliations thus ingrained
tion 800), making a total of 1,200 persons. an
1 intimate idea about the ‘way of life’ in ® carlv
are able to see disease at an go a long way in conditioning students to
For all the families in the defined popu- Jvillage.
STa
ge.
So
they
get
an
opportunity
’
of
|
work in rural areas.
lation we have a family file. During
the r, an earl7 diagnosis, and of practising
An understanding
of luiiuuuno
functions vi
of lo
*-?®
dispensary hours, on presentation of cards
nil
uuucxsiauuiug ui
We conclude with the happy note that
^Preventive measures they learn in theory.
bearing the
family uuuiuei
number ajxu
and xxxuxwuucu
individual uxgaxxo
organs xjx
of wxxxxxxuxxxiy
community development is al»B.
■1C lauuiy
‘Operation Kalianpur’ though still in its
miU-By
seeing
diseases
in
their
natural
Each
tNK
number off the patient, individual cards are imparted
i
• > to
• the students.
•
t- , month
----- u ,MK
infancy, has been a success. 11 is gratifying to
■ students can get the first hand know- note that our objects are being fulfilled.
taken out by one of the para-medical staff students transcribe the code numbers of
socio-cultural back- Those aspects of medical training that can
and passedd to us. Students take histories, the diagnoses made in the previous mondj® founj0 low
and
examine patients
p"t:en
*e
znd make
mzke laboratory
Lb"”’"™ from die International Classification J® Th- anects the health of a community. not be provided by hospital-clerkship are
lseff the magnitude of this factor being provided at this centre, which is
ions. Reaching a provisional dia
dia- Diseases. They are also made to comply® when
investigations.
gnosis, they suggest a line of management. the study of‘World Health’ by Brockingtof® observe th t.ilemselves, among other things, nothing but a new approach to teaching of
For every patient, one of the students is and their progress is reviewed and difficult?® *dvc* in th’ vi"a8ers 8° f°r relieving them- social and preventive medicine: ‘Bed-side
the fields even when latrines are Teaching of Social and Preventive Medicine.’
responsible for one month. The teaching solved. The Professor and Head of “p®
At G.S.V.M. Medical College, in order
to provide a unit capable of giving such
training to undergraduates, an attempt to
start a Training Health Centre was made at
Kalianpur. In January 1963, the limited
staff of this department made a modest
attempt to materialise the dream of compre
hensive medical care for the small population
in Kalianpur Block. With this centre as the
nucleus of practical training in this subject,
it is hoped that graduates adequately trained
to impart medical care will be produced.
I
VOL. V, JULY 1966
INDIAN JOURNAL OF MEDICAL EDUCATION
ethod also provides excellent situations
r introducing preventive concept
acquisition of more iSRvledge at the under
graduate stage.
inclusion
It is well-recognized that no amount of 1.
rricular reform, programme structuring
id increase in hours of study of this subject
r of any other subject, for that matter) 2.
n yield fruitful results unless the quality
’ teachers improves. One of the most
standing obstacles in the way of developg preventive and. social medicine is the 3.
■oblem of attracting teachers with imagiation, teachers who not merely remember
it also understand, teachers who have the
itellectual resources to think in terms of
I'sordered structure and function of the
lind and body. There is still a great deal
f sickness and as John Ellis said, and
.ckness is much more easily defined and 4.
isualized than positive health. Outstanding
aen and women qualifying from our medical
±ools are attracted, in the main, to clinical
isciplines- The most challenging opporinity for preventive and social medicine 5.
,es in developing within the students, the
ower to use knowledge (Elhs 1961). In a
developing country like India this is the
irime necessity rather than the mere
REFERENCES
Allen, L. ‘Teaching and Training of Under.
graduates in Preventive and Social Medi.
cine’. Ind. J. Med. Edu., 3, 251, 1964.
Ellis, J. R. ‘Choice of Remedy’in Conference
on the training of the doctor for his work
in the community’. Edinburgh 21st-29th
Sept., 1961.
Leavell, H. ‘Suggested objectives for the
Seminar on Teaching of Preventive and
Social Medicine in relation to the Health
Needs of the Country’. Paper presented
at the Seminar on 6th September 1965
at New Delhi under the auspices of the
National Institute of Health Administra
tion and Education.
Taylor, C. Proceedings of the Medical
Education Conference held under the
auspices of the Government of India,
Ministry of Health, New Delhi, November,
1955.
World Health Organisation, ‘Preventive as
pects in the teaching of Pathology",
Technical Report Series, 175, 1959,
Geneva.
The Continuous Community Survey as a Teaching
Technique in Social and Preventive Medicine—-'
BY
M. Alfred Haynes,* K. P. Joseph,j- K. Madhavan Pillai,J S. Raman§
Department of Social and Preventive Medicine, Medical College, Trivandrum
A teaching community is as important to
a Department of Social and Preventive
Medicine as a teaching hospital to a Depart
ment of Medicine or a Department of Sur
gery. Although it is possible to teach the
principles of social and preventive medicine
without such a laboratory, it is accepted
that teaching would be far more meaning
fill if appropriate use is made of such a
community.
At Trivandrum Medical College, an
essential feature of the third year course is a
continuous community survey of a segment
of the Medical College Health Unit. The
purpose of this survey is not specifically to
accumulate data for administrative pur
poses, although this is a valuable by-product.
The survey is an important element in the
teaching of public health and public health
statistics. This paper, therefore, is not
intended to emphasize the results of the
survey which are primarily of local interest
but to demonstarte the continuous survey
method as a teaching technique.
Materials Required
The first requirement is an appropriate
community. Here it was decided to limit
the survey area to one segment of the Medi
cal College Health Unit—Attipra Panchayat.
This is a single village of over 20,000
Population, located about four miles from
the college. It is probably not a typical
tillage in India from the point of view of
Population size or density. The density is
2>791 per square mile.
The size and density of population which
obtain in this village are not critical features
the experiment. A certain population
size is required to demonstrate certain statis
tical principles and an optimal population
density ma}’ reduce transportation problems.
The study of population need not be limited
to a single village. If the Department or the
Medical College has a service area, one
advantage of surveying this area is that the
data collected could be most appropriately
put to use.
Communities which are located close to
medical colleges may over the years develop
resistance to surveys, especially when con
ducted for purely academic purposes.
Surveys and service should, if possible, go
hand in hand.
When an epidemic of cholera threatened
Attipra Panchayat, the same students per
formed mass immunizations of the school
children. The continuous survey was begun
in Attipra Panchayat at about the same time
a more intensive programme of medical care
associated with the training of our house
surgeons in the management of primary
health centers was initiated.
Transportation may have to be provided in
many cases. A college bus and a depart
mental van have been used in Trivandrum,
and the survey is carried out on Saturday
mornings when the vehicles are easily
available.
A mimeograph machine or similar equipment for reproducing questionnaires is
usually available in metrical institutions. At
Trivandrum, the Department has its own
machine which was provided by US-AID.
However, getting quality’ paper in sufficient
quantity may be a real problem and it has
sometimes proved necessary in our case to
salvage the unused pages of previous surveys.
t Professor and Chairman
§ Lecturer in Biostatistics
* Visiting Professor, US-AID
1 Lecturer in Sociology
521
-7
—‘
I
q
After some testing in the field; the question
naire may be printed.
vol. v, JULY 19^
with lecture andW provide an educational
experience to an entire community.
un*
Preparation for the Survey
The same kind of preparation as for
administrative surveys is necessary. In
our case it was necessary to map the area so
that, when student assignments were given,
they could have a reasonably clear idea of the
location of the houses assigned. The
panchayat house numbers were used for
house identification and for drawing samples.
A complete list was obtained from the pan
chayat office. The mapping was done by
the health inspector of the Medical College
Health Unit with the assistance of health
assistants. Some members of the faculty
accompanied these workers, not so much to
assist in the mapping as to determine the
feasibility of assigning students to certain
areas and to ‘get a feel for’ the practical pro
blems which might arise.
To obtain the best results from the survey,
the lecture schedule has to be planned well
in advance. Only in this way is it possible
to plan the appropriate survey (or, laboratory
exercise, as it might be called) so that the
survey can be related to lecture and viceversa.
Two types of questionnaires are used—a
basic questionnaire and a specific question
naire. The basic questionnaire is used at
each visit throughout the year. The specific
questionnaire coincides with the special
area being covered by the lectures. For
example, a special sanitation survey will
coincide with the lectures on environmental
■sanitation or a special nutrition survey with
lectures on nutrition. In the preparation
of these surveys, it seems most practical,
wherever possible, to adapt material from
previous surveys to the specific purpose.
In our own case, the basic questionnaire
draws heavily from the Baltimore City
Health Survey but it is modified to suit local
conditions. An environmental survey speci
ally designed for developing countries has
recently been published (Gremliza, 1965).
Most departments of social and preventive
medicine have at various times done sur
veys which could easily be adapted to this
purpose. The essential difference lies in
co-ordinating a series of urveys into a con
tinuous programme designed to coincide
Early in the course of lectures, there k
a discussion of methods for determining how
many diseases are prevalent in a community
Such basic concepts as rate, prevalence and
incidence are considered. One compares
various ways of estimating prevalence from
institutional data, diagnostic surveys and
household surveys. The advantages and
disadvantages of these methods are weighed.
Many of the points with reference to house
hold surveys are subsequently demonstrated
in the course of the year.
For example, one weakness of household
surveys is the lack of diagnostic precision.
Even though the survey is done by medical
students, the morbidity data leaves a great
deal to be desired from the point of view of
diagnostic accuracy. This is so because the
information is based on case history and,
at this stage of his career, the student is not
very sophisticated either in case study or
diagnosis. Changes take place during the
course of the year as the student’s diagnostic
ability increases.
Early in the course, the students are given
a basic introduction to the various statisual
methods used in investigations of this kind.
Sampling is discussed as the most effiaeM
and economical method for community
surveys. The first lecture in statistics,b
on random sampling. Through care™
experiments, the principles of random samp"
ling are illustrated and the common
in purposive sampling is
The students learn about other mem
of sampling such as stratified ranu >
systematic and sequential sampling.
Actually, systematic sampling is nsed
the survey largely because of conv
and simplicity in allocating the n .
Under certain general assumptions ao
community, systematic sampling worn
least as accurate as simple random
The sampling fraction used is iands«nd«d
concepts of sampling variation ana
error are also discussed quite
reduction m the sampling error an
the increase in accuracy with m
sample size is also discussed.
522- INDIAN JOURNAL OF MEDICAL EDUCATION
Method and Results
CONTINUOUS COMMUNITY SURVEY AS A TEACHING TECHNIQUE
t>23
During the course^r the survey students found more convenient to take one half of
.^cover this fact for themselves as the vo- the class each week, while the other half was
•.jmc of data increases. Complicated mathe- at the college. If the students arc arranged
juatical symbols are not used at any stage into groups with some students acting as
the medical student has a constitutional group leaders, the supervision can be accom
allergy to mathematical notations. Mathe- plished with only two faculty members.
pjatical rigor is sacrificed for simplicity and
If the survey is to be a meaningful ex
,5 intuitive approach is followed in explain- perience in community medicine, it is
jpg certain principles at this stage. This important that the findings be discussed as
jpay be an unorthodox approach to statistics soon as possible. For example, some of
[,ut the teaching of statistics in medical the data from the basic questionnaire is
colleges offers a wide field for experimenta almost immediately useful in the teaching of
tion, especially if medical students are going descriptive statistics. The data on age and
t0 be challenged by a subject which so often house-hold composition can be used in dis
bores them.
cussions of mean, median, mode, frequency
The eleven questions of the basic ques distribution, histogram and normal curve.
tionnaire are all discussed with the students
Population estimates can be derived from
and they are told why each question is asked, the sample and these estimates can be
how each question is to be asked and why compared with other methods of deriving
the answers are precoded. This, in a sense, intercensal population estimates. The esti
corresponds to the training of interviewers, mates derived from the sample should be
but is actually used as a teaching device to derived within given confidence limits and
demonstrate certain principles in public the technique once learned can readily be
health. For example, the first question in translated to other problems in clinical
the basic questionnaire deals with the names medicine.
of persons in the household. The total
The same applies to standard error.
number of persons so identified provides
the denominator for various rates to be When we had sampled 8 per cent of the
derived from the survey data such as the houses, the population estimate was 22,300
birth rate. In most cases, the denominator to 24,000 (95 per cent CL). Extrapolation
cannot be derived from much of the institu on the basis of the previous decade gave an
tional data since one cannot clearly define estimate of 20,954. To arrive at population
the population at risk. In fact, the survey estimates from the survey data, due con
data provides many clear-cut examples of the sideration has to be given to the ancillary
three necessary components of a rate and, data available from the panchayat (e.g.,
since the questions must be so framed as the total number of houses), to the inter
to elicit this information, the review of the views not completed and to the reasons for
questions is a good teaching device. In non-completion. These are exactly the type
order to be sure that there is no ambiguity of problems which may arise in some
*n the questions, the students are asked to epidemiological studies.
give suggestions on the exact translation of
Our survey estimate of births during the
•he question from English to Malayalam. previous calendar year were more than three
After a brief experience in the field, the times the number of births registered in the
students become quite adept at obtaining the area. This is as impressive as any other
“ata on the questionnaire and each student way of demonstrating the importance of
^vers 2 or 3 houses in the allotted time. proper registration of vital statistics. The
Since the students return to the same area birth rate computed on the survey data was
*»ch time, they become increasingly familiar 35 per thousand and the death rate 10 per
*>th the area and this helps to make the work thousand, giving a natural increase of 2.5
per cent.
easier.
During the first half of the year, the
Some interesting results were obtained
Indents go to the field on alternate weeks. on the morbidity data. One question in
**th the addition of the junior group and the basic questionnaire dealt with all ill
an enrolment of 185 students, it was nesses in the home during the preceding two
5-t iNdian journal of medical education
V0L- V> JULV 19^
weeks. The reported rate ofillness was very however, is n^ignificant). Chronic
mtich lower than that reported in the U.S. ditions rank BfKer on survey than on k
or the U.K. White, et al, compares the health center records and it is clear that °
sickness rate obtained by surveys in the U.K. chronic conditions in the community
and the U.S. and estimates that, in these come to the attention of the doctor at
Uac
countries, in the course of a month as many primary health center level.
as 750 persons out of a population of 1,000
These and other findings of the sun.
adults experience what they recognise as
are discussed with students at various tin/
injuries or illnesses (White, 1961).
in the year as data are accumulated. *
In our survey, where the recall period is survey that is not analyzed and discussed
two weeks, only six per cent of the adults loses a great deal of its educational
report any' illness during the two-week value.
period.
While it is recognized that, with
Special questionnaires may have a more
more efficient probing, a higher rate of restricted but important value. A special
illness may be reported, there is apparently questionnaire was used to identify the
a wide gap in the recognition of illness in natural community leaders who were to form
this area as compared with the U.S. and the the health committees for the various wards
U.K. It is likely that many illnesses are of the panchayat. We are indebted to the
just taken for granted and only the more Rural Health and Family Planning Institute,
serious illnesses are recognized. This is Gandhigram, for its ideas on the selection
borne out by the fact that in Western coun process, (Gandhigram 1964). These ideas
tries one-third of the people with repotted were slightly modified but retained in
illnesses consult physicians, whereas in our principle.
area 92 per cent of the adults with repotted
The population sampled was asked on one
illnesses sought relief. The large reservoir
of unrecognized illnesses is of great con occasion to name the persons in their ward
sequence to medical care. As medical whom they would like most to advise them
on
health matters. The names most fre
services become more readily available,
these unrecognized illnesses become more quently mentioned in each ward were select
important and the demand for medical care ed for the health committee. When the
names were later presented to the panchayat
increases with the supply.
committee, they were so impressed with the
It is of interest to note that as many as selection that they wanted to be informed
26 per cent of the patients sought medical of the process. What is most important here
relief from Ayurvedic physicians, while 47 is that the medical students were themselves
per cent used the services of the Medical involved in the process of identification of
College Hospital or the Health Unit. In the community leaders and have learned the
our area, 74 per cent of the sick take advant fundamental idea that in community medicine
age of modem medical care. This finding it is important to involve the community s’
may, however, reflect the proximity of the much as possible in the decision making
area to the medical college. On the other about a health programme
hand, the ‘vaidyans’ enjoyed a high prestige
These committees are now at wort
in the community and a number of them co-operating with the house-surgeons posted
were elected to the health committees.
in the village and assisting in programmes of
The public health importance of various tuberculosis control, mass immunizations
diseases is roughly reflected in the relative and other preventive programmes which
frequencies of the diseases reported. Both
the community survey and the primary health they have themselves requested.
Analysis of the survey data ran be done by
center records show respiratory, gastro
intestinal and skin diseases to be of major students, by machine or both. In any
importance. Respiratory diseases are of the it is important that some of the interview’
highest frequency according to the health be carefully reviewed and edited by froW'
is especially so early in the cow
*
center records, while gastro-intestinal con This
It will thus become clear what problems cm
ditions are of the highest frequency judged be remedied by further clarification «
by the community survey. (The difference,
THE CONTrNUOUSJIOMMUNITV SURvJ AS A TEACHING TECHNIQUE
525
mental concepts of community medicine.
Opposed to this view, however, is the idea
that the community is more than an accu
mulation of families, the same as the whole
is more than the sum of the parts.
It is possible in the family approach for
1
the student not to see the forest because
piscussion
3
i
This experiment has met with unexpected ofthe trees. A proper community approach
includes a family approach but not vice versa
' s enthusiasm on the part of the students who The medical college at Trivandrum has had
4
seem to enjoy periodic visits into the
considerable experience with the family
! community. We feel that the community approach. The students as well as the
| and its problems are a more appropriate
I focus for emphasis is India than the family families were often bored with the frequent
I or the household. The present system of visits although in many cases the students
I medical care based on the network of pri- were able to develop a close acquaintance
I maty health units requires that the physicians with the family and take keen interests in
| be trained in the proper assessment and their problems. The Department is now
1 solution of community health problems. emphasizing the community approach. In
| Some means must be found to divert the a sense, this represents a return to the com
I attention of the physicians from his pre- munity approach which was also used when
I occupation with medical relief at the primary the Department was started. (Department
of Social and Preventive Medicine—1955I health centre, to integrated health manage- 56). Both methods may have their appro
I ment of the unit. It is hoped that continuI ous visits to the community during the third priate place.
Finally, it should be mentioned that the
year, coupled with a study of community
health problems would help to broaden the survey method is not enough in itself. It
scope of the future physicians beyond the must be combined with seminars and lec
walls of the established centre. Certainly tures to make the experience meaningful.
the student who walks through the village Furthermore, the third year programme is
on a Saturday morning cannot miss seeing only one unit in an integrated programme
the evidence of improper sanitation or which also includes the fourth year teaching
malnutrition. If he discusses health with and the house-surgeons’ programme. Each
the heads of the households, he soon learns part adds to the total education and experi
of their interest in eliminating scabies and ence in community medicine.
worms from their children. What he does
REFERENCES
not see should impress him as much as what
be does see and this can all be used in the Department of Preventive Medicine, Medical
| teaching process. Social and preventive
College Health Unit Health Survey, Trivan
; medicine is an applied science which one
drum Medical College Journal, Vol. 4, 1955-56.
j 'corns by doing.
■
fl
.1
1
certain points ’^0 the students. At Tri
vandrum, the analysis has so far been done
by house-surgeons posted in the area and
by faculty. Later more use will be made of
students and machines for tabulation and
analysis of data.
Gremliza, F. G. L. A method for Measuring the
Quality of Village Conditions in Less Developed
The emphasis in this programme has been
Rural Areas. American Journal of Public
the community rather than the family.
Health 55:107. January 1965.
*■ is a moot question in social and preventive
medicine circles if teaching should begin Review of Programmes of the Pilot Project 195964. Institute of Rural Health and Family
Jith the family or with the community.
Planning, Gandhigram.
rhn<!» —
favour the family approach
it on grounds that the family is the White, Kerr, L., Williams, T. Franklin and
Greenberg, Bernard, G. The Ecology of Medi
Z^damental unit of society and that by
cal Care. New England Journal of Medicine
of the family one acquires the fiinda265:18 November 2, 1961.
Longitudinal Family Studies by Clinical Students
BY
Dr S. M. Marwah
Professor and Head of Department of Preventive and Social Medicine, Banaras Hindu
University, Varanasi, U.P,.
these examinations, family-side discussions
were held on a student’s records, observa
tions, achievements as well as future potenti
alities of a student’s study-cum-action plans.
The slum areas being situated within walking
distance of the college, its associated hospi
tals and the hostels, the students visited their
respective families on their own. However,
a supervised visit was provided once a week
for two hours. During these visits, the staff
and the students were transported by the
college bus. During these visits, basic
mixtures and drugs for minor ailments,
immunising agents, family planning appli
ances (cafeteria approach), cheap sanitary
finings like latrine scats, smokeless chullah
designs, etc., health educational equipment
and a field laboratory service were made
available to the students. Further, a student
could pick up a bag of any of the afore
mentioned items from the department when
he visited on his own. During the super
vised visits, a team of teacher, social worker,
midwife, sanitarian, statistician and labo
ratory technician was available to assist
students as well as for supervision. No
doubt the emphasis was on the holoistic
approach which included management of
clinical conditions in the homes, which
occurred very frequently. However, the
deliberate emphasis in the familyside studies
was on social anatomy, social physiology,
soicial pathology, social therapeutics and
their relationships among themselves as well
as among the social, environmental and
clinical components of the total medical
practice.
E Man is a social animal. Medicine is a
■ social science and medical practice is a social
■ action. The ‘ward’ for medical practice is
K constituted by a society or a community in
■ a defined area and the ‘bed’ is constituted
■ by a family. As such familysidc teaching
E is as essential in social medicine as bedside
■t teaching is essential in clinical medicine.
E Since the establishment of the PSM depart|E? ment in BHU in 1963, the teaching and the
E periodic or final MBBS examinations in the
E subject are familyside. The groups of the
■ 1 families constituting the ‘improvised wards’
j for scientific but realistic teaching in human
;• life situations were the slum area of the
f BHU township (Sunderbagia) and the
i adjoining Varanasi corporation slum area
(Sunderpur). The 4-5 years experiences
I S. of the projects were reported (Marwah, et al.,
I • 1964, Marwah 1966 & Marwah, et al., 1966)
I I and arc being further reported separately.
I However, the objective of this paper is to
I i outline guidelines as evolved over the years
I " for the longitudinal family studies with built
I t in total family care by the clinical students.
I , The baseline for experimenting with the
K guidelines through trial and error was pro■ vided by W.H.O. (1960).
I
K 1. Dynamics of longitudinal family studies
E . in BHU
jH • Each student was allotted one family at the
Mr start of his clinical years. He was made the
K pivot to systematically develop the holoistic
K approach under guidance for the study of the
E total family problems and for gradual scek| J; ing of the solutions to the priority problems
-F within the available resources during his
El three clinical years. To boost a student’s
ft learning as well as serving while learning,
. J1' periodic as well as university examinations
JS were held using the same family. During
Social Anatomy and Social Physiology
of a Family
On the analogy of systemic examinations of
a case, a student was guided in his diagnostic
523
2.
524
INDIAN JOURNAL OF MEDICAL EDUCATION
approach to undertake the examinations of
the basic components or ‘systems’ of a
family’s social anatomy. These examina
tions and observations were recorded on the
printed family folders and they were illus
trated by diagrams to emphasise the pro
blems as they were at the start of the study,
as they could be, if medical knowledge was
applied and as they were, at various periodic
assessments in three years period of contact.
(a) Social anatomy of a family was out
lined under the following ‘systems’
or components. Component (vi)
though strictly not a component
of social anatomy was included to
complete the guideline for a family
study.
(i) Family structure i.c. name,
age, sex, and relationship
wise break-up of all
members.
(ii) Literacy of members.
(in) Socio-economic level i.c. earn
ing (memberwise income),
occupation, calculated per
capita income, family’s
financial assets and liabili
ties.
(i'zj) Environmental factors and
their hazards or assets i.e.
water-supply, faecal dis
posal,
refiise
disposal,
housing conditions with
state of ventilation, lighting,
household hygiene, per
capita floor area, availability
of kitchen, kitchen garden,
soakage pit and maintenance
of animals.
(z>) Dietetic factors i.e. assessment
of family nutrition through
diet survey by questionnaire
or weighment method, diet
habits and family budgeting
with a view to outline the
best advantage of the diete
tics to the family.
(vi) Preventive health examination
of all members incorporat
ing the family, past and
VOL. VII, NOVEMBER 1968
present histories, immuni
sation history, systemic exa
mination, anthropometry,
personal hygiene including
menstrual hygiene in
females, and orodental
hygiene, and indicated labo
ratory investigations.
(6) The social anatomy of the family was
further supplemented by the social
anatomy of the family neighbour
hood, the locality (i.e. Sundcrbagia
or Sundcrpur), and of the area
incorporating a detailed listing of
medical, health, health-related and
welfare agencies from where the
family in particular and the area
in general could derive certain
benefits.
(e) Social Physiology: The students were
given lecturc-cum-discussion hours
in the field on the functions of a
family. The implications of the
biological, childrearing, economic
and social functions of a family
were driven home to the students
so that they could grasp the
philosophy of holoistic approach
in social medicine to ultimately
seek to promote the functions of a
family and not merely to over
emphasise the health or medical
entities. In his diagnostic appro
ach, the student was guided to
analyse the complex relationships
and interactions of the components
under (a) and (6) for the normal
functions of a family. The factor
wise deviations from the ‘normals’
as defined in classroom or field
discussions were picked up for
studies in social pathology and
social therapeutics of the families.
In short, the student’s mind was
gradually orientated to view the
family allotted to him as a ‘social
organism’ in ecological setting with
biological implications.
3. Social Pathology and Social Therapeutics
Social anatomy, social physiology, social
pathology and social therapeutics in 0“s
environment outside the body were empha
sised to complement (and not replace) the
525
LONGITUDINAL'FAMILY STUDIES BY CLINICAL STUDENTS
concepts of the inter-relationships of the
traditional teaching of the anatomical, the
physiological, the pathological or the thera
peutical phenomena within the human body.
This may be illustrated by the following
examples:
(a) The students analysed the nutritional
factors of diets consumed by the
respective families to outline the
implications on the health of the
family members. They also out
lined the diet habits and the possi
bilities of educational approach to
family budgeting for maximal utili
sation. Thus, they were guided
both to integrate knowledge of
nutritional aetiologies or pathology
with social aetiologies or pathology
and to seek solutions in integrated
therapeutics i.e. by coordinating
both traditional and social thera
peutics.
(6) At the start of the training, the students
recorded and drew the complete
plans of the respective houses of
their families. They also made
plans of what the houses should be
and these were based on classroom
learning supplemented by field
discussions. At periodic assess
ments and especially at the end of
three years assignments, they re
corded and drew out the respective
changes achieved through social
therapeutics and discussed their
possible implications in the health
of the families.
(c) The students were guided to view (1)
peptic ulcer not onty as a clinicopathological but as a socio-dinicopathological resultant entity of a
patient’s lifetime social and clinical
aetiologies, (ft) typhoid cases not
as simple actions and reactions
between B. typhi and the human
body but as a complex of B. typhi,
human body, environmental factors
like food, water hygiene and social
factors like availability or utilisa
tion of immunisations! service.
These two examples illustrate the
socio-clinico-pathological approach
cultivated in the students for defined
clinical entities.
(d) While the management of the common
clinical conditions was supervised
by PSM teachers, the students
were encouraged to take the condi
tions requiring specialist diagnosis
and treatment to the respective
faculty members but with complete
records of environmental and
social etiologies for discussion to
arrive at diagnosis and subsequent
total therapeutics in the homes.
4. Inter-relationships
Throughout classroom or familyside
discussions both in diagnosis and therapeutic
tics, efforts were made to educate students’
minds towards seeking interpretations of
health and disease phenomena in a total
manner and not merely in isolated or restric
ted terms. In fact, the whole range of
human biology and human sociology and
their complex interactions were well demon
strated during longitudinal family studies
with built-in actions for improvements within
available resources. The labour pains to
cultivate broad-based concepts with builtin idealistic philosophy may be most agoni
sing but the rewards in opening at least
some young minds to experiment during
their lifetime are also overwhelmingly
gratifying.
Conclusion
So far in social medicine, the emphasis is
on teaching broad-based concepts and ideali
stic philosophies without organised partici
pation experiences for the students. It is
felt that if total medical practice is to be
taught, then it should be taught in an atmosphere of organised running of a total care
programme with associated research programmes. To do it realistically, it is suggested that just as every faculty provides seven
beds per admission for clinical training,
every faculty should have at least five families
per admission for total care. The department of PSM may be responsible to organise
it but like any other ‘ward’ all the faculty
members should participate in running it.
In BHU, the improvised ‘wards’ suffered
from the disinclination of the faculty to
2
1
r7j
5L
526
INDIAN JOURNAL OP MEDICAL EDUCATION
view them as ‘wards’ for social medicine,
resulting in several shortcomings, not
presented here. These ‘wards’ can be made
to become areas of intensive integrated
research, training and service, within the
rural or urban practice fields. In demons
tration and teaching value, they should be
made comparable standards to clinical
ward teaching standards. This can be one
of the effective ways of stimulating the
students to view Social Medicine as an
evolving form of scientific but social action
for total medical practice.
VOL. VII, NOVEMBER 1968
Health. First Report (Chapter—Health
Problems BHU Harijan Colony and Medi
cal Students Integrated Training). Vara
nasi. BHU Press. Reprint 1965: 84:97.
2.
3.
REFERENCES
1.
Manvah, S. M,, Rao, N. S. N., Rangpal, P.
and Gaur, S. D. 1964. B.H.U Campus
4.
Manvah, S. M. 1966.
Undergraduate
Training for Comprehensive Medical Prac
tice Through A Students’ Family Advisory
Service. (WHO) Med. Ed. Bull.. Vol XI .
No. 1:2-11.
Manvah, S. M., Rao, N. S. N. and others,
1966. BHU Campus Health 2. (Chapter
-BHU Harijan Colony Health Problems
And Successes and Failures of Students
Integrated Teaching).
Varanasi. BHU
Press: 111-127.
Wld. Hlth. Org. Techa. Bep. Ser., 190, 194.
40-41.
Place of Psychiatry in Undergraduate Medical Education
During The Years of Basic Medical Sciences
BY
Dr K. C. Dube,
Superintendent, Mental Hospital, Agra
Aim of Undergraduate Medical Edu
cation
In order to approach the subject let me
quote from the Constitution of the World
Health Organization:
‘Enjoyment of the highest attainable
standard of health is one of the funda
mental rights of every human being,
without distinction of race, religion,
political belief, economic or social
conditions’.
This provides our main objective. With
this object in view—which in fact is the main
object of Medical Education, I have deve
loped this thesis, freely drawing references
from recent literature on the subject.
It the Second World Health Organization
Expert Committee on Professional and Tech
nical Education of Medical and Auxiliaiy
Personnel, all agreed that though the curri
culum might vary from country to country,
medical educators have certain basic respon
sibilities i.e. to train men and women for the
care of the sick, to make them conscious of
the need to employ every known means for
prevention and elimination of disease and to
encourage them to use their technical know
ledge to raise the standard of living and
health in their people, generally.
To train such young men and women to
tend to the sick, to practice and to prevent
disease and in all other aspects of the art of
healing, they need to be trained in the basic
ground work on which their more advanced
technical knowledge has to be built.
In recent years in other countries there
has been a major re-orientation towards the
teaching of‘Basic Medical Sciences’, and the
teaching of Psychiatry or of Psychological
Medicine has been actively incorporated in
the undergraduate curriculum. The term
‘Psychiatry’ is used almost synonymously
with ‘Psychological Medicine’. The latter
may mean ‘Psychological aspects of Medi
cine’. The term ‘Psychiatry’ is used here
to represent the wider interpretation.
Psychiatry is an off-shoot of Internal
Medicine and has developed into a separate
discipline by process of gradual differentia
tion from Internal Medicine. And ‘Psychi
atry’ then was confined to the teaching of
‘ Psychoses ’ unrealistically. Medicine itself
has been compartmentalized into separate
specialities. There has been a great concern
over this fragmentation of Medicine in speci
alities and sub-specialities, and as Ewing
Cameron says ‘the whole man disappears and
disintegrates in scattered confusion of his
dismembered parts’.
Due to tradition the main trend of approach
in Medical Education has been disease
centered i.e. the treatment is aimed in
treating the disease but not the diseased
person. The corner-stone of the present
teaching of Medicine has been the Anatomy
of the dead, the Pathology of the diseased
and the Somatic Physiology which has taken
little account of the Psychology of the patient
—the patient as a person taken as a whole
which is developed in the theory known as
‘holoistic’ approach in Psychology.
It is mere euphemism to think that treat
ment of a sick man is being carried out
without the consideration of the man himself
in his environment, i.e. without consideration
of the .human factors and with no thought to
the fact that the main disease has occurred
in a particular setting and possibly the disease
527
Community Medicine and Medical Education
BY
Carl E. Taylor, M.D.
Rural Health Research Projects, Narangvial Khurd, P. O. Kila Raipur, Ludhiana, Punjab
Adapting medical education to the needs
of India clearly requires a new and expanded
emphasis on Community Medicine. The
achievement and failures of the past 10 years
permit a clear statement of practical innova
tions which can work if given adequate
faculty support.
No subject has received so much attention
in speeches and so little practical attention
by medical educators as the health needs of
village communities. This discrepancy is
due mainly to the large volume of speech
making and only partly to the slow build-up
of efforts. The speech-making is valuable
in so far as it creates a climate for implemen
tation. We can no longer postpone action,
however, because of the excuse that we don’t
know what to do.
A solid foundation of achievement in the
past 10 years now provides a basis for plan
ning. Our present knowledge is derived
from the numerous ‘experiments’ in com
munity medicine which have quietly been
taking place around the country.
The verbal enthusiasm for rural teaching
which followed the 1955 All-India Congress
on Medical Education carried the flavour
of much of the general development planning
in India during that period. The goals and
ideals were impeccable but so exalted that
their translation into performance would
have been possible only if all medical educa
tors and students had been paragons of dedi
cation. We all shared a kind of enthusiastic
naivete that made us believe that difficult
goals would be readily attained. Without
this willingness to try anything, many of the
important achievements of that period would
have been impossible.
numerical growth of the medical profession
was considered the first priority to meet
the mass needs of a rapidly expanding popu
lation. This effort has in itself been a
clearly defined challenge demanding pheno
menal investment. It is increasingly evident
that the race with population growth requires
the medical profession to realistically reap
praise its own rule as part of national health
system. The goals of the past are not neces
sarily the best response to the challenges of
the future. The greatest hope continues
to be that the leaders of Indian medical
education have always strongly supported
the maxim that medicine must be responsive
to the needs of society. More bluntly the
fact is that health services must be organized
for the good of the people and not to meet
the personal needs of doctors for material
gain or scientific satisfaction or altruistic
motivation.
In this brief analysis two points are stres
sed: some basic principles of community
medicine are restated as they apply especially
to the needs of India’s village communities;
secondly, new challenges for change and
innovation are presented in the exciting
pattern which is emerging from past efforts.
Background
First, a few words of history are indicated
to help provide understanding of a kaliedoscopic transition in terms.
Community medicine is not merely a new
label applied to old efforts. As the old un
popular subject of hygiene began its frenzied
struggle to keep from being drowned by the
flooding growth of scientific clinical medicine
it tended to turn toward the relative security
1
Post‘‘n^ePendence burst of energy of Public Health separatism. One of the
ed to great accomplishments in medical most unfortunate legacies of western medi
education which now appear to have been cine as transplanted to developing countries
more quantitative than qualitative. A rapid was the separation of curative and preventive
393
I.
I
395
394 INDIAN JOURNAL OF MEDICAL EDUCATION
VOL. IX, JUNE-JULY 197oV- COMMUNITY MEDICINE AND MEDICAL EDUCATION
III. Application of Principles of Com
medicine. The maintenance of this dicho These may be used profitably in both the] medicine. It goes beyond that, however, 1 munity Medicine to Indian Conditions
tomy has been as much the fault of public pre-clinical and clinical periods of prepara-' to a group of special competences and skills.
The following section gives more detail
It
is
demonstrably
wrong
to
say
that
com
tion.
Great
variation
exists
among
the
health practitioners as of clinicians. Be
on the knowledge, skills and attitudes which
cause they were so low in the pecking order colleges in the size, facilities, staff activities^ munity medicine will eventually work itself (
needed.
of medical prestige as to be almost ignored, and degree of control over the health center I out of a job when other clinical departments areThe
discussion is not intended to be
public health physicians have tended to get by the medical college. Now it is increas.t take over because no other discipline can inclusive. It is selective in the sense that
their professional satisfaction outside of the ingly recognized that a single health center; cover the special areas of knowledge and an attempt is made to give priority to parti
practice.
It
must
also
be
agreed
at
the
usual range of medical activities. An is not enough and the next evolutionary step I
cular
emphasis
which seem important in
awareness that they were contributing more will be to have a medical college serve as a; beginning that arbitrary limiting of the term
to overall improvement of health than their regional base for comprehensive health care.L is wrong because it must be applied diffe India today.
rently
in
varying
situations
and
places.
A. Basic Sciences of Community Medicine
clinical colleagues increased their feeling of
Within medical faculties there was some;
Medical specialties are generally defined
satisfied isolation when both clinicians and decrease in the low caste stigma of public]
One
in curriculum
vne of
O1 the
Ulc early decisions
. ....................
..
the public tended to ignore them. The only health as a result of the use of the term pre-| cither according to the group of people they
or by the type of activity. and skills planning ioi
for piovuti.v
preventive and cccic!
social medic'^e
medicine
times they could count on being noticed was ventive and social medicine. Some clini-l» serve
WI.V — -j .
was that teaching should extend from the
"T"‘ Community
when there was a major epidemic for which cians were attracted to professorships with!;& which occupy their ttime.
----1 • - . 1 course
-- -through th
beginning
of
the
medical
theA
they were blamed. The public health pro a resulting transfer of glamour from their;I medicine can be separately identified on |
internship. Now with the progressive matumatu
fession drew a special personality type of old familiarity with clinical wards. Political ft-I both scales.
ration
of
the
concept
of
community
medicine
dedicated and underpaid sanyasis who and financial support also improved the I
The patient of community medicine is it is even more important to restate this
appeared as anything other than glamorous image of this field. There was, however, a II obviously the community. The community
role models to medical students. The image simultaneous loss in glamour through theli is composed of individuals just as a forest is principle and to clearly define what it means.
of this part of medical practice needed to be punitive approach taken in developing rural I composed of trees but it has its own special The basic sciences of community medicine
changed in order to incorporate it into the health work. With the decision to turn:t characteristics. A woman is either pregnant must be built into the preclinical curriculum
not pregnant, uuu mvou
_______
along with the basic sciences of clinical medimainstream of medical education and rural health centers over to preventive and 5I or or
not about
pregnant
most
communities
are cine. The relative emphasis on the follow| always
3 -------perbut
cent
pregnant.
Similarly
practice.
*-"-on-mnt
ftimilarlv
social medicine many medical educators k ’• ■" ’ ---- c--------™<;t be
studied ing specific disciplines and their timing and
I gestalt issues to be adjusted to local conditions:
The first step in the change process was relaxed back into their traditional roles. I the illnesses of a community mustThe
othe reorganization of teaching in new depart Students and interns were then forced to » within their ecological setting.
1.
The most general term covering the
ments of preventive and social medicine. take their dose of village work as though it; " of the whole community brings an under- basic orientation that needs to be developed
Thousands of words both in publications were bad-tasting medicine. Since no one! ’ standing that is quite different from seeing is ecology. Although this discipline had its
and speeches went into definitions of what really knows how rural teaching should be: | separate individuals as patients. The con- roots in plant and animal studies the present
the new image was to be. Curriculum time done clinical teachers were safe in severely' j corn for the individual is not lost in the need is to make it truly relevant to under
allocations recommended by a long series criticising the courageous attempts of pre■ £ . process but he is seen in relation to the standing the human conditions in India.
of conferences was for teaching in each year ventive and social medicine teachers to pio■ | group. Health care becomes more than As the study of the relationship between
& mere manipulation of inner functions of
of the medical course. Actual implementa neer this new area.
B individuals and focuses much more on man and his environment it provides a good
tion varied with convincing arguments for
base for understanding the environment.
both preclinical and clinical emphases. II. Definition of Community Medicine, I the conditions which surround him. The
' I fundamental and preventable causes of
2.
Equally fundamental are the group
Obviously the ultimate decisions about what
It is time now to really create a new image• | illness are usually community determinants. of disciplines usually included in the social
was actually taught were mainly determined
by the personal predilections of particular and a new atmosphere..- The label of com‘ I .To apply community health care a doctor sciences. Selective and relevant contribu
professors. Clinically oriented teachers of munity medicine should help. The first1 | needs special knowledge, skills and attitudes. tions to understanding the organization of
preventive and social medicine wanted requirement in this new effort will be to get’ g Traditional medical education does not man in groups and interactions between
strong linkage with clinical subjects. Those the active participation of the whole medical1 s provide this understanding and practice. individuals arc fundamental because other
departments most concerned with research faculty.
It is no longer reasonable to expect even the people are the dominant component of the
environment of most individuals.
activities in epidemiology or social medicine
The struggle to adequately define the g mature physician to pick these up spontastressed the basic sciences of preventive various labels which have been applied to E; neously. The basic sciences of community
3.
Statistics provides a quantitative base
medicine. The old arguments on both this elusive field of medical activity have & medicine are largely ignored today. Even for community understanding and should
sides are still valid. Students need first the tended to degenerate into bickering over | more important there are special skills of make community medicine a more scientific
foundation of a basic introduction to ecology, trivialities. Distinctions in terms have been gi diagnosis and health care which need to be and less intuitive discipline than most kinds
epidemiology, the sociology of medicine clouded by over-definition. The greatest | developed with as much precision and care of medical practice.
and demography. Then they certainly value of the new term communin’ medicine & as present practitioner training in wards and
4.
Epidemiology
is the .diagnostic
dis-r.
------ aJ -----need a well organized educational experience is that it can be used as a fresh start to ■ operating theaters. Most critical are a
group of ethical standards that can now be cipline of community medicine. It is
during a practice period in the clinical years. identify a general area. In general, this
| defined, which call for basic modifications ecology applied to health problems. It can
A major emphasis has appropriately been field must be recognized to share a gray area £. in the values and attitudes of the doctor who be practised at the level of the family just as
on the development of rural and urban of association with all the clinical disciplines I| undertakes community responsibilities.
effectively as with larger communities.
health centers as teaching laboratories. in what has been called clinical preventive
396
INDIAN JOURNAL OF MEDICAL EDUCATION
Epidemiological information provides the
basis for much of the intuitive approach of
the highly skilled clinical diagnostician.
Expectations of when to look for particular
combinations of health variables and their
outcomes derive largely from awareness
of probabilities in particular community
groundings. Certain types of people come
down with particular conditions and clinical
ambiguities are often resolved best on the
basis of the epidemiological trial of knowing
what to expect according to variables of
time, place and person.
VOL. IX, JUNE-JULY 1970
must either take leadership or find them- I
selves controlled by administrators and
politicians. Of particular interest is the
great growth of administrative research
exploring areas that were previously left to
ad hoc and intuitive decisions. Not only
must medical colleges begin to provide
opportunities for doctors to learn health
administration but they must also take
leadership in research in health systems.
The field practice area therefore has the
potential of becoming equal in importance
to the ward and the laboratory as a base
5.
Demography is an increasingly impor for teaching and research.
tant basic science in medical education.
2.
The doctor is the leader of the health
Rapid population growth appears to be the team. No other aspect of medical educa
spontaneous factor most directly controlling tion has been so much left to chance as pre
change and development in India today. paring the doctor to work with health col
All health variables are directly influenced leagues. In a primary health center he will
by number of people. The medical pro be responsible for at least 40 co-workers and
fession must perceive its own responsibility the number grows every year. This change
for birth rates in addition to its traditional is even more dramatic than the parallel
concern with death rates.
movement in hospitals for more and more
6.
Genetics, Nutrition and Child responsibilities to be carried by auxiliaries
Growth and Development provide under —a change that is forced by the increasing
standing of the person. Each is controlled technocracy of medicine. To be a team
by varying environmental determinants. leader requires a drastic change from out
They are worth studying independently dated concepts of solo-practice. The new
because they mediate the more general role requires a chance to practice in a field
setting where the young doctor begins to
environmental forces.
understand that there are many tasks includ
B. Applied Sciences of Community Medicine ing clinical functions of medical care, which
auxiliaries can do better than him on a
On the foundation of understanding the routine basis. He must learn to delegate
disciplines of community medicine it is down so that the complicated judgmental
necessary in the clinical years to develop problems can be referred up. Learning to
appropriate skills through practice. Many work together with others requires practice.
of these should be applied routinely in clini
3.
Community control measures can
cal practice with individual patients. To
properly care for people the doctor should now be applied on a widespread scale for
incorporate social and preventive measures. many diseases. This is most true of many
He must, however, also learn to deal with basic preventive procedures that remove the
the community as a whole because a group causes of disease. In general these include
approach is often most efficient, economical public health functions such as sanitation,
vector control, mass education and social
and humane.
and legal measures. Every doctor should
1.
Administration of health care has be involved in community activities especi
grown rapidly in importance. Partly as a ally those which are applied at the personal
result of demographic change and the in level such as immunization and nutrition.
creasing complexity of society there is a
4.
Family Planning programs are here
general insistence on better organization. mentioned separately because of their vital
In fact in some countries health care now role in building a better India. Both com
ranks as the fourth largest industry both in munity and individual approaches must be
its requirements for manpower and money. blended. The fact that in many primary
As people insist on better organization doctors health centers approximately half the total
community medicine and medical education
staff effort is going into family planning is
an indication of its significance in India’s
health program already. The pressure is
bound to increase because the population
problem will not be easily solved. Some
family planning experts are saying that one
of the greatest obstacles to effective family
planning program in India is the medical
profession. It is the responsibility of the
leadership in the medical colleges to dis
prove this indictment.
397
Another basic attitude growing out of the
ecological view is the recognition that medi
cal care is not always the greatest need of a
community. Health benefits may be better
achieved by non-health developments. The
doctor may therefore promote the greatest
health gains by non-medical means.
IV. Emerging Pattern of Community
Medicine in India
Among the dramatic health achievements
C. Basic Changes in Attitudes and Values of the post-independence years one with
particular long term benefit is the progressive
No combination of knowledge and skills evolution of a system of regionalized health
will by themselves be sufficient preparation care. The whole program is built on the
for the practice of community medicine. comprehensiveness of care in the sense that
Both must be supplemented by a changed the old dichotomy between preventive and
attitude, a modified set of values that goes curative services is being eroded away. The
beyond that usually associated with medical whole system of primary health centers as
ethics.
the peripheral service units linked back
When a doctor takes on the responsibility through increasing specialization to taluk—
of caring for a community as his patient he district and medical college hospitals pro
has to change his understanding of his pri vides an anatomical framework which is
mary responsibility. He can no longer fairly well developed. The physiology of
think in terms of doing everything possible this system is not yet functioning, however,
for a few selected individuals. Fie must because the two-way linkage flow is not
learn to apply an appropriate scale of priori working.
Education and consultation
ties to the choice of health problems which should flow to the periphery and patients
most require attention. He must also learn and problems should be referred centripe
to think in terms of cost/benefit ratios in tally.
judging what control measures to apply.
The greatest lack in the system in rural
This requires ajudicious amount of appar
ently ruthless saying ‘No’ by the doctor to India is an adequate base of subcenters.
individuals who present themselves for To really reach the villages there must be
symptomatic care of minor complaints which a sub-center for about 3000 people. It has
should normally be treated by auxiliaries. been demonstrated in our field research as
Rather than only treating complaints that well as in other places that a new type of
spontaneously come to him, he reaches out ‘ambulatory nurse midwife’ is needed to
to the community in continuing appraisal provide the needed services at the village
of relevant problems. The community level. In the first place they should inde
doctor must reserve his facilities and atten pendently provide the bulk of routine symp
tion for those health problems which he and tomatic medical care. If the doctor is
the community select as having highest relieved of this burden he can do the tasks
priority. There will never be enough which are really important for the health care
resources to care for all health demands and of the many village communities in a PHC
rational allocation requires courage and block. This ANM can also carry out the
village level preventive and family planning
much skill in public relations.
The community doctor gets his satisfac services which will provide the real basis for
tion less directly and overtly than the clini health improvement in the country. But
cian. The results of his efforts are often they can work effectively only with appro
referred in time. Patient response is not priate supportive supervision.
For medical colleges the most exciting
usually direct and openly warm because
Prevention does not evoke gratitude as future potential of development is in moving
readily as relieving pain or fear from existing actively into community responsibility. In
the past, medical educators have spoken of
398
INDIAN JOURNAL OF MEDICAL EDUCATION
VOL. IX, JUNE-JULY 1970
out a co-ordinating system. Community
care admittedly adds to the complexity of
medical education. It has been clearly
evident from experience thus far that it i$
not sufficient to merely turn community
medicine over to a single department. All
departments, especially those with clinical
responsibility', must be involved to make a
significant impact on medical students.
The needed synchronization of effort will,
however, not happen spontaneously. With
out stimulation and co-ordination this intri
cate anatomy of organization will remain
inert. The simplest administrative measure
would be to expand the role and resources
of the department of community medicine
to fill the co-ordinating responsibility.
A fixed percentage of the medical college
budget could be allocated to ensure that
the field activities are not eventually
crowded out. To really provide the status
needed, however, a dean of community
extension should be appointed on a par
with the academic dean and the superin
tendent of the teaching hospital.
We have had too many halfway measures
and too much frittering away of resources in
partial solutions. The need for bold and
decisive action is evident. Some colleges
V. Co-ordination
should take up the evident challenge of the
No complex organism can survive with new community medicine.
their responsibilities as being a tripod of
teaching, research and clinical sendee. To
this we need now to add the fourth leg of
community service.
The climate is now right for some colleges
to really pioneer in taking regional responsi
bility for medical care. Heads of clinical
departments should be responsible for
service in a whole district. For instance, a
department of surgery should assume res
ponsibility for seeing that simple surgery
in health centers and small hospitals is pro
perly done. Staff should rotate back and
forth from center to periphery. If appro
priate linkage is established the patient
should be able to get the diagnostic preven
tive and therapeutic services he needs as
close to his home as the sophistication of
facilities will permit. The health centers,
public health services and small hospitals
would be considered part of the medical
college just as much as the teaching hospital
now is.
The eventual goal is to have a medical
college not limited by hospital walls. It
must be decentralized, reaching out to in
corporate community health care facilities
in a whole region.
30d
THE INDIAN JOURNAL OF MEDICAL EDUCATION
VOL. XII.
NOS. At
The above scheme will, to a great extent, fulfil they barely learn history taking and clinical
the objectives of teaching community medicine examination they finish with the subject.
in a rural setting to the undergraduate students.
The other difficulty is about the field practice
At present in many of the medical colleges this areas both urban and rural. Some medical
is not possible due to various reasons. Firstly colleges do not have rural field practice areas
the subject of Preventive and Social Medicine under the Department of Preventive and Social
even to-day docs not enjoy the status of a Medicine and the department has to rely on
fullfleged subject in many universities in the goodwill and co-operation of the medical
cluding the Gujarat University. It is tagged officer of the Primary Health Centre. As all
on to the subject of medicine in theory Primary Health Centres are not suitable for
carrying only 25 per cent of the total teaching purpose, one with an ideal set up
marks in Medicine without there being should be placed under tire department. This
any oral or practical examination. Naturally will help in two ways—firstly it will help in the
the students who are generally examination field training of the junior lecturers and
minded also give less importance to the subject. secondly an ideal set up can be provided to
The most discouraging development is the the students learning community medicine.
Medical Council of India’s recommendation to
hold a separate examination in Preventive and
The staffing pattern of the Department is
Social Medicine with the II professional exaini- still far from satisfactory in most of the medi
. nation (vide its number MCI/9(5)/MED/583). cal colleges and consequently field experiences
Teaching of community medicine in the field is for students cannot be organized in a satisfac
only possible during the clinical period when tory manner.
the students start learning history taking and
The above are some of the obstacles in the
clinical examination. Then only 12 months
remain for teaching Preventive and Social way of organizing a community oriented pro
Medicine and with 4 subjects for examination gramme of teaching which forms the most
at the II M.B.B.S. level, the hours available to important facet of the undergraduate medical
the subject will be most insufficient. When education.
“ The Teaching of Nutrition to the Undergraduate Medical Students
with Reference to Community Needs ”
by
A. R. Shah, m i>., d.I'ED, *
Aslis laid Projector of Pediatrics, li. J. Medical College & Cioil Hospital, Abmedabad-16.
Nutrition adequacy is important in the life of an individual from the lime of gestation to lhe lime of
acceptance of full responsibility as a socially functioning adult. The knowledge of nutrition is most
important to the medical students. Nutrition and its various aspects are discussed. Nutrition is taught
at present al various stages without recognition and adequate consideration. Now it is lime for con
sideration of planning for leashing of nutrition, e.g.,wl
leach, who should leach, how and what
should be taught.
There are now many advances and researches
Malnutrition
concerning
medical
science and allied
branches. The expanded horizon of research
has resulted in various disciplines like bioenLow capacity to work
I gineering, biochemistry, histochemistry, immu
nochemistry, ,ccneticsu nuclear medicine and
various other branches which were not named
Low income
or heard of before a few decades. All these'
researches are mainly carried out in developed
countries. It is very difficult for us even to
---- - ------------------------- Inadequate diet.
imitate them at lhe present contest. Unfor
tunately at the present moment our medical
The needs of the community are enorm
nudents arc only interested and excited with ous. Our population is suffering at all risk
,.
laboratory techniques, various machines and periods ; e.g.,
(1)
Low average birth weight (2. 8 Kg).
sophisticated appliances and they are apathetic
to the actual needs of the community. Probably
(2)
High infant morbidity &. mprtality
(80-120). Ten times higher than ’western
the fault docs not lie with the students but with
countries.
their educators who have failed to infuse them i
(3)
1-4 year mortality: 30-50 times higher
with real needs of the community. The rural
than western countries.
population is 80% and most of the population
(4)
10 per cent of total world population
is undernourished and inadcqyatedly looked
suffer from malnutrition.
after. Nutritional adequacy is important
(5)
20 per cent of world population (700
iin the life of an individual from the time
million)
suffer from iron deficiency suffi
of gestation to the lime of acceptance of
cient to alter productive capacity.
full responsibility as a socially functioning
I adult.
(6)
Most of the patients suffering from diseases
are malnourished as undernutrition and
infection act synergistically.
t
I
I
I ■
JULT-DECEMBER, 1973
Integrated Pre-Clinical Teaching
by
H. Jana, M.SC, MBBS, Ph.D, Prof, of Physiology,
P. C. Mehra, MBBS, M. SC, Prof. of Anatomy,
Smt. N. H. L. Municipal Medical College, \
Ahmcdabad-G.
Change in the present set up of medical education is recommended by many, but actual implementa
tion is yet awaited. Expansion of certain subjects and reduction of time of leaching in preclinical
subjects are contradictory suggestions, but a reasonable solution can be found.
Assessment methods, criteria for promotion of teachers and students’ participation in leaching and
research are discussed. Some administrative reforms are also suggested.
Aims of medical education
In the face of development of science and
technology in our country since independence,
and with the greater need for advanced health
services to the dangerously increasing popu
lation, the system of medical education has
undergone very little transformation than it
was due. At this stage we do require not only
basic doctors to man the health units, but
also specialists in Medicine, Surgery, Anaes
thesia, Obstetrics & Gynaecology, Psychiatry,
Dermatology, etc., and devoted research
workers who will be in a position to modify
the treatment methods to suit best to our
social and economic conditions, and lay
emphasis on the health projects of national
importance. We are pained to note that
inspitc of realisation of the above facts by
our leading medical men and administrators as
is evident from their speeches and publications
in the journals, like the I.J.M.E. and J.I.M.A.
very little has been actually done to that
effect. We are waiting for the day when
those high ideals will be translated into
practice.
We would like to concent'-’.'s on tire pre
clinical teaching with which we are entrusted
for more than two decades, and try to express
a few words not only on the problems again
but more about their solutions.
Content of curriculum and the time available
It has been rightly stressed that the teach
ing to the undergraduates in medicine should
be broad-based so that the doctors of tomor
row are capable of satisfying the three needs
enumerated earlier and at the same time
adjusting to the changing requirements of the
society. For this purpose, entrants to the
medical college should have undergone mini
mum three years’ degree course with biology
and mathematics. During the preclinical
period, the students should be learning not
only Anatomy including Histology and
Embryology and Physiology including Bio
chemistry, but also the subjects like Biophysics,
Elementary Sociology and Psychology, elements
of Medical Genetics, and Biostatistics.
With the ushering in of the electron micros
copy, tissue culture, histochemical techniques,
cryostat, micro dissection techniques and
experimental embryology, the curriculum in
Anatomy is increasing in arithmetical pro
gression. Similarly, Physiology may be said to
INTEGRATED PRECLINICAL TEACHING
307
increase in geometrical progression pari passu sometimes to move from one teacher to
with the better understanding of the sub- another, because of the teachers’ specialisa
cellular phenomena by dint of our growing tion in a particular branch, or their maintain
knowledge in biochemistry and biophysics, ing water-tight compartments of what system
with the emergence of techniques like chro they teach. It may be that the student has
matography, Electron-microscopy, differential approached another teacher who has not
centrifugation,
subcellular-chemical
and taught that topic, with the hope of under
enzyme technology, micro-electode techniques, standing the subject better, which is a possibi
micro-iontophoretic application, stimulation lity. It is well known that we understand a
of single nerve fibres etc. The portions of the topic much better when we read the work on
two subjects which our preclinical students the same topic by different authors. We
are expected to learn are really voluminous. recommend some such flexibility should be
These are heller visualised when we compare there for the undergraduate students. We
what we learnt when we were students and also feel that one may find in these, the cause
what we arc teaching to the students today, of student indiscipline and justification in
or when we compare I lallibertan’s Physiology students’ demand for their participation in
with Best and Taylor’s or Guyton’s. Same is planning the teaching programme or the mode
true of Anatomy also. And the teachers, of examination.
rather specialists in particular branch of Solution to these problems:
Anatomy or Physiology appear to be fond of
Solutions of all these problems lie in giving
imparting all their knowledge to the under
graduates. This is another reason why the due. consideration towhat topic and how much
curriculum has inflated to a great extent, of a topicshould betaught during the preclinical
because we follow not the duration of course period, keeping an eye to the problems enumand hours of teaching but the increased girth merated already. One does not find any other
alternative than to trim the existing syllabus in
of the textbooks recommended.
Anatomy and Physiology , in order to accom
Wc are all aware that medical educationists modate other subjects which are equally
have cut down the preclinical teaching period important and essential for making the back
from 2 years to 11 yrs. Sometimes admission ground of medical education sound.
is delayed and the final examination is early,
To quote WHO’S (1962) ’ recommendation
so that in actual practice, only a little over
It is largely in the choice of appropriate
one year is available. Did they think of really
cutting down lhe syllabus ? At the most they factual matter from the almost unlimited range
have talked about the teaching of the basic of scientific knowledge that future teachers can
principles in the subjects, but no concrete display their judgement. Much that is in
cluded at present tends to be traditional and of
steps have been Taken.
intellectual or practical value. ”
Younger and younger students are entering
We may be fairly correct in saying that only
the medical colleges and they are made to
devour more and more of the courses in less than l/6th medical students take up
shorter period. Luckily the younger genera surgery as their career; only they require
tions are better equipped in their mental detailed knowledge of Anatomy. If it is so,
power ; they are trying to adapt, but it is too can we not think of limiting the hours of
much to cope with. Students are kept busy dissection, and of confining our teaching from
for 6-7 hours a day in the college alone; there much smaller sized text books than Gray’s
is hardly any time left for them to discuss Anatomy ?
among themselves or to meet the teachers for
Very few students are going to be research
lheir difficulties. How far the teachers will be workers. Then is it not wise to teach only the
available for the purpose is also a question. principles of the techniques involved, and to do
Many teachers have a tendency to come late away with the detailed procedures, obsolete
and go away early and make use of maximum theories, and superfluous exercises at the
leave possible. It may be the prevaling hard undergraduate level, in the teaching of
days and socio-economic conditions may be Physiology. Similarly one can think of elimina
responsible for tins attitude. Even when a ting the techniques of histology, certain tests
student approaches a teacher, the student has and exercises in- Biochemistry which arc
308
THE INDIAN JOURNAL OF MEDICAL EDUCATION
not much of 'clinical use and which most
of the medical men arc not going to
perform in their future carrier. Other field
where this axe can fall is the experiments
on amphibians. Otherwise it would be impossi
ble to include teaching of clinical examination
of various systems of the body, which is very
essential and useful. Integrated teaching pro
gramme between Anatomy and Physiology both
in theory and practical, if planned properly
and carried out intelligently, can spare several
hours of teaching during which seminars,
discussions, tutorials and other new and effective
methodscan be successfully employed, replacing
the conventional didactic ones.
The aim of teaching should be to make the
students understand the subject, so that they
can go smoothly over other topics, not taken
up in the class. The teachers should guide the
students as to how much they are expected to
read and know about the subject, rather than
to spoon-feed them.
Taking one and a half years for the prer
clinical course, the effective teaching period
comes to about 42 weeks in all, which works
out to approximately 1400 hours (42 X 33).
These hours^have been alloted to the subjects
of preclinical course as follows :—
Block I—500 hours devoted for Gross Anatomy:
Lecture
... 120 hours
Dissection
... 250 „
Museum
...
10 „
Demonstrations
... 110 ,,
Seminars, discussions
...
10 „
Total
Block 11—400 hours
History of Medicine
Histology
Embryology
Genetics
Psychology
Sociology
Preventive Medicine
Biostatistics
Biochemistry-theory
,,
-practical
10.
Family planning
JI. Medical Film
1.
2.
3.
4.
5.
6.
7.
8.
9.
Total
VOL. Xll
XOS. 3 a 1
Block III—500 hours.
1. Lecture (sec Appendix)
... 200 hours
2. Practicals-Experimental
...
80 „
3. Practical-Clinical
...
80 „
4. Tutorials
...
80 „
5. Seminars, group discussions,
debates
...
60 ,$
Total
...
500 hours'
Assessment of the Students Performance
Without going into the details of this often
discussed and debated topic, we would like
to stress the following:—
1. Semester wise written, oral and practical
examination, with both essay type and objec
tive type of questions in the theory paper.
2. Introduction of medera,tion system at
the University theory examination, in order to
make the assessment uniform, and to impose
some check and control over the practice of
going over answer papers hurriedly and in a
very short time.
