Title

Critical Public Health: Operationalising a Vision

Creator

K R Nayar

Ritu Priya

Date

2007

extracted text

I°ll\
Critical Public Health: Operationalising a Vision
K R Nayar and Ritu Priya
Centre of Social Medicine and Community Health
Jawaharlal Nehru University, New Delhi
Even when public health was experimenting unsuccessfully with various reorientations to produce
socially sensitive physicians in the 1970s and 80s (Poulose and Natarajan, 1989; Panackel and
Ramalingaswami, 1990), there were instances of alternative experiments in the provision of
training, research and practice in public health. It is possible to delineate three distinct processes
at work that are inspiring dissatisfied professionals to break out of the set pattern (Qadeer and
Nayar, 2005). The first of these is complete dissociation between the practitioners and the
conventional institutions. These professionals set up their own experimental projects of providing
alternative models of care, training and education for health workers. Among the several
examples are those such as, the Shaheed Hospital run by Chattisgarh Mukti Morcha which is
experimenting with a need based hospital for workers of an industrial area and Rupantar, an '
organization involved in training and monitoring work of community health workers {Sen, 2001).
Similar efforts are afoot in Bilaspur and Maharashtra (Ashtekhar, 2001). The Community Health
Cell being run in Bangalore is an innovative group of public health workers providing support to
different voluntary groups and individuals, both at the level of training as well as research. Other
examples are the well-known establishments like 'Comprehensive Rural Health Project, Jamkhed'
and 'Foundation for Research in Community Health', both in Maharashtra. The second trend is to
develop interactive and multidisciplinary networks of professionals and social activists to share
ideas and experiences, generate debates and take up socially relevant research. The Medico
Friends' Circle (MFC) is such a group set up in the early 70s ,(Priya, 1986). Through its meetings,
activities, research and publications, it has argued for a new vision of public, health. Health Watch
is another network set up in the 1990s, which is focusing.on monitoring the implementation of the
ICPD agenda of a target free, voluntary and comprehensive family welfare program. The third set
is the evolution of teaching institutions that are taking up the challenge of rejuvenating public
health. Some medical schools such as CMC, Vellore, AllMS, New Delhi and the Centre of Social
Medicine and Community Health (CSMCH) at the Jawaharlal Nehru University (JNU) have been
experimenting with alternative programs of teaching and research. The University of Health
Sciences at Pune was also set up with the idea of bringing in an integrative approach to the
teaching of medicine.

In this note, we would focus on the academic programmes of CSMCH at JNU, which had a vision
and a dream to bring together bio-medical and social science perspectives for a critical Public
Health. While the value of the Centre's efforts has been appreciated, its very success is seen to
pose challenges to its impacting on the mainstream- "While these suggestions (for a public health
curriculum) are very relevant, it is somewhat unfortunate that the JNU department has become
somewhat marginalized because of its 'critical questioning' and overall 'radical' image..." (Narayan,
R. 1991). A brief profile of the Centre is given in appendix 1.
Mandate of CSMCH...

It is a challenging task when a vision based on interdisciplinary linkages between bio-medical and
social sciences have to be operationalised. In the fifties, when there was a rethinking on including
social sciences in the medical curriculum, the general attitude was "they are young, somewhat
inexact, and often pretentious. Their findings are presented in a horrible jargon which obstructs
clear thinking" (Simey, 1954). Social sciences are not a unitary field of enquiry; consisting of a
number of disciplines, each with varying perspectives and theoretical orientations. It is difficult to
visualize one social science and therefore it is all the more difficult to identify a core area or the
concepts necessary to work in public health.

One of the major objectives of CSMCH, as visualized by the working group for setting-up the
centre, was to investigate health problems within the context of social, cultural and behavioral
aspects of the community. Social Science was to be a major contributor in this, especially for
realistic planning of community health services. It was therefore proposed that the centre would
be located in the School of Social Sciences. In fact, this is the only public health academic centre
located in a school of social sciences with a view to bridge the gap between available knowledge
and its social application. This was also thought to be a way to provide a meeting ground for
medical and social sciences with a common focus of making health services meaningful to the
society.

