The Development of the Discipline of Public Health; Experience of U.S and Latin America; Lessons for India
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- Title
- The Development of the Discipline of Public Health; Experience of U.S and Latin America; Lessons for India
- Creator
- Neha Madhiwalla
- Date
- 2007
- extracted text
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The Development of the Discipline of Public Health; Experience of U.S and Latin
America; Lessons for India
Neha Madhiwalla
Introduction
The experience of other countries is an important reality-check. It gives us an insight into the
common themes, struggles and fault-lines, which emerge across different societies and eras as
public health begins to emerge as an independent discipline. This paper is limited to the
experiences of the United States and Latin American countries, although the European
experience also has a lot of relevance to us. However, this history is quite well known and I hope
that the readers will be able to draw parallels. Rather than provide a chronological history, I intend
to concentrate on the dominant issues as they emerged through the history of the past 100 or so
years, during which professional public health practice emerged in the two regions. It is important
to remember that several terms have been used, which also signified other ideological and
conceptual differences. Public health, social medicine, community care, community health all
have been used alternatively at different times. 'Public health' suggests a wider approach
focusing on state action, which incorporates a multi-pronged strategy including sanitary reform,
improvement of infrastructure, health education, therapeutic interventions as also a system of
surveillance and monitoring backed by legal sanctions. On the other hand, 'social medicine' and
'community health' suggest alternatives of medical care delivery along with a stronger emphasis
on preventive measures. A wide range of perspectives have prompted such experiments - '
ranging from revolutionary governments to the compulsions of und.er-developed countries, which
do not have the infrastructure or personnel to provide professional care to all.
Brief historical review
In the U.S., public health has a modern history of about 130 years, starting in the 1870s. The
American Public Health Association was founded in 1872, which was initially dominant by
doctors, who constituted 90 percent of its members. It strongly supported the establishment of
public health boards and professionalisation of public health practice. Formal public health
departments emerged in the early 20th century, encompassing contagious disease control, food
inspection, plumbing, school health, child health, the licensing of physicians and midwives, and
campaigns against specific conditions such as "social evil" (prostitution). However, the massive
growth of personnel in public health occurred with the setting up of county level public health
departments in the inter-war period. The interwar period was a time of dramatic social change, in
fact crisis and was also marked by the development of radical social policy The Depression led to
the impoverishment of large sections of the population, prompted massive migration and the
problems of urban health. Thus, radical social policy, which was directed at providing wideranging benefits to the poor, emerged simultaneously. Naturally, this situation opened up many
more avenues for the practice of public health. With the initiation of federal funding for local public
health departments (largely for maternal and child health), the arena of public health (which
hitherto was concentrated on preventive health) widened to incorporate a large number of poverty
relief measures - basically in nutrition and health education. The other landmark development,
which affected public health practice in the US, was the emergence of a system of limited social
insurance for the poor. As is well known, the U.S does NOT have a system of universal health
insurance, but has limited provisions for certain vulnerable groups (Medicaid and Medicare).
In recent times, public health has again come into focus in the US because of the resurgence of
infectious diseases like HIV/AIDS and tuberculosis. Moreover, public health has become quite
globalised with a large number of multinational health programmes in fields as varied as
HIV/AIDS and malnutrition.
In terms of public health education, the US has 33 accredited schools of public health, which
produce in excess of 5000 postgraduate professionals each year. The first school of public health
to be established was the Johns Hopkins School of Hygiene and Public Health in 1916. They
have a nodal body called the Association of Schools of Public Health. While the curriculum in
these schools is not standardised, they are evolving a consensus on 'core competencies' which
draw upon a wide range of disciplines, including epidemeology, law, sociology, ethics,
communication and geography. The various associations of specialized public health practitioners
have been developing guidelines for 'core-competencies' required in their work, which are being
brought together.
American schools of public health accept students from medical as well as non medical
disciplines, which has had both advantages and disadvantages. The multi-disciplinary approach
has enriched the teaching of public health and provides opportunity for the sharing of varied
experiences. On the other hand, because the students come from different disciplines, designing
a standard curriculum for the masters level has been very challenging. To add to the problems,
reviews have shown that unlike earlier times, when the schools attracted more experienced in
service professionals as students, most of the recent recruits are young graduates with either no
or very limited field experience.
■ In November 2002, the Institute of Medicine (IOM) released 2 companion reports: The Future of
the Public's Health in the 21st Centuryl and Who Will Keep the Public Healthy? Educating Health
Professionals for the 21st. Century.2 The first report highlighted the great achievements of the
past few decades in regard to improving public health in the United States but also noted that we
have failed to reach our potential relative to the investments that have been made. As can be
seen in Figure 1, the report, among other recommendations, advocated a broadbased ecological
—apprsaeh-to-think-ing-aboat-tl're ■ auftiple determinants of health.