3. A provision for inspection by the Indian
Medical Council is there, but merely taking
note of the number of examiners and their
qualifications, number of students in each
batch at the practical examinations, etc., some
times from the office, how far it serves the
purpose of maintaining uniform standard is
doubtful.
4.
One glaring example of non-implementation of the useful recommendations is the
practice of not including in the theory exami
nation the marks of viva voce test, which is so
... 500 hours important to assess the ability and capacity of
the students to imbibe and understand the
subject. The practical examinations being so
...
4 hours mechanical, including with it marks of viva
... 100 „ voce nullifies the value of the latter.
...
50 „
Maintaining of journals—often as many as
...
18 ,, five— we think needs revision so as not to tax too
...
18 ,, much on the students’ time, and the assessment
...
5 „ of thesame should be left to the internal assess
...
6 „ ment only.
...
6 „
5.
Awards of distinctions, medals and prizes
...
80 „
should be based on the marks of external exa
...
85 „
...
24 ,, mination only.
...
4 „
6.
In the practical examinations our aim
should be to assess how far the principles
... 400 hours underlying the practical lessons haye been
JULY-DECEMBER, 1973
grasped by the student and to verify these
principles by the given experiment. The
students are not expected to master the techni
ques in the faceofa myriad of practical lessons,
in a short span of time. Keeping this in view,
it does not seem to be the correct practice to
examine the practical biochemistry after the
students left the lab,, as is the practice in many
universities. The student may be allowed to
use laboratory note-book in the examination.
INTEGRATED PRECLINICAL TEACHING
309
2. The work and efficiency of the teachers
should be judged by his teaching ability, his
participation in research work, and in his
interest and skill in the development of the
various activities of the department. His pro
motion should be guided by these intrinsic
values and not by the chronological age in the
department.
3. Experienced teachers in the subject, as
many of them as are available, should beTeacher'. duliew, responsibilities, and bis role in consulted in the designing and planning of the
medical
education, while changes in the
planning the medical education.
existing system of teaching and assessment in
In this area also we would suggest the intro the subjects are contemplated. Besides the
duction of the following:
--e-clinical teachers, the specialists in other
1. To have an Office Assistant or Secretary disciplines of medicine, medical administrators
to the Professor and Head of the department to and students representatives should also be
utilise his experience in his subject of specia taking part in the deliberations. Students are,
lisation to the maximum advantage for the in this arrangement, in a position to place
organisation of teaching and research work of their specific needs and difficulties for consi
the department rather than spending much of deration. This may greatly cut down the
his time on casual leave reports and work as student unrest.
purchase clerk etc. Obviously, it is economical
and does justice to the tax payers’ money.
]ULY-DECEMBER, 1973
Evolution of Social Medicine and the Problem of Training
EVOLUTION OF SOCIAL MEDICINE AND THE PROBLEM
I ment of the ill, prevention of disease, promo
tion of health and searching for more areas
for such action.
191
(3) Whether pne likes or does not, a medical
student is examination oriented and examina
tion stimulates attention of the student to the
teaching. The examination has to be at the
proper level when a student is expected to be
able to learn the subject. By the very nature
of the subject of P.S.M. a candidate can be
properly examined in it only when he has
studied the clinical subjects well. Earlier
placement of the examination in P.S.M. will
not allow the examiner to test the students
s> -ently and the student in his turn will
allow gaps and deficiencies in his study and
interest. Such deficiencies are sufficient
obstacles to the learning by the students of
social responsibilities, practice of social medi
cine and even Preventive Medicine and
Epidemiology. Teaching of these subjects
also become seriously hampered.
If such arc the responsibilities of Modern
Medical practice, the training of such practi
tioners becomes a matter of concern. This
Association is vitally involved in the matter.
It would be useful to go into some points as
regards the training of medical practitioners in
India. There are now more than 100 medical
| colleges where training is going on towards
I developing the students into practitioners of
comprehensive medicine. Such efforts are
about
the
state
privilege
versus
individual
Medicine is as old as humanity. From the
I evident in all these institutions which at the
earliest times, man has been looking for and liberty. The philosophy propounded by Marx, I same time show good deal of deficiency in
using whatever was available at the time for writings of Mill, action by carl of Shaftsbury i training progi.mmie and in the facilities for
cure of the diseases. Prevention has similarly and Simon were directed towards these pro I the same. Whereas al) departments in the
been sought after from the earliest of times. blems.
' medical colleges are working in a complemenEvidence of pre-historic efforts for prevention
So far as health is concerned, one of the i tary manner for developing young and unis available in plenty in magics, customs, most important contributors was Virchow. Al j initiated minds, the preventive and social
(4) Every medical college is under one of
traditions etc. The concept and practice of a member of the German Parliament Virchow I medicine Department has the special responsi- the three ownerships, viz. Government, local
Social Medicine is of more recent origin. That crossed verbal swords with Bismarch on the ; bility in teaching theory and practice of social body or Private Organisation. Primarily, the
social factors which affect and action at the duties of the newly formed Germanic statu I medicine. Hence some of the difficulties owner is responsible for fulfilling minimum
society level are needed for preservation of the towards the welfare of its citizens. For the affect the P.S.M. departments are mentioned standards recommended by the Medical
health of the edmmunity has been appreciated first time he coined the word Social Medicine below:—
Council of India for under or post-graduate
at a such later date rather recently that for (of course in German) and spoke that medi
training. It is a notorius fact that many of
(1) The training of an undergraduate has such authorities are not carrying out those
treatment and prevention.
cine was another name for Politics. So
to
be
in
the
class
room,
the
hospital
and
the
Individual action by heads of States in ingrained were the facts of social medicine it Community. All training must be complemen minimum instructions in full. The Medical
different parts of the We ’ \ for health of the his mind, Virchow, the intrepid researcher, tary, to one another. It is clear that guidance Council of India is entrusted by the Govern
citizens are mentioned in history. Even state the real genius, the father of Cellular Patho for such training and the training institutions ment to guide and inspect the teaching faci
action for such sanitary construction for the logy, the discoverer of Foray, the Anthro have to bo concentrated at one place under one lities and examination standards in the Medical
population as the Cloaca Magna are known. pologist and the Politician fought for practice authority. Such unification has not yet taken Colleges. Unfortunately such responsibilities
are not sufficiently fulfilled. So one finds a
But almost all these are products of individual of social medicine.
place in all medical colleges of the country very large number of institutions continue to
action.
From the 19th century every State had beet much to the detriment of teaching the commu- be recognized though they have not fulfilled
The relation between the state and the showing signs of accepting the Philosophy ol (nity aspect of health and the needed services.
its, minimum recommendations.
individuals of the state has been much debated State responsibility and State action for tbr
(2) Staff position in the P.S.M. departments
since the time of Plato. However, it has since health of the individual citizen. During the
. Above certain deficiencies have been pointed
been accepted that the State has responsibility 1st World War and the II, World War their of the medical colleges are very poor. If one out. There is another neglected field where
towards the individuals and they individual intervening period and particularly that follow understands that teaching in the community efforts in proper training can offer good divid
towaids the society which is represented by ing the I Ind World War, medical profession weds a mountain of time, one can perceive end. That is the compulsory post MBBS
the state. A sort of uneasy balance between has been taking more and more interest u th? present shortness of staff even more. It examination traineeship. Much uninformed
the power of the State over the individual regards identifying areas of social responsibi has to be appreciated also that in the teaching criticism can be heard when this training so
citizen in limiting his liberty and the liberty lity and social action for health of the natios of the different subjects which are included wisely introduced by the Medical Council of
of the individual citizen is continuing. The The 1945 San-Francisco Conference declare! under the umbrella of P.S.M. non-medical India comes up for discussion even decrying
recent pleadings before the Supreme Court of that every state should ensure the four ft» teachers should contribute heavily. Such it as wastage of time, and a year’s holiday or
India are continuation of the evidence of the doms for its citizens. One of them being free teachers should be only those who know their a picnic which should be abolished. On the
same dilemma which was evident since civiliza dom from disease. So it is that today it II lubjects sufficiently in order to be able to teach other hand instead of being carried away by
Kudents of undergraduate and P.G. Study.
tion evolved the state.
accepted all over the World that health servia To list them these teachers should be for this unfortunately popular current of despair
Nevertheless, it has been deeply appreciated and medical practice are based not only o? zciology, medical entomology and statistical it is easy to do so rather than to strive against
.re serious thoughts and efforts have
that without state action welfare of the indivi aiding the individual for prevention of itti aethods in Epidemiology and health services. odds
dual is not possible. In the 19th century cure from disease, but also on inducing socu A medical social worker or a statistician on a been directed to it, this period of training
can
be
one
of intense interest and practice of
action
for
the
community
as
a
whole
in
treathere was an upsurge of human thoughts
dericul pay is not the person who can under comprehensive medicine by the trainee students.
lie such teaching.
A model has been developed in the Medical
by
A. K. Niyogi
Department of Preventive & Social Medicine, Banaras Hindu University, Varanasi-5, (U.P.'J
192
the INDIAN JOURNAL OF MEDICAL EDUCA1ION
College, Baroda, by starting a curative and
preventive General Practice unit in the
main teaching Outdoor Hospital. Its success
has been quick and very satisfactory as regards
the understanding of Social Medicine and
practice of comprehend-_ medicine by the
rotating interness.
VOL. XII
NOS. 3 a t
The sum total of effect of these deficiencies
shown above is that the Country is getting
medical graduates we are not modern in their
thought and action and who are unable to
fulfill their responsibility.
These are the problems that are being placed
before the attention of this Association today.
Mobile Rural Hospitals for Rural Health Service
EDUCATION AND TRAINING OF HEALTH PERSONNEL
by
P. K. Duraiswami
Dinclor, Co-ordinaling Agency for Health Planning, 45 South Extn. Part II New Delhi-49
The medical Education needs constant re-crientation according to health needs of the community.
The outstanding requirements to-day are;
(a)
Rural bias; 75% of our population lives in villages and they produce 70% of our
gross national product (GNP)
(b)
Preventive & Promotive aspects over and above curative
(c)
Eantily welfare & planning
All these could be implemented if Teachers from Medical Colleges went to villages for service 67
training. Ear this purpose if we build permanent establishments:
(a)
They would be very costly
(b)
Mobility will be hampered
Therefore, Mobile Training-cum-service Hospitals is the proper answer.
The Government of India has announced that it is intended to establish such one hospital attached
to each of the 105 medical colleges.
Medical education has reached a stage in
its long history, when a departure from the
traditional structure of the past has become
almost imperative not only in developing
countries, but also in developed countries. In
September 1965 it was considered necessary in
Great Britain to appoint a Royal Commission
I to review under-graduate and post-graduate
• medical education in the light of national
jneeds and resources and the Commission has
made valuable recommendations. Medical
; education in the United States of America has
t undergone several changes since the submission
of the Flexner report on medical education in
■ 1910. There is a rsing tide of feeling in the
I Vnited States that medical education in all its
I fhsses is not keeping pace with the wants and
1 seeds of the population it strives to serve,
Conferences on Medical Education
Since our independence a number of
conferences on Medical Education have been
held in our country. During the discussions the
policy on medical education has been criticised
that the under-graduate curriculum is
unrealistic, as it does not meet the great
demands of a developing country with a large
rural population and with the problems of com
municable diseases, malnutrition and popula
tion explosion. As a matter of fact.it has been felt
that the pattern and content of the educational
programme should be so adjusted as to provide
training for the practice of medicine in rural
areas where 75 % of our population lives and
produces about 70 percent of our Gross
Natii nal Product. At present the Clinical
training of the under-graduates and post-
194
THE INDIAN JOURNAL OF MEDICAL EDUCATION
VOL. XlMkoS. 3 & 1 ]
JUl.r- DECEMBER, 1973_
MOBI^RURAL HOSPITALS FOR RURAL HEALTH SERVICE
however, stay for three months, as required by
the Medical Council of India which has fact,
suggested that this period could be extended
to six months with advantage.
195
promptly move into that area and control it
graduates is being built round a frame-work of clinicians actively participate in the tramming i
effectively and the students, interns and the
laboratory and other sophisticated investiga programmes conducted in rural settings, the i
primary health centre staff will thus gain
tions in a city hospital. When these persons training programmes will not yield the best :
valuable
practical experience in controlling
possible
results.
During
the
Third
Conference
'
are placed in working conditions so far different
epidemics. It will be advantageous not only
from those they were used to in the institutions of the Deans and Principals of Medical ■
Thus each clinical teacher will have at the * the students and interns but also to the
where they were trained, they feel utterly Colleges held in Delhi in 1967 under the auspices
most 5 final year students to teach at a session
helpless when they join a Primary Health of the Union Ministry of Health and Family : unlike in the medical college hospital where primary health centre doctors and private
Centre. They soon become complete misfits in Planning, several deans and principals stated ! the nimihci will be much larger. Each teacher medical practitioners in the neighbourhood if
rural areas where quacks flourish on the cre that it would be possible for clinicians to par- i will, therefore, be able to devote individual the teachers hold regular clinical conferences
dulity and ignorance of the population. The ticipate in training programmes carried out in I attention to every student. Similarly each and short refresher courses to enable them to
keep their knowledge up-to-date.
pattern of training in most medical colleges is a rural environment, if suitable residential
intern will he able to gain adequate practical ^It is indeed gratifying that some mobile
still largely oriented to curative medicine, in accommodation and other basic amenities
experience under tlie supervision of his_teachers
spite of all efforts made by the Government of could be provided to teachers in clinical
during his three months’ stay in the mobile hospitals such as the one attached to the
India and the Medical Council of India to lay subjects and preventive and social medicine,
hospital, as there will be no house surgeons, Nagpur Medical Colkge held them regularly
much greater emphasis on the preventive and students and interns in rural areas.
' registrars and assistant surgeons in the mobile at every camp. The interns and students
promotive aspects of health than curative
It must be remembered that construction of
hospital. It is, therefore, highly advantageous working in this mobile hospital also conducted
medicine and thus bring down the cost of buildings in rural areas takes a long time.
to (he interns if their period of stay in Mobile surveys under the supervision of their teachers
medical care in a poor country like ours.
Since the launching of the Primary Health I Training-cum-Servicc Hospitals is increased to for detecting cases of filariasis, and also black
It has been admitted all round that there Centre Scheme in 1952, only 67 percent of the six months, as recommended by the Medical pigmentation due to adulterated cocoanut oil.
existing
5,200
Primary
Health
Centres
have
Council
of India.
The interns and students of the Aurangabad
has been a definite deterioration in the stan
Medical College examined 5,276 persons when
dard of medical education. Apart from the buildings of their own. During the same
All the students and interns will receive
lowering of the standard of general education period it had been possible to provide only clinical training in the Mobile Training-cum- the mobile hospital attached to the college
due to various factors, the-', has been a pheno- about 60 percent of the quarters required by Servicc Hospitals during the forenoon and in functioned in Sillod taluk and found that
the
Primary
Health
Centre
Doctors,
30
percent
56.6 percent of these persons had goitre. This
minal increase in the number of medical
the afternoon they will visit the homes of
colleges from 25 with an admission capacity of of those required by the Public Health the villagers along with their teachers. was later confirmed by the Maharashtra State
less than 2,000 in 1947 to the present figure of Nurses/Lady Health Visitors and 25 persent of The training and service programme which Health Authorities who found out that there
those
required
by
the
Auxiliary
Nurse
Midwives.
was
deficiency of iodine in drinking water.
97 with an admission capacity of over 12,000,
will be closely supervised by the teachers
without a proportionate increase in the num It is for those and other equally important will include the following: (1) work in the The incidence of diabetes, tuberculosis, leprosy
and venereal diseases among tribal populations,
ber of teachers in practically all the medical reasons that we had evolved the multi-purpose
Training-cum-Service
Hospital out-patient and in-patient sections and in the has been recorded by supervised surveys con
colleges. It is proposed to set up some more me Mobile
laboratory of the mobile hospital, (2) ante ducted by interns and students working in the
dical colleges before the end of the Fourth Five Scheme.
natal clinic, (3) well-baby clinic including mobile hospitals attached to Osmania Medical
Year Plan when the number of admissions will
immunisation, (4) imparting health education College, Hyderabad, Baroda Medical College
increase to about 13,000. Assuming that 11,000 Mobile Training-cum-Service Hospital scheme
including motivation for family planning, (5)
\/
to 12,000 medical graduatesand 3,000 to 4,000
I will now briefly describe the Scheme as it specific morbidity surveys to ascertain disease etc.
post-graduates will qualify every year after the was originally evolved and later indicate the
Some valuable lessons have been learnt
end of the Fourth Five Year Plan, job oppor modifications that have been found necessary and malnutrition prevalence, (6) collection of
statistics, (7) involvement in the national during the working of the Mobile Trainingtunities should be made available for them in in the wake of the experience gained during I vital
programmes for eradication or control of cum-Scrvice Hospital Scheme which was
rural areas both in the public and private the working of the sixteen Mobile Trainingsectors to forestall unemployment and “brain cum-Service Hospitals set up so far. Each communicable diseases and the family plann launched by the Govt, of India in October
ing
programme
under the supervision of State 1970. For want of time I will deal with one
drain”, as over 70 percent of the existing Mobile Training-cum-service Hospital which
doctors who practise modern medicine are is attached to a Medical College is a 50-bed, Public. Health and Family Planning officials or two important ones here. Out of 50 beds,
practising in cities, large and small towns. It adequately equipped tented hospital. It u and (0) assisting in the implementation of 20 beds had been originally ear-marked for
is, therefore, necessary to orient the undergra provided with an electric generator so that the school health and mid-day meal programmes. ■ tubectomy cases. It was observed in almost
all the mobile hospitals that soon after a
duates, interns and post-graduates to the cura hospital can function in remote rural area
The active participation of the medical, h :tal had started to function at a new Camp,
tive preventive and promotive aspects of rural where there is no electricity. The hospital h*i
nursing and paramedical personnel of the
out-patient attendance and the number of
community medicine to enable them to work in also a mobile X-ray unit. Adequate accom Primary Health Centres in the vicinity is very
admissions
high but they tapered off
rural areas.
modation is provided in tents to all the staff essential, as it will not only ensure their proper after 8 to 10were
weeks. It was found advantageous
In this connection I would like to draw your members, students and interns. A t:acha orientation to the curative, preventive and in several ways to utilise almost all the beds
community for tt’bectomy cases at this time. In this way
attention to the widespred dissatifact:on of the from each of the departments of medicine, promotive aspects of rural
present method of training of the under surgery obsterics and preventive and sociii medicine but also enable them to follow up it wa. possible to reduce the number of beds
graduates,
interns
and
post-graduates medicine will stay in the hospital with 10 W the cases treated in the mobile hospital after in a mobile hospital from 50 to 25 and thus
in all aspects of Rural Comunity Medicine. 15 final year medical students, 10 to 12 to nun. st moves to the next Camp after a period of bring down the expenditure for each mobile
Many teachers in Preventive and Social ing students (with thejr own sister tutor) fora J to 4 months, In the event of an outbreak hospital. At a meeting of the Consultative
Medicine have pointed out that unless month, by turn. Ten to fifteen interns will, «f an epidemic th? mobile hospital can Committee of the Member? of Parliament
196
vol. xn
THE INDIAN JOURNAL OF MEDICAL EDUCATION
fpr the Union Ministry of ^islth and Family
Planning held on 20th October, 1972, the
Minister is reported to have, told the members
and eventually all the 105 Medical Colleges
would be provided with such hospitals.
of assistance
to Voluntary Organizations runging hospital!
and dispensaries in rural areas, job opportuni-
increased.
Health-Co-operatives
The Co-ordinating Agency is also keenly
interested in providing technical guidance to
. As mentioned already, it is not enough if all concerned in setting up “ Health Co
doctors are oriented to rural community medi operatives” in rural areas with the help of
cine. Simultaneously efforts should be made those villagers who can afford to pay for their
to create job opportunities for them in rural health and medical care. It is proposed to
areas to prevent unemployment and “ brain start a Health Co-operative for the benefit of
drain”. It is proposed to increase the number about 4,000 families of the Bangalore Dairyof primary health centres and upgrade a Co-operative for the benefit of about 4,000
certain percentage of the primary health families of the Bangalore Dairy Co-operative
centres into 25-bed hospitals and provide them Union in Kalur and surrounding villages,
with specialists during the Fifth Five Year abovt 60 Kilometres from Bangalore. St.
Plan. As I mentioned a few minutes before, John’s Medical College will be involved in this
the Government of India are contemplating programme and it will provide the services of
to extend the Mobile Training-cum-Service its specialists as well as facilities for hospitali
Hospital Scheme to involve eventually all the sation of deserving cases in the Medical College
105 Medical Colleges. If this is supplemented hospital in Bangalore. In return, St. John’s
by harnessing the facilities provided for health Medical College will utilise the Rural Health
and medical care in rural areas by the exist Co-operative for orienting their students and
ing hospitals and dispensaries run by all interns to rural community medicine to enable
Christian and non-Christian Voluntary Organi them to practise in rural areas. Exploratory
sations and also by providing the required talks have also been held with Dr. V. Kuden,
number of mobile dispensaries per district, it Managing Director of the Kaira District
will be possible to ensure health and medical Co-operative Milk Producers’ Union. He it
care to rural people living even in remote keen to start a Health Co-operative to serve i
areas. At present there are about 900 Mobile population of about 25 lakhs living in about
Service Units for vasectomy and insertion of 700 villages. If this scheme succeeds, it can
I.U.C.D. Each unit has a doctor, a nurse be extended to five other Milk Producers'
and an attendant and a vehicle. With an Unions in Gujarat alone and later to other
additional expenditure of about Rs. 3,000 per. States. I need hardly, add that when the
“ Mobile Service Unit ” per annum for drugs scheme is fully implemented it will provide job
and dressings health medical care can be opportunities to a large number of doctors,
provided to the rural peopi... They will accept nurses and paramedical personnel.
family planning more readily if each family
In so far as private practice in rural areas
can be sure that its first two children will
survive by better health care including is concerned professional bodies such as
the Indian Medical Association, the Associ Uion
immunisation.
of Surgeons of India etc., are making efforts
The Co-ordinating Agency for Health to enable doctors, either singly or in groups to
Planning is making strenuous efforts to bring start private practice in rural areas and loans
together all Christian and non-Christian on easy terms are available for them from
Voluntary Organizations in each State with a Nationalised Banks. Some State Governments.
view to co-ordinating their activities for supple are also offering stipends for fixed periods and
menting the efforts of Government in provid other incentives to doctors who are willing te
ing health and medical care to our large popu- set up private practice in rural areas. Docion
latien. The Agency has already sueeeeded may stay in those rural or semi-urban areu
in its efforts in 11 States. If for the Fifth Five where basic amenities such as, residcntisl
Year Plan Government can work out a pattern accommodation, potable water, facilities fa
Job Opportunities for Doctors in Rural Areas
}ULT- DECEMBER, 1973
MOBILE RURAL HOSPITALS FOR RURAL HEALTH SERVICE
197
collaboration with the uVlICEF
education of their children are available and
purchase scooters, motor-cycles or jeeps with
loans from Nationalised Banks to cover as
many villages as possible They should make
it a point of providing to the rural population
preventive and promotive health care in
addition to curative medical care. If Govern
ment can provide them with the necessary
vaccines, and drugs for treating cases of
malaria, tuberculosis and leprosy free’ of
charge, it will ensure successful implementa
tion of our National Programmes for eradica
tion or Control of Communicable Diseases.
In conclusion, I would like to state that the
Mobile Training - cum - Service Hospitals
attached to Medical Colleges have an import
ant role to play in orienting teachers, students
and interns to rural community
medicine.
It is bound to take quite some time to construct
the required buildings for 25-bed upgraded
primary health centres and for residential
accommodation required not only for the
upgraded primary health centre staff but also
for the teachers, students and interns who will
stay in these centres for specified periods. Early
steps should be taken to create enough job
opportunities in rural areas for a large number
of general medical practitioners and specialists
who qualify every year from all the Medical
Colleges, to forestall unemployment and
“ brain drain ”,
J.t.\'UAltr-JUNE 1974
A Model for Introduction of Social Science Through
Teaching of P-.mily Health Care—Innovations at Lucknow
*
by
B. G Prasad, m.d.. d.p.h., d.t.m., f.a.m.s.*
Regional Adviser in Comnunity Health Services, W.H.O., SEA RO New Delhi,
Si? 44
S. B. Nayar, m.s.w., ph.d.
Lecturer in Medical Social Work, Department of Social and Preventive Medicine,
King George's Medical College, Lucknow
A model of social science teaching to undergraduates through family health care is described
Commencing at the preclinical stage where introduction to basic elementary knowledge is given, it is
carried over to paraclinical years with assignment of two families to students for studying real life
situation. This is followed by clinical integrated teaching in social paediatrics and social obstetrics
and finally during internship training by work in rural and urban families in order to arrive at
community diagnosis and undertake community action.
Introduction
I
The emergence of a complex social order
leading to the multiplicity of ailments that
could no longer be considered exclusively or
ganic, has necessitated a combined (epidemio
logical and sociological) approach and concep
tual changes in medicine and planning. Payne1
has very rightly remarked l< We have tended
to regard man simply as a biological animal
with biological needs....... We have largely igno
red the fact that he is a social animal and that
it may be at least as important to his health to
satisfy his social needs and behavioural urges
as his purely biological ones ”. To achieve this
some formal training in sociology for the
physician is desirable (Reader’, Freeman ct al.’,
Saunders', Royal Commission on Medical Edu
cation'). An increasing number of medical
educationists (Reader
,
*
Morton and Cottrell’,
Reader and Gos/, Goss and Reader
)
*
regard
the sociologist as an integral part of training
programme. But choosing the methodology
for such a training programme poses a big
challenge to the teaching of social and preven
tive medicine. The concept of family health
care has become the embodiment of these
newer trends in medicine-care replacing
cure, health replacing illness and family/com
munity practice shunting off individual
practice. Introducing this concept before the
students in a realistic and practical form
as a felt need of community, requiring
different skills at different planes of practice is
the job which departments of Social and Pre
ventive Medicine teaching community medicine
have to achieve. In such an approach a har
monious blending of the techniques of medicine
and social sciences would give the student a
comprehensive understanding of man in
health and sickness and an intimate acquain
tance with his physical and social environ
ment (General Medical Council’). Although
opinions may vary as to the feasibility
of such an integration of two disciplines
in medical curriculum, its imperative need
cannot be sincerely questioned. It no doubt
means some basic changes in teaching schedule
and methodology but that should not be grud
ged. Institution of medicine is a social organi
zation after all and it,.is a truism about such
organizations that ‘ one can make big changes
only by making big changes ’ (Becker and
Geer10).
Model at Lucknow
It was felt that the social science inclusion in
the basic medical curriculum should cover all
Presented at the University Grants Commission Institute for Teaching of Social Sciences in Medics!
policies, New Delhi, October 6—11, 1969.
the main areas of sociological application in
medicine, viz., social etiology, ecology of
idiscase, social . components in therapy and
stcluibilitation, medicine as a social institution, sociology of medical education (Kendall
I and Merton"). Most of the direct contnbutions of sociology can be placed under
: these topics. Not only prevention, diagnosis,
prognosis or treatment were looked into for
sociological contributions in a general educa
tive approach on care, but the very institution
! of medical practice, the practitioner, the set
ting of practice and the patient, as components
affecting care, are included. This includes an
understanding of disease, its etiology, ecology,
community processes in the evolution of disease
pathology, impacts of disease on social spec
trum, total responsibility of the physician in
the said spectrum, medical care as part of
human welfare measures, the evolution and
organization of the complex institution of hos
pital, the peculiar characteristic of organized
care, other components in care, like, therapeu
tic relationship, utilization of care services by
the society, changing needs of community,
community practices conducive for then----- tic
efficacy etc. The curriculum as has beet, plan
ned, thus is a comprehensive one to include all
the details from the introduction of basic and
elementary social sciences to the applied as
pects in care and to changing community needs
in terms of care practices.
The teaching programme in family health
care is slowly and gradually introduced to the
medical students right from the impressionable
phase of pre-clinical period to extend through
|Mra-climcal and clinical years to internship
In pre-clinical years—In the pre-clinical years
during second and third semesters 30 lectures
and one psycho social clinical demonstration
conference are given in basic social sciences i.e.
dernentary sociology and psychology (Prasad
and Jain1*). Lectures in the second semester
include society and culture, man and his envitvnment and concept of human ecology, social
iiutitutions, social disorganizations and social
pathology, socio-economic factors affecting
health, family as the unit of medical care,
social anatomy, social physiology, etc. These
kcluics stress on the need to study man as a
member of the society, his motivational be
haviour, and the role of society in patterning
,ums and attitudes with a view to bring to
A MODEL OF SOCIAL SCIENCE TEACHING
the fore the influences affecting the receipt of
care, and medical care as part of the social as
piration. The need to see man in his natural
environment is highlighted and family affec
ting medical care and illness, and individual
receptibility to care are stressed, with an em
phasis on environmental factors affecting
disease process, causation and the impacts of
the same upon the social settings.
In the third semester the students’ attention
is focussed to human endeavours in care, and
hospital as a social institution is presented
before them. At this stage they are also given
ideas on life cycle of man, family life, and
principles underlying it. At this level lectures
are also imparted on population problem,
occupation and health, economic value of
health and economic loss due to ill-health,
social anatomy and physiology of a village as
typical replica of the Indian community,
beliefs and customs, folk medicine and social
structure. It is brought to bear on the medi
cal students that the folk medicine of a people
is not a random collection of beliefs and
customs but that it constitutes a fairly wellorganized and consistent theory of medicine.
It throws light upon the. nature of man’s
relationships to his environment and it enables
the members of a cultural group to meet their
specific health needs in ways at least minimally
acceptable (Saunders'). This, it is expected
will give the student an idea of normality and
abnormality in divergent cultures so that as
a future physician he can adjust to and under
stand the folk needs instead of practising
a correct but theoretical approach ; it is in
a way a training in the attempt to get the
physician down to earth in his practice.
The picture with the above lectures becomes
comprehensive—human being, the patient,
society, the spectrum of illness, institutions
catering to care and attitudes affecting human
being, environment, the organization in charge
of care and social and individual implications
and aspects of illness. Other than these,
special lectures are arranged on psychology
with an emphasis on behaviour, personality
and social psychology.
Para-clinical years— Once the_contrast bet
ween the folk medicine and scientific medicine
is brought to bear on the student and once he
understands the community and its aspira
tions; the student when he enters the fourth,
JASl'Altl-JUNE 1971
MODEL OF SOBIAL SCIENCE TEACHING
•nd mlegiatcd teaching of social obstetrics and of observation and advisory. Here he func
so«i.d paediatrics. Clinical situations are tions as an apprentice doctor and gets his
chosen from neonatal, obstetrics, gynaecology real training in medicine to function as
fifth and sixth semesters in the para-clinical
and paediatric clinics and social etiology, part of the general community welfare
years is sent to the field of his practice for
socio-diagnosis and social therapy and rehabi programme. The picture of a primary health
observational studies. The student should
get as much opportunity as possible to study gets familiar with the need for family based litation are assimilated with regular clinical centre as part of the community development
health and disease in its natural setting, so practice of medicine, gets an opportunity to and therapeutic programmes. At a two-hour h'oek is brought before him and he is taught
that the real picture is completed before him see multiple etiology of disease, sees the session, the student presents the history, the uo play his role in the wider social obstetrics
Specific assignments in social
at this particular time when he has started to patient as a person, his role in the family, medical social worker supplements it by the millieu.
be involved with practice of medicine in influences of the family upon health and ill social history collected by her during the week, paediatrics and social obstetrics and family
hospital. The students are also taught the ness, the spread of disease in the family trellis, the clinician introduces the problem and dis planning are given to him in which he
principles of health education early in fourth the need to control illness/maintain health at cusses its clinical aspects and two teachers from acts as the incharge of family units with a
semester (Bagga and Prasad1’). The students are the family level and the. ineffectiveness of the Social and Preventive Medicine department view to collaborate in the general health and allotted two families (Prasad1*) at this time, one solitary
solitary medical team in the fight against|(<me being a social scientist) supplement the welfare programme, creating in him a social
in health (Prasad and Nayar18)—a family illness and preservation of health. The student! knowledge, pointing towards completion of sense, getting him actually involved in not only
having a mother with a new born infant, and comes to think about the comprehensive healthscare which extends beyond the hospital. medical care, but also in general family welfare
the other in desease—a family having a case of care as should be practised in the completion! Bearing and rearing practices and beliefs and services (which are being introduced on a
pulmonary tuberculosis (Prasad1’).
The of care ; the relief measures which form part! customs in health and disease are brought out. countrywide level in the Fourth Plan). The
former family study spreads throughout the of care and hitherto considered purely welfarei The acceptance and rejection of scientific medical aid, the families get, are being given
fourth and fifth semesters while the latter is measures are integrated in a total approach! medicine is discussed. The student is taught to them as part of the general community
restricted to the sixth. One family per student with the necessary sociological skills and techl to think epidemiologically and socially in his welfare measures. The interns arc to function
(the first) is given for advisory health care and niques involved in an ideal medical care-| practice. The importance of prevention is dis- as community physicians and welfare workers
one (the second) for analytical study of the they make a social science approach to the cu.-sed. Health education techniques, family at large, bringing with them family welfare
problem of illness, the role of the student problem of illness, rather see medicine as life advices, case work therapy, etc., are used measures (including family planning), applied
form of applied biological science. Muck in the clinical situations in care in modifying nutrition programmes and domiciliary midwif
being restricted to adwsory level.
more he learns through the teaching of family care practices. The two hour exercise in a ery and immunisation services. The social
SJde by side, the socio-clinical demonstra health care about ‘ man as a whole’, 1 man hi joint and integer ted teaching, twice a week, is paediatrics and obstetrics planned at the under
tion conferences (Prasad and Nayar1’) which _____
____ ...
____ health,
_____ , ’ _.ij
disease,’, ___
the ‘rpublic
in tpublic
tha to
t answer the four questions (1) what is the graduate clinical level extends to the internship
start in third semester are continued in the ‘multifactorial causation ’, the ' totality irl present condition ? (2) how the condition has le-el for active involvement in real life situa
para-clinical years on diseases such as tuber medicine, ’ ‘ human relations ’ particularly theJ arisen
’ “? (3) ’how could
1J it ’have 1been prevented
*“'1 ?3 tions in community practice.
culosis, leprosy, venereal diseases, diabetes,
J and (4) what is its management ?
physical handicaps (caused by smallpox, deaf doctor patient relations, and the importance ol
The families allotted to each intern for com
ness and poliomyelitis) and other situations ' health education ’ and ‘ continuity in care
'
Internship period—The health care as should pleting the socio-medical investigation, analysis
like accidents, which call for a community in every day practice.
be practised by the physician in the communi- and presentation are discussed in the fortnightly
approach besides tlie utilisation of the availa
The students learn a lot about a propci, (y> *rurai anj urban, is exposed to the interns seminars on individual families and group data
ble medical or surgical techniques. Through
these the total need of an illness situation is therapeutic relationship which facilitates cart Jur;ng the compulsory rotating internship of 3 on a number of families (usually about twentyacceptance,
because the approach '.?
to -be
the j months placement in the community in the five) covered by a batch’ of interns. -Health
—e, be??""
impressed upon the students and they are and creep'.?
made to realise that in absence of supplemen families is upon self initiative and they get an; department of Social and Preventive Medicine. education and other action programmes are
tary social therapy, drug therapy alone may opportunity to develop skills of their own in i Here again assignments in comprehensive care undertaken for specific socio-medical problem
not be effective. These demonstration con- handling people under the social scicntist'i arc given and a group of families (3 rural and in a village for community diagnosis and
sereness have an active participation of social supervision. The value of doctor-patient rela 10 urban) are assigned to each intern for inves action (Prasad18).
tionship as a necessary and valuable ingredient tigation, social and clinical diagnosis and
fcience teacher.
in therapeutic endeavour is brought to bear management of care and therapy at the Rural Discussion
Clinical Years—The fundamentals of social upon the students as a result of social science Health Training Centre, Sarojini Nagar (inclu
The model of introduction of social science
. science education is imparted not only through education. Besides the training aims at making ding its Primary Health Centre) and at the through teaching of family health care at
the family health care studies but also through the student a community physician as against Urban Health Centre, Alambagh. The Urban
•cknow is developed and integrated in the
joint integrated teaching sessions in social the clinical practitioner of individual medicine Health Centre has been specially developed as total.teaching through a graded progamme to
obstetrics and social paediatrics twice a week The lectures on social sciences and the training a teaching model of comprehensive family be absorbed through different phases.
where attempt is made to present disease as imparted by the social scientist and health ' hcaJlh care in an urban community (Gupta 18).
Stage I (Pre-clinical) —The introduction of
a social pathology. These sessions are held educationist is hoped to inculcate in them a ’ Family practice of medicine is stressed and
with students of seventh to ninth semesters sense of community and team work feeling in [. social, preventive and curative components in students to basic elementary knowledge in
social
sciences supported by a psycho-socioinvolving the participation of teachers from the practice of medicine.
therapy and rehabilitation are highlighted and
departments of Obstetrics and Gynaecology,
the intern is made in charge of the programme clinical demonstration.
Social obstetrics and social'paedialrics in famil} I at against his assignment in the undergraduate
Paediatrics, and Social and Preventive Medi
Stage II (Para-clinical) -The assignment of
cine and the medical social worker. The case health care—Maternity and child health care ; curriculum where the student’s role was more two families to the student (after he has been
is discussed in all its aspects - clinical, social and the problem of the vulnerable groups d
mother and children is presented through joint j
find psychological.
12
THE INDIAN JOURNAL OF MEDICAL EDUCATION
vol. xin //os. i <i
!
shown the reciprocal relationships that tic lit
with the culture. The ‘life-history approacf
to medicine help reveal how individuals J
groomed and fitted into culturally defirf
situations and forced to fulfil their social rui,
and often can show at what price, adaptatii
*
are made; it becomes standard data to stuj
the predicaments in which individuals fit
themselves as a result of rapid social chan®
when they are caught in cultural cross-curral
that impinge upon them (Simmons a‘«
Wolff31). The social science focus on the ■
dividuals and group processes and the real
trends in medical sociology on the role of pcpectives in medical care and problems |
medico-social convergence, all tend to plJ
medical practice in a more practicable Irt
and make it more humane and applied. Tt
aim of modern medical education should I
none the less than introducing these soa
science concepts in the betterment of care.
THE INDIAN JOURNAL OF MEDICAL EDUCATION
taught the principles of health education) to
study the real life situations and to provoke
him into thinking not only medically but also
socially and epidcmiologically.
Stage III (Clinical)— The integrated teach
ing sessions of clinical, social and preventive
obstetrics and paediatrics on cases to present
the ‘totality of medicine’ and the need for
‘ comprehensive health care ’ in daily practice.
Stage IV (Internship) - In this period there is
actual assignments in family care. There is
allotment of 3 families in rural and 10 families
in urban community for collection of detailed
socio-medical data for analysis, tabulation and
discussion in fortnightly seminars and motiva
ting these families by health education for
acceptance of scientific medical care, including
improvement of environmental sanitation,
maternal and child health and family planning
services, immunization, and other health pro
motional and preventive measures. Allotment
is’also made of socio-medical problems for in
vestigation and action in a village. Indepen
dent work and improvisation is learnt in these
community assignments, and also the metho-:
dology of ‘community diagnosis’ and commu
nity action by directly working with and
among the people through team work method
in health care.
In short, practice of medicine as a social
science is visualised throughout the teaching
programmes in family health care. The failure
of clinical medicine to meet the .specific and
overall needs of the individual and community
is well recognised through these programmes.
Practice of medicine cannot be confined to
laboratories or wards—the need to practise it
in human laboratory is no less important. It
is time one has to understand that man is the
core of medicine. “ Looking at man with the
naked eye, he is c Individual. Studying man
with microscopes, both visual and electronic,
he is biological. Stepping back and viewing
man through a telescope, he becomes a small
unit of society. All three perspectives are re
quisite for full comprehension”. (Stieglits30) It
is felt that a social science approach to medicine
will modify the errors in its present day prac-_
tice. The scientific advancements in sociology
are making it sufficiently equipped to offer a
clarity of vision to the modern medicine. The
new interests in the individual as a person has
References
1.
Payne, A.N.M. in Pan American Hat
Organization Scientific Publication X
123, p. 3, 1965.
2.
Reader G. G. in Hand Book of Media
Sociology (edited by H. E. Freenuf
S. Levinc anchL. G. Reader); pp. 14
Prentice-Hall, Inc. Englewood Oil
New Jersey, 1963.
3.
Freeman, H. E., Levine, S., Read '
L. G. in Hand Book of Medical Soc i
logy, Prentice-Hall, Inc. Englewo'
Cliffs, New Jersey, 1963.
4.
Saunders, L. in Cultural Differences! r
Medical Care, Russel Sage, Foundati:
New York, 1954.
5.
Royal Commission on Medical Edu i
tion in Report of the Royal Cominisi g
on Medical Education 1965-68, p. 1! L
109, Her Majesty’s Stationery Off,
1968.
Morton, R. K., Cottrel, L. S., in Sa {
logy Today, pp. 229-246, Basic Ba
Inc., New York, 1959.
' 7. Reader, G. G. Goss, M. E. W. in To |
sactions of the 4th World Congrea I
Sociology, 2, pp. 139-152, 1959.
;
6.
8. Goss, M. E. W., Reader, G. G. in Sa i
Problems, 4, pp. 82-89, 1959.
jANUAHT-JLWli 1974
9. General Medical Council Recommen
dations as to Basic Medical Education,
p. 9, 1967.
10. Becker, H. S., Geer, B. in Hand Book
of Medical Sociology (edited by H. E.
Freeman, S. Levine and L. G. Reader),
p. 184, Prentice-Hall, Inc. Englewood
Cliffs, New Jersey, 1963.
11. Kendall, P. L., Merton, L. K. in Pati
ents Physicians and Illnesses (edited by
E. G. Jaco.), The Free Press of Glencol,
Inc., New York 1958.
12. Prasad, B. G., Jain, V. C.: Teaching of
Behavioural Sciences in the M. B. B. S.
course. Ind. Jour. Med. Edu., pp. 8,
198-201, 1969.
13. Bagga, S. L., Prasad, B. G. : Health
Education Training of Basic Doctor.
Ind. Jour. Pub. Health, 8, 97-100, 1964.
14. Prasad, B. G.: Family Studies by
Students —Innovations at Lucknow.
Lancet. 757-758, 1960.
15. Prasad, B. G., Nayar, S. B.: Familv
Study on the Growth and Develops . ..
i
MODEL OF SOCIAL SCIENCE TEACHING
15
of an Infant with its mother. Ind. Jour.
Paed., 30, 446-453, 1963.
16.
Prasad, B. G. : Pulmonary Tuberculosis
in India. Br. Jour. Dis. Chest, 55, pp.
169-184, 1961.
17.
Prasad, B. G.; Nayar, S. B.: Clinical
Conference Demonstration in the teach
ing of Social and Preventive Medicine.
Ind. Jour. Med. Edu., 4, 25-29, 1964.
18.
Gupta, S. C.: Family Care at the Urban
Health Centre, Alambagh. Jour. Family
Welfare, 12, 39-45, 1966.
19.
Prasad, B. G.: An approach to intern
ship programme in Social and Preven
tive Medicine. Ind. Jour. Med. Edu., 5,
484-488, 1966.
20.
Stieglits, E. J. in Social Medicine Its
Derivations and Objectives (edited by
Iago Galdston), Commonwealth Fund,
pp. 87-88, 1949.
21.
Simmons, L. W., Wolff, H. G. in Social
Sciences in Medicine, Russel Sage Foun
dation, New York, 1954.
TEACHING PATTERN OF SOCIAL AND PREVENTIVE MEDICINE
IN MEDICAL COLLEGES
by
Dr. J. S. Mathur,
Dr. S. M. Marwah,
Dr. B. K. Trivedi,
Sri N. S. N. Rao,
Professor of Social & Preventive Medicine, G. S. V. M. Medical College, Kanpur.
Professor of Social & Preventive Medicine, College, of Medical Sciences, Varanasi.
Reader in Social 13 Preventive Medicine, S. N. Medical College, Agra.
Statistician, College of Medical Sciences, Varanasi.
Trends in medical education have been colleges are not equipped with the knowledge of
changing and more emphasis has been placed basic doctor to serve in the community.
on comprehensive health care for the individual
For the first time, the Health Survey and
and the family in the community. During the Development Committee (1946), advocated for
past two decades there has been considerable a change in medical curriculum, in medical
rethinking regarding the curriculum content colleges in India, to provide undergraduates
and methodology of teaching in medical educa training in comprehensive medical care and
tion at the undergraduate and postgraduate social medicine. The subject of Social and
levels. The teaching of “ Hygiene and Public Preventive Medicine had variable growth in
Health” in the old medical curriculum was different medical colleges in the country. The
gradually changed in relation to social needs of departments varied in medical curriculum,
the community, with the result in the recent teaching, staffing pattern, allotment of teach
years newer concept developed in the teaching ing hours, facilities for field training, examina
of preventive medicine. This has emerged in the tion pattern etc. which lead to the development
concept of Social and Preventive Medicine.
of individual department in its own fashion.
The present article has collected information
The teaching and organisation of Depart from different medical colleges on the multiple
ment of Social and Preventive Medicine has variables in the subject.
changed considerably during the last 10 years.
A questionnaire for collecting information
This subject has suffered from developmental
care, attention, and uniformity in comparison regarding organisation and teaching of Social
with the older disciplines in the medical faculty and Preventive Medicine was developed and
in different medical colleges. During the last sent to the departments of Social and Preven
decade due to non-uniform development of the tive Medicine of 84 Medical Colleges in the
speciality, the impact of the departments does country, during the month of November 1966.
not appear distinct with the result that the The proforma thus sent contained questions on
subject in different medical colleges has total admission capacity, duration of teaching,
hours of teaching, syllabus etc. Two reminders
suffered.
were sent to the departments from where the
It is important that the concept of Social information was not received within a reason
and Preventive Medicine should be well under able period.
Out of eighty four medical
stood by all medical persons including general colleges only forty five (53.57 percent), sent
practitioners, specialists and administrators. their reply to the questionnaire. A similar ques
This can be achieved, by radical changes in tionnaire was sent to different medical colleges,
medical education, uniformity in undergradu three years back (1963) and at that time only
ate medical curriculum and methodology of sixteen colleges showed a positive response.
teaching. Non-uniform and irregular develop The information then collected was inconclu
ment of the subject in the undergraduate sive and incomplete and hence has not been
course affect the postgraduate education. Due included in the present study. The reason for
to haphazard development of the departments low response in 1963 might be due to the fact
of Social and Preventive Medicine the young that departments in different medical colleges
graduates qualifying from different medical were not fully developed.
48
the Indian journal of medical education
VOL. X.
NO. 4.
teaching pattern of social and preventive medicine
December, 19Ji
49
Table II
OBSERVATIONS AND DISCUSSION
Duration of M.B.B.S. course in different Colleges
ADMISSIONS :
The admission capacity per year of different
medical colleges varied. It ranged between 50
and 200 students each year (Table I). All these
medical colleges are recognised by Indian
Medical Council. Thus we see that only 18.2
percent colleges were admitting less than 100
students. The variable admission capacity of
Duration in years
|'______
Colleges
No. of admissions
Number
75
Percent
2
4.6
6
13.6
100
8
18.2
125
4
9.1
150
13
29.5
175
3
200
Total
33
7
4
1
73.3
15.6
8.9
2.2
45
100.0
TEACHING CURRICULUM :
The teaching of Social and Preventive Medi
cine is mainly grouped into theory in the form
of didactic lectures, practical in laboratories
and field visits (Table III). There has been no
uniform pattern of teaching the subject in dif
ferent medical colleges. The subject in theory
classes was taught for varying hours in the
majority of the colleges (83’8 per cent) the
theory lectures in the subject varied between
100 to 200 hours, during the entire period of
preclinical and clinical curriculum. Indian
Medical Council (1962) recommended a mini
mum of 166 hours for theory lectures in Social
and Preventive Medicine during entire medical
curriculum. Thus only 43.1 per cent of the
respondent medical colleges were following
the recommendations of Medical Council of
India.
Table III
Pattern of Teaching Social & Preventive Medicine during entire medical curriculum
Duration (in hours)
6.8
8
18.2
*
44
100.0
M.B.B.S. COURSE:
adhering to five year course. But 11.1 per
cent medical colleges were spending more than
five years period for this purpose (Table II).
These institutions did not clearly report whether
this period is inclusive of premedical course or.
is exclusively being utilised for the teaching of
medical subjects.
No. classes
25
50
75
100
125
150
175
200
225
250
250 &
Total
Field Visits
Practical
Theory
* one college has not stated its admission capacity.
The total period spent for teaching and
training the undergraduates was not uniform in
all the colleges. Of the total respondent colleges
73’3 per cent had accepted the recommenda
tion of the Indian Medical Council and were
running M.B.B.S. course for 4| years period.
15'6 per cent were still (at the time of study),
Percent
Total
Distribution of Colleges according to the admission capacity
'
Number
4.6
5.0
5.6
6.0
Table I
50
_______
Colleges
different medical colleges depends on a number
of factors like, the requirements and resources
of the State, availability of equipment, teaching
staff etc. In none of the medical colleges 77 the
student-staff ratio as recommended by Indian
Medical Council existed.
No.
Percent
No.
Percent
No.
Percent
_
_
__
1
8
7
8
6
7
2
2
2
—
—
—
2.3
18.6
16.3
18.6
14.0
16.3
4.6
4.6
4.6
14
12
11
2
4
32.6
27.9
25.6
4.6
9.3
—
—
—
—
—
15
19
4
5*
—
—
34 9
44.2
9.3
11.6
—■
—
—
—
—
—
—
—
—
43J
99.9
431
100.0
43J
100.0
i Two colleges did not send information regarding it.
• Include one college with over 200 field visits.
■
—>—
—
—-•
—
—
■ ’■
?
50
THE INDIAN JOURNAL OF MEDICAL EDUCATION
VOL. X.
XO. 4.
Practicals in the subject are not held at all in
32’6 per cent of the medical colleges. In rest
of the medical colleges (67’4 per cent) practicals in the subject are held for a varying period
ranging between 25-100 hours. Indian Medi
cal Council recommended a total of 101 hours
for practicals and seminars.
country ” held in September 1965 under the
auspices of the National Institute of Health
Administration and Education, New Delhi,
recommended that in order to teach effectively
Social and Preventive Medicine in the commu
nity, the rural and urban field practice areas
should be provided with adequate staff as pait
However the field visits were being organised of Social and Preventive Medicine Department.
in varying number by all the departments of It further recommended that during the under
Social and Preventive Medicine of all the res graduate period the student should spend
pondent medical colleges. Nearly 89.1 per cent adequate time in the urban practice field and
of the departments were arranging upto 50 should have exposure to the rural practice field
hours field visits. In the remaining 20.9 per as well.
cent colleges field visits upto 100 hours were
arranged. It is clear from the table that now Preclinical Teaching:
more emphasis is being laid on practicals and
Social and Preventive Medicine is taught
field demonstrations for training basic doctors both in preclinical and clinical years, therefore
in comprehensive medical care.
The con the teaching of the subject was further analy
ference on “ Teaching of Social & Preventive sed on the basis of its teaching in preclinical
Medicine in relation to the health needs of the and clinical years (Table IV).
Table IV
Duration of Teaching Social & Preventive Medicine at various stages of curriculum
Theory
Duration (in hrs.)
Not taught
10
25
50
75
100
125
150
175
200
225
250
250 &
Total
Practicals
i
Field visits .
Preclinical 11
Clinical
Preclinical 1| Clinical || Praclinical | Clinical
No. Percent | No. Percent | No. Percent No. Percent 1 No. Percent! No. Percent
----—-------- -————.—:------------ -----
24 . 55.8 —
— 39 90.7 15 34.8 39 90.7
2 4.65
2
4.6 —
—
4
9.3
4 9.3 2
4.65 3 7.0
8 18.6 —
— —
—
7 16.3
2
4.65 10 23.3
8 18.6
1
— 11 25.6 —
2.3 —
_ 19 41.1
1
2.3
1
2.3 —
—
__
—
3
7.0
5 11.65
—
— 10 23.3 —
—
_ 3 7.0
3
7.0 _
—
—
7 16.3
—
11 25.6 —
_ __
_
9.3 —
—— —
-1 ■ —
-_
—
—
5 11.6 —
— _
_ _
—
— —
rf- —
— __
_ __
1 2.3
sc.. ■
—
1
2.3
—
3
7.0
■ —
— ■■ ■ i
—.
—
43*
99.9 43
*
‘ Two colleges did not give this information.
100-0 43
*
100.0 43
*
100.0 43
*
100.0 43
*
TEACHING PATTERN OF SOCIAL AND PREVENTIVE MEDICINE
DECEMBER, 1971
51
During the preclinical years, of the total Clinical Teaching:
Majority (73.8 per cent) of the medical
respondent medical colleges 55.8 per cent were
not teaching the subject of Social and colleges were devoting 100 to 200 hours for
Preventive Medicine in theory. 23.2 per cent theory lectures during the entire clinical period.
department of Social and Preventive Medicine 4.6 per cent of the colleges utilised less than 75
were devoting less than 25 hours for theory. hours for this purpose. Four colleges were
Only 18.6 percent respondent colleges accep spending 250 hours or more for teaching Social
ted the recommendations of Indian Medical and Preventive Medicine.
Council (1962), which lays down that in the
About one third of the respondent colleges
preclinical period a minimum of 50 hours be (34.8 per cent) were not arranging practicals
devoted to the teaching of Social and Preven in the subject during clinical period. The
tive Medicine, of which 37 hours be devoted remaining colleges made provision for field
for lectures, 4 hours for visits, and 9 hours for visits in the Social and Preventive Medicine
practicals and seminars. It can be said that syllabus during clinical period of undergradu
during preclinical period most of the medical ate study for ten hours to 100 hours. Two
colleges were not giving due attention to the colleges (4.65 per cent) had no provision for
subject as per recommendation of the commit field visits in the training programme of Social
tees for improvement of the teaching in the
subject because of paucity of time duration. and Preventive Medicine.
During clinical period, most of the medical
Shortage of medical staff for teaching Social
and Preventive Medicine and also non availa colleges were devoting the recommended hours
bility of teachers in social sciences like sociology, for the subject, while others were devoting hours
anthropology, psychology has led to differen in close proximity to the recommendation.
ces in teaching patterns in different medical
colleges. In majority of the respondent colleges Examinations:
(90.7 per cent) no provision was made in the
Pattern of examination in Social and Preven
time table for practicals and field visits in the tive Medicine also varied from one college to
subject.
another. Three of the respondent colleges do
not
hold any examination in the subject,
The practical hours in laboratory varied in
the remaining colleges from ten hours to 125 whereas in four such colleges examination in
the subject is held as a part of medicine.
hours.
Table V
Pattern of Examination in Social and Preventive Medicine
Total
Year of examination
Total Marks allotted
for the subject.
50
150
200
250
300
400
2
—
2
1
1
-
5th or final
No.
Percent
1
2
8
4
1
4
14
1
—
1
4
6
24
6
1
I..’ :.i
9.5
14.3
57.1
14.3
2.4
2.4
15
35.7
21
50.0
42
100.0
—
—
4th
3rd
—
100.0
Total
Percent
6
14.3
52
THE INDIAN JOURNAL OF MEDICAL EDUCATION
VOL. X. NO. 4.
DECEMBER, 1971
Of the remaining colleges a majority of 14
colleges hold examination in final year as a
separate paper in Social and Preventive Medi
cine. In colleges where separate examination in
the subject is held the total marks allotted again
varied. The total marks allotted to the subject
ranged from 50 to 400. The marks in theory
paper ranged from 75 to 180, for viva voce
20 to 100, for practicals, 25 to 110 and
for sessional 10 to 100. One college conducted
examination in two stages, one at the
end of 6th semester and another at the end
of 9th semester. Thus three main patterns of
examination were observed in the subject
impress on 5th year (i) In some colleges no
examination was held in the subject (ii) exami
nation in the subject was the part of medicine
and (iii) a separate examination in the subject
at the end of 3rd or 4 th year or final year of
medical teaching.
The teaching of Social and Preventive Medi
cine runs parallel to the teaching of clinical
subjects. Moreover for the effective teaching
and training in Social and Preventive Medicine
a knowledge of clinical subjects is essential. If
the present doctors are to provide comprehen
sive medical care, the examination in the
subject should be at the end of clinical years.
Postgraduate Courses:
Postgraduate Degree in Social and Preven
tive Medicine was awarded by 16 and Diploma
in Public Health by five of the respondent
colleges. One college was imparting training
to sanitary inspector, D.M.O.H., and M.O.H ,
D.T.M. & H. course was run by one college
only.
Thus the teaching pattern in preclinical and
clinical years of undergraduate medical curri
culum and method of examination in Social
and Preventive Medicine was found to differ
from one medical college to another. No
uniform pattern was adopted although from
time to time committees and conferences made
recommendation on the proper and uniform
development of this department in various me
dical colleges of the country and also on the
uniform pattern of teaching and training the
medical graduates in the subject. The recom
mendation of the Indian Medical Council are
mandatory and the States were free to imple
ment these recommendations either in toto or
in part depending on their resources and requi
rement. In the subject there is no forum like
All India Association as exists in other disci
plines of the medicine, which may help in
bringing the uniformity in teaching the subject
in different medical colleges.
Social and Preventive Medicine is a separate
subject. Besides teaching its own subject, it
has contributions from all the branches of medi
cine. But it has its own technique to improve
health of the community, hence this subject
cannot be tagged to any other subject taught
during the medical courses. Indian Medical
Council (1962) recommended a separate paper
on Social and Preventive Medicine, but its
sub-committee (1964) emphasised and recom
mended separate examination in the subject
with 50.0 per cent marks each for the written
and practicals. It further recommended that
the case histories, and performance at the field
training centre, should also be taken into
account for purposes of assessment in the final
examination. Greatest harm would be done to
the subject by abolishing examination in the
subject or attaching it secondary importance
by making it a part of any other subject of the
medical curriculum. The subject had suffered
in the past when it was taught by part-time
teacher, used to be health officer of the muni
cipality, who took the job of teaching (then
Hygiene and Public Health) with secondary
importance. Medical Officer of Health was alre
ady overburdened with the work of municipality
or corporation and had little time to devote to
teaching the subject. Bhore Committee (1946)
while surveying the health problems of the
nation, expressed its dissatisfaction on medical
education on two accounts (a) the manner of
presentation of topics under Hygiene and Public
Health, and (b) the practice of placing a total
responsibility of teaching on a public health
official.
Information, in a preplanned questionnaire,
regarding total admission capacity, duration of
teaching, hours of teaching and syllabus was
collected from 84 medical colleges in Novem
ber 1966. The response rate was 53.57 percent.
The following conclusions were drawn:—
1.
The admission capacity in respondent
medical colleges varied from one college
to another and it ranged between 50-200
in 91.8 percent of the colleges.
teaching pattern of social and preventive medicine
2. Duration of teaching of undergraduate
medical curriculum in 73.3 percent res
pondent colleges was four and a half years
and in 11.1 percent colleges it was more
than five years.
3 Duration of teaching hours for theory
lectures, practical and field visits also
varied from one college to another. There
was no uniform pattern regarding allot
ment of teaching hours, in Social and
Preventive Medicine during preclinical
and clinical period of medical curriculum
in different medical colleges. Majority
of medical colleges were not teaching the
subject in the form of lectures, practicals
53
and field visits during the preclinical
period.
4. Pattern of examination in Social and
Preventive Medicine also varied from
college to college. Majority of the res
pondent medical colleges were holding
examination in the subject in final year
of the undergraduate medical study as a
separate paper. The allotment of marks
for theory and practicals in the subject
was also non uniform.
5. A definite forum for bringing the unifor
mity in teaching and training of medical
graduates in Social and Preventive Medi
cine is required.
REFERENCES
1. Report and recommendations of the con
ference on the teaching of Preventive and
Social Medicine in relation to health
needs of the country, National Institute
of Health and Family Planning, 1966.
2. Sub-committee of Indian Medical Council
minutes on the development and stand
ardisation for study of Preventive and
Social Medicine and Public Health for
undergraduate students, 9th November,
1964.
3. Report of Health Survey and develop
ment committee I, XIII, 160-161,
1946.
REVIEW OF UNDERGRADUATE EXAMINATION
JANUARY-JUNE 1974
Review of undergraduate examination patterns in Preventive &
Social Medicine incorporating field training in India
by
A. P. Verxna, Reader,
S. M. Marwah, Prof. & lid. of the Dept.
K. Tewari, Reader,
community medicine as is the case with various reasons our students are still examina
other clinical disciplines (Marwah, et al. tion oriented and pay scant attention to a
1971). Meanwhile a review of the examination subject or topic which they feel are not
systems in P.S.M., however, provides a con important from the point of view of examina
tradiction to the aims and objectives of existing tions.
training programmes. These areas are sum
(ii) In eleven universities the examinations
marised hereunder:
in PSM are conducted at IV year level with
(i) In a number of medical colleges in India the para-clinical subject (Table I, based on
there is still not a separate examination in personal communication, 1970).
P.S.M. It is a well recognised fact that due to
College of Mcdicjl Sciences, B. H U., l'aranasi-5.
This article reviews examination pattern of P. S. M. in medical colleges of 36 universities of India
(obtained through a questionnaire) and makes comparison with its own system at B. H U. At other
places weightage is given on theory examinations. . The practical examinations are “ Lab. specimen
identification” type and fail to provide adequate support for the field Coining programmes which are
practically non-existent. A plea is therefore made that comprehension abilities cannot be developed or
assessed without facing or tackling problems in real life situations.
The appended list of examination questions provides a fair range of exercises, from classical public
health to present day health care concepts. In view of the authors, validity of all examination systems
must be based on needs of the society (e.g., provision of basic doctors). This can be refinedfrom lime
to lime through trial and error approach.
The University Grants Commission appoint
ed an expert committee~in 1957 which was of
the view thatExamination is the aspect of
educational process which is intimately linked
with its other important aspect— teaching and
learning - that teaching and learning and
examination actually constituted unit of func
tion. Teaching as well as learning are bound
to be affected by a deceptive examination
system since both are dominated by the.
objectives that govern the examinations. ”
Examination is a complicated psychological
and social interaction between the examiner
and the pupil and is determined by many
subconscious factors on the part of student and
temperament and professional competence of
the examiner (W.H.O., 1968).