Thirty-five years of experience in offering academic programmes, undertaking research, providing
consultancies and engaging with the Stale and civil society has given us rich insights regarding
the nature of public health education suitable to our context. We have increasingly realized that a
bio-medically and statistically oriented public health academic programme alone will not be able
to capture the 'health culture' of the community (Banerji, 1986). Nor will merely 'adding on’ social
science and qualitative dimensions be sufficient to create a realistic public health approach. In
fact, one of the strong points of CSMCH is the integration of the people's viewpoint with the bio­
medical components and epidemiology into the teaching programmes of the centre. One of the
remarkable achievements is that it has been able to give a new direction to the concepts and
.knowledge’"of public health by developing a body of knowledge through use of social science in
general and political economy approach in particular in the study of community health problems
and programmes in India.

Approach to Community Health/Epidemiology
Public health as visualized by CSMCH uses a "holistic epidemiology that examines society not as
a cohesive outcome of the working of its institutions but as a social structure with its inherent
processes which are not dependent upon internal institutions or external stimuli, which operate
dialectically and influence disease and health patterns" (Qadeer, undated). According to Qadeer,
this potential in classical epidemiology was lost due to decontextualisation. The reductionist
approach and the so-called thrust for universality failed to capture contextual complexities and
denied epidemiology the opportunity to become a science that could best serve public health. In
addition, it did not attempt to study collectivities and instead focused on the individual, the family
and the immediate environment or to study social processes that contribute positively to health
(Priya, 1987). Epidemiology is envisioned in the discourse of CSMCH as a holistic science, which
covers the varied and complex social, economic and political dimensions of the human
environment. This is why the epidemiological vision of the centre is closely linked to political
economy and the social sciences.

Approach to Social Sciences
In recent years there is a proliferation of social science studies on health-related themes largely
as a result of renewed interest in the area and change in the funding strategies, mainly of
international agencies. Several universities and research institutes have initiated study
programmes and research in this field and substantial contributions have been made in a number
of social science disciplines such as sociology, psychology, anthropology, political science,
history and the favorite of the funding agencies-economics. The consequence is that the problem
of health, which requires a complex multi-dimensional social analysis, is approached more or less
similar to the six blind men examining an elephant (Nayar, 1993). An entirely different trajectory is
the one adopted by what can be called as the fact-finding approach which is largely outside the
academic system especially by non-governmental agencies undertaking research. Thus, there
are largely two broad categories of health social sciences, one which is still predominantly
academic and analytical in orientation but with specific discipline based data analyses, which
may then be brought together aggregatively into multi-disciplinary studies. The other, often
practiced outside the academic institutions, is essentially fact-finding in it approach.

CSMCH has adopted a paradigm that follows the epistemology of an interdisciplinary approach,
wherein the various disciplines are conceptually integrated and the core is defined and dictated
by the needs of health status and health services. It is for this reason that issues of social
inequalities and stratification including gender, caste, class etc. have been part of the social
science discourse in the centre. These are then continuously fed into the teaching programmes of
the centre keeping in mind the need to synthesize them with the existing approaches in
epidemiology. The social sciences are used to understand the sociology of health (health status
determinants and health service organizational dimensions) as well as the sociology of human
knowledge about health (the various health sciences including modern medicine, public health
and laypeople's knowledge).