The second report-Who Will Keep the Public Healthy?-also underscored the need for a
broadbased ecological approach to human health and identified 8 specific content areas needed
to address new challenges: communication, community-based participatory research, cultural
competence, ethics, genomics, global health, informatics, and policy/law. Other recommendations
involved providing access to lifelong learning opportunities for public health practitioners,
encouraging greater weight for community-based participatory research in academic promotions,
and enhancing faculty involvement in policy development and implementation.
Another interesting finding that has emerged from the recent review of public health education is
that only about 20 percent of the students are joining government departments of public health. A
large proportion is joining various voluntary agencies, insurance companies, international
organizations and various pharmaceutical and health corporations.
In the Latin American countries, the development of public health had a much more overtly
political history. Inspired by the European experiments in public health reform of the 19th century,
Latin American pioneers in public health were keen to emphasize that the root causes of ill-health
were in poverty and inequality. Unlike other countries, in Latin America, attempts were made to
actualize these ideas._ Perhaps, one reason could be because there were several medical
professionals in the leadership of the revolutionary struggle. Many of them had been trained by
the first generation of adherents to Virchow's ideas who had established departments of
pathology and social medicine in the medical schools. A notable leader among them was
Salvador Allende, who later became president of Chile. As in Europe and the U.S., the 1920s and
1930s were a vibrant age for public health reform, against the background of active working class
movements and progressive public policy. At the end of 1930s, as minister of health, he initiated
broad-based reform aimed at improving the living conditions of the people, equalizing distribution
of income and resources. His attempts to universalize healthcare access and restrain the market
in healthcare often brought him into confrontation with the medical fraternity. His experiments in
social medicine were brought to a halt with the coup-d'etat in 1973.
Meanwhile, in Argentina, Che Guevara too was evolved his own vision of 'revolutionary medicine',
which also emphasized the importance of social change and equity for improving health instead of
techno-managerial solutions. All these ideas came to fruition in Cuba, after the revolution in 1959.
Broadbased health reform (including nationalization of the health service, housing and nutrition
programmes) emerged as part of the revolutionary transformation of society.
From my limited reading of the Latin American history, what seems to be emerging is that public
health is understood more as 'social medicine', which emphasizes the importance of social
transformation for improving health. Rather than a separate discipline of public health, what
seems to be emerging is a strong social orientation to the different professional disciplines related
to health (medicine, administration, planning).
Emerging themes
Admittedly the history of the U.S is very different from that of Latin America, as are their problems.
However, when these two histories together with the history of public health in Europe are studied
carefully, we find several common themes. These could a 150 be of relevance to the development
of public health in India.
Conflict with medicine
A dominant theme emerging in all these histories is the professional opposition of the medical
profession to the consolidation of public health. There are several reasons for this opposition. At
the most superficial level, widespread public health measures threaten to reduce the need for
curative care, which is the mainstay of the medical profession. However, this does.not seem.tc..be._
adequate reason to explain the persistent hostility between public health and.medicine In most
countries, medical education and the practice has emphasized on .the individual and on
individualism. Attitudes, which are not consonant with good public health practice. Moreover,
medicine has always emphasized technological measures over less sophisticated, but more
effective social measures. Medicine, as a profession has also shown much less inclination to work
in collaboration with others, who have a different kind of expertise. Public health, on the other
hand, is implicitly multi-disciplinary, requiring the input of a wide range of disciplines including the
social sciences, engineering; management and statistics.
In the U.S. this conflict led to a movement for establishing public health schools, distinct from the
medical faculty, which also allowed entry to non-doctors. While the medical profession was
wealthy and enjoyed a great of political clout, public health practitioners had the backing of state
power. Public health was largely the preserve of the state, and it enforced its writ through laws. In
Latin America, this conflict was resolved by radically altering the social structure of society as a
whole and the medical profession in particular. Inspite of this, many of the experiments in social
medicine collapsed with the fall of revolutionary governments. In Cuba alone, where there was a
sustained experiment of social medicine possible, a real transformation of the profession was
possible.
In India, therefore, a moot question emerges for us. Are medical colleges really the institutions,
which can be expected to provide leadership in public health education. Should we not assume
the contradictions between medicine and public health, which emerged everywhere in the world,
will also become apparent in India? Secondly, what will be the political, social orientation of a
medicine-led public health movement? Thirdly, we must remember that, worldwide, public health
is becoming disengaged with medicine, and emerging as a profession in its own right, with its own
methods and theories. Thus, would we not be anachronistic in expecting our medical institutions
to develop public health as a sub-specialty?