This is valid and true both in cults and
concepts of a broad-based discipline like
P.S.M. Many medical schools in the world felt
the need to revise their curricula, not many of
them have initiated scientific research into
the nature and evaluation of teaching and
examination methods. In all countries they
bear the mark of culture and tradition and
needs of the place (W.H.O., loc cit.). This is
extremely valid for a new discipline like PSM
too and is exemplified by laying down of a
syllabus which encourages the habit of memo
rizing and resort to notes and guides because
of the repetition of similar questions in succes
sive examinations (U.G.C., loc. 'cit.).
The Education Commission (1965) while
recognising the chronic nature and magnitude
of the problem remarked “ We are convinced
that if we are to suggest any single reform in
university education it should be that of
examinations
In the field of medical educa
tion too, the outstanding medical educationist,
late Alan Gregg after visiting various Medical
Colleges in India remarked “ Change the spirit
and purpose of examinations in the Medical
Colleges....... ” (Wahi, 1963).
For purposes of medical education, ‘ inten
sive care units' through family advisory
schemes (Marwah, 1966) should be demarcated
out of the urban or the rural practice fields of
the P.S.M. departments for an effective
demonstration of family medicine and
TABLE I
Examination in P.S M.
Number
Names of Universities
I. At IVth year level
(II Professional) along with
Pathology, Pharmacology’,
Forensic Medicine.
Eleven
Allahabad, A.I.I.M.S. New Delhi,
Osmania, Indore, Calcutta, Meerut,
Patna, Agra, Darbhanga, Lucknow,
Ranchi.
II. At the Final Year Level
(III Professional) along with
Surgery, Medicine, Gyn. &
Obstet., Ophthalmology.
Twenty one
Andhra, Aligarh, Bangalore, Baroda,
Behram, Gujarat, Delhi, Jamnagar,
Kolhapur, Kerala, Kashmir,
Marathwada, Mysore (3 universities),
Rajasthan, Sambalpur, Tirupati,
Utkal, Karnatak and B.H.U.
III. 6 months before III
Professional Examination
Four
Guntur (alongwith Ophthalmology),
Pondicherry, Punjab (Amritsar,
Ludhiana, Rohtak), Punjabi
University, Patiala.
It may be emphasised here that for inculca
tion of concepts of comprehensive health care
the students require all the skill and knowledge
of medicine, including clinical disciplines. To
assess the student before he has acquired
the necessary skills and knowledge in com
prehensive health care amounts to putting the
cart before the horse.
(iii) In these colleges vyherq separate
examinations for PSM are held at the final
2
year level, the examination system itself seems
faulty. While the students are supposed to
be trained for comprehensive health care in the
background of the family and the community,
the assessment consists of only theory and
viva-voce
examinations and occasionally
spotting of a few specimen slides, seme statis
tical exercises and assessment of practical
records (Table 2).
FOL. Xlli
THE INDIAN JOURNAL OF MEDICAL EDUCATION
18 .
NOS. 1 & i
TABLE II
Total marks
Theory marks
14.0%
21.5%
11.0%
11.0%
15.0-50.0% 2.5-15.% (10)
(mostly 25.0%)
(13)
(mostly 25.0%)
—
27-7%
6.6% (1)
—
43.0%
33.3%
37.5 — 75.0% (18)
(Mostly 50.0%)
21.5%
45.0%
15.0-50.0% (13)
(mostly 25.0%)
180
150
55.5%
35.5-66.6%
(mostly 66.6%)
49.0%
50.0-80.0%
30.0%-70.0%
16.6%
26.0-33.5%
(mostly 33. 5%)
—
Note:
No. of Univ.
Viva
230
225
200
135
100
50
Day to Day
Practicab
20.0-50.0%
—
25.5%
—
—
25.5%
—
30.0%
One
Two
Eighteen
One
Five
One
Two
Two
(i) % indicates range of marks allocations,
(ii) % in brackets indicate the most frequent allocation.
(iii) Bracketed figures against the % range of marks indicate number of the medical colleges in that group.
The above table highlights the fact that
much weightage has been given to the theory
part of the examination.
The practical
examinations too at most of the places
are of ‘ lab-specimen-identification ’ type,
usually conducted at the examiners table
along with viva-voce, though the detailed in
formation regarding this could not be collected.
Day to day assessments were done only in 17
out of 32 universities (personal communication,
1970). This system of examination to assess
the student’s skill and knowledge in the practice
of comprehensive health care and his com
prehensive abilities as a 1 basic doctor ’ in
community medicine are apt to be fallacious.
The above facts make it abundantly clear
that the examination system in P.S.M. fails to
provide adequate support for the training
programmes viz. training for comprehensive
health care and as such reforms in the P.S.M.
examination system are urgently required.
Mathur, et. al. (1971) have emphasised in an
earlier communication also that if the present
doctors are to provide comprehensive medical
care, the examination in the subject should be
at the end of clinical years. A definite forum
for bringing the uniformity in teaching and
training of medical graduates in Social and
Preventive Medicine is required.
To get a meaningful experience of examina
tion system in P.S.M., the department of Pre
ventive and Social Medicine, Banaras Hindu
University has been experimenting with a new
approach described hereunder to highlight the
experiences of the last eight years. A sketch of
training programmes highlights the purposes
and significance of examinations.
PSM Training at Banaras Hindu University
The teaching of PSM at BHU is throughout
44 years and the university examination in the
subject is held at the end of this period.
During the preclinical 14 years the philosophy
of comprehensive health care is introduced
in the light of epidemiological triad and the
interrelationship of social and biological
sciences to health and disease in an individual,
the family and the community (Marwah, et. al.,
1969). The teaching hours comprise of one
hour lecture per week (total about 40 hours
during preclinical period). *
During first year and last 1| years of the
three clinical years, the PSM training consists
of one hour lecture and two hours field training
per week while during intervening six months
e. immediately preceding second professional
i.
examination in para-clinical subjects the trai
ning comprises of one hour lecture per week
JANUARY-jUNE 1974
REVIEW OF UNDERGRADUATE EXAMINATION
only. The students are allotted a family each
for the longitudinal study of 3 years during the
field training hours (Marwah, 1968). During
the field visits the students are required to
carry on supervised studies of health and dise
ase situations in the families and the communi
ty and provide total medical care within the
framework of existing resources. Frequent
socio-clinical conferences in the field and group
discussions in the classroom further crystallize
the concepts and provide insight in the subject.
PSM Examination System in BHU—
1. Day today assessment—Some of the objec
tives and purposes of assessment, as communi
cated in previous pages, are stimulation of the
teachers and the students to work regularly, to
reduce failures and to avoid anxiety and appre
hension in students. To achieve this end day
to day assessment has been given considera
ble weightage at BHU. Out of 150 marks in
theory and viva voce 25 (16.6%) and 100
marks in practical 25 (25%) are given for day
to day work. The theory sessional marks are
given according to performance of the students
in the terminal/sessional theory and viva-voce
examination conducted during the course of
I-V year. The practical sessional marks are
given on the basis of student’s performance in
sessional practical examinations, practical re
cords and specially designed students assess
ment cards which arc maintained by respec
tive batch teachers for performance of the
students during “ family advisory service ”.
These assessments are further broad-based by
involving all the senior teachers in the sessional
examinations for example, each teacher is asked
to put one theory question in the sessional
written examination out of the topics taught by
him and he is also required to assess it. Similarly,
teachers are rotated to assess the students of
other batches in the field practical examina
tion. Further, the students’ attendance in
theory and practical class is also given due
weightage.
Final University Examination:
The theory and viva voce test in the final
university examination are conducted like any
other place. However, greater emphasis is
laid on the assessment of practical aspect and
principles and concepts rather than on memo
rising facts and figures which are not so rele
vant to the understanding of subject.
2.
19
The practical examination consists of the following:
I. A long case consisting of study and dis
cussion on the socio-economic and health and
disease spectrum of a given family.
II. Two short cases, out of which one per
tains to a socio-clinical or clinico-epidemiological study and discussion on the diagnosis and
management on a given case in relation to the
family and the community background and
another case of environmental, psychological or
nutritional problem in the family or the com
munity.
The Long Case:
In the past the students were required to
present the socio-economic and disease and
health situations in the family which they were
required to follow up during the clinical years
and the management of various problems and
situations within family and community resour
ces. The idea was to assess the students’ broad
understanding on the subject.
However, since 1968 the pattern has been
changed slightly inasmuch as the students are
now allotted a new family on lot basis because
it was seen that some of the students were pro
viding monetary help in their anxiety to
improve the socio-economic and health status
of the family. During the same year another
change was effected i.e. the students were
required to study one facet of the family e.g.
environmental sanitation, nutrition, psycho
social conditions etc., because it was realised that
in a given period neither the examiner nor the
examinee were able to fully discuss all the pro
blems in the family and their implications on
health status. Thus it may be observed that
the examination system is all the time under
constant review and assessments and suitable
modifications are made in the light of past
experiences. The short cases are also picked
up from the family and community situations.
Here again the attempt by the examiners is to
initiate the students into discussions around
principles and concepts in the practice of com
munity medicine. A list of illustrative exami
nation questions are given in the appendix.
Our experience has shown that about 25
students can be examined conveniently in this
manner in about five hours. The students are
allowed to study and comment on long and
short cases. During this period they spare 20
minutes for a few spotting and simple statist!-
20
THE INDIAN JOURNAL OF MEDICAL EDUCATION
VOL. XIII
NOS. 1 S’ 2
JANUARY-JUNE 1974
cal exercises and viva-voce. This experience
is not in agreement with WHO (1968, loc. cit)
that both oral and practical examination even
under best of circumstances are time consuming.
Prospects and Retrospects
It is often argued that exercises in the inter
pretation of data are not realistic because they
neither stimulate nor duplicate the real life
situations. The practical examinations where
students are assigned the families are observed
by the examiners, appears to meet satisfactory
standards of relevance and validity, since it
yeilds actual samples in a realistic context
(WHO, 1968, loc. cit.). Ideally a sound exami
nation system must satisfy two important con
ditions. It must be valid, i.e., it ought to
measure some definite achievements which is
required to be measured. Secondly, it must be
reliable (use of a check list), i.e. it ought to
measure accuracy of whatever it is expected to
measure (U.G.C. loc. cit.).
7. In a nutshell the examination in P.S.M.
should be an attempt to analyse the cognitive
(application of concepts e.g., attitudes, habit
values and judgements in evaluating total
situation and ability to create a new synthesis),
psychomotor skills in application of scientific
technologies and affective domains i.e. accep
tance of responsibility for patient’s welfare and
concern and consideration of patient and his
family’s welfare.
8. In conclusion, the present communication
is only a short review of attempts being made
by this department through 8 years of indepth
experimentations by trial and error to tackle
the complex problem of assessments which we
finally consider as recall of core knowledge,
competency during application, analyses and
synthesis of facts evaluation, both rational and
necessary.
References
The nutshell aim and purpose of the assess
ment according to Sinha (1963) is (i) to stimu
late both teachers and students to work regu
larly and sincerely, (ii) to guide the students to
learn the subject and to develop self-confidence
(iii) to reduce failures. In addition to this the
student should be able to logically argue in a
given situation and come to a tentative con
clusion (Wagle, 1966). Besides these W.H.O.
(1968, loc. cit.) has proposed additional objec
tives which are given hereunder :•
1. Opportunity to exercise attitude and res
ponsiveness to the total situation.
2. Opportunity to test skills involving all
senses with observation of performance by the
examiner.
3.
Evaluation of the enquiring mind.
4. Recognition of medical capabilities and
limitations (which justifies the background
concept of graded care to students (Leavell,
1965) within available resources).
5. Ability to establish effective relationship
with colleagues and other members of health
team.
6. Willingness to use medical capabilities to
contribute to community and patient’s welfare
(which will perhaps include the action com- •
ponent of our B.H.U. undergraduate training).
I. W.H.O. In the review-on the nature
and uses of examinations: Public Health
Papers. No. 36. J. Charvat, C. Me
Guive' and V. Parsons. Geneva, 1968.
2. U.G.C.: Report of the examination
reforms quoted by Education Commis
sion; 1, 1967.
3. EDUCATION COMMISSION:
Report on the Standards of the Uni
versity Education by U.G.C. Examina
tion reforms.
Chapter X : 76-82, Ministry of Education, Govt, of India,
New Delhi, 1965.
4. Wahi, P.N.: Medical-education in fer
ment. Edit., Ind. Jour. Med. Educ. II:
182. 1963.
5. Marwah, S.M. Undergraduate train
ing for comprehensive medical practice
through a student’s family advisory
service, W.H.O. Med. Educ. Bull., XI:
2-11, 1966.
6. Marwah, S.M., Varma, A.K., Tewari,
I.C.: Family and community medicine
in medical education. Bharal. Med.
Jour., 3: 124-128, 1971.
7. Mathur, J.S., Marwah, S.M.., Trivedi,
B.K., Rao, N.S.N.: Teaching pattern
of Social and Preventive Medicine in
Medical Colleges. Ind. Jour. Med-.
Educ., X: 47-53, 1971-
8.
REVIEW OF UNDERGRADUATE EXAMINATION
Marwah, S.M., Varma, A.K. Shukla,
K.P.: An improvised project of graded
comprehensive care for teaching com
prehensive medicine. Ind. Med. Gaz.
IX- 41-50. 1969.
2!
Outline the possible health hazards of
the large family or health hazards of
family’s cottage industry' and your
management.
vi) Outline the health hazards to the
Sunderpur community of the occupa
tion of X in the family and your
management of the same. (The occu
pation might be a milk seller or a
sweetmeat seller or a washerman).
v)
Marwah, S.M.: Longitudinal family
studies by clinical students. Ind. Jour.
Med. Educ. VII: 523-526. 1968.
10.
Sinha, T.P. : Method of assessment of
an undergraduate student. Ind. Jour.
Med. Educ. II.: 177-178. 1963.
11.
Wagle, M.M.: Assessment and examina 2. Illustrative examples of short cases (both
tion of students. Ind. Jour. Med. Educ. environmental and sociological) are:
V: 584. 1966.
(i) Outline concurrent and terminal dis
12.
Leavell, H.R. Comprehensive health
infection under (i), (ii) or (iii) of 3.1.
care for India, Ind. Pub. Hlth. Asscn.
in the family Y.
Souvenir. B.H.U. Press, Varanasi: 5-9.
(ii)
Inspect and report on a well or a hand
1965.
pump or a PRAI latrine or a family
soakage
pit or a compost pit or a kit
Appendix
chen garden or a family house or a
school building and so on.
Illustrative examples of long and short
Examination Course.
(iii)
Report on the chlorine demand of a
well water or the presumptive coliform
II. Illustrative examples of long cases are
count of the inoculated media.
i)
study the case X in the family Y and
outline the management within the
(iv)
Outline rehabilitation of a handicapped
family’s realistic life situations.
child. This might be a blind or a deaf
mute or an infantile paralysis child.
ii)
Undertake contact tracing of the index
case X in the familial contacts of the
(v)
Outline the social practices connected
family Y and outline your manage
with the infant’s feeding in the family
ment of the problem in the family Y.
Y and your management of the health
connected problems.
iii)
Outline the socio-economic aspects of
the disease X in the family Y and
(vi)
Outline your approach to the problem
discuss the health implications of the
of personal hygiene or food hygiene or
problem and your management of the
household hygiene or lice-infestation
same.
or helminthic infestations (i.e. children
with positive stool results) in the
The case X for a family Y in (i), (ii) or (iii)
family Y.
might be tuberculosis, leprosy, typhoid, tra
choma, rheumatic fever, diabetes, filariasis
(vii) Outline the impacts of Employees
and so on.
State Insurance Scheme on the manage
ment of the case X in the family Y and
iv)
Examine the antenatal or postnatal
(viii)
so on.
■ mother or infant or toddler or school
child X in family Y and outline your
management.
9.
Hp- ’8U. - \
The Role of the PHC Medical Officer in Implementing
Community Medicine
B. Swarajyalakshmi
Aset. Professor, Department of Social Cd Preuenliue Medicine, Andhra Medical College, Visakhapatnam.
Introduction I
trained personnel make this task difficult.
However an effort has been made by the
The concept of preventive medicine has
national government and the primary health
widened far apart since the bacteriological
centre at the peripheral level is the attempted
era when prevention of disease was taken to
mean specific immunisation against known answer to this call for provision of comprehen
diseases. Health and disease arc recognised sive health care.
now as dynamic processes and not '* States ’ and
The unique characteristic of community
these processes are continuously being in medicine is that it is relevant to every specia
fluenced by multiple factors pertaining to the lity of medical practice. The physician
host, the agent and the environment. A applies his knowledge and techniques to
balance between the favourable and unfavour individuals whereas the practitioner of com
able factors is health. A disturbance in the munity medicine approaches the problem on a
balance will result in disease. A knowledge community basis by attempting to reduce
of the natural history of disease process and health hazards in air, food, water, soil, etc. In
the application of preventive measures at the our country both these responsibilities have to
known levels will therefore involve a co-ordina be carried out by one physician and that is the
tion of several disciplines and organisations medical officer of the primary health centre.
far beyond the reach of the conventional The quality and range of his knowledge and
medical services which only aim at mitiga skills and his attitude towards his work will
ting an obvious illness. Thus the compre largely determine the health of the individuals
hensive concept of ‘ Community Medicine’ and families making up the communities. Our
or ' Community Health ’ has come up. country is faced with problems of contamina
Community medicine now pervades the tion of water, food and soil by human excreta
realm of the entire community and individual and diseases carried by animals and insect
efforts for protecting, improving, and main vectors. Underlying these, are factors like
taining the health of the people. Its aim is poor housing, poverty, illiteracy, malnutrition,
physical, mental and social well being of the and deeply rooted customs, beliefs, and habits.
individual, and it is concerned with motiva Working under such conditions, the medical
ting individuals and groups to move towards officer of the primary health centre must
that goal. And for this purpose it makes use play a multiple role. He must undertake the
of several methods and techniques. The entire treatment of the disease in the individual, play
' Community ’ is the focus which is given the role of family counsellor, may have to act
* Community study ’, ‘ Community diagnosis ’, as health officer and administrator, and also
and ‘ Community treatment ’. The individuals undertake research into the basic health
constituting the community arc also important; problems of the area.
the whole is as important as the parts which
How should he do it ?
make up the whole.
The programme I am trying to outline here
What should be done ?
is not new to administrators and teachers who
For a Governmental agency in a developing equip the medical graduate with the necessary
knowledge
and skills. The duties and respon
country like ours, the provision of community
medicine would mean that comprehensive sibilities of the medical officer of the Primary
health care including preventive, curative and Health Centres have been enunciated, expoun
health promotional services should be made ded, and discussed again and again, through
available to all pea »le. Shorta -e of funds and circulars publications and seminars. Still we
JULY-DECEMBER 1675
THE HOLE OF THE PHC MEDICrti
find that the enthusiasm of the medical
graduate wanes when he finds himself in the
environment of the Primaiy Health Centre. I
may submit here that I have had the privilege
of participating in the training of undergra
duate medical students, and following up tneir
assignments after graduation as medical
officers of the Primary Health Centres in the
capacity of District Family Planning Officer
for sometime. With guidance and encourage
ment from the supervising officers, I found,
that they could perform the duties expected
of them to a satisfactory extent.
The medical officer conducts out-patient
clinics in the mornings in the primary health
centre. Usually there is heavy rush of patients,
but most of it is due to ‘old patients'—those
who have been already examined by the
medical officer and have been given prescrip
tion. If the outpatient clinic is regulated so
that the doctor sees only the new patients and
relegates the old patients to the compounder
for ‘ repeat medicine ’, he will be in a position
to go into detailed history and do justice to
clinical examination and arrive at a diagnosis.
In the afternoons, he plans tours of the villages,
where he combines preventive work like health
education, control of communicable diseases,
and supervision of the work of other staff.
During these village tours, he can visit patients
requiring special attention like tuberculosis.
For cases requiring detailed study in the home
environment, he can make a separate note
and include them in his tours of the villages.
During these visits to the house, he can utilise
some time for health education, bringing out
the points relevant to the causation and control
of the particular disease. A record of such
interesting case studies, including epidemiologi
cal investigations would be very useful.
tection and holding arc essential. Since these
diseases require prolonged care, the domiciliary
treatment under the national programmes is
not met with success. The question of defaulters
poses a problem for successful treatment at
home. The situation can be much improved
if the medical officer infuses confidence in the
patients by occasional visits to their homes
and persuades them to continue the treatment
with regularity. This sort of personal inter
vention also gives prestige and support to the
peripheral worker who is not otherwise given
much recognition. Again it gives the medical
officer an opportunity to study the disease as
it occurs and progresses in the natural environ
ment of the home and the community.
In MCH and Family Planning programme,
an intimate, informal contact with the mothers
and fathers is necessary. Many medical
officers neglect the MCH part of the pro
gramme and do not give adequate supervision
to the work of the auxiliary nurse midwives
and health visitors. They do not interest
themselves in the registers maintained for
MCH. It may be worth stressing that, from
the records and registers maintained for MCH
services alone, it is possible to obtain the birth
rate, fertility rate, and the infant and pre
school child mortality rate and maternal mor
tality rate of the area without conducting any
specially-designed, time-consuming survey.
In motivating the 'target couples’ for Family
Planning, the role of the medical officer is
strategic. His active lead lends support to
the extension workers in Family Planning and
dispels doubts and hesitancy on the part of
the people.
In the programmes for the control and
eradication of mass disease, the medical officer
has a major role to play. The eradication
programmes for malaria and small pox have
entered the maintenance phase in many areas.
Any slackness of vigilance will result in rever
sion to the beginning stage. Continuous
supervision of the peripheral workers for
coverage in vaccination, early detection and
prompt control (or containment) measures in
the event of occurrence of a case, will be of
paramount importance.
It may be questioned whether the medical
officer can find the time to involve himself
actively in all these programmes as outlined
above. It is not necessary that he should over
burden his daily routine. He does not have
to carry out all the above functions everyday.
Occasional home visits, well-planned in
advance, and occasional but meaningful
scrutiny of the records and registers will make
a lot of difference to an otherwise uneventful
routine work at a primary health centre. The
young medical graduate who looks upon rural
health work as something like a undeserving
punishment can transform it into an interesting
epidemiological study which will be richl)
rewarding in experience.
In the programmes of control of chronic
diseases like tuberculosis and leprosy, case de
It is in his own hands : he should have th
right attitude and the will to work in the righ
126
THE INDIAN JOURNAL OF MEDICAL EDUCATION
direction. He is the health educator ever
motivating people towards the goal of * Com
munity Medicine’.
Wegman, M. E. (1967) : Comprehensive
Personal Health Services, A.J P.H. 57,
1:2, Jan. 1967.
3.
McGrcvan, E. G. (1969): Community
Health —A Distinctive Speciality, NIHAE
Bulletin 2, 5. 1969.
References :
1.
VOL. XIV Nt. 2
2.
Winslow, C. E. A. (1952): The Economic
4.
value of Preventive Medicine, W.II.O.
Chronicle 6-7, 8, 1952.
Taylor, Carl E. (1970): Community Medi
cine and Medical Education, I.J. Med Ed.,
Vol. IX, Nos. 6 & 7 (1970).
A Guide for Planning Community Health Education Programme
H i9 -'s E\
Nawal Kishore
Director of Post Partum Programme & Head of the Deptt. of Obstetrics and Gynaecology.
R. S. Misra
Lecturer in Health Education, Obst. & Gynaecology Deptt.
D.
N. Pandey
Statistician-cum-Lecturer in Social and Preventive Medicine, S.H. Medical College, Agra.
Man is both part and product of environ
ment. His physical, psychological, social and
cultural behaviour reflects in constant struggle
with the environment. Any change in either
man or environment of which he is a part, is
ipso facto a change in the other. Behaviour is
based on the principles of ‘Hedonism’ i.e.
‘Pleasure seeking and pain avoiding’, man
adheres to his old practices, values and stand
ards to which he is attuned and rather tries to
escape from the innovations although they
are more useful suiting their change and the
demands of the time. This applies to the
health practices also.
Health is a crucial aspect of human life, it
is a complex phenomenon conditioned by a
multiplicity of factors and invariably prone
to constant changes. The primary responsi
bility of a public health practitioner is to
initiate change in individual and society for the
improvement in health practices. The change
occurs in two ways. First is natural change
which is slow and steady in nature and being
a process it takes its own course in free and
frank environment. Force, fear and fraud
cannot be applied very easily to enhance its
implications. Second is a planned change
where individual interference is always
possible. In this context change is always
directe towards the achievement of predeter
mined goals. The role of change agent is to
provided a bridge between many sources of
knowledge and furthermore number of
agencies for its application. Such a mission
cannot be accomplished by mere gathering and
distribution of information alone but requires
broad-based public health education pro
gramme planned on scientific and systematic
foundations of human learning and social
change affecting the existing health values and
standards.
Planned change can be introduced either by
force, coercion or through education. In the
case of force and fear the achievement of goal
is easier, but the effect is not long lasting.
■c
As soon as the pressure of force is reduced the
people will revert to their old practices. The
last alternative is to bring change through
education. Being a process it involves agencies
at different levels, such as specialists, adminis
trators, supervisors, workers, and the public.
To make the discussion more specific and
clear these categories can be classified in two
groups, specialists, administrators, supervisors
and the workers as the change agent and
general public and their leaders who are
the recipient as the client system. Change is
the net result of interplay between the change
agent, client system and the environment.
Effective changes in health practices do not
just happen, they have to be brought about
through designing good programmes, which
do not develop merely by wishing for them,
but by working hard for them. The effective
programmes for change in community health
practices result from choice not by chance or
by trial and error.
Ideal planning needs
actual involvement of both change agent and
client system.
The efforts have been made to collect and
systematise the experiences gained in the
course of planning, implementing and evalua
ting various health education programmes in
the community. The discussion in the present
paper is prominently confined to the concept,
factors influencing the change, principles,
steps and importance of planned programme
with diagrammatic presentation of a guideline
for planning a community health education
programme. This may be useful to profes
sional health educationists in their practical
lab. situation.
Concept: Programme planning for change
in health practices is a deliberate course of
action designed carefully to attain predeter
mined goals. Being a process it details out
the objectives, .tasks and procedures in a
sequence to transform the decision into
action.
haviour
it has been emphasised that mere dissemi
nation of technically correct information
designed for general application does not
serve the purpose but needs consideration of
motivating factors that shape the human
behaviour. The application of principles of
learning and social change have given promi
sing results to change in health behaviour.
The community where change is
i-e
brought should be thoroughly studied in its
total perspective such as physical, social,
cultural and economic conditions prevailing.
(ii)
Location of problem and its solutions :
It is envisaged that the health problem
under consideration should be based on felt
needs and the real needs of the community so
Internal factors or
psychological
1. Past experience
2. Motive, needs
3. Aspirations
4. Education
5. Perception
6. Beliefs
7, Apprehension
8. Value system
External factors or
cultural factors.
_>
Knowledge
•I
Attitudes
Behaviour
These factors may be internal (Psychological),
such as perceptions, motives, aspiration,
beliefs, value system etc and external (socio
cultural) i e. customs, norms, traditions,
communication set etc. play a vital role in
change process.
Principles:
«-
1. Customs and traditions
2. Norms
3. Folkways and mores
4. Power structure
5. Communication set
6. Reference Groups
7. Service facilities
8. Psycho-social support
that the people may feel more contented.
People should be helped to help themselves
rather than to give them direct solution.
(iii)
Fixing the priorities and objectives :
Few health problems which need immediate
solution and affects the large section of the
society should be taken on the priority basis.
The next problem for the next time and soon.
This process will develop a continuous action
from the public who are the real consumers of
the fruits and after sometime they will be
able to solve their problem themselves.
The scientific planning aims for change is
always based on fundamental principles.
Effective and realistic planning considers the
existing local conditions and the felt needs of
the community. The manageable and real
approach always keeps in mind the resources (iv) Plan a Programme :
(men, money and material) and the objectives
In proposed outline of the programme, in
i.e. short range and long range to be achieved.
The involvement of client system through volvement of local agencies, official and
their leaders ensures greater success of plan non-official, working in the area in other
programme,
should be given importance. Plan
ning. The categories and agencies involved
in the programme are assigned clear-cut res should be time-bound and target-oriented.
The
methods
and media must be decided with
ponsibilities with technical support. Flexible
and liberal approach widens more chances of the clear definition of the objectives to be
success with the provisions of assessment at reached.
(v)
Implementation of the Plan :
every step.
Execution of the plan should start involving
*
Step
the community leaders, programme staff,
The key of success in bringing the change supportive staff etc. The proper training such
in health practices through planning strictly as orientation training, refresher courses and
depends upon the steps followed by the change pre-service training will streamline the action
to be taken in the community.
agent.
• 122'
THE INDIAN JOURNAL OF MEDICAL EDUCATION
VOL. XIV NO. 2
JULY-DECEMBER, 1975
A GUIDE FOR PLANNING COMMUNITY HEALTH...
(vl) Evaluation and Feedback:
References i
The programme assessment should move
along with programme with all the stages
spelling out the criteria of success and indica
tors of the progress. This may be done in the
light of achievement of goals, input and out
put, process adopted, media used and co-opera
tion and co-ordination of various agencies.
The necessary modifications can be made at
any stage in the light of community needs.
1.
Knatson, Andie L. :
Individual,
Society and Health Behaviour 1965 : 357-358.
2.
' Extension education in community
development’ (1961): Directorate of
Extension, Ministry of Food & Agricul
ture, Government of India, New Delhi.
3.
Guide to extension work in Family
Planning, C.F. P. I. Monograph No. 12,
N. I. F. P., New Delhi, 1970, pp. 14-26.
4.
‘Guide to Community Developments’
(1957) : Ministry of Community Develop
ment and Co-operation, Government of
India, New Delhi.
5.
Subbiah, S : Comprehensive Guideline
for planning, implementation and evalua
tion of Health Education, 1967’. Inter
country workshop, W. H. O., New Delhi
(Unpublished paper).
6.
Rao, S K.: ‘ Community health adminis
tration perspective in planning and
evaluation’, 1970, Background Paper
Workshop on Research method to Family
Planning Programme, N. I. F. P., New
Delhi.
7.
* Programme Planning ’
(Background
Paper) 1968. I.R. H. & Family Planning,
Gandhi Gram. (Madurai).
8.
‘ Programme Planning and Evaluation.’
Background Paper 1969, N. I. F. P., New
Delhi.
*
Important
:
The programme in black and white serves
the purposes of a guideline and considerably
helps to choose the alternative courses in
order to minimise the chances of failures.
The proper sequencing of activities saves
the time, efforts and resources and avoids the
heavy risks of wastage The continuity to the
programme is ensured through planning a
programme for change and helps in evalua
tion and feed-back mechanism in relation to
objectives defined.
Conclusions :
Proper planning is an integral part of all
health programmes. Once it is initiated it
continues till the determined goals arc
achieved and planning a health education
programme based on needs and requirements
of the people widens the avenues of greater
success. Systematic follow-up of the steps in
programme development for introducing new
or strange into stable and resistant socio
economic and cultural milieu shall go a long
way in providing scope for the involvement of
people and enables them to improve their lots
through changes in the existing situations.
Community Health and Curricula for Health Personnel
H. S Gandhi
Drax of Studio and Profcsior of Education & Training, Katicnal Institulr of Health Adninirlralion and Education,
New Delhi.
I nt rod action
Before one goes into the main problem of
curriculum planning for different categories
of health workers in community health,
it is essential to define the meaning, and
scope of the words ‘Community Health’, its
relationship to Health Services Adminis
tration in our country and the roles that
physicians and other health workers need
tb play in this service programme.
placing these services near enough for their
benefit through small units of health adminis
tration and through health education. The
people have also begun to assert for these
objectives in the shape of growing demands by
the society claiming more and more its right
to receive adequate health care and to benefit
from the progress in medical science and
technology.
These socio-political considerations have
therefore led to the district health services
including its peripheral centres, and sub-cen
tres forming the key clement in health services
administration in our country. These centres
strive to provide basic health services to the
people more particularly rural people. National
disease control eradication programmes and
limited programmes of health insurance and
social security arc also available to the public.
Sophisticated health services come from the
State level or city health centres including
teaching hospitals and other specialised health
agencies. Excepting perhaps the centres of
excellence like teaching and other large hospi
tals all too often these centres suffer from
severe constraints of finance, staff, equipment
In terms of its relationship to our health and essential supplies, transportation etc., to
services, a programme of public assistance, accomplish what needs to be done for the
suffice it to say that preventive and therapeutic community. In other cases there is lack of
services which history divided into separate desire and motivation to innovate to over
public health services and hospital-based cura come such difficulties and to do whatever is
tive services are being brought together as possible within those constraints. This then is
community health services under common the level at which comprehensive health enre
staff and administration. Since the commen is delivered to most of the population and the
cement of Five Year Plans national objectives sum of the activities carried on in these organi
for health services for the country require that sations for this responsibility constitutes one
medical care should be available to every of the basis for formulating curricula for
individual and which should be comprehensive health workers be thry physicians or health
in terms of diagnostic, therapeutic and preven auxiliaries, etc. It is therefore imperative
tive care. Further, these objectives lay a that health personnel need to be trained no
special emphasis for the health care of rural only in the technical functions and tasks bu
populations and on people's participation by also for administration of community healt}
The phrase ‘community health’ as we now
mostly accept is concerned with the delivery
of integrated and comprehensive health care
to populations as against individuals. It
comprises a number of methodologicsof which
epidemiology is central but which also includes
biostatistics, demography and social sciences
more particularly behavioural sciences. Addi
tionally, it concerns itself with the methods
and techniques of health planning, delivery,
administration and management and evalua
tion so that the benefit of technical knowledge
and professional skills are delivered to the
communities efficiently and effectively.
services at various levels including hospitals
and medical practices as well as in the tradi
tional public health measures.
care explicit to the students as they do on the
hospital wards.
As the definition also provides for his role
for linkages of services, a management and
operational issue, for integrated and com
culum planning for health workers relates to prehensive care it is clear that our physicians
the roles that physicians and other health even at the level of undergraduate training
workers need toplay in this service programme. must be prepared for administrative respon
Regarding the role of phvsicians, it may be sibilities if we desire that as incharges of
considered at two levels: The basic physician community health centres they function
and the community health specialist. The efficiently and effectively. Available data
Medical Education Committee Report 1969 shows that there is gross under-utilization of
has defined the term ‘Basic Doctor
*
as one who our staff and facilities and poor guidance and
is well conversant with the day to day pro supervision of workers It serms much more
blems of the rural and urban communities is possible within the existing constrnii ts with
and who is able to play an effective role in the better leadership and if managemer t of these
curative and preventive aspects of the regional centres could be toned up. A set of ’basic
and national health problems. Besides being sciences’ exists for the student who is learning
fully well up in clinical methods and treat to practise community medicine on a scientific
ment of common conditions, he should be basis and these are behavioural and social
able to judge which conditions should be sciences, epidemiology, biostatistics, demogra
administrative
referred to a hospital or a specialist Accor phy, disease prevention,
ding to the Committee, he should also be able sciences and environmental sciences. There is
to immediately provide aid for acute emer now no question as to the need for the
gencies and should have the necessary motiva physician in community health practice to be
tion and facilities for constant advancement in a good administrator. He must have sound
medical knowledge and methodologies of care. basic knowledge and skills in planning and
organisation as well as in the management of
The above description provides a fairly good personnel and finances. This training for
basis for the preparation of basic doctors in administration must be provided in the under
technical as well as delivery aspect.’ of these graduate curriculum after which it becomes
services at the undergraduate level of medical too late for most of them. These aspects,
education. Curriculum therefore must be however, do not seem to be strongly represen
adapted to achieve the objective of creating ted in the existing curriculum for the training
such a medical manpower equipped with of young doctors.
knowledge, abilities and motivation necessary
for the effective carrying on of their activities
The community health specialist or mana
in the fields of prevention, treatment, rehabili gerial physician has much greater and com
tation and, more generally, health promotion. plex responsibilities and roles to play in this
Other adaptations would also be needed. It programme. He possesses the distinctive skills
is evident that teaching institutions as centres and knowledge as well as the needed attitudes
of over-specialisation and excellence currertly for community health administration and
are in contradiction to the proper kind of co-ordination of different services. Broadly
education to the students who would be able his involvement in health services adminis
to deliver the goods as per needs and against tration rests on several roles and responsibili
the conditions of limitations prevailing in our ties as under:
centres particularly in the district health
services complexes. Medical faculties must
1. To determine the health needs of
now come forward for much greater involve
populations in terms of both quality and
ment for purposes of training of basic doctors
quantity and to identify and working
in our health care delivery system. Such a
towards future needs.
development can also lead to useful researches
2. To assess the competence, quality and
for improving health care delivery and influen
di’tribution of health care resources
cing curricular reviews It is the question of
within the community in terms of the
medical educators making serious attempts for
assessed needs.
making the process of comprehensive health
■Community Health Physician
*
The third aspect in our discussion of curri
IR6
THE INDIAN JOURNAL OF MEDICAL EDUCATION
3.
Planning, organisation, administration
and management of health care service!
including evaluation and responsibility
for their optimal effectiveness.
4.
To undertake and/or promote research in
health services administration for greater
efficiency and effectiveness and for
solution of health problems.
1’0/.. XII’ No.
M.C.H. & Family Planning
Public Health Nursing
Health & Extention Education
Environmental Health Services
Occupational Health Services
Education and Training
Health Planning & Evaluation
Neither list may be exhaustive and sse can
May even provide consultation services have differences on this thinking. These lists
when capabilities for such a role become are also not that mutually exclusive.
Epidemiology for instance is both a basic and
available.
applied science, for community health.
Curriculum contents for the preparation of Research methodology is in fact an applied
specialist categories of community health subject but had to be grouped with basic
physicians would come from the same adminis sciences for reasons of students requirement
trative and other sciences already enumerated to have some working knowledge before he
before with one or two more subjects such as moves on to his doctoral research.
health economics, research methodology in
Physicians can also be involved to develop
community health, public administration and managerial
competencies through short-term
sciences for developing skills in human com inservice orientation training programmes for
munication etc. Further, each of these
comprehensive
care as is being done at the
subjects would go into considerable breadth
and depth depending upon the category of National Institute of Health Administration
specialist to be trained. Diploma level com and Education, New Delhi. For instance, the
Staff College Course of 8-9 weeks’ duration is
munity health specialist may not be required
to acquire that level of competency as would offered to senior health executives (district
be the case for instance of a doctoral level level and above) coming from diverse fields
such as hospital and medical care, general
community health specialist who in addition
to managerial competencies may occupy health services, medical education, nursing
positions of administrative research, consulta administration etc. including primary health
tive and teaching positions or a combination care of rural communities. This gives the
of these assignments. Here too the universally participants an opportunity of examining
accepted idea of dividing the curriculum into different administrative practices in their
‘basic sciences’ and ‘applied sciences’ helps special fields in order to prepare them for
develop
working knowledge
in basic still higher opportunities in the future. The
sciences before the student begins to study the curriculum during this training besides
applied subjects. For instance for M.D. the contents for social sciences, statistics,
(Community Health) programme conducted administrative sciences etc. is reinforced
at the National Institute of Health Adminis with modern management techniques as an
tration and Education, New Delhi, the element of their further development for
subjects included in each category are as health care delivery.
under:
An important consideration for training in
Basic Sciences
managerial competencies is to elicit maximum
participation of the students This can be
Ep'demiolorpr
ensured by involving the students in various
Public Administration
kinds of group dynamics such as the syndi
Social Sciences
cates, group field studies, prepared case
Health Economics
studies, lecture-discussion sessions, role play
Biostatistics
ing, panel discussions etc. These methods
Demography
greatly enhance the capabilities of an
Research Methodology
administrator in making use.of his knowledge
and skills for effective and efficient health
Applied Sciences
care delivery as well as for effective function
ing as team member. As such these teaching
Public Health Administration
M<-djc»l Care & Hospital Admn.
methodologies should bo considered at the
5.
JVLT-DECEMBER 1975
CO.
time curricula for community health training
are designed.
Other Health Workers
< < II
<« ‘
-U » ...
done by different members of the health
team. Thereafter one is concerned to provide
sound technical training for each category of
personnel identified for delivery of health
care services to the community. The training
objectives must then be defined in terms of
knowledge, skills, and attitudes to be impart
ed. The curricula will be prepared on the
basis of these objectives which in turn would
also influence the choice of teaching methods.
The professional value of these categories of
health workers does not merely depend on
the technical knowledge and skills that they
possess, their value very much depends upon
the human culture and attitudes acquired by
them in their capacity as health workers.
They also need to be introduced to social and
administrative sciences for managing their
work with the people as well as for the
organisations they serve. They must be able
to observe, analyse and evaluate factors which
influence health and understand the purpose
of the activities carried on in the community.
The other key personnel in the system are
the various categories of health workers,
hospital or institution
based
*
and others
functioning as front line health personnel or
first contact functionaries with the population.
Some of these functionaries would belong to
full professional grades while others would be
classified as auxiliaries who have to be trained
simply for specific functions and tasks and
to work within an organised health service
providing for guidance and supervision.
Their role as an instrument for development
of health services and even as a factor in the
development of the community at large
demands their adequate preparation. Their
training must be adapted to the population’s
needs. The first task of these workers in
helping to develop the health services is to
try to extend their activities to cover the
whole population. So far as the fixed rural
All curricula should be sufficiently flexible
health infrastructure is concerned, observa for the introduction of new subjects of study
tions show that only 20% of the population or the reduction to a minimum, even the
are reached by health services. This means deletion, of sections which have become
at the peripheral level these workers will obsolete, or unnecessary or of low priority.
generally need to be mobile. This would
As such there should be a mechanism to cons
call for a dynamic approach for their develop tantly review the objectives and curriculum
ment through training so that they seek out contents of these programmes either by con
problems instead of sitting and waiting for
current or terminal evaluation or both.
them duly supported by the health centre Better still would be to observe the trained
infrastructure more particularly by the
personnel on the job for assessing the quality
middle level auxiliaries.
of curriculum administered while under
The principles already enunciated would training. This is the best form of evaluation
equally apply for framing the curricula for to judge whether the worker is performing the
various categories of these workers. The role, functions and tasks for which he was
first step therefore, is to define the functions trained and whether he is able to work in
of these categories of health workers. Help organisations, teams or with people for results
to identify the functions can be derived from and solution of problems. To this extent
situational analysis and the selection of therefore resources should be allocated for
priorities in relation to available resources follow up evaluation of the participants for
which influence the nature of work to be needed changes in the curriculum.
Teaching of Preventive & Social Medicine : A Model
By
Shiv Chandra
M.D., Lecturer in Preventive & Sacial Medicine Dr. Sampurnanand Medical College,
Jodhpur.
T. P.Jain
M.D., DPH, MPH, Pprofessor & Head,
Department of Preventive & Social Medicine, S.M.S. Medical College,
Jaipur.
ABSTRACT
Preventive and Soeial Medicine by its nature is never likely to be as interesting as
Medicine or Surgery, and a challange to the teacher of this subject is to make it as
effective, interesting and practicable as any other clinical subject. With this idea a
symposium was kept in PSM Department, Medical College, Jaipur, wherein the
teachers of different cadres and seniority from the Medical Colleges of Rajasthan
participated, and students, interms and residents staff opinion was also collected. In
the currentlsession teaching programmes were framed on the basis of conclusions
drawn from this symposium, which proved to be highly effective and easily acceptable
to the students with a desired outcome. In the present paper the methodology with
outline of contents broupht out from the symposium has been presented. Such pro
grammes can be followed by Medicai Colleges affiliated to different universities with
suitable local modifications.
Introduction
In early fifties Medical Educationists rea
lised that Medical Education is focussed on
the diagnosis and management of diseases
which often were not major health hazards.
This preoccupation was reflected in the services
provided which were costly, mainly curative
and for few urbanites. This was in sharp
contradiction to WHO definition of health,
which stressed health for all and interdepen
dence of promotion of health on one hand and
prevention and cure of disease on other. It
was then in this direction to equate disease
curative service with health care, Departments
of Preventive and Social Medicine were created
in 1956 in Medical Colleges of India, with
following expectations :
a)
Undertake the teaching of Preventive
Medicine and Public Health.
b)
Organise and undertake teaching of
Epidemiology and Social Sciences.
c)
Organisation and administration of Rural
and Urban Health Training Centres, for
training undergraduates, so as to get
them oriented on desired lines.
d)
Function as a catalyst aad co-ordinator
especially for clinical departments so that
all of them can add preventive and social
component in their teaching.
e)
to play its role in preparing a ‘Basic
Doctor'.
22 THE INDIAN JOURNAL
OF MEDICAL EDUCATION
Since then many methodologies have been
evolved and much experimentation has been
undertaken particularly at undergraduate
level. Although this subject provides an
important perspective, not provided by any
other discipline, yet teaching of PSM could
never be made as interesting as Medicine or
Surgery. Bhatia (1972) collected and classified
the reasons for failure to achieve the desired
results in teaching PSM, from eminent medical
educationists and experts in Preventive Medi
cine. A reason which could further be added
to the list is, lack of timely provision of well
organised Rural and Urban Field Demonstra
tion Centres and develop training facility in
them. These reasons might have made
Shrivastava Committee (1975) to comment
that PSM Departments have not met with
significant success. Still the committee did
not move in the direction of solving these
problems.
Recently Medical Council of India (1977)
in its recommendations laid down the new
strategy to teach community Medicine at
undergraduate level. Although the com
mittee has rightly recommended that teaching
of community Medicine be continued at all
levels, but it has failed to realize that the
knowledge of-subject can be properly assessed
only when student has studied clinical subjects
well.
In the present paper a model has been
prepared to teach Preventive and Social
Medicine, keeping in view the- contents and
curriculum recommended by MCI. In all,
the course of M. B., B. S. can be divided in
four phases to demarcate the levels of teaching
this subject.
Ill
VOLUME XVII No. 1
M.B.B.S. (Clinical) : Practical Demons
trations and Theory Lectures.
Internship : Field Training
Preclinical Teaching :
At the time of entering into the Medical
Schools, students should be given an idea of
what Medicine is ? In the light of history of
public health, changing role of a Doctor in the
society should be emphasised. Series of six
lectures (in continuation) can be kept covering
different Medical systems in existence, tradi
tional Medicine vis a vis Primary Health Care,
Role of a Basic Doctor and Concept of Team
Approach.
JANUARrfiUNE 1978
TEACHING OF PREVENTIVE & SOCIAL MEDICINE... 25
each semester during this period, covering
following topics :
1. Introduction to Preventive Medicine, Beha
vioural sciences, sociology and Public
Health.
2. Ecology of Health, Health Indicators,
Natural History of Disease and levels of
Prevention.
3. Concept of Dispensary and Health Centre,
Community Health and role of a Basic
Doctor.
4. Nutrition and Preventive Medicine.
5. Genetics and preventive Medicine.
These lectures should focus over the public
health aspect and the teachers should not be
over-emphatic for physiological and clinical
aspects of nutritional and genetic diseases.
Paraclinical Period :
Clinical Course :
Field Training : After passing cut I
M.B., B.S( examin, i.e. in IV Semester stu
dents should be taken to field preferably in
remote rural area for 10-15 days. During this
first exposure students should be encouraged
to gain faith in the community and an impact
should be made at this budding phases to
to learn the importance of cooperative living
and action and combining the physical work
and intellectual pursuits. During such expo
sures students can learn about: a) Snrvey
technique and sampling methods (b) Collec
tion, compilation and presentation of data (c)
Rural Health Organisation (Team Approach)
(d) Rural Sanitation i.e. disinfection of wells
and installation of Sanitary Latrines (e) Princi
ples and Practice of Immunisation (f) Sur
veillance for Small pox/Malaria (g) School
Health Programme etc.
I
M.B.B.S. (Preclinical) : Theory lectures.
II
M.B B.S. (Para-clinical) : Field Training
Theory Lectures : At the rate of one
and Theory Lectures.
lecture a week, 15-20 lectures can ba kept in
Practicals : Once a student has passed out
II M. B.. B. S. Examines practical training
should be started in two components.
Afternoon practical sessions
(including Field Visits) '
and
Morning Posting
(emulating Clinical Ward Postings).
Afternoon Practical Sessions : In
these sessions number of students should not
be more than 15-20 for the demonstrations
kept in the Department, teaching aids like
models, charts, and specimens should be used.
Evaluation of this teaching should continue
through oral quizes or written objective type
questionnaire. Afternoon session can be com
pleted in approximately 50 Demonstrations
and 20 visits, as outlined in Appendix-1
Family Care Programme : Family health
advisory service is a tool and teaching tech
nique for epidemiological exercise to demons
trate the relationship to health and disease to
total environment and thus to enable the
students to comprehend the problem in larger
context Lakhanpal (1978) have defined the
family care exercises as to teach systematically
the Anatomy. Physiology and Pathology to
be studied and therapy to be given according
to the socio-economic and cultural conditions
of the family in the same pattern as we study
in an individual. The following method is.
practised in the PSM Department at SMS
Medical College, Jaipur for family care
training.
At one time a group of 25-30 students is
posted in Urban Field Practice Area where
each student is allocated two families. He
notes down the particulars of family and com
munity in an advisory note book. Students
are asked to prepare a note on Medico-social
factors responsible for the health/disease con
dition found in that family. Work of every
ten students is supervised by one teacher. We
strongly feel that one teacher should not have
more than ten students under his supervision
so as to pay full attention.
Apart from studying these families in their
natural setting, eaeh student is given a project
for which information is collected by the group
as a whole on the predesigned protocol. This
information is pooled into common Master
Charts kept at the Centre. At the end of
survey, each student takes out the information
relevant to his/her project from thesa Master-ss
Charts. After analysing data and collecting I
literature on the subject, presents it before hisoj
group. A list of such projects is given in Lowe"p
and Kostnelwski (1973), students develop
the concept of carrying out research work an 1
presenting the same before a group through
such an exercise.
24
THE INDIAN JOURNAL OF MEDICAL EDUCATION
Morning Posting : In the routine clinical
Programme, two weeks posting in the PSM
Department should be kept, in the morning
hours. This posting should be utilised in
teaching epidemiology which is the Central
science of P. and S. M. Students should be
taken to those area where clinical work of pre
ventive and social medicine is being carried
out. Appendix II shows the model of Morning
Posting Programme.
VOLUME XVII Ho. 1
JANUAHTtJUNE 1978
Clinical teaching are to be kept viz—
Preventive
Obstetrics
Outline of Afternoon Demonstration/Practical Teaching in Preventive
and Social Medicine to Undergraduates
and
Health Problems of different Age groups.
Planning and Administration
different Health Programmes.
Topic
Demonstration
Visit
Water
Chemistry, bacteriology and purifi
a.
Filteration Plant
cation (4-5)
b.
Sanitary well
Insanitary well
Air
Health effects, prevention, control
and Indicators of Air Pollution (1)
Film on Air Pollution
and control
Housing and
Ventilation
Through models (1)
Visit to a slum and a
modern Housing Colony.
Lighting, Noise and
Radiation
1 Demo, each
Solid Waste
Disposal
One lecture
including
Occupational Health and Social Security.
Mental Health
Theory Lectures : Throughout last three
semesters one to two lecture a week covering
the topics which emulates the contents of
National and International Organizations.
Intership Programme (Jain and Tomor,I973).
REFERENCES
1.
Bhatia, J. R. : Teaching in Preventive & Social Medicine Reasons for failure to
achieve desired results
!.
*
A review, I. J. Med. Ed., Vol. XII, 21-26, 1973.
2.
Jain, T. P. & Tomor, V.N.S. : Internship Programme with a different approach. I.J.
Med. Ed. Vol. XIV, 127-130, 1975.
3.
Lakhanpal, U., Singh, D., Kakkar, M.L. 4 Manchanda, S. : Family Care, A learn
ing process. J. Ind. Ass. Prev. & Soc. Medicine, 3.42—0, 1978.
4.
Lambo, T. A. : Health and Disease around the World in Health Needs of the
Society A Challenge for Medical Education Ed. Gallhorn, A., Fulop, T. and
Bankowski, z„ (CIOMS), WHO, Geneva, 1977.
5.
Lowe, C. R. & Kostnclwski, J. : Epidemiology: A guide to teaching
(IEA), Churcill Livingstone, London, 1973.
Medical Council of India : Recommendations on Undergraduate and Postgraduate
Medical Education, 1971.
7.
Medical Council of India : Community Oriented Medical Education. Recomme
ndations to teach Community Medicine, December, 1977.
8.
Niyogi A. K., : Evaluation of Social Medicine & Problem of Training, Ind. J.
Med. Ed. Vol. XII, 190-192, 1973.
9.
Shrivasta Committee on ‘Medical Education & Support Manpower
Publication New Delhi, 1975.
10.
WHO ; Report of a Seminar on‘Teaching of Preventive & Social Medicine’held
in Ceylon (WHO Project: SEARO, 0110), 30.XI.66-XII.66. New Delhi-1969.
-
Excreta Disposal
Models of different types of latrines
and water closet system (1-2)
Medical Entomology
Models, specimens and slides of
different insects/insecticides (4-5)
a.
Trenching, Grounds
Sewage Treatment
Plant
b.
Military
Demons
tration Unit.
Urban/’Rural
Unit.
Malaria
Disinfection
Specimen on disinfectants (1)
—
Helminthology
Specimens and Models of different
Helminths (2-4)
—
methods
6.
25
APPENDIX-1
Epidemiology (General, Communicable
and Non Communicable Diseases).
Social and
Paediatrics.
TEACHING OF PREVENTIVE & SOCIAL MEDICINE...
$
Population Programme By Audiovisual
statistics,
aids,
Population
Demographic cycle and Organiza
tion of Family Planning Programme (5)
'ICSSR
Contraceptives
Two demonstrations
a.
Urban Family wel
fare Clinic
b.
R.P.P.T.C.
c.
Film on Population
explosion and Demo
graphy
ti
VOLUME XVII No. 1
THE INDIAN JOURNAL OF MEDICAL EDUCATION
Health Education
Different methods and media used
Hospital
(4)
different media
situation
JANUARTIJUNE 1978
TEACHING OF PREVENTIVE & SOCIAL MEDICINE... 27
for
APPENDIX-II
MORNING POSTING PROGRAMME
Preferably to an exhibition
Industrial Health
Occupational Health hazards (2)
Any Industry
showing
Topic
Day
Proposed Venue
health hazards.
1.
E. S. I. Dispensary
Vital Statistics
Birth
and
Death
Registration
Municipal Health Office
Introduction Levels of Prevention, Breaking the
Infectious disease hospital.
channels, principles of prevention.
2.
Immunization
3.
Cross Infection/Allocation of different
Immunization clinic
Averages, SD, Sampling
Morbidity
and
Mortality
and
—Census office
area
of
Attached Hospitals.
Hospital.
Fertirity Indicators (15-20)
Antirabic clinic
5.
Fever with rashes
Infectious Disease Hospital
6.
Poliomyelitis different levels of prevention.
Rehabilitation Centre
7.
Faeco-Oral group of diseases
Infectious Diseases Hospital
8.
Epidemiological Intelligence
Dy CMHO (Health) Hospital
9.
Tuberculosis
District TB & Chest Clinic
10.
Vector Borne Diseases
Distt. Malaria Organization.
Record Room
NOTE:
1. Such programme makes about 50 Demostration and 20 visits.
2. Benefits of local situation can be taken by keeping visits to places of public health interest.
3, Figures in paranthesis indicates number of demonstrations.
11.
Presentation of Hospital study/Disinfection Procedure.
12.
Assessment.
An Experiment on Re-orientation of Undergraduate
Teaching of Community Medicine
*
By
S'MT. K. V. Santha
Professor of Social and Preventive Medicine, Stanley Medical College, Madras
Introduction :
The subject of hygiene in the medical curr
iculum with its emphasis on impersonal ser
vices like envirot mental sanitation and its
principles and practices metamorphosed first
into Social and Preventive Medicine and lately
as Community Medicine. These chr nges in
nomenclature reflected the growing emphasis
on the holistic concept of total man in total
environment with greater stress on community
diagnosis and management of disease proce
sses and txtending comprehensive health care
to the community incorporating special per
sonal services such as maternal and child
health including family welfare, school health,
nutritional services etc. This re-oriented
curriculum in community medicine was intro
duced for medical undergtaduates of Maoras
University during 1977. In the previous
routine, the pattern of the examination consi
sted of a written and viva-voca test. In the
newly introduced semester system, the pattern
has been changed into one of written, oral
and practical examination of the university
level and internal assessment at the depart
mental level. Such a far-reaching change in
the concept of the discipline warranted radi
cal changes in the teaching methodology from
abstract theoratical class room lectures to
more purposeful practical demonstrations,
supervised firJd training, integrated teaching,
clini-co-social conferences and family follow
up studies. In order to incorporate these
aspects of the curriculum into the teiching
programme, practical schemes both for tea
ching and evaluation had to be drawn up.
The details of these schemes are discussed in
this paper.
Material and Methodology :
The material available being the curri
culum and syllabus for teaching and the
course content as prescribed by Indian Medi
cal Council and Madras University, a time
table at the institutional level was formulated.
Methods of teaching consisted of lectures with
audiovisual aids, demonstrations, laboratory
work seminars, symposia, workshop, super
vised field training, field visits, exercises on
stat stical and
epidemiological problems,
clinico-social studies and integrated teaching
programmes with other allied departments.
Schemes of practical training and practical
examination were evolved by the Department
of Social and Preventive Medicine, Stanley
Medical College, Madras and three batches of
students numbering a total of two hundred
and sixty two trained and examined so far.
*Perject report submitted for 6lh A'ationol course cn Educational Stiener for Medical Teachers, J1PMEH, Pondicherry.
*
20
THE INDIAN JOURNAL OF MEDICAL EDUCATION
The second clinical year students who are
to appear far Part I of the final MBBS.
examination comprising of community medi
cine; forensic medicine, ophthalmology and
otorhinolayngology and divided into four
MAT—AUGUST 1981
VOLUME XX Me. 2
batches and posted for training in these four '
departments for one month each in the for- f
enoons. During this one month posting in ;
community medicine the following programme 1
of training was implemented.
^MUNlTv ,
India^'56^ .
AN EXPERIMENT ON RE-ORIENTAHON 21
Recording And Internal Assessment:
Recording of the day to day work during the entire training was carried out under super
vision in the record formulated for this purpose. At the end of the training for each batch,
a model examination similar to that the university was conducted and marks obtained were
incorporated in the internal assessment.
University Examination :
No. of days
9 A. M. to 12 Noon
Two
Anti-rabies clinic
Four
a)
Details of training
_________________________________________
1
Management of dog bite and
prevention of rabies.
Field training
The marks allotted for the university prac ical examination are forty and duration for
each batch is one hour The programme consists of:
a)
Spotters
(Annexure I)
Three specific questions were given for each of the ten
spotters and students were asked to write the specific
answer for these question. Mark for each question
being half.
Marks allotted
—
Fifteen
Time allotted
—
Twenty minutes
b)
Exercise
(Annexure II)
One epidemiological or one statistical exercise for each
candidate.
Marks allotted
—
Five
Time allotted
—
Ten minutes
c)
Clinico social case
presentation;
(Annexure III)
Marks allotted
Time allotted
At the Primary Health Centres.
1.
Acquiring knowledge about the functions
and set up of P.H.C.
j
2.
Maternal and Child Health and Family
1
Welfare programme.
3.
4.
b)
Eight
Field visits
a)
Laboratory work
b)
Under Five clinics
Malaria surveillance
Chlorination of the water sources
To institutions and installations of public
health importance such as water works,
milk project etc.
]
|
Spotters and specimens on preventive
medicine, demonstration of public health
chemistry experiments and statistical and
epidemiological exercises.
Maintenance of road to health card and
immunisation programme.
|
1
1 Results
Eight
Integrated teaching-clinico
social case discussion
With emphasis on scabies, leprosy STD
and malnutrition among children
. Eight
Hospital services (community service) and family
follow up
Kitchen diet section, water supply, ward
hygiene and sterilization and record
keeping at the S. M. C. Hospital,
—
—
Twenty
Thirty minutes.
Each candidate was required to examine the given
case, elicit the clinico family and social history of
the patient, fill in the proforma given and discuss
with examiners
The incorporation of practicals in the
scheme of training has improved the standard
of understanding of the subject and created
interest in the learning process of the subject
besides infusing a greater sense of enthusiasm
on the part of the staff For the first
time a small change from disease oriented
teaching in medical course has been achieved
by this. It has also improved the overall
percentage of result in this subject.
Limitations
Lack of specific guidelines from the uni
versity on the training programme and
examination in the subject has resulted in
lack of uniformity in teaching and exam
ination pattern in all the medical colleges
under the same university.
1
2.
The time allotted for the pratical exami
nation was found insufficient.
3.
It is too early to assess whether this change
in training will meet the challenge of an
22
THE INDIAN JOURNAL OF MEDICAL EDUCATION
VOLUME XX Nt. 2 f,
MAT-AUGUST 1981
educational programme of training health
personnel able and willing to provide
comprehensive health care.
Summary and Conclusions
The above experimental project revealed
that the students showed greater involvement
and evinced better interest in the subject and
consequently more benefitted. The imple
mentation of integrated teaching programme
was found to be of great help for better com- ■
prehension and coverage of the diverse facets ■
of the natural history of disease processes and
their control and prevention. There is a felt t
need for early steps to standardise the practi- '
cal ttaining programme and examination ;
scheme in community medicine in all the J
established departments of Social and Preve- !
ntive Medicine of all medical colleges within 1
the purview of the university of Madras.
Schetr e o! practicals
Sri Venkateswara University, Tirupathi
Kerala University, Trivandrum
iii)
Recommendations of Medical
Council of India.
New Delhi 1976
iv)
MBBS, course syllabus in
community medicine
V) Public Health paper—71
I.
2.
3.
2.
P. Vivax
1. Identify.
2. Mention the drug that is effective against
this stage of the parasite.
3. Mention the other stages found in peri
pheral blood.
3.
Anthrax (Model) Face
1. Identify.
2. Name the causative agent.
3. Name the preventive measures.
4.
Mansonia eggs
I. Identify.
2. Mention the disease transmitted in the
adult stage.
3. Mention the control measures for the
equatic stage.
5.
Ragi
1,
2.
3.
University of Madras, Madras 1976
Personnel for Health Care, Case studies of
educational programmes Volume 11—1981,
i
Identify and name the solvent.
Mention the contraindications.
Name one rare complication.
Smallpox vaccine
REFERENCES
Scheme of practicals
QUESTIONS
SPOTTERS
I am indebted to Dr. A. S. Aswathiman, Dean and Dr. S. T. Sundaraj, Vice-Principal, ;
Stanley Medical College, Madras for affording necessary facilities and encouragement for
implementing this scheme. Thanks are also due to Dr. T. Ganapathy, Professor of Social |
and Preventive Medicine, Madras Medical College and Dr. C. P. Madhavan Kutty Director
Department of Social and Preventive Medicine, Trivandrum Medical College for their ■
valuable suggestions. The unstinted co-operation of the staff of my department in imple
menting the programme is also gteatefully acknowledged.
i)
23
1.