Pedagogy and the logic of course structure

The centre has two separate programmes, M.Phil in social sciences in health for social scientists
and an M.P.H programme for doctors/nurses. The course structure in the centre is a dynamic
entity, which is constantly evolving and changing depending on the addition of new knowledge
based on the review and research undertaken by the faculty themselves and the '
students'feedback. There is an internal logic to the structure of courses. The common binding
course for M.Phil and M.P.H is the one that focuses on the fundamental concepts of health and
health service planning interwoven with the organization of health services in the country.
Through this course, students get an opportunity to understand the evolution of health services in
the country and the social, programmatic and epidemiological issues with regard to the general
health services and various national programmes. This is followed by the M.P.H students
undergoing some common sessions in social sciences with the M.Phil students. This kind of a
synergy is intended to bridge the gap between social sciences and bio-medicine. ■ For social'
sciences, there is a problem of dissimilarity as we get students from varied backgrounds.
Therefore, there is an additional challenge of bringing students belonging to various social
science disciplines onto one common platform. This is the rationale for having bridge courses
such as "Social Sciences: Towards an integrated approach" for social scientists wherein the
theories and concepts needed to work in the area of community health are delineated. M.P.H
students go through the same course in social science although they are not expected to cover
the course as extensively as the social scientists. This is followed by courses which focus on the
social science issues in community health and research methodology. The M.P.H. students also
go through a course on Epidemiology in which they learn to understand the different perspectives
within the discipline itself, to view it as a science rather than merely as a set of methods, and to
use its approaches and methods for interdisciplinary research and health planning. These core
courses are followed by optional courses that apply the interdisciplinary perspective to various
dimensions relevant to public health, such as women's health, communicable diseases,
population and health, environment and health etc. as well as indepth study of contributions of
disciplines such as medical anthropology, social psychology in community health and operations
research. The course structure can be seen in appendix 2. Field exposure visits, review of current
literature and strongly interactive discussion sessions form a major part of the teaching methods.
From the students' point of view, the perspective and the courses that the centre offers denote a
shift from the earlier disciplinary backgrounds. This may be equally applicable to doctors and
social scientists. For the doctors it is also a process of re-examining their perspectives and
becoming consciously aware of the social, cultural and political role of health, the health sciences,
health services and health personnel. A brief note on the students' background, fee structure and
democratic mechanisms for students' involvement in evolution of the academic programme and
institutional
ethos
is
appended
(appendix
3).
The students' research also evolves out of the teaching programme, to a large extent through
assignments (such as writing a synopsis on a research topic for the course on research
methodology), independent seminars based on the interests of the students, issues observed
during fieldwork etc. The student's own past exposure to health and development issues, links
with health institutions and understanding of community problems also influence the themes they
choose to study.

Team Work for public health
One of the important hallmarks of public health academic work is the need for teamwork.
Teamwork helps in transcending the limitations of disciplinary boundaries of faculty involved in
teaching and research at the centre. Teamwork is practiced primarily in teaching individual
courses. Most core courses are organized along these lines wherein more than one faculty
member is involved in teaching courses. Often, it has involved faculty with medical and social
science
backgrounds
working
together
on
a
course.
In research, there is an effort to pursue the same spirit of teamwork. This is reflected in the many
publications of the faculty over these years. One of the great opportunities to demonstrate the
teamwork in research was made possible in a large multi-centric project on "Monitoring shifts in
health sector policies in South Asia". The entire faculty of the centre was involved in the various
stages of planning and operationalisation of this project which examined the shifts that had taken
place in the health sector in India after the implementation of Structural Adjustment Programmes
in terms of changes in the health status of lhe population, shifts in the delivery and utilization of
health services and the process of decentralization as a part of reforms. At least two major
publications which evolved out of this team work laid the foundations of the critique of structural
adjustment and health sector reforms in India (Rao, 1999; Qadeer et al., 2001)
Concluding Observations

It is indeed challenging to develop a public health academic programme which needs to
overcome the limitations of a decontextualized epidemiology and a mere fact-finding social
science that only aggregates inputs of the various disciplines. Our experience shows that it is
■pussible-to delineate the minimum core areas of social sciences that can establish the syn.erg'y
with epidemiology and community health. The political economy perspective offers a bridge to
establish such a synergy within which health and health services and programmes including
family planning can be understood and analysed in a holistic way. The strength of CSMCH lies in
the development and continuous rethinking of such a holistic perspective, which may fall within
the realm of'critical public health'.

References
Ashtekar, Shyam (2001): "Revisiting the Community Health Worker" In Qadeer I, Sen K, Nayar
KR (eds.). Public Health and the Poverty of Reforms : The South Asian predicament. New Delhi:
Sage, pp.427-35.Banerji D (1986). Social Sciences and health service development in India:
Sociology of formation of an alternative paradigm. New Delhi: Lok Paksh.
Narayan, R„ (1991). Recent Initiatives Towards an Alternative, Ch. 14 in Medical Education Re­
examined, Medico Fried circle and CED, Mumbai, pg.176.
Nayar KR (1993). Social Sciences in health: Towards a Paradigm. IASSI Quarterly,
Vol.12, No.1&2, 1993, pp.153-159.Panackel J, Ramalingaswami P. (1990):" The Uphill Task of
Adapting Medical Education to Community Care", World Health Forum; Vol.11, No.(1), pp.96-7.
Poulose KP, Natarajan PK.(1989):" Re-orientation of Medical Education in India: Past, Present
and Future", Indian J Public Health; Vol.33, No.(2), pp. 55-8. Priya, R. (1986). Voluntary Action
For An Alternative Health System'. Lokayan Bull, Vol.4, No. 3-4, 1986.Priya, R. (1987). The
epidemiological approach: Its elements and scope. MFC bulletin, 132, September, pp. 1-5.
Qadeer, I and Nayar KR (2005). Politics of Pedagogy in Public Health. Social Scientist, Vol.33
No.1-2, pp.47-75
Qadeer, I, Sen K and Nayar KR eds. (2001). Public Health and the Poverty of Reforms: The
South Asian Predicament. New Delhi: Sage.
Qadeer I.(undated). Critique of Methods and Science: The role of objectivity in the science of
public health and health policy. Paper presented in the international conference on "Health
systems and social development: an alternative paradigm in health systems research. RIAGG,
Maastricht,.Netherlands.
Rao, M. ed (1999). Disinvesting in Health: The World Bank's Prescriptions for Health. New Delhi:

Sage.
Sen, B. (2001): "Peoples Health Care Initiatives in Chattisgarh District, Madhya Pradesh" In
Qadeer I, Sen K, Nayar KR (eds.). Public Health and the Poverty of Reforms : The South Asian
Predicament. New Delhi: Sage. pp. 413-18.
Simey, T.S. (1953):" Introduction to Social Sciences". In The first Conference on Medical
Education 1953 (Proceedings), London, O.U.P, pp. 148-152.

Appendix
Profile of CSMCH

1

The Centre of Social Medicine and Community Health was started in 1972, as one of the
problem-oriented centers located in the School of Social Sciences. Its mandate was to develop
the contours of public health as a discipline suited to address the needs of the country, with a
special focus on the needs of the underprivileged sections. Over the years its work has focussed
on Health Systems Research and Public Policy Analysis with an interdisciplinary perspective.
While..engagjng in. universal public health .issues and debates, the Centre keeps a context specific
approach. While it relates to global developments in health and health services, the South Asian,
Indian and within India the state-specific contexts get greater emphasis.
Courses offered are an M.Phil/Ph.D. in Social Sciences in Health for social scientists and a
Masters in Community Health/Public Health (a pre-Ph.D. programme equivalent to the M.Phil) as
well..as._a_P h.D.Jordo.c tots_and_Durs.es._The. M.P.hiLand MPH_are-cov.ered-o.v-et_1_5-2_years.-The
programmes equip the students with an interdisciplinary perspective for studying the societal
dynamics of health and the modes of dealing with health problems, for analyzing policy
approaches relevant to health and for conducting health systems research contributing to policy
and programme formulation. The M.Phil students come with a post-graduation in sociology,
psychology, economics, history, social work, public administration and other allied subjects. The
doctors are required a minimum of a medical graduation with one year experience in community
health and the nurses a M.Sc. with Community Nursing. The admission intake is of about 20-25
students each year, with 14-18 social scientists and 6-8 doctors /nurses. At any time there are
over 50 students actively pursuing their research after having completed the course work. A
majority of the students have found employment in various universities, research institutes, state
and para-statal health services, NGOs and UN agencies.

The Centre has a faculty strength of ten with an equal number having medical and social science
backgrounds. Prof. D. Banerji continues to be associated as Prof. Emeritus. The faculty research
interests include history of health services development, international and national health policies
and service systems, the political economy of health, health culture, epidemiology, nutrition and
communicable diseases, population policies, health manpower development, worker's health,
environment and health, women's health, urban health as well as methodologies for health
systems research and health policy and programme formulation. Faculty members have been
playing an advisory role for research and planning to the Ministry of Health & Family Welfare,
State Governments, WHO, UNAIDS, other universities, research organisations and non­
governmental
organisations.

The Centre has organised a number of international and national conferences and seminars.
Over the last decade these have been on themes related to the transitions in international and
national policy environment. World Bank prescriptions on Investing in Health, Protecting folk and
tribal herbal medicinal knowledge and practice in the context of the Bio-diversity Convention and
Intellectual Property Rights, Impact of Structural Adjustment Policies on Health, Reproductive
Health in Primary Health Care, Societal Concerns and AIDS Control Strategies in India,
Challenges in Policy and Implementation for Making Essential Drugs Available for the Poor in
India,. The thrust of these has been to analyse the implications of current policy trends on the
health status and access to health services of the underprivileged sections. There was also some

effort to search for spaces that allow for protecting and enhancing the entitlements of these
sections in the given context. These have been variously organised in collaboration with and
financial support from the Indira Gandhi Rashtriya Manav Sanghrahalya, the UNFPA, UNICEF,
The European Commission, RIAGG (Maastricht), Dept, of Public Policy (Cambridge), STAKES
(Finland), Centre for the Study of Developing Societies (Delhi), Coalition for Women, Population
and Environment, Coalition for Environment and Development (Finland). Several books,
monographs and reports have been published as outcomes of these efforts.