The agencies ofpublic health
Historically, public health has largely been the preserve of the government, whether revolutionary
or otherwise. The state was the largest, sometimes the only, employer of trained public health
personnel. This scenario is changing, with a wide range of possibilities now available to students
of public health, ranging from insurance companies, to international NGOs to large corporations.
However, this also raises a concern for public health educators about the focus of public health
practice. What kind of professionals should they train? What kinds of fieldwork training should
they provide? What kind of jobs should they prepare students for? Moreover, it was much easier
to predict the demand for personnel when the government was the primary employer. The
situation is much more complex today. Also, given the wide range of agencies involved, it is
inevitable that those who establish and run training institutions will have a varied political/social
perspective. Once more agencies are interested in recruiting trained public health professionals,
they are bound to have an interest in funding training institutes and influencing the curriculum to
ensure that they get professionals of the kind that they require. Thus, the government is likely to
lose monopolistic control both over the funding of these institutions as well as the curriculum.
Within this range, how does one standardize certain norms is very important. Thus, it would be
noteworthy that 'ethics' has been identified as one of the 'core competencies’ that graduates in
public health must posses. In our context, we may have differences of opinion about formal ethics
training. However, given that it is inevitable, that professional public health education is going to
be funded by, controlled by arid responsive to different state as well as market institutions, what
are our options? On the political ‘rant, it is important to ensure Jhat institutions that have,
demonstrated their social commitment do not get left out of the race. However, one also has to
ensure that all students of public health are exposed to some kind of progressive ideological
perspective - whether it be through ethics or human rights. Thus, we should emphasise that these
get integrated within the curriculum, as we have been demanding for medical education.
Theories and methods
A critical difference between professional public health and clinical medicine is in its foundations
and practice. For public health- to emerge as an independent discipline, it has to evolve its own
epistemology. While it is commonly understood that the origins of public health are eclectic,
drawing from various disciplines, it has to arrive at an understanding about its own theories and
methods. Public health students, in most parts of the world, are drawn from the medical as well as
social sciences, and, hence, building a common foundation is necessary. In the U.S., this seems
to have been a major challenge. However, there may be something to learn from their history.
Each school has a different emphasis, often emerging from its research strengths and its
pioneers' work. However, over the years, a consultative process has been put in place. An
interesting point is that this curriculum designing process has taken care to ensure that the actual
practitioners are involved, through their associations. Eventually, the demands of public health
practice must inform curriculum design. At the same time, it can not merely be a haphazard
compromise of dominant interests. Similarly, the shape of the public health curriculum cannot be
dictated by the presence of certain charismatic/influential individuals. It has to be objectively
designed to meet the requirements of the field. At the same time, it is necessary to allow for
certain amount of flexibility and specialization. In this respect, it may be more useful to study the
experience of other professions in India, apart from medicine. For e.g. social work, management,
public administration have all evolved in a much more decentralized manner as compared to
medicine. To varying degree, they have also developed a core set of theories and methods including certain principles of pedagogy. For all of this, it is, firstly, important to accept that public
health is a professional discipline in itself, which has to draw upon medicine as well as the various
social sciences.
Suggested reading
Brandt Allan M., Martha Gardner; 'Antagonism and Accommodation: Interpreting the Relationship
Between Public Health and Medicine in the United States During the 20th Century'; American
Journal of Public Health; May 2000, Vol. 90, No. 5
Mullan Fitzhug; 'Don Quixote, Machiavelli, and Robin Hood: Public Health Practice, Past and
Present'; American Journal of Public Health; May 2000, Vol. 90, No. 5
Perdiguero E., J Bernabeu, R Huertas and E Rodriguez-Ocaha; 'History of health, a valuable tool
in public health'; J. Epidemiol. Community Health; 55;667-673
Porter Dorothy; The History of Public Health: Current Themes and Approaches
Shorten Stephen M., Elizabeth M. Weist, Mah-Sere Keita Sow, Allison Foster, and Ramika Tahir,
'Implementing the Institute of Medicine's Recommended Curriculum Content in Schools of Public
Health: A Baseline Assessment'; American Journal of Public Health; October 2004, Vol 94, No.
10
Waitzkin Howard, Celia Iriart, Alfredo Estrada, and Silvia Lamadrid; 'Social Medicine Then and
Now: Lessons From Latin America'; American Journal of Public Health; October 2001, Vol S-1, No.
10
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