Acknowledgements
it)
AN EXPERIMENT ON RE-ORIENTATION
ANNEXURE-I
Identify.
Mention the nutritive value for 100 gms.
of this.
The advantages of its use over others.
6.
Culex female
1. Identify.
2. Mention favourite breeding places.
3. The diseases transmitted.
7.
4 AQ tablets (labelled)
1. Mention the adult dose and duration of
treatment.
2, What is its importance ?
3. What is the action of this against the
parasite ?
24
THE INDIAN JOURNAL OF MEDICAL EDUCATION
VOLUME XX No. 2
8.
Paris green
1. Identify.
2. Mention its use.
3. Mention its mode of action.
9.
Cresol (Labelled)
1. Mention the percentage commonly used
2. Mention its uses.
3. Mention its mode of action.
10.
Loop
AN EXPRIMENTION RE-ORlENT 25
MAT-AUGUST 1981
AN N EX U R E-II
1.
Practical Exercises in Community Medicine .
In a town the following vital data for the year 1971 was recorded.
1. Identify.
2. Mention its use.
3. How is this sterilised ?
Population
70,000
Live births
2,500
Still births
30
Deaths
1,120
Infant deaths
280
Maternal deaths
31
T.B. deaths
68
Calculate the crude death rate, crude birth rate, infant mortality rate, maternal
mortality rate, still birth rate and tuberculosis death rate.
2.
Calculate the amount of bleaching powder in grams required to chlorinate a
swimming pool measuring 20'X10' and having 10' of water with 331/3% of
available chlorine in bleaching powder so as to give 2 P. P. M. of chlorine (given
— 1 eft of water = 6.25 gallons of water).
(If definite blue colour is seen from the 3 white cup onwards, in the
Harracks apparatus )
3.
In a town with a adult female population of 10,000 twenty five persons were
diagnosed to have cancer cervix for the past two yearss Calculate the prevalence
rate of cancer cervix in that population and suggest the preventive measures to
the same.
4,
In a town with a population of 50,000 persons were examined for microfilaria in
their peripheral blood and for clinical manifestations of filaria. Of this 50 persons
showed microfilaria in their peripheral blood and 100 persons showed clinical
manifestations for filaria. Calculate the microfilaria rate, filaria disease rate and
filaria endemicity rate.
5.
A rat flea survey was conducted in a village and 20 rats were caught one day.
On combing the rats. 40 rat fleas belonging to xenopsylla cheepis species were
identified. Calculate the specific flea index and comment on the result.
26
THE INDIAN JOURNAL OF MEDICAL EDUCATION
VOLUME XX No. d
Evaluation of ‘Morningness-Eveningness’ in human
Circadian Rhythms by Self-Assessment
Questionnaire, A Preliminary Study
in Medical Students
A N N EXU R E—III
Proforma for Integrated Approach to a Clinical Case
Name of the patient:
Sex
Age:
Income! 'By
Address 1
'
Complaint:
'
D. N. Deshpande,
I Associate Professor of Physiology,
History of previous illness :
A, G. Chandorkar
I Professor of Pharmacology
II Family History :
Members of the Family :
Name
Age
Sex
i
Occupation
Education
Relationship
Immunisation!
to the
status.
patient.
Hereditary History :
Food habits
Per capita income
Expenditure
Environmental History :
Physical
Biological
Social—Ignorance, illitracy, customs & habits
What is the probable source of infection ?
Natural History of the Disease
What level of prevention has failed and
what are the reasons for the same. ?
What are the remedial measures to be taken
at the individual and community level. ?
Dr.
V. M. Medical College. Solapur
‘Morningness and Eveningness' in medical
f students , and staff was determined by using
! ‘.Self ; assessment Morningness-Eveningness
■ questionnaire' of. Horne and Ostherg (1977).
! .61,37% students and 60.00% staff members
I .were moderate to- definitely morning type,
• .34.37% : students and 40 03% staff were of
f 'neither- type and only 1.25% students were
moderately evening type? None of the sub
jects werer of definitely evening type. An
; advance of 60-90. min ■ in. the arising time of
[ morning type of individuals as compared to
E neither type or moderately evening type, with
E po. significant defference in their mean bed
t time, was also observed. Earlier awakening is
| due to a low thresholds for arousal associated
I- with higher , level of arousal in the morning
| which declines rapidly in the evening, Since
| the. arousal level, learning and subsequent
recall are. significantly related, the knowledge
of individual variation in circadian rhythms
of our student population would help in
planning their learning experiences at a time
when their arousal level is at optimum and
would result in better receptivity, memory and
performance.
:
Further when these morning type students
would later, as residents and casualty officers
would perform duties round the clock, it is
likely that they may not be at their best
during evening and specially at night and
their performance hence may be affected both
physically and mentally. It is suggested
that while alloting such emergency duties, the
person's circadian variation should be taken
into consideration and the ‘Principles of entra
inment' employed in shift work may be utili
sed to make them more suitable to their job
requirements.
Since, O'Shea (1900) reported on the diff
erences in cricadian rhythms of individuals
and grouped them as ‘Morningness' and
Eveningness', these individual differences in
circadian rhythm have attracted great interest.
Yet only few systematic studies have been
carried out to confirm these two categories,
(Freeman and Hovland, 1934; Kleitman, and
Folkard, 1975).
Oquist (1970) proposed a Swedish language
Momingness Eveningness Questionnaire which
Teaching of Medicine in The Community"
Through Field Practice Areas: Some Considerations
by
R. N. Srivastava, md. (hons), dph, dih, fipha.
Professor and Head of the Department, Social & Preventive Medicine, M. L. B. Medical College, Jhansi.
ABSTRACT
There are many obstacles to a change in the existing traditional structure of medical education.
However a need exists for a radical change in view of the present social and health needs of the
community and health care delivery system of the country. In bringing about such a change, the
quality of medical education should not suffer. Only the contents should change to commensurate
with the need of the community. This necessitates teaching of medicine in the community for
which a ‘ teaching community ’ is required in addition to a ‘ teaching hospital ’ attached to each
medical college. Such a community based teaching can only be organised through field practice areas.
Il has been emphasised that the objectives of field practice programme should be defined, in clear
terms, at the first instance and the design of leaching and training may be developed accordingly.
The aim and operational objectives of field practice programme have been defined. In view of these
objectives some guidelines in initialing community teaching of medicine through field practice areas
have been evolved. Based on these considerations an outline of a model of a rural field practice area for
undergraduate medical students and for a medical college admitting 100 students has been
discussed.
General
Medical Education in India is at cross-roads.
A critical evaluation of the existing medical
education system in India, to ascertain it’s
utility in it’s present state, will reveal that a
departure from the traditional structure is im
perative. It is because the medical education
system of today has failed to produce doctors
who can fulfil the needs of local community,
both rural as well as urban. The reasons of
the failure are many and have been high-lighted
at many conferences and committees, national
and international in character, and need not
be elaborated in the present context. However
it is also now amply evident that there are
many obstacles to a change in the existing
traditional set-up of medical education
(Mahadevan, 1971).
It need no research to say that today’s medi
cal educational system is sophisticated—cura
tive care oriented rather than priority oriented —
community based. Further it has limited rele
vance to the jobs that need to be done by the
young doctors. Medical education needs to be
oriented to meet the community needs and
should commensurate in contents with the exis
ting and health care delivery system of the
community and country. Hospital training,
no doubt, is an essential part but it is only a
part of the total training and have many serious
limitations in the present social and health
needs of the community. As such we have to
• Working paper presented at the 3rd. Annual Conference of the Indian Association of Preventive & Social Medicine
held on Jan. 22-24 '73 at A.I.I.M.S., New Delhi.
32
THE INDIAN JOURNAL OF MEDICAL EDUCATION
consider seriously a change in our medical edu
cational system so that the training of medical
students, right from the earliest stages, can be
undertaken in the community environment.
This will necessitate complete orientation of
medical education from the hospital to the
community and will mean radical changes in
the pattern of training. However it is felt that
in bringing about such a change, the quality of
medical education must not suffer, only it’s
contents should change according to the social
and health needs and health care delivery
system of the community.
Such an orientation in medical education
requires a 1 teaching community ’ comprising
of a fairly good cross-section of the community,
rural as well as urban, in addition to a ‘ teach
ing hospital’. The solution lies in developing
field practice areas (urban as well as rural)
attached to each medical college. It is through
these field practice areas that a medical college
should transform itself into a powerful and
vigourous health activity to function as a social
institution and in which students participate
actively to undergo training in community
based medicine.
It is however essential to define the objec
tives in the first instance and then develop the
field practice areas and design the teaching and
training programme in accordance with these
objectives. Principal guidelines need to be
enunciated to achieve these objectives.
Objectives of Field Practice Programme
The objectives of field practice programme
have to be viewed in the broad context of the
objectives of medical education.
Today in India, the objectives of medical
education should be to produce good ‘ basic
doctors’ who are “professionally competent
and emotionally prepared ’ to cater to the
social and health needs of the community,
rural and/or urban. They will not only be
clinicians and therapists, but also will make
their contribution in the preventive and pro
motive aspects of health of the community,
functioning as Leader of the health team and
making optimum use of the available limited
resources.
VOL. XU
NOS. 1 & 2
Operational objectives of the field practice
programmes should be to orient the students
to the:
i.
local problems of health and disease;
ii.
broad concept of genesis of diseases
prevalent in the community;
iii.
i ole of social, cultural and economic
factors governing the incidence of physical
and mental illnesses of the community;
iv.
development of diagnostic sense which is
not dependent on elaborate laboratory
tests and other sophisticated investigations
in handling day to day ailments;
v.
population problem in relation to health ;
vi.
ways, best suited in the present context,
to prevent and treat diseases in the family
and community environment and with
limited resources;
vii. problem of environmental health and
their solutions;
viii.
team concept, where the doctor has to
function as leader of the health team,
being capable of guiding other members
of the team in the implementation of
national health programmes and other
preventive measures;
ix,
development of effective communication
with local population in order that he
functions as health advisor to the com
munity. With these objectives in view,
guidelines for field practice programme
may be evolved,
Same Guidelines:
The following may serve as guidelines in
initiating community teaching of medicine
through field practice areas :
1.
The students need to be trained in an
environment in the community, as similar as
possible to that, in which they are actually
going to work.
2.
The students need to be involved in real
life situations where they see and participate in
the practice of medicine in the community,
may be rural, urban or sub-urban. ‘ Make
believe’ type of participation is now well
Speaking precisely, the aim of the field pra known for it’s ineffectiveness in teaching and
ctice programme should be to help produce training programme.
such a ‘basic doctor’ with the attributes
3.
Teaching and training of students in
desired in him.
community settings should no longer remain to
JANUART-JL’NE, 1973
TEACHING OF MEDICINE IN THE COMMUNITY
be the responsibility of the department of social
and preventive medicine alone but has to be
shared actively by the other clinical depart
ments of the faculty like general medicine,
general surgery, pediatrics, obstetrics and
gynaecology etc. Clinicians should recognise
the field practice areas as much in their dom
ain as the hospital and laboratory.
4. Field practice areas should be considered
as projection of medical college in the com
munity rather than a separate entity and
have a pride of place in no way less than
wards or laboratories in the overall set up of
the college.
5. The concept of health team, with doctor
as the team leader needs to be introduced.
Ideally it should be such that the medical
students and other health workers are trained
together in the field practice areas so that they
are able to understand each other’s work as
member of health team which is concerned
with the delivery of health care services to the
community.
33
The Model
The model of a field practice area and
design of teaching and training, which is being
discussed presently, has been conceived for a
medical college admitting 100 students for
teaching and training of undergraduate medical
students and for a rural community. However
it will be utilised for post-MBBS interns and
postgraduate students of any clinical subject
including social and preventive medicine.
Further only broad outlines are discussed
leaving details which can be worked out later.
The model is presented under the following
headings:
Criteria for the choice of field practice area:
It should provide a good cross-section of
the rural community and should be at a work
able distance from the medical college.
It is suggested that four Primary Health
Centres situated in four different directions and
at a distance ranging from 16 to 24 kms. from
the medical college may be selected to develop
them as rural field practice area. They may
6. A part of students’ clinical clerkship time be designated Teaching Primary Health
should be spent in community setting, in the Centres.
field practice areas, outside the teaching
Organizational Framework:
hospital.
At the college, the College Council (consis
7. A purposeful and correlated curriculum ting of all heads of the departments with Dean/
need to be developed for the teaching of Principal as the Chairman) should lay out
medicine in the community. This is essential
broad policies regarding organization of field
if the limited time available, of the students, practice areas and design of teaching and trai
is to be gainfully utilized.
ning there. The College Council should also
8. And finally as Tiwari (1970) has said evolve an effective curriculum.
A sub-committe of the College Council
“ it will need to encompass, first and foremost
a change of mind all along the line, a deter consisting of Dean/Principal as the Chairman
mination to translate into action what has been and heads of the departments of general
discussed over a number of years, a genuine medicine, general surgery, obstetrics and
gynaecology and pediatrics as members with
acceptance of a new order of priorities and a head of the department of social and preven
recognition of a new scale of values. ”
tive medicine as member-secretary should
With the foregoing consideration of objec work out details of the day to day programme
tives and guidelines of field practice pro of teaching and training in field practice areas.
gramme a broad outline of a ‘ model ’ of field The District Medical Officer of Health and
practice area and the design of teaching and Family Planning/Chief Medical Officer of the
training there may be drawn. It may however District may be given ex-officio appointment
be confessed at the very onset, that “ the idea in the faculty and should also be coopted as
may be easier to conceptualise than to success member of the sub-committee.
Some additional staff and transport shall be
fully exemplify ” in the present set-up, but the
model is discussed here as it may have some required at the college. It is suggested that in
potentialities in developing teaching of medi addition to the existing staff, one Reader/
cine in the community.
Associate Professor in each of the departments
34
THE INDIAN JOURNAL OF MEDICAL EDUCATION
of general medicine, general surgery, obstetrics
and gynaecology, pediatrics and social and
preventive medicine may be provided to under
take additional load of work as field training
programme is time consuming. It is also sug
gested that four light vehicles may be provid
ed for the mobility of teaching staff from the
college to the field practice area in addition to a
college bus for the transportation of students.
At the Teaching Primary Health Centre,
the teaching and training programme shall be
co-ordinated by the Lecturer in Social and
Preventive Medicine who shall reside there.
Additional facilities of buildings, staff and
transport are also required to be developed at
each of these Teaching Primary Health
Centres. Additional budget will also be required
to be provided. It is suggested that residential
accomodation should be provided for the
Lecturer and hostel accommodation for 20-25
students; hospital accommodationforadditional
25 indoor beds; and a seminar/lecture room
with projection equipment.
In addition to the staff already available at
the Primary Health Centre, one lady doctor
should also be appointed.
Medical Officer of the Teaching Primary
Health Centre including the Lady Medical
Officer should carry teaching designations
I'OL. XII
NOS. 1 & 2
(Demonstrators, Tutors) and may be allowed
to undertake postgraduation in any of the
major clinical disciplines like medicine, surgery,
obstetrics and gynaecology, pediatrics and
social and preventive medicine.
Research and Demonstration Components:
In the Teaching Primary Health Centres
the usual health care delivery system consisting
of medical care, control of communicable
diseases (including activities pertaining to
national health programmes) maternity and
child health services including family planning,
school health services, vital statistics registeration and verification, improvement of environ
mental sanitation and health education should
be organised by the usual staff of the centre
on scientific lines under the guidance of
teachers from medical college. In the early
para-clinical years, the students in small
batches, should pay frequent observational
visits to these Teaching Primary Health Centres
along with teachers from the college to see the
various functions in operation. In the clinical
periods they should stay at the Primary Health
Centre for a period of atleast one month to
participate in these activities, in small batches
of 10—15 each, in a few selected villages under
supervision of teachers from the college,
working with the staff primary health centre,
including para-medical staff.
The seven basic functions of the primary health centre, in which students need to
participate, may be developed on scientific lines under guidance of the teachers from the
departments of the college as indicated below :
Medical Care
General Medicine
General Surgery
Obst. & Gynaecology
Pediatrics
Control of Communicable
Diseases
General Medicine
Pediatrics
Social & Preventive Medicine
Maternity & Child Health
Services
Obst. & Gynaecology
Paediatrics
Social & Preventive Medicine
Family Planning
Obst. & Gynaecology
General Surgery
Social & Preventive Medicine
Environmental Health
General Medicine
Social & Preventive Medicine
TEACHING OF MEDICINE IN THE COMMUNITY
jANUARr-jUNE, 1973
School Health
General Medicine
Paediatrics
Ophthalmology
Dentistry
Social & Preventive Medicine
Vital Statistics
General Medicine
Social & Preventive Medicine
Social & Preventive Medicine
General Medicine
General Surgery
Obst. & Gynaecology
Paediatrics.
Health Education
35
Joint Clinics at the Primary Health Centre and community rounds may be held in the villages
along with students for practical teaching and training in the field. The students by rotation
should attend to indoor patients, outdoor clinics, emergencies, domiciliary confinements, etc.
In a few selected villages around the head Administrative Coordination
quarters of the Teaching Primary Health
The field practice areas should be adminis
Centre, comprehensive health care may be tered by the Dean/Principal of the college who
developed. Students being made responsible may designate one of the teachers from the
for curative, preventive and promotive health departments of social and preventive medicine
care services of a few, say about 20 families, to run the day to day administration. How
which they look after and follow during their ever it is desirable that a full time officer-inposting at the Teaching Primary Health Centre. charge of the field practice areas like the
The same families may be alloted to the new Superintendent of a Teaching Hospital, may be
batch of students posted subsequently to main appointed to run day to day administration of
tain the continuity of care. This innovation the field practice areas and develop liason with
may bring about some new ideas for a family the district health authorities. He should be with
based comprehensive health care programme a postgraduate qualification in public health.
in rural areas and may be a very good piece
As mentioned earlier, the field practice area
of research in medical care delivery system should be considered as projection of the
through participation of students.
medical college and not as a separate entity
What is actually needed is the following to belonging to one particular department.
be demonstrated to the medical students in Clinicians should be as much involved in the
teaching, training and practice of medicine
the field practice area :
—Existing health care delivery system in in the field practice areas as the teachers from
the department of social and preventive
operation in the rural areas ;
medicine.
—Simple diagnostic techniques;
In the end I conclude with the remark that
— Community outlook towards problem of for developing an effective teaching and train
health and disease and their prevention ing programme in the field practice area, it
and treatment;
is essential that the faculty members develop
—Comprehensive health care for rural tolerance for each other, develop cooperation
community as ultimate goal in health among themselves and finally interdependence
care delivery system.
in the teaching of medicine in the community.
REFERENCES
MAHADEVAN, B:
TIWARI, T. R.:
Drawbacks of our current medical education system, Proceedings:
National Conference on Medical Education p. 71, Indian Medical
Association, I.M.A. House, Indraprasatha Marg, New Delhi. (1971)
Role of health centre complex in medical education, Keynote
address, Ninth Annual Conference, Indian Association for the
Advancement of Medical Education. I. J. M. E., 9 p. 273. (1970)
ZE 'ZT H t
^-1 - 'i- - ri oaj - 'ptu$ I
TRAINING OF MEDICAL STUDENTS UNDER COMMUNITY
MEDICINE POSTING
r~\p -
BANSAL,R.D., SRINIVASA,D.K.,SOUDARSSANANE,M.D.,NARAYAN.K.A.,
RAMALINGAM, G., ADAIKALANATIIAN, L
Department of Preventive and Social Medicine,
Jawaharlal Institute of Postgraduate Medical Education and Research,
Pondicherry- 605 006
ABSTRACT
As per the recommendation of the Medical Council of India.thc second clinical year (senior) students
of JIPMER are imparted training under “ Community Medicine Posting” by Department of Preventive
and Social Medicine in rural field practice areas. Batches of 15 - 20 students are posted for 3 hours every
day for one month. Based on previous experience the programme has been modified and phased as Village
Health Survey, Community diagnosis presentation and Clinico-social case presentations. Analysis of
pre-tests and post tests showed that the knowledge of the students improved significantly aftcrpractical
fidd exposure in the community medicine posting. Their attitude towards villagers also changed.
3®ents liked the programme and felt that it helped them.
INTRODUCTION
As per the recommendations of the Medical 1980. Bansal et al1 have reported about the com
Council .of India,2,3 the community medicine post munity medicine posting in JIPMER including the
ing for II nd clinical year (senior) students is being educational objectives and methodology. Since
carried out in JIPMER, Pondicheery since Feb. thcnjhc posting was modified based on feedback
IKAUNUNU Of- MEDICAL STUDENTS UNDER COMMUNITY MEDICINE POSTING
from students and staff. This article reviews the
modified community medicine posting in JIPMER
and analyses the same for the year 1985.
Educational Objectives of the Commu
nity Medicine Posting including ClinicoSocial case Presentations:
posted in batches of 15 - 20 (total about 60) in the
Department of Preventive and Social Medicine for
one month between 1000 to 1300 hrs. every day.
The day-to-day work schedule is given in annexurc
L
Modifications done in the Posting
There was no change in the educational objec
tives of the Community Medicine posting and Clinico-social case presentations. These were:
During the first few years from 1980 the commu
nity diagnosis part of the posting was only for 10
days including analysis and presentation. Then
students were taken to the urban field practice area
a)
Community Medicine Posting
for 8 days to work with field health personnel and
thereby understand their working pat tern and also
At the end of the posting the student should be able to work on the clinico-social case allotcd to them
to — i) plan and organise a health survey, (Bansal et al,) *. Later based on the periodic staff
ii) describe the demography and socio-economic review meetings in the department and suggestions
status of the population surveyed and compare the from students to improve the community medicine
same with national statistics, iii) identify the posting, the urban health centre posting was
health needs and problems of the community stopped and the posting in rural area was increased,
including tire type and extent of common morbidi since students indicated that they wanted more time
ties prevalent in the area, iv) interpret the health to-work in the village for community diagnosis; be
statistics of the community, v) describe the health sides, they are taken to urban field practice area
sources available to the community, vijsuggest once every week for their family health advisory
appropriate promotive and preventive actions to be proagramme which is spread over two semesters.
taken.
The various changes made in the community
b)
Clinico-Social case Presentation
medicine posting were:
h The student should be able to — i) elicit the agent,
host and environmental factors in the natural his
tory of disease, ii) suggest appropriate promotive,
preventive and qurati ve measures for the patient,
his/her family and the community.
1.
Administration of pre-test and post-test (see
Day 1 and 25, Anncxurel).
Details of the Modified Community
Medicine Posting:
2.
More time for village health survey to allow
satisfactory coverage.
The II nd Clinical year students (seniors) are
This was to assess the gain in knowledge of
students through the postings.
3.
Visit to the local PHC and local office for reg-
The Indian Journal of Medical Education
istration of births antftalhs.
attended the post-test. FWpurposes of analysis the
following grading was used according to the per
centage of correct responses to each question, viz;.
below 30% - poor; 30% to 50% - below average;
5.
One full day for school health.
50% to 60% - average; 60% to 70% - above
average; 70% to 80% - good; 80% and above - very
6.
One seperate day for chlorination of a well and good.
environmental sanitary round.
The pre- test showed that an average of 85% of
7.
Cases for clinico-social presentation were the students had correct ideas about general life (in
identified by the students from the village during cluding general health practicc)and socio-eco
their health survey.
nomic status of villages as evidenced by their re
sponses to questions like percentage of rural popu
Analysis of Pretests and Post-tests for the lation in India, village administration, common
year 1985:
occupations, common crops grown, common types
of houses, whether overcrowding is a problem,
A total of 61 students attended thepretestand59 common source of water supply, method of refuse
and excreta disposal ctc.(Table 1).
TABLE 1
But this was not so regarding demography, vital
Students’ knowledge about general life and sociostatistics, health knowledge, attitude and practices
economic status of villagers
of
villagers, health care, health services including
Correct responses in %
Questions
Pre-test
Post-test
duties of field health personnel, etc. The knowledge
of
students in these areas was poor to below average
85
1. % of rural population
80
in India
on the whole (28%) in the pre-test. But this changed
90
2. Common occupation in
78
significantly in the post-test -average to very good
villages.
on the whole (65%) - which indicates that practical
70
92
3. Common crops grown
98
98
4. Village administative
field exposure helped the students in these areas.
set-up.
Details are given in Table 2. This was found true
73
5. Common type of houses
72
97
96
■k Whether over-crowding
even in the last batch of students which attended the
™ is a problem.
posting in rotation by the term end and therefore
92
7. Common source of water
88
supply.
had already underwent most of the theory classes.
4.
Daily health talk by students.
8. Is water chlorinated regu
larly.
9. Method of refuse-disposal
lO.Method of excreta dispo
sal.
91
95
86
98
88
100
Average
85.7
91.0
The attitude of the students about the villagers
also changed. In the pretest most of them felt that
rural people were uncooperative, suspicious and
very superstitious. During the post-test they felt that
villagers are more cooperative, trusting and only
somewhat superstitious. Their attitude was the
The Indian Journal of Medical Education
TABLE2
TABLE 3
Students’ knowledge in pre-test and post-test
Correct responces in %
Questions
Pre-test
1. Male female ratio in India 47
k 2. Average family size India
5
’ 3. Literacy rale
18
4. Monthly pcr-capita income 18
5. % population sick at any
28
given lime
6. CBR
8
7. CDR
5
8. IMR.
26
9. Antenatal cases per 1000
14
10. Eligible couples per 1000 2
11. Beliefs of villagers about 59
causes of diseases.
12. Most popular family plann -34
ing method in villages.
13. Health personnel available 54
in the villages
14. Person giving immunisa 26
tion in villages.
15. Routine immunisation
13
to under five
16. Persons providing antenata!46
care in villages
17. Persons conducting most of56
the deliveries in Villages
18. Place where delivary
58
is commonly conducted in
V villages.
Average
28.7
Post-test
68
51
76
81
61
59
56
63
22
5
86
80
90
76
25
81
85
98
616
Students ’ assessment cf their gain in knowledge
through the commu nity medicine posting
Poor
Fair
Good
1. Clinical ability
17
under rural
conditions
2. Understanding
2
Epidcmilogy and
natural history
of disease
3. Application of
5
principles of pre
vention in clinical
practice
4. Ability to estab
2
lish good rela
tionship with
villagers.
5. Understanding
4
socio-economic
factors in
disease.
6. Health education
4
7. Other communi 14
ty health measures.
8. Ability to get
7
along with prof
essional colleagues
and auxiliaries.
9. Ability to learn
2
from practical
experience.
10. About rural
life.
11. Research and
12
survey methodlogy-
57
17
27
59
12
26
47
22
20
46
32
13
46
37
Questions
Average
6.2
Very
__ Good _
9
37
30
37
46
22
10
23
46
24
18
46
34
17
49
34
35
34'
19
27.6
43.0
23.2
same both in the pre^P. and post-test about the
villagers’ friendliness, dependability, honesty and
religiousness. It may be noted that more students in
the post-test felt that the villagers are pessimistic.
Students also understood and appreciated impor
tant aspects like community involvement, health
economics, and multisectoral approach in solving
problems related to health.
While assessing their gain in knowledge through
the community medicine posting, on an average
^.2%of the students rated it as very good, 43% felt
good, and 27.6% termed it as fair. Table 3 gives
die figures in detail. It may be noted that almost
70% of students termed their gain as “good/very
good” with reference to understanding epidemiol
ogy and natural history of disease, application of
principles of prevention in clinical practice and
understanding socio-economic factors in disease,
whereas 57% students termed their gain as only
“fair” with reference to clinical ability under rural
conditions indicating that there is need for rein
forcement in the latter category.
Students’ suggestions to improve the post
ing
L Most of the students felt that the posting should
be increased by another 15days.
They felt they can meet all the people in the
village if they go to village in the early morning
hours (eg. 0700 hrs.) rather than 1000 hrs.
3. They felt that they should stay in tire village
itself for the whole month of the posting to allow
comprehensive understanding of their life.
4.
Students were of d^iew that the question
naire for village health survey should be structured
by themselves after briefing and guidance.
5.
Students felt that nutritional survey can also
be incl uded in the health survey.
CONCLUSION
In addition to the theory and practical classes
direct field exposure of students in the practice of
Preventive and Social Medicine helps them to learn
and remember more. Personal involvement helps
in reinforcement of knowledge.
ACKNOWLEDGEMENT
The authors express their thanks to Dr. O.P. Bhargava, Director, JIPMER, Pondicherry, for his en
couragement and help.
REFERENCES
1. Bansal R.D., Satpathy S.K., Bina Dasgupta,
Moni G.S., Ramalingam G: Orientation training
for medical students under community medicine
posting , JIPMER, Pondicherry. UME XXI (2) p 4852,1982.
2.
Medical Council of India - Recommendations
for under-graduate Medical education -1977.
3.
Medical Council oflndia-Rccommcndations
for graduate Medical education -1981.
ANNEXURE
DAY-TO-DAY SCHEDULE DURING
COMMUNITY MEDICINE POSTING
Day 1: pre-test is administered to the students on
thefollowingregardingthevillages: ^Demogra
phy, 2) Topography and geography, 3) Socio
economic status, 4) Environmental sanitation, 5)
Health knowledge, attitude and practices (includ
ing customs and beliefs), 6) Vital statistics, 7)
I^alth care and health administration , 8) StuflRts’ idea of rural people.
Then a detailed briefing is done on community
diagnosis and methodology of village health sur
vey.
Day 2: Students are taken to the village of post
ing. They identify the village leaders (formal and
non-formal), talk to them and win their confidence
and cooperation for conducting the health-survey
of their village. They also make-a spot map of the
village.
Day 3-9: Students do the house-to-house village
health survey in smaller batches (3-4) and collect
data with the help of a predesigned questionnaire.
Everyday they give health talk to groups of villagers
on ^pific, relevant topics.
Day 10: Students visit the local school/bal wadi/
anganwadi and carry out a detailed sanitary round
of the school. They do health check-up for the
children and if possible see the school health rec
ords. Health talk is given to the children.
Day 11: Asanitary round of the village is done
to observe the cnviroM^ntal conditions and a
health talk is given. Thc^also chlorinate a well.
Day 12: Students are taken to the local PHC.
They have a meeting with the health workers to
understand their duties and their nature of field
work. Later they visit theofficeof Registration of
births and deaths.
Day 13-14: Students in small batches (4-5) work
on selected clinico-social cases of public health
importance which they have identified in the vil
lage like: pulmonary TB, leprosy, malnourished
child, expectant mother, any other communicable
or non-communicable disease of interest like RHD,
enteric fever, STD, etc.
Day 15t19: Presentation and discussion of clin
ico-social cases arc done with a senior faculty staff
as moderator.
Day 20-22: Students do analysis of data col
lected.
Day 23-24: Presentation and discussion of com
munity diagnosis and recommendations with a
senidr faculty staff as moderator.
Day 25 : Post-test is administered on the same
pattern as the pretest In addition students give their
own assessment of gain in knowledge through the
posting and also give suggestions to improve the
posting.
Neefts for Understanding Community Medicine
Mrs. H. Dhillon
Dirtclor, Community Medicinr, Christian Midieat Collrgt, Ludhiana,
F.
C. Eggleston,
Professor of Surgery, Christian Medical College, Ludhiana.
c/
B. Cowan
Professor of Medicine, Christian Medical Collrgt, Ludhiana.
During the past few years, there has been
much discussion concerning the need to re
orient medical education and medical practice
so as to provide better total service to the
public. Medical science has been progressing
rapidly, particularly in the past 50 years, to a
point where brilliant results can be obtained,
but often only through the expenditure of
ever-increasing financial resources. While
no one would deny the right of all individuals
to the best care possible, it is obvious that only
wealthy societies or affluent individuals can
afford the same.
The solution is obvious. The solution is to
get physicians involved and interested in com
munity medicine. Before examining possible
methods of developing physicians so skilled,
we should examine and determine what we
mean by ‘Community Medicine’ and what we
expect of those who might commit their life
efforts to this work.
We believe it is very important to recognise
that community medicine is not simply another
term for public health. While the two are
undoubtedly related, as indeed, are all forms
of medicine, public health to-day has certain
Because of this, and because it is generally very definite commitments; in the preparation
accepted that the medical community has as and control of epidemics, and in the overall
its primary responsibility the health of the sanitation and water-supply of the community.
total population, new methods of health care While community medicine must encompass
delivery have been looked for. To this end, many of these aspects, it seeks to go further
community health programmes have been ini and to determine the needs of the individual
tiated and developed. Their basic goals have community, and how best they can and should
been to provide the best care possible to be met, and eventually develop a programme
maximal population within a reasonable cost. for this purpose. In accordance with this,
However, development of the basic delivery community medicine includes a large amount
systems is the responsibility of Government of practical therapeutic medicine which will
and is sensitive to political changes. Unfor vary from one geographical district to another,
tunately, too frequently, in the past parti but certainly will include, in India al least,
cularly, those responsible for beginning or knowledge of communicable diseases, nutri
managing such systems have been too far from tional deficiencies, maternal-child health
the actual fields of service to understand their family planning care besides, internal medicine,
numerous problems. Unfortunately, only in- O
pntnaimc
ophthalmology,
public health, and some of
I frequently have physicians with adequate tll\. more: simple^
simple surgical
surgical skills.
skills. The
The corn
com-
field experience been associated with the pro- munity health physician to-day must be able
gramming agencies. Equally unfortunately, t0 diagnose disease, to treat the majority of
too few physicians have such field experience, ailments, and to know which conditions
This, however, seems to be changing and require referral for specialized therapy.
many physicians are seeking to establish com
munity programmes which will be suitable to
As stated earlier, the problem has been to
the environments in which they are situated, get physicians involved and motivated to work
However, too often these programmes are in this field. To say that such service is not
based upon the genius or commitment of one challenging is puerile, to say it is not intellecor two workers who stimulate others to join tually stimulating, is ignorance. There are
with them. Not often enough are they based not adequate inducements, however, to-day
on doctors or para-medical workers trained or nor have there been so in the past. Motivapurposefully in these fields.
tion of physicians has frequently been a desire
1,18
TUB INDIAN JOURNAL OF MEDICAL EDUCATION
to serve. While this is the ideal motivation,
there is no question that financial remunera
tion, and position in society have also played a
very large role. Indeed, it is wrong to expect
all physicians to be motivated by the concept
of service and by this alone, even as it is
wrong to expect all lawyers or engineers to
have similar motivation in their work.
VOL. XIV NO. 2
tology, pediatrics, obstetrics, and gynae
cology and ophthalmology.
Surgical fields
should emphasize minor surgery and the
recognition of major surgical problems needing
referral to more specialized centres. Quite
properly a large segment of time must be
devoted to public health work, and we believe
experience in administration and the develop
ment of useful para-medical workers should
Accepting the fact that financial remunera be included. It is our belief that at the end
tion and social status arc motivation in any of training, an examination should be given
field of work, it becomes important to ask and accreditation awarded if the candidate be
ourselves if we have provided these stimuli to successful.
encourage physicians working in community
Where should such a training take place?
medicine. The answer is an unequivocal no.
The physician who goes into a clinical field Medical Colleges, affiliated as they arc to
. such as surgery or medicine may rise to be a Universities, should not be the only places.
professor, a physician of status, or he may The present curricula direct the attention of
enter private practice and receive large mone the student to the minutiae of the diseases of
tary rewards which are certainly unavailable the few who come seeking help, and the needs
to those in the fields of community medicine of the community from which these patients
or its allied branches. The innate abilities of come is often overlooked. While none would
the community physicians and the surgeon understimatc the impoitance of good medical
may be equal but recognition of this by the care being given in hospital, there is no hope
public as well as by the medical profession of training doctors for the developing world
itself is not. It, therefore, becomes important so long as this aspect of their training is left to
to establish measures to recognize both the department of Social and Preventive Medi
importance of community medicine and the cine. This department is probably the one
ability of the physician whois well trained which can most easily co-ordinate theory, field
work and the active participation of all the
and capable in this field.
clinical departments. Ideally this could be
We, therefore, propose and believe that done by having in each clinical department at
community medicine should be recognized as the level of Assistant Professor, a teacher res
a separate and distinct postgraduate field of ponsible for the Community Medicine teach
study and should receive suitable educational ing of that department. This docs not mean
and financial rewards. Quite obviously the that he alone will teach this aspect but, will
academic reward would be the establishment see to it that the community health teaching
of suitable and recognizable degrees in com to the undergraduates posted in his depart
munity medicine and the financial rewards ment is taught by the most appropriate
would be to recognize community medicine as faculty member, for example, malnutrition in
a specialized field in its own right. Without the homes, by the teacher in the pediatric
this, we do not believe that it is practical in department whose special interest is in disease
India to-day to hope for adequate develop of nutrition. This person will have to work
ment in this most important and most per with communities to be able to appreciate the
tinent area.
needs of community.
It is easy to say there is no syllabus for
Entrance into Medical Colleges is highly
education in community medicine. This is a competitive and few who gain admission do
specious argument, for the development of so with the ambition of becoming Community
such a syllabus could easily be stimulated by Health Physicians. This term is still synony
agencies such as the Indian Medical Council, mous with the need to live in a village, to
the Association of Physicians of India, or the forgo the amenities which many now consider
office of the Director of Health Services. necessities, and to commit social if not pro
Clearly any such syllabus must include basic fessional suicide since this speciality has until
therapeutics in the fields of medicine, derma- now no post-graduate training or qualification.
JULT-llECEMBER 1975
NEEDS FOR UNDERSTANDING COMMUNITY MEDICINE
■ However, few of us who are specialists to-day,
I entered medicine with that speciality in mind :
opportunity in certain departments and the
enthusiasm and expertise of clinicians whom
we admired were factors which influenced
many of us. Why could this not be true for
Community Medicine?
In Christian Medical College, Ludhiana, we
i have realized the need for exposure of the
i medical students from the first year, to the
i community, its problems and the relevance to
i the course they have started. Someone, usually
the community health team with the help of
; the Social and Preventive Medicine Departi ment guides the students in their involvement
I with families in the city area, and conducts
I regular meetings of the whole class and
i teachers to share information and discuss pro• blems. Faculty committed to Community
Medicine could alter the present curriculum
without any radical changes at Medical Council
of India or University level, i.e. we do not
have to wait for these changes although obvi
ously they are desirable and must come. Con
currently, with the formal course in Social
and Preventive Medicine the clinical students
are exposed to the community aspects of all
they arc learning.in the wards, every lecture
course can have at least one session devoted to
the community aspect of the subject, and in
this way the faculty themselves receive the
training in a skill which is new to them and
and increases not only their knowledge, but
effectiveness as teachers. As the course pro
ceeds, the students arc taught in the com
munity as well as in the wards. For example,
the field staff finds a problem in the course of
their home-visiting. It may be a child with
malnutrition, a man with bladder stones, a
diabetic ease or rheumatic heart disease.
The field team ‘workup’ the family, send a
synopsis to the appropriate clinical teacher,
pediatrician, surgeon or physician respectively
and that teacher, instead of bedside teaching
in a ward, will take his class to the home
where the field team present the problem.
Teaching on all aspects is given by the clini
cian who may at first need guidance from the
Community Health Department but soon
learns that what is needed is the highest quality
of clinical teaching. This is teaching not
119
‘ watered down ’ by the field circumstances,
but * sharpened ’ so that the potential doctor
is being taught to manage the situation with
out complicated facilities, i.e. his clinical
acumen is being trained and less reliance is
being placed on his ability to interpret a
battery of expensive laboratory procedures,
which arc largely irrelevant for the developing
world.
By the time that the final examination is
over the student is prepared for community
internship. This, therefore, is not a new
speciality of which the intern is afraid but one
in which he is already familiar with the pro
blems. He already knows how to study a com
munity, learn its needs, make a community
diagnosis, make treatment programmes and
evaluate their effectiveness and understand the
priorities of the community. This makes his
internship interesting as he learns man
agerial skills and how to become a leader of
the medical team. Already we have found
that, just as one’s first house-job often
decides one’s future career, community
health internship motivates the graduate
to take this discipline on a career basis.
This has already happened in Christian
Medical College cvcnthough the under
graduate preparation is still not being done in
sufficient depth by a sufficiently large propor
tion of the faculty. However, once a young
doctor has caught this vision and sees in this a
challenge demanding the highest possible
curative skill and continual education rather
than stagnation in a cul de sac where third
class practice goes unnoticed, the problem now
is, what is the next step? Following gradua
tion field experience is mandatory, but there
comes a time when a post-graduate qualifi
cation is not only necessary for his own pro
fessional satisfaction, but the lack of this
may debar him from holding a teaching post
where he in turn can influence others. There
fore now is the time to press those responsible
for the under-and post-graduate curricula of
the country to lose no time in reshaping the
training programmes that the potential com
munity physicians, who are already enthusias
tic about remaining in this field, may not be
discouraged and leave it for areas where the
rewards arc more easily obtained.
JANUARY-JUNE 1974
2.
Health Needs of The Community
*
by
K. N. Rao, M.D., FAMS, FAPHA, LLD (HOn)
1.
The theme of the Third World Medical of the less developed countries in different
Education Conference that was held in Delhi stages of social development, burdened with
in 1966 was “Medical Education in the Ser poverty, sickness, illiteracy, and struggling to
vice of Mankind.” It is indeed appropriate benefit from the advances made in science and
that the 4th conference in 1972 is following it technology to catch up with the other two, as
up as a logical sequence the “ Educating to speedily as possible. As such when the ques
tion of educating the tomorrow’s doctors is
morrow’s doctors ” as its theme.
considered, it is necessary to ask, for which
1.1
Evolving Mankind : Evolving man has World? The needs of the communities and the
passed through three phases. The first was people of the third World in Asia,. Africa,
strictly biological and during this phase human Latin America and West Pacific island are
beings acquired the basic habits of dealing different and their environments physical, bio
with one another which still govern the beha logical and social are so varied.
viour of the individuals, communities and
nations. The Second phase was the beginning
1.3
In the preamble to the Constitution of
of cultural development like domestication of the World Health Organisation, the following
animals, hunting, arts and crafts, religious are some of the principles enshrined :—
practices and seeking of new things. The third
“ Health is a State of complete physical,
phase began with the Neolithic Man and in
the last 10,000 years, gradually acquired all mental and social well-being and not merely
the qualities and culture of modern civilization absence of disease or infirmity.
and inventions. Health as a part of cultural
“The enjoyment of the highest attainable
development began to appear as a great human standard of health is one of the fundamental
activity. At the end of this phase in 1945, rights of every human being without distinction
Man developed the capacity to destroy himself of race, religion, political belief, economic
by inventing the nuclear device. The fourth and social condition.
phase ushered the organisation of United
“ Governments have a responsibility for the
Nations and the allied agencies for the benefit
health of all people which can be fulfilled
of all mankind.
only by the provision of adequate Health and
1.2 The march of progress and develop Social measures.”
ment, however, has not been uniform for all
All the Governments who are UN members
mankind and as such in this spaceship “Earth” have attested to the above principles.
there are three words with different social sys
With the organisation of the UN and its
tems with different needs. The First, the World
of the advanced Western Nations with the allied agencies, the revolution of the rising ex
highest Gross National Product; the second, pectations of the peoples of the emerging
the Communist World with a different social countries and the Health revolution are set in
system and social values and the third the World motion.
Presented at the Family Health Workshop, India International Centre, Organised by the Population Council
of India,
Health Status and Health Needs
In determining the Health needs, the Histo
rical, Political, Cultural, Economic, Demogra
phic, Environmental, Epidemiological and
Scientific and Technological, etc. determinants
have to be considered.
HEALTH NEEDS OF THE COMMUNITY
23
of unemployment, and in other cases of unde
served want.
“ The State shall make provision for secur
ing just and humane conditions of work and
maternity relief.
“The State shall regard the raising of the
2.1
Historical determinants: The Bhore level of Nutrition and the standard of living of
Committee (1942-46) in its recommendations its people and the improvement of the public
kept some of the following principles for health as among its primary duties.”
future health development in our country.
The Planning Commission was established in
“No individual should fail to secure ade 1950 and Health development has been taken
quate medical care because of inability to up as an integral part of the socio-economic
development of the country. The Health sec
pay for it.
tor has received about 4 to 5% of the plan out
“ In view of the complexity of modern lays for its programmes. They are broadly,
medical practice the health services should establishment of Primary Health Centres in the
provide, where fully developed, all the Rural areas and expansion of institutional
consultant, laboratory and institutional facilities; development of Health Man Power,
facilities necessary for proper diagnosis Control of communicable diseases such as
Malaria, Smallpox, Cholera, Tuberculosis, etc;
and treatment.
environmental hygiene; Family Planning and
“ The health programme must, from the other supporting programmes for raising the
beginning, lay special emphasis on preven standard of the health of the people.
tive work. The creation and maintenance of
as healthy an environment as possible in
2.3 Cultural Determinants: The cultural
the homes of the people as well as in all determinants of the Health care system in
places where they congregate for work, India had a great past from the time of the
amusement or recreation are essential....... Indus civilization. The Ayurvedic system was
“The health services should be placed as at its height upto the Moghul Conquest when
close to the people as possible in order to the Unani system was introduced. These two
ensure the maximum benefit to the com systems still flourish in the country and a large
munities to be served. The unit of health population patronise and obtain relief. With
administration should therefore be made the advent of East India Company, .Western
as small as it is compatible with practical medicine was introduced and the public health
considerations.
movement started. The present Hospital sys
“ It is essential to secure the active coope tem began in Madras, Calcutta, and Bombay
ration of the people in the development and later at the headquarters of the districts
and Taluks besides rendering medical relief
of the health programme...........
through dispensaries and mobile units to serve
2.2
Political Determinants : The Directive remote areas. To man these institutions, Medi
Principles of State Policy in the Constitution of cal Colleges and Medical Schools were estab
the Republic of India state as follows
lished on the lines of the then prevailing sys“The state shall, in particular, direct the tern of medical education in U.K. with little
X
emphasis on community medicine_
policy towards securing............................
....... that the health and strength of workers,
After the advent of independence parallel
'
men and women and the tender age of child systems of medicine are operating, with the
0®
ren are not abused and that citizens are not encouragements of the Government, though by’
p
forced by economic necessity to enter a voca and large the modern system of medicine is
tion unsuited to their age and strength.
gradually extending its scope and services.
“ The State shall within the limits of its eco Primary’ Health Centres are developed in 5500
nomic capacity and development, make effec blocks each with 80 to 100 thousand popula
tive provision for securing the right to work, tion, and they are expected to offer integrated
to education, and to public assistance in cases health services to the people.
24
THE INDIAN JOURNAL OF MEDICAL EDUCATION
vol. xiii
nos. i st 2
The cultural determinants are further ham consumes the savings leaving very little for
pered by linguistic, ethic, religious beliefs, investment for development to raise the levels
customs, poverty, superstition and illiteracy of living. Further one third of the children
impeding the progress of modernization and die before the Age of 5. The total deaths
under the Age of 14 are 3.28 million a year
social change.
and under the age of one 1.4 million. The
differential mortality according to social class
2.4
Demographic Determinants:
indicates that the majority of deaths occur in
2.4.1
India with 2.5 per cent of the world’s the third, fourth and fifth social classes. Con
land area has 15 per cent of the world’s popu sidering the money value of man and the
lation. The population of India recorded at economic loss that is incurred consequently it
the 1971 census was 547.4 millions with a ratio is for consideration whether this huge economic
of 932 females to 1,000 males. Population waste should be permitted to go on or it is to
growth is 2.45 per cent per annum. The den be prevented. The relationship between Fer
sity of population is 180 per square km. The tility and infant and child mortality has been
literacy rate is 29.35 per cent (Males 39.49 and fully established.
females 18.47 per cent). The urban population
Population, Food and Nutrition are interrela
is 108.8 million (19.9 per cent) with 438.6 mil
ted and nearly all the problems of family life
lion (79.1 percent) rural population.
and Family Health depends on its size.
The birth rate (Sample Registration System)
Public Health and Medical education are
is 38.8 Rural (1969) and Urban 32.8 per 1,000.
Total 37.5. The death rate (S.R.S.) is 17.5 per vitally concerned with population, their
1,000 in 1969. Total mortality is estimated as numbers, age, sex, composition, migrations,
9 million (1961). Infant mortality rate (1969) birth and death rates in Age specific groups.
139 (1935) 174. Age specific Infantile mortality Overpopulation affects the health of the com
munity adversely both physically and mentally.
rate for 1969 shows:
Population in India is growing at the rate of
2.4
per cent per annum which means the popula
Total Below
7-28 29 days to 6 months to tion would double itself before the end of the
7 days
days 6 months
1 year
century unless effective steps arc taken. Wins
22 6
low has made out that poverty breeds disease
42.7
1969 139.9 42.7
32.1
and disease breeds poverty. After the advent
of the demographic revolution a new pheno
The expectation of life (1968) is 53.2 males mena is taking place. Poverty-disease-popula
and 51.9 for females. Basic data and Age tion increase-Poverty-disease. This chain of
specific death rates (1961) (Annexe).
interactions can only be broken by the adop
tion of fertility control.
Population increase over 1951 census is 213.7
million.
2.5
Environmental Determinants:
2.4.2
Population Pressure: The interaction
2.5.1
Housing: National Sample Surveys
between Population and health is well known.
showed that in Rural areas about 73 percent
Health in the family or a social group depends of the households live in “ Kucha ” and about
on the dynamic relationship between the num
bers and the space they occupy and the skills 2 per cent in “Pucca” houses; in urban areas
houses are 25 per cent and 8 per cent
they have acquired to provide for their needs. such
respectively; the remaining ones both in urban
The well-being of a family or a social group or
and rural area being of the mixed type i.e.
a nation depends on the ratio between resour partly “Kucha” and partly “Pucca”. Density
ces and population. If the resources are cons-. per room in rural areas was found to be 2.4
tant and the population increase in numbers persons and in urban areas 2.2 persons. Ave
the levels of living will fall, in a family or a rage floor area per person in the rural and
nation.
urban area was 77.8 and 69.5 square feet res
In India children under the age of 14 number pectively. The conditions in the Metropolitan
nearly210 million (1961) i.e. 40 per cent of the and industrial cities and capital towns arc much
total population. This large dependency rate worse,
JANUARY-JUNE 1974
HEALTH NEEDS OF THE COMMUNITY
25
2,5.2
Facilities such as tap water, etc. are lems of life, high fertility, the demographic
largely unknown in rural areas but by the end disease pattern of infants and children and
of the third plan 1700 villages are provided poor levels of living arc all present in this
with piped water supplies. 30 per cent of the social group. There is a distinct health deficit
villages and hamlets are without adequate among the poor. These form the major seg
water supply. 20 per cent are without any ment of the people in rural areas and in urban
satisfactory source of water supply. People slums. Poverty is a causative factor in human
mostly depend on wells, ponds, and tanks for ill-health. As we are committed to the social
drinking water. In urban areas 47 per cent of betterment of this disadvantaged group, the
the households do not have tap water facilities • working of the Primary Health Centres and
Urban Centres serving them should have com
and 30 per cent depend on wells, tanks, etc.
prehensive health services. The physician of
2.5.3
Sanitation: Even after the three plans, tomorrow should as a team leader solve the
the environmental sanitation with particular problems arising in the delivery of health care
emphasis on water supply and sewage disposal services to all segments of the population.
remains one of the major public health prob A compulsory Health Insurance Plan to all
lems on account of enormous outlay that is members of the society with contributions for
required. About 2 million deaths are caused this group made by the State would take away
by water borne diseases and about 45 million the stigma of poverty.
people suffer from ankylostomiasis.
2.6 Economic determinants: The average
2.5.4
Urbanisation, Industrialisation and National Income per capita (1966-69) is
Rs. 315.1 (314.9 in 1961-65). It has been
rural, urban migration:
found that consumption expenditure per
The 1971 census has shown with 19.9 per cent person during 30 days is about Rs. 20 in the
of the population are in the urban areas. It rural sector and about Rs. 27 in the urban
should be noted that a population of 109 million sector. The expenditure on health in
from the urban India which alone can rank India is about 0.6% GNP and Rs. 2 per
among the biggest countries in the world. On head per vear when compared to Ceylon 2.8%
further analysis it is found that 142 cities, with GNP and Rs. 17, and US 1.2% GNP and
1,00,000 or over, have 52.4 per cent of this Rs. 140 (1954-56), per head per year. This
popluation. Without adequate housing, sani expenditure however does not represent the
tary facilities and employment opportunities total spending. The National Sample Surveys
for the migrants, the condition is getting of India suggest that even the poorest rural
precarious. The social consequences of mush communities spend 2 to 3% of private income
rooming and squatter settlements in almost for drugs and medical care. In India where
all cities have become a public health hazard. the public expenditure on health is particularly
Political violence, student unrest, extensive low, the implication is a great “ inequality
housing shortage, break down of public trans in the distribution of expenditure on medicine
port, water supply, electricity, etc. have become and medical services. ” * (P. C. Mahalanobis
a routine feature of our urbanisation. Urban 1959). The lower half of American households
development with integrated Health and Social account for 37% of total private expenditure
Services requires a long range planning to for medical services, and the corresponding
avoid the fate of Calcutta repeating itself all figure for India is 6%. So far in India the
over. The problem of pollution of the envi concept of “Investment” means only physi
ronment is real in our cities. Air pollution, cal investment. Investment in Health and
water pollution and even radiation hazard Education is investment in “ human capital ”
need our increasing attention.
but this realization is yet to come to our plan
ners in India in our approach to development.
2.5,5
Social Environment: Poverty and Health
Epidemiological Determinant! and Health
Poverty affects all aspects of life including 2.7.
situation in India.
Health, illness and related behaviour. The
2.7.1
Mortality and Morbidity: Women:
mortality and morbidity rates are high in lower
socio-economic classes. High rates of illiteracy, In the recent census it is seen that there are
high rates of non-utilization of the existing only 932 females for 1,000 males. There is
health facilities, traditional approach to prob greater mortality and morbidity amongst
26
THE INDIAN JOURNAL OF MEDICAL EDUCATION
women. There is no data on female infanti
cides. The maternal mortality is 6.8 per
1,000 live births (1968). In the rural areas
85% of women continue to have the services of
the indigenous dais at the time of child birth.
In the rural areas even at the time of child
birth, when it is a matter of life and death,
services are inadequate and mothers continue
to deliver in unhygenic environments resulting
in high perinatal and maternal mortality and
maternal morbidity. It is estimated that 9
million abortions occur of which 30 to 40%
are stated to be induced. The disability and
deaths abortion causes in women are not
accurately known but this would explain partly
the ratio between the males and females in
India.
, 2.7.2 Children: The proportion (1961) of
children under the age of 1 is 3.78% with
28.3% age specific death rate; under 5 is
12.67% with 13% deaths, and 5 to 14 24.5%
with 6% age specific deaths. This shows
47.3% of the 9 million deaths occured under
the age of 15. The total number of births per
annum are about 21 million (1961). The
infant mortality forms 6.76 per 1,000 popula
tion (I.M.R. 159). According to parity 24%
(first), 13% (second); 11»% (third); 11%
(fourth); 13% (fifth); 11% (sixth);
17%
(seventh and others) infant deaths took place
(Gordon). 10.71 deaths per 1,000 livebirths
are due to the low birth weight; 20.3 due to
tetanus, 27.8 Diarrhoea, 107 Pneumonia,
5.7 Measles per 1,000 live births (Khanna
Study). These figures are of great significance
for taking preventive action.
2.7.3
Causes of Deaths—1962-64.
I. Infective and Parasitic diseases
2.
Disease of Respiratory system
3.
Early infancy
4.
Senility
5.
C.V. Diseases
6.
Nutritional diseases or disease
of blood forming organs
7. Digestive system
8.
Accidents, Poison, etc.
9.
Diseases of C.N.S.
10.
Neoplasm
11.
Miscellaneous
14.42%
15.78%
13.23%
10.90%
9.21%
8.65%
9.24%
6.87%
4.67%
4.2%
3-6%
VOL. XIII
NOS. I & 2
2.7.4 Prevision of Medical Care : In 1968
there were 3,107 hospitals; 6,764 dispensaries
giving a bed population ratio of 0.4 beds per
1,000 population. 5,500 Health Centres
(Unopened 250: without M.O. 400).
Family"'Planning Services: Family Planning
Services are available in 34,000 family plan
ning centres and sub-centres located in the
urban and rural areas besides 800 mobile
units. The aim is to reduce the birth rate to
32 by 1974. Of the 97 million (1961) couples
in the reproductive age group only 11% have
been reached by one or the other of the
contraceptive services offered.
2.7.5 Health Man Power:—Physicians
103, 184 (1966) ; 80% in urban areas. 5,673
Dentists, 74,564 Pharmacists; 57,621 Nurses;
Nurses/Doctors ratio 1 :2 (Normal 3:1)
It may be noted that the Health Pyramid is
inverted and that there are more doctors than
nurses. The proportion of doctors to para
medical personnel should be 1 : 20. Doctor/
Population ratio is 1 per 4,800 (1968). At
present 95 medical colleges have about 12,000
admissions. It was estimated that the number of
indigenous practitioners in the country varies
between 200,000 to 400,000.
2.7.6. Social Security: The industrial
population is over four million who are cover
ed by the Employees State Insurance Aet.
With the inclusion of families for medical
benefits about 20 million population are thus
cared for. There is need for extension of the
service to include Agricultural labour.
The Government employees, the Defence
Service personnel, the railways, and other
specialised groups have arrangements for
health care. Even in these groups there is no
comprehensive health service and there is a
need for reappraisal of the quality of the social
security and the benefits they obtain.
2.7.7' Communicable Diseases :
Malaria; The National Malaria Eradication Programme is expected to continue beyond
1975. Out of 393.25 units in the country in
1968, 209.88 are in the maintenance phase;
183.77 were in the consolidation and attack
phase. The Malaria Programme had a set
back since 1S65 due to irregular supplies of
chemicals. There is no adequate epidemio
logical surveillance for want of proper basic
health services in position. Reintroduction pf
JANUARY-JUNE 1971
HEALTH NEEDS OF THE COMMUNITY
27
Consequences ef ill health: In addition to the
Malaria in some pockets is reported. The
establishment of basic health services and the diagnosable conditions there -are incipient
retention of Malaria Workers as basic health diseases and general debility caused by low
staff for all public health work is considered levels of living, undernourishment and malnourishment. This is largely responsible for the
fundamental.
low productivity and efficiency.
Smallpox Eradication: In 1968 there were
34,741 cases with 7,727 deaths. The progress
at present is reassuring. The maintenance 2.8 Scientific and Technological Determinants
phase requires intensive primary vaccination
2.8.1. In the twentieth century there has
program and epidemiological surveillance.
been remarkable progress in the. field of
Diphtheria continues to cause preventable _ scientific discoveries and their application to
Medicine. The introduction of antimicrobial
deaths.
drugs and pesticides has revolutionised our
Cholera: 18,145 cholera cases occured in therapeutic efficiency and the control of insect
1968 with 2,916 deaths.
borne diseases; longevity of man has been
Tuberculosis: 1.5 to 2.5% of the population increased; diseases have been brought under
require clinical attention. It was stated that control; mortality has been reduced, which
out of 502 clinics only 195 are equipped. has resulted in the high population growth.
15 demonstration centres are functioning to- Death rates have fallen steeply in the last
dav. Mortality due to Tuberculosis is estimated 20 years though not to the same extent as in
to be 100 per 100,000 population. 10 to 12% advanced countries without any comparative
rise in the levels of living and reduction in
arc resistant organisms.
birthrate, thus hampering social and economic
The estimated number of the Leprosy cases is development.
Advances in contraceptive
2.5 million of whom 20% are infectious. 182 technology have given us tools for fertility
control units and 1,136 SET centres are control but their use is lagging behind. There
functioning.
is hope that improved methods would be
Eilariasis : It is another major public health available in the forseeable future which would
problem. 126 million people are living in help developing countries in their economic
endemic areas. - It is estimated that 45 million and social progress.
people are infested with Ankylostomiasis. 10%
2.8.2
Mass Media and Communications: The
of the population are infected with Amoebiasis. use of modern technology in communications
Cardio Vascular diseases : 3.2% urban mor with rural masses in the field of Health educa
tion promises great dividends. The Satellite
bidity and 2.8% rural morbidity.
instructional Television experiment (SITE)
Blindness: There are 2 million totally blind that will be launched in 1974 offers great
and 4 million partially blind people in the coun advance in the use of mass media, in- health
try. T rachoma is very common in many of the education, agricultural innovation and family
States in the North.
planning.
Diabetes : 2 to 5% of the population suffer
from Diabetes and it is not known how many 3. Health Needs
of them are under treatment.
3.1
In conformity with the recommendations
Nutrition: For an average Indian the of the Bhore Committee and Mudaliar Com
Caloric requirement is 2,300 ; but the Calories mittee, the principles outlined in the preamble
available are only 87% The number of to the Constitution of the World Health
undernourished are about 25-30% and mal Organisation and the directive principles of
nourished are estimated to be 60%. The State policy there is a great need for a Health
direct relationship of Nutrition to health of Policy declaration, including Social Security
the individual and the community is obvious. for every citizen of this country. The concept
Recent work indicates that the Nutrition of of comprehensive health care gives hope for
the pregnant women and preschool children mankind. Promotion of health, prevention of
(0-5 years) is considered essential for the disease, early diagnosis and treatment and
prevention of infantile mortality and mental rehabilitation have become parts of the
spectrum of the comprehensive health
$ubnormality in children,
28
THE INDIAN JOURNAL OF MEDICAL EDUCATION
VOL. XIII NOS. j & 2
services, "'hich specifically include the con gical service throughout the country has become
tribution of a variety of personnel and com imperative. It is estimated that 9 million
munity services.
The aim should be the abortions occur and that 30-40% are induced.
organisation of a comprehensive health service. The Health Centres need equipment and
to meet the Needs of the people. This requires : visiting consultant sendees.
(1)
Planning the delivery of the total services
during the next decade or two. (2) Deter 3.2.3
Surveys and Research in Health Practices:
mining the number and quality of rlcalth Man Multiphasic Screening techniques may be for
Power required for these services, and (3) early detection of disease. There is need for
Planning the education of the required health operations research and systems analysis of the
Man Power.