The Centre faculty have jointly coordinated a collaborative project over the past 3 years on
Monitoring Shifts in Health System Policies in South Asia. The collaborating partners are health
research institutions from Sri Lanka, Bangladesh, Nepal, Pakistan, Kerala and Andhra Pradesh in
India, Belgium, Finland and England. This is funded by the European Commission and is in the
process of completion. It has attempted to analyse national data 'sets of the region to bring
together evidence on the impact of structural adjustment and Health Sector Reforms on health
status, health services and health planning processes in the region. Collaborative linkages have
been formalised for faculty exchange, sharing of information, and joint research with the Global
Social Policy Programme based at the University of Sheffield and. with the University of
Heidelberg.

... ¥ ..
Appendix
Course Structure

Master of Philosophy (M.Phil) in Social Sciences in Health
Core Courses
1. Community Health and Its Organisation in India ■
2. Research Methodology
3. Social Science Issues in Community Health
4. Social Sciences :Towards an Integrated Approach
5. Review of the Current Issues in Social Sciences in Health

Master of Public Health (MPH)
CoreCourses
1. Commuiiiiy Health and Its Organisation in India
2. Epidemiology
3. Health Services and the Community
4. Research Methodology
5. Review of Current Issues in Community Health
Optional Courses
1. Population Problem and Family Planning Programme in India
2. Communicable Diseases
3. Nutrition and Maternal and Child Health
4. Rural Health Services
6. Comparative Studies in Health Systems
7. Operational Research and Systems Analysis in Community Health Research
3. Political Economy of Health
9. Application of Anthropology in Health
10. Application of Sociology in Health
11. Workers' Health in India
12. Women and Health
13. Urbanisation and Health
14. Communication and Health
15. Environment and Health
16. Gender, Development & Health
17. Current Trends in Sociology
18. Social Psychology and National Development Programmes

2

19. Psychology in Community Health
20. Vital Statistics & Health and Information System
21. Health Manpower Planning in India
22. Health Planning and Health Economics
23. Community Health Nursing Education and Administration
24. Hospital Administration and Medical Care Services in India
25. Education and Training of Health Workers

* Optional courses are common for M.Phil and MPH

Appendix 3
An Inclusive & Democratic Ethos:
A Note on institutional Characteristics
The JNU campus is a microcosm of the Indian nation, drawing students from every nook and
corner of the country and from every group and stratum of society. To make sure that this is so,
annual admission tests are simultaneously held at 37 centres spread across the length and
•— breadth of the-country, and special care is taken to draw students from the underprivileged castes
and ethnic groups by reserving 22.5 per cent of seats for them. Candidates belonging to
backward regions of the country are also given deprivation points in the entrance examinations. 3
% of the seats are reserved for the physically challenged students. Apart from this, deprivation
points are given to other backward classes where women candidates are awarded 10 points as
against 5 for the men. Overseas students form some 10 percent of the annual intake. Students'
------- hostels-and-blocks-of-facuity-residences-are interspersed with one another, underlining the vision
of a large Indian family. (For details please see http://www.inu.ac.in).
Participation in student union activities and other elected representative bodies is viewed as an
important part of the students' life on campus. Healthy norms of student politics have been
developed by the student body, with support from the faculty.

One of the important features of JNU is the democratization of decision-making in academic
affairs. Academic matters pertaining to the centres are discussed in the Student Faculty
Committees (SFC) with equal representation of teachers and students. Students also give
continuous feedback on the courses through the SFCs. Students are also involved in the board of
studies which approve the courses for each of the centres as well as represented in the Academic
Council of the university.
Apart from a large number of Merit cum Means scholarships offered to deserving students based
on parents' income, the university has also instituted a number of scholarships and fellowships for
the weaker sections and others. The fee structure of the university is as follows:
Tution fee Annual: Rs. 240
Other fees Annual: Rs. 154
Room rent in hostels Rs. 240 (annual).