Health structure and its functions for effecting
further improvements. Functional or job
analysis is very much needed for the develop
3.2 Planning delivery of Health Services
ment of the health team and for the proper
3.2.1
Basic Health Services: In view of the education of the Health Man Power. The
great inadequacy of the existing Health services Indian Council of Medical Research has
there is great need for the establishment of been encouraging such research which requires
Health centres to reach a population of 30,000 to be ploughed back.
and beyond and for the location of sub centres
3.3
Determining the number and quality of
for 5,000 population. The Rural Health
Services require high priority in view of the Health Man Power required for the services :
fact that 80.1% of the population live in the
There is need for building up the needed
rural areas. Without the establishment of the
basic health services it would be not possible Health Man Power to man the health services
to enter the maintenance phase of National to come. The quality of the Man Power
deserves prior consideration as without it there
health programmes.
will be an uneconomic use of personnel for
■work which does not require higer skills. The
3.2.2 MCH and Family Planning Services in Com
stock
of existing Health Man Power indicates
prehensive Health Care:
that the health Pyramid is upside down with
In our traditional society in the rural matrix, more doctors at the top and fewer paramedical
the large amount of vector macro parasitive personnel at the bottom. There is therefore
diseases have been reduced. With the sustained need for a greater number of Nurses and
human fertility, the high birth rates have para medical personnel to take over delegated
caused high dependency demographic pattern responsibility and relieve the Physicians for
with high proportion of infants and young extended professional work. Greater coverage
children. This is leading on to a demographic of the population could be achieved if the
diseases pattern with high proportion of ill physician, as the team leader, assigns work
health of infants and pre-school children. In under his supervision to the health assistants
the absence of decisive, action for preventive and Nurses to give comprehensive care. The
services there is a high mortality in infants entire sequence of events required to improve
under one and pre school children. This again health care is the recognition of the need for
leads on to increased fertility as the parents comprehensive health care and effect the
would like to have some children. This vicious necessary changes to remove the constraints.
cycle of cumulative causation is sustaining high
3.4
Planning the Education of the required
birth rate. This cycle can be interrupted by
combined action in fertility control, immuniza Man power:
tion against preventable diseases and reduction
3.4.1
In the education and training of the
of protein caloric deficiency nutritional health professions and technicians, the social
diseases. This vicious cycle of high, fertility objectives, the curriculum, the methods of
and high infant , mortality can only be broken teaching, assessment and evaluation of the
by the provision of basic health services. Hence educational outcomes require emphasis.
the need for extensive infrastructure of basic
health services in comprehensive health care.
3.4.2
Training of the health team: As far
With the passing of the Medical Termination as possible training of the health profession?
of Pregnancy bill the need for good Gyntecolo- should be as' a team.
JANUARY-JUNE 1974
HEALTH NEEDS OF THE COMMUNITY
29
3.4.3
In the education of the physician and (2) redistribution of functions of health
other personnel Social Sciences such as Socio workers to work as a team with the physician
logy, Psychology, Anhtropolgy Economics, Poli as the team leader; (.3) to effect changes in
tical Science in addition to-demography ai d the educational programme both in the type
statistics, should find a place early in the curricu of personnel and the content of curriculum ;
lum. The above sciences should form the basic (4) Continuing Education for all health
sciences for the discipline of community workers: (5) Evaluation and operational re
medicine which should be integrated through search in education and services.
out the curriculum in all the years.
4. Obstacles to Progress
3.4.4
The pattern of educational experiences
In all developing countries including India
.for the doctors of tomorrow needs to be based
on the “World” they are to serve. It is there are many obstacles to progress. Gunnar
needless to add that in a quarter century of Myrdal in his books, Asian drama and the
effort Health Needs of villages has been paid challenge to World poverty, brings out vividly
little attention by medical education. Rural why some countries remain poor. Amongst
and Urban health centres should be considered the obstacles there are five factors which
as teaching laboratories for community medi require attention. First the uninformed and
cine. To apply community health care a ill prepared leaders, secondly the civil services
doctor needs special skills and attitudes. The that arc untrained for development economy,
principles of Administration of health care, third the financial procedures of the old
the concept of health team, appreciation of colonial administration, fourthly the technical
community control measures to diseases, expert not having a role in decision making
Maternal child and family planning services and fifthly the lack of participation of the
should form the basis of training in Community people in all walks of life in developmental
medicine for the physician to play a vital role activities.
in the building of better India.
5. Agents of Social Change
3.4.5 At the 23rd World Health Assembly, 5.1 Medical Educators : In thefieldof medical
the education of the Health professions was education the teacher is the kingpin for
considered at the technical discussions and five effecting adaptation and change. The com
elements emerged as fundamental to the mitment of the teacher to social objectives is
efforts of National Health Administration vital for the preparation of the Social physi
for securing health personnel best suited to cians of the future.
local needs. For the implementation of
5.2 Education : To effect rapid social change
comprehensive health care it was realised
that highly trained physicians alone do and development it is necessary for us to
not meet the situation. The physician remember H.G. Wells ’ prophetic words that
the
World is engaged in a race between Educa
should be ready to assume leadership of a
team of health workers including auxiliaries. tion and Catastrophe and unless all men and
women
have been properly educated, neither
Adaptation of education for the health pro
fessions to the local health needs and resources the individual nor the country as a whole will
and a judicious distribution of functions to the ever be able to attain a decent standard of
other members of the team was emphasised. living and take their place in the modern
National Health Administrations are enjoined world before the end of the century.
(1) to bring about close cooperation between
5.3 Let the physician of tomorrow, be an
the National Health Services and those res agent of social change and in his preparation
ponsible for education of the health personnel; let us dedicate our efforts.
30
VOL. XIII
THE INDIAN JOURNAL OF MEDICAL EDUCATION
NOS. I & 2
JANUARY-JUNE 1971
Base Data Used to Calculate
an Estimated Age-Specific Death Rate for India—1961
Age
Structure
0-11 months
1 year
2
3
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70 and over
.
Persons
in each
group
(in millions)
Deaths
in each
group
(000’s)
Pro
bability
of death
at age
Percent
age popu
lation in
each age
Percent
age death
in each
age
16.6
15.2
14.2
13.4
12.8
58.0
49.7
43.0
38.0
34.3
30.-4
25.6'
21.6
18.1
14.6
11.4
8.5
5.7
7.1
2,543
458
337
245
140
362
179
220
215
233
291
375
432
463
480
488
468
403
700 (est)
.1532
.0301
.0237
.0184
.0139
.0063
.0036
.0051
.0057
.0068
.0096
.0147
.0200
.0256
.0329
.0428
.0551
.0708
.1000
3.78
3.46
3.24
3.05
2.92
13.2
11.3
9.9
8.7
7.8
6.9
5.9
4.9
4.2
3.3
2.6
1.9
1.3
,1.6
28.3
5.1
3.7
2.7
1.5
4.0
2.0
2.4
2.4
2.6
3.2
4.1
4.8
5.1
5.3
5.3
5.1
4.4
8.0 (est)
438.9
9,000
100%
100%
= 438.9
= 9 million
million persons
persons
CDR = 21/1000 population
ALL AGES
CBR = 41.3/1000 population
.
Sources:
1) Census of India, Paper No.2 of1963, 1961 Census Age Tables Section II, adjusted population
by single year of age, p. 35 (It may be noted that the number for year 0-11 months, i.e. 16.6
million, is recognized by the authors to be under-enumerated).
2) Census of India, 1961 Census : Life Tables 1951-60. Age-specific mortality estimated from
probability of dying between ages 0-99, by single year of age, All-India (males) as applied to
total age group by single year 0-5, and 5 year sections thereafter. Problem of non-terminal
series was handled by estimating proportion of deaths reported occuring from age 70-99 to total
deaths in the series. This was chosen in preference to probability for females (despite some age
specific variation for women 15-44) because authors believe female ages to be more likely under
enumerated, especially in ages 1-10. Since only rough proportions were desired, it did not seem
necessary for this exercise to undertake a more elaborate weighting and averaging between
males and females.
with the courtesy of USAID
HEALTH NEEDS OF THE COMMUNITY
Health:
Selected Achievement and Targets
(Numbers)
£1
No.
Item
1960-61
1965-66
1968-69
antici
pated
(0)_
(1)
(2)
(3)
(4)
(5)
1
2
3
4
5
6
beds
primary health centres
medical colleges
annual admissions
dental colleges
annual admissions
185600
2800
57
5800
10
281
240100
4631
87
10520
13
506 _
255700
4919
-93
11500’
586
281600
5427
' 103
13000
15
800
70000
27000
86000
45000
102520
61000
137930
88000
19900
36000
48000
70000
390.00
390.00 •
—
393.25
112.985
70.385
209.88
393.25
30.00 '
—
393.25
80.26
170.36
142.63
220
427
502
582
10
26500
15
35000
15
■ ’ 35000
17
37500
1973-74
targets
15
manpower
7
8
9
doctors
*
nurses
auxiliary nurse-midwives
and midwives
control of diseases
10
11
12
13
national malaria eradication
programme (units)
attack phase (units)
consolidation phase (units)
maintenance phase (units)
~
93.25
270.00
tuberculosis control
14
15
16
clinics
demonstration and
training centres
isolation beds
*In practice.
31
JULT-DECEMBER, 1973
Evolution of Social Medicine and the Problem of Training
by
A. K. Niyogi
Department of Preocntiiie fi? Social Medicine, Banaras Hindu University, Varanasi-5, (U.P.)
Medicine is as old as humanity. From the
earliest times, man has been looking for and
using whatever was available at the time for
cure of the diseases. Prevention has similarly
been sought after from the earliest of times.
Evidence of pre-historic efforts for prevention
is available in plenty in magics, customs,
traditions etc. The concept and practice of
Social Medicine is of more recent origin. That
social factors which affect and action at the
society level are needed for preservation of the
health of the community has been appreciated
at a such later date rather recently that for
treatment and prevention.
Individual action by heads of States in
different parts of the World for health of the
citizens are mentioned in history. Even state
action for such sanitary construction for the
population as the Cloaca Magna are known.
But almost all these are products of individual
action.
The relation between the state and the
individuals of the state has been much debated
since the time of Plato. However, it has since
been accepted that the State has responsibility
towards the individuals and they individual
towards the society which is represented by
the state. A sort of uneasy balance between
the power of the State over the individual
citizen in limiting his liberty and the liberty
of the individual citizen is continuing. The
recent pleadings before the Supreme Court of
India are continuation of the evidence of the
same dilemma which was evident since civiliza
tion evolved the state.
Nevertheless, it has been deeply appreciated
that without state action welfare of the indivi
dual is not possible. In the 19th century
there was an upsurge of human thoughts
about the state privilege versus individual
liberty. The philosophy propounded by Marx,
writings of Mill, action by earl of Shaftsbury
and Simon were directed towards these pro
blems.
So far -as health is concerned, one of the
most important contributors was Virchow. As
a member of the German Parliament Virchow
crossed verbal swords with Bismarch on the
duties of the newly formed Germanic states
towards the welfare of its citizens. For the
first time he coined the word Social Medicine
(of course in German) and spoke that medi
cine was another name for Politics. So
ingrained were the facts of social medicine in
his mind, Virchow, the intrepid researcher,
the real genius, the father of Cellular Patho
logy, the discoverer of Foray, the Anthrapologist and the Politician fought for practice
of social medicine.
From the 19th century every State had been
showing signs of accepting the Philosophy of
State responsibility and State action for the
health of the individual citizen. During the
1st World War and the II, World War their
intervening period and particularly that follow
ing the Ilnd World War, medical profession
has been taking more and more interest as
regards identifying areas of social responsibi
lity and social action for health of the nation.
The 1945 San-Francisco Conference declared
that every state should ensure the four free
doms for its citizens. One of them being free
dom from disease. So it is that today it is
accepted all over the World that health service
and medical practice are based not only on
aiding the individual for prevention of and
cure from disease, but also on inducing social
action for the community as a whole in treat-
EVOLUTION OF SOCIAL MEDICINE AND THE PROBLEM
nsent of the ill, prevention of disease, promo
tion of health and searching for more areas
for such action.
If such are the responsibilities of Modern
Medical practice, the training of such practi
tioners becomes a matter of concern. This
Association is vitally involved in the matter.
It would be useful to go into some points as
regards the training of medical practitioners in
India. There are now more than 100 medical
colleges where training is going on towards
developing the students into practitioners of
comprehensive medicine. Such efforts are
evident in all these institutions which at the
same time show good deal of deficiency in
training programme and in the facilities for
the same. Whereas all departments in the
medical colleges are working in a complemen
tary manner for developing young and un
initiated minds, the preventive and social
medicine Department has the special responsi
bility in teaching theory and practice of social
medicine. Hence some of the difficulties
affect the P.S.M. departments are mentioned
below:—
(1) The training of an undergraduate has
to be in the class room, the hospital and the
Community. All training must be complemen
tary, to one another. It is clear that guidance
for such training and the training institutions
have to be concentrated at one place under one
authority. Such unification has not yet taken
place in all medical colleges of the country
much to the detriment of teaching the commu
nity aspect of health and the needed services.
191
(3)
Whether one likes or does not, a medical
student is examination oriented and examina
tion stimulates attention of the student to the
teaching. The examination has to be at the
proper level when a student is expected to be
able to learn the subject. By the very nature
of the subject of P.S.M. a candidate can be
properly examined in it only when he has
studied the clinical subjects well. Earlier
placement of the examination in P.S.M. will
not allow the examiner to test the students
sufficiently and the student in his turn will
allow gaps and deficiencies in his study and
interest. Such deficiencies are sufficient
obstacles to the learning by the students of
social responsibilities, practice of social medi
cine and even Preventive Medicine and
Epidemiology. Teaching of these subjects
also become seriously hampered.
(4)
Every medical college is under one of
the three ownerships, viz. Government, local
body or Private Organisation. Primarily, the
owner is responsible for fulfilling minimum
standards recommended by the Medical
Council of India for under or post-graduate
training. It is a notorius fact that many of
such authorities are not carrying out those
minimum instructions in full. The Medical
Council of India is entrusted by the Govern
ment to guide and inspect the teaching faci
lities and examination standards in the Medical
Colleges. Unfortunately such responsibilities
are not sufficiently fulfilled. So one finds a
very large number of institutions continue to
be recognized though they have not fulfilled
its, minimum recommendations.
(2) Staff position in the P.S.M. departments Above certain deficiencies have been pointed
of the medical colleges are very poor. If one out. There is another neglected field w’here
understands that teaching in the community efforts in proper training can offer good divid
needs a mountain of time, one can perceive end. That is the compulsory post MBBS
the present shortness of staff even more. It examination traineeship. Much uninformed
has to be appreciated also that in the teaching criticism can be heard when this training so
of the different subjects which arc included wisely introduced by the Medical Council of
under the umbrella of P.S.M. non-medical India comes up for discussion even decrying
teachers should contribute heavily. Such it as wastage of time, and a year’s holiday or
teachers should be only those who know their a picnic which should be abolished. On the
subjects sufficiently in order to be able to teach other hand instead of being carrie'd away by
students of undergraduate and P.G. Study. this unfortunately popular current of despair
To list them these teachers should be for it is easy to do so rather than to strive against
sociology, medical entomology and statistical odds-where serious thoughts and efforts have
methods in Epidemiology and health services. been directed to it, this period of training
A medical social worker or a statistician on a can be one of intense interest and practice of
clerical pay is not the person who can under comprehensive medicineby thetrainee students.
take such teaching,
A model has been developed in the Medical
192
THE INDIAN JOURNAL OF MEDICAL EDUCATION
College, Baroda, by starting a curative and
preventive General Practice unit in the
main teaching Outdoor Hospital. Its success
has been quick and very satisfactory as regards
the understanding of Social Medicine and
practice of comprehensive medicine by the
rotating interness.
VOL. XU
NOS. 3 & 4
The sum total of effect of these deficiencies
shown above is that the Country is getting
medical graduates we are not modern in their
thought and action and who are unable to
fulfill their responsibility.
These are the problems that are being placed
before the attention of this Association today.
Training in Preventive and Social Medicine
reasons for failure to achieve desired results-ii
analysis of reasons
by
J. R. BHATIA, MD, DCH, DPH.
Associate Professor of PSM (Community Health). All India Institute of Medical Sciences, Ansari Nagar, New Delhi-16
In the previous paper published in this issue in its application and implementation. While it
of the Journal, the author reviewed the rea is quite logical to expect a physician (in the
sons identified by medical eduacators, vice west) who sees a limited number of patients a
chancellors and others for failure to achieve day, and who is backed by well organised
desired results, in the matter of training in official and voluntary social welfare agencies
Preventive & Social Medicine. These reasons of the community to attend to social and
were categorised under the following headings : environmental factors that are responsible for
1. Inadequate appreciation of the role of initiation or progression of disease, it is unrea
Preventive and Social Medicine in Educa listic to entertain similar expectations when
almost all basic physicians (in India) are
tion
literally buried under the load of scores and
2. Inadequate and / or inappropriate effort even hundreds of sick patients that throng his
inputs
clinic, more so when the official and voluntary
social welfare agencies are either non-existent
3. Inadequate teachers’ motivation
or poorly developed. The kind of social and
4. Quality of teachers in the Departments of preventive action that an Indian physician can
Preventive & Social Medicine
take has to be different and limited in its scope.
5. Discrepancy in training and practice
This latter has yet to be worked out and
6. Inter-departmental stresses in Medical determined under native conditions. Another
important consideration, in this connection and
Institutions:
following from the first, is lack of commonly
7. General atmosphere in the country
agreed concept and scope of practice of, and
training in this discipline, in the minds of
8. Rejection by the students
teachers of the discipline, other faculty teachers
The authorities who propounded the reasons of the medical college, medical eductors and
reviewed in the first paper, did not elaborate general/political administrators. Instead of
on these reasons. A critical analysis is needed providing a rich field for planned experimenta
to understand the factors that are responsible tion,1 this situation has given rise to confusion,
for emergence or continuation of these reasons. mutual recrimination and frustration.
The following paragraphs are an attempt at
such analysis:
2.
Inadequate and/or Inappropriate Effort Inputs:
1.
Inadequate Appreciaton of the Role of Pre
Teachers of preventive and social medicine
ventive & Social Medicine in medical education who have been held (so far) primarily responsi
is perhaps one of the most important reasons ble for failure to achieve desired results, have,
for failure to achieve results. The concept of by and large, taken the plea that they have
preventive and social medicine in relation to not been given adequate facilities and funds to
clinical practice originated and took shape in organise training in a comprehensive manner.
west european socio-economic and medical care They point out that the departments have
environments. Its importance into socio-econo large number of vacant staff positions, meagre
mic and medical care environment of a poor or no community health centres in rural and
country like ours, was bound to create difficulties urban areas to be used as field training areas,
28
THE INDIAN JOURNAL OF MEDICAL EDUCATION
VOL. XII
NOS. 1 & 2
no mechanism by which they can work in live ‘applied aspects of preventive medicine’1
clinical situations in the teaching hospital and are undermined under the circumstances, it
no indoor beds to keep in contact with problems should not surprise anyone.
of communicable diseases. To this list may
Quality of Teachers in Departments of
be added their isolation, in perhaps the 4. Preventive
& Social Medicine :
majority of medical colleges, from live public
The ‘ quality ’ of a teacher depends, besides
health activities and health services adminis
natural
and
acquired
aptitude for teaching, on
tration. Effort inputs by the departments of
preventive and social medicine, particularly in the type of training he has received, opportuni
the field of clinical preventive medicine under ties to practise what he teaches and relevance
these conditions, amount to no more than of his teaching to interest and motivation of
theoretical and sterile exercises, disliked by the majority of the students body. It may be
students and teachers alike. Integrated semi assumed that aptitude for teaching in teachers
nars and combined teaching sessions, sometimes of the department of preventive and social
stimulating and useful, on most occasions, do medicine is of the same order as in teachers in
not achieve the purpose, as the students easily other departments. On the question of their
training, it might be stated that senior teachers
recognise their concocted character.
are mosdy trained in conventional public
3.
Inadequate Teachers’ Motivation :
health while many of the seniors and majority
Training in preventive and social medicine of junior teachers have postgraduate training
ideally ’ permeates ’3 teaching programme of in departments of preventive and social medi
all medical disciplines, which carries the implica cine. Generally speaking, teachers in the
tion that the total faculty of the medical department do not have the same facilities for
college must be properly and fully motivated practical work responsibility in clinical preven
and deliberate and planned efforts are made tive medicine or health services administra
to achieve such permeation. Motivation of tion—the twocoursesthey are assigned to teach—
the teachers in the departments of preventive as clinical teachers have in their respective
&
social medicine to do their best in this regardfields. Add to this the rather weak interest
can be taken for granted as training in pre of the students in the subject (see below), the
ventive and social medicine is the only reason verdict of ‘ poor quality ’ will appear a little
why they have been engaged as teachers and unfair.
it is only through such training that they can 5. Discrepancy in Training and Practice :
hope to progress in life. Teachers in other
“ Experience has shown that the habits
disciplines however may not have similar
compulsions and or may not bend their taken by the student into his profession are
energies to deliberately planned programme those acquired through self-participation,
towards this end. They have their own com rather than through lectures and quizzes ” and
mitments and may not have time, energy or “The practitioner of medicine, as a rule,
willingness to take on “ additional worries.” rarely enlarges the scope of his medical view
This is likely to happen more often in the clini point after graduation, although within this
cal disciplines as clinical teachers, of all the limit he educates himself in detail and tech
faculty in the medical college, are preoccupied nique ”—these two quotations from ‘Selected
with extensive service loads which they consider Papers of Dr. John B. Grant’,8 underline the
as claiming their first priority. That this need for ensuring that only those teachers who
has actually happened has been suspected by are actively engaged in service work connected
many people.8 Recent trend in medical with the subject of their teaching should under
colleges of diluting the responsibilities of the take training of undergraduate medical
departments of general medicine and surgery, students. Any teacher not actively engaged
by instituting sub-speciality departments and in such work may inspire but cannot succeed
assigning them responsibility for undergraduate in changing attitudes and work habits of his
training in their respective specialities, has students. Clinical preventive medicine (which
aggravated the situation as such departments is an integral part of the practice of clinical
focus attention on the minutae and emphasise medicine) taught by teachers in the depart
laboratory aspects of medicine. If the motiva ment of preventive and social medicine, who
tion of clinical teachers to practise and teach are themselves not actively engaged in the
JANUARY-JUNE, 1973
TRAINING IN PREVENTIVE AND SOCIAL MEDICINE—RESULTS II
practice of clinical medicine cannot carry
conviction to the students. In this connection,
a quotation from Bhore Committee, who
originally recommended creation of depart
ments of preventive and social medicine is
relevant: “A preventive habit in clinical
medicine can only be cultivated in the practice
of clinical medicine and-not elsewhere....... If
the physician is to practise preventive medi
cine, he must be taught that subject by his
clinical professors. ”6 The same remarks apply
to training in courses on community health i.e.
community pathology and diagnosis, conven
tional public health activities and structure
and function of health services organisations
and institutions—but to a lesser extent. Even
though not carrying actual responsibility for
such services in the country’s health organisa
tion (with some exceptions) the senior teachers
at least had close contact with such services
before coming to medical colleges and the
departments in many cases have working
relationships with primary health centres.
Even in this field, service responsibility of
teachers in the departments of preventive and
social medicine is not as profound as that of
teachers in clinical departments in respect of
treatment of patients in the teaching hospital.
6.
Inter-departmental stresses in Medical
Institutions:
29
tional rivalries and jealousies in check and
weld the entire faculty into one force directed
to the achievement of this common objective.
7.
General Atmosphere in the Country:
In the pest-independent era in our country,
a yawning gap between promise and perfor
mance has been noted. In the field of medical
education, Col. Amir Chand, whose contribu
tions to reform in medical education will be
recognised by all. in a paper contributed to the
Souvenir of the IX Annual Conference of the
A.A.M.E. (1970,, said “The present pattern
I.
of medical education has been widely criticised.
Its defects have been brought out and reforms
have been suggested by many....... Catch
phrases and changed nomenclature are being
introduced and widely advertised to show,
advertently, as if things were progressing, but
that, at least in this country, is self-deception,
more or less....... The Medical Council of India
laid down that the subject (preventive and
social medicine) is to be brought in collabora
tion with other departments throughout the
entire course of training of the undergraduate—
in the college, in the associated hospitals and
in the field units of the area. Is this being
done in the actual practice, in the manner in
which it is intended by the Council to be
done ? No, it is not being done, except perhaps
in rare instances.” 7 The implications are
obvious.
It is difficult to find a complex social institu
tion without its own internal social stresses,
and if they have been present in medical 8. Rejection by the Students:
When a young student enters medical
colleges and teaching hospitals, it should sur
prise no one. Differences of opinion between college, he has a certain image of a physician.
‘ basic science ’ or ‘ laboratory ’ depart This image, in the main, is that of a profes
ments on the one hand and. “clinical” or sional person who receives sick people, diag
‘ hospital ’ departments on the other, are noses their disease and treats them. The other
well known. Introduction of a ‘ Third type ’ part of the image is that there are ‘chotta
of department in this social structure has doctors’ and ‘ burra doctors’—the general
raised new problems. Is this department one practitioners and the specialists. He has also
of the basic (para-clinical) departments or a known the difference between the salaries and
clinical department ? Difference in the status status of these two types of doctors. Preven
and location of the departments of preventive tive and community health services are not a
and social medicine on the basic-clinical part of this image of a physician—such duties
spectrum in different medical colleges and in are for ‘ health officers’. This differentiation
the same medical college at different times in duties and status of three types of doctors is
reflects partly, the movement of rivalries and re-inforced and amplified by the environment
jealousies in the medical colleges. The objec of a teaching hospital, where the difference in
tives of preventive and social medicine i e. the duties/practice of departments of clinical
change in the attitudes of teachers and students medicine and preventive and social medicine is
to the way medicine is practised, are not more clear and sharp. He becomes certain
likely to be achieved until strong, purposeful that both the society and the profession value
and devouted leadership keeps inter-institu curative services, especially at specialist level,
THE INDIAN JOURNAL OF MEDICAL EDUCATION
30
much higher than the preventive and commu
nity health services. No wonder he decides to
do only the minimum necessary by way of
training in preventive and social medicine, in
order to cross this ‘hurdle’ and get his degree.
Under the circumstances of our society and
profession the students’ attitude of rejection
seems rational and justified.
This analysis of possible reasons for failure
to achieve desired results in training preventive
and social medicine, together with its com
panion first paper, is intended to stimulate
interest of the medical education institutions
FOL. Xll
NOS. I & i
and authorities who are responsible for our
educational policies in the direction of detailed i|
study of the problem along scientific lines and |
making planned experiments to rectify the 3
situation.8 We cannot afford to postpone any
longer this much talked of and urgently needed
reform in our system. Many approaches and
strategies to achieve the desired objectives
have been suggested from time to time. In
the papers to follow, the author plans to
review and discuss these approaches, strategies
and methods in an effort to arrive at a blue
print for action.
CITED REFERENCES
R.V. Sathe: The Teaching of Preventive
and Social Medicine in relation to Health
Needs of the country: Report and Re
commendations of
the Conference.
National Institute of Health Administra
tion and Education, 1966, p. 43.
2.
Conard Siepp (Editor), Health Care for the
Community, selected Papers of Dr. John
B. Grant: The American Journal of
Hygiene, 1963, p. 98.
Sushila Nayar (Dr.) Minister of Health :
3.
Address at the Conference on The Tea
ching of Preventive and Social Medicine in
relation to health needs of the country;
National Institute of Health Administra
tion and Education, 1966, p. 5.
4.
Govt, of India, Ministry of Health:
Report of The Health Survey and Planning
Committee, Vol. 1, p. 331.
5.
Conard Siepp (Editor), Health Care for the
Community, selected Papers of Dr. John
B. Grant; The American J. of Hygiene,
1963, pp. 99-100.
I.
6.
Govt, of India, Ministry of Health:
Health Survey and Development Committee, 1
1946, Vol. Ill, p.144.
7. Amir Chand : Heed for Operational Rese
arch-. SOUVENIR, IX Annual Con
ference of the Indian Association for the
Advancement of Medical Education,
22nd to 24th Jan., 1970: p.21. College of
Medical
Sciences,
Banaras Hindu
University.
8.
Amir Chand : Heed for Operational Rese
arch-. SOUVENIR, IX Annual Con
ference of the Indian Association for the
Advancement of Medical Education,
22nd to 24th Jan., 1970: p.22. College of
Medical
Sciences, Banaras Hindu
University.
THE INDIAN JOURNAL OF MEDICAL EDUCATION
20
VOL. XII
NOS. 1 (3 2
in their area as such knowledge can be of tre
2. Social scientists should be given positions
mendous help to the public health doctors inter suitable to their training and experience and,
ested in improving the health status of the peo as far as possible, their role should be wellple. A well-planned study of folk medicine, with defined ;
adequate emphasis on the role of “ Syanas ” .
3. Social Scientists should orient their stu
(Spiritual healers) can be intellectually stimu dies, from the point of view of the needs of the
lating for the social scientists and at the same public health projects or programmes and, as
time highly useful for the doctors. The social far as possible, avoid long-term, and or only
scientists can perhaps make a major contribu knowledge-oriented studies. However, at the
tion in the training of health personnel as, same time, they should not sacrifice the quality
especially in the rural areas, most of the time of their contribution, for example, if they find
the problem of communication between the that the fashionable KAP studies in family
administrator and the health personnel or bet planning are not quite reliable they should try,
ween the doctor and the other health personnel tp conduct depth studies by following the tra
is so acute that the health targets set are, ditional anthropological method:
rarely met. The social scientists can profitably
4. Social Scientists, will do good to com
be involved in all stages of planning, imple
mentation and evaluation of health pro bine their research interest with service part of
grammes. The best suited social scientists to the public health programmes ;
public health, however, are the ‘ action social
5. Social Scientists should not be called
scientists’ and not the ‘arm-chair social scien only to study the post-mortum effects of a
tists’, who in the opinion of this author are public health programme. On the contraryprobably ‘misfits’ owing to their lack of in they should be involved in it right from the
beginning;
terest in field assignments.
6. Social Scientists’ valid contributions to
Suggestions for better collaboration
public health should be timely recognized as
1. Well trained social scientists, preferably this will encourage them to make further con
representing the disciplines of sociology, social tributions ; and lastly,
7. There should be sufficient understand
or cultural anthropology’ or social psychology’,
having adequate knowledge and practical ing, tolerance and cooperation between the
experience of public health, should be encou social scientists and public health doctors as
raged to work in the public health depart without this the public health programmes
will fail to produce the desired result.
ments ;
1. Lyle Saunders :
2.
Some Contributions and Limitations of Behavioural Science in
Public Health, ‘Swasth Hind’ Vol. VI, May, 1962 No.5.
Hugh R. Leavell : Health Programme Evaluation—How may the social scientist help ?
(Mimeographed) 1964.
Training in Preventive and Social Medicine
REASONS FOR FAILURE TO ACHIEVE DESIRED RESULTS—I
A. REVIEW
by
J. R. Bhatia, m.d., d.c.h., d.p.h.
Associate Psofessor of P & S M (Community Health) AU India Institute of Medical Sciences, Ansari Nagar,Neu> Delhi. 16
Introduction
up a spirit of social service in the ’medical
student, the teaching of preventive and social
Sir John Ryle’s renunciation of the chair of medicine should start from the 1st year of the
clinical medicine in favour of establishing a medical course and that students should be
centre for study of social and preventive medi given experience in community health work.
cine in early 1940s, focussed attention of medi They further recommended that teaching in
cal educators to the urgent need for reorient
preventive and social medicine should per
ing medical practice and teaching to include meate the entire course of medical training in
preventive and social aspects of disease and medical colleges and should extend even to the
promotion of health. Closely following this period of internship. It was advocated that
event, Bhore Committee1 considered the health this teaching should be integrated with that of
needs of India and made detailed recom other departments, particularly clinical depart
mendations on howto introduce preventive and ments. It was felt that the cooperation of
social bias in the training of doctors and prac these other departments was basic to and essen
tice of medicine in this country. They recom tial for success. Dr. R. V. Sathe,8 Vice-Chan
mended the creation of a new department of cellor, Bombay University, in his address to
preventive and social medicine having full NIHAE convened conference in 1965, summed
time professor and other teachers. In 1955 at up the objectives of preventive and social
the Medical Education Conference convened in medicine teaching as “ Shifting emphasis from
New Delhi by Govt, of India,’ there was a purely individual curative approach to a
unanimous support for the creation of a community centred preventive approach in the
department of preventive and social medicine ultimate direction of evolving a curriculum
in each medical college. Since then Medical that is in tune in meeting nation’s health
Council of India has made organisation of a needs.”
full-time department of preventive and social
medicine a precondition for extending recogni Developments:
tion to medical colleges. Last 15 years have
witnessed a phenomenal growth of these
Since 1955, medical education in India has
departments and almost all the ninety-three
medical colleges have organised full time included, in undergraduate curriculum, train
ing
in
department of preventive and social medicine.
The Bhore Committee underlined the catalytic
i. knowledge and skills of “clinical preven
function of the new departments and the 1955
tive medicine ” ;
Conference suggested that these departments
ii. broad understanding of community health
“ should be manned by persons who would be
able to bring about a complete change in the
services and health services structure of
existing approach to the teaching of medi
the country ;
cine. ” * Details of how the subject of preven
tive and social medicine should be taught were iii. awareness of the importance of physical
and social/environmental factors in the
also discussed in the 1955 Conference.4 The
conference recommended that in order to build
causation and progression of disease;
22
THE INDIAN JOURNAL OF MEDICAL EDUCATION
KOL. XII
NOS. 1 & 2
To this end, several steps have been taken. health services and health services administra
tion. It was presumed that a few visits to rural
Such steps include—
health centres during the undergraduate train
1. Creating departments of Social & Pre ing period and three months residence in a
ventive Medicine with whole time teachers of primary health centre during internship, w'ould
professional and other ranks.
generate enough enthusiasm, interest and liking
2. Creating Rural and Urban Health Centres for rural health work in at least a good per
where students spend varying periods of time centage of the student population, so that some
during or immediately after their formal of them would elect to accept service work in
rural areas.
undergraduate course.
3. Allocating increased curriculum time and Assessment of Impact:
including teaching of social and preventive
These hopes have been belied, taking the
medicine in all the years of medical training.
country as a whole. Reports and claims of
4. Reserving three months of one year some limited and sporadic success in orienting
internship for. training in a primary health the thinking of the students towards community
centre.
medicine concepts have been published from
5. Introducing the students during their time to time but no medical school is in a posi
undergraduate training period to concepts of tion to claim that the objectives of teaching
family health care, clinical social case review, preventive and social medicine have been
epidemiological approach and community achieved to any significant extent. In fact,
there is a wide-spread fear that this teaching
health structure and administration.
has, in many cases, further alienated the
The newly created departments of preven feelings of the undergraduate students, who
tive and social medicine were expected to :
have started developing negative attitude
i. organise and undertake teaching of basic towards the subject and the activities that it
sciences e.g. Epidemiology, behavioural seeks to train in. The Health Survey and
sciences, statistics, etc. for a proper under Planning Committee, 1961, expressed their
opinion that “ training in Public Health in
standing of medicine’s role in society
rural areas in collaboration with the depart
ii. undertake teaching of preventive medicine ment of preventive and social medicine has not
and conventional public health ;
been quite a success. ” 11 Dr. R V. Sathe
iii. organise and administer rural and urban addressing a N.I.H.A.E convened conference
health centres and use them for training on teaching of preventive and social medicine
medical students so as to give them orienta in 1965, voiced the feelings of many other
educationists and medical college deans and
tion along desired lines;
faculty, when he said “ Despite these multiple
iv. function as a catalyst in stimulating other developments, the impact of this discipline of
departments specially clinical departments, preventive and social medicine on the medical
so that all of them teach preventive and colleges as a whole including their various
social medicine in relation to their subject;8 departments, is not as distinctive and enduring
v. function as a coordinating agency for the as one would have hoped. It would seem that
purpose of ensuring that all the other a greater degree of appreciation of the nature,
departments of medical colleges, include role and contribution of a department of
preventive and social aspects of diseases in preventive and social medicine to medical
their teaching; ’ and
education is necessary. ”18 A similar opinion
vi. “ help preserve in the medical student the was expressed by the Hon’ble Minister of
ideals and ideas of service with which he Health, Dr Sushila Nayar,18 while inaugura
ting
the Conference. To quote from Col.
enters medical college.” 10
Amir Chand “Hassuch teaching (ofpreventive
It was believed that clinical departments & social medicine) which has been expected to
would eventually take complete responsibility have been going on for several years, made any
for clinical preventive and social medicine after real impact on the teaching and practice of
which the department of preventive & social ‘ Medicine, or Community Medicine, if you like
medicine would continue to teach community to call it? No, it has not”. ■'
TRAINING IN PREVENTIVE AND SOCIAL MEDICINE
JANUARY-JUNE, 1973
’ In the last 4-5 years a little different emphasis
is emerging. There is increasing dissatisfaction
with medical education process as a whole
(distinct from and in addition to dissatisfaction
with training in preventive and social medicine).
Third Conference of Deans and Principals of
the Medical Colleges held in New Delhi in
August 1967, Central Council of Health meet
23
ing in April 1968 and Medical Education
Committee Report 1969 have all voiced this
feeling and have made recommendations de
signed to reorient basic objectives of medical
education to make it genuinely “ Indian ” in
character and “need-based”.18 These two
streams of dissatisfaction are closely connec
ted—in fact, the first is only a part of the second.
Reasons for Failure:
While there is a good deal of agreement that
the objective of orienting medical students to
preventive and social aspects of disease and
making them interested in community health
services and work in rural areas, has not been
achieved during the last 15 years of our efforts,
the reasons for this lack of success have not
been fully probed. Reviews made by several
professional conferences and medical educators
focussed their attention on the functioning of
departments of preventive and social medicine,
but not much has been discussed or enquired
into regarding the contribution of other depart
ments, especially clinical departments, in rela
tion to teaching of this discpline. In the last
4-5 years, as indicated above, medical educa
tion as a whole has come under critical review.
Some of the important reasons identified by
medical educators, vice chancellors and others,
are summarised in the chart below:
Reasons for Failure to Achieve Desired Results
in Training in Preventive and Social Medicine
Authority
Time (Year)
Remarks
Efforts were “ fragmentary and not a part
Of established mechanism which is in
tegral to the daily routine of clerkship and
intern years. Further-more students feel
their extraneousness to the major con
tents of his ordinary work. He may
acknowledge their value in principle but
he does not subconsciously accept the
necessity of undertaking these measures
as an essential part of his routine to the
same degree that he does in the case of
corresponding measures which he partici
pates in the diagnosis and cure of disease.”
G.B. Grant
1928
John B. Grant: Health
CareoftheCommunity,
edited by Coard Seipp.
The American Journal
of Hygiene, Mono
graph Series 21, 1963
Taught solely by public health teachers.
Bhore
Committee
1946
Still valid — (author’s
view).
Strengthen the Departments of Preventive.
& Social Medicine.
Mudaliar
Committee
1961
The Indian Association
for the Advancement of
Medical
Education
Souvenir Number of
IX Annual Conference,
1970.
Inadequate appreciation of the nature,
role and contribution of a Deptt. of PSM
to medical education,
R.V. Sathe
1965
NIH A E Convened
Conference'
Reason
Still valid — (author’s
view).
24
THE INDIAN JOURNAL OF MEDICAL EDUCATION
VOL. XII
NOS. 1 & 2
JANUART-JUNE, 1973
TRAINING IN PREVENTIVE AND SOCIAL MEDICINE
25
Reason
Authority
Time (Year)
Remarks
Reason
Authority
Time (Year)
Remarks
Inadequate “ dialogue” between Depart
ment of PSM and clinical departments.
R.V. Sathe
1965
do
1970
Dr. Sushila
1965
NIHAE Conference on
The Teching of PSM
in relation to Health
Needs of the country.
General atmosphere in the country of
passing resolutions but not implementing
them.
Col. Amir
Chand
“ With the institution of chairs of PSM,
teachers of medicine and surgery, eye.
ear, nose, throat, Gynaecology and obste
trics etc. have in many cases, ceased to
teach the preventive aspects of their own
subjects or to give due importance to
prevention of disease.”
Failure of Medical Colleges to ensure
collaboration between clinical depart
ments to teach PSM.
do
do
The Indian Association
for theAdvancement of
Medical
Education
Souvenir Number of
IX Annual Conference,
1970.
do
Failure of teachers of different subjects
to carry responsibility of teaching pre
vention of disease as it applies to the
individual.
do
It is human to try to shirk what is
difficult.
do
do
do
Rivalries and jealousies can’t be brushed
aside easily.
do
do
do
Necessary motivation to bring about
desired change is lacking.
do
do
do
Wig and
Bajaj
do
Implied in recom
mendations for correc
tive measures.
do
do
do
do
Indian Journal
of
Medical
Education,
June-July 1970.
Lack of “ mutual appreciation of role of Dr R.V. Sathe
PSM and sister departments to achieve
the common objective.”
do
do
do
do
Failure to practise what the teachers teach
in the Deptt. of PSM
Dr. H. V.
V aishnava
do
do
Lack of close integration of PSM as a
subject with other subjects.
Failure to attract teachers of good quality
Dr. V. Ramalingaswamy
do
do
Teaching of clinical medicine is too much
hospital oriented.
Inadequate arrangements for collabora
tion of teaching programmes of various
departments.
NIHAE
Conference
do
Implied in
recom
mendations for correc
tive measures.
Failure of clinicians to have built in
mechanisms and facilities for prevention
and health promotion in their service
units.
do
do
do
Absence of rural and urban field practice
areas.
do
do
do
Inadequate staffing of Deptt. of PSM.
do
do
do
Inadequate staffing of fiield practice areas.
do
do
do
Lack of motivation or weak motivation of
teachers.
D.N. Pai
Absence of clinical teachers from com
munity health centres.
The reasons mentioned in the above chart may be broadly classified as falling in one of the
following categories: ■
1.
Student rejection because not relevant to
his professional objectives.
do
Poor student-teacher ratio.
do
Inadequate effort in the proper utilisation
of existing facilities.
do
Memiographed paper
Undated
(about 1967) entitled “Utilisation of
Urban Practice Field
by Clinical, Para-Clini
cal Departments in
teaching of Individual
and Commu nity
Health,
Inadequate appreciation of the role of Preventixre and Socia 1 medicine in medical
education.
2.
Inadequate and / or inappropriate effort inputs.
3.
Inadequate teachers’ motivation.
4.
Quality of teachers in the departments of Preventive and Social medicine.
5.
Discrepancy in teaching and practice.
6.
Inter-departmental stresses in medical institutions.
7.
General atmosphere in the country.
8.
Rejection by the students.
The author subjects these reasons to a critical analysis and discussion in a separate paper
published elsewhere in this issue,
26
THE INDIAN JOURNAL OF MEDICAL EDUCATION
VOL. XII
NOS. 1 & 2
CITED REFERENCES
9.
World Health Organisation, Geneva:
1. Government of India, Ministry of Health :
Promotion of Medical Practitioners’
Health Survey and Development Com
mittee, 1946.
Interest in Preventive Medicine 1964,
P. 11.
2.
Government of India Press, Calcutta:
Government of India Press, Calcutta:
Proceedings of the Medical Education 10.
Proceedings of the Medical Education
Conference, 1955, p. 52.
Conference, 1955, p. 52.
3.
Government of India Press, Calcutta:
Proceedings of the Medical Education 11.
Goverment of India, Ministry of Health :
Conference, 1955.
Report of the Health Survey and Planning
Committee Vol. I. 318.
4.
Government of India Press, Calcutta:
Proceedings of the Medical Education 12.
Sathe, R. V.: The Teaching of Preventive
Conference, 1955, Appendix 5.
& Social Medicine in relation to Health
needs of the Country: Report and
5.
Sathe, R.V.: The Teaching of Preventive
Recommendations of the Conference.
& Social Medicine in relation to health
National Institute of Health Administra
needs of the Country: Report and Recom
tion and Education, 1966, p. 41.
mendations of the Conference; National
Institute of Health Administration and
13.
National Institute of Health Administra
Education, 1966, p. 9.
tion and Education: Report and Recom
6.
World Health Organisation, Geneva:
mendations of the Conference on the
Promotion of Medical Practitioners’ Inte
Teaching of Preventive and Social Medi
rest in Preventive Medicine, 1964, p.12-13.
cine in relation to Health Needs of the
Country, 1966, p. 3-8.
7.
Government of India, Ministry of Health,
Health Survey and Development Com 14.
Amir Chand: Need for Operational
mittee, 1946, Vol. III. p. 127
Research : SOUVENIR, IX annual Con
ference of the Indian Association for the
8.
a) Government of India, Ministry of
Advancement
of Medical Education, 1970,
Health, Health Survey and Develop
p. 21.
ment Committee, 1946, p. 146.
Duraiswami, P.K.: Need-based under
b) World Health Organisation, Geneva : 15.
graduate Medical Education. The Indian
Promotion of Medical Practitioners’
Journal of Medical Education, Vol. IX,
Interest in Preventive Medicine, 1964,
Nos.
6 & 7. June-July, 1970.
p. II.
ACKNOWLEDGEMENT
The basic approach to analysis of problem
of training in Preventive and Social Medicine
implied in this paper and others to follow, has
been the result of experiences with the A.I.I.
M.S. Community Health Project at Ballabgarh.
The author is grateful to staff of Ballabgarh
Project and the faculty of the Institute who
helped in giving a shape to this approach. I
am particularly indebted to Prof. V. Ramalingaswamy, Mr. Ramachandran and Dr.
P.V. Gulati for frank criticism and useful
suggestions.
AN APPROACH TO UNDERGRADUATE TRAINING IN SOCIAL &
PREVENTIVE MEDICINE
by
Dr. S. K. Mehrotra, Lecturer
and
Dr. J. S. Mathur
?rt'Jessor & Head of Department, Department of Social and Preventive Medicine, G.S.V.M. Medical College, Kanpur,
Introduction
health agencies which do not introduce com
munity outlook in the students of this subject.
G.S.V.M. Medical College, Kanpur is one of
the institutions where community oriented prac
tical training has been organised for under
graduates during the paraclinical period of 1|
years. Although Medical Council of India
(Zoc. «'/.) has recommended the teaching of
social and preventive medicine throughout the
whole period of medical study, but due to the
meagre staff and resources at Kanpur it could
not be implemented in preclinical and clinical
periods.
The teaching and training of the paraclinical
students are being imparted through didactic
lectures, demonstrations, visit to health agen
cies, laboratory exercises and the field work in
the community on various community health
problems.
Didactic lectures, visits to health and welfare
agencies and demonstrations are commonly
organised in any medical college. Our special
interest remains in reorganisation of practical
training. During didactic lectures students are
The rural and urban health centres form the given instructions in family care programme
basic laboratories for the teaching of the under and teachniques of interview in community to
graduates in social and preventive medicine. utilise principles of medical social work. Our
In these field practice areas family studies special problem remains far more unsatisfac
should be assigned to inculcate in the student tory students teacher ratio of 25: 1 instead of
the basic concept of a social physician. Besides, 10: 1 recommended by the Medical Council of
it will help the student to develop community India (Zee. cit). In order to improve training,
outlook, to study the various environmental imparting of instructions and supervision, our
factors and their role in the disease causation endeavour remains to keep sub batches small,
and in the maintenance and improvement of consisting of never more than 25 students
(Fig. I.). Even with the batches of this size
health of the community.
active co-operation of families is available to
The practical training in social and preven the students. Mathur (1961) however reported
tive medicine in most of the medical colleges that with large groups of students the family
still remains in the form of visits to a few co-operation is vanishing.
Modern medicine is preventive, positive,
Cf,llective, community oriented and community
managed. The age old practice of medicine
bits also shown a shift from the hospitals and
clinics to the practice of medicine in the
community. Indian Medical Council (1969)
bits also recommended a shift of teaching of
medicine from hospital to primary health cen
tre, thus rendering comprehensive health care
*<> the family rather than to an individual sick
nian. This concept has formed the basis of
national health programmes (Patel, 1970).
T herefore with the changing needs of the
society in the light of social changes and scien
tific and technological advances made in the
'Vorld, dynamic changes in the medical educa
tion are being brought in to produce basic
•lectors who should be able to render a com
prehensive medical care to the community.
•Similar recommendations have already been
Ptade by W H.O. (1964), NIHAE conference
(1965), the Medical Council of India (1969)
knd Medical Education Conference (1970).
16
THE INDIAN JOURNAL OF MEDICAL EDUCATION
VOL. X.
NO. 4.
Fig. I
Distribution of students for practical training.
PARACLINICAL CLASS
(Second/Third term)
(consisting of 140 students)
Practical Demonstration
* Field batch
I
I
BATCH A
(Consisting of 70 students)
BATCH B
(Consisting of 70 students)
1
__________________ f Sub batches
Sub batches
Aa
A.
A, B.
Chemical
Bacteriology
Museum & Demon
laboratory
Entomology
strations on
laboratory
infectious
diseases hos
pital, family
planning, P.H.C. etc.
i
Ba
b3
b,
1. Family study
2. Socio-clinical
3. Graded comprehen
sive health care.
4. Medical care.
Field work—The village is divided arbitrarily
in sectors. Each sector is supervised by a teacher,
paramedical staff and a postgraduate student.
The teacher allots families to undergraduates in
his own sector. The detailed village map along
with other details is provided at the entrance
of the village. Every student is alloted a health
topic including service programmes to work up
on in the 4-5 rural families. Some of the topics
are given below:
(v) Survey of water supply including
bacteriological examination of water
and suggest measures for improve
ment.
vi) Study the attitude towards family plan
ning and provide family planning ser
vices to the needy couples.
vii) Study the beliefs and customs in regard
to common communicable diseases (or
pregnancy, child birth) and provide
i)
Study immunity status and perform
health education.
immunization.
After they are being given a preliminary out
ii)
Perform diet survey and plan a low cost line, the students themselves are required to
balanced diet for the family.
prepare a proforma on the alloted topic under
iii) Study the incidence of anemia in rela the guidance of the teacher incharge and post
tion to iron intake or worm infestations graduate of the batch. This practice enables
them to consult the literature on the health
and suggest remedial measures.
topic and thus enhances their knowledge.
iv)
Study the anenatal and postnatal cases Usually the topics are being changed for the
and provide maternity services.
subsequent batches.
• Note—The batches for field and practical demonstration rotate every week.
+ These sub batches are again divided into small groups depending upon the number of students in each sub
batch. Each sub batch works in respective sector of the village.
DECEMBER, 1971
TRAINING IN SOCIAL & PREVENTIVE MEDICINE
The paramedical staff contacts the families
beforehand and prepares a favourable working
atmosphere in the families. On first visit the
students are being introduced to the members
of the alloted families by the paramedical staff
and on subsequent visits they go themselves and
work under the supervision of the departmental
staff. The department provides in the field the
necessary equipment, vaccine and routine medi
cines. Besides, a technician, dispenser, midwife,
health visitor, sanitary inspector, and a social
worker remain in the field to provide necessary
help concerning their nature of work. College
bus and UNICEF vehicles are made available
for quick transport of students, staff and equip
ment.
The necessary investigations like urine, stool,
blood examination, etc. on individuals or ana
lysis of water wheresoever needed are done by
the students themselves, either in the field or
in the departmental laboratories. Specialised
investigations e.g. radiogocical are conducted in
the various specialised laboratories of the college
on reference from the department teachers.
Besides his own topic of work each student
also renders graded comprehensive health care
in the alloted families. After examining the
patient they write down the prescription which
are being countersigned by the respective tea
cher of the batch and then the medicine is
being given by the pharmacist in the field. The
students have to record these observations in
their practical note books. The UNICEF mate
rial assistance is of great help in carrying out
these field programmes. The socio-clinical
conferences are also arranged in batches on the
cases found in the alloted families. Besides the
teacher holds discussion with the students on
the topic with the family to emphasise the role
of various factors in health and disease.
After repeated visits the students fill in the
desired information of the families in the duly
checked and approved proforma. The students
are also given reference cards for medico-social
problems encountered in their a Uoted families.
These cards are being handed over to parame
dical staff of their batch who follow up and
return back the completed reference card after
discussing with the students the medicosocial
problems. During the field-visits the students
in small batches are given exposures on applied
statistics. The statistician tells them regarding
designing, sampling techniques, collection,
compilation, interpretation and diagramatic
17
representation on the rolling black boards using
the data collected by the students themselves.
The practical application of statistics has also
been recommended by Mathur el al. (1964)
and Jain (1964). After completing the pro
forma they compile, analyse the data and pre
sent it in tabular and diagramatic form, apply
statistical tests, draw out the conclusions and
make necessary recommendations. They also
give suggestion to the families and render the
promotive, preventive and curative services to
these families. Throughout, their work is chec
ked up daily in the field by the respective
teacher.
Demonstrations and agency visit:—The demons
trations are arranged on vital topics soon after
the students have been imparted knowledge
through lectures on the topic. In the demons
tration they are given exercises i.e. to draw low
cost balanced diet, to correct defects in envi
ronmental models etc. Demonstrations are also
held in public health and welfare agencies like
water works, infectious disease hospital, pri
mary health centre and industries. They solve
the exercises and write the demonstration in the
practical note books which after being signed
by the teacher incharge of their batch are sub
mitted in the department the same day.
Laboratory Exercises:—The students are given
training in laboratory on water chemistry,
bacteriology and entomology. In the labora
tories they are being given a preliminary talk
and demonstration of the experiment which
they have to perform on the day.
They do
the exercise at their own and write their metho
dology and findings in the practical note books
which are being checked by the respective
teacher incharge of the batch. They are not
allowed to take away the practical note books
to their homes. This practice discourages the
students regarding the habit of copying from
the books or from fellow student’s note books
and makes them to complete the work the same
day. Some of the exercises of the laboratories
are given below :—
i)
Life cycle of arthropods through the entomological slides, draw their labelled sket
ches and enumerate the characteristic
features and the stage of development at
which the control measures should be
undertaken.
ii)
To perform a bacteriological examination
of water.
THE INDIAN JOURNAL OF MEDICAL EDUCATION
18
VOL. X. NO. 4.
To estimate chlorine demand and residual family. They draw out small working proforma
and collect the desired information and neces
chlorine in water.
sary health advice in being given to the family.
iv) Estimation of nitrites and nitrates in the Besides they are also examined within the
water.
families on the previous work on the allotted
v)
Estimation of chloride or hardness in the topics.
water the sample of water for these exa
minations are drawn from the village
Concluding remarks:—-This type of community
wells of Rural Field Training Centre, oriented training is found to be much more
Kalyanpur, tap water and river water. educative as the students practise in the labora
They interpret the results and suggest tory as well as in the field what has been taught
measures to improve them.
to them in the lecture and what they have to
Examination:—The students are evaluated practise in real life. Besides they learn how to
periodically by day-to-day and terminal exami collect data, analyse them and present them in
nation in theory, field and laboratory exercises. the statistical form. They also have an exposure
In the university examination also they are to the rural health problems and practice gra
evaluated in a theory paper as well as in the ded comprehensive medical care in the rural
fields, laboratory and in uiva voce. In the field community. Such training imparted in the
examination they are being allotted a small undergraduate period have definitely benefithealth topic, besides the work already done by ted and improved compulsory rotating interns
them, to work upon in two hours in the allotted training programme in the department.
iii)
REFERENCES
1. Jain, P.O. ‘Biostatistics and Medical Stu
dents’, Med. Edu. Bull., W.H.O. Regional
Office for South East Asia, Vol.IX.No.
1, 2-5 (1964).
2. Mathur, J.S., Undergraduate Training in
Family, Punjab, Med. Journ. Vol. XVI,
No. 11,499-503 (1967).
3. Mathur, J.S. and Rao, N S.N., Teaching
of statistics in the undergraduate medical
curriculum, Med. Educ. Bull., W.H.O.
Regional Office for South East Asia,
Vol. IX, No. 1, 6-8 (1964).
4. Patel, B.P., Reorientation of Medical
Education for community Health Servi
ces, Swasthya Hind, Vol. XIV, No. 10,
291-298, (1970).
5.
National Institute of Health Administra
tion and Health Conference: Report and
Recommendations of the conference on
‘The teaching of preventive and social
medicine in relation to the health needs
of the country’ held at Vigyan Bhawan,
New Delhi, September 6-9, 1963.
6.
Medical Council of India; Report of the
review commmittee of the Medical
Council of India (Undergraduate Medi
cal Curriculum) New Delhi (1969).
7.
Report and Recommendations of Medi
cal Education Conference, under the aus
pices of Ministry of Health, Government
of India, New Delhi (1970).
8.
W.H.O.: Teaching of Medical Student
for comprehensive Medical Practice
W.H.O/Educ./126,8 Jun, 1964, W.H.O.
Geneva (1964).
o - 3 6. -30
Key Note Address
MANAGEMENT & SERVICE RESPONSIBILITIES OF THE
DEPARTMENTS 01 PREVENTIVE ANr SOCIAL MEDICINE
Dr. N. V. R. Ram
Senior Professor & Chairman
Health and Population Management Division .
Indian Institute of Management, Bangalore
At the outset I want to thank the organizers of the
VI An India Conference of the Preventive and Social Medicine
Departments for having given me this- opportunity to be with
them and share some of my thoughts.
All of us now accept tha.u
prevention is better than cure and prevention of diseases
within the community is the best form of immediate health care.
On this basis, if departments of Preventive and Social Medicii.’s
in the Indian Medical Colleges owe their existence, one would
like to give some thoughts as to how they have executed this
responsibility.
It is t’-_in context T consider their service
responsibility.
ORGANIZED TO LOOK INWARDLY
The departments o
Preventive an.
Social Medicine in
different medical colleges are nearly LOO now.
Their full
complement of staff will consist of a professor, associate
professor, two assistant professors, three tutors, one epidemio
logist, two social workers and one statistician.
total of eleven personnel.
This makes a
Those who do not have the full
complement of this personnel are looking inwardly to fulfill
this complement of personnel.
What are their responsibilities
when once their full complement of staff is achieved?
- LOOKING OUTWARD
Looking outward is considered in its narrow sphere of
managing the services at the attached field practice area.
Normally all departments will have a primary health center and
an urban health center as their field practice area.
field practice area,
In this
students are trained, and professors too
- 2 get their seeping into community health.
It is hoped, that the
students get their necessary rural bias and thereby become more
receptible for ideas of serving the commu lity, the rural masses,
etc.
It is common knowledge that the students do not get
<■
inspired to serve the rural areas by their mere orientation ±n
the rural practice field.
If that were so,
the unwillingness
of doctors to go to rural areas would have diaappeared long ago.
However,
even in the rural practice field,
the PSM Departments
do tend to look inwardly rather than outwardly.
The inward look
gives them the concern of their not being able to manage the
Primary Health Center themselves.
Because PSM is normally
under the administrative control of the principal,
the professor
of PSM has some kind of link responsibility for giving services.
In the normal kind of management
practice, the person who is
responsible to deliver the goods should also have the control
capability for resources.
In this case, the situations seem to
be of a different nature.
I am not pleading for greater control
capability for the PSM departments in the rural practice area.
This is a matter for greater amount of study in depth and
debate.
The concern here is that even within the rural practice
field, the practice of looking inwardly makes the Preventive &
Socia' Medicine department
a medical coljige based discipline
rather than a discipline of community health.
Service
responsibility of the Preventive and Social Medicine department
extends not only to the rural practice field but also to every
kind of rural area wherein prevention has assumed such great
importance.
The fact that it has assumed such an importance
is amply evidenced by the data which has come about in various
studies that 80% of the cases in the Primary Health Center are
diseases which could have been prevented by better sanitation
and personal hygiene.
So, the stress is on health education.
Looking outwardly one should also notice that.100% of patients
attending any PHC come from within 10 kms of such a PHO. This
means about 80% of the block in which the PHO is located is not
covered by the PEC.
Therefore, the service responsibility of
the PSM extends beyond the borders of their departments and
PHO rural practice area to the villages in the remote corners
of the country.
3
PRESENT PRE-OCQUPATION
The present pre-occupation of the PSM department hag been,
apart from inward looking is also on making studies in the
epidemiological status, community care etc.
These studies are
good in" themselves only if they can be applied by way of
This means studies should have:
improved practices.
-- reproducibility
-- reliability, and
-- reality.
Let me explain this.
Any pattern of health services which is
applicable in any rural set-up should have the reproducibility
value in other rural centers.
The data that is produced should
be reliable enough to have a basis for a semblance of reproduci
bility elsewhere.
From this it obviously follows, that
rationality behind the kind of studies should lead us towards a
new health policy for India.
TOWARDS A NEW HEALTH POLICY
The present health policy is a policy of medical care
rather than health care.
It can never be called sickness care.
Medical educatioR^isC$re-occupied with increasing the
number of
*
colleges and producing more number of doctors.
The
result has been that we have produced more number of doctors
than we can absorb in the open market for which we produce them.
Medical education is in the premises of hospital-cum-college
with some sprinkling of
rural practice,and field dem-onstration
given by PSM department.
The result has been, apart from the
disastrous consequences of nearly 10,000 doctors being unemployed,
there has been undesirable trend of more than 50% of doctors
going for specialization.
Specialization has become an end
in itself to suit medical debtors rather than to suit/the needs
of the community health.
What are the considered thoughts of
PSM departments to shape the medical education policy.
- 4 Public health policy has been one of irstituting verticl
health programmes and then thinking as to how we can integrate
this into the basic health services given by the PHD.
care has become sporadic sickness care.
Medical
All this has resulted
in the image of the doctor still being good, whereas the image
of the hospital is bad.
As a consequence of this, prevention is being imagined
as exclusive sphere of PSM department even by the doctors.
The
PSM department naturally occupies a place of secondary
importance within the compound of the medical colleges, com
pelled to look inwardly and forced to look selfishly, without
much of a new direction.
PSM Department has the responsibility
to shape a new health policy for India if it considers the
above situation as unsatisfactory.
DIRECTION NEEDED
The direction that the PSM Departments need to take
in the area of prevention is broader than the activities that
are now being carried out by them.
If nearly 61% of our deaths
are from preventable causes, the direction that the Preventive
and Social •'ledicir.e Department has to take is very clear.
If 80% of the diseases which come to the PHO «ould have been
prevented by the primary care at the source, the direction that
the PSM Departments have to take are in ameliorating the
suffering of these.
This is more imperative in view of the
fact that only 20% of the population covered by the PHD come to
the PHD.
The image of the PSM department will get a new status
if they become articulate about the needs of the community
and thereby the needs which direct us towards a new health
policy.
The new health policy will not be the continuation of
what we are following so far.
It will be one with a concern to
the majority of the masses and their diseases.
It will be
one which will have a concern to give some medical care for
many before expert care for a few.
It will be one which will
make the policy makers realise the compulsive need,
of
establishing more rural health care before a grandiose hospital.
It will also be the one in which the distinction between public
5
health and individual health in a conceptual level and,
hospital care and dispensary care in the organizational level
will ..lerge into what is called as community oare.
It will
also be one in which the number of terminologies which will
exist will all take its due place under the term, community
health.
The present different nomenclature like public health,
preventive and social medicine, administrative medicine,
community medicine will all find a common goal in the community
health.
All this will give new challenge and meeting this
challenge will give a distinct image to the community health.
As to how to meet these challenges and whether it will be
easy, is not a subject matter here.
■A-ll that I can say is, that the
be met.
challenges have to
When we have met the challenge we would be able to
give answers as to what should be the minimum medical care
expenditure before we ask for 300 more crores for malaria.
This will also help us to think as to why we should establish
one more medical college hospital with Rs. 7 crores expenditure.
It will also tell us as to what we have achieved by way of
Rs. 1850 crores of investment on health in four five year
plans.
It will also tell us as to what we should do in a
predicauient wherein we are looking as to where our three
billion rupees have gone in our national family planning
programme as only 15% of the target couples are covered.
This
means, new responsibilities for the PSM departments to make
a dent for the success of the national programmes of this
eeuntry.
Above all, it will help institutions like hospitals, -
PICs, dispensaries etc.
efficiently.
to operate more effectively and
This is a challenge that has to be met.
you all success in this.
Thank you.
I wish
VOL. IX, JUNE-JULY 1970
392 INDIAN JOURNAL OF MEDICAL EDUCATION
7
years of its establishment has' expressedconcept of the A.I.I.M.S. could be extended
their admiration for the speed with which with benefit to other institutions in the
the Institute has progressed in education country. Teachers and investigators must
and research to significant academic heights. be trusted by the administration and a for
ward looking policy evolved by which
'Fhe principle of whole time faculty and teachers, students and administrators are
the concept of the Institute as a residential all unified together in one essential task of
university where the faculty and students elevation of academic standards. Mediocrelive together in the campus have also played laboratories can only train mediocre men.
a significant part in enabling the Institute
This is a time where sermons and satire,
to reach its present stature in the world of irresolution and despondency abound in our
science and education.
public life. Breast beating about low stand
ards does not solve prdblems nor will plati
tudinous sermonising on priorities in educa
The Relevance of the A.I.I.M.S.
tion and service. Gloom about resources,
The relevance of the A.I.I.M.S. to present a recurring theme in scientific circles, tends
Indian conditions is many sided. Autonomy to sap the will of the scientist to go forward
by which the growth and development of and design effective measures. The des
academic programmes and policies are in pondence inhibiting intellectuals can be a
fluenced largely by the scientific community serious psychological barrier to scientific
itself has proved to be an encouraging ex and technological development. Throughperiment. The extension of this principle discovery of the newer purposes of learning,
to other teaching anil research institutions through bold and imaginative policies in the
in India would serve to liberate the creative support of scientific research can grow a
forces in these institutions and channelise new hopefulness. The way the A.I.I.M.S.
their energies to elevation of standards.
has grown and developed provides opportu
Excellence in a few centres only removed nities for new thinking on the whole pattern
from the main stream of national life can of medical education and medical research.
The greatest and deepest need of an insti
only lead to scientific aristocracy. The
principles which guided the formation of the tution is to be needed.
Community Medicine and Medical Education
BY
Carl E. Taylor, M.D.
Rural Health Research Projects, Narangwal Khurd, P. O. Kila Raipur, Ludhiana, Punjab
Adapting medical education to the needs
of India clearly requires a new and expanded
emphasis on Community Medicine. The
achievement and failures of the past 10 years
permit a clear statement of practical innova
tions which can work if given adequate
faculty support.
No subject has received so much attention
in speeches and so little practical attention
by medical educators as the health needs of
village communities. This discrepancy is
due mainly to the large volume of speech
making and only partly to the slow build-up
of efforts. The speech-making is valuable
in so far as it creates a climate for implemen
tation. We can no longer postpone action,
however, because of the excuse that we don’t
know what to do.
A solid foundation of achievement in the
past 10 years now proiides a basis for plan
ning. Our present knowledge is derived
from the numerous ‘experiments’ in com
munity medicine which have quietly been
taking place around the country.
The verbal enthusiasm for rural teaching
which followed the 1955 All-India Congress
on Medical Education carried the flavour
,of much of the general development planning
jin India during that period. The goals and
■ideals were impeccable but so exalted that
'their translation into performance would
have been possible only if all medical educa
tors and students had been paragons of dedi
cation. We all shared a kind of enthusiastic
inaivete that made us believe that difficult
goals would be readily attained. Without
this willingness to try anything, many of the
‘Important achievements of that period wotdd
have been impossible.
; The post-independence burst of energy
led to great accomplishments in medical
{education which now appear to have been
more quantitative than qualitative. A rapid
numerical growth of the medical profession
was considered the first priority to meet
the mass needs of a rapidly expanding popu
lation. This effort has in itself been a
clearly defined challenge demanding pheno
menal investment. It is increasingly evident
that the race with population growth requires
the medical profession to realistically reap
praise its own rule as part of national health
system. The goals of the past are not neces
sarily the best response to the challenges of
the future. The greatest hope continues
to be that the leaders of Indian medical
education have always strongly supported
the maxim that medicine must be responsive
to the needs of society. More bluntly the
fact is that health services must be organized
for the good of the people and not to meet
the personal needs of doctors for material
gain or scientific satisfaction or altruistic
motivation.
In this brief analysis two points are stres
sed: some basic principles of community
medicine are restated as they apply especially
to the needs of India’s village communities;
secondly, new challenges for change and
innovation are presented in the exciting
pattern which is emerging from past efforts.
I.
Background
First, a few words of history are indicated
to help provide understanding of a kaliedoscopic transition in terms.
Community medicine is not merely a new
label applied to old efforts. As the old un
popular subject of hygiene began its frenzied
struggle to keep from being drowned by the
flooding growth of scientific clinical medicine
it tended to turn toward the relative security
of Public Health separatism. One of the
most unfortunate legacies of western medi
cine as transplanted to developing countries
was the separation of curative and preventive
394 INDIAN JOURNAL OF MEDICAL EDUCATION
VOL. IX, JUNE-JULY 1970
medicine. The maintenance of this dicho These may be used profitably in both the
tomy has been as much the fault of public pre-clinical and clinical periods of prepara
health practitioners as of clinicians. Be tion. Great variation exists among the
cause they-were so low in the pecking order colleges in the size, facilities, staff activities
of medical prestige as to be almost ignored, and degree of control over the health center
public health physicians have tended to get by the medical college. Now it is increas
their professional satisfaction outside of the ingly recognized that a single health center
usual range of medical activities. An is not enough and the next evolutionary step
awareness that they were contributing more will be to have a medical college serve as a
to overall improvement of health than their regional base for comprehensive health care.
clinical colleagues increased their feeling of
Within medical faculties there was some
satisfied isolation when both clinicians and decrease in the low caste stigma of public
the public tended to ignore them. The only health as a result of the use of the term pre
times they could count on being noticed was ventive and social medicine. Some clini
when there was a major epidemic for which cians were attracted to professorships with
they were blamed. The public health pro a resulting transfer of glamour from their
fession drew a special personality type of old familiarity with clinical wards. Political
dedicated and underpaid sanyasis who and financial support also improved the
appeared as anything other than glamorous image of this field. There was, however, a
role models to medical students. The image simultaneous loss in glamour through the.
of this part of medical practice needed to be punitive approach taken in developing rural
■ changed in order to incorporate it into the health work. With the decision to turn
mainstream of medical education and rural health centers over to preventive and
practice.
social medicine many medical educators
The first step in the change process was relaxed back into their traditional roles.
the reorganization of teaching in new depart Students and interns were then forced to
ments of preventive and social medicine. take their dose of village work as though it
Thousands of words both in publications were bad-tasting medicine. Since no one
and speeches went into definitions of what really' knows how rural teaching should be
the new image was to be. Curriculum time done clinical teachers were safe in severely
allocations recommended by a long series criticising the courageous attempts of pre
of conferences was for teaching in each year ventive and social medicine teachers to pio
of the medical course. Actual implementa neer this new area.
tion varied with convincing arguments for
both preclinical and clinical emphases. II. Definition of Community Medicine
Obviously the ultimate decisions about what
It is time now to really create a new image
was actually taught were mainly' determined
by the personal predilections of particular and a new atmosphere. The label of com
professors. Clinically oriented teachers of munity medicine should help. The first
requirement
in this new effort will be to get
preventive and social medicine wanted
strong linkage with clinical subjects. Those the active participation of the whole medical
departments most concerned with research faculty.
activities in epidemiology or social medicine
The struggle to adequately define the
stressed the basic sciences of preventive various labels which have been applied to
medicine. The old arguments on both this elusive field of medical activity hate
sides are still valid. Students need first the tended to degenerate into bickering o'C
foundation of a basic introduction to ecology, trivialities. Distinctions in terms have been
epidemiology, the sociology of medicine clouded by over-definition. The
and demography. Then they certainly value of the new term community medici
need a well organized educational experience is that it can be used as a fresh star
during a practice period in the clinical years. identify a general area. In general,
A major emphasis has appropriately been field must be recognized to share a 8™/
on the development of rural and urban of association with all the clinical discip> .
health centers as teaching laboratories. in what has been called clinical prete
COMMUNITY MEDICINE AND MEDICAL EDUCATION
^medicine. It goes beyond that, however,
to a group of special competences and skills.
It is demonstrably wrong to say that com
munity medicine will eventually work itself
out of a job when other clinical departments
take over because no other discipline can
cover the special areas of knowledge and
practice. It must also be agreed at the
beginning that arbitrary limiting of the term
is wrong because it must be applied diffe
rently in varying situations and places.
Medical specialties are generally defined
either according to the group of people they
serve or by the type of activity and skills
which occupy their time. Community
medicine can be separately identified on
both scales.
The patient of community medicine is
obviously the community. The community
is composed of individuals just as a forest is
composed of trees but it has its own special
characteristics. A woman is cither pregnant
or not pregnant but most communities are
always about 3 per cent pregnant. Similarly
the illnesses of a community must be studied
within their ecological setting. The gestalt
of the whole community brings an under
standing that is quite different from seeing
separate individuals as patients. The con
cern for the individual is not lost in the
process but he is seen in relation to the
group. Health care becomes more than
mere manipulation of inner functions of
[individuals and focuses much more on
the conditions which surround him. The
fundamental and preventable causes of
illness are usually community determinants.
;; To apply community health care a doctor
[heeds special knowledge, skills and attitudes.
^Traditional medical education does not
provide this understanding and practice.
It is no longer reasonable to expect even the
mature physician to pick these up sponta
neously. The basic sciences of community
inedicine are largely ignored today. Even
more important there are special skills of
diagnosis and health care which need to be
(developed with as much precision and care
as present practitioner training in wards and
Operating, theaters. Most critical arc a
Jroup of ethical standards that can now be
lefined, which call for basic modifications
n the values and attitudes of the doctor who
’idertakes community responsibilities.
395
III.
Application of Principles of Com
munity Medicine to Indian Conditions
The following section gives more detail
on the knowledge, skills and attitudes which
are needed.
The discussion is not intended to be
inclusive. It is selective in the sense that
an attempt is made to give priority to parti
cular emphasis which seem important in
India today.
.4. Basic Sciences of Community Medicine
One of the early decisions in curriculum
planning for preventive and social medicine
was that teaching should extend from the
beginning of the medical course through the
internship. Now with the progressive matu
ration of the concept of community medicine
it is even more important to restate this
principle and to clearly define what it means.
The basic sciences of community medicine
must be built into the’preclinicai curriculum
along with the basic sciences of clinical medi
cine. The relative emphasis on the follow
ing specific disciplines and their timing and
issues to be adjusted to local conditions:
1.
The most general term covering the
basic orientation that needs to be developed
is ecology. Although this discipline had its
roots in plant and animal studies the present
need is to make it truly relevant to under
standing the human conditions in India.
As the study of the relationship between
man and his environment it provides a good
base for understanding the environment.
2.
Equally fundamental are the group
of disciplines usually included in the social
sciences. Selective and relevant contribu
tions to understanding the organization of
man in groups and interactions between
individuals are fundamental because other
people are the dominant component of the
environment of most individuals.
3.
Statistics provides a quantitative base
for community understanding and should
make community medicine a more scientific
and less intuitive discipline than most kinds
of medical practice.
4.
Epidemiology' is the diagnostic’’dis
cipline of community medicine. It is
ecology applied to health problems. It can
be practised at the level of the family just as
effectively as with larger communities.
396 INDIAN JOURNAL OF MEDICAL EDUCATION
Epidemiological information provides the
basis for much of the intuitive approach of
the highly skilled clinical diagnostician.
Expectations of when to look for particular
combinations of health variables and their
outcomes derive largely from awareness
of probabilities in particular community
groundings. Certain types of people come
down with particular conditions and clinical
ambiguities are often resolved best on the
basis of the epidemiological trial of knowing
what to expect according to variables of
time, place and person.
VOL. IX, JUNE-JULY 1970
must either take leadership or find them
selves controlled by administrators and
politicians. Of particular interest is the
great growth of administrative research
exploring areas that were previously left to
ad hoc and intuitive decisions. Not only
must medical colleges begin to provide
opportunities for doctors to learn health
administration but they must also take
leadership in research in health systems.
The field practice area therefore has the
potential of becoming equal in importance
to the ward and the laboratory as a base
5. Demography is an increasingly impor for teaching and research.
tant basic science in medical education.
2.
The doctor is the leader of the health
Rapid population growth appears to be the team. No other aspect of medical educa
spontaneous factor most directly controlling tion has been so much left to chance as pre
change and development in India today. paring the doctor to work with health col
All health variables are directly influenced leagues. In a primary health center he will
by number of people. The medical pro be responsible for at least 40 co-workers and
fession must perceive its own responsibility the number grows every year. This change
for birth rates in addition to its traditional is even more dramatic than the parallel
movement in hospitals for more and more
concern with death rates.
responsibilities to be carried by auxiliaries
6. Genetics, Nutrition and Child —a change that is forced by the increasing
.Growth and Development provide under technocracy of medicine. To be a team
standing of the person. Each is controlled leader requires a drastic change from out
by varying environmental determinants. dated concepts of solo-practice. The new
They are worth studying independently
role requires a chance to practice in a field
because they mediate the more general setting where the young doctor begins to
environmental forces.
understand that there are many tasks includ
ing
clinical functions of medical care, which
B. Applied Sciences of Community Medicine
auxiliaries can do better than him on a
On the foundation of understanding the routine basis. He must learn to delegate
disciplines of community medicine it is down so that the complicated judgmental
necessary' in the clinical years to develop problems can be referred up. Learning to
appropriate skills through practice. Many work together with others requires practice.
of these should be applied routinely in clini
3.
Community control measures can
cal practice with individual patients. To now be applied on ,t widespread scale for
properly care for people the doctor should many diseases. This is most true of many
incorporate social and preventive measures. basic preventive procedures that remove the
He must, however, also learn to deal with causes of disease. In general these include
the community as a whole because a group public health functions such as sanitation,
approach is often most efficient, economical vector control, mass education and social
and humane.
and legal measures. Every doctor should
1. Administration of health care has be involved in community activities especi
grown rapidly in importance. Partly as a ally those which are applied at the persona
result of demographic change and the in level such as immunization and nutrition.
4.
Family Planning programs are here
creasing complexity of society there is a
general insistence on better organization. mentioned separately because of their vita
In fact in some countries health care now role in building a better India. Both com
ranks as the fourth largest industry both in munity and individual approaches must e
its requirements for manpower and money. blended. The fact that in many primary
As people insist on better organization doctors health centers approximately half the tot
COMMUNITY MEDICINE AND MEDICAL EDUCATION
staff effort is going into family planning is
an indication of its significance in India’s
health program already. The pressure is
bound to increase because the population
problem will not be easily solved. Some
family planning experts arc saying that one
of the greatest obstacles to effective family
planning program in India is the medical
profession. It is the responsibility of the
leadership in the medical colleges to dis
prove this indictment.
C. Basic Changes in Attitudes and Values
No combination of knowledge and skills
will by themselves be sufficient preparation
for the practice of community medicine.
Both must be supplemented by a changed
attitude, a modified set of values that goes
beyond that usually associated with medical
. ethics.
When a doctor takes on the responsibility
of caring for a community as his patient he
has to change his understanding of his prii'.mary responsibility. He can no longer
: think in terms of doing everything possible
for a few selected individuals. He must
. learn to apply an appropriate scale of priori[' ties to the choice of health problems which
' most require attention. He must also learn
! to think in terms of cost/benefit ratios in
I judging what control measures to apply.
((This requires a judicious amount of apparj-ently ruthless saying ‘No’ by the doctor to
t individuals who present themselves for
^symptomatic care of minor complaints which
should normally be treated by auxiliaries.
Rather than only treating complaints that
■spontaneously come to him, he reaches out
to the community in continuing appraisal
of relevant problems. The community
[doctor must reserve his facilities and atten
tion for those health problems which he and
;the community select as having highest
priority. There will never be enough
[resources to care for all health demands and
rational allocation requires courage and
much skill in public relations.
I . The community doctor gets his satisfac
tion less directly and overtly than the clini
cian. The results of his efforts are often
.deferred in time. Patient response is not
Usually direct and openly warm because
Prevention does not evoke gratitude as
lily as relieving pain or fear from existing
397
Another basic attitude growing out of the
ecological view is the recognition that medi
cal care is not always the greatest need of a
community. Health benefits may be better
achieved by non-hcalth developments. The
doctor may therefore promote the greatest
health gains by non-medieal means.
IV.
Emerging Pattern of Community
Medicine in India
Among the dramatic health achievements
of the post-independence years one with
particular long term benefit is the progressive
evolution of a system of regionalized health
care. The whole program is built on the
comprehensiveness of care in the sense that
the old dichotomy between preventive and
curative sen-ices is being eroded away. The
whole system of primary health centers as
the peripheral service units linked back
through increasing specialization to taluk—
district and medical college hospitals pro
vides an anatomical framework which is
fairly well developed. The physiology of
this system is not yet functioning, however,
because the two-way linkage flow is not
working. Education and consultation
should flow to the periphery and patients
and problems should be referred centripe-
The greatest lack in the system in rural
India is an adequate base of subcenters.
To really reach the villages there must be
a sub-center for about 3000 people. It has
been demonstrated in our field research as
well as in other places that a new type of
‘ambulatory nurse midwife’ is needed to
provide the needed services at the village
level. In the first place they should inde
pendently provide the bulk of routine symp
tomatic medical care. If the doctor is
relieved of this burden he can do the tasks
which are really important for the health care
of the many village communities in a PHC
block. This ANM can also carry' out the
village level preventive and family planning
services which will provide the real basis for
health improvement in the country. But
they can work effectively only with appro
priate supportive supervision.
For medical colleges the most exciting
future potential of development is in moving
actively into community responsibility. In
the past, medical educators have spoken of
398
INDIAN JOURNAL OF MEDICAL EDUCATION
VOL. IX, JUNE-JULY 1970
out a co-ordinating system. Communitv
care admittedly adds to the complexity of
medical education. It has been clearly
evident from experience thus far that it is
not sufficient to merely turn community
medicine over to a single department. All
departments, especially those with clinical
responsibility, must be involved to make a
significant impact on medical students.
The needed synchronization of effort will,
however, not happen spontaneously. With
out stimulation and co-ordination this intri
cate anatomy of organization will remain
inert. The simplest administrative measure
would be to expand the role and resources
of the department of community medicine
to fill the co-ordinating responsibility.
A fixed percentage of the medical college
budget could be allocated to ensure that
the field activities are not eventually
crowded out. To really provide the status
needed, however, a dean of community
extension should be appointed on a par
with the academic dean and the superin
tendent of the teaching hospital.
We have had too many halfway measures
and too much frittering away of resources in
partial solutions. The need for bold and
decisive action is evident. Some colleges
V.
Co-ordination
should take up the evident challenge ol the.
No complex organism can survive with- new community medicine.
their responsibilities as being a tripod of
teaching, research and clinical service. To
this we need now to add the fourth leg of
community service.
The climate is now right for some colleges
to really pioneer in taking regional responsi
bility for medical care. Heads of clinical
departments should be responsible for
service in a whole district. For instance, a
department of surgery should assume res
ponsibility for seeing that simple surgery’
in health centers and small hospitals is pro
perly done. Staff should rotate back and
forth from center to periphery. If appro
priate linkage is established the patient
should be able to get the diagnostic preven
tive and therapeutic services he needs as
close to his home as the sophistication of
facilities will permit. The health centers,
public health services and small hospitals
would be considered part of the medical
college just as much as the teaching hospital
now is.
The eventual goal is to have a medical
college not limited by hospital walls. It
must be decentralized, reaching out to in
corporate community health care facilities
in a whole region.
Need-Based Undergraduate Medical Education
BY
Dr P. K. Duraiswami
Director General of Health Services, Government of India, New Delhi
i; Today medical education has reached a
stage in its long history, when a departure
from the traditional structure of the past
has become almost imperative not only in
developing countries, but also in developed
countries. In September 1965 it was con
sidered expedient in Great Britian to appoint
;a Royal Commission to review medical edu
cation, under-graduate and post-graduate,
in the light of national needs and resources,
■including technical assistance overseas, to
advise Her Majesty’s Government on what
principles future development, including
■its planning development, should be based.
The Royal Commission which submitted
its report in April 1968 made the following
important recommendations in so far as the
.under-graduate medical education was con
cerned : (i) The duration of the under-gradu
ate course should remain five years, (ii)
The course should be as flexible as possible.
Its content should be grouped into compul
sory elements, options, and elements in
which a choice may be made between a
Series of limited alternatives, (ir'i) A total
■period of about nine months should be
ivailable for optional courses in which a
ttudent could (after advice) broaden his
Acquaintance with several subjects or study
jne in greater depth. He should be able to
tpend this time in clinical subjects as well as
£e basic medical sciences, (<i>) The under
graduate course and graduation should be
ollowed by a compulsory year of intern
ship similar to the present one but better
controlled by the universities than now.
This should preferably be completed by all
Students, including those from overseas, in
the region adjoining their medical school.
’.v) Registration after satisfactory comple
an of internship, should enable the indidual to practise under supervision, but
tould not entitle him to independent clinid practice in Britain.
In the United States the basic medical
qualification of M.D. can be obtained only
after a four-year course in high school, a
four-ycar course in college in which a candi
date receives his pre-medical training in
such subjects as chemistry, physics, biology,
and another four-year course in a medical
school. In addition to these academic
requirements, prospective medical students
are expected to take the Medical College
Admission Test, which was developed in
1947 by the Association of American Medi
cal Colleges. Generally, two years of medi
cal school would be devoted to the preclinical subjects and the remainder to the
clinical fields.
Since submission of the Flexner report on
medical education in 1910, medical educa
tion in the United States of America has
undergone several changes. Probably the
most important one pertains to the develop
ment of speciality training after medical
school. According to the National Advisory
Commission on Health Manpower, by 1967
less than two per cent of medical school
graduates go into general practice. The
vast majority continue their education after
graduation from medical school with a view
to become specialists, teachers or research
scientists. Today the completion of medical
school and the awarding of the M.D. degree
thus represent not the termination but only
a midway point in the education of the
American physician. The emphasis on
specialty training and research has also
effected a basic change of the character of
the American medical school, which has
become a research and post-graduate educa
tion centre in addition to its erstwhile func
tion of training under-graduates.
On the other hand, there is a rising tide
of feeling in the United States of America
that medical education in all its phases is
too
. May-August 1986
Pattern of Internship Training in
Community Medicine/Preventive &
Social Medicine in India
By
Centre or Upgraded Primary Health Centres.
It has further stipulated that the posting in
Community Health work should be for a
minimum period of six months. Medical
Council of India has also recommended that
‘‘Each Medical College should be in total charge
of three Primary Health Centres and the
number of primary Health Centres should be
gradually increased so as to cover the entire
district.”
RD. Bansal
In the light of the above recommendations
-the Department of Preventive and Social
Medicine, Jawaharlal Institute of Postgraduate
Medical Education and Research, Pondicherry
made an attempt to gather certain information
from various medical institutions in order to
review the pattern of internship training in
Preventive and Social Medicine including the
' physical facilities available for it.
Professor & Head of Pepartment
M. Danabalan
■Assistant Professor
D.K. Srinivasa
Associate Professor
And
Adaikalanathan
■Medical Officer
.Department of Preventive & Social Medicine
■Jawaharlal Institute of Postgraduate Medical Education & Research,
Pondicherry.
Date of Acceptance on 1st May, 1986
Material and Methods
This study was undertaken by the Depart
ment of Preventive & Social Medicine,
v? Jawaharlal Institute of Postgraduate Medical
Education & Research, Pondicherry during the
A review of the pattern of internship training in Preventive and Social Medicine/
Community Medicine in various medical colleges of India was made by the Depart
,■ period March to October, 1985. A self| ‘ administered questionnaire (proforma) wos
ment of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate
Medical Education & Research. Pondicherry. Information obtained from eighty-five
... despatched to the Heads of Departments of
medical institutions were analysed and the pattern of training available in them were
/ . P & SM in the one hundred and eleven
evaluated in the light of the recommendations of Medical Council of India on this
medical colleges in India during April 1985.
subject.
The proforma gathered information concerning
Introduction
pattern of internship training in P.S.M./
broadly outlined the training to be given during /I
this period. It has emphasised that internship/! |K Community Medicine including certain parti
Medical Council of India has made several
shall include training in Medicine, Surgery B
culars of physical facilities available and
■recommendations
regarding
compulsory
financial support obtained. Till the end of
and Obstetrices & Gynaecology and in ’ *
rotatory internship training (1983). It has
Community Health at Rural Health Training
October, 1985, filled-in proformas were received
Pattern of Internship Training in...41
from eighty-five medical colleges. The data
obtained were analysed.
RESULTS
Type of Medical Institutions
Of the eighty-five institutions, sixty-nine
(81.2 per cent) were state government colleges
whereas seven were private (8.2 per cent),
four central government (4.7 per cent), three
autonomous (3.5 per cent) and two municipal
(2.4 per cent) medical institutions.
Annual Intake of Undergraduates
The annual intake of undergraduates ranged
between 50 and 210] Seventeen medical
colleges (20 per cent) had admissions between
50 and 75, twenty-four colleges (28.2 per cent)
between 75 and 100,
thirty-two colleges
(37.6 per cent) between 100' and 150 and
twelve institutions (14.2 per cent) had more
than 150 admissions annually. '
abstract
Total Duration of Posting in P.S.M...
The total duration of posting in Preventive
and Social Medicine in various medical
colleges was between one month and six and a
half month. It was less than three months in
twelve institutions (14.1 per cent), three
months in forty-five (52.9 per cent) and six
months in twenty-seven institutions (31.8 per
cent). Only in one college (1.2 per cent) the
total duration was more than six months viz.
six and a half month.
42 The Indian'Journal of Medical Education
Availability of Health Centres
(I) Rural Health Centres/Primary Health Centres
(H.C.)
Four medical colleges (4.7 per cent) did
not have an attached rural/primary health
centre (H.C.). These four institutions included
two municipal, one central government and
one private college,
Out of the eighty-one institutions with rural
centres, seventy-three (90.1 per cent) had only
one centre each whereas only eight (9.9 per
cent) had three or. more centres attached to
each of them.
(11) Urban Health Centres
Twenty-one institutions (24.7 per cent) did
not have an urban health centre. All these
were state government institutions. .
Residential accommodation in Health Centres .
Rural centres of sixty institutions (74.1 per
cent) had residential'facilities for their • interns
whereas urban centres of fifteen colleges
(23.4 per cent) had such facilities.
.. Number of Interns Posted at a Time
The number of interns posted at a time "in
the health, centres varied between , two and
.thirty-five. 7
... ' ..
7 77.7
In.rural centres, of four.medical colleges
*(4.9 per cent) the number of interns posted at
a time was more than thirty whereas in those
Pattern of Internship Training in ...43
Volume XXV Mo. 2
of eight institutions (9.9 per cent) it was
between twenty one and thirty and in those
of thirry-two institutions (39.6 per cent) it was
between eleven and twenty. In rural centres
of only thirty-two medical colleges (39.ff per
cent) this number was less than ten] Five
institutions (6.2 per cent) did not provide this
data.
Hay-August 1986
jjoni the state governments. Eighteen colleges
(22.2 per cent) received the funds from the
state governments and medical collenes jointly
Break-up of Postings in P.S.M.
(1) Rural Posting
i (Table I).
The duration of this posting ranged
1
The funds for urban centres of twenty-eight between two and twenty-four weeks. In
| medical colleges (43.6 per cent) were given by thirteen colleges (16.4 per cent) it was between
i the colleges themselves whereas that to sixteen sixteen and twenty-four weeks, in forty-five
(25 per cent) was from the state governments. colleges (55.5 per cent) it was between six and
Twenty institution (18.6 per cent) obtained finan twelve weeks and in twenty institutions
In urban centres of five institutions (7.8 per
cial support for their urban centres from the (24.5 per cent) it was between two and four
cent) the number of interns posted at a time ;
colleges and the state governments jointly weeks. Three institutions (3 6 per cent) did
was between twenty bne andthiity whereas in •
while six (9 4 per cent) received it from the not indicate this duration (Table II).
those of eight (12.5 percent) it was between
eleven and twenty and in those of forty-two
; municipality.
(if) Urban Postings
college (60.7 per cent) it was below ten. -Two institutions (3.1 per cent) did not post any
Population Coverage of Health Centres
The duration of this posting varied from
intern to their urban centres. Seven colleges •,
one to twelve weeks. In five colleges (7.8 per
(10.9 per cent) did not furnish this information. -¥
• The population coverage of rural centres cent) the duration was between eight and
ranged between 5000 and 5 lakhs whereas that
twelve weeks, in nine (14.1 per cent) between
Administrative Control of Health Centres
> :of urban centres ranged from 1500 to 10 lakhs.
six and eight weeks and in thirty-seven
colleges (57.9 per cent) between one and four
The administrative control of rural centres a U? Rural centres of two colieges (12.3 per cent)
weeks. Eleven colleges (17.2 per cent) did
of thirty five colleges (43.2 per cent) was with «
served less than 25,000 population.each, twelve
not furnish this information (Table H).
the medical college's themselves whereas that of 3 |rf(I4.8 per cent) between 25,00 •_ and 50,000
thirty (37 pes cent) was with the medical colleges
' .fifteen (18.5 per cent) between 50,000 and one
and the state governments jointly (Table I).S ■ lakh and twenty-one (25.8 per cent) more than (Ii7) Postings in other departments/agencies
' .one lakh each. Rural centres of twenty-three
Though the posting pertains to P.S.M./
...On the other, hand, the administrative'.institutions (28,5 per cent) did not provide
Community Medicine ' “on paper’, eleven
control of urban centres of- thirty-four '3
information about their population coverage.
medical
colleges (12.2 per cent) ‘deputed
*
medical colleges (53 per cent) belonged • to. the 7,
interns to other departments/agencies during
institutions themselves' whereas' that of nine
| jg Urban centres of thirty-five colleges
(14 per cent) to state governments and that of | Brpl.6 per cent) catered to less than 25,000 their posting in P.S.M. Hence the actual
another nine (14'.per cent)'tothe colleges-and J i./population each, sixteen (25 per cent) between posting in P.S.M. in these institutions was
state governments.jointly.
/,^5,000 and 50,000 and fifteen (23.4 per cent) much less than the duration mentioned (f.e..
three months in six colleges and six months in
_ -x.
...ui'.m e.- .c'.:;-.iu? S
to more than 50,000 each. Ten medical
five). The duration of posting to other
Agencies Providing Financial Support '
- /
colleges (15.6 per cent) did not mention the
departments/agencies was between four and
■ . Population coverage of their urban centres.
Financial support to rural centres of forty- ji
four medical institutions (54.3 per cent) came
Medical Colleges : Administrative Control & Financial Support of Health Centres
ADMINISTRATIVE CONTROL
AGENCY
FINANCIAL CONTROL
Urban Health
Centre
Rural Health
. Centre
Urban Health
Centre
Rural Health
Centre
No.
%
No.
%
No.'
%
No.
%
34
53.1
35
43.2
28
43.6
18
22.2
9
14.0
30
37.0
16
25.0
44
54.3
Municipalities
8
12.5
1
1.3
6
9.4
T-
—
*
Dual/Joint
9
14.0
15
18.5
12
18.8
18
22.2
Others
2
.3.2
—
—
1
1.6
—
Information not available 2
• 3.2
-
-
1
1.6
1
1.3
100
81
100
64
100
81
100
TOTAL
64
- ri‘r~'an<i State Governments jointly?
TAble i
'
May-August 1986
■J '
Medical Colleges and Break-up of Posting in P.S.M. by duration and placement
MEDICAL COLLEGES
PLACEMENT :
DURATION
IN WEEKS
Urban Health
Centre
NIL
Volume X X V No, 2 I
Medical Colleges
State Governments
44 The Indian Journal of Medical Education
TABLE i
Primary Health
Centre
Other Department/s
Agencies
Not known
%
No.
—
-
-
-
3
13.0
No.
%
No.
%
No.
2
3.1
—
-
%
14
21.9
3
3.6
3
3-4
23
36.0
17
20.9
2
18.2
3
13.0
2
18.2
9
39.3
9.0
3
13.0
6—8
9
14.0
21
25.9
9—12
5
7.8
24
29.6
1
16-24
•—
-
13
16.4
-
—
2
8.7
Not Known
11
17.2
3
3.6
3
27.3
3
13.0
TOTAL
64
100
81
100
11
100
23
100
Pattern of Internship Training in
2
27.3
46 The Indian Journal of Medical Education
eighteen weeks. These departments/agencies
included Departments of Paediatrics and
Obsterics & Gynaecology, Family Planning
clinics and Post Partum Units, Civil Hospitals
and National Social Service.
It was further observed that in eight
(66.7 per cent) of the twelve institutions where
the P.S.M. posting was less than three months
the interns did not have any ‘deputations’ to
other departments/agencies, However, the
other four (33.3 per cent) did not provide this
information. Among these colleges with a
three months’ posting in P.S.M., twenty-eight
(62.2 per cent) did not have such deputations
whereas six (13.3 per cent) had, while eleven
(24.5 per cent) did not give this data. Of the
seventy-eight colleges with six months’
posting or more in P.S.M. fifteen (53.6 per
cent) did not have this ‘deputation’ whereas
five (17.9 per cent) had it while eight colleges
(28.5 per cent) did not furnish this information.
Discussion
;
It was evident from the observations made
that many of the medical colleges faced
difficulties in implementing the recommendadations made by Medical Council of India
regarding internship training in Preventive and
Social Medicine.
Only one-third of the institutions provided
six months’ internship training in P.S.M. as
suggested by M.C.I. The posting was for only
three months or even less in the other twothirds of the colleges. Many reasons could be
identified for this ‘reduced’ exposure of interns
Volume XXV No. 2
to community health in a majority of theinstitutions.
Many of the institutions admitted a large
number of students annually. Thirty-eight of
them had an annual admission of more than
one hundred and twenty five students. Fiveper cent of the institutions did not have rural
centres attached to them and twenty-fiveper cent of them had no urban centres. Only
ten per cent of the colleges had three rural
centres attached to them as suggested by
M.C.I. Twenty-six per cent of the colleges
had no residential facilities for interns in
their rural field practice areas in spite of the
fact that rural internship was essentially aresidential training. In sixty per cent of therural centres with residential facilities, the
number of interns posted at a time was betweeneleven and thirty-five. Many of the institutionslacked sufficient teaching staff in the discipline
of P.S.M. The funds provided to various
medical institutions under Re-orientation of
Medical Education (R.O.M.E.) scheme by
Government of India for construction of
residential facilities for interns in the rural
centres were inadequate.
On account of these reasons many instir
tutions were forced to ‘depute’ the interns to
other departments of the medical colleges or
agencies outside these institutions during their
posting in P.S.M. Hence the six months’.
posting in P.S.M. in these institutions was
more on ‘paper’ than in actual practice.
In view of the above situation with regard
to internship training in P.S.M. in medical,
Pattern of Internship Training in...47
May-August 1986
instiutions in the country it is suggested that
the entire pattern of this training be critically
reviewed at the national level. This review
could be initiated by VI • Jieil Council of India
or Ministry of Health and Family Welfare,
Government of India in the context of the
National Health Policy outlined by the
government. The review tg committee could
also devise different strategies to overcome the
difficulties/hurdles faced by various medical
institutions in relation to internship training in
P.S.M,
Acknowledgement
The authors wish to express their sincerethanks to Dr. O.P. Bhargava, Director,
Jawaharlal Institute of Postgraduate Medical
Education and Research, Pondicherry for his
continuous encouragement and support and
to all the Heads of Departments of Preventive
& Social Medicine/Community Medicine of thevarious medical colleges for their active co
operation in promptly providing us the
necessary information pertaining to internship.
training in their departments.
REFERENCE
Medical Council of India—Recommendations on Graduate Medical Education, 1983.
12
The Indian Journal of Medical Education
Volume XXIV No. 2
'
REFERENCES
1.
Guilbort J.-J. Educational Hand book for Health Personnel
(1981) offset No. 35,
W.H.O.
2.
Malleson, N. (1965);
A handbook on British Student Mental Health, Society for
Objectives of Training in M.D.
Community Medicine
F
By
Research in to Higher Education, London, SRHE 3, No. 3, 218.
J.
Plaee, B. J.
S. Gill
3.
Malleson, N (1967) Medical Students Study Timo and
1, 169. SRHEE.
K. Ramachandran
4.
Malleson, N„ D. M. Penfold and M.Y. Sawiris (1966) Medical Students study: The
way they work, B. J. Med., Ed., 2, 11-19 SRHEE No. 2,115.
Department of Briostatistics, AllMS and Faculty of Centre for Community Medicine, AU MS.
5.
Payne, J. 1969). Research in Student Mental Health, Society for
Higher Education, London, SRHE 3, No. 3, 218.
6.
Popbam J. M., (ed) Evaluation in Education Berkley Me Chutchan 1974.
7.
Popham W. J. (ed) 1971b). Criterion-Referenced Measurement: an Introduction;
Englewood Cliffs, N. J. Educational Technology Publication;
8.
Scravio Anderson and Ball Samual The Profession & Practice of Programme
Evaluation, Sage Publication, 1978 London, California.
Med.
Ed.
Centre for Community Medicine, AlIMS, New Delhi,
Research in to
Introduction :
The Centre for Community Medicine, All India Institute of Medical Sciences, has
prepared a revised list of objectives, both general and intermediate (instructional), for
its three year postgraduate training programme leading to the degree of M. D. in Community
Medicine. These objectives are presented here not as a final document, but with a view to
initiate discussion on the subject. It is also hoped that the sir ring of training objectives
will lead to greater uniformity between different institutions engaged in post-graduate
education in Preventive and Social Medicine or Community Medicine. Comment on what
follows will be welcome.
The Centre for Community Medicine shall be concerned with training of specialists
who after successful completion of the course have the necessary skills to play the roles of
Teachers
Researchers
Administrators
And other service personnel in this discipline
1.
General Objectives :
1.1
The trainee should possess an in-depth understanding of the Community, including
the major determinants of health and disease.
1.2
He should be able to plan and carry out investigations into the health problems
of the Community and its special groups (Community diagnosis), with a view to
take necessary corrective action.
1.3
He should be able to carry out epidemiological investigations into communicable,
non-communicable and nutritional diseases and suggest appropriate solutions to
the problems of public health importance.
14 The Indian
Journal of Medical Education
Volume XXIV No. 2
1.4
He should be able to plan, implement and evaluate primary health care services
and other appropriate intervention strategies.
2.
Intermediate Objectives
2.1
Basic Sciences : In order to achieve the overall objectives given above, he shall
acquire sufficient knowledge in the following basic sciences as relevant to com
2.1.1.
Biostatistics (Including Technical Demography)
At the end of the Course,“the'student should be able to ;
' " *
distinguish between categorical, measurement and count variables as well as
nominal, ordinal, interval and ratio scales ;
munity health.
2.1.1.1
May-August 1985
Objectives of Training.-! 5
2.1.1.9
describe the concept of linear regression both with reference to a single indepen
dent variable and more than one independent variable. Fit a linear regression
by the method of ‘Least squares’ and use it for prediction purposes ;
2.1.1.10
define different measures of morbidity and explain the related concept of units
of measurement and choose the appropriate measure in given situations ;
2.1.1.11
define crude and specific mortality and fertility rates,
standardised rates ;
2.1.1.12
describe the columns of life table and thejconstruction of a life table from age
specific death rates. Apply life table analysis to evaluation of effectiveness of
contraceptives as well as evaluation of clinical and surgical interventions in
chronic diseases.
Compute and interpret
Epidemiology
prepare a frequency distribution and cumulative frequency distribution tn
describing biological and related observations and understand the use of
relative frequencies ;
.1.2
2.1.1.3.
define measures of location (mean median, mode, quartiles, percentiles) and
measures of dispersion (range, standard deviation, quartile deviation) and make
appropriate choices among them for descrioing a given set of data ;
2 1.2.1
describe and interpret the distribution of diseases/health related conditions
according to time, place and person ;
2.1.2.2.
2.1.1.4
define probability (using the frequency approach) and conditional probability and
state and use the addition and multiplication rules of probability, appropriately ;
investigate systematically common-source epidemic outbreaks of diseases,
computing attack rates and using them to trace vehicle of transmission ;
2.1.1.5
describe the concept of a probability distribution. Describe the properties of
Normal, Binomial and Poisson distributions and their simple applications in
(b)
Define : 1 Crude and specific mortality rates including case fatality rate ;
(ii)
Incidence and prevalence rates and explain their relationship ;
medical research ;
(iii)
Standardised rates and describe their appropriate use ;
2.1.1.2.
2.1.1.6
describe the logicalbasis of statistical inference explaing the concepts of random
sampling and sampling distribution. Describe standard error as a measure
The student, at the end of his training period, should be able to :
2.1.2.3.
2.1.2.4
of precision ;
2.1.1.7
Choose and perform simple tests of signifisanoe from among the Z-test, student’s
*t’ test and the Chi-square tests, and also the one way and two way analysis of
variance tests. Give evidence oF^grasp of the assumptions on which these tests
are based.
2.1.1.8
describe the terms ‘First’ and ‘Second’ kind of errors and level of significance and
Confidence interval. Distinguish between ‘Statistical Significance’ of a result and
its ‘practical importance’ in medical application ;
2.1.2.5
(a)
distinguish between rates and ratios describe their uses in Epidemiology ;
distinguish between experimental and observational studies as well as between
observational association and causation. List and explain the criteria (of con
sistency, strength, specificity and biological plausibility) that supports causat
inference from an epidemiologic study 1-
design the following types of epidemiologic studies :
(a) Descriptive
(b) Case-control
(c)
Prospective
true.''
(d)
Cross-sectional
•==s ■;. (e)
Randomised clinical (prophylactic) trials ;
16
Ths Indian Journal of Medical Education
May-August 1985
Objective of Training—17
2 1.4.3
He should be able to plan broad environmental sanitation strategies, and should
have the ability to implement simple sanitation programmes ;
2.1.4.4
He should have a working knowledge of public health laboratory practice, includ
ing the taking and forwarding of samples for relevant microbiological testing,
and the interpretation of results :
2.1.4.5
He should be able to recognise the insects of medical importance and relate their
life cycle to disease transmission. He should also be able to implement the
common procedures of vector control.
define and interpret relative risk and attributable risk ;
2.1.2.7
2.8
2.1
Volume XXIV No. 2
recognise cohort effect while using and interpreting cross sectional data ;
2.6
2.1
(a) describe the appropriateness of a community screening programme based on
knowledge of the natural history of the disease' and the available intervention
technology.
(b) design community screening programmes using the concept of sensitivity and
specificity (and the related false positives and false negatives).
2.1.2.9
describe current knowledge on clinical epidemiology of major problems of public
health importance in India ;
2.2
T.2.10
2.
describe the elements of the epidemiologic approach to programme evaluation,
2.2.1
Applied Epidemiology Including National Health Programmes
Behavioural Sciences :
2.2.1.1
The student shall acquire detailed knowledge of the epidemiology of all important
communicable and non-communicable diseases and the measures to prevent them
at the individual family and community levels.
2.2.1.2
Through their active participation in the National Health Programmes against
communicable diseases in their various phases, the student shall be able to plan,
implement and evaluate similar programmes independently (for this purpose the
students shall undergo special training at the National Institute of Communicable
Diseases, Infectious Disease Hospital New Delhi ; Tuberculosis Clinic, Leprosy
Hospital etc.).
2.2.1.3
The student shall have the ability to plan and organise general health sui veys as
well as special morbidity surveys.
2.2.1.4
As a part of their training, the student shall investigate epidemic outbreaks and
organize community control measures including health education and immunisa
tion drives. Relevant data collection and preparation of reports will be part cf
this exercise.
2.1.3
2.1.3.1
Understand the relevance of behavioural sciences in community medicine ;
2.1.3.2
Understand the structure and function of the family and community, including
ways, power structure, social stratification and social change ;
2 1.3.3
Understand the social determinants of health and disease, including social
epidemiology ;
2.1.3.4
Able to construct and pretest questionnaires, and cany out and interpret simple
sociological surveys including knowledge, attitude and practice (K.A.P.) studies ;
2.1.3.5
Familiarity with the psycho-social aspects of health related behaviour, doctor
patient relationship and the sick role ;
2.1.3.6
Familiarity with the concept of social security, and with social welfare agencies
and voluntary health agencies ;
2.1.3.7
Understand the importance of medical economics; costing ; and the relevance of
cost-benefit and cost-effectiveness analyses.
2.1.4
Human Ecology
2.2.2
2.1.4.1
The student should possess an in-depth knowledge of various ecological factors
and their impact on health and disease status of human populations ;
2.2.2.1
2.1.4.2
He should be able to plan and carry out simple investigations of major environ
mental hazards and interpret the results.
Z.2.2.2
Applied Disciplines
Maternal and Child Health & Family Welfare : Student should :
be acquainted with the magnitude of health needs and problems of the mothers
and children ;
be acquainted with the Maternal and Child Health Services at National .nd
International level.,
18
Volume XXIV Na. 2
MayAugusi 1985
possess organisational and management skills in administering health care services
for the mothers and children at community and at the National level.
(ii)
Knowledge of the nutritional diseases and ability to diagnose and treat those
diseases in the individual and the community.
2.2.2.4
be able to screen to identify and manage high risk mothers and children ;
(iii)
2.2.2.5
understand the family health needs and problems as the family health physician ;
Ability to plan and carry out nutritional assessment, including dietary
surveys, in the community, and the ability to interpret these findings and
suggest suitable remedial action at the community level.
(iv)
Ability to organise community education programme in nutrition.
The Indian Journal of Medical Education
2.2.2.3
2.2.2.6
be able to provide comprehensive health care to the families and learn dynamics
of family social interaction.
2.2.2.7
2.2.2.8
be able to organise and impart training programmes for the paramedicals
functioning for Maternal and Child Health and Family Welfare Services :
2.2.2.9
develop knowledge and understanding for evaluation and assessment of the
M.C.H. Services provided to the community or at the National Level;
2.2.3
The student shall acquire :
(i)
Knowledge of the principles of administration, including personnel manage
ment and team concept.
(ii)
An understanding of the organisational structure of health services at the
various levels : state, national and international etc. and their evaluation.
(iii)
Knowledge of the organisational frame work of health services at the state
and district levels including job description of various health professionals.
Occupational Health :
(i)
Objective of Training...19
Health Services Administration
2.2,5.
possess sufficient knowledge of various aspects of human reproduction, growth
and development, population dynamics and family welfare planning, including
modern contraceptive techniques :
—
The studens have the
knowledge of the major occupational diseases, their diagnosis, management
(iv)
Knowledge of relevant international and national health legislation
*
(v)
Skills to organise medical care for the family and the community.
(vi)
Ability to organise in service training programmes for various categories of
health workers.
(vii)
Ability to work as an effective member of health team as well as health team
leader.
and prevention.
2.2.4.
(ii)
ability to identify and assess occupational hazards in major representative
industries, and suggest suitable preventive measures.
(iii)
an understanding of the steps in the organisation of occupational health
services.
(iv)
knowledge of the existing legal provisions relevant to industry, including
social security measures.
Public Health Nutrition
2.2.6.
Health Education
2.2.6.1
The students should possess an understanding of the communication process,
channels of communication and methods of decision making in the community.
2.2.6.2
He should be skilful in the practical use of the common methods and media of
health education, knowing their advantages and disadvantages.
2.2.6.3
He should be able to plan and carry out surveys of local beliefs and practices
relevant to health and disease and evaluate 'he affect of health education
programmes.
The student shall acquire :
(i)
Knowledge of the nature and magnitude of the nutritional problem at the
world, national and regional levels and their relationship with the overall
socio-economic development.
20
Volume XXIV No. 2
The Indian Journal of Medical Education
1.2.6.4
The student should be able to plan, implement and evaluate special health
education campaigns.
2.2 7
Pedagogical Methods : The student shall
2.3
methods and
educational
(i)
Acquire a basic knowledge
psychology.
(ii)
Know the elements of curriculum planning and instructional objectives.
(iii)
Conduct didactic sessions, tutorials, and community field practicals.
of pedagogical
The student should be able to accept the responsibility for making the initial
decision on every problem the patient may present, including treatment and/or
referral.
2.3.2
The student should be able to provide adequate primary health cars at the
individual, family and community levels.
2.3.3
He should be able to carry out initial and in-service training of various categories
of medical and paramedical workers.
2.3.4
He should be able to plan, implement, supervise
care services at the community level.
and
evaluate
primary health
To achieve these Intermediate objectives the following courses are necessary :—
Course
8.
9.
10.
Principles of Preventive Medicine
Rehabilitation
Genetics
Behavioural Sciences
Radiation Hygiene
Environmental Health and ecology
Epidemiology & Epidemiologic
Methods
Research Methodology
Microbiology & Parasitology .
Entomology
Where Covered
C.C.M. (Centre for Community Medicine)
C.C.M.
C.C.M.
C.C.M.
C.C.M.
C.C.M.
Objectives of Training...21
Course
11.
12.
13.
14.
15.
16.
17.
18.
19.
Clinical Disciplines : Primary Health Care
2.3.1
1.
2.
3.
4.
5.
6.
7.
May-Autust 1985
• 0.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
Public Health Nutrition
Occupational Health
Communicable Diseases
Non-Communicable Diseases
Maternal and Child Health
Family Welfare & Sex Education
Growth and Development
Clinico-social case Reviews
Demography and Population
Dynamics
Health Statistics
Statistical Methods
Health Education and Communication
Pedagogical Methods
Primary Health Care and
General Practice
National Healtn Programmes
International Health
Public Health Law
Non-governmental organizations
Public Health Administration
Mental Health
Where Covered
Rural Health Centre (R.H.C)
R.H.C.
C.C.M.
R.H.C.
Urban Health Centre (U.H.C )
U.H C.
U.H.C.
U.H.C.
C.C.M.
C.C.M.
C.C.M.
C.C.M.
C.C.M.
Rural Health Centre (R.H.C.)
R.H.C.
C.C.M.
C.C.M.
CC.M.
C.C.M.
C.C.M.
It will be mandatory that all P.G. Students satisfactorily complete all the above
mentioned courses.
The residents will spend about 12 months each at the main C.C.M., Urban Health
Centre ana Rural Health Centre.
The initial four months will be at the Centre itself for orientation to the discipline,
basic courses and selection of topics for thesis etc. The next two years would be spent
basically in the U.H.C. & R.H.C. (July batch first to Urban Health Centre and then to Rural
Health Centre and January batch vice-versa). The last eight months would again be at the
C.C.M.
C.C.M.
C.C.M.
C.C.M.
C.C.M.
At all three places, the M.D. Students would have pre-defined service responsibilities,
research tasks and training.
The Students have also to submit a “Thesis” as a result of original investigative work
under a faculty guide.
A healthy child e
is a happy child
An Approa^ to Syllabus Analysis and Restructuring
In Social and Preventive Medicine
By
K. Raghava Prasad
rtofissn of Social and Preventive Medicine, S. V Medical College. Tnufiati.
ABSTRACT
The traditional •syliabi’ of subjects in medical curriculum are usually inadequate
in many respects and do not permit integration between teaching, learning and eva
luation. A traditional syllabus in Social and rreventive Medicine of M.B. B S.
Course and its revised version arc analysed with respect to elarity using a metnod
modified from that adopted by Association of Indian Universities. The improvements
to make it more comprehensive and purposeful io the light of requirements of a
scientific syllabus are suggested.
Syllabus of a subject in any curriculum is
a crucial document which permits integration
between teaching, learning and evaluation.
The traditional syllabus, usually “a list or
topics with lo's of dashes in between/' is
inadequate in many respects. Restructuring
of syllabi is one aspect of the Minimal Reforms
Programme suggested with respect to exami
nation system. The syllabus document must
include a statement of educational and
instructional objectives and the techniques of
teaching and evaluation procedures.
The existing syllabi in medical curricalum
are often arbitrary, unrealistic and super
ficial. They are usually formulated in a
casual, hurried and ad hoc’ manner and do
not offer clear guidance as to what and how
a teacher shall teach and how does he know
what he has taught Sometimes they do not
even specify the content areas completely. To
make the syllabus comprehensive, dynamic
and purposeful, it has to be revised and this
revisiou is best done by a Committee of
Teachers who analyse it critically and rewrite
it to render it a valid and meaningful guide
to the teacher, student, paper setter and
examiner.
The existing syllabus can be analysed
with syllabus analysis proforma used by the
Associa'ion of Indian Universities (AIU).
This proforma helps us to determine “how
clearly the syllabus provides guidance." By
using a rating scale of 5 points and total score
of 100 it enables computation of overall
co-efficient of clarity whose minimum
value is 20.
After critical analysis the syllabus can be
restructured to include :
1.
Objectives and scope of the course.
VOLUME XXU No.
71 ' INDIAN JOURNAL OF MEDICAL EDUCATION
2.
MAY-AUGUST 1983
2
, Content outline in terms of units and TOPIC: PUBLIC HEALTt^PbfVbNISTRATION
SUB-TOPIC : PRIMARY HEALTH CENTRE
topics in paper sequence.
23
(Pnc).
3.
Suggested teaching/learning methods 1.
and activities.
4.
Time factor.
5.
Suggested evaluation techniques and
Specific Objectives :
tools.
Essential books
reading lists.
enumerate the functions of the indi
vidual members of the health team
at a PHC.
understand the distribution of work
between the male and female health
workers in a sub-centre and to
prepare a monthly plan of home
visits for those workers ;
(2)
and supplementary
The syllabus in Social and Preventive
Medicine ' ( SPM ) prescribed by
Sti
Venkateswara University in 1975 for the
M. B. B. S. Course (Appendix I) was analysed
with respect to clarity by using a modified
version of AIU, proforma (Appendix II).
The proforma was administered to eight
teachers in the department of SPM and the
average co-efiicient of clarity obtained
was 40.
The S. V. University in 1981 adopted the
syllabus in SPM as formulated by the Andhra
J’radesh State Medical Education Conference
Held in 1980. This revised syllabus has also
been analysed similarly and the coefficient
is found to be 65. A portion of the revised
syllabus dealing with the topic Public Health
Administration is given in Appendix III.
The clarity of syllabus could ba further
improved by incorporating, among other
things, specific objectives, teaching-learning
methods, time schedules and techniques of
evaluation for all sub-topics. To illustrate,
such improvements for the sub-topic ‘‘Primary
Health Cenre" are suggested below.
understand and appreciate the role
of the supervisors and the methods
of supervision ;
(3)
2.
1.
Records, registers and returns.
2.
Staff meeting of PHC.
Give suggestions
effectiveness.
(4)
explain the role of the PHC in im
plementation of various ongoing
national health programmes and
(5)
enumerate and describe the legisters
and records maintained in a PHC
and the periodical returns to be
prepared.
Teaching Learning Methods :
e g. Identify the one unrelated or wrong
answer :
rated teaching (2 hours) :
National Health Programmes,
Duties of the Female Health Worker
include :
Evaluation :
Written rest incorporating the follow
ing types of questions.
3.1. long answer questions : e.g. Describe
the set-up and functions of a PHC.
(a)
Antenatal case registration.
(b)
Intranatal Care.
.,c) Smallpox vaccination of infants.
,(d) Helping the doctors during clinics.
0 O Q
REFERENCES
Monograph on Syllabus Analysis and Restructuring, Association of Indian Univer
sities, New Delhi, 1982.
2 1. Lectures (2 Hours) ;
1.
Concept of comprehensive health
care.
2.
Overall organisation and functions
ot PHC.
2.2. Tutorials ( t hour) :
Planning
of
supervision.
house
visits
improving its
3 3. Multiple choice question :
2.5. Seminar : Paper presentation or Integ
3.
for
3.2. Short answer questions . e.g. Explain
what is a target couple register.
2.4. Game : eg. UNICEF strategy game.
*
The student should be able to :
(1)
AN APPROACH SYLLABUS 75
Field Demodulation (6-8 Hours):
and
*A game which provides insight into how UNICEF’s strategy for basic services works.
76
THE INDIAN JOURNAL OF MEDICAL EDUCATION
APPENDIX I
VOLUME XXII NV'2
£
Regulations and Syllabi Relating to NI.B.B.S. Degree Examination,
Sri Venkateswara University, 1975
MaY-AUGUST 1983
5-
SYLLABUS IN SOCIAL AND PREVENTIVE MEDICINE
1.
Social and Preventive Medicine
”
3.
(1)
Water-supply : Sources of supply-chance of contamination—methods of
purification—water borne diseases—mode of spread and their preventien.
(2)
Refuse and Exreta disposal : Principles and methods applicable to rural
and urban populations—soil pollution and contamination of water supplies
conservancy and composing various types of latrines and their suitability
to different situations.
(3)
Food : Function of foods in relation to health—balanced diets - food-borne
diseases ; methods of spread and their control.
(4)
Housing and Ventilation : General principles of planning of environments
in relation to housing.
(5)
Climate in relation to health : Influence of climatic factors in relation to
health and diseases—s'udies of climate in epidemiology of diseases.
Epidemiology and Statistics
Get era! principles of epidemiological studies in the understanding of diseases in
individuals and among populations—use of statistics as a tool in the analysis of control of
the chain of diseases causation and effects.
4.
(1)
Maternal and Infant Health; including family planning. Objectives of
prenatal and post-natal care-domiciliary health services—maternal, infant
and child health protection, Family Planning.
(2)
Child and School Health : Principles and objectives of pre-school and
school child-investigations and treatment.
(3)
Industrial health : General Principles of occupational hazards in the pro
duction of specific and non-specific occupational health problems—prevent ion and control of high mortality and morbidity among industrial
populations,
(4)
Malnutrition in relating to Preventive Medicine : the part played by
malnutrition in the causation of nutritional syndromes and diseases.
Methods of investigation by diet and nutrition surveys—signs and symp
toms of deficiency diseases, control of undernutrition and specific nutrition
disorders.
Environmental Sanitation.
An understanding of the main general principles relating to environmental sanita ion,
without any details or construction and maintenance of sanitary appliances and works,
which form the domain of sanitary engineer and public health officer. This applies to
following subjects of study.
.
Special Health Services
General principles relating to the organisation of special health services, with regard
to the health of the individual in so far as It relates to the part played by the medical
practitioner.
Philosophy and discipline of Social and Preventive Medicine in relation to epidemio
logy or communicable and non-communicable diseases.
2.
Communicable diseases
Genera) principles of spread of infection—levels of prevention and general lines of
control of the following groups of infectious di-eases ; viz., Water borne diseases ; enterio
AN APPROACH TO SYLLABUS 77
infections ; respiratory (droplet) infections ; communicable diseases of childhood ; chronic
endemic diseasss-^Tuberculosis, Leprosy and Venereal diseases, Insect-borne diseases ;
disinfection and disinfestation.
6.
Public Health Administration
Public Health Organisation-General obligations of medical practitioners and physi
cians to Health Services—Objectives and organisation of Rural Heahh Centres.
THE INDIAN JOURNAL OF MEDICAL EDUCATION
• > VOLUME XXII Xo. 2
MhY-^UGUST 1983
APPROACH TO SYLLABUS
APPENDIX II
.« ■: '•
APPENDIX III
■'
SYLLABUS ANALYSIS PROFORMA
*
•
■
Not at
all clear
Maximu
1
5
5
■5
■5
Objectives :
Students should be able to
What should the teacher teach ?
a. All subject matter
b. Activity of student
c;■ ‘ Link with other subjects
d. Deptn of treatment
1
TOPIC : PUBLIC HEALTH ADMINISTRATION
SCORE.
Very
Clear
1.
I,
function as a medical officer ;in. charge of health centre.
II.
make community diagnosis and draw "up a plan of programme to meet the needs
of the community based on priority, along with leaders and utilising community
resources to the extent possible ;
III,
implement a programme in the community, being health and allied staff and
village leaders and volunteers ; and
'
IV.
manage patients and perform all skills needed by a community doctor.
4
4
4
3
3
3
3
2
2
2
2
1
1
I
1
5
4
3
2
i'
2.
5
4
.3
2
1
5
.4
3
2
5
5
.5.
4
4
4.
3
3
3
Basic principles of Health Administration, Planning Cycle, Management Functions.
and Evaluation ; Recept concepts in health care delivery, Evolution of health care delivery
in India ; Administrative organisation of health services in India at various levels ; Primary
Health Centre—staffing and functions—relation to community development, Community
Health Volunteers ; National Health Programmes; Role of International and Voluntary"Health Agencies.
5
5
4
4
3
3
4
20
. 2. .Why should the teacher teach ?
Students’ knowledge to be
developed
b. Students' attitudes to be
changed
c. Students' skills and abilities
to be developed
a.
3.
4.
.
1 .
15
2
2
2
1
T '
1
15
2
2
1
1
How should the teacher teach ?
a. Methods of teaching
b. Teaching/iearning aids
c. Lesson plans and time allocation
How does the teacher know what he has taught
a.
b.
Methods of evaluation
Type and frequency of tests
10
60
Coefficient of clarity (in percentage) :
’Modified from proforma given by AIU.
79
..
SUB-TOPICS (in iogical sequence) :
SEPTEMBER-DECEMBER 1932
Lesson Plans for Teaching Preventive and Social
Medicine in Pre-Clinical Course
By
S.B Rotti,
Senior Resident
S P. Mehta,
Professor & Head of the Department
Department of Prevmtive & Social Medicine Jawaharlal Institute of-Post-graduate Medical
Education and Research Pondichery (.India').
Summary
independently and effectively both under rural <
Latest recommendations of Medical Council and urban settings. Recommendations of
Medical Council of India April 1977 as
of India regarding the teaching of Preventive
and Social Medicine were implemented with modified upto April 1978 stress that the,
teaching of Preventive and Social Medicine/ ■
some modifications in Jawaharlal Institute of
Community Medicine should have a place '
Post-graduate Medical Education and Research,
throughout the teaching period, and that the \
Pondicherry during the academic year, 1980-81
mainstay of the training programme should ,
for pre-clinical students. The course consisted
be lecture-demonstrations, group discussions
of lectures, hospital visit and visits to health
and seminars with a minimum of didactic
institutions engaged in intervention pro
lectures. It is also prescribed that the detailed \
grammes. Lesson plans were prepared for
curriculum drawn should include at least 30 :
each of these sessions. Lesson plan for one
hours of lectures, demonstrations, seminars
of such sessions has been described. Evaluation
etc., together with atleast 15 field visits spread :
was done based on the records submitted by
over 18 months of the pre-clinical course, i
the students. The responses were graded based
on the scoring system, using check list. Majo Hospital visits and visits to health establi
shments in rural and urban areas are also,
rity of the students (88.52%) faired as excellent,
recommended, to introduce students to the
very good or good. Suggestions to improve
principles of practice of medicine and also to
the session have also been highlighted.
make them familiar with elementary nursing,
practies ; practices of sterilization ; injection
Introduction
and dressing techniques ; necessity for record
keeping ; art of communications with patients
The main objective of medical education is including history-taking ; medico-social work ;
to produce a medical graduate in modern immunizations against diseases ; and health
scientific medicine capable of functioning check-up. .
LESSON PLANS FOR TEACHING PREVENTIVI
The universities have not reeommended 30-35 students each. The topics for lecture
prescribed common programmes in this regard. classes were as follows :
So there is a scope tor tue medical colleges to
I. History of medicine.
chalk out tneir own programmes. Certain
2. Introduction of Preventive and Social
suitable topics can be chosen and clear guide
Medicine.
lines for training laid down. To incorporate
3. Levels of prevention.
this programme in the present set up some
4. Art of communication and history
amount of adjustment between the fecultiess
taking.
and better co-ordination by different section
of the hospital with the department of Proven
5. Role of social factors in the causation
tive and Social Medicine, will have to be
of the disease.
ensured. This doesn’t involve any extra
6. Scope of health education in hospitals.
financial burden on the colleges. Ettorts
7. Sources and uses of statistical data in
should be made to do it methodically, based
the field of medical sciences.
on specific learning objectives, clear outline
of the methods and aids, and evaluation of the
In all 9 topics were chosen for the hospital
visits. The anangements of the visits was
activities.
done as shown in appendix-L The subject
Lesson plans prepared by Directorate matter for the lectures and hospital visits was
of Medical Health and Family Welfare, chosen out of the recommendations of Medical
Uttar Pradesh for the training of community Council of India as revised upto April 1978.
health volunteers have proved useful for the Lesson plans for hospital visits were piepared
trainers as well as trainees. Similar effort has in the department after discussing them in
to be made by the teachers of Preventive and detail over three sessions of 3 hours eaeh. All
Social Medicine for effective implementation the 3 domains, namely, congnitive, psychmotor
and effective, were kept in mind while pre
of the recommendations in this regard.
paring the lesson plans. Each topic consisted
of learning objectives ; learning experiences
Material and Methods
including methods and aids and evaluation.
This paper highlights the activities of the Out of nine only one lesson plan about a visit
first course conducted between August and Octo to Rural Health Centre has been described in
ber, 1980 for the 1st MBBS students who took
admission in June, 1980, in Jawaharlal Institute
of Post-graduate Medical Education and
Research, Pondicherry. The course consisted of
a' series lecture classes of one hour each
followed by hospital visits of two hours each
arranged on consecutive Saturdays between 10
AM and 1 PM. The lectures were common for
the whole batch, and for the hospital visits the
- batchjvas divided into two equal groups of
detail in this paper.
VISIT TO RURAL HEALTH CENTRE
1.
Lent ning Objectives
At the end of the session, students should
be able to :
(a) Tell the differences between a Rural
Health Centre (RHC) and a hospital.
36 THE INDIAN JOURNAL OF MEDICAL EDUCATION
VOLUME XXI No.
(b) Enumerate the staffing p; ttem of the
RHC.
(c)
2.
List the activities of the RHC.
Learning Experiences including Methods
and Aids
The methods adopted were lectures, lecture
demonstrations and group discussions. Aids
used were charts in the RHC ; registers and
records maintained in the RHC ; instruments
and equipments used for diagnostic purposes ;
drugs in the pharmacy; demonstration plot
containing models of sanitary . well, soakage
pit, different types of latrines ; and black
board. Time allotted (minutes) for various
activities was as follows :
Introductory lecture
...
. 10
Lecture-demonstrations
(20 minutes each for
medical officer ; records
room clerk and laboratory
in-charge; MCH staff; and
sanitary insp -ctor
...
80
Group discussion
...
30
Students were taken to the Rural Health
Centre, Ramanathapuram whieh is a rural
field practice area of the department of Pre
ventive and Social Medicine, Jawaharlal
Institute of Post-graduate Med cal Education
and Researth (J1PMER) Pondicherry. An
introductory lecture was given by the staff
member of the department accompanying the
students. In introductory lecture description
of the RHC ; differences between the RHC
and hospital ; staffing pattern of the RHC
were highlighted. Each group of students was
divided into four sub-groups. These sub-groups
attended in rotation, Medical Officers, Public
Health Nurse, Clerk in-charge of medical re
cords and Sanitary Inspector. In lecture-demons
trations by various workers of the RHC, students
were told about the various activities carried
cut by tbem in simple words avoiding too many
technical words and explaining some of tne '
latter wherever their usage was unavoidable. ;
Students were encouraged to ask questions if i
they were not clear. In group discussion, dis- ,
SEPTEMBER-DECEMBER 1982
LESSON PLANS FOR TEACHING PREVENTIVE- 37
Sub-group IIIMedical records.
—Pharmacy.
—Laboratory.
—Injection and dressing
room.
—Wards.
—Minor operation theatre.
Sub-group IV :—Activities for providing
safe water and for dis
cussions were guided by the resource persons, ■
posal of human excreta
one for each group, consisting of staff member '•
and other waste products.
of the Department of Preventive and Social t Evaluation
Medicine, and medical officers of the RCH
Ideally, evaluation of all the domains
Each group choses its leader to conduct the i
should be done both before and after the
discussion and one more student was asked to ■
session. But the faculty felt that most of the
recc rd and report salient features of the
topics selected were almost new to the trainees,
discussion. Each sub-group was given the
and also it was difficult to get some more time
following guidelines for discussion.
allotted for such programme amidst busy
Sub-group I :
—Staffing pattern of the .
schedule in Anatomy and Physiology. Hence
pru-sessional evaluation could not be done.
RHC.
Evaluation was done after the session was
—Care of the minor ill
nesses.
—Care
of tuberculosis,
leprosy
and
Malaria
Cases.
—Registration of births and
deats.
Sub-group II : —Care of the pregnant and
lactating women.
—Servics
for
women in
child-bearing age.
—Growth and development
of children.
—School health.
—Training of the indigenous
dais.
the lectures, demostrations and group dis
cussion. The results of the evaluation are
shown in Table-1. The performance varied
from good to excellent among 54 (88.5%)
students; and -from fair to poor among
7(11.5%). The students were asked to give
suggestions at the end of the session to
improve the lessons. Their suggestions were
as follows :
Two students expressed that methods
and aids were inadequate and suggested
that the groups should be divided into
still small sub-groups. 5 students expressed
that time was inadequate and suggested that
the visit should be scheduled still earlier in the
morning (around 8.30—9.00 A.M.) and that
session should last for minimum of 6 hours,
so that adequate time may bo given for obser
vation and discussion.
Conclusions
over
A programme consisting of vi-its to
hospital sections and peripheral health insti
tutions as envisaged in the recommendations
of the Medical Council of India, April 1977
revised upto April 1978, was introduced with
some modifications to pre-clinical students,
during the academic year 1980-81. Lesson
plans were prepared for each of these visits,
keeping congnitive, psychomotor and a affective
domains in mind. Lesson plan on one of the
topics has been described. Lesson plan
consisted of learning objectives, learning
experiences along with methods and aids and
evaluation. More stress was given on lecture
respectively;
demonstrations and group discussions. EvaCombined results of both the groups were lation was done based on the ecords sub
mitted by the students. T^e performances were
as follows :
61 out of 65 students attended these graded based on the scoring system, using
sessions. Almost all participated actively in check list. Majority of the students (88.5%)
Students were asked to submit a write up
in a record book about the objectives of the
visit and the detailed account of the learning
ixperiences of the visit, and were also asked
to give suggestions if any about the method,
time allocation for different activities and
improvement of the whole exercise. These
records were evaluated based on the check-list
prepared keeping the learning objectives in
mind. Marks were assigned for each record.
Performance was adjudged as excellent, veiy
good, good, fair or poor if the score was
75-100, 65-74, 50-64, 35-49 and less than 35
LESSON PLANS FOR TAECHING PREVENTIVE... 39
38 THE INDIAN JOURNAL OF MEDICAL EDUCATION
faired as excellent, very good or good. Suggestions to improve the session were useful and
were worth
sessions.
VOLUME XXI NO. 3
incorporating
in
SEPTEMBER-DECEMBER 1982
Table 1
subsequent!
Details of performance of the students
Acknowledgements
We acknowledge our thanks to Dr.
M.N. Ghosh, Director Jawaharlal Institute
of Post-graduate Medical Education and
Research, Pondicherry, for his encouragement.
Excellant
Very good
Good
Fair
Poor
REFERENCES
1.
2.
The Medical Council of India (1978)—Recommendations on Under-Graduate Medical
Education (Adopted by the Medical Council of India in April, 1977 and revised upto
April 1978) Pub. The Medical Council of India.
Directorate of Medical, Health and Family Welfare, Uttar Pradesh, (1979).
plans for training of Community Health Volunteers.
DMHFWS, Lucknow, U.P.
No. Students
No.
Percent
Grade
Reprints from Dr. S.B. Rotti, M.D.,1
Assistant Professor Department of Social anJ[
Preventive Medicine, Kasturba Medical College,;
Mangalore-575 001.
Total
16
10
28
5
2
26.2
16.4
45.9
8.2
3.3
61
100.0
Lesson
Pub. Joint Director (NSFP),
APPENDIX-I
Schedule of vists to Hospital and Peripheral Health Centres
for Pre-Clinical Students
Group I
1.
Nursing Practice-I (Bed-making,
Pulse, Temperature and Respiratory
________________ GrouP 111
Art of Communication
rate)
2. Art of Communication
3. Immunising agents and Oral Re
hydration Mixture
Nursing Practice-I
Practice of sterilization
Immunising agents and Oral Rehydration
Mixture
Urban health centre
4.
Practice of strilization
5.
Injection and dressing
6.
Urban Health Centre
7.
Rural Health Centre
8.
9.
Rural Health Centre
Record keeping
Role of Social factors in the causaction of malnutrition.
Injection and dressing
Record keeping
Scope and Functions of
Social and Preventive Medicine Department
BY
DR. 0. M. S. SIDDHU,
Professor of Social and Preventive Medicine, G. R. Medical College
Gwalior, Madhya Pradesh
Scope
At the undergraduate level, the
teaching programme should not be de
signed as such to produce ready-made
Medical Officers of Health, this is
surely the province of postgraduate,
but it must include the basic proces
ses and facts upon which any type of
future specialisation and knowledge
can bo added.
Teaching of Preventive Medicine to
undergraduate
medical
students
should focus mainly on the principles
and practice of protecting health,
which are directly applicable to phy
sicians, caring for individual patients.
The broad understanding of the
patient, including the psychological,
social and cultural features as well
as the biological, is essential for
effective patient care, which is also
known as comprehensive medicine.
Comprehensive medicine means that
the physician should attempt to pro
vide that is necessary and feasible for
his patient’s health. The patient’s
environment may be important iu
influencing his health and therefore
may be the concern of his physician.
A patient’s emotional problem, his
reactions to environmental stress such
as poverty and ignorance, his persona
lity, habits, his reactions to his disease
all are equally important and must be
studied. Social and cultural factors
influence every patient’s adaptation
and should be considered as a routine.
Even when these environmental factors
cannot be manipulated to the patient’s
advantage, as we are facing today in
many cases in our country, but still
an appreciation of these and their
effects upon the patients is necessary
for an appropriate understanding of
the individual and his health.
2. To adequate the undergraduates
their role as physicians in health
services to the community which lay
groups are becoming increasingly
interested in their problems of health
services and are already active with
plans of their own. The science and
art of advancing health and preven247
248
Indian Journal of Medical Education
Vol. I, April, l'J02
ting disease is as broad as medicine Epidemic Assistants, Social Workers,
itself. It is dependent on many Village level workers and many others.
other fields of medicine for advance He must be made aware of the con
ment of knowledge and application of tribution that each can make to an
Preventive Medicine. The goal of improvement of individual and collec
health now calls for not only the cure tive health in the community.
or alleviation of disease, it calls for
He must also be made aware about
prevention of disease and even it
looks beyond to strive for maximum, the wide range of facilities and "
resources,
which the community pro
physical, mental and social efficiency
for the individual for his family and vides for the health and welfare of its ■
for the community. The physician citizens, e.g. Malaria Eradication Pro
should be aware of the effect of living, gramme, B.C.G. Vaccination against
habits, food, clothing, housing, work, Tuberculosis Leprosy scheme, Filaria,
recreation and social and family Venereal, Trachoma, Yaws, Smallpox
Sickness
Insurance
relationships on health directly or Vaccination,
indirectly. He should co-operate with Scheme, Family Planning and many
health authorities by early reporting others. He should have the broad
of communicable diseases, births and goals of health always in mind, a
deaths, thus helping in collecting spirit of scientific inquiry, a broad
data vital to community health pro understanding of the natural history
motion and preservation of health by of disease, a knowledge of people as
means of giving advice to mothers well as of disease to the environment
during pregnancy, health supervision and the ability to call into play
of children and also maintaining a whatever services may be necessary
periodic health inventory of the adult to secure comprehensive health care.
He shouid be made aware when to
members of the family.
refer cases to the specialists.
To help the individual, what he can
3. It should be the function of
do to improve his own health, when
to look for medical guidance and how Social & Preventive Medicine Depart
to follow it. To cut down the line of ment to bring the profession of
demarcation between preventive and medicine more close with people it
curative activities. Not to examine serves and this cannot be achieved
a patient only from one angle of without the broad education in the
organic disorder of any organ but also humanities.
keeping in mind the psychological,
4.
It should be the function of
social and cultural background of the
occurrence of symptoms and signs of Social & Preventive Medicine Depart
ment to give a wide concept of
disease.
Medicine than can usually bo obtained
The undergraduate must know how in their training at the bedside in the
to work in co-operation with a great operation theatre or in the laboratory.
variety of members of the team
5.
Preventive Medicine must give
within the hospital and within the
community, e.g. Nurses, technicians, students basic information and more
sanitary inspectors, Health Visitors, importantly, excite their curiosity:
, Midwives, Dais, Health Educators, about the kinds of things which may
The Scope and Factions of Social and Preventive Medicine ...
affect people’s health, students should
learn to consider both the efforts of
conditions in the physical environ
ment such as housing or working
surroundings and conditions in the
social environment such as the effect
of family relationship, ethnic, reli
gious and educational influences. The
nature and effects of arrangements
for providing and paying for medical
care and trends in medical practice,
should also be studied. The Pre
ventive Medicine should help the
students to develop sound attitudes
of viewing individuals in their enti
rety as complex human beings in a
complex and changing environment
and of seeking ways to promote and
maintain patients health, under
standing that it is more effective to
prevent disease than .to care it and
also making them realizing that to
enjoy life as physician and not to be
disturbed at odd hours of the day
and night it will be better to keep
people from becoming sick. Preven
tive Medicine requires that students
know the community and its re
sources as they relate directly or
indirectly to health. This includes
understanding of the role of the
Governmental and non-governmental
health agencies, social and welfare
agencies, International Health Agen
cies and legal resources. It gives
the student an appreciation of his
future role as a physician in relation
, to comprehensive health services.
249
to explore out the multiple causes of
disease. To prevent or modify a dise
ase information such as the following
is required.
Disease agent factors - biological,
nutrient, physical, chemical, mecha
nical or psychological conditions,
which contribute to disease occurrence.
The characteristics of man in this
connetion - his
personality, habits
and customs inherent, characteristics
of age,- race, sex etc. and defence
mechanism.
The character of environment, its
social, economic, biological, and
physical aspects.
Teaching of Biostatistics :
Through the study of biostatistics,
medical students develop an attitude
toward all scientific data, procedures
and observations, trends in morbidity,
mortality and natality rates relating
to the health and welfare of the com
munity and this arises in the stu
dents, responsibility of conveying such
information to the health department
promptly and correctly.
Biometry ;
Teaching of Epidemiology ;
It introduces the student to a body
of knowledge concerning the concept
of variability, range of normal values,
appraisal of scientific data, design of
experiments, methods of presenting
da ta.
I
Students need to understand both
! the epidemiological approach and the
■ kind of knowledge required to dotcr■ mine the epidemiology of a particular
| disorder. The first comprises the
basic principles fo epidemiology. The
I second encompasses the methods used
It stimulates the students to look
for ways to apply the principles and
practice of Preventive Medicine in
the widest variety of situations for
individual patients and also at com
munity levels.
Specific preventive
measure :
vol. I, April, 1962
|
Teaching of History of medicine ;
Research :
A view of medicine in its historical
setting also helps the students to gain
a fuller awareness of the role of
physician in society.
He should
understand the evolution of his pro
fession, how present concepts have
evolved. Furthermore appreciation
of the evolution of medicine in the
past prepares the student to accept
change in the future.
Activity stimulates both teaching
and learning. Research may be conducted in a wide variety of fields
and involve a wide variety of disciplines e. g. epidemiological studies of
disease, Control or eradication of any
disease prevailing in the area, can
guide state Governments in policies
of public health.
;
:]
’
_•
J
3
J
5
COLLOBORATIVE STUDIES
WITH OTHER DEPARTMENTS
AND AGENCIES.
‘
2&0
Indian Journal of Medical Education
Teaching of Social Sciences ;
Social Anthropology, Sociology and
human ecology, Personal Hygiene and
Psychology, will give a background to
■ the students to understand the pro
blems of people relating to health and
disaese.
The teaching in Preventive Medi
cine can help the students to acquire
requisite knowledge of the normal
development, structure and function
of the human being of the manner in
which physical, chemical and biologi
cal agents, as well as hereditary
factors, psychological factors, living
habits and social forces affect the
the human being favourably or unfa
vourably of the general techniques
and resources available to the indivi
dual and the community for the
prevention of disease and the main• tonance of health, of the social and
cultural settings in which health
education and medical practice are
carried on.
Consulting
service to other
departments and agencies.
;
Particularly in the case of biosta- 4
tistics, preventive medicine can aid J
other departments in the design and |
planning of laboratory and clinical j
experiments with particular reference l
to the selection and size of random . •
samples necessary to attain signifi- I
cant results.
Domiciliary Medical Service :
The department of Preventive Modi- -J
cine may take part in programmes •,
which provide care in the homes of' ;
patients or may take responsibility ■
for directing them. In our country j
this can bo initiated by giving domi- .1
ciliary treatment in cases of tuber- |
culosis.
3
The Scope and Functions of
Social and Preventive Medicine Department
By
Dr.C.M.S.Siddhu,M.D.,D.P.H.
Professor of Social and Preventive Medicine
G.
R. MEDICaL COLLEGE
Gwalior, Madhya Pradesh
November 1961
SCOPE AND FUNCTIONS OF
SOCIAL AND PkjVJi'.TIVE MEDICINE DEPARTMENT.
Scope
At the undergraduate level, the teaching program should not be
designed as such to produce ready made Medical Officers of Health, this
is surely the province of postgraduate, but it must include the basic
processes and facts upon which any type of future specialization and
knowledge can be added.
Teaching of Preventive Medicine to undergraduate medical students
should focus mainly on the principles and practice of protecting health,
which are directly applicable to physicians, caring for individual
patients.
The broad understanding of the patient, including the Psycho
logical, social and cultural features as •veil as the biological, is
essential for effective patient care, which. is also known as comprehensive
medicine.
Comprehensive medicine means that the physician should attempt
to provide that is necessary and feasible for his patients health.
The
patient1 s environment may be important in influencing his health and
therefore may be the concern of his physician.
A patient's emotional
problem, his reactions to environmental stress such as poverty and
ignorance, his personality, habits, his reactions to his disease all
are equally important and must be studied.
Social and cultural factors
influence every patient1 s adaptation and should be considered as a
routine.
Even when these environmental factors cannot be manipulated
to the patients advantage, as we are facing today in many cases in our
country, but still an appreciation of these and their effects upon the
patients is necessary for an appropriate understanding of the individual
and his health.
2.
To adequate the undergraduates, their role ?.s physicians in health
services to the community which fflqy groups
becoming increasingly
interested in their problems of health services and are already active
with plans of their own.
The science and art of advancing health and
preventing disease is as broad as'medicine itself.
It is dependent on
many other fields of medicine for advancement of knowledge .’.nd applica
tion of Preventive Medicine.
The goal of health now calls for not only
2
the cure or alleviation of disease, it calls for prevention of disease
and even it looks beyond to strive for maximum, physical, mental and
social efficiency for the individual for his family and for the community
The physician should be aware of the effect of living, habits, food,
clothing, housing, work, recreation and social and family relationships
on health directly or indirectly.
He should cooperate with health autho
rities by early reporting of coiimuni cable diseases, births and deaths,
thus helping in collecting data vital to conrtun' ty health promotion and
preservation of health by means of giving advice to mothers during pre
gnancy, health supervision of children and also maintaining a periodic
health inventory of the adult members of the family.
To help the individual, what he can do to improve his own health,
Wien to look for medical guidance and how to follow it.
To cut down the
line of demarcation between preventive and curative activities, Not to
examine a patient only from one angle of organic disorder of ary organ
but also keeping in mind the psychological, social and cultural back
ground of the occurrence of symptoms and signs of disease.
The undergraduate must know how to work in cooperation with a
great variety of members of the team within the hospital and within the
community, e.g. Nurses, technicians, sanitary inspectors, Health Visitors
Midwives, Dais, Health Educator, Epidemic Assistants, Social Workers,
Village level worker and many others.
He must be made aware of the
contribution that each can make to an improvement of individual and
collective health in the community.
He must also be made aware about the wide range of facilities
and resources, which the community provides for the health ard welfare
of its citizens, e.g. Malaria Eradication Program, B.C.G. Vaccination
against Tuberculosis, Leprosy scheme, Filaria, Veneieal, Trachoma,
Yaws, Smallpox Vaccination, Sickness Insurance Scheme, Family Planning
and many others.
He shouldhave the broad goals of health always in mind'.
a spirit of scientific inquiry, a broad understanding of the natural
history of disease, a knowledge of people as well as of disease to the
environment and the ability to call into play whatever services may be
necessary to secure comprehensive health care.
when to refer cases to the specialists.
He should be made aware
3
3.
It should be the function of Social & Preventive Medicine Depart
ment to bring the profession of medicine more close with people it serves
and this cannot be achieved without the broad education in the humanities.
4.
It should be the function of Social & Preventive Medicine Depart
ment to give a wide concept of Medicine than can usually be obtained in
their training at the bedside in the operation theatre or in the labora
tory.
5.
Preventive Medicine must give students basic information and more
importantly, excite their curiosity about the kinds of things which may
affect people's health, students should learn to consider both the
efforts of conditions in the physical environment such as housing or
working surroundings and conditions in the social environment such as
the effect of family relationship, ethnic, religious and educational
influences.
The nature and effects of arrangements for providing and
paying for medical care and trends in medical practice, should also be
studied.
The Preventive Medicine should help the students to develop
sound attitudes of viewing individuals in their entirety as complex
human beings in a complex and changing environment and of seeking ways
to promote and maintain patients health, understanding that it is more
effective to prevent disease than to care it and also making them
realizing that to enjoy life as physician and not to be disturbed at
odd hours of the day and night it will be better to keep poeple from
becoming sick.
Preventive Medicine requires that students know the
community and its resources as they relate directly or indirectly
to health.
This includes understanding of the role of the Govern
mental and Non-governmental health agencies, social and welfare
agencies, International Health Agencies and Legal resources. It gives
the student an appreciation of his future rwle as a physician in
relation to com-prehensive health services.
Teaching of Epidemiology:
Students need to understand both the epidemiological approach
and the kind of knowledge required to determine the epidemiology of a
particular disorder.
The first comprises the basic principles of
epidemiology.
The second encompasses the methods used to explore
out the multiple causes of disease.
To prevent or modify a disease
information such as the following is required.
Disease agent factors -
biological, nutrient, physical, chemical,
mechanical or psychological conditions, which contribute to disease
occurrence.
The characteristics of man in this connection -
his personality,
habits and customs inherent, characteristics o' age, race, sex etc. a nd
defence mechanism.
The character of environment, its social, economic, biological,
and physical aspects.
Teaching of Biostatiscics:
Through the study of biostatistics,
medical students develop an attitude toward all scientific data, pro
cedures and observations, trends in morbidity, mortality and natality
rates relating to the health and welfare of the community ard this
arises in the students, responsibility of conveying such information
to the health department promptly and correctly.
Biometry;
It introduces the student to a body of knowledge concerning the
concept of variability, range of normal values, appraisal of scientific
data, design of experiments, methods of presenting data.
Specific preventive measures:
It stimulates the students to look for ways to apply the principles
and practice of Preventive Medicine in the widest variety of situations
for individual patients and also at community levels..
Teaching of History of Medicine:
A view of medicine in its historical setting also helps the students
to gain a fuller awareness of the role of physician in society. He should
understand the evolution of his profession, how present concepts have
evolved.
Furthermore appreciation of the evolution of medicine in the
past prepares the student to accept change in the future.
Teaching of Social Sciences:
Social Anthropology, Sociology and human ecology, Personal Hygiene
and Psychology, will give a background to the students to understand
5
the problems of people relating to health and disease.
The teaching in Preventive Medicine can help the students to
acquire requisite knowledge of the normal development, structure and
function of the human being of the manner in which physical, chemical
and biological agents, as well as hereditary factors, psychological
factors, living habits and social forces affect the human being favour
ably or unfavourably of the general techniques and resources available
to the individual and the community for the pr
nntion of disease and
the maintenance of health, of the social and cultural settings in which
health education and medical practice are carried on.
Research;
Activity stimulates both teaching and learning. Research may be
conducted in a wide variety of fields and involve a wide variety
of disciplines e. g, epidemiological studies of disease, Control or
eradication of any disease prevailing in the area, can guide state
Governments in policies of administration of public health.
Colloborative studies with other departments and agencies.
Consulting service to other departments and agencies.
Particularly in the case of biostatistics, preventive medicine
can aid other departments in the design and planning of laboratory
and clinical experiments with particular reference to the selection
and size of random samples necessary to attain significant results.
Domiciliatry Medical Service:
The Department of Preventive Medicine may take part in programs
which provide care in the homes of patients or may take resnonsihility
for directing them.
In our country this can b
initiated by giving
domiciliary treatment in cases of tuberculosis.
Dr. C. M. S. Siddhu, M.D.,D.P.H,
Professor of Social and Preventive
Medicine, G.R. Medical Col~lego,
Gwalior, Madhya Pradesh
The Teaching Programme for Preventive
and Social Medicine
BY
T. D. CHABLANI,
Professor of Preventive & Social Medicine, Armed Forces
Medical College, Poona-1.
^Tl,e teaching programme for Provenand Social Medicine can only be
visualised
a. Firstly, against the total back
ground of medical training of
which Preventive and Social
Medicine forms an integral part.
b. Secondly, the aim and scope of
medical training which remains
dynamic to fit in with
i
(c)
low level of health education.
(d)
changing conditions of society.
(e)
increasing demand for better
medical care
(f)
progressive population increase.
It is this background of the coun
try which is prejudicial to the
nation’s endeavours to achieve rapid
progress towards National Economy
and Industrialisation.
the extent of medical know
ledge
It is a recognised fact that nation
al economy is based on human
the changes in the role of medi economy, there is therefore a close and
cine in general, and in parti reciprocal relationship between work,
production, strength of the country
cular,
and the ‘capital’ which is constituted
iii
the background of the country by the health of its people. In this
and society in which Preven- task of protecting and increasing the
tive and Social Medicine is to ‘health capital’ the primary role is
obviously assigned to the medical
be practised.
profession.
Background of the Country
The Physician’s Task
With reference to our country’s
background, the important features
The changes in the role .of medi
to remember are :cine require from the physician that
he should not only apply general
(a)
Indifferent environmental sani principles but also assimilate addi
tation
tions to medical knowledge as they
arise. In addition, since national
(b)
widespread condition of ill- economy is based on human economy,
health.
the physician’s activities need to be
ii
213
214
Indian Journal of Medical Education
Vol. 1. April, 1962
(iii)
Chronic ailments Of Unknown
multifactorial etiology are the
outstanding unsolved problems,
where a stitch in time from the
practitioner would be of value
e. g. in coronary thrombosis,
hypertension, malignant dis
ease, degenerative ' diseases,
chronic disorders of psycho
genic origin and psychosis.
(iv)
Education of patients, advice
on health and family problems,
details of infant care, domestic
management,
translation of
dietetic instructions into house
hold terms, control of infec
tions in the home, all these lie,
in practice, on the borders of
doctor’s province
but the
family practitioner is not usual
ly in a position to undertake
this type of education.
directed towards prevention and
handling problems of a social nature
with reference to health and disease
because of wide recognition of the
social character of medicine.
Against this requirement from the
physician let us see to what extent
the physician is fulfilling the basic
requirements.
The general observation is that :Most medical
practitioners
spend most of their time seeing
sick persons, to whom their
foremost obligation is to esta. blish a clinical diagnosis and
institute appropriate therapy.
(a)
•
(b)
Medical practitioner’s time is
taken in treatment of patients
whom he rarely sees until they
are sick.
(c)
He seldom exercises preventive
and promotive functions in a
(v)
direct and immediate sense
although within his domain.
■ This, in short, is the concept of
approach to disease.
But this
approach has to change because :-
' (i)
Clinical diagnosis is rarely
completely adequate and medi
cation is rarely more than an • (vi):
aspect of treatment. '■
Relations within the family;
dietetic and smoking habits,
proper balance of exercise and
rest are matters for personal
decision
and
consequently
subject to influence of personal
. advice which is often within
the physician’s scope to give.
Social medicine constitutes a
necessary stage in the evolu
tion of medical science as social
. Concept of medicine which
diagnosis clarifies and comple
does,.not relate the patient to
tes diagnosis, social treatment
environment is incomplete.
supplements
medical treat
Protection of health exclusively
ment and social hygiene forti
fi;om the hygiene and sanita
fies individual and collective
tion point of view, without
■hygiene.
reference to living and working
" conditions
or' social and
With reference to these situations
economic factors cannot be my comments are that these situa
fully effective unless parallel tions .
and adequate measures for the
’ improvement of both physical
(a) Call for co-operation of the
and mental health are also
medical practitioner to engage
■ ■
introduced.
in the preventive social field
(ii)
Tlic Teaching Programme for Preventive <(• Social Medicine
simultaneously with the prac
tice of clinical medicine' within
the family and in the commu
nity.
(b)
Call for partnership of effort
between doctor, health nurse
and medical auxiliary which is
, needed in relation to medical
earc.
But unfortunately the
auxiliary medical services are.
not fully developed and wher
ever these exist full advantage
is not taken.
Given this partnership, the right
attitude of mind, and the right
conditions of practice, it is
beyond doubt that the family
doctor could do much to improve
health and prevent disease and
contribute materially towards
protecting and increasing the
health capital of the nation.
(d)
The curriculum lacks coherence
because the courses in Hygiene
and Public Health are usually
scheduled towards the end of
the last year, as a theoretical
course. By that, time the stu
dent has already developed his
attitudes and preferences and
is naturally fully oriented to
wards the individual care of
the sick.
(e)
It is too much concerned with
factual detail, and too little
■with method and the develop
ment of a critical attitude of
mind.
(f)
It does not emphasize that-
(i) there are three major features
of illness
These arc the defects in the doctor
patient relationship today as I see it.
the physical,
I would like to emphasize that
these defects in the doctor-patient
relationship are the results of draw
backs in the curriculum of the
undergraduate
the social.
(a)
215
and organised public-health and
. medical-care services.
the emotional and
(ii) and that these are intimately
interwoven in the pattern of
disease and that they must be
considered together rather than
as separate entities
The teaching is concentrated
almost entirely on the patient
In the medical curriculum the
in hospital, and is thus divorced
from the realities of the'circum- essential requirements therefore are
stanees in which the patient
(a) Integration and correlation be
became ill and to which he will
tween clinical and preventive
return on leaving hospital.
aspects to be introduced for
(h) It tends to have an exclusively
better comprehension of medical
ciinicopathological outlook, and
science..
consequently, neglects the rela
(b)
Functional
relationship be-x
tionships between the patient
and his environment.
tween the clinical sciences'to
be emphasized.
(c)
It does not include adequate
instructions in matters upon
(c)
Orientation of teaching from the
which health largely depends :
predominantly individual and
e.g. nutrition, housing, personal
curative approach to a more
hygiene, socio-economic status,
family and community minded
216
and preventive one which is
of fundamental importance.
(d)
(e)
Vol. 1, April, 1962
Indian Journal of Medical Education
To ensure at the undergraduate
stage that the ‘ basic doctor ’
has a proper understanding of
the basic principles of ‘ health
and disease ’ to be of maximum
use to the community among
whom he will practise, to the
exclusion of details which form
part of specialists courses only.
What are its effects on the
individual, family and com
munity ?
How is it detected and dia
gnosed as early as possible ?
How is it treated and its illeffects avoided ?
How is it prevented and
controlled in the individual,
family and community ?
That the undergraduate is Fourthly,
taught to adopt an attitude and
How does disease propagate in
spirit of scientific prevention.
the community ? How can
A preventive habit in medicine
such propagation be elminacan only be cultivated in the
ted ?
practice of clinical medicine
What are the responsibilities
■which implies a thorough inte
of the physician to the indi
gration of preventive and cura
vidual, family and com
tive medicing. Further, in
munity ?
medical practice, observation
and examination, diagnosis and
treatment, are always based on
synthesis. This indivisibility
in medicine implies indivisibi
lity in training.
Keeping these in mind, I would
recommend that the undergraduate
be given a plausible and suitable
understanding
of the following
aspects :
Firstly,
\
What are the goals of Medicine?
Secondly,
What is ‘ health ’ ?
How is ‘health ’ maintained?
How is ‘ health • measured ?
What are the factors which
affect health I
Thirdly, .
What is ‘ disease ’ ?
How is it produced ?
Fifthly,
What is comprehensive medical
care ? How can it be obtained?
Are social agencies available ? '
To intelligently understand the
answers to these aspects the student
will have to undergo training in a
number of disciplines, both fundamamental and applied. But the student
must be made to appeciate. that the
individual disciplines are not the end
in themselves but are the parts of one
whole.
This concept must be ingrained into
the student simultaneously during
both preclinical and clinical course,
from, the very start of his career and
not left to be developed in later years
as otherwise the picture formed will
be distorted and integration of the
total picture difficult. To give con
crete suggestions, I have summarised
the main aspects of integrated tea
ching of both curative and preventive
medicine.
217
The Teaching Programme for Preventive and Social Medicine
How to Integrate Teaching Programme
Preclinical Depart
ment
A. To deal with concept
of health, e.g..
Preventive & Social Medicine
Department
To complete the
and to deal with
picture of health
Criteria of normality
biological variation.
and
their
Internal
environment
and its maintenance.
External environment affecting the
internal environment - physical
biological and social.
Normality of
inter
nal environment.
Picture of health.
Laboratory studies in
relation to the normal.
Field studies to know the normal.
I
I
I
I
I
|
b
I
Biological variations.
^^ormal stress
I
Methods of comprehension of bio- |
logical variation (Biostatistics).
|
I
I
periods
and changes in the
Imdy - e. g. child
hood. adolescence, pu
berty, adult life, sene
scence and death.
Environmental factors and their |
effect on such periods iu the cycle of |
human life.
|
. ...
I
I
J
To
com
plete
the
picture
of
health.
21S
Indian Journal of Medical Education
Vol. I, April, 1902
Clinical Department
Preventive & Social Medicine
Department
B. To deal with con
cept of disease e. g.
study of
To complete the picture of disease
and to deal with e. g. study of
1
Patient in hospital
ward or outpatient
department.
Patient in his usual environment
with the family.
2
Diagnosis
of his
condition - clinical
and other investi
gations.
3
Laboratory investi
gations.
4
Study of course of
illness.
5
Treatment of pati
ent.
6
Rehabilitation
patient.
of
Clinical Department
11
1
1
|
Study of conditions at home, condi 1
tion of the family - other early cases. 1
1
*1
|
|
|
|
1
Natural history of disease support y
ed by statistical evaluation. Effect 1
on family - production of stress.
1|
1
Treatment of cause of illness - |
1
advice and education of the family.
I
1
Rehabilitation of the person and 1
family. Advice on achievement of i
health. Welfare and further protec
tion, i. e. comprehensive medical 1
1
care.
Study of epidemiological investi
gations of the cause of illness -routes
by which disease propagates.
To
compplete
the
picture
of
disease
PLUS
field
surveys
and
research
Preventive & Social Medicine
Department
C. To deal with concept
of disease with refe
rence to subject, the
individual a frag
ment of society.
To complete the picture as it affects
people as a whole, the subject being
the family and community.
The place of practice,
being
at outpatient
department or hospital
ward i.e. away from
natural environment of
disease.
The place of practice - being at
home and the community at large i.e. ||
the environment where disease was '
produced and to which the patient |
will return after recovery.
J1
People
as a
whole.
The Teaching Programme for Preventive <fe Social Medicine
With reference to post examination
training of interns
In my view, at least 3 months in a
1-vear internship should be devoted
to work in urban and rural health
centres where alone the now graduate
will get an opportunity to practise
preventive and social medicine under
supervision. It is essential to wean
away the young graduate from the
ivory ' tower mentality which inevit
ably develops in the highly systema
tized academic atmosphere of a
"teaching hospital. This can only be
done in a primary health centre
where the young doctor will face the
problem of dealing with the healthy
person seeking to maintain health and
the sick as part of a family unit and
not merely a member in a hospital
ward.
Finally, the curriculum should be
periodically reviewed taking into
account the changing characters of
medical practice and conditions
219
required in medical practice so that
preventive and curative medicine
could become a reality and medical
care an effective team endeavour.
To summarise, our society today
calls for a physician whose objectives
will always be to conserve and im
prove health, to interpose barriers
to malfunction and disease and -to
extend the knowledge that makes
those possible in the community.
In addition to requisite knowledge
and ability to diagnose and treat
disease, he must have broad goals, of
health always in mind, and a spirit of
scientific enquiry, a broad understand
ing of natural history of disease, a
knowledge of people as well as
disease, an insight into the relation
of both people and disease to the
environment, and lastly, the ability
to call into playwhatever services
may be necessary to secure compre
hensive health care and build the
‘health capital’ of the nation.
Hp-SGL356
INDIAN JOURNAL OF MEDICAL EDUCATION
(«) In view of the rapid industrialization
going on the country, stress needs to be
laid on teaching of occupational diseases
and industrial health to the medical under
graduates.
(tn) Sufficient stress should be laid on
VOL. V, APRIL 1966
teaching some of the personal health services
such as maternity and child health and school
health, applied nutrition and the control and
prevention of the important mass diseases
prevalent in the population viz., malaria,
filariasis, small-pox, cholera, tuberculosis,
trachoma, etc.
APPENDIX
DEPARTMENT OF SOCIAL AND PREVENTIVE MEDICINE
K.
G. Medical College, Lucknow M.B.B.S. Course of Study
Pre-clinical years
35 lectures on medical aspects of human
ecology to include meaning and scope of
social and preventive medicine, environment,
natural history of a disease process and
levels of prevention; society, social develop
ment and behaviour, population problems,
beliefs and customs in relation to health and
disease with particular reference to Uttar
Pradesh; people’s health and economic loss
due to ill-health; elements of medical genetics,
environment and health, physical environ
ment and psycho-social environment; 15
lectures on elementary biostatistics; 10
lectures on elementary and social psych
ology (in 2nd year M.B.B.S.); and 10
clinical demonstration conferences (5 in 1st
year and 5 in 2nd year) to illustrate the
multiple causal aspect and social origin in
the disease, the circumstances which led to
the disease and the application of various
levels of prevention in the disease. Total
70 hours.
Para-clinical years
Eight lectures on health education with
particular stress on doctor-patient relation
ship and the role of family or community
doctor as a health educator; 20 lectures on
environmental hygiene to include water in
relation to health, collection and disposal of
waste, air and ventilation, houses and build
ings, lighting and noise, rural sanitation,
rodents and arthropods-life cycle and
control; 4 lectures on industrial hygiene;
5 lectures on nutrition and food hygiene, and
4 lectures on personal hygiene. Four de
monstrations on environmental hygiene and
nutrition. Total 45 hours.
Clinical years
30 lectures on principles of epidemiology
and control of infection and prevention and
control of common communicable and noncommunicable diseases and disabilities es
pecially of the Tropics viz., malaria, filariasis,
kala-azar, plague, typhus, cholera, enteric
fever and dysenteries, poliomyelitis, infec
tive hepatitis, diphtheria, tuberculosis, small
pox, chicken-pox, measles, mumps, whoop
ing cough, cerebro-spinal fever, influenza,
trachoma, leprosy, venereal disease, yaws,
rabies, tetanus, anthrax, common helminthic
infestations, endemic goitre, epidemic
dropsy, lathyrism, cardio-vascular diseases,
diabetes, cancer, accidents, blindnes, and
occupational diseases. 15 lectures on per
sonal health services (maternity and child
welfare, family planning, and school health),
community organisation (rural and urban),
international health and international health
agencies, the role of general practitioner in
prevention and control of diseases, and vital
statistics. Ten demonstrations on water
works, maternity and child welfare centres,
family planning, school health, small-pox,
vaccination, B.C.G. vaccination, health of
workers in factory and primary health centre.
Total 55 hours.
In the beginning of the para-clinical years
each student is allotted one family with
an expectant mother or a new-born infant,
for submitting a growth and development
socio-medical case study after a year’s study
in the 3rd year. During the 3rd year
each student is given a family with a case
of tuberculosis for submitting a sociomedical case study after 4 months study.
Each family study is allotted marks out of the
marks reserved for day-to-day examinations.
Total 30 hours.
A
APPENDIX ’B*
'
>■
Curriculum on Social and Preventive Medicine
for Undergraduate Teaching
Summary
(a)
The teaching of Social & Preventive Medicine should take place throughout
the teaching period.
During the pre-clinical period, a minimum of 50 hours be devoted to the
teaching of social & Preventive medicine.
In the clinical period, about 250 hours be devoted to the teaching of the
subject.The details are included in the report.
(d)
During the student’s attendance at various departments, which is now
required under medicine and surgery, such as infectious diseases, T.B.,
leprosy, V.D. etc., emphasis should be laid as much on the preventive as
on the clinical and therapeutic aspects of these diseases.
(e)
In addition to the teaching undertaken by the departments of social &
preventive Medicine, a joint programme with other departments is essential
in order to give the students a comprehensive picture of man, his health and
lines s.
Jf) Stress be laid on national programmes, including those of control of
communicable diseases and family planning and health education.
(g)
A separate examination in social & preventive medicine may be undertaken
in the 2nd professional examination. Questions on the preventive and social
aspects of diseases should also be included in the examination in clinial
subjects at the final M.B.B.S.
(h)
An epidemiological unit as an integral part of every hospital in order to
achieve a comprehensive study of disease by the students should be established.
(i)
The objectives of the internship should be clearly defined and that a proper
training programme be oriented for this period. Objectives and the methods
by which the internship could be made into a much more satisfying and
fruitful experience than at present have been laid down. This is one of
the weakest links of the teaching programme and there is an urgent need
for sharpening and for planning in this phase of education.
(j)
As regards the qualifications of the teachers, it is highly important that
all teachers in social & preventive medicine should have as far as possible
and had adequate administrative experience in addition to the teaching.
experience.
(b)
(c)
The following are thenecommendations o^ the council:
UNDERGRADUATE OR M.B.B.S. COURSE CURRICULUM
1.
Pre-clinical
The present educational system requires those students intending to undertake
medical studies to chose the science group of subjects. In order to prepare
the student for professional education, and to foster in him the social
concepts which are essential to the professional doctor as a citizen and as
a practising physician in the community; the element of humanities which
has been omitted, should be added in the pre-clinical years. Hence it is
imperative that the social aspects of medicine should be introduced as
a separate subject aling with other disciplines.
(b)
A minimum of 50 hours be devoted for Social & preventive medicine in the
pre-clinical period. The following subjects should form a part of the
teaching in this discipline:
i)
Personal Hygiene.
ii)
Bia statistics and vital statistics.
iii)
Human Ecology).
(iv)
Elementary psychology
(v)
Elementary social science.
(yi) Normal growth anddevelopment.
(vii) Nutrition and dietetics.
(a)
A number of these items could be undertaken in collaboration with the
departments of physiology and bio-chemistry^ and should form an integral part
of their teaching.
(c)
The teaching of social & preventive medicine should be undertaken by the
department of social and preventive medicine in coordination with other
departments.
.2
2
CLINICAL
2.
A course of systematic instructions in the principles and practices of social
and preventive medicine which should extent throughout the whole period
of study.
(b)
There should'be a minimum of 250 hours in total for attendance of lectures,
lectures, demonstrations, seminars, conferences, field visits and practicals
during the clinical period.
(a)
The following subjects should be included in the teaching programme:
Medical statistics, including collection, tabulation, presentation and
the interpretation of data, and the use of statistical methods.
Environmental Hygiene, including man and his environments, oocupationsl
and industrial hygiene, village and town sanitation, bacteriology of
water, milk, food and food hygiene,
(iii)
Parasitology, helminthology and entomology in relation to communicable
diseases, their prevention and control.
(iv)
Principles of epidemiology.
(v)
Communicable diseases, their prevention and control.
(vi)
Public Health administration, including the requirements of international
health, social security, public health law, and the role of international
and other health, organizations.
(vii)
Advanced courses on nutritional deficiencies.
(viii)
Community medicine Teaching should include clinico socio-pathological
conferences with other departments, maternal and child health, the
care of mothers and infants including family planning and school health
supervised field study and visits.
(i)
(ii)
In order that the discipline of social & preventive medicine is presented
in its proper perspective, every effort should be made to coordinate the
teaching programme of the department with the various departments of
medicine, surgery, obstetrics and gynaecology etc. to give the student
the correct and integrated approach to the practice of medicine.
(d)
To study disease in a comprehensive manner it is essential that an epidemio
logical unit
be set up in the out-patient department of the teaching
hospital. Such an epidemiological unti will enable the students to understand
the social, economic and environmental factors in relation to illness
4during his training period.
(e)
During the students attendance at the specialist departments, instruction
in the preventive aspects should be emphasised during the study.
(i)
Acute infectious diseaseas and other local endemic diseases, for example
trachoma goitre, filariasis etc.
(ii)
Tuberculosis.
(iii)
Preventive aspects of psychological medicine and psychiatry.
(iv)
Preventive aspects of- leprosy
(v)
V.D. Control.
(vi)
Preventive aspects of dietetics and Nutrition information on all
national health programmes and the role of international health
organisation should be given in order thatthe medical-graduate may
participate the successful implementation of these schemes during his
career after graduation.
(f)
In order to make the students practise what is being taught,it is absolutely
necessary that the hospital where he works and the hostel where he resides
should be involved along with the professors of the various disciplines of
the hospital, andother authorities concerned, to take a keen interest in
the environmental sanitation.
(g)
Principlies of health education including the education of hospital and
health staff, patients and tkeir relatives within the hospitals.
(h)
The medical students should be given demonstration on family planning at
a family planning centre attached to the medical college or at a recognised
health centre during the regular course for undergraduate training either
under the department of obstetrics and gynaecology or Social & preventive
medicine. The concept of family planning and population control should be
emphasised by all disciplines.
(i)
Every student should be required to submit one satisfactory written history
of a community health survey undertaken under the guidance of staff of
the social and preventive medicine in a rural area, and one written case
history of a patient followed up with the assistance of the epidemiological
unit, in coordination with the department concerned and the department of
social and preventive medicine.
(c)
3.
EXAMINATIONS
(a) There should be a separate university examination in social andpreventive
medicine which may be held along with other subjects at the 2nd Professional
examination.
(b) The case histories, and performance at the field training centre, should also
....3
5
be taken into account for purposes of assessment on the final examination.
4.
COMPULSORY ROTATING INTERSHIP—RURAL TRAINING
It is essential to outline the objectives that are to be achieved duringthe
3 monnths rural stay during internship period. An outline of the objectives to be
achieved is suggested.
(a) Adminsitrative aspects.
(b) Preventive aspects.
(,c) Clinical aspects.
(a)auministrativf. aspects
(1) Under administrative aspects, rural intership should serve to orient thte
the student in the political structure and administration of a rural area,
and the actual working of those organisations concerned with local self
government namely, zila parishads, the panchayat sanities and other facts
of community development work.
(2)
It should serve to orient the intern with the concept of team work with
para-medical health workers, namely, the health visitor, the vaccinator, the
sanitary inspector, the social scientist and th health educator, especially
in connection with national health programmes.
(3)
It should orient the intern inthe social dynamics of a community. This has an
important bearing in health work. This should include the
dynamics of
leadership, the motivation of a community and the various important facts
of influencing leaders in the promotion of health programmes. This is an
integral part of the application of health education principles in the promotion
of development work.
(4)
It should serve to orient the doctors on the administrative aspects of various
national health programmes which are an integral part of work at the primary
health centres. These should primarily be such programmes as
(a) the malaria eradication programme.
(b) small pox eradication programme
c) tuberculosis control.
d) family planning.
(e) certain specific communical diseases, such as filaria, leprosy,
trachoma, V.D. etc.
(5)
It would serve to put the health programmes in the perspective of the overall
national development programmes, namely, agriculture, education social
welfare etc.
S
(B) Preventive Aspects
(1) It should serve to orient the intern in the organisation and management of
a comprehensive health service for a community. This programme should
invariably include the enrironment of the community.
(2)
It should serve to orient the doctor on the keeping of adequate statistical
records and of the interpretation of health indices.
(3)
It should serve to orient the intern in the role of individual members of the
health team and of important leaders in a community.
(4)
It would serve to orient the doctor towards the effective utilization of all
resources in the community for promotion of health programmes.
(5)
It would serve to indicate that illness is an episode in the total frame
work of an individual’s health. The need for adequate contact tracing and
follow-up of sick patients after therapeutic treatment should be demonstrated
to the maximum in a rural community.
(fi) It should give an indication of the priority needed of various facts of
health programmes, such as the importance of immunization, importance of
school health programmes, importance of nutritional education, care of the
pre-school child etc.
(7) Ihe social effects of illness on an individual and family, and the result of
socio-economic factors in causing illness should be demonstrated.
(8) The planning and evaluation of a community health service.
(C) Clinical.Aspects
(1) It should sharpen an individual's diagnostic capacity, so that he may be
.able to make use of his individual senses without dependence on expensive
aids, such as laboratory, X-ray etc.
(2)
It should permit of an individual taking responsibility for minor illness
and surgical complications.
(3)
It should serve to indicate his limitations and realization of when to call
for consultative services of a referral.
4
The methods by which this could be achieved:
(1) A planned programme in order that all students should have an opportunity
to meet with village representatives and to participate in village meetings,
especially those of the health committee. In order to effectively demonstrate
the role of community leaders in a health programme, it should be the
duty and responsibility of the staff of the rural field centre to form
a health committee in every rural field training area.
(2) The role of other officials in the village, namely the teachey, the village
level worker etc. should also be demonstrated and the students should
be given an opportunity to meet with the block development officers
and his staff, and to become familiar with the other development programmes
in the village.
(?) Svery effort be made to ensure that the hostels and the houses of the
staff of the health centre, as well as the surroundings of the centre
itself should be such that minimum facilities, such as protected and safe
water latrine etc. are provided. Wherever possible the students should
be made to live in the village, but under hygienic conditions which
are capable of reproduction by the villager.
(4)
The students should have an opportunity of visiting and being demonstrated
the various national health programmes. For this purpose, the staff
of the va^ieus field training area should liason with the staff of the
various national Health programmes.
(5)
It should be ensured that the primary health centre is supplied with
adequate vaccines and sera and modern drugs.
(6)
The administrative aspects of running a primary health centre should
be demonstrated to the students, and they may be allowed to make
suggestions in such matters, as the purchase of drugs, the type of
basic equipment, the cost of the diet etc. and how the Centre funds could
best be utilised.
(?) The students should have every op ortunity of working with the health
centre staff and visiting the homes. The principles of health education
and the approach to a community, and of an individual should also be
effectively demonstrated to them and the students be required to practise
this under skilled supervision.
(s) To effectively implement the above requirements the staff.of the field
training area be adequate in number, be properly trained, hnd have the
facilities to undertake the teaching and training that are required.
Schedule of Teaching Social & Preventive Medicine for Under
Graduaie_S_tudi£S_in. Medical College
Preclinical Period Hours available - 50
Subject
A.
Orientation Courses:
Introductory Lectures
—History of growth of
understanding of disease
causation.
—Concepts of Community
Medicine.
—Graded concepts of
health and diseases
2.
Genetics.
—Heredity and Health
Concepts of Heredity—
Mechanism of Heredity
—Transmission of normal
characteristics in man
—Public Health implication
of Heredity and Preventive
of Heredity diseases.
3.
Normal Growth and Development
—Concepts of normality
1.
devut-io-n from mot-mat
Didatic Lectures
(Hours)
v. .
191 3
Practical/
Discussion
Classes
Seminars
5
„ , . x
Suhject
Didactic
Lectures
(hours)
Visits
Practical/
discussion
classes
Seminars
—Dimentions of growth—
physical, intellectual,
emotional and sexual.
—Life cycle of man-infact,
toddler, school going,
adolescent, adult and
normal aging.
B. Applied Courses:
1.
Bjo-Statistjcs
8
4
■—Introduction to
Bio-statistics
—Collection, tabulation
and presentation of data.
—Variation, frequency,
normal and skewed curves.
—Single figures to represent
mass data-mean mode and
median.
— Measures of dispersion
from mean
—Range, standard variation
and. standard error.
—Variability of observations.
—Tests of significance.
2.
Introduction psychology
6 Child
Guidance
clinics—4hrs.
—Definitions, scope,
methods and branches
of psychology.
—Consciousness, mental
development, intelligence,
personality.
—Abnormal mind.
—Disintegration and diseases
of personality, insanity
etc.
—Social psychology, sociali
sation, inter-personal
• influences, role and role
conflict, inter-group
tension and prejudices.
3,
Introduction to Sociology
—Definitions-society,
community, family etc.
—Social organization.
—Social institutions-courtship, marriage, divorces etc.
—Culture-variability.
—Culture and health
—Practices.
—Social change.
4.
Personal Hygiene through
different periods of life.
Discussions—
5 hrs.
6
C_l_i_n_i_c_a_l
Subject
P_e_r_i_o_d
Didactic
Visits
iectures J”"""
~
(.hours;
yjait
hours
1. Man and Environment
Practicals
(Hours)
20
--Concept of ecology.
—Climate and health
—Air, ventilation and
atmospheric pollution.
—Water supply-rural and
urban
—Excreta^ disposal-rural
and urban
—Housing and health.
Water works
Sewage dis
posal works
Field surveys
in rural and
urban areas
—Village and town
planning
—Occupation and health
industrial hygiene,
diseases and accidents
Visit to
factory. Visit
to village and
town Planning
Organisation.
2'
2
5
4
—Rat and inspect control.
2. Nutrition
15
—Nutritive value or some
commonly used food
stuffs in India
—Diets according to various
physiological needs-diets in
certain diseases.
—Diets-balanced and ill-balanced
—Deficiency diseases
—Diseases transmitted by
—food and food poisoning
3. Medical Statistics
1(F)’
4(E)
10
4(E)
—Need for vital and health
statistics vital health
statistics in India.
—Registration of birth and
deaths and notification
of communicable diseases
in India.
—Rates and ratios relating
to nationality, mortality
and morbidity.
—Standardised death rates.,
—Life tables
4.
io(s)
5(D)
Integrated teaching.
Introduction to
epidemiology.
—Definicion and purpose.
5.
6.
Spifiemiblogy.
6
—Natural history of
disease and levels of
prevention
—Illustration in relation to
a few simple diseases.
.7
7
Didactic ________ Visits .
Lectures Place of
hours
(hours) visit
7. Communicable diseasesprevention and control.
—Investigation of an
epidemic.
—Mechanism of transmission
—Immunity and resistance
—Prevention of Small poxchickenpox-measles-diptheria-leprosy-tuberculosis.
Malaria-filaria-intes tinal
parasites-cholera-typhoiddysenteries-plague-tetanustreponemal diseases-rickettsiasis and typhus arthropedborne and other viral diseases
25
8. Preventive aspects of noncommunicable diseases
4
9. Demography and family
planning.
6
10. Preventive medicine
6
Practical
{Hours5
—Periodical health exami
nation.
—Immunisation programmes.
—Prevention of long term
illnesses.
—Geriatrio-rehabilitation
io(s)
11. Integrated teaching.
9(D)
12. Social medicine
6
—Definition
—Social aetiology.
—Social Pathology.
—Social therapy and
rehabilitation.
Visit to rehabi
litation centres
and aftercare homes
for women.
13. Applied aspects of
genetics.
3
(14) Medical care
12
—Hospital.
—Polyclinics and health
centres—health team.
—The role of general
practitioner medical
practioner records.
—Comprehensive medical care
—Voluntary health organisation
—Medico-social work.
(L5y’ Public Health Adminis
tration
—International Central
and State Health Ad
ministration.
—Local Health Services
12
Municipal
Corporation.
Primary Health
Centre
8
Didactic
(hours)
Subject
___ Visit______
hours
Place of
visit
—Community Develop
ment and National
Extension service pro
gramme-health centre.
—Personal health services.
—Health legislation in
India.
Practical
(hours)
12(S)
2
16. Health Education
io(s)
6(D)
9
17. Integrated Teaching.
18. Revision.
------------------------------------
Practical include the followings (d) - Discussion classes.
(e) - Exercises.
(F) - Film show.
(s) - Seminars.
Breakdown of
hours
I Professional
II Professional
Period.
Total:
Lectures
Visits
Practicals
Seminars
Total
37
129
4
29
9
92
50
250
166
33
101
300
SEMINA E
on
TEACHING OP SOCIAL & PREVENTIVE MEDICINE
4th to 8th May 66
TRIVANDRUM;
'SOME THOUGHTS ON TEACHING OP SOCIAL
PREVENTIVE MEDICINE"
K.A. Pisharoti
Principal, Sanitation Paculty
Gandhigram Rural Institute
GANDHIGRAM
AND
SOME THOUGHTS ON TEACHING OF ENVIRON
MENTAL SANITATION TO MEDICAL UNDER
GRADUATES
K.A. Pisharoti
I.
INTRODUCTION;
"Why should I learn about Latrines and Water Supply? What
relevance has a study of soakpits or ventilation of a Cinema
Theatre to my profession as a Medical Officer? ..These are the
comments often heard from a medical undergraduate or a doctor e
of a Primary Health Centre who attends an orientation course in
Public Health. Teachers in Environmental Hygiene are getting
increasingly concerned over the development of this negative -
attitude on the part of the young undergraduate towards an im
portant subject, which probably contributes-
to the maximum mor
bidity to-day in India. It is the responsibility of the teacher
to help the students develop correct attitudes and adopt teach
ing methods aimed at promotion of these attitudes. Learning is
related to one's own needs and perceptions and throughout the
five years of his career in the Medical College, the students
are exposed to patients as patients alone, who received treat
ment for their immediate pathological condition only. It is
but rares if not totally absent, that he is made to think about
the environment which has contributed to this illness. This
being the case, it is now time for us to consider as. to whether
improvement in teaching could alter the situation and help the
undergraduate to appreciate the need to study Environmental -
Sanitation and use the knowledge in his day-to-day profession
as Medical Officer.
11 • THE EEED TQ STUDY ENVIRONMENTAL SANITATION
Before we deal with the subject of teaching environmental
sanitation, let us, for a moment, think about the need for a
study of this subject, as related to Indian conditions. In
India, the Primary Health Centres have been recognized as the
peripheral unit for providing an integrated medical care-cumhealth services programme to the community at large. While a
few thousand of these centres have already been established,
more are contemplated in the future. The Medical Officer fun
ctions as the leader of the health team in providing this in
tegrated health care programme to the community and is assisted
:2
in his task by a numer of other paramedical staff. Apart from
providing medical relief, the medical officer, as the leader
of the team, lias also to look forand identify these factors in
the community, either actual or potential, that has contributed
to the morbidity and mortality among the population entrusted
to his care. An analysis of these factors and planning for pro
grammes to meet these and evaluate their effectiveness should
thus essentially occupy a major portion of his time. In most
of the countries, the statutory responsibility for the directin
of health programmes including environmental sanitation, is laid
on the medical officer, while the Sanitarian helps him in dis
charging this function and also carry out the day-to-day and
village level activities in sanitation. For this reason and also
because of the fact that no supervisor can effectively discharge
his functions unless he recognizes 'clearly the role of his super
visee and his duties, it is necessary that the Medical Officer
should be equipped by training and experience in performing
these roles.
Now that Malaria has been almost eradicated, faecal-borne
diseases account for the largest amount of morbidity and morta
lity in India. It has been estimated that in the decade between
1940 and 1950, 27,438,000 persons died in India from enteric
diseases. The morbidity should be at least 20 to 25 times more
than that. Helminthic surveys conducted in Uttar Pradesh and
Madras recently, have shown an overall infection rate of 50 to
60%. The famous saying that in some of the tropical and s emitropical countries, "the worms infesting the people metabolise
more of the produce of that country than do the inhabitants",
is quite relevant to our country. Also the medical officer of
a Primary Health Centre who is a practicising community physi
cian and not merely a therapist for certain individual patholo
gies, must have a
clear knowledge and understanding of how it
is cheaper to treat the environment and control disease rather
than individually treat every case and wait for it occur again.
Modern medicine is concerned not only with treatment, but pro
motion of positive health, of which Environmental Sanitation is
a major part.
It may still be argued that a majority of the medical
graduates take to private practice and are not saddled with -
direct responsibility for Environmental Sanitation work and
why should they take to a study of the subject of sanitation?
Ultimate improvement in envrionmental sanitation depends upon
t
:3
the adoption of hygienic practices by the population at large,
-which calls for radical habit changes.
Sanitation is presently
defined as "A Way of Life. It is the quality of living that is
expressed in the clean home, the clean farm, the clean business
and industry, the clean neighbourhood, the clean community. Being a way of life, it must dome from within the people; it
is nourished by knowledge and grows as an obligation and an
ideal in human relations." An individual health worker like the
Health Inspector on the auxiliary nurse-midwife cannot bring this
change by their efforts alonei A patient who goes to the gene
ral practitioner for treatment of worm infestation or amoebiasis or filaria, gets a prescription for treatment and he gets
cured also within a reasonable time. But soon after treatment,
he reverts to his age-old practices and environment and gets
reinfected. Under the circumstances, would it not help if the practitioner, apart from prescribing a treatment also prescribes
a few hygienic practices for his patient, just like the use of
latrine or drinking of boiled water or avoid mosquito-bite etc.
And coming from a person in whom the patient has developed' a
trust, the advice will have better chances of being followed.
Often, it has been stated that in improving the sanitary prac
tices of the people, "Many voices talking about Sanitation are
better than one voice." If the attempts to remove the ignorance
of the people could therefore be on a wider front, the results
too would be quicker. Thus even the General Practitioner has
an effective role to play in improving the sanitary practices.
While these basic facts are well understood, still there
is a big gap when it comes to the question of practice.
III.
Why this Gap?
In the writer's opinion, a medical undergraduate will
begin to understand the role of environmental sanitation only
if, during his own clinical study of cases, he is taught to see
the patient in relation to the patient's own environment, i.e.
physical, social and mental. At present he studies the
pathology of the patient but never, till he comes to the fag-
end of the course realises that there is what is called a
pathology of the patient's own immediate home surrounding and
the pathology of the community in which he lives. And by the
time he learns about it, not in relation to his patient but
in fragmented compartments, it is too late for him to appre
ciate its significance. Hence, even from the first clinical
:4
cases the undergraduate should be trained to see the patient
in relation to his environment. Thus the teaching of environ
mental sanitation as another aspect
of Social and Preventive
Medicine should be related to the patient and should be fieldoriented so as to reduce the gap.
IV.
HOW TO OVERCOME THIS GAP?
IV.1. Stress the role of environment in the transmission of
disease:
It is now generally recognized that the man's health status is a function of his heridity and the accumulated effects
of his environment as they act upon his mind and body. Even
though a genetic man is man determined by his heriditary charac
teristics alone, such a person cannot actually exist, because
even at birth, the infant will reflect the balance of the gene
tic characteristics acquired at conception and the influence
of the intra-uterine environment.
Dr.alfred Grotjahn wrote early in this century, "The'-
Social basis of disease may te considered under the follow
ing heads: Social conditions that (a) may create or ffavour a
predisposition for a disease, (b) may themselves cause disease
directly; (c) may transmittthe causes of disease; and (d) may
influence the course of a disease." It is a simple matter to
illustrate each of these tenets with quite common and generally
accepted examples: (a) there is good evidence that malnutrition,
extreme fatigue and exposure to cold and dampness areamong the
conditions that may create or favour a predisposition for disease such as tuberculosis; (b) occupational diseases and
some
accidents are/among a large group of illnesses that may be
traced quite directly to the causative force, wholly or in part,
of social conditions; (c) the socalled crowding and filth di
seases (such as typhus fever and dysentery) are clear examples
of diseases' in which "social conditions may serve to transmit
the causes of disease; (d) lack of education or of income that
may result in delayed or inadequate medical care, or possibily
a failure to get it altogether, is an example of a situation
where "social conditions may influence the course of a disease."
It will thus be seen that the social conditions envisaged
by Hr.Grotjahn, embraced man's total environment, and in addi
tion to the pathology of the disease, the students should be
stiwnulated
to think and analyse the social basis for the -
:5
disease, whenever applicable.
Since Environmental Sanitation is a major component of
the total environment thus envisaged by Dr.Grotjahn, the ■ teaching of Environmental Sanitation also should be against this
background.
IV.2. Help- the Medical man to see his patient in relation to his environment.
It is not enough if the undergraduate gets an idea of the
factors of the total environment that embraces a man and which
affects his body and mind. To get these ideas fixed in his mind
and make him automatically see any patient in relation to his
environment, the medical man should be trained to see his own
patients in the Medical College hospitals in relation to their
environment. To achieve this goal, facilities should be made
available for the Social and Preventive Medicine Department
to give separate clinics for special cases. This should be done
right from the beginning and not as part of his Public Health
internship towards the end. The tutoring thus should include not
only pathological symptoms, but social and environmental condi
tions too.
IV.3. Organization of a field service-cum-demonstration area
for teaching Environmental Sanitation.
.
.
In addition to this tutoring in the hospital wards, the
medical undergraduate should have facilities tolfollow up the
'
patient to his home and community environment. To facilitate
1
this, a field service-cum-demonstration area should be organized
•
as part of the Department of Social and Preventive Medicine.This
. area should include the corporation or municipality where the
:. Medical College is located and also 5 or 6 panchayat anions or
'■ Community Development Blocks, adjacent to the same. Since it is
expected that a large percentage of the patients who com to
. the hospital for treatment will be from 10 miles radius, the
field service-ciuji-demonstration area shall also be located with
in this distance of the Medical College. This should not pre
clude us from taking the students to areas beyond this distance
forstudies on special diseases like guinea-worm, and demons
trate the causative factors at spot.
The field service-cum-demonstration area should be wellstaffed and should providef acilities for investigation, sur
vey and development of a minimum Public Health programme based
on the needs of the community. Since it is expected that cer
tain
:6
facilities that may not be normally undertaken by the health agency may have to be developed in the field demonstration area
as part of the student training,
a contingent amount should be
made available to the Department of Social and Preventive Medi
cine for expenditure on programmes developed for teaching pur
poses. The organization of the field demonstration area will -
also involve additional workload on the Social and Preventive
Medicine Department by way of giving technical guidance (routine
administrative set-up will vest with the public health agency of
the district or corporation) to the students,and/s%aff of the
Social and Preventive Medicine Department has to be augmented
proportionately to take the extra workload,and,transport pro
vided. To make the field area reflecththe realities of the Indian
situation, maximum efforts should be made to g et the work carried
out using medical auxiliaries in the field under the direction of
qualified medical officers. A suggested set-up of the field area
is annexed. (A'nnexure
i
). The learning opportunities of the
medical undergraduate in Environmental Sanitation in this field
area will generally fall under three or four phases:
TV.4. Phase I: Planned field visits over a period of time of
3 years or less.
Questioning a patient on his physical and social environ
ment in a hospital ward is only a first step in the teaching
process. This has to be followed up further. To make a specific
suggestion in relation to Environmental Sanitation, let us sup
pose that a group of medical students are shown a case of typhoid
in a hospital ward; or they come across a number of people in
the out-patient who have sought treatment for hookworm. Apart
from treating the patient,’ the students should follow up their
patients to their home.to study about their immediate home
environment. The patients ehosen could be those Ao come from
the field demonstration area and it will not be' difficult to do
this. When once the student goes to the village, they could
in addition to the patients' homes, choose a few neighbouring
houses also for study and. a group of 2 students could take 50
houses for study purposes. During the first phase of their
field visit which should coincide with the first year of cli
nical stdues and the starting of the training in Environmental
Sanitation, the students will thus make a study of the imme
diate environment of the families assigned to them, viz., type
of house, living conditions, hygienic practices, attitudes to
wards disease, knowledge, water supply, latrine etc. The student
will maintain a family fclder for each of the families chosen
:7
and record their observations and also record all cases of sick
ness in that family for the rest of the year and arrange for
treatment. They will also make helminthic or other, studies among the households as indicated and prepare spot maps on
morbidity (with special reference to those due to poor sani
tation) in the houses allotted to them. At the end of this
period they should be helped to analyse and interpret the data
gathered and make further searching enquiries, to continue -
their work.
Phase II: During the second phase of their field study
which should follow closely after the first, students will
continue to make observations of the families allotted to
them. In addition, they should now go farther into the community
and study the prevailing conditions in.the area, actual or po
tential, which has exerted a favourable or unfavourable influence
on the health of these families and of the inhabitants as a
whole. This survey will be a total Public Health Survey including
all aspects of Environmental Sanitation like Water Supply, Defaecation habits, Pood Sanitation etc. Since all the houses in
the village or a ward of a municipality would have been allotted
to groups students, they can pool their family data record and
also village survey record to draw conclusions. They should be
helped to correlate their morbidity data with those elements of ■
environmental sanitation in the village which have contributed
to this morbidity. Thus, by a self-study and analysis under su
pervision and guidance, the students will, try tosee the patients
of the families allotted to“ them in relation to their environ
ment.
In the survey that he now makes, the student should
select and involve local leaders. The opinion of the leaders are respected by the people and they can help the students to
gather accurate data on some of the particulars they want. Fur
ther, if the local leaders are involved in survey and planning
phases of the health programme, their cooperation in the accep
tance phase will be easily forthcoming. Ultimately, it is the
people who should take responsibility for improving tf their
own individual and community health needs and as such, the in
volvement of leaders at this stage will be most useful.
Phase III: The third phase of the planned programme of
teaching/Enviio nmental Sanitation will be to help them to plan
and implement programmes in environmental sanitation based
:8
on the health needs as gathered by factual data. The student at
this stage should be helped to set out priorities, how to plan
for implementation of programmes involving other health per
sonnel and local leaders, how to implement thes ame and evaluate
their work. They should be clearly made to see the roles of the
different members of the health team carrying out specific res
ponsibilities for action; For example, it is not necessary for
the doctor to do all aspects of latrine construction work,"but
he should definitely see the relationship between.non-use of
the latrine and faecal-borne diseases in the village and be able
to plan for a latrine promotion programme, utilising the para
medical staff.
It is also important that the field work will relate not
only to environmental sanitation work, but cover the total
Public Health needs of the population under study. Experience
of the RcA Project at Poonamalee has revealed that where scabies
is a problem in the village, it is difficult to get people's
cooperation for any other health programme, unless a control pro
gramme for scabies is initiated. The Gandhigram experience has
further proved that to get maximum participation from the people,
it jis better to approach the people with a health programme,
rather than adopt a piecemeal approach. As- such, it is better (
that, for maximum benefits, a total Public Health programme in- •
eluding Environmental Sanitation is developed in the village
rather than an environmental sanitation programme alone.
IV.5. School health
Among the various programmes developed at the village level,
high priority should be given to school health. Children have got "
pliable mind and attitudes and catching them at a young age will
help in promoting the correct attitude among the s tudents towards
sanitation. As teaching of environmental sanitation in primary
schools should start with development of opprotunities for stu
dents to practise sanitary practices, the provision of the most
essential elements of school sanitation should find a place in
the programme. Further details of this are available in the
article "Minimum Programme of Environmental Sanitation in the
Field Demonstration Area." (Annexure II).
IV.6. Minimum Programme of Environmental Sanitation in the
Field Demonstration area.
A minimum programme of Environmental Sanitation should
be d eveloped in the area chosen for field study and demonstration
by the by the Social and Preventive Medicine Department. The
programmes being continuously developed should include:
P.T.O.
1.
Provision of adequate and safe water supply
in all villages of the Block;
2.
A phased programme to cover as many of the
households as possible in the Block with
sanitary latrines;
3.
A comprehensive school sanitation programme
to cover
(a)
provision of safe water supply to schools,
provision of at least a two-seated sani
tary latrine and
(c) a hygienic kitchen-cum-store for safe
storage of food articles and sanitary
cooking.
(b)
4.
Provision for the disposal of sullage.
5.
Provision for a community compost-yard
for every village and hamlet of the village.
6.
Improvement of sanitation in food-handling
establishments
7.
Sanitation of the dairy and cattle-sheds.
( Details about these are given in Annexure II)
TV.7. Pinal Report by the Student:
The students should be asked to keep record of their
field study and observations in the villages allotted to them
for work. It is to be understood that the choice of the vil
lage was not arbitrarily done but was a result of the follow up
of the first clinical patient, a victim of the insanitary condi
tions, allotted to him. The student will thus prepare.a project
report which should involve an environmental diagnosis of his'
patient and of many similar ones that he came across in the
area over the two to three years' period and an environmental
treatment. The preparation of this Report should be obligatory
and form part of the final assessment.
(See Annexure III)
V.
Coordination of activities in field service area
with that of the Social and Preventive Medicine Department
There is a great need for coordinating the training ac
tivities with that of regular service functions in the field
demonstration area. To achieve this, a committee consisting
of the staff of the Social and Preventive Medicine Depaxtaent
and those in charge of the Primary Health Centres, Municipa-
: 10
lilies and the District should be formed and this committee
should be in charge of the entire field progranme.
The medical officers of the Primary Health Centres,
should, in addition to their duties, act as field guides
for the students of the Medical College and some of them,
after some experience, could also function as part time staff of the Social and Preventive Medicine Department.
VI.
Teaching Staff in Environmental Sanitation:
The teaching in Environmental Sanitation should be
made effective and interesting. The subject of Environmental
Sanitation should be taught to medical students by persons
who possess a high degree of competence in the subject. It
may not be right to think that any Civil Engineer could handle classes in Environmental Sanitation for medical stu
dents. The teacher himself should have had training and
and experience in Public Health.
The teaching itself should be so directed as to
make the student understand the role of collaborative fun
ction in Environmental Sanitation, its role in relation to
disease and interpret conditions and plans for effective
programmes; he should also be helped to see the contribution
that other personnel like the Sanitary Engineer, Sanitarian
etc. can make. The undergraduate should also receive ex
perience in team approach to solve problems
in Environ
mental Sanitation.
VIII.
Laboratory Work:
The teaching of Environmental Sanitation could also
be made interesting by giving a practical bias to the whole
subject. Every Department of Social and Preventive Medicine
should have ample facilities for laboratory work in En
vironmental Smit ation and also for making epidemiological
investigations.
IX.
Observation Visits:
A programme of planned visits to environmental sani
tation works like Water Works, Sewage Works, Pasteurization
Plants etc. should be organized. This makes the lectures and
readings far
:11
more intelligible to the students. This will also help his
-
future executive functions as Health Officer and also add to
the general education of the undergraduate.
X.
Teaching Environmental Sanitation along with
concerned Disease.
Still another way by which the undergraduate can be
made to appreciate the relationship between the disease and
the environment is to teach Environmental Sanitation approp
riate to the disease along with the disease itself. This could
be done by adjustment of classes and time-tables between the
Department of Medicine and the Department of Social and Preven
tive Medicine.
XI.
Industrial Health
Both the General Practitioner and the executive Health
Officer are brought face to face with illnesses of occupational
origin. Occupational health will assume problems of high magni
tude in view of the rapid industrialisation in India. The teach
ing of Environmental Hygiene in the special circumstances of the
Workshop and the Factory is thus important. The Department of
Social and Preventive Medicine should have facilities to study
problems' of occupational health and utilise them for teaching
purposes.
CosclusioSi
An attempt has been made to diagnose the causes for the
unfavourable attitude among the medical undergraduates towards
a . study of the subject of Environmental Sanitation. It is
felt that the role of the teacher in sanitation is to help the
students develop correct and favourable attitudes towards the
subject taught. One way of doing this is to orient the teach
ing of the subject in such a way that the students learn to
look at the patient in relation to the factors of his physical
and social environment. In addition to bedside teaching, an ef
fective way of doing this is by developing a field service-cumdemonstration area attached to the Social and Preventive Medicine
Department of the Medical College. In this area, the students will follow the patient to his home and study his home and com
munity environment especially relating to sanitation. Helping him
:12
to carry out proper surveys, analyse his records, identify those
factors of Environmental Sanitation which are contributing to
the morbidity in the village and develop programmes aimed at
finding solution to the problems might help him to appreciate
the value of Environmental factors in transmission of disease.
The student will know that ultimately it is better and cheaper
to treat the environment and prevent diseases,rather than treat
the sick alone, forgetting the environment.
FIELD SERVICE -
CUH
- DEMONSTRATION AREA.
Annexure I
STAFF
I-----------------------j
UNIT
} Primary Health
i
Centre
}
(80,000
{ Population)
{
■
I|
:
;
Staffed by --j
I
J
MEDICAL OFFICER
i
j
I
|
i~ - Asaisted by —!
■I
e.+„^
,
Staffed by
I
Peripheral Units
for every 5,000
Population
{
I
I
----- | MEDICAL OFFICER - 1 i— Assisted by
i
1
i
i--------------------- -j]-------------------- '
||
II
i
[
|
I
'
J
{
________________ |
"F
II
1'___________
| Sub-Centres
| (for every
i
20,000
} Population)
1
i
I Anxi 1i ary Nurse
I
o,
.
| Midwife
- 1 I
- oxaliea oy----- j Basic Health
1
I Worker
- 1 '
<
1
I
—|
i
{
{_
Public Health
Senior
Sanitarian
Statistician
Junior
Public Health
Engineer
Health Visitor
1
,
1
1
1
Sanitary Inspector
1
,T
.
Mason
1
Laboratory
Technician
1
______________________
[
I
i
i
i
|
NOTE:
1• Compounding and other Administrative Staff
to be posted in addition.
2. Most of the staff are already available under
the reorganised Primary Health Centre set up.
J. Additions! cost of one such unit will be
Rs. 80,000/- per year.
ftwuzxotwz- 7T
COMPONENTS OF AN ENVIRONMENTAL SANITATION
PROGRAMME THAT REQUIRE ATTENTION IN THE
FIELD SERVICE-cum-DEMONSTRATION AREA
While environmental sanitation covers many aspects, a
comprehensive programme consisting of the following compo
nents may be considered for execution in the field area:-
1)
Provision of adequate and safe water supply
in all the villages of the Block;
2)
A phased programme to cover as many of the households
holds as possible in the block with Sanitary
latrines;
3)
A comprehensive school sanitation programme
to cover----(a) provision of safe water supply to
schools,
4)
5)
(b)
provision of at least a two-seated sanitary
latrine and
(c)
a hygienic kitchen-cum-store for safe
storage of food articles and sanitary
cooking.
Provision for the disposal of sullage;
Provision for a community compost yard for every
village and hamlet of the village;
6)
Improvement of sanitation in food handling estab
lishments;
7)
I.
and
Sanitation of the dairy and cattle sheds.
Provision cf safe and adequate water supply
The need to rpe provide safe and adequate water supply
to every village is so well-recognized that it needs no exp
lanation. The present programme in Community Development
Blocks aim at (i) Sinking new wells in those villages where
adequate water supply is not available and (ii) Providing
overhead tank supply system for villages where the people
come forward. But the execution of these programmes is not -
done in a systematic manner and there is need to put it on a
scientific basis. To meet this, a survey should be first conducted of all the villages in the Block area to find out
(a) the existing sources of water supply, (b) their adequacy,
(c) safety, and (d) possibilities of development of addition
al sources. When once the survey is completed and data pro
cessed
2/
a master plan for the whole Block area, based on the follow
ing, can be drawn—
1)
Villages for which overhead tank supply could
be developed from local sources;
2)
Groups of villages for which water has to be
tapped from a common source and supplied through
a common distribution system;
3)
Villages, which by nature of their small size,
hafe to depend on dispersed sources like wells
for a long time to come.
Once the villages are grouped and rough estimates
of e<jst worked out, the whole scheme should be discussed with
the members of the panchayat union and ways of financing the
same thought about. It will be quite evident that the resour
ces e£ available from the Government will have to be supple
mented by local efforts mostly by raising of water-tax by the
local panchayats. The Panchayat Union members should decide on
•the priorities and phasing of the programme and raising of lo
cal resources, so that they will have a sense of participation
in the preparation of schemes and their execution.
Pending
the execution of the Master Plan, a sanitary
survey of all the drinking water wells in the block area -
should be carried out by the health staff. It is common obser
vation that many of the wells require improvements by way of
protective platform, proper casing, waste water disposal faci
lities, etc. The estimate for carrying out the repairs should
then be prepared and the works carried out expeditiously in
2-3 years. The local Panchayat and Union Funds should be uti
lised for this.
In view of the depletion of ground water tables due to
to heavy pumping for irrigation and other purposes, it is now
found that most of the shallow wells get dried up in summer .
It may therefore be necessary to take the supply from the deep
er layers in future. It is therefore suggested that each com
munity development block^in the proposed service area be pro
vided with at least a/^and-boring set which could be utilised
to put up bore wells up to 120 feet. It will also be preferable
to provide the additional sources of water supply through bore
wells.
The villages under Group (3) above which have to
3/
depend upon dispersed wells for many more years to come, should receive attention and the wells in these areas be covered and fitted with hand pumps. The new sources can be -
bore wells. To look after the maintenance of these hand pumps
the Panchayat Union should appoint mechanics and store ade
quate spare parts and charge the cost of maintenance, pro-tata
to the village panchayats.
As an immediate measure, the maternity centres in-the
villages, the Balwadies, the Panchayat and Village schools
should be provided with a protected drinking water source.
II. Excreta .Disposal
Experience has shown that while the water supply pro
gramme is accepted readily by the people, continued and pro
longed and educational efforts are needed to motivate the
rural population towards acceptance and use of latrines. It
is also found that in every willage, there is a section of
population which is more ready to accept latrines than the
others. In view of the need for sustenance of efforts over
a period of time in the same village and the inadequacy of
workers, it is also b itter to initiate the programme in a
responsive
few selected/villages at first, work there for some time,
before moving to new areas. It will also be not possible to
cover the entire village by a latrine programme in the first
round itself.
In spite of their demonstrated failure to meet the -
excreta disposal needs of the rural population many a time, -
voices are heard from responsible people in favour of provi
sion of public latrines in villages. The argument most common
ly raised in favour of public latrines is that all the houses
in rural areas do not have space for household latrines, and,
as such, something should be done for these houses too. But it
is often forgotten that not more than 2 to 3$ of the house
holds in villages do possess or use latrines and more than 50$
of the houses have space for household latrines. Since the con
centration in initial stages of the latrine programme should
be to create a social acceptance of the programme and to see
that the latrines constructed are well-maintained and used, it
is better to concentrate on the programme for the individual
households initially. After a few years, when the programme
4/
gains acceptance, it will be easier to solve the problem for -
others. At present, very few of the panchayats have either the
money or the skill to maintain public latrines properly and'
efficiently.
In the Athoor Union area (Madurai District) the cpnstruction of household latrines are subsidised to an exteht. The
subsidy for each latrine comes to Rs.16/- and is meant to meet
75% of the cost of pan, trap, pipes and pit cover. In two of
the villages, based on a suggestion made by the people, a re
volving fund scheme has been tried. Under this scheme, the Health Committee is given an interest-free loan of Rs.500/-
and the Committee gives Rs.50/ to each household who wants to
construct the latrine, to meet the cost of lining pits, brick
is
enclosure etc. The money/collected back in 10 monthly instal
ments and the loan amount recovered every month is again plough
ed back. At a recent meeting of the Panchayat Union members and
other selected leaders from the Block, it was unanimously ag
reed that this scheme is good and should be introduced in all
the villages. To meet the demand for supply of materials, it
is also necessary to set up a workshop for a group of blocks
for manufacture of latrine materials.
Based on the execution of the latrine programme in
five contiguous blocks in Madurai District over the last few
years, the following suggestions are given for a latrine pro
motion programme
1.
in the proposed sdrvice area:
To set up a latrine parts manufacturing workshop
in each block or for a group of 2 to 3 blocks,
for manufacture of cement pans and traps, pipes
2.
and pit covers.
To select about 8 to 10 responsive villages ini
tially for the development of the programme,These
villages to be selected at the Panchayat Union
Council meeting. After the programme develops,
momentum in these villages eould be added cm in
a phased manner.
3.
To subsidize the construction of every household
latrine to the extent of 75% of cost of pan: and
4.
trap, connective pipes and pit cover.
To give an interest-free loan of Rs. 1000/- ( or
-at the rate of Re.1/ per head of population)
for setting up a revolving fund for construction
TEAWING OF COMMUNITY HEALTH IN HOSPITAL AND HEALTH
CENTRE COMPLEX AT THE K.G. MEDICAL COLLEGE, LUCKNOW
B.G. PRASAD and J.K. BH AT NAG AR - LUCKNOW
The teaching of community health aims to accomplish the
object of medical education, which is to train doctors in the
concept and practice of comprehensive health care to raise the
level of the health of the people, the ultimate goal of medicine.
Community health teaching should not only be carried
out throughout the medical curriculum but also continue in the
internship stage to demonstrate and involve them in the practice
of community health in the urban and rural practice areas.
Community health can best be taught through inter
disciplinary method both at the hospital and the health centre
complex to train the doctors in totality of medicine and the
concept and practice of comprehensive health care.
In collaboration with the three departments of Social
and Preventive Medicine,. Paediatrics, and Obstetrics &
Gynaecology at K.G. Medical College, Lucknow, interdisciplinary
teaching of community health in Social Obstetrics and Social
paediatrics is being carried out at the weekly neonatal and
children's clinic held at the respective departments, for the
senior (sixth to eighth semester) medical students.
This
enables the students to observe and learn the importance of
social and clinical factors in health and disease and realise
that health care cannot be compartmentalised and for completeness
and continuity extends beyond the hospital.
The interdisciplinary teaching of community health,
its demonstration and practice by actual participation is given
to the interns during their posting for three months in the
Department of Social and Preventive Medicine for working at
the health centre complex comprising of Urban Health Centre
Alambagh, and the various components of Rural Health Trainihg
Centre, Sarojini Nagar — Primary Health Centre and the
Experimental Teaching Health Sub-centres at Banthra and Mati.
This enables the interns to acquire skill and attitudes
appropriate to the practice of'community health in live situations
and above all to appreciate, understand and accept the concept
and practice of comprehensive health care and of team approach.
THE COMMUNITY ORIENTED PHYSICIAN EDUCATOR
AND THE FUTURE PHYSICIAN
N.
C.
SOWMINI - MADRAS
Major historical high lights concerning the evolutionary
concept of community health.
Consideration is given to the three dimensional
approach to community health; namely the community from which
the patient comes, the hospital community and the community to
which the patient returns.
attention is given to the causative
factors which underlie the failure for the implementation of
this approach.
Emphasis is placed on the role of the community
oriented physician educator and his responsibilities relative
to the future physicians.
2
MOTIVATING THE HOUSE PHYSICIANS IN
COJ.1JTNITY HEALTH IN HOSPITAL SETT TIC
M.S.
NARAYANAN - MADRAS
In Tamil Nadu. Royapettah Hospital in Madras City
caters to the needs of. the medical students of Kilpauk Medical
College.
Like any other general hospital it consists of various
outpatient clinics.
for
The outpatient departments are divided into units
purposes of teaching the. students.
The Unit taken for this discussion consists of
Tuberculosis, Paediatric and-Family. Planning Clinic.
The various problems arising from one discipline but
inter linking the other disciplines are enumerated and the
teacher plans a detailed program for the student.
In imple
menting the interdisciplinary approach, the community-oriented
teacher selects a few patients for study from all the three
clinics and guides the students in the relationship of one
discipline to the other and its impact on society.
This gives
the student;-., the plans, elevations, sectioned views and an
overall perspective of the subject regarding the patient as well
as the Community from where he comes.
FAMILY CARE -. AN INTERDISCIPLINARY TRAINING PROGRAMME.
A. RAHMAN - .CALCUTTA
The all India Institute of Hygiene and Public Health
undertakes field training of different categories of public
health students (DFH., DMCW., M.E.(PH), DHE., Dip. Diet etc.)
at the urban Health Centre, Chetla the ur'gan practice field of
the Institute.
The various departments of the Institute
(Preventive & Social) Medicine, P.H., Administration,
Environmental-Sanitation, Health Education, Maternity & £hild
Health etc.) participate in organising and implementing the
training programme with, the following objectives:
1. To enable the students to understand-the different
Medico-social problems in the families and their relationship with
the environment.
2.
To find out the consequences of ill health and its
effects on the family and the community.
3.
To help the students to find out the reaction of the
individuals, families and the community towards the disease
and the existing service facilities.
4.
To enable the students to find out the resources of
the community for the solution of- the problems.
Routine health services through the health centre are
provided to the families located at Chetla, an area under the
jurisdiction of the Calcutta Corporation.
Two families are allotted to each team of students and
six visits are given by the students to each of the families.
During the visit @ach team records in the family folder the
family composition, socio-economic and environmental conditions
ef the families, the important events and the state of health
of the individual members of the families.
The interdisciplinary nature of the programme becomes
operative in dealing with health problems encountered by the
students. These need services of-various members of the health
team — physicians, nurses, laboratory and X-ray personnel, ■
health educators, sanitarians etc. available at the health
centre.
The student is exposed to'the integrated programme
by personal participation.
INTER-DISCIPLINARY TEdCrii-iG CT COMMUNITY HEALTH IN HOSPITAL
: B.K. MAHAJAN - J AfciNAG AR
Interdisciplinary teaching ef community health in
teaching hospitals and health centres is a useful technique in
medical education to prepare 'basic doctors', oriented temeet
ths needs cf developing society, particularly so in India.
h good number of attempts and experiments- made in this
direction, at the instance cf teachers in Preventive and fecial
Medicine in different medical colleges, in the last 15 years
in India and abroad, have been reviewed.
The response given
by teachers of other disciplines is varied and not found to be
lasting except in rare cases.
N© evaluation has been made but
it is worthwhile taking th? stock of achievements made thus far.
Objectives and advantages cf such teaching are outlined and
hurdles are discussed in the light cf the separate development
cf curative and preventive branches of medicine.
Integrated teaching of community health has been done
through cl ini co-social case of conferences on cases from wards
and health centres.
Another rich field is the outpatient
departments of hospital for interdisciplinary teaching. The
present paediatric or children clinics giving only curative
services and well baby clinic giving mainly preventive' services
should be -integrated into one ' children health clinic' for
teaching and demonstration of Integrated community health services.
Antenatal clinics should be likewise reorganised so that they
draw normal and abnormal cases both and render total preventive,
proactive and restorative services.
Specialised clinics such
as T.B., V.D., diabetes, filaria, etc., and infectious diseases
wards are other glaring fields for interdisciplinary teaching.
Responsibility for implementation of such teaching
should not be that of teacher in Preventive and Social Medicine
but that cf college Council for lasting results.
Integrated
teaching requires integration of disciplines, time, staff and
philosophy which can be dene at Council level only.
INTERDISCIPLINARY -TEACHING' OF COMMUNITY HEALTH
AND FAMILY PLANNINGD.
ANAND,
SHRIN3VASA
and
CHAKRAVORTY
-
PONDICHERRY
During recent years considerable emphasis has been
laid on integrated teaching.
One of the most productive areas for
work relates to integration of teaching related to MCH and
Family Planning.
The paper deals with an experiment in such
an integrated approach carried out by the departments of
Obstetrics and Gynaecology and Preventive and Social Medicine
at JIFkER.
Broadly stated, the paper will deal with the methodology
followed in planning the block teaching for medical interns
which will be carried out with the technical resources available
in the conmrunity.
An attempt will also be made to carry out before and
after survey based on the use of tools designed to study attitudes
and skills of medical interns in the cognitive psycho-motor and
effective domain.
FELD TRAINING IN OBSTETRICS Al© EYNAECOLOGY
FCR THE UNDERGRADUATES
RQ-IIT
V. BHATT
-
BARODA
A student gets used .to the methods for diagnosis and
treatment of diseases he sees in the hospital practice.
He is
rarely aware of the situations prevailing in the homo set up.
The knowledge about the socio-ecnomiC background of the people,
the social customs, the way of life etc. is a must for every
medical man before ha can do full justice to his patients. ' This
is true for all branches of medicine and specially so for Obstetrics
and Gynaecology.
a medical student is used to see the. confinements
within the four walls of the labour room.
It is necessary for
the medical student to see how obstetric complications during
pregnancy and labour are managed in the home set up.
We have planned the field visits by our undergraduate .
and Internees students to the small peripheral centres round
about (21 miles) the city of Baroda where the Medical College is
situated.
Our aim is to take the medical student during his
clinical term to-these centres, but the batch of students being
very large we are not able to take .them for Obstetric training
at present.
The staff of the Obstetrics dept, visits the
seven peripheral centres (Chhani, Karjan, For, Waghodia, Savali, P
Padra and D^bhoi) once a week or as necessary.
One resident
doctor and an intern accompanies the consultant.
The intern
is given all the opportunities to witness and observe the coflditions
prevailing in the village.
He. is encouraged to visit the homes
of the patients and see for himself how they live.
He observes
how deliveries are conducted in small centres as well as at home.
He gets an idea how obstetric complications like placenta
praevia, eclampsia etc., are managed before sending to' the
general hospital.
This first hand information on the field gives him
confidence to manage similar situations when he would be incharge
of the centres.
He learns from the mistakes' made by others
in these centres.
We feel that the student is better armed with knowledge
if his hospital training is supplemented by field training in
different subjects.
We work in close cooperation with Preventive
L'edicine Dept, and the Paediatric Dept.
Our method of
field training is on from 1967 and we feel that it has served
useful purpose.
We propose to discuss the problems involved in arranging
the field training.
SURVEY OF CURRENTLY .JUED COOKWARES AND
COOKING METHODS USED BY . .fWWIT.l&S
K.N. AGARWAL, M-. GUPTA and D. AGARWAL
-
VARNASI
Five hundred and eighty seven families of low and
middle income groups were interviewed to find out the currently
used utensils for cooking.
it was found that all families were
using iron knives and iron tawas for cutting vegetables and
making chapatis, respectively.
However, the use of iron vessels
for the preparation of dal and vegetables was negligible.
It
was also found that there was loss of dietary minerals in
vegetables by preliminary washing'prior, to cooking.
ROLE CF CALORIE AND PROTEIN INTAKE ON PHYSICAL
GROWTH
M. GUPTA
- VARNASI
and K.N.-AGARWAL
The weaning and introduction of semi- sol ids were earlier
in children of educated parents especially those of educated
mothers.
The nutfient intake was decreased with increasing
birth order.
Better anthropometric indices were found for
children taking calories >1200, total protein over 35g. and
animal protein over 20 g. Per day.
NUTRITION REHABILITATION CENTRE
Teaching through student
participation.
A.S. CHIKERMALE, A.K. NIYOGI - BARODA
INTRODUCE ION;
In a preliminary study done with the help of the Dept. .
of Preventive Medicine it was seen that about 66% of cases of
Protein Calorie. Malnutrition discharged after very adequate
hospital treatment died in less than one year.
The main
shortcoming of thek hospital treatment was its high cost and the
children relapsed when they returned to their home environment
and diet which had caused the disease.
The Nutrition Rehabilitation Centre was therefore
started in 1069 to manage severe cases of malnutrition by offering
an inexpensive diet consisting of locally available and culturally
acceptable ingredients, cooked by the mothers under the super
vision of the P.H.N. and the doctor, so that the mothers realise
the significance of proper diet in the prevention and management
®f malnutrition.
Method of Treatment of Malnutrition;
Phase I: Acute stage, with anorexia, infection,
diarrhoea, and high katabolism, managed in the main ward with
antibiotics, milk drip, etc.
This generally lasts one week.
Phase II:
Correction and Rehabilitation:
2-3 weeks.
In addition to nutrition rehabilitation the mothers
are also instructed about the importance of hygiene, immunisations
and other preventive and promotive measures.
Phase III:
Follow
up at home.
Results;
The rate of improvement during the hospital stay was
better than in the earlier cases, and there were no complications.
o -
The post-discharge mortality came down from 66>i to a mere 5$.
The survivors •.'.era steadily improving in health.
Other children
in the family were also given better diet.
The nutrition
education spread in the community in some measure; some of the
neighbour^ •.’.’are also giving similar diet to-their children.
The student , interns and the postgraduate students
are actively involved inthe nutrition rehabilitation centre
a ctivfty►
TEACHING OF INFECTIVE DISEASES IN MEDICAL WARDS
P.S. SHANKAR
-
GULBARGA
The heal th. of a community is- affected adversely by
the infective disease's.
The incidence is related to the
reservoir of infection, facilities for its spread, living
environment dietary habits and social conditions.
Such cases
ar? to be studied at the home' atmosphere by the medico-social
worker, health inspector and medical, student.
The data so
obtained gives an insight into the problem in the community..
The discussion of such a case in the medical ward of the hospital
is done as combined clinics by the teachers of Department of
Medicine and Preventive medicine.
The curative and preventive.
aspects of the disease is stressed.
POSS TELE AETIOLOGY CP BRAIN DAMAGE AID ITS PREVENTION
G. SUBR AHU ANY Ail and K.N. AG AR’./AL —
VARANASI
In a preliminary study children having brain damage
were subjected to clinical and extensive bio-chemical investigations.
These investigations were aimed to exclude:
1.
2.
3.
4.
Aminoacid metabolic defects.
Mucopolysaccharide defects.
Carbohydrate metabolic defects.
Meta chromatic leukodystrophy.
The absence of any bio-chemical defect and detailed
clinical history have suggested that the brain' damage was mainly
due to asphyxia neonatorum,which is preventable. The role of
ebstetr©clan, paediatrician and community health doctors will
be discussed.
np-s^Dept. of Preventive & Social Medicine
St. JOHN'S MEDICAL COLLEGE
BANGALORE-34,
«**«*»■»*»««*»«****#******»«»*»»«■»*»**»■»*******«*«*«»«*«*■»«»#
If
■xIf
If
If
-x
Report on Visits to
*
%
Departments of Preventive and Social Medicine
If
If
If
If
If
*
If
If
If
*
If
If
by
If
If
If
If
If
If
If
If
If
If
If
If
If
%
%
If
Carl E. Taylor, M.D. F.R.C.P(C), Dr. P.H.
Director of Program for
Teachers of Preventive Medicine
Harvard School of Public Health
If
If
If
If
If
If
If
If
If
If
If
If
If
If
If
If
If
If
If
July - August, 1959
If
If
If
If
If
If
If
If
If
«*#«##**««*»#*«««»«*««»*»«**«*»*»««*««#»«*««*»**««#«»*#«#«»«
I,
INTRODUCTION
This return to my second homeland after an absence of
years has brought more gratification than I can possible express.
My overwhelming impression is amazement at the tremendous achieve
ments and progress, which are especially evident to me because of
having been away. Far more significant than the magnificent new
medical buildings in the cities are the changes in villages I have
known intimately in past. And again more important than any build
ing is the continued working of an exciting ferment of new ideas
and bold planning, Wien we used to discuss in meetings of the Health
Panel of the Second Five Year Plan what seem'd to me challenging but
too optimistic goals I did not believe that achievement would be
this real. The adaptation of scientific medicine to the needs of
the country is a tangibly developing process. "
.
My visits in six weeks have included Departments of Preventive
& Social Medicine in 19 Medical Colleges in nine States and well over
two dozen rural and urban health centres. In addition to numerous
lectures and discussions I have had opportunity to informally question
groups of medical students and interns in most of these Medical
Colleges. Theiy frank and illuminating observations have proved to
be one of the most instructive features of my visits
Throughout this strenuous trip the generosity and thoughtful
ness of my hosts have left me so profoundly grateful to so many that
I cannot begin to list them. The welcomes from administrators,
colleagues, medical students and especially village folk have been
typical of Indian cordiality. Particular appreciation should be'
expressed however, to Shri Karmarkar, Central Unister of Health,
dhri V. K. B. Pillai, Secretary of Health Ministry and Colonel
Jaswant Singh - Director General of Health Services for making
arrangements for my visits and clearing my way of administrative
difficulties. This trip was paid for by ICA funds and to the
staff of the TCM and Rockefeller Foundation would also like to
express my thanks for help
travel plans and the detailed pro
gram.
II.
PURPOSE OF VISITS
A.
The primary justification for this travel to India, Thailand
and Japan during the summer of 1959 was a desire to further improve
the Program for Teachers of Preventive Medicine at Harvard School
of Public Health. During the three years since this Program opened
steady evolution in our planning has occurred. With two groups now
graduated it was felt that visits to the men on their home ground
would provide further insight into the relative usefulness of various
parts of the Program. Forty four teachers from eightenn countries
have spent one - two years in our inter-university program (Eight
Departments of Preventive Medicine in the Eastern US cooperate with
us by providing teaching rosidcncies). Since fourteen of these
teachers have come from India it was logical to concentrate travel
in this area.
2
B.
On arrival in Delhi, the Central Health Ministry requested
an evaluation of present developments and recommendations for
future planning for Departments of Preventive and Social llcdicinc.
The time for this is particularly opportune because in the Five
Years since the 1955 All India Conference on iiedieal Education}
major decisions have been made by the Indian iiedieal Council and
University Faculties,
C,
In the course of visits to each iiedieal College it has been
possible to provide some assistance in local planning. A deliberate
attempt has been made, however, to do this unostentatiously through
the conviction that stimulation of local iniativc and ingenuity
leads to maximum enthusiasm and long-term development. I find too
that specific and deta.i 1 cd advice by foreign "experts" often con
flicts with that of previous "experts" and thus leads mainly to
confusion,
III.
BACKGROUND OF PRESENT DEVELOPIENT.
Preventive & Social Medicine is a comparative newcomer to the
academic disciplines of Iiedieal Education, The transition from teach
ing Hygiene to the relatively wide orientation implied in the new
title has gain rapid acceptance in the past five years, Jill too
often, however, a new cloak has been assumed without actually chang
ing subject matter or methods. While Western medical educators con
tinue their semantic wrangling about the relative merits of various
ways of presenting the components of what Americans call Preventive
and Europeans call Social iiedicino, India has wisely accepted the
WHO recommendation to combine the terms.
Two specific conditions make it possible for India to assume
world leadership in developing this discipline. First, is the his
torical tradition of the Ayurvedic emphasis on prevention. This is
important not for dsentimental reasons but because these concepts
are deeply engrained in the cultural orientation of common people.
They expect every doctor to be interested in and assume responsibili
ty for preventing illness and complications. The culturally accep
ted dietary and personal hygiene practices of course require reinter
pretation. Strong popular pressure ensurcsthat these responsibili
ties will not be completely delegated to auxiliary Public Health
workers as they were in Western medicine before the present awaken
ing of interest,
A second influence comes from the patern of ' Nat.-i.,n.<l Health
Services being developed under the Five Year Plans, The provision
I of integrated preventive and curative services in Primary Health
I Centers makes it imperative that doctors be taught appropriately.
In adopting Western medical education to the needs of India two of
the major emphasis are the particular responsibility of Departments
of Preventive & Social Iiedicino.
3
1)
Developing in students the attitude and ability to
apply preventive measures routinely while caring for
individuals and families.
2)
Creating an understanding of rural sociology and
village community organization so that a medical
graduate can assume the responsibility for a Primary
Health Center with some assurance that ho has been
trained for the job.
Tlic present gap between the wards of teaching hospitals and
condtions under which most doctors work is too great. Transitional
steps arc needed so that doctors learn not only how to practice high
quality comprehensive medicine but also how to adapt and apply it
under all conditions.
IV.
A.
G3irjR.'JJIZj-.TIOi-IS FROM OBSERVATIONS
Dangny:ofeIhadDquat,0 ’cImplementation of Teaching Programs:
1)
Faculty Reaction - A new discipline struggling for
acceptance must not antagonize professional colleagues.
Healthy scepticism challenges the new-comer to demons
trate practical contributions in teaching and research
If hasty and inadequate implementation of a complex and
difficult endeavor is attempted there is danger that
early problems may lead to a negative pro-judgement by
colleagues. This is happening in some places I have
been. Faculty suspicion is aroused by much talk and
little action. Some clinicians are strongly of the
opinion "L’e can do all the teaching needed in pre
vention and do not need so called specialists."
Even more common is the continuing misunderstanding
expressed to me by several Professors of Medicine and
others in thinly veiled comments which mean in essence:
"This social medicine stuff is a luxury which you can
afford in the lie st. Thy do not you go back to America
and let us get on with the real job of treating our sick
people". These reactions can be not not by words but by
demonstrations by conpetent people that there is a contri
bution to bo made.
2)
Student Frustration - Even moro significant is a type of
negative rcation in medical students for which I was
unprepared. In approximately half of the new departments
visited students and interns expressed deep frustration
about the difficulties encountered in trying to help poor
families. This was shown most dramatically in a medical
college where I had been asked to lecture to a 5th year
class which had been vrorking for 2 years on a Family
.'.dvisor program. Because of limited staff, supervision
had been mainly through a "family book". Students were
expected to fill out a detailed family record schedule
printed in the book, keep a record of their home visits
and then were graded on this book as part of their pro
fessional examinations. After half an hour of lectur
ing I asked for comments from the class. I touched off
an explosion. They seemed to have been waiting for
such a chancec '.nth great unanimity they said "the only
thing we have learned is that there is nothing you can
do to help poor people", ^s I probed I' got the response.
"If the government will give free drugs, doctors may be
able to treat the poor, but there is no use trying to
teach them anything about prevention. Our families were
too poor and too ignorant to follow the advice we tried
to give them, he have decided that until, their general
socio-economic conditions improve there is nothing that
poor families can do to improve their health", hhen I
asked about the student’s attitudes at the start of the
experience they convinced me they had gone to their
families full of idealistic desire to serve. Then some
illustrative anecdotes came out, the most flagrant
being a student who told about a rickshaw driver's
family with severe nutritional lack, ’..hen I asked what
nutritional advice he had given, he said "-.hy, I told
them to eat fruit such as apples and papayas". No one
had told him about the experiments in Madras showing
that a few leaves from plants growing as weeds in most
courtyards will, also meet the need for vitamins and
minerals.
Tlie obvious lesson is that it is even worse to send
students into a family experience unsupervised than it
would be to turn them loose on a clinical ward without
supervision. The problems are even more complex. Stu
dents need support in the emotional involvements they
develop, to learn scientific objectivity without becom
ing cynical.’ They need to be shown how to help families
within the limits of their own professional obligations.
Until these field activities can be set up as appropriate
teaching experience it is better not to start. Students
particularly asked for seminar discussions, even in large
groups of 50 plus, where they could present their cases
and then discuss with classmates and teachers what could
be done to help their famili.es,
Ifc are today particularly conscious of the need for
developing initiative in villagers. Medical students
arc all too easily caught up in the general attitude
of waiting for the government to come in with help.
The need for getting across to doctors the concept of
"helping the people to help themselves" was never more
clearly defined than after recent observations in
5
community development work. Doctors with the proper
orientation also will be r.iorc active in sponsoring
community services to provide assistance for families
unable to help themselves.
B,
Staff <gbjgKt".,~c
It is not surprising that the most critical, need is for
appropriately prepared staff. hy primary objective was to visit
departments to which graduates of our program at Harvard had
returned. They arc facing two problems:
1)
Their own appointments arc being complicated by legalis
tic interpretations of rules about teaching experience.
A policy statement is needed since in a subject this new
it will be some tine before anyone has the necessary
teaching experience. I believe that the Indian Medical
Council has wisely, though unofficially, agreed to some
relaxation of requirements about years of teaching ex
perience in preventive and social medicine and psychiatry.
Newly trained men will be able to work more effectively
if they arc given administrative control and appropriate
status rather than being subjected to some maneuver such
as being placed under traditionally oriented public health
people who have themselves had no teaching experience in
modern preventive and social medicine,
2)
Subsidiary staff will have to be found. At this stage it
is my opinion that if the department head has appropriate
orientation his subordinates can be recruited less on the
basis of their qualifications and more with attention to
their interests, '.c need to "beat the bushes" of other
specialities such as medicine, microbiology and public
health to locate latent interest and put it to work.
Specialized training can come later. Particular attention
needs to be paid to obtaining auxilliary staff such as
social workers, public health nurses, statisticians and
health educators, especially in health centers.
The need for staff with special training in this field
will continue for some time. It is hoped that the new
program at Calcutta will help to meet this need. The
principle of giving public health specialists orientation
in clinical medicine and vice versa seems to bo substan
tiate
C.
Dangers of Regimentation of Curriculum
Since this is a now discipline we still have much to learn about
how it can best be taught. The several model curricula which have
been prepared in the last 5 years should be considered only as a
tentative patterns. Increasingly I am convinced that it will bo wrong
6
to rigidly standardize curricula, even for the several radical
colleges within one university.
This is an integrating discipline. The local ecology of a
medical school and the particular skills of the departmental sta.ff
determine where and by wha.t means integrati on can be best achieved.
In one school the Departments of medicine and psychiatry : .ay be
cooperative and the hospital facilities appropriate for developing
a coordinated outpatient teaching program with follow-up visits
to homes. In another coopcrati n with Pediatrics and a children's
clinic nay achieve the same function by being adapted to a Family
Clinic, Igain local resistance nay make it logical for Preventive
and Social llcdicino to have its own clinical facility in a rural
health center, infectious disease wards or some specialized clini
cal activity. Similar local conditions may apply to the prcclinical
period. The selection of the areas in which integrated teaching
can be developed should be left open, but the ultimate objective of
getting all dopartrants to teach prevention should be clearly
defined.
Similarly the tiring of the various pants of the curriculum
should be left to 2.:cal dccisi -ns. There may be good reasons in
particular schools for concentrating teaching a.t certain times.
It is necessary, of course, to list general material to be
covered. To conduct fair examinations all students should have
an opportunity to learn the basic subject matter. The examiners
should be concerned vdth general principles and the approach of the
student rather than detailed knowledge of facts.
This approach is well stated in the last report of the British
radical Council. Thea have changed their previous policy of sotting
up detailed and rigid curricula. They now encourage experimenta
tion and the trial of new approa.chos in medical education,
D.
Course Content of Preventive and Social iicdicinc
It is useful to distinguish between teaching which is a co
operative function with other departments and that which is a
specific responsibility of this department. The subject matter
can again be .divided according to the general period in curriculum
in vdiich it con logically be placed. .2 tentative list of these
coi.poncnt parts is given in Table I as a suggested pattern per
mitting local flexibility.
It will be noted that the some division of functions by time
periods has been attempted as is found in the general curriculum.
The prcclinical period is devoted to learning basic knowledge, main
ly about the normal. The clinical period is devoted to learning how
to apply this knowledge to the problems of health and disease. The
internship is to give opportunity for assuming responsibility under
supervision in selected duties; there should bo no attempt to cover
the whole range of preventive activities any more than a clinical
internship is designed to give experience with all clinical conditions
7
TABES
I
Cours Content of Preventive and Social medicine Curruculum
Cooperative
Functions
Specific
Functions
Field
'.fork
Preclinical Period
(Basic
knowledge)
Human growth and
development,
Nutrition, Psycho
social" maturation
Ecologic awareness of
environment of indiv
duals and families,
Ifodical Sociology,
especially rural
Demography Biostatis
tics,
Family studies
(laboratory course
in medical socio
logy).
Clinical
period
(applica
tion of
basic
knowledge
to health
problems)
Preventive measures
for specific diseas
es, especially
oomunicable
Environmental Hygiene,
Epidemiologic method.
Community Organiza
tion for Health
(public health with
sub-specialities),
Follow-up of patients
to home to observe
effect of environ
ment on illness and
of illness on family.
Observation of Public
Health activities.
Rural
Internship
(responsibilityunder supervision)
E,
Research projects
Responsibility for
all health functiors
in group of families
or part of village.
Rural Sociology and Village Develop:-.ent
Perhaps the greatest lack in the preparation of teachers of pre
ventive and social medicine is in experience and knowledge of village
conditions, I have found faculty members who are beaching the some
what pessimistic attitude which has disturbed mo in students, that
there is little that can be done for poor people until their socio
economic conditions spontaneously improve, The realization that
doctors do have contributions to make in raising living standards
tends to be ignored.
liucli has boon learned about rural sociology and village develop
ment in India in the past 10 years, .-1 least one member of each
department should keep up with this area. This can be done through
8
association with centers such as Gandhigram, Allahabad agricultural
Institute, Gokhalc Institute of Social Sciences at Poona and the
Community Develops .^nt Scheels in each area - particularly those for
Block Dcvclopsucnt Officers and Social Education Organizers. The
importance of intensive research in this an-a by tho departments
themselves is particularly apparent.
F.
Rural Internships
Recently passed requirements for tho immediate sotting up of
internships in rural health centers have caused more agonizing
effort on the part of medical college departments than any other
single activity. The whole process is so new and complex that it
is only by trial and error that progress will bo made.
A fundamental concept which must be accepted is that a teaching
health center should be just as different from a service health center
as a teaching hospital differs from a service hospital.. The major
requirement is for staff who know how and have time to teach. In
addition special facilities will have to be provided.
Perhaps the commonest error I have observed in organizing teach
ing health centers is to set up a "merry-go-round" type of activity.
In an attempt to be comprehensive short experiences arc provided in
all sorts of health center and public health activities. Very little
opportunity results for the "responsibility under supervision" charac
teristic that should distinguish internships. The group of interns
told of a houschol survey in the course of which they had encountered
a case of acute appendicitis obviously requiring surgery. They wore
terribly frustrated when because of local red tape and the fact that
they wore now supposed to be doing preventive work, they were unable
to arrange to get tho patient to a hospital for surgery.
|
!
|
I
.
1
i
At Nagpur I found an excellent program which resulted from a
suggestion made by the interns themselves. A pair of them assume
responsibility for a hamlet of 30-50 houses. They run a dispensary
in a room contributed by the people; they do household surveys,
vaccinations, health education, preschool and school ago exams, and
all typos of sanitation work. Both interns and village people were
enthusiastic. The supervision was excellent. Ab Ludhiana and other
places attempts arc being made to have interns undertake limited
research projects.
Tho other major problem observed is administrative. All too
often the effort is made to merely use a primary health center under
the usual administrative control of the State Health Services. If
this is recognized as an important teaching arm of the Medical College
it should be under some sort of control by tho Department of Preven
tive and Social Medicine. There is no advantage in trying to have
separate service and teaching staff in the center with divided
administrative control because if interns are going to be given res
ponsibility they should be taught by the service staff. Teaching
9
staff coring in from outside might be useful for observation but not
when tlic emphasis is on participation,
separate "teaching officer"
tends to think he is above service,while if one is appointed he should
realize he con teach best through the service activities,
Attracting Physicians to '.'ork in Pri'.ary Health Centers
G,
Few issues in medical planning in India arc as immediately inpor
tant as getting a better rural-urban distribution of doctors. There
can be no doubt but that it is better to attract doctors to the
villages rather than having to force them to go against their will,
Hany of my discussions with medical students and interns focussed on
this problem and it was obviously a favorite "bull-session" subject
aaong then, Groat emotional resistance is being created against
village service by the very tone of compulsion being used in official
pronouncements on the subject. The political realities of the present
crisis have created a situation whore, unless the medical profession
can come up with imaginative proposals, popular pressure is going to
aggravate the developing nisunderstandings and resentments, The
people in the villages arc inpatient about the health center build
ings standing idle for lack of staff and they have i.iany votes.
As I have talked with dozens of groups of students and interns
a fairly consistent and clear definition of their problem, areas has
emerged. As I asked how many students originally cone from villages
I obtained ratios ranging from 1/10 to 1/3, 'hen I asked what pro
portion would be willing to go to villages the ratios ranged from
1/3 to about 2/3, But they want certain changes to be made.
I 1)
.
’
I
2)
Remuneration - Vest Bengal has a.H its health centers
staffed by starting doctors at Rs, 450,00 plus per month
and giving security. Until political demand forces up
salaries there is no point in criticizing the doctor’s
service motivation.
Of great interest to me was the high degree of importance
attached to professional stimulation. Repeatedly I heard
objections to "getting stuck in the villages mud indefini
tely". There were many v;ho said that an open door of pro
fessional advancement at the end of a period of village
service would attract them greatly. This applies especially
to .or best young doctors who arc often highly idealistic
and would welcome three years in a village to satisfy their
service motivation. They are afraid that if they once get
out of the scramble up the academic ladders they will never
get back on. In many places it would he held against a
candidate for M.S, or M.D, if he had been "wasting his time"
in a village. Added to this is the undeniable truth that
if obtaining professi ;nal advancement depends on being in
a place where one’s work is noticed then it seems logical to
work in teaching words under the professional leaders who
count.
- 10 -
The only sort of compulsi-n for village service which
I would personally consider at this time would be to require
j candidates for post graduate degrees to have served two or
1 three years in a village. It would .be more dcnocractic,
instead of such compulsion, to give priority and credit in
select!.n to those with rural service. I believe they
would be infinitely better consulting physicians and sur
geons and better teachers for having had an opportunity of
coping with health center problcns and developing their own
ingenuity and initiative. Getting the best graduates to
village service would add prestige to the whole activity.
.
3)
Repeatedly concern is expressed that routine work in a
health center is dull and lacks challenge. This is merely
an indication of the need for presenting a clearer image
of what the work is. One good young doctor in a health
center told of how much time he spent writing prescrip
tions for iron mixture for anemia. eases, '.hen he was
stimulated to check stools a large number of eases of
hookwor:.i cane to light and he was faced with a challeng
ing problcr.i in prevention,
4)
•
5)
Amenities arc important to :.x>st doctors. Such facilities
as housing, safe water, transportation, opportunities for
recreation and social contact are desirable. If the service
is for only 2-3 years these problems do not loom as large
as anoung doctors considering the- possibility of lifetime
service. For the latter questions such as educational
opportunities for children become importqnt,
adequate working facilities arc essential if good doctors
arc going to be attracted. .although some ability to adapt
I and be creative is vitally important the doctor must be
, provided with basic drugs and equipment. The budgets now
allotted arc scaring off many good persons.
6)
Opportunity for association with other doctors makes up for
many other deficiencies. Chances to talk over problcns with
colleagues arc needed to clarify thinking and relieve
emotional involvement. Particularly desirable is some
arrangement for periodic association with speciality consul
tants,
/7)
in incidental observation is the fact that the proportion of
girls in a good many medical colleges is climbing rapidly,
A ratio of 50 - 70/6 is no longer unusual, -s ©pro girls
appear for qualifying exams and with their sexual supciiori-’
ty in getting high grades in the theoretical, questions asked#
the trend will increase unless selection methods change. It
is understandably harder for girls to go into village sorvivc
and the proportion of rural doctors available will therefore
decrease.
11
8)
H.
The question of family pressure on doctors to go into lucra
tive practice I consider soluble only as it bccop.cs evident
that one can no longer immediately walk into a lucrative
city practice.
Need for Resaarch
To gain solid recognition as an academic dcsciplinc there is need
for sound research contributi ons. Ranging alongside of the clinical
and laboratory approaches to research is the epidemiologic approach.
In a medical faculty the Department of Preventive and Social Medicine
should be in a position to provide field research skills to many
different types of problems with the great advantage of being able to
work in close association with prcclinical and clinical specialists.
Tlic immediate questions to be tackled should concentrate on the major
health problems of the geographical area and the mere definition of
such problems is in itself a great contributi ..n, Increasingly, as
medicine evolves in India, it is probable that research interest will
shift to the application of the methods of behavioral sciences to
health, Jji annual mooting of persons interested in epidemiologic
research at the ICliR meetings would be an important stimulus to
encourage such effort in medical college departments,
I,
Exai-iinations
Great variation has developed from one university to the next
on the question of separate examinations in preventive and social
medicine. Those who have included this examination under the general
medical examination have done this as part of the very desirable
longterm objective of dc-cmphasizing examinations generally. It is
also thought that this will help to integrate preventive and curative
learning, Ono or more questions in this subject are supposed to be
included in medicine but specialists in the field have little or no
say in setting questions or grading, My observations convince me
that this is the wrong means to a desirable end.
In the minds of Indian Medical students the prestige attached to
particular specialities is largely conditioned by the'points assigned
in professional examinations. There are, in addition, certain depart
ments which have an intrinsic prestige based on tradition, with sur
gery and medicine being good examples, Struggling new specialities,
which lire all agree should be encouraged, for the present need to rely
on artificial stimuli to their prestige such as is provided by exami
nation points. If we arc going to start dc-omphasizing examinations
the disciplines which should take the load are medicine and surgery.
Such procedures as increasing the marks for practical ward work arc
logical stops. The analogy comes to mind of the story the prophet
Nathan told King David in the Bible.
wealthy men had large flocks;
a poor man had a single lamb which he nurtured as a member of his
family, then a guest camo the wealthy man took the poor man's lamb
for his feast, Medicine can afford to give up its examination prestige
and should not be swallowing up the small lambs of preventive and social
medicine and pediatrics. On the matter of whether integration is ....
12
achieved it seems evident that if this is desired the place to start
is in teaching and not in examining.
J,
Transport ati on.
A final observation is that preventive and social medicine relies
on good transportation as the life blood of its field program, ’with
out transport which can be used in a fairly uninhibited way regular
staff supervision becomes i: possible. Students too need facilities
to get them quickly into contact with their families, International
agencies have and should continue to help with this need.
V.
BECOI2SHD..TIOKS
A,
Poorly organized, teaching programs in preventive and social
medicine lead to faculty resentment and student frustration, ..ctivitics should be developed in sequence as soon as appropriate conditions
prevail rather than attempting to start everything at once. The follow
ing specific prerequisites arc essential:
1)
2)
3)
.Adequate staff both in numbers and in preparation
Field facilities such as properly developed health
centers,
Transportation.
B.
The most important teaching job in preventive and social medicine
is developing right attitudes which requires getting student’s parti
cipation, Field experience, especially with families, should not be
started until adequate supervision can be provided to prevent student
frustrati on and uncontrolled cmoti .nd involvement,
C,
Rigid curricula arc undorsirable. Each college should bo per
mitted flexibility in developing a teaching program to fit local needs,
Tliis applies"especially to the priority accorded to the sequence in
which special field programs vri.ll be developed,
D,
To meet examination standardization requirements, a general
listing of basic subject matter is sufficient, - separate cxai.iination in preventive and social medicine is still necessary. It should
deal primarily with principles and observation of the student’s
approach to problems,
E.
The staff shortage requires continuing full scale use of the pro
grams for Teachers both at Calcutta and Harvard, In addition, atten
tion will have to be given increasingly to nmriTHnfy staff.
F,
I-iorc adequate preparation in rural sociology and village develop
ment needs to be provided for staff members.
G,
Programs in rural health centers require- imrxdiatc attention:
1)
A teaching health center should have staff selected as
carefully as any other medical college teaching staff and
13
with the same relationship to the medical college in
terms of permanence and encouragement to do research,
2)
Facilities should be designed specifically for teaching
with appropriate hostel accommodation,
3)
The service staff of the center should all participate
in teaching but their service load should be adjusted
to make good teaching possible. This requires limiting
the population served to 20,000 - 40,000 for the usual
center with three doctors.
4)
The teaching responsibility for and, if possible, the
administrative control of the health center should be in
the Department of Preventive & Social hcdicine,
5)
Interns activities should be concentrated in limited
areas, to provide real responsibility under supervision,
H.
In selecting candidates for 11. D., 11. S. and other specialty
training priority should be given to those who have served in
village health centers and possibly this should be a prerequisite
for specialization,
I,
.Ji annual meeting on epidemiologic research as part of the
ICi-H. meetings would be an important stimulus to preventive and
social medicine departments to undertake cooperative field research
with other specialists.
- Media
RF_MP_8_E_SUDHA.pdf
Position: 2237 (3 